Abstract
Accounts of frontline health care workers experiencing distress in the midst of the COVID-19 pandemic highlight the need for accessible psychological support for them. Prior to the pandemic, medical residents and physicians often experienced difficulty receiving counseling due to concerns about confidentiality, stigma, cost, time, and reportability to licensure/credentialing bodies. Since 2004, the OHSU Resident and Faculty Wellness Program (RFWP) team has sought to reduce these barriers by providing on-site free, confidential, individual counseling and medication management. Utilization of this program is high with over 500 physicians a year seeking care; 38% of all OHSU residents/fellows and 7% of all faculty eligible for our services participated in 2019-20. In the present essay, we describe how our model of care for trainees and faculty was a key wellness resource during COVID-19.
Similar to other accounts of lower help-seeking by health professionals initially during the pandemic, we experienced a slight downturn in utilization rates during the initial weeks of when the pandemic struck our area, but quickly returned to normal and exceeded prior levels. All appointments shifted to telehealth visits and a number of physicians expressed gratitude for the opportunity to talk through concerns and strengthen coping. A number of physicians requested medication consultations to address severe insomnia, anxiety, and depression. We hope that being present in our physicians’ lives when they are exposed to COVID-related stress or trauma will keep them safe, help them cope with difficult experiences and losses, and ultimately facilitate both recovery and post-traumatic growth.
In anticipation of a surge of COVID-19 cases, our chief medical officer at Oregon Health and Science University (OHSU) recruited faculty involved in wellness efforts to develop and implement a plan to protect the emotional well-being of frontline clinicians and staff. Accounts of frontline health care workers experiencing exhaustion, fear, anxiety, grief, depression, and moral distress in the midst of the COVID-19 pandemic in China, Italy, and New York City1,2 were foremost in our minds as we reflected on how to deliver urgently needed psychological support to our health care community. An institutional wellness task force composed of psychologists, psychiatrists and other physicians, social workers, chaplains, nurses, researchers, administrative staff, and communication experts quickly mobilized. This team promoted existing psychological support services and developed new initiatives based on needs identified through anonymous surveys of academic medical center employees and on best practices for psychological first aid and disaster responsiveness. 3
New wellness resources included a concierge phone line staffed by medical students providing information and referrals to resources, a 24 hour crisis hotline within the employee assistance program, a COVID-19 wellness email portal responding to inquiries, a wellness website providing updated information and list of resources, on-site staff respite spaces with relaxation apps, yoga mats, wellness kits, and refreshments, and a consultation service offering resilience training for team leaders. These resources were promoted through multiple channels of communication including nightly emails from health system leaders, fliers posted in work areas, the wellness website, and announcements in team meetings and huddles.
Access to existing individual counseling services was identified early on in our wellness task force as a critical need for health care workers—especially once they had time to pause and reflect upon the emotional impact of their experience during the pandemic. 4 Although not everyone impacted by traumatic events will need wellness services, confidential and timely access to a professional counselor is essential for health care workers exposed to trauma in the medical role. A safe place to reflect on and process distressing experiences, to address intense emotions, and identify healthy ways of coping will support recovery from trauma and loss and facilitate the return to normal functioning.
The OHSU Resident and Faculty Wellness Program (RFWP) is the primary site for delivering individual counseling and psychiatric evaluation and treatment to all Portland-based medical residents, fellows, and OHSU faculty (approximately 3000 physicians and other faculty). During this pandemic, we hoped that our longstanding efforts to reduce known barriers to help-seeking would continue to make it possible for distressed trainees and faculty to receive comprehensive care. In the present essay, we describe our efforts to reduce barriers to seeking professional wellness services and how our program responded to unique aspects of providing care during COVID-19.
Promoting Help-Seeking by Reducing Known Barriers: Our Model of Care
Recognizing the stress, burnout and “moral injury “
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widely present in the medical profession long before the pandemic, OHSU developed the Resident and Faculty Wellness Program (RFWP) sixteen years ago to provide wellness services to physicians. In order to connect distressed health care professionals with resources, we needed to understand how to best reach them and what barriers could prevent access to personal health care. Earlier studies of help-seeking5,6 among medical students, residents, and faculty physicians documented perceived barriers including:
concerns about confidentiality stigma and stoicism fears about reporting to credentialing or licensure boards financial concerns demanding clinical schedules identifying counselors experienced in working with physicians.
These barriers, and high levels of perfectionism and self-reliance endemic in medical culture, have limited physician access to comprehensive mental health treatment and are cited as a possible factors in the higher suicide rate among medical professionals. 5
The institutional wellness task force promoted our RFWP during COVID-19 to all Portland-based medical residents and fellows and OHSU School of Medicine faculty. The RFWP provides free, unlimited, confidential counseling, coaching, medication evaluation and management. Importantly, our clinical team is not involved in evaluating or training residents/fellows. Our treatment records are separate, with no documentation in the health care system’s electronic health record. We host annual psychoeducational workshops to residency and faculty groups to promote help-seeking and share de-identified narratives of physicians benefiting from coaching, counseling and/or medication treatment. A number of trainees have acknowledged that they were more comfortable about seeking out services after a trusted senior or chief resident shared that the “wellness program helped them.”
In our educational outreach efforts to promote help-seeking, we also emphasize the Oregon Medical Board’s licensing application questions which confirm participation in our wellness program is not reportable (only impairment is reportable) and discuss strategies to find time to schedule an appointment. Our team (cumulative 3.9 FTE) of four psychologists, a psychiatric nurse practitioner and a psychiatrist are highly experienced in working with medical trainees and faculty physicians. In addition, we are available to consult with residency and faculty leaders and chief residents when they are concerned about a distressed colleague and are considering a referral to our program. Physicians may never be compelled to seek our services and we refer to the community for mandatory treatment or fitness for duty evaluations.
The RFWP leadership also developed a peer support program in 2016 and trained over 50 faculty and resident peer supporters who reach out to clinicians after a significant adverse professional event such as tragic and unexpected patient outcomes, or any exposure to trauma in the medical role. The RFWP and the Peer Support Program are funded by the academic health system.
Utilization of Wellness Program Prior to and During COVID-19
Our wellness program’s annual utilization rates by medical trainees are higher than those typically seen in US university counseling centers, community mental health centers and other academic medical settings. 7 When surveyed in 2013, residents and program directors expressed a high level of satisfaction with RFWP, a willingness to seek care through RFWP, and fewer perceived barriers to treatment than seen in prior studies of physicians. 8 Annually, over 500 physicians a year seek care through the RFWP; 38% of all OHSU residents/fellows and 7% of all faculty eligible for our services participated during the academic year of 2019-2020.
Similar to accounts by other wellness experts who reported that health care professionals are often unable to pause and seek out psychological support while working on the front lines during the pandemic, 4 we experienced a slight downturn in utilization rates during the initial weeks in March and early April 2020 when the pandemic struck our area, but quickly returned to normal and even exceeded levels of utilization than seen in prior years. At the end of the academic year of 2019-20, the number of sessions increased 18% over the last year’s rate—indicating that our program was visible and accessible to distressed trainees and faculty during this initial 4 months of the COVID-19 pandemic.
We are not sure why the utilization rates varied during the first month of pandemic impacting our health system but we heard from faculty and residents already engaged in counseling (prior to COVID) that they were initially adjusting to multiple and ongoing changes in clinical roles while trying to keep themselves, their families, staff, learners, and patients safe from COVID-19. As predicted by a frequently cited model of phases of a disaster, 9 the “heroic/community cohesion” phase of this disaster response was evident when residents and faculty participating in the RFWP offered their scheduled counseling appointment to others with a more urgent need. We assured them that we had the capacity to expand to meet with other distressed clinicians. We also experienced a significant increased interest in physicians requesting training to offer peer support to their colleagues. In response we provided additional training of peer supporters and created a filmed interview with a key peer supporter on the importance of offering peer support during COVID-19. This filmed interview was shown by our team during our Department of Psychiatry Grand Rounds and posted on our website.
Within days of our state’s enactment of COVID-19 safety guidelines, all RFWP appointments shifted to telehealth visits—a change that a number of residents and faculty working remotely and in the hospital found even more convenient than in person sessions. RFWP clinicians reported that many of these health care workers expressed gratitude for the opportunity to talk through their concerns, strengthen their coping strategies, reflect on meaningful experiences, and receive emotional support. Because our sessions are unlimited, we are able to provide the appropriate dose of treatment and continuity of care typically needed for psychological recovery. In addition, a number of physicians requested medication consultations to address severe insomnia, anxiety, and depression.
Caring for Health Care Professionals in the Future
It is now clear that COVID-19 will be impacting our lives for months or years to come and an increasing number of residents and faculty are seeking psychological support for a wide range of personal and professional concerns including symptoms of “disillusionment,” overwhelming exhaustion, and fears about an unknown future– consistent with the model of community recovery from disasters. 9 Psychological distress among healthcare workers certainly predated the pandemic and we have long understood the need for mental health services to support institutional efforts to create a healthy workplace. We hope that being present in our physicians’ lives when they are exposed to COVID-related stress or trauma will keep them safe, help them cope with difficult experiences and losses, and ultimately facilitate both recovery and post-traumatic growth. If we really want to thank the “heroes” in our midst, we need to provide a strong safety net that includes accessible, high quality services including coaching, counseling, and psychiatric medication management. And we need to normalize physicians receiving treatment to strengthen their personal well-being and to sustain their important work with patients during this pandemic. 10
Footnotes
Acknowledgments
The authors wish to thank Anna Anderson, PMHNP, Timothy Beecher, PhD, Marina Valdez, PhD, Mark Kinzie, MD, George Keepers, MD, Liz Stevenson, JD, Micaela Sandoval, and Nathan Naruponjirakul for their contributions to the Resident and Faculty Wellness Program. The authors also wish to acknowledge the work of the COVID-19 Wellness Task Force leadership (Anna Bohnengel, Andrea Cedfeldt, MD, Renee Edwards, MD, Megan Furnari, MD, Kai Roller, LCSW, Abigail Lenhart, MD, Milly Seeley, and Natasha Spoden, MS).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
