Healthcare workers can't get off the COVID-19 rollercoaster

Healthcare workers left the proverbial loading platform in 2020 for a ride of COVID-19 surges that only get tougher, not easier, to stomach. 

Accelerate, incline, peak, fall, plateau — repeat. 

It's the sequence of COVID-19 healthcare workers have experienced several times. The pace and degrees of incline vary depending on the state or region they're in, but the rollercoaster's order is always the same. 

Some of the minutiae are familiar to real-life rides. Toward the peak is when cameras flash, for instance, capturing split-seconds of healthcare professionals' alarmed faces. Eventually the track dips downward and the workers fall, never to ground level but somewhat closer. They take a breath. The photos and headlines recede, no longer capturing how "burnt out" they are. They welcome back patients whose care was postponed — anxious people whose "elective" cancer procedures are finally back on. Maybe they manage to take a quick vacation or, nearly as appealing these days, staycation. 

As healthcare workers continue accelerating along this exasperating track, they look around to realize they've lost fellow passengers along the way. Some colleagues have gotten off the ride, others have left the park completely to exit healthcare for good. Cheers that once encouraged them from the loading station have gone quiet; oddly, it's threats and harassment they hear from the ground, hardly helping. The plateaus only last so long, and never long enough to meaningfully prepare for the next hill. 

"We think we're over it, then something else happens," says Peter Pronovost, MD, PhD, chief quality and clinical transformation officer of University Hospitals in Cleveland. "Then we're over that, and something else happens."

Soon enough, healthcare workers take a turn to confront a new variant, a looming incline leading to another dreaded hill. The ride goes on and speeds up. Omicron has pushed the fastest mph yet. 

 

The total energy never goes back up

The highest point of any rollercoaster is its first hill, because friction and drag immediately begin robbing the car of energy. At the top of the first hill, a car's energy is almost entirely gravitational. From there, the total energy never goes up. It's downward for the rest of the ride due to frictional losses. The maximum hill rollercoaster cars can climb gets smaller and smaller. If a car tries to take a bigger hill later on the ride, it will only roll back down the way it came.

This rule of physics makes the idea of a COVID-19 surge rollercoaster more than a figure of speech. 

The first surge of COVID-19 in early spring 2020 was dark, frightening and devastating for our healthcare system. It has only been a loss of energy from there, even with the newfound availability of vaccines and therapeutics. People may think the longer we coexist with COVID-19, the more familiar it becomes, and the less it shocks the healthcare system. What we're seeing is that each surge only adds to the trade-offs and injuries of the preceding one, with little time to recover. 

"Because society is open and people are moving on with their lives, it's honestly like there is huge cognitive dissonance by hearing how hard it is for healthcare workers and hospitals," says Vineet Arora, MD, academic hospitalist and dean for medical education at University of Chicago Medicine. Omicron is the fastest-moving variant yet, bringing through hospital doors a surge of unvaccinated patients or those with COVID-19 on top of chronic conditions while simultaneously sidelining healthcare workers with mild infections. While writing this piece, COVID-19 hospitalizations hit a record high in the United States. "This surge feels different. In some ways it is more complicated," says Dr. Arora.

Omicron's complications supplement the longstanding problems healthcare workers confront daily and voice repeatedly. Understandably, they are to the point of wondering whether anybody hears them.

"We are two years into this pandemic and facing many, if not all, of the same problems," says Megan Ranney, MD, a practicing emergency medicine physician and associate dean for strategy and innovation with Brown University School of Public Health in Providence, R.I. "There are all these issues pre-dating COVID that we just dealt with. They got worse. Then as soon as surges stop, everyone stops thinking about fixing the system."

A high-level review of the issues: Supply shortages. ("I cannot order oral ciprofloxacin for a patient to go fill," Dr. Ranney says.) Violence and hostility toward healthcare workers. The seemingly accepted exodus of full-time healthcare workers from the U.S. workforce, and those still looking to leave this year. An inadequate public health structure that begets countless challenges, including COVID-19 testing capabilities that are still "as messed up as a pile of coat hangers," as one expert put it. Health inequities. Bureaucracy. Intensifying misinformation and a patchwork of deficient ways to manage it. 

"We are showing up to a workplace where we can't do our job the way we were trained to do it. That's what I feel is really different about omicron," Dr. Ranney says. "This surge is laying bare the issues that were there preceding the pandemic. They have gotten worse repeatedly throughout the surges, and no one seems to care." 

 

Cheers to jeers to quiet

When we have the luxury of hindsight, sociologists would be wise to study the about-face healthcare workers experienced in 2020. Some 670 days later, it is no less stunning. 

Healthcare workers markedly fell from the nation's collective thinking with a strange amount of ease. In little time, people had fewer qualms to meet them with mistrust, resentment and hostility. Decades of physicians' experience and specialized training were dismissed while fallacious Facebook posts from non-experts were upheld as fact. In emergency rooms strained by COVID-19, nurses and staff faced threats from patients to a degree that left government officials pleading with the public for a return to civility. Hospitals mobilized and took out full-page ads in local newspapers, begging adults with ample access to COVID-19 vaccines to accept them. When the willfully unvaccinated landed in the hospital with COVID-19, they turned to the same people they spurned to care for them. 

Healthcare workers' exhaustion doesn't unfold in a vacuum, but in an ecosystem where goodwill, trust and support from the public is on the decline. The public's growing appetite for a return to normal, or some semblance of such, is apparently at cross-purposes with compassion for healthcare workers' experience right now. 

"The thing about burnout is not only are healthcare workers burned out, but the public is, too," says Dr. Arora. "We don't see the public outpouring of support for healthcare workers left behind with the aftermath of our pandemic response as a nation, which is, 'Let the cases and hospitalizations rise.'"

Most healthcare professionals will tell you the reason they went into medicine is simple: to help people. This is an extraordinary commitment worth protecting. We would be sorely mistaken to assume it runs in endless supply, that healthcare workers' ability to endure is limitless. 

Omicron's proximity to the holiday season has certainly put healthcare workers' goodwill to the test. Ahead of the holidays, healthcare leaders began to see omicron's wave approaching.

"It was the most frightening experience to see the trajectory of the number of new cases," says Dr. Pronovost. 

Hospitals sent messages to staff, encouraging them to avoid holiday gatherings and do all they could to not get sick. When people did get infected with COVID-19 despite their best efforts, colleagues were called to the front lines. During a season people rely on for restoration, healthcare workers were reminded there is no slack in the system. 

"There was a lot of personal responsibility placed on healthcare workers to do their best to serve their communities," says Dr. Arora, speaking on behalf of friends and colleagues at hospitals in various regions of the U.S. "That goodwill is on top of two years of exhaustion and accusations and demoralization. People are spent."

Dr. Arora says she picked up on something in private conversations with physicians and healthcare workers during omicron's incoming wave that stands out compared to other surges: a quiet solitude. "There was just this sense of, 'I can't control this anymore. I'm not going to say anything. I'm just going to focus on self-preservation. Instead of asking for anything, I'm going to focus on my family and myself and try to get through this.' That's where a lot of people are right now."

If this is the stretch of the hellish rollercoaster ride where people begin to fall quiet, that's a troubling sign for everyone — healthcare professionals, their employers and, most importantly, patients. Good leaders know silence is scary and can kill a company. It goes beyond fraud and malfeasance. "All too often, behind failed products, broken processes, and mistaken decisions are people who chose to hold their tongues rather than to speak up," wrote authors of the 2003 article "Is Silence Killing Your Company?" published in Harvard Business Review

Here's where authentic, courageous leaders come in. Between social, governmental and business problems, leaders are up against an awful lot. But at this point on the ride, honest leadership in U.S. hospitals and health systems is more noticeable and needed than ever. 

 

Good leaders seek solutions 

"The healthcare systems I've seen weather this best are those where leaders get in the trenches with the front lines," says Dr. Ranney. "Those that have had the most difficult experience are where leaders do not understand the hard issues."

Most every leader would likely claim to be in the trenches with their front lines at this point, two years in. That's management 101. But healthcare workers feel the difference between lip service and real effort. They always have; now they're just more sensitive to it. 

"When problems are hitting the fan, are you only showing up at 10 a.m. on a Tuesday to take a look? Or are you willing to really sit down with folks and either help out, or be present, and work on solutions when the problems are actually there," says Dr. Ranney. "Not in a 'let me be here and show my face' way, but in a way of 'let me help the team, brainstorm and get the solution they need and not let off until we've gotten through the other side of it.'"

The first half of 2020 was surely difficult for hospital leaders, but there was also a high-gloss coating over those days where leaders acknowledged the difficult circumstances, but pointed to possibilities. The spirit of innovation was rich and hopeful. Leaders pointed to the pre-pandemic version of healthcare we'd never go back to and pointed ahead to healthcare with less bureaucracy, red tape, burden, waste. Never let a good crisis go to waste was a mantra repeated time and time again. 

And while the pandemic hasn't given leaders much time to make the sweeping system changes they identified as necessary, physicians said it is crucial for workers to see their leaders advocating for change, pushing for improvements and courageously going to bat to make work fundamentally better for their employees. This goes beyond employee wellness efforts or greater pay. 

"One thing that strikes me: We have increased the number of patients staff have to care for, for the most part. But we have done nothing to reduce the work per patient," says Dr. Pronovost. "There are many things we can do." 

They range from the tactical to the broad. Technology can automate vital signs and pour them into the EHR, reducing burden on clinicians. Solutions can track lost supplies, saving up to 20 percent of nurses' time on the job. Insurers can get realistic about prior authorizations for expensive but potentially lifelong medications that keep patients out of crowded ERs during COVID-19 surges. Policymakers can step into the fray, working with The Joint Commission to waive documentation requirements that add no value. (Dr. Pronovost has been asking UH clinicians for the top five to 10 things they are required to document where the burden exceeds the benefit of documenting it; he wants to assemble a list put forth from clinicians across the U.S.)

It's about time health system leaders quit touting yoga or meditation as a cure-all. Workers are looking at them now, at this point of the ride, to take far bigger swings on their behalf. 

"Now it's the extreme with burnout," says Dr. Pronovost. "If the message is yoga, self-care or a raise to think we solved the problem, it's really misdirected. We need authentic leadership, the balance of hopeful and humble. Hopeful that we will get through this. But also the courage to confront our current reality: It sucks. Let's not pretend this isn't really hard. Now how can we make your work better?"



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