On the last Sunday of April, a top-notch emergency room doctor in Manhattan, New York City, the United States, decided to end her own life. The tragic death of Lorna Breen was fueled by a series of traumatic events she had to face amid this pandemic.
While relentlessly battling on the frontline, her family members said that the sight of dying patients left and right, many of whom could not even be transferred from the ambulance, had left her broken. At the time of her death, Breen was in recovery and had just returned to practice after contracting COVID-19 the previous week.
This story could happen to any healthcare provider who puts their life on the line today. Suicidal thoughts are not uncommon among depressed individuals, as burnout is not new among physicians.
Physician burnout is defined as a work-related syndrome that leads to emotional exhaustion, signs of depersonalization and reduced self-accomplishment. Assessment of physician burnout is conducted through a validated survey tool called the Maslach Burnout Index (MBI). In the US where physician-burnout phenomena are more widely studied, identified contributors include total working time, administrative workload and individual factors such as work-home conflicts.
Adding COVID-19 to the cocktail creates unprecedented stress among the physician community. A shortage of medical supplies, unfamiliarity with the crisscrossing new evidence, uncertainty about the extent of disease spread and fear of contaminating their loved ones are a few of the many potential triggers.
Since personal protective equipment (PPE) is scarce, medical staff often have to endure wearing such equipment for their entire shift. Apart from the general discomfort from layering, reports on COVID-19 PPE-related skin damage are increasing. Collectively, burnout leads to an increased risk of major medical errors, low productivity and depression that are detrimental to the physicians and the patients they serve.
The deaths of at least 25 Indonesian doctors so far have been attributed to COVID-19 and many have to self-isolate because of the exposure or as a result of showing symptoms. Apart from the high risk of falling ill from direct exposure to the coronavirus, some of the often-overlooked burden for the doctors is the psychological frailty from burning out. In the pre-pandemic era, the Indonesian healthcare system was already overburdened by the patient load, overstretched medical infrastructure and a flawed national payment scheme.
The doctor-to-patient ratio in Indonesia is approximately 0.4 per 1,000 population in 2017, among the lowest in Southeast Asia according to the World Health Organization. As the pandemic accelerates without yet reaching its peak, Indonesia’s health system will continuously be overwhelmed by infectious individuals needing testing and care.
Resident physicians are among the most vulnerable to developing burnout. Published studies on physician burnout in Indonesia have been conducted among residency training programs. For instance, pediatrics and anesthesiology programs in two different centers in Bandung, West Java, were found to have depression and burnout rates as high as 23.9 percent and 44 percent, respectively.
However, the percentage of burnout during this pandemic is predictably beyond baseline. As juniors who are default volunteers during COVID-19 era, the resident doctors often must work long hours in order to meet patient needs, carrying academic responsibilities, dealing with administrative paperwork and reporting to their supervisors.
Unlike fellow residents from other countries such as the US and Australia, and even our closest neighbors such as Singapore and Malaysia, Indonesian resident physicians are the only ones who must pay their own tuition and are essentially unpaid. This situation creates insecurities and is psychologically far from ideal to begin with. Without safeguards from potential health and economic impacts, it is also unclear whether financial relief offered by the Indonesian government includes compensation for resident doctors.
Many healthcare providers are still facing difficulties in accessing their right to get tested whenever indicated.
The need to address this issue is urgent since any hope of an end to the war remains bleak. Scientists recommend measures at all levels. At the individual level, physicians must remind themselves that practicing self-care is part of medical professionalism. At the institutional level, the length and number of shifts should be adjusted accordingly to allow adequate recovery time for each member of medical staff.
Since many elective surgeries and non-urgent medical appointments are being put on hold, repurposing the personnel to COVID-19 posts should be considered. Unnecessary administrative work should be cut out, and when possible, those working from home could help remotely through encrypted electronic medical records to reduce hospital time. Importantly, evaluating burnout should be done to provide supportive care before it becomes too late.
The government needs to be engaged in different facets. Transparency is key to instilling trust among the public and healthcare workers. Prioritizing an adequacy of medical supplies and protective equipment will provide a sense of safety.
Many healthcare providers are still facing difficulties in accessing their right to get tested whenever indicated, an alarm call that means the government needs to ramp up the gold-standard testing on an even bigger scale.
Some local governments have offered support to medical practitioners through local initiatives. In Jakarta, hotels near hospitals are provided to minimize commuting and to reduce the risk of infection for family members. In West Java, Governor Ridwan Kamil has shown his progressiveness in increasing the polymerase chain reaction (PCR) testing capacity, updating real-time mapping and pushing industries to produce locally made PPE.
More importantly, the authorities have to prepare adequate infrastructure and public health preparedness for the next wave of the pandemic. For all we know, this will not be the last.
People can also help as social pillars to take care of the caregivers within their capacities.
Obeying the policy on social distancing is vital to contain the virus spread and to prevent the overwhelming of hospitals. Many social movements have shown positive signs of solidarity toward physicians and their teams. Fundraising to distribute PPE, new production of ventilators for intensive care units, bulk supplies of vitamins and food supplies from local businesses are directly and indirectly helpful in supporting physician wellbeing.
We cannot afford to lose another Dr. Breen before our eyes. The increased degree of physician burnout has now emerged as a global crisis that we need to address and intervene to stop. In the case of a prolonged pandemic, having dysfunctional frontline staff will certainly obstruct any economic and public health endeavor that we pursue in the long run.
Graduate student researcher at Boston Children’s Hospital and master’s in medical sciences in immunology candidate at Harvard Medical School. The views expressed are personal.
Disclaimer: The opinions expressed in this article are those of the author and do not reflect the official stance of The Jakarta Post.