Double pandemic, Dr Forte and the fork in our road

Ben Caesar

There are currently not one but two pandemics affecting healthcare workers. COVID-19 was preceded by the pandemic of burnout amongst doctors, nurses and allied health professionals. The coalescence of these two pandemics are compounding the risks to the wellbeing of all healthcare workers, particularly those on the frontline. However, it is possible that these two pandemics occurring simultaneously may offer us an opportunity to create a new working environment as we search for different ways to deliver medical care.

Double pandemic

Healthcare workers were already teetering on the brink of the burnout Abyss, but nevertheless, everyone rallied to the calls of their governments to help manage this unprecedented crisis. The physical, psychological and emotional strains have been recognised, and emergency measures have been put in place. These, however, have been haphazard and piecemeal crisis management. Any attempts to address the underlying causes of burnout have been relegated to the backburner. The short-term resilience of all members of staff has been exceptional but running on those high levels of adrenaline for many months at a time is unsustainable and takes an additional toll.

In the UK, the public’s initial overwhelming support, often compared to the ‘Blitz spirit’ of the 1940s, is slowly waning as the pandemic becomes part of normal day to day life. The easing of restrictions and the return to a semblance of normality is giving the patients the impression that normal service is resuming within the NHS. This couldn’t be further from the truth. Within orthopaedics, whilst trauma services continue, but in a less efficient manner due to the restrictions required as a result of the COVID-19 virus, elective operating is at a fraction of its previous levels.

The public are increasingly frustrated that their planned surgeries are still not happening and may not happen for many months to come. This is adding to the stresses on the clinicians who feel a sense of moral injury that they cannot provide the levels of service expected of them. Originally a military term, moral injury can be defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code. In the COVID-19 pandemic, many of us are having to live with uncomfortable decisions about the allocation of limited resources.

Greenberg’s article in the BMJ earlier this year highlights the risk of moral injury and burnout on frontline staff who have to struggle with the adversity of the current pandemic1.

Dr Forte

My unexpected journey into the world of physician burnout started on 25th June 2016, Armed Forces Day. I met a veteran in a wheelchair who was the secretary for my grandfather’s old regimental association. We got chatting and I asked him if his wheelchair use was as a result of an injury he’d sustained whilst in the Army. His reply was not unlike many soldiers, sailors and airmen that I would subsequently meet.

He could remember an incident when the trouble started, jumping from the back of a 10-ton truck, but, as is the way with service personnel in general, he just put the pain in his back out of his mind and carried on. Progressively his back pain worsened, and now retired and living off his pension, his back pain was so severe that he couldn’t walk and was forced to resort to a wheelchair to get around.

Having taken the gentleman’s details, I spent the following Monday calling around various contacts and investigating the Armed Forces Covenant. By close of play, I had organised a pain clinic appointment for him within four weeks and had started along the road to setting up the Chavasse clinic, a service I now run in Brighton for the MSK care of Service Personnel and Veterans. The clinic is unique in that I work in close partnership with a mental health specialist nurse from The Veterans’ Mental Health Transition, Intervention and Liaison (TIL) Service (formerly known as London Veterans’ Service (LVS)).

It was because of the significant number of veterans that I was seeing with PTSD and other mental health issues in conjunction with their MSK issues, that I needed to become more informed about the signs and symptoms of these disorders.

Post-traumatic stress disorder and burnout

As I began to learn more about PTSD, I wondered whether this was something surgeons might suffer from too. In fact, I discovered there were similarities between the signs and symptoms of PTSD and physician burnout but also significant differences, as shown in Table 1.

We conducted a study investigating levels of burnout in acute specialties in Brighton’s major trauma centre2. The results of our study using the Copenhagen Burnout Inventory demonstrated that 36.7% of physicians surveyed showed high levels of burnout. This was consistent with Shanafelt’s work with US surgeons using the Maslach Burnout Inventory which showed 40% of respondents had either a high emotional exhaustion score and/or a high depersonalisation score, and were considered burned out3 .

What was also apparent was that there were a significant number of physicians on the precipice of burnout, with a further 56.3% showing moderate levels of burnout and only 7% showing low levels of burnout. This gave a combined figure of 93% of respondents demonstrating either moderate or high levels of burnout. This study was different in its response rate of over 75%, compared to Shanafelt’s paper where the response rate was 32%.

Prior to its publication, this work was presented in 2019 in several meetings and had varied responses. For example, at CSOS, there were numerous questions from the senior members of the audience including the Surgeon General who asked if, as the senior member of the chain of command, whether he was putting his military personnel in harm’s way by sending them to work in the NHS.

By contrast, at the BOA, I was not asked a single question by the audience about my presentation. Afterwards, when I spoke to a friend who had also done significant work in this field and told him that no one had raised any questions about the paper or its implications, his response was, “As orthopaedic surgeons, we simply do not have the vocabulary to discuss this yet.” This wasn’t the first time I’d heard this.

The cost of burnout

A majority of doctors (80%) in a 2019 BMA survey were at high/very high risk of burnout with junior doctors most at risk. Burnout was driven mostly by exhaustion rather than disengagement from one’s role as a doctor.

Burnout, fatigue and work unit safety grade were independently associated with major medical errors4 .

In this paper, 54% reported symptoms of burnout, 32% reported excessive fatigue, and 6.5% reported recent suicidal ideation. 3.9% reporting a poor or failing patient safety grade in their primary work area and 10.5% reporting a major medical error in the prior three months.

The suicide rates among doctors were higher than those in the general population and among other academic occupational groups. The rate has been variably estimated at between two and five times the rate of the general population5-8 .

The relative suicide risk is higher amongst female doctors compared to men although the crude mortality rate is the same8 .

An estimated 4.6 billion USD were lost per annum as a result of burnout in the US9 .

NHS sickness rate hit record high during COVID-19 peak with more than 1 in 20 NHS staff days lost10 .

The fork in our road

With the help of two amazingly creative people, the writer, Regina Tingle, and the artist, Robin Smith, known for his work on Judge Dredd, we produced a comic strip to illustrate the dilemma of burnout in physicians – ’Dr Forte and the Abyss’. Through a dreamscape fantasy journey, we invited the orthopaedic community to engage with the all too often taboo subject of burnout.

Following the BOA congress in 2019, I was overwhelmed by the response I received from members of the audience, as clearly, I had touched on something. I’ve never before received fan mail via social media. The BOA was also incredibly supportive, and, after discussion with the President and the Secretary, we had planned to send out a questionnaire to the membership to assess the levels of burnout amongst orthopaedic surgeons in the UK. The questions were submitted for council approval just prior to my deployment overseas in January, and then, whilst I was away, we were struck by our second pandemic. COVID-19 arrived and changed our world completely.

There is room for optimism. If the organisational structure of healthcare delivery in the UK is reimagined for a post-COVID environment, and takes into account the need to optimise the healthcare workers’ physical, psychological and emotional health so that they may provide their very best for their patients, then we have an opportunity for post-traumatic growth as we enter the new normal. Sadly, if this opportunity is missed and there is a return to trying to squeeze more out of us in these difficult times, the burnout pandemic will escalate further with detrimental effects for patients, healthcare workers and the NHS. We are at that fork in the road and the route we choose to follow will have profound effects for years, maybe decades to come.

Currently, Prof Mansoor Khan and I are working on a further paper looking at what the military have learned about managing their service personnel’s psychological and emotional wellbeing in times of high stress and crisis, and how these tools can translate to the NHS environment. We hope that this may offer some guidance to those looking to manage the burnout pandemic where they work, and to help build a supportive working environment in their own departments for the benefit of their patients, colleagues and supporting staff.

References

References can be found online at www.boa.ac.uk/publications/JTO.