‘You didn’t agree to put your life on the line’

‘We all signed up to be healthcare workers because we want to do good and we want to help other people. But it’s not like being in the Defence Force – you didn’t agree to put your life on the line.
 
‘You know that it’s going to be stressful, but this is a level of stress which is a magnitude more than any of us have ever expected.’
 
That is Associate Professor Natasha Smallwood, a respiratory physician working at Royal Melbourne Hospital who is undertaking a research project looking into the psychosocial impacts of the pandemic on healthcare workers. 
 
It is no secret that burnout is prevalent among the medical workforce, but in the face of a health crisis mental health concerns have significantly increased.
 
Dr Jocelyn Lowinger is a former GP who has facilitated multiple peer support groups for GPs experiencing burnout.
 
Dr Lowinger told newsGP most of her clients prior to the pandemic were relatively new Fellows trying to overcome lack of confidence and feelings of imposter syndrome. Since the pandemic started, however, that has shifted.
 
‘I’m now starting to see a lot more people struggling with motivation, whether it’s study for exams, or struggling with an existential crisis,’ she said.
 
‘Which is, “I don’t know why I’m doing this work anymore”, “Every patient is irritating me, and I’ve lost patience”.
 
‘When we drill down into that … it’s a sense of having lost meaning in their work.’
 
Associate Professor Norwood told newsGP she started to see the effects as early as March, and knows of at least three people who have decided to reassess their careers as a result of the pandemic.
 
‘I was talking to one of my trainees who was in clinic with me and she said, as a consequence of the pandemic, she was going to give up her dream to be a specialist,’ Associate Professor Smallwood said.
 
‘I’ve heard other people say, “I don’t want to work in this environment, this isn’t for me” … because they have felt unsupported. Particularly [because of] hierarchical relationships, which often occur in hospitals, people have felt that they had no choice and that they had to do certain things.
 
‘Now that’s not a small thing, because that’s someone’s whole life that’s been affected.’
 
The World Health Organization (WHO) issued a report in May highlighting that healthcare workers are extremely vulnerable to the pandemic’s mental health impacts.
 
That was evidenced in a Health Sector Report released by the University of Melbourne on 17 July.
 
Defining stress as feeling ‘tense, restless, nervous or anxious, or is unable to sleep at night because his/her mind is troubled all the time’, 61% of GPs reported feeling more stressed than usual from mid-April to mid-May.
 
Among the significant contributors to stress were inadequate access to personal protective equipment (PPE), as well as a fall in income.
 
Associate Professor Norwood said the concept of ‘moral injury’ – where healthcare workers cannot provide the best care for patients because of restrictions – has also had a significant impact on doctors’ mental health.
 
‘We all know restrictions have to be there, they are a public health intervention,’ she said.
 
‘But many of us have also had really sad stories either from patients we’ve cared for, or other people who’ve shared experiences … whether that’s an older person or a young person with cancer, who couldn’t die with their family around them because of restrictions.
 
‘A lot of my work is in very severe lung disease, and what I’ve always really focused on is good quality care for people, particularly in the last years of life. So to hear those stories breaks my heart because it goes against the entire model of care that I have developed over the last 10 years as a specialist.
 
‘All of us, whether we’re in primary or secondary care, are hearing these stories and finding it very difficult to live with those, when that’s not the type of care we want to give to our patients.’
 
Associate Professor Norwood believes the absence of a coordinated governmental response has contributed to the mental burden.
 
‘At the start of all of this I read this really interesting paper, an Australian study from La Trobe that talked about burnout and anxiety and depression in healthcare workers and actually put forward an idea that said they’re not mental health problems, they’re actually organisational problems,’ she said.
 
‘And if we don’t have good organisation and good leadership, then this is actually a workplace safety issue.
 
‘These are problems that only occur because these people work in these high stress environments, and if you take that away and manage them better, people don’t have to experience that.’
 
Dr Lowinger said while for some healthcare workers the pandemic is the last straw in an already fractured relationship with their work, for many others seeking a way out is largely attributed to burnout.
 
‘As a community and as professionals, we’re running high on cortisol and adrenaline,’ she said.
 
‘Much of routine life is no longer automatic; you have to think through everything, especially here in Melbourne where even going to the supermarket is a cognitive effort.
 
‘Work is different, you have to wear masks, the change to telehealth. That’s another thing I’ve heard: “I’ve switched to telehealth now and I’ve lost all my joy in work. I want to see people”.
 
‘So it feels like there is always this energy being used and that’s exhausting.’
 
On top of that is the seeming unending uncertainty.
 
‘We don’t know when this is going to end,’ Dr Lowinger said. ‘We don’t know when life is going to stabilise, let alone approach something that we could call “normal”.
 
‘So if you’re already running close to the edge, any extra little stress that you could normally push past is now intolerable.’
 
Dr Lowinger says doctors should not underestimate the impact of the pandemic, even those outside of Victoria who feel their practice is back to normal.
 
‘There are still so many things in our lives that are not normal,’ she said. 
 
‘A lot of us doctors are not so good at recognising distress [in ourselves] until it is really bad, especially burnout, I think it’s hard to see it in yourself. We tend to be stoic and get on with it.’
 
Dr Lowinger said signs to look out for include exhaustion, cynicism and feelings of hopelessness – as though ‘nothing you do makes a difference’.
 
She urges people to reach out to somebody they trust and to also check in on their peers.
 
‘It’s about taking a proactive look at yourself, and putting in place things to systematically try to reduce your arousal levels routinely and regularly even if you feel fine. It’s just building it into [your routine],’ Dr Lowinger said.
 
‘If this was asthma and you felt good, you’d still be taking your preventer medications. We need to see it as something chronic that we need to manage proactively all the time, and that means looking after ourselves all the time.’
 
Associate Professor Norwood agrees.
 
‘It’s hard to continue to work when you’re hurting yourself. But also, we just don’t offer our best care,’ she said.
 
‘So unless we attend to our own self-care and mental health, we can’t really look after our patients.’
 
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