In summary, we found that burnout across frontline specialties increased between early 2020 (near the onset of the Covid-19 pandemic) and June 2022. Frontline physicians reported exhaustion (the effects of which appeared to be cumulative), demoralization resulting from inadequate staffing, and perceived inadequacy of administrative efforts to mitigate problems. Another source of professional stress was patient anger fueled by polarization. System-level workplace support interventions outside of pandemic control interventions and improved telehealth functionality were relatively infrequent. Mitigating factors associated with lower odds of burnout included working in critical care, longer experience since residency and workplace provision of improved telehealth functionality. Respondents placed highest priority on workplace interventions to increase financial support and increase nursing and clinician staffing.
The COVID-19 pandemic challenged the American healthcare delivery system and degraded the health and wellbeing of U.S. physicians. Beyond the risk of death and severe illness attendant to working in healthcare settings, particularly before vaccines were available, high pandemic-related workloads and personal stressors have taken a continued toll on the emotional and psychological wellbeing of healthcare workers. Our findings of increased burnout among US frontline physicians are consistent with other research. A national survey of physicians in the United Kingdom (UK) found that 47% experienced a decline in mental health and 34% experienced a decline in physical health since the pandemic began.15 A similar study of family medicine physicians in the United States and Canada found high levels of depersonalization (36%) and emotional exhaustion (67%).16 A national survey of emergency room physicians in Canada found that while 84% reported negative emotions, such as anxiety or fear, most did not seek mental health support.17 These findings are especially concerning in light of the already high levels of burnout and emotional exhaustion among physicians that preceded the pandemic.
In the study by Linzer et al., U.S. physicians and advanced practice clinicians experienced increasing rates of burnout throughout the pandemic.4 Consistent with the JDR model, lack of control over work and a fast-paced, chaotic environment were associated with more burnout, whereas mitigating factors such as feeling valued and experiencing good teamwork were associated with less. These findings are consistent with comments by some primary care physicians in our survey who described the benefits of belonging to strong teams with a sense of camaraderie.
There is concern that increasing burnout will result in early retirements, further contributing to the clinician workforce shortage18–20, though data on physician retirement rates in the US during the pandemic are lacking. Our finding that longer experience in practice was associated with lower odds of burnout is consistent with a survey of family physician educators.16 It suggests that workplace support interventions directed to the needs of younger physicians will be important to sustain the physician workforce.
The CDC, AMA, and Joint Commission on Accreditation of Hospitals (Joint Commission) among others made recommendations on supporting healthcare workers during the pandemic.21–23 Our study directly solicited the priorities for workplace support from frontline physicians. It is clear from our respondents that system-level interventions are needed to improve staffing, increase compensation (which may add both material and symbolic value), and build effective teams. Workplace interventions directed at individual wellness may have benefits for some individuals but are perceived by other as attempts to transfer responsibility for system-level problems to individuals. Yoga classes, meditation apps, and peer counseling, commonly offered by health systems, are not perceived as solutions to the critical system-level challenges contributing to burnout.
In terms of the JDR model7, interventions are needed that increase resources that are functional in achieving work goals, reducing job demands, or stimulating personal growth through work. It is striking that improved telehealth functionality, a system-level intervention that fits this resource definition, was associated with lower odds of burnout. Interventions that provide an avenue for physicians to change burdensome aspects of the EMR or to suggest other workplace improvements have been piloted.24
Intervention research is needed to evaluate the potential benefits of system-level changes. Cluster-randomized trials, regression-discontinuity designs, or step-wedge designs could evaluate the impact of interventions to build effective teams and innovative staffing models. Interventions that enable physicians to devote 20% of their medical practice to a part of their work that is especially meaningful to them have been suggested to be effective.25 Policy changes, including nurse to patient ratios (which may impact physician workload) and work hour limits and/or workload limits for physicians also deserve further research.26,27
We sampled the physician specialties we considered most likely to care for patients infected with COVID-19, hence the perspectives of other specialties were not represented. Our findings may also be limited by the low response rate; however, a comprehensive sampling frame enabled weighting of responses to enhance the representativeness of the respondents to the population of frontline physicians. Our results represent frontline physicians’ perspectives on what workplace support interventions were implemented and what is needed going forward. While health system administrators might tell a different story, the perspectives of the potential recipients of workplace support interventions are key.
Although some impacts of the pandemic on health systems and physicians may be attenuating as the high rates of hospitalization and death due to COVID-19 have decreased, physician burnout and effective workplace interventions to mitigate burnout remain important areas for research. A concern before the pandemic, physician burnout will remain a challenge going forward. Future pandemics and other serious challenges to the delivery of health care are likely, and implementation of what we learn through research about workplace interventions to support clinician wellbeing will enhance the resilience of both individuals and health care systems.