Preparing for the Next Pandemic, Today: A Call to Action

By Al’ai Alvarez, MD, and León D. Sánchez, MD, MPH, on behalf of the SAEM Wellness Committee

The latest Omicron surge pushed the emergency department (ED) infrastructure to limits we have never seen before. Our colleagues, and ourselves, became vulnerable to contracting this latest strain of COVID-19 virus not only at work but from everyday routines. We had to adapt quickly to this new set of challenges. Within two short weeks during the winter holiday break, significant numbers of our workforce contracted COVID-19. The CDC outlined new isolation measures to preserve the ability to provide care for the public.

As we braced ourselves for another unprecedented surge, it was heartwarming to see our emergency departments take on more deliberate efforts to address our well-being. We hope to learn from this and urge everyone to create spaces to discuss these experiences as we forecast the recovery phase of the pandemic.

Before the COVID-19 pandemic, so many of us pushed ourselves to extremes and never called in sick, regardless of our state of being. In contrast, during the pandemic, referring to Maslow’s hierarchy of needs, we saw institutions subsidizing or offering free hotel stays for physicians who contracted COVID-19 or had family members at home with COVID19 and needed to isolate themselves from them in order to avoid catching the virus. Some institutions even sent care packages and offered mental health support. These measures allowed the effected to convalesce, heal, and catch up on much-needed sleep. Centralized information during times of chaos was critical. Our department relaunched weekly “COVID Chronicles” to update faculty, staff, and trainees on the latest information on testing, isolation, and other lessons learned. We also set up virtual listening sessions and gatherings to foster a sense of community and share stories and experiences. These gatherings reminded us that two years into this pandemic, childcare continues to be challenging, and the burden of shouldering this problem falls on our colleagues who are parents and, disproportionately, women. Hearing about the stress and frustrations of others helped all of us to acknowledge the challenges many of our colleagues, mostly mothers, have been experiencing. Solutions were offered, such as creating pods to provide support and last-minute childcare, and a reminder from our medical director that the backup-call system is designed for emergencies (including last-minute childcare), helped mitigate the unrealistic expectations we held for ourselves. Our department also instituted shift forgiveness for the duration of the CDC five-day isolation period. It also helped to hear our leaders, including the chair, normalize expectations to mend and heal and take a break while on shift to clear our minds, grab a snack, and/or get some fresh air.

Taking Steps Toward Healing

Yet we need to think beyond these short bursts of support to the longer term. Here are suggestions from members of the SAEM Wellness Committee. We acknowledge that some of these suggestions may not

“Two years into this pandemic, childcare continues to be challenging, and the burden of shouldering this problem falls on our colleagues who are parents and, disproportionately, women.”

be realistic for your department, but we urge you to nevertheless have an open discussion with your leadership to allow for customization. We must start somewhere.

Beginning this July, consider offering one week off for each attending in the scheduling pool. Do not make this time off a part of the attending’s usual monthly clinical time complement (i.e., do not deduct the from the attending’s monthly allotment of shifts). This can serve as a small token of recognition for the 110% effort everyone has contributed since the beginning of the pandemic. We suggest doing this sequentially for however many faculty your emergency department schedule can accommodate per month. This signals to everyone that you hear their concerns, notice their exhaustion, and acknowledge that what they experienced was real and consequential, with long-term effects that need to be addressed.

This is just the first step to allow for healing. Most of us have yet to catch our breaths, let alone have time to process and accept the trauma we’ve endured and reflect on where we’re at and how far we’ve come. We need to be able to process our lived experiences, which is not unlike the posttraumatic stress experienced by combat personnel. The institutional provisions for safe, confidential, subsidized mental-health support are critical to this success.

Beyond these short-term solutions, we must acknowledge the need to reimagine how we practice in our specialty. The way we have practiced in our specialty is no longer sustainable. For years, many of us showed up to work sick, without ever considering calling in. Paternity leaves were not commonplace, which further put the onus on women to take care of their families at the cost of their advancement. Many of us do not even take breaks while working on shift. This must change.

Hard Truths and Tradeoffs

This will require open discussion about hard truths and tradeoffs, but after all, EM is all about maximizing how we use our limited resources. Here are other tangible examples to ponder: • What are realistic patients-per-hour metrics? • Is there enough time to do documentation on shift, or are people working unaccounted hours? • Do we build additional staffing to account for boarders? • Do we schedule enough people to allow for an actual time break on shift? • How many shifts a month should be considered full-time? • What are optimal hours even when there are no other academic responsibilities? • Should there be financial incentives for evenings, nights, weekend shifts? • At what age should we stop doing overnight shifts? • Should we pay for call systems to cover emergency absences?

These proposed solutions will come at a cost, but we must be willing to discuss the tradeoffs (e.g., seeing fewer patients, having a lunch break, having real vacation time, etc.) even if it means being paid less. Salary cuts should not be on an individual basis either; instead, investments must be reallocated with calculated risks and benefits of prioritizing well-being. We believe that generational differences in some of these solutions need attention and customization. While there is no one-size-fits-all solution for any group, we need to come together to understand and discuss our limits and boundaries and make explicit what we are ready to sacrifice. As EM physicians, we have risen to every challenge that has come our way. For as long as our specialty has existed, we’ve worked under the belief that “If no one else will do it, we will.” This includes initiating Buprenorphine in the emergency department, boarding psych patients, etc. At some point, we have to say, “no.”

Every time we take on a new task without getting additional resources, we degrade both the patient and clinician experience in the emergency department. We have accepted hallway care, boarding, and a litany of other tasks because no one else was willing to. Questions such as “Is this the best for our patients,” alongside “Who will take care of us?” should be included in any conversation on reform. We cannot continue to provide a patch to a broken system fueled only by our sense of responsibility and can-do attitude as emergency medicine physicians.

We can learn from our first responder colleagues, especially the Fire Department of New York (FDNY). Three to four percent of the FDNY workforce died on 9-11. After the search and rescue subsided, we heard these familiar narratives: “I just can’t. I’m done. I have nothing else to give.” FDNY retirements in the first six months of 2001 were 274; in the first six months of 2002, 661 retired.

In the next five years, how will our specialty handle another pandemic, another local disaster, or the 15th surge of COVID-19? Without intentionality for healing, we could see mass resignations not unlike what we are now witnessing outside of our specialty. Worse, we could see a rise in deaths by suicide.

We don’t want another empty “thank you.” We want actions to show that leadership, and we, acknowledge our lived experiences. We need to discuss a future work environment that promotes longevity and healing. What got us here will not sustain us. In the long run, we must adapt to preserve our specialty and our wellbeing. The time for change is now.

ABOUT THE AUTHORS

Dr. Alvarez is clinical assistant professor, department of emergency medicine, and director of well-being, Stanford University School of Medicine. @alvarezzzy

Dr. Sánchez is associate professor of emergency medicine, Harvard Medical School and chief, emergency medicine, Brigham and Women’s Faulkner Hospital, Boston, MA.