From the Editor
As we come to understand the new normal – a world of PPEs and precautions – we need to consider not just the implications of the virus on today’s work, but tomorrow’s.
In the first selection, we look at a new paper on physician burnout. In The New England of Journal, Drs. Pamela Hartzband and Jerome Groopman (both of Harvard Medical School) argue that burnout will not be remedied by offers of exercise classes and the other usual prescriptions. Drawing on organizational psychology, they call for a fundamentally different approach, built on autonomy, competence, and relatedness. At a time of COVID, “health care professionals are responding with an astounding display of selflessness, caring for patients despite the risk of profound personal harm. Our efforts are recognized and applauded.” Now, they argue, is the moment for action.
Are people with schizophrenia at particular risk during this pandemic? In the second selection, we consider a new Schizophrenia Bulletin paper by Dr. Nicole Kozloff (of the University of Toronto) and her co-authors, who answer this question with a convincing yes. “We suggest that thoughtful consideration of the implications of COVID-19 for people with schizophrenia may not only reduce the burden of the global pandemic on people with schizophrenia, but also on the population as a whole.” They offer recommendations.
Finally, in the third selection, a reader responds to last week’s Reading. Rachel Cooper (of the University of Toronto) considers the inpatient experience. “Those of us who have spent time on psychiatric units, particularly while on forms (or held involuntarily), can speak to the immense isolation and feelings of violation of having our basic liberties removed. In this time of COVID, those with the privilege of not having had the experience of being in hospital involuntarily are getting a small taste of that isolation.”
Please note that there will be no Reading next week.
DG
Selection 1: “Physician Burnout, Interrupted”
Pamela Hartzband and Jerome Groopman
The New England Journal of Medicine, 1 May 2020
Before the onset of the Covid-19 pandemic, each day seemed to bring another headline about the crisis of physician burnout. The issue had been simmering for years and was brought to a boil by mounting changes in the health care system, most prominently the widespread implementation of the electronic health record (EHR) and performance metrics. Initially, the prevailing attitude was that burnout is a physician problem and that those who can’t adapt to the new environment need to get with the program or leave. Some dismissed the problem as a generation of ‘dinosaur’ doctors whining and pining for an inefficient, low-tech past. But recently, it has become clear that millennials, residents, and even medical students are showing signs of burnout. The unintended consequences of radical alterations in the health care system that were supposed to make physicians more efficient and productive, and thus more satisfied, have made them profoundly alienated and disillusioned. The problem has become even more urgent with the realization that it’s costing the health care system approximately $4.6 billion a year.
So begins a paper by Drs. Hartzband and Groopman.
The authors note various attempts at addressing physician burnout, from exercise classes to greater access to child care.
There is scant evidence that any of these measures have had a meaningful impact, as shown by a recent meta-analysis of 19 controlled studies evaluating a total of more than 1500 physicians. These data lead to the inescapable conclusion that currently proposed solutions do not address the underlying problem: a profound lack of alignment between caregivers’ values and the reconfigured health care system.
They argue that we need to look to organizational psychology, and the work of Gagné and Deci. They emphasize:
- Intrinsic motivation. “People may perform an activity because they find it interesting and derive spontaneous satisfaction from the activity itself…”
- Extrinsic motivation. “They may receive a tangible external reward, so that satisfaction comes not from the activity itself but from that reward.”
- “But Gagné and Deci showed that tangible extrinsic motivators, such as monetary rewards, can paradoxically undermine intrinsic motivation.”
They note the uniqueness of those in health care. “Doctors, nurses, and other health care professionals have traditionally viewed their work as a calling. They tend to enter their field with a high level of altruism coupled with a strong interest in human biology, focused on caring for the ill.”
Then, drawing on the work of Gagné and Deci, they argue: “The problem of burnout will not be solved without addressing the issues of autonomy, competence, and relatedness.”
To be more specific:
- “Autonomy… means having the right to act with a sense of volition and having the experience of choice.” They note that physicians have less control over time.
- “Competence was once viewed as having a deep fund of medical knowledge and exercising clinical judgment appropriately with each patient.” They worry that this has been undermined by health reforms, which have reduced competence to checking boxes on an EMR.
- “Relatedness is the psychological feeling that one belongs, has interpersonal attachments, and is connected to the social organization.” They argue that this is undermined by a system that is focused on metric and money, out of synch with physicians who want to focus on patients.
So, as an example:
Competency can be restored by purging the system of meaningless metrics while maintaining a core of evidence-based measures, allowing for clinical judgment, and honoring individual patient preferences.
They go on to conclude:
With the Covid-19 pandemic, medicine is at a crisis point. Health care professionals are responding with an astounding display of selflessness, caring for patients despite the risk of profound personal harm. Our efforts are recognized and applauded. During this interlude filled with uncertainty, there has been a sense of altruism and urgency that has unexpectedly catalyzed the restoration of some elements of autonomy, competency, and relatedness.
This paper is well argued. The description of autonomy, competency, and relatedness is interesting and relevant – and certainly goes beyond the usual argument that burnout is just about EMRs, etc. And they do well to tie the conversation to our COVID moment.
The authors don’t consider whether the good will we see today will translate into action on physician burnout in the coming months. Physician burnout, after all, has become something of a buzz term, mentioned often but perhaps in a perfunctory way, and usually meaning – well – exercise classes. If ever there was a reconsideration of medicine and its practitioners, now would be that time. But is the prescription too big even for this big moment?
https://www.nejm.org/doi/full/10.1056/NEJMp2003149?query=featured_coronavirus
Selection 2: “The COVID-19 Global Pandemic: Implications for People With Schizophrenia and Related Disorders”
Nicole Kozloff, Benoit H. Mulsant, Vicky Stergiopoulos, and Aristotle N. Voineskos
Schizophrenia Bulletin, 28 April 2020
Starting in January 2020, coronavirus disease-19 (COVID-19) has rapidly developed into a global pandemic with the number of deaths continuing to climb worldwide. The World Health Organization (WHO) and many governments have promulgated social distancing and social isolation to slow the spread of the virus (ie, “flatten the curve”). These public health efforts are targeting the entire population. However, these strategies may be less effective for certain marginalized groups, notably those with schizophrenia and related disorders (referred as schizophrenia in the rest of this manuscript). Features of these disorders, such as delusions, hallucinations, disorganized behavior, cognitive impairment, and poor insight, and sociodemographic characteristics, including living in congregate housing and homelessness, may put these individuals at higher risk of becoming infected with COVID-19. Furthermore, people living with schizophrenia are at greater risk for adverse outcomes, including death, because compared with the general population, they typically have poorer physical health, greater socioeconomic disadvantage, are more socially disconnected, and experience pervasive stigma and discrimination.
So begins a paper by Kozloff et al.
The paper focuses on four areas.
Factors That Put People With Schizophrenia at Elevated Risk of Acquiring COVID-19 and of Experiencing Poor Outcomes
“As schizophrenia is characterized by impairments in insight and decision-making capacity, it may be harder for people with schizophrenia to adopt and adhere to the protective measures recommended to prevent infection (eg, hand washing, social distancing or isolation, confinement).” They note the draw of substance: “Comorbid substance use disorders, highly prevalent in schizophrenia, may compound impairments in judgment and decision-making.” And they note the reality of vulnerability: “People with schizophrenia are overrepresented in vulnerable populations that are at increased risk for COVID-19 outbreaks, including prisoners and individuals experiencing homelessness.”
“Multiple factors increase the risk of poor outcomes from COVID-19 in people with schizophrenia.” They mention tobacco: “Smoking, which is prevalent in more than 60% of people with schizophrenia, may increase the risk of disease progression and severe complications from COVID-19, including death, via its effects on lung health and immune responsiveness…” They also note physical health comorbidities.
Mental Health Impact of COVID-19 on Schizophrenia
The authors note: “Previous outbreaks have had persistent mental health effects: following the 2003 Severe Acute Respiratory Syndrome (SARS) pandemic, significantly elevated rates of psychiatric disorders and psychological distress were present.
They worry about the impact of social distancing on those with schizophrenia. “Social distancing practices could have a particularly negative impact on individuals with schizophrenia. Typically, individuals with schizophrenia on average have smaller and poorer-quality social networks than the general population.”
Impact of the COVID-19 Pandemic on the Management of Inpatients and Outpatients With Schizophrenia
The authors note the impact on inpatient wards, drawing from the experience in Asia. “A COVID-19 outbreak in a South Korean inpatient psychiatric unit infected 100 of its 102 patients and resulted in 7 deaths, at the time accounting for nearly half the COVID-19-related deaths in the country. Factors identified as having contributed to this outbreak were the lack of ventilation due to windows having been sealed shut to prevent suicides, and restrictions on the use of hand sanitizer due to fears that some patients would drink it.”
As for outpatient work: “The immediate impact of COVID-19 could be even greater in outpatient settings, where the majority of mental health care is delivered.” They note the challenges to evidence-based care, like the work of ACT teams.
Clinical Research
The authors see significant challenges to clinical research during this pandemic. They note that both the FDA and NIH have issued guidelines emphasizing the safety of participants. They wonder about limiting in-person visits, and the potential of virtual study visits. And they worry: “A prolonged cessation of new recruitment into ongoing research studies, coupled with the reduction or elimination of in-person research visits will exacerbate the challenges already present in schizophrenia research, including challenges in study retention.”
The paper closes with seven recommendations; four are highlighted here:
- “Addressing the social determinants of health, including ensuring safe and comfortable housing and implementing strategies to reduce health disparities, should be a foremost priority.”
- “Guidelines for resource allocation in the context of the outbreak may help protect vulnerable populations by ensuring fair and consistent decision-making, acknowledging this may be challenging in the short-term, but remains a long-term goal.”
- “Inpatient mental health settings should develop capacity to rapidly isolate people with suspected and confirmed COVID-19 from each other and nonaffected patients; limit and screen people coming into the facilities; perform infection control training and audits, including proper use of personal protective equipment; and make contingency plans to introduce alternate trained personnel in case frontline staff become ill.”
- “Outpatient mental health settings and their funders should embrace the use of telepsychiatry and other digital health interventions to support continuity of care.” The authors go on to make some more specific recommendations, including less frequent bloodwork with clozapine.
This is an incredibly detailed paper, pulling together the latest information, with 61 citations. (!) For those of us trying to understand COVID and major mental illness, the author have done a real service. And I fear that this summary verges on the superficial.
And, of course, the paper closes with a series of practical recommendations. The authors should feel good about the fact that many of them are being implemented. Around the time that this paper was published, as an example, CAMH – the country’s largest mental hospital – issued a press release noting that virtual care visits had increased by 750% from March to April.
And perhaps we should all feel good about the fact that the Canadian experience with COVID for those with mental illness has been so different than, say, South Korea’s – at least for now.
Selection 3: Letter to the the Editor
Rachel Cooper
1 May 2020
Dear Editor:
I read your comments about Masha Gessen’s New Yorker article with interest. I was struck by your final remarks and wish to offer an alternative perspective on the take-away messaging of the article.
You wrote: “Whether the ward is in Wuhan or Westchester County, New York, the problems are obvious: some people with severe mental illness are unlikely to maintain social distancing and most psychiatric units are claustrophobic.”
Those of us who have spent time on psychiatric units, particularly while on forms (or held involuntarily), can speak to the immense isolation and feelings of violation of having our basic liberties removed. In this time of COVID, those with the privilege of not having had the experience of being in hospital involuntarily are getting a small taste of that isolation.
In recent weeks, our society has had to grapple with the loss of control. But being hospitalized for psychiatric illness, in itself, is an experience of being stripped of control – doubly so when mental illness has already robbed you of this feeling, or feelings of safety and security. For those requiring hospitalization during COVID, an already difficult and often traumatizing experience is made even more intolerable by the fact that health care providers and hospital staff are gowned, masked and gloved. These protections dehumanize the people providing care and reinforce power differences between patient and health care professional. Recent policies that have barred visitors from hospitals could, I imagine, have the result of making patients feel even less like patients and more like prisoners.
I’d urge you to use your platform to help your readership better mentalize the psychiatric patient experience in these times of COVID. Rather than blaming the patient for their inability to maintain social distancing, help your readership understand the gravity of claustrophobia of the experience of being in hospital. Now, more than ever, psychiatric patients require more humane, compassionate care.
Rachel Cooper, BA (Hons.)
Service User Educator, Department of Psychiatry, University of Toronto
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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