VOLUME 33, ISSUE 1

This year ushered in unforeseen circumstances that challenged our practice methodologies, our resolve, and our psychological soundness. It began in December 2019 when a new virus emerged and rapidly spread across Wuhan, China. The virus was a coronavirus that was linked to a severe and rapidly spreading respiratory disease. The World Health Organization declared the outbreak a public health emergency of international concern. By January 2020 this disease appeared in the United States and was a full-fledged pandemic by mid-March.1

This novel new corona virus, now commonly referred to as COVID-19, leads to the clinical manifestation of severe acute respiratory syndrome caused by the corona virus (SARS-CoV-2). The virus is transmitted from person to person primarily through respiratory droplets.1 The only information we initially had was that symptoms typically appear between 2-14 days after exposure to the virus and can include fever, chills, cough, shortness of breath, fatigue, body aches, headache, sore throat, congestion, nausea, vomiting, diarrhea, and the loss of the sense of taste or smell, with the latter being the most distinguishing symptom from influenza (the flu) or the common cold. Initial recommendations promoted hand washing, covering one’s mouth when sneezing or coughing, social distancing, travel restrictions, commercial and educational lockdowns, and facility closures.

By March, COVID-19 was a clearly a public health crisis in the United States, prompting many governing bodies to issue stay at home orders and school closures and the recommendation for quarantining of symptomatic individuals. A stay-at-home order was issued by the Governor of Texas for the time period of March 31st until April 30th. Healthcare was considered an essential service, thus hospitals and clinics remained open. It was during this time that the term “essential worker” became a common term in our daily conversations. While other businesses and industries were able to offer some sense of protection for their employees by having them work from home, healthcare workers experienced no such luxury. There was consensus that the protection of healthcare workers was of the utmost importance, however many hospitals and clinics did not have an adequate stock of personal protective equipment (PPE). The PPE items that proved to be in the most critical short supply included surgical masks, N95 masks, disposable gowns, and even gloves during the early portion of the pandemic. This ill-preparedness had a profound negative impact on the morale of anesthesiologists. Complicating matters further, evidence was lacking regarding which masks were most effective. Many physicians felt that we should use the same protective equipment that healthcare staff in China had been publicized using: N95 respirators, disposable gowns, gloves, surgical hats, and in some cases, hazmat suits. There was a general sense of panic when it became painfully obvious that most facilities could not offer these supplies readily to all who wanted/needed them. Many media outlets reported widespread mask, glove and cleaning supply shortages and commented about the great lengths people were taking to acquire these supplies from unregulated online suppliers.

Initial recommendations to stay isolated at home in order to prevent the spread of COVID was so effective that it caused many people who may have actually needed to seek medical care to remain at home instead of seeking care. Research in Michigan showed that many children missed their well-child and vaccination appointments.2 Communities that have a decrease in percentage of vaccinated people could be vulnerable to diseases such as measles and pertussis in the future. Some have claimed they would rather have COVID than continue living with strict precautions for the next several months. This sentiment has contributed to public disregard for mask mandates and social distancing initiatives.

Statewide gubernatorial support came in the form of an executive order from the Texas State Governor. On March 22, 2020 Governor Abbott issued an order that directed all health care professionals to “postpone all surgeries and procedures that are not immediately medically necessary to correct a serious medical condition of, or to preserve the life of, a patient who without immediate performance of the surgery or procedure would be at risk for serious adverse medical consequences or death, as determined by the patient’s physician.”2 This was in an effort to preserve rapidly depleting supplies of PPE needed to address the COVID-19 pandemic. This was updated on June 25th to clarify that surgeries may proceed if they will not deplete hospital capacity needed for COVID-19 patients. While this direction was helpful, many questions remained. What alternatives to traditional PPE could safely be used when traditional supplies were exhausted? Was it ok to obtain PPE from unregulated sources outside of the hospital/clinic, such as from online markets? How should we proceed if we developed symptoms? How long does one have to be symptomatic until they test positive for COVID-19? For many anesthesiology groups, the availability of COVID testing for themselves proved challenging. Employers were faced with the dilemma of limited test availability compounded by the fact that employees who were under suspicion for having the disease would no longer be available to provide care for the patients in the hospital. There were certainly varying opinions on which employees should be tested and reliable guidelines do not exist to provide consistent guidance on how best to proceed.

The healthcare industry has been facing a catastrophic event that it was grossly unprepared for. This has created heightened anxiety and stress amongst anesthesiologists because the crux of our scope of practice necessitates close face to face contact. We are fighting on the front lines while simultaneously worrying about protecting the health and wellness of ourselves, our families, our colleagues, and our patients. It is not uncommon to perceive failures in adequate protection of healthcare staff as too great of a risk for us and our colleagues. Many have expressed frustration with perceived delays in their institution’s handling of the pandemic, including delays in mandating patient COVID-19 testing prior to procedures, recommendations on when symptomatic staff can continue to present to work, mandated vacation usage when ill or when quarantining (which some fear may contribute to underreporting and compound exposure risk), furloughs, and pay cuts. Personally, the authors are thankful for the swift response by Dr. Luis Ostrosky-Zeichner, Professor of Medicine and Epidemiology, and Vice Chair of Medicine for Healthcare Quality at UTHealth Houston. Dr. Ostrosky and his team have held virtual Infectious Disease (ID) rounds disclosing the latest Centers for Disease Control guidelines throughout the pandemic. They have given departmental grand rounds presentations (two specific for the Department of Anesthesiology) and continue to release a weekly digest of current COVID-19 guidelines and breakthrough information. In addition, the University of Texas Houston Department of Anesthesiology created a COVID taskforce focused on mobilizing PPE supplies, proffered respirators for all anesthesia faculty and residents, created protocols for intra-operative management of COVID patients, and provided resources and regulations for faculty at increased risk for COVID related complications secondary to age, pre-existing conditions, etc.

Physicians fighting on the front lines for months during this unprecedented public health crisis have been susceptible not only to illness but to psychological stress. It is now known that older adults (over 65) and people who have severe medical conditions like diabetes, heart disease, lung pathology, or immunosuppression are prone to develop more serious complications from COVID-19 illness. Many were unsure of how best to proceed in order to keep susceptible employees safe. Should age restrictions be placed on anesthesiology faculty who will have direct contact with patient airways? If they are excluded from certain activities, how long should this last? How high is the risk? What should the return to work criteria be for physicians who contract COVID-19? What should physicians with underlying health conditions do to protect themselves and their family members? How can their departments support them? Should they be allowed to use Paid Time Off/sick days to limit contact with patients? We are aware of some colleagues who did just that during the height of the pandemic. While some may argue that this could lead to widespread staffing shortages, there is the additional concern that a physician who is not themselves well cannot adequately care for patients.

Many physicians have made the difficult decision to retire or close their practices due to the stress and burnout that has come with the pandemic. Several sources show data that 6% of practices have closed, with possibly more to follow by the end of this year. A TMA survey showed 68% of physicians in Texas have had fewer hours of work and 62% of Texas physicians had experienced a pay cut as of May.2 Physicians cite various reasons for practice closure ranging from decrease in patient volume, concern for their own health, and even a need to care for their grandchildren, as many daycares around the country have closed. Some have saved their practices with unconventional means such as a GoFundMe page.2 Some well-established practices are able to stay afloat with savings from previous successful years.

As the one-year anniversary of this pandemic in our country approaches, the “COVID fatigue” has begun to set in.3 This new hurdle will continue to challenge our emotional wellbeing. We have seen the American people move through stages of a disaster: first, banding together as a community, next, the current stage of disillusionment and exhaustion. The general public’s desire for life to return to normal has resulted in more lax social distancing and less mask wearing. This unfortunately increases healthcare workers’ exposure to the virus as we continue to work through waves of this pandemic. For most of us, the initial waves of the virus found us taking extra precautions to keep ourselves, our families, and our patients safe. We purchased personal respirators and some of us isolated from family, even at home. As time goes on, those of us who have successfully avoided the virus or have had a mild case, tend to also have mask fatigue, often resulting in less vigilant PPE usage.

Ultimately the COVID-19 pandemic is not only a public health concern, but an ethical crisis for physicians. Increased stress has led to increased symptoms of burnout which can result in reduced availability and quality of care rendered. Healthcare worker burnout is characterized by mental and physical exhaustion, depersonalization, lack of self-worth, or disconnection from work or colleagues. The prevalence of burnout among anesthesiologists was already on the rise with 50% of anesthesiologists reporting symptoms of burnout in a 2016 Medscape Lifestyle Report.4 Anesthesiologists complained of loss of enthusiasm for work, feelings of cynicism, and low sense of personal accomplishment. Burnout can also manifest as exhaustion and disengagement.5 The COVID-19 pandemic and the inherent confusion on policies that go along with any new viral pandemic can be expected to compound the problem the preexisting burnout issues. Furthermore, burnout can lead to increased risk of alcohol and drug abuse, depression, suicidal ideation, and posttraumatic stress disorder. This can have disastrous effects not only on physicians and their families but can directly impact the quality and safety of patient care rendered. The American Medical Association’s Code of Ethics states that physicians have a responsibility to maintain their own health and wellness, to promote the health and wellness of colleagues, and to preserve the quality of their performance, because physician wellness directly impacts patient care.

It is imperative that healthcare organizations, hospitals, and departments are aware of this problem and are proactive in mitigating stress and burnout among their physicians. This is the time to focus efforts on physician wellness programs. Our institutional home, UT Health Science Center at Houston, has created a UT Physician Burnout Taskforce to identify and address sources of burnout on our campus. In addition, our Department of Anesthesiology has a Wellness Committee that is actively engaged in identifying sources of departmental stress/burnout and creating solutions to mitigate the problem. Finally, Dr. Ekeoduru created the Perioperative Anesthesia-Crisis Response Team (PART), designed to assist faculty and residents in times of professional crisis with a goal to reduce work-related stress and burnout. Specifically, physicians are given the opportunity to discuss case-specifics that contributed to poor outcomes, they are supported in preparation for root cause analysis reviews, and they are connected with risk management and legal assistance when necessary. Additionally, they are educated on specific support tools offered by the UT Employee Assistance Program.

In addition, we encourage physicians to prioritize self-directed stress relief initiatives by taking advantage of numerous online aids such as Nike training club, Headspace, and the Calm app to name a few of the free (at the time of publication) options. Anesthesiologists can also engage in journaling, mindfulness exercises, meditation (one of the authors swears by the Peloton meditation classes), yoga, and other forms of exercise. Anesthesiologists can also seek spiritual support and healing, since many religious organizations are offering virtual worship opportunities. Lastly, physicians can inquire which supportive programs are available via institutional employee assistance programs. As an example, UTHealth Houston employee assistance program offers confidential free counseling and WorkLife services to help employees balance the demands of personal and professional life. It is imperative that we maintain our personal health and wellness to protect the vitality of our specialty.