Building community during the COVID-19 pandemic: a system level approach to physician well-being
Serena Siow, MD, Carmen Gittens, BMBS, Janet M. de Groot, MD
Before the COVID-19 pandemic, physician burnout was identified as reaching crisis proportions, and the pandemic is expected to worsen the already perilous state of physician wellness. It has affected physicians’ emotional health, not only by increasing workload demands, but also by eroding resilience under increasing pressures. The mental health consequences are expected to persist long after the pandemic subsides. With physician wellness increasingly recognized as a shared responsibility between individual physicians and the health care system, system-level approaches have been identified as important interventions for addressing physician well-being. In this article, we describe two evidence-guided initiatives implemented in our hospitalist network during the current pandemic: a trained peer-support team and facilitated physician online group discussions. These initiatives acknowledge the emotional strain of physicians’ work and challenge the “iron doc” culture of medicine. Our efforts build community and shift culture toward improved physician wellness. We suggest that the pandemic might be an opportunity for our profession to strengthen our support networks and for physician leaders to advance physician wellness in their work environments.
CITATION: Siow S, Gittens C, de Groot JM. Building community during the COVID-19 pandemic: a system level approach to physician well-being. Can J Physician Leadsh 2021;7(4):166-170 https//doi.org/10.37964/cr2474
Physician wellness in peril
Before the COVID-19 pandemic, physician burnout was already identified as reaching crisis proportions. In 2018, 30% of Canadian physicians reported high levels of burnout and 8% reported recent suicidal ideation.1 The adverse psychological impact of COVID-19 predicts worsening of the already perilous state of physician wellness. Health care workers providing care to patients with COVID-19 experience increased mental health symptoms, including depression, anxiety, insomnia, and distress.2 A recent Canadian Medical Association survey shows high levels of anxiety and increased fatigue among physicians one year into the pandemic.3 The chronicity of the pandemic threatens physician resilience as strain accumulates over many months. Concerns about worsening post-pandemic burnout and post-traumatic stress disorder exist, and the mental health consequences of the pandemic are expected to persist long after the pandemic subsides.4
Emotional impact of health care work
The emotional burden associated with health care work is heavy, and there are many real and perceived barriers to seeking help. Physicians have individual emotional responses to clinical experiences. The nature of the work is demanding, often wrought with uncertainty and the pressure of high-stakes decisions. Physicians routinely witness suffering, death, and grief. They are prone to secondary trauma and have been called the “second victims”’ of medical errors and adverse patient events.5 Furthermore, there is a long-standing “iron doc” culture of medicine where physicians uphold stoicism and perfectionism to prove competence. As a result, they may come to deny and minimize their feelings to avoid emotional distress. Top
The pandemic has added layers of complexity to providing patient care, while also eroding factors that maintain resilience under pressure. Relentless workload demands and the continuous flow of patients without moments of reflection can be barriers to processing emotions and grief. Furthermore, physicians feeling distress may feel alone in their experiences, especially in a culture that denies or minimizes the importance of recognizing one’s own emotions. The pandemic has furthered social isolation, with many physicians providing virtual care from home or working in different settings than usual. Adherence to public health recommendations has led to physical and social distancing from colleagues, friends, and support networks. Unfortunately, the stigma against physicians seeking help for emotional concerns is pervasive, with shame and fear often preventing those needing help from seeking it.
Left unchecked, attempts to cope using dysfunctional mechanisms can have detrimental effects on emotional well-being. Prolonged detachment, for example, potentiates cynicism, depersonalization, and burnout. “Working harder” can take the place of dealing with internal turmoil and exhaustion. Feeling isolated, some may become “hyper-independent” doing multiple tasks themselves, adding to the sense of isolation. Keeping busy and helping others provides distraction and avoidance from self-connecting. Failing to address emotions and grief compounds chronic stress and drives burnout. Burnout is associated with disrupted personal relationships, addictions and substance use disorders, and death by suicide.6-8 Meanwhile, patients suffer from decreased quality of care, increased medical errors, and poor outcomes.9,10Top
System approach to emotional and social support
Physician wellness is increasingly recognized as a shared responsibility between the individual physician and the system.11 Previously, physicians were expected to manage the demands of medicine through personal strength and resilience alone. Recently, 83% of Canadian physicians reported high levels of resilience1 and physicians demonstrate higher resilience compared with the general population.12 Recommendations to improve physician wellness often emphasize the need for greater personal resilience. However, system approaches to wellness show greater benefit than efforts targeted at individual physicians.13
Having a sense of community at work is a priority for physician wellness, particularly during a crisis. Social support during a pandemic lowers stress and anxiety, and improving support is critical to well-being.14 A randomized trial showed that connecting with physician colleagues improves engagement and reduces burnout.15 Physicians are more willing to seek support from fellow physicians than from formal assistance programs or mental health professionals.16 Physician support is thought to be the most effective support system, as “peers have the unique qualification of having ‘been there’; experiencing similar stressful situations… in the past.”16
Sharing experiences with colleagues was identified as a factor associated with resilience after adverse events.17 Relating to others enriches our lives in various ways: “groups that provide us with a sense of place, purpose, and belonging tend to be good for us psychologically. They give us a sense of grounding and imbue our lives with meaning. They make us feel distinctive and special, efficacious and successful. These effects can buffer wellbeing when it is threatened.”18 Viewing experiences as a collective “we” instead of as an individual “me” supports resilience and well-being. Top
Initiatives developed during the pandemic
Our hospitalist team of 170 physicians provides care to a large proportion of COVID-19 patients in Calgary hospitals. An assessment of Calgary hospitalists revealed that emotional and social connections were important to maintaining a sense of community at work during the pandemic; therefore, members of our team quickly developed a system-level approach to support physician wellness based on social and emotional support. These strategies included trained peer support and facilitated online group discussions. Top
We launched a peer-support team to support our hospitalist colleagues during difficult times. Well Doc Alberta provided training and guidance, with 21 family physicians attending a 4-hour training workshop to build empathetic listening skills, identify supplemental resources, and recognize when a peer may be at risk of harming self or others. Peer-support team members volunteer to support their colleagues with any issue at any time: for example, work-life imbalance, adverse events, workplace inequity, personal conflicts, financial concerns, professionalism matters, or career track indecision. A list of provincial resources was distributed, including contact information for the Alberta Medical Association Physician and Family Support Program. Psychological safety was preserved by asking peer-support team members to track the number of contacts and general category only. This initiative challenges the stigma associated with asking for help, recognizing that we all need help at some point in our careers.
Six months following initiation of the peer-support program, five formal contacts and multiple (over 40) informal contacts were reported. An anonymous survey conducted at the same time showed that knowing peer support is available supports the well-being of 83% of the hospitalist physicians who responded. Top
Physician group discussions
We created an online space — called Virtual Doctors’ Lounge — for physicians to connect with each other, share experiences, and maintain resilience. Group discussions explore the emotional impact of practising medicine and support recognition that we are not alone in our challenges. We discuss coping strategies and explore solutions to system issues. This preventative approach to recognizing day-to-day stress mitigates chronic stress and might keep physicians from reaching crisis states. Discussions are facilitated by psychiatrists and mental health clinicians.
Our pilot sessions with hospitalists (n = 12) reported increased connection and less distress, with 92% willing to attend again. We completed our second phase with Calgary physicians of all specialties and are planning a next phase. Top
We build community through initiatives that bridge informal support (e.g., hallway conversations) and formal support (e.g., provincial physician health program). We each have the responsibility of normalizing the emotional strain of our work while challenging the existing “iron doc” mindset. Seeing ourselves as the “imperfect but good doctor” involves compassionate awareness of our own experiences, so that we can connect meaningfully with our colleagues. As a culture, acknowledging our humanity while practising medicine may eliminate the stigma attached to seeking help. Further, allowing oneself to be vulnerable in communities of practice has the potential to support personal growth and greater resilience.19
Our initiatives allow physicians to share experiences without fear of judgement and acknowledge lived experiences with mental health, bias, and microaggressions. We promote civility and compassion for each other and, above all, acceptance as human beings. Fostering a sense of community moves us from isolation toward connection. The existence of our system-level initiatives enhances visibility of physician wellness as a priority and accelerates culture change. Top
Our views align with physician leaders who believe that targeting culture change is necessary to advance physician wellness. We experienced the benefits of strategies to support physician wellness through peer support and facilitated online discussions. We recognize the limitations of using these approaches alone and emphasize that these are only two of many strategies in our comprehensive framework to improve physician well-being. We also advocate strategies that improve practice efficiency, address workload demands, and advance wellness as an organizational priority. Nevertheless, we believe that a system-level approach to offering social and emotional support builds community and culture change. Nurturing our capacity for connection advances an ideal medical culture that promotes compassion and supports physicians as human beings. The pandemic is an opportunity to strengthen our support networks and do better than merely survive. With social and emotional support from our colleagues, we hope for progress toward positive growth and improved well-being, together. Top
1.CMA National Physician Health Survey — a national snapshot. Ottawa: Canadian Medical Association; 2018. Available: https://tinyurl.com/svm22e4f
4.Veldhuis CB, Nesoff ED, McKowen ALW, Rice DR, Ghoneima H, Wootton AR, et al. Addressing the critical need for long-term mental health data during the COVID-19 pandemic: changes in mental health from April to September 2020. Prev Med 2021;146:106465. https://doi.org/10.1016/j.ypmed.2021.106465
7.Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, et al. Special report: suicidal ideation among American surgeons. Arch Surg 2011;146(1):54-62. https://doi.org/10.1001/archsurg.2010.292
8.Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res 2014;14:325. https://doi.org/10.1186/1472-6963-14-325
13.Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med 2017;177(2):195-205. https://doi.org/10.1001/jamainternmed.2016.7674
14.Rambaldini G, Wilson K, Rath D, Lin Y, Gold WL, Kapral MK, et al. The impact of severe acute respiratory syndrome on medical house staff: a qualitative study. J Gen InternMed 2005;20(5):381-5. https://doi.org/10.1111/j.1525-1497.2005.0099.x
15.West CP, Dyrbye LN, Rabatin JT, Call TG, Davidson JH, Multari A, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014;174(4):527-33. https://doi.org/10.1001/jamainternmed.2013.14387
16.Hu YY, Fix ML, Hevelone ND, Lipsitz SR, Greenberg CC, Weissman JS, et al. Physicians’ needs in coping with emotional stressors: the case for peer support. Arch Surg 2012;147(3):212-7. https://doi.org/10.1001/archsurg.2011.312
19.Delgado J, Siow S, de Groot JM, McLane B, Hedlin M. Towards collective moral resilience: the potential of communities of practice during the COVID-19 pandemic and beyond. J Med Ethics 2021;47(6): 374-82. https://doi.org/10.1136/medethics-2020-106764
We thank Dr. Jane Lemaire, Alicia Polachek, and the Well Doc Alberta team for providing training and guidance to develop the Calgary Hospitalist Peer Support Team. We thank Dr. Brienne McLane, Dr. Leanne Owens, and Linda Goddard for their involvement and contributions to the Virtual Doctors’ Lounge initiative.
Serena Siow, MD, CCFP, is a family physician, hospitalist, and physician leader in Calgary. She is a clinical assistant professor in the Department of Family Medicine, Cumming School of Medicine, University of Calgary. Since writing this article, she has become deputy section chief for medical inpatients, Department of Family Medicine Calgary Zone, Alberta Health Services. She has a special interest in wellness coaching.
Carmen Gittens, BMBS, CCFP, is a family physician and hospitalist in Calgary. She is a clinical lecturer in the Department of Family Medicine at the Cumming School of Medicine, University of Calgary.
Janet M. de Groot, MD, FRCPC, is a psychiatrist at the Tom Baker Cancer Centre and Foothills Medical Centre in Calgary. She is a professor in the Departments of Psychiatry, Oncology and Community Health Sciences at the Cumming School of Medicine, University of Calgary.
The opinions expressed in this article are the authors’ own and do not represent those of their institutions or organizations.
No funding was received for the submission of this article. The Calgary Hospitalist Governance Association provided funding for a physician wellness survey and peer support training.
Dr. Siow conceived and drafted the article. Drs. Gittens and de Groot made substantial contributions through multiple drafts and revisions. All authors contributed critical intellectual content, gave approval for the version submitted for publication, and agree to be accountable for all aspects of the work.