Canadian Medical Association

The impacts of events such as the COVID-19 pandemic affect health care leaders and their staff much more than the general population. They put themselves at elevated risk to care for patients and help others — and in doing so increase their risk of experiencing negative physical and psychological effects including stress, distress, trauma and other harms that may take a toll on their wellbeing. 

Key indicators of distress

Even though distress manifests uniquely in different people, a guide published by the U.S. Center for Substance Abuse Treatment outlines some general physical and behavioural indicators health care leaders can watch for in their teams:

  • Initial: Exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal
  • Severe: Continuous distress without periods of relative calm or rest, severe dissociation symptoms, intense intrusive recollections that continue despite a return to safety 
  • Delayed: Persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, avoidance of emotions or activities directly or remotely associated with the trauma

Causes of distress

Many different factors contribute to distress among physicians. Using the COVID-19 pandemic as an example, these might include:

  • Risk of infection due to exposure
  • Risk of transmission to family members and friends 
  • Increased work hours due to large volume of patients, disrupting work–life balance
  • Witnessing colleagues get sick as a result of the virus
  • Limited availability of personal protective equipment and other critical resources 
  • Deciding how best to allocate limited resources in an ethical, rational and structured way
  • Having to deny services to patients due to capacity or scarcity of resources
  • Being unable to tend to personal needs and self-care (e.g., sleep, diet, exercise, family responsibilities)
  • Limited knowledge available about the virus (e.g., characteristics, risk factors, transmissibility, optimal treatment)
  • Social prejudice and stigmatization from others due to exposure

How distress affects physician wellness 

Unless proper supports are in place, prolonged exposure to traumatic factors such as those listed above can lead to psychological distress or disorders among physicians.

Some adverse psychological outcomes resulting from trauma include: 

  • Burnout: 
    A psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment. For physicians, this can mean feeling drained or being unable to cope with work, emotionally distancing themselves from their work, and having difficulty doing everyday tasks. 
  • Depression:
    A common and serious mood disorder lasting for at least two weeks that causes persistent feelings of sadness and hopelessness, along with a loss of interest in activities a person once enjoyed. Depression can also present with physical symptoms such as chronic pain or digestive issues.
  • Post-traumatic stress disorder:
    Recurrent, involuntary and intrusive distressing memories of a traumatic event. This can include dreams related to the event, dissociative reactions (flashbacks) in which the physician feels or acts as if the traumatic event is happening again, and intense or prolonged psychological distress when exposed to things that symbolize or resemble an aspect of the event.
  • Anxiety:
    Excessive, difficult-to-control anxiety and worry that occurs most days for at least six months and causes clinically significant impairment in social, occupational or other important areas of functioning. People with this kind of anxiety have three or more of the following symptoms:
    • Restlessness or feeling on edge
    • Being easily fatigued
    • Difficulty concentrating
    • Irritability
    • Muscle tension
    • Sleep disturbance (e.g., difficulty falling or staying asleep, unsatisfying sleep)
  • Persistent complex bereavement disorder (formerly complicated grief disorder): 
    An unusually disabling or prolonged response to the loss of patients, loved ones or co-workers. This disorder causes feelings of extreme and prolonged yearning for the deceased, accompanied by destructive thoughts and behaviours that make it difficult to resume normal life.
  • Compassion fatigue:
    The profound emotional and physical erosion that takes place when “helpers” (such as health care workers and caregivers) are unable to refuel and regenerate. When they work with clients who have experienced trauma, helpers often notice that their fundamental beliefs about the world are changed or possibly damaged due to the repeated exposure to traumatic material. 
  • Moral injury: 
    Psychological distress resulting from actions taken (or not taken) that violate a person’s moral or ethical code. For physicians, such actions might include feeling let down by having to work with insufficient resources or having to choose which patients receive life-saving resources when supplies are limited.
  • Ongoing mental health problems: 
    Some health care staff will possibly struggle for an extended time following a traumatic incident. 

How health care leaders can respond

Leaders can use the following practical tips and strategies to support the wellbeing of staff in both training and practice settings.

1. Provide daily basic resources 
Health care leaders should provide their teams with the following items for the duration of the crisis: 

  • Food (free or subsidized) and water
  • Personal protective equipment 
  • Childcare and eldercare resources
  • Transportation, parking and lodging
  • Physical activity resources
  • Command centres or other organizational decision-making bodies

Existing health and wellness programs should also be sustained.

2. Maintain regular, transparent and supportive communication
Organizations such as Anxiety Canada and the National Academy of Medicine emphasize the importance of communicating clearly, honestly and often during a crisis. This can include:

  • Providing staff with all of the relevant policies, procedures, resources, training and education so they are as prepared as much as possible for the traumatic experiences they may face 
  • Holding town hall meetings to announce and roll out new procedures, research findings, policies or processes
  • Normalizing the reactions staff experience so they don’t feel isolated
  • Staying in touch on a regular basis to address uncertainty and help staff work through grief, reconstruction, re-integration and recovery
  • Sending out weekly wellness messages
  • Holding debriefing sessions shortly after a procedure or at the end of the day — while events are still fresh in mind — to assess what the team did well and what they can do differently next time

Communication should also be two-way, with physicians encouraged to speak freely and openly about the stressors they face. An article in the New England Journal of Medicine recommends that health care leaders establish anonymous hotlines and other reporting mechanisms to allow staff to voice their concerns — and advocate for themselves and their patients — without fear of reprisal. 

3. Foster psychosocial and mental health
It is important to be proactive when it comes to mental health. You can promote and foster mental wellness during a crisis in a number of ways, such as:

  • Creating interactive recharge rooms (spaces for respite with meditative elements and relaxing lighting/music)
  • Reminding your staff that they are valuable and you are all in this together
  • Modelling support-seeking behaviour to encourage others to do the same
  • Reaching out to people in need
  • Facilitating peer support groups to foster team cohesion, including establishing a peer check-in system 
  • Facilitating visits from therapy dogs

The Center for the Study of Traumatic Stress also highlights the importance of providing grief leadership, when and where appropriate, which involves anticipating and acknowledging grief, using rituals to honour losses, and being visible and present to staff who need support.

Finally, make sure staff are aware of the physician-specific mental health services that are available through provincial physician health programs as well as national resources such as the: 

  • Wellness Support Line, which provides 24/7 bilingual counselling services to physicians, learners and their immediate families
  • Physician Wellness Hub, an online resource centre providing comprehensive, evidence-based wellness content and guidelines, including self-care resources
  • Wellness Connection, a virtual space where physicians and learners can access peer support resources (including weekly virtual group sessions)

Topics

Policies, standards and best practices Leadership and professional development Depression Peer support Self-care Burnout

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