Our world changed in March 2020. The first cases of COVID-19 were identified in the U.S. and the idea of front-line health care workers took on a deeper meaning. At that time, our understanding of what the virus could do, how it could be transmitted and how it could be treated was unclear at best. We wondered if we would have enough personal protective equipment (PPE) to safely care for patients. This progressed to the understanding that we may not have enough beds, ventilators or even health care workers.

Fellowship programs thought about how to best ration their fellows to maintain an uninterrupted service line and training environment. Clinic rotations turned virtual and meetings moved online. Adapting to this new way of life was uncomfortable, and honestly frightening, because none of us had ever managed a pandemic like this.

The evolution of thought and emotion can be seen on social media. Through the pandemic, I have been scrolling through personal social media accounts and news articles to stay abreast of the latest developments. This routine is where I gather frustration, amusement and information, but I'm often disheartened. In the beginning, there was general concern from the public and a certain respect for what the authorities were doing. Soon, frustration with social distancing emerged. I began to see debates rage over the steps to prevent COVID-19 with mask effectiveness and school attendance policies as headlining topics. When actual treatments came online, the debates combined with politics and turned to the utility of different therapeutics. Now we're still debating past topics and vaccination has been added to the mix. All of these are on display with assumptions that every side is black or white, right or wrong, with no areas left for interpretation.

In Mississippi, we have our share of trouble. On August 20, a story in the Mississippi Free Press plus a tweet from @EricTopol let me know that my home and current state was leading the entire world in COVID-19 cases.^1,2 The author William Faulkner said, "To understand the world, you must first understand a place like Mississippi."

I have a lot of pride in the people of my state for many reasons. The people's industriousness, friendliness and jovial spirit that resonate in our music and art are topping this list.

However, scrolling as I do, you'd think we are at war with one another. Our clinics and hospitals are overrun, with the Mississippi State Department of Health reporting case numbers higher than we have ever seen.³ My own institution now hosts both federal forces and the charitable organization Samaritan's Purse, which set up field hospitals in two of our parking garages. A year and a half into the pandemic, even with an effective vaccine, there are so many patients that we're putting people outside, in one of my old parking spaces, in deep south Mississippi in August because this is the only place left.

We physicians want to help make the situation better. In the beginning, we encouraged our patients to stay home, social distance and mask up. We felt that we just had to get to the point of vaccination to end the pandemic. Now, vaccines are widely available. But much like many of you, I am meeting resistance when discussing vaccination with my patients. There are concerns over myocarditis, fertility, the makeup of the vaccine, and the list continues. Many of these concerns are reflected in social media and driven by misinformation. I do my best to dispel myths, encourage prevention measures and, of course, vaccinate, but there are still many who decline.

The road to COVID-19 eradication has been long, and it seems the finish line keeps being moved back with no real end in sight. With this, I find more and more physicians and health care workers describing their exhaustion along with the unexpected development of near contempt towards the unvaccinated. Why are people who have dedicated their lives to helping others now struggling with resentment? I think the answer is quite clear: burnout.

Understanding Burnout

In 1996, The Maslach Burnout Inventory Manual described burnout as "a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people."⁴ The manual goes on to describe emotional exhaustion as "that which makes workers feel they have nothing left to give at a psychological level."

The depersonalization is described as "negative, cynical attitudes and feelings about one's clients," which "can lead staff members to view clients as somehow deserving of their troubles." This problem was not only for mid- to late-career physicians but also for trainees. A 2009 burnout literature review published in The Journal of Graduate Medical Education yielded an estimate that, depending on specialty, 27-75% of residents experienced burnout.⁵

For myself, this pandemic most certainly brought emotional exhaustion. At points, daily schedule changes became essentially expected. Concern over not only catching the virus but bringing it home to my family was constant. Social distancing strained personal relationships. Obtaining and wearing full PPE to see patients with suspected or confirmed COVID-19 added valuable time and complexity to what might have otherwise been straightforward consults. Topping this complexity with the further development of distrust and vaccine hesitancy, as the pandemic drags on, makes it no surprise that depersonalization has begun.

Given all this, it's no wonder that fellows may now lack a sense of personal accomplishment. An article published in the Journal of the American College of Cardiology (JACC) detailed the results of an April 2020 survey distributed to adult and pediatric cardiology FITs.⁶ Just over 28% of cardiology fellows responded. Of these, 41% were uncomfortable with institutional PPE recommendations, 81% were anxious about contracting COVID-19, and 69% reported that their call schedule was changed by the pandemic. The majority of respondents had concerns over their ability to meet educational requirements and their future job opportunities.

ACC's 2020 Well-Being Study of 1,288 cardiologists, fellows in training (FITs) and cardiovascular team members conducted in November 2020 found that burnout nearly doubled when comparing pre- to peak COVID-19 levels, reaching 38%.

Though these perceived pressures evolved through the pandemic, burnout as a problem among cardiovascular professionals and trainees precedes the pandemic. Results of the 2016 ACC Professional Life Survey showed that 27% of U.S. cardiologists are burned out, and nearly 50% reported being stressed with less energy.⁷

Taking Action

The ACC has made addressing clinician wellness a Strategic Priority. The Board of Governors (BOG) Task Force on Member Wellness combined efforts with the Membership Work Group on Wellness in spring 2019 to increase awareness and sense of wellness, work on strategies to mitigate burnout and engage clinicians along the way.

Among the tangible outcomes from this work is the Clinician Well-Being Portal, with links to ACC advocacy efforts to reduce administrative burdens, detailed well-being resources and events, as well as information centering around diversity and inclusion. The wellness initiatives across all ACC committees are cataloged by the membership wellness work group. The portal also includes a link to the official ACC Member Hub Well-Being and Burnout group, where members are encouraged to connect and discover outlets for improving their lives. Finally, the site has been updated with an entire section on COVID-19-specific well-being news, articles, podcasts and other resources.

For FITs specifically, the BOG Task Force made recommendations and provided access to resources included on the Well-Being Portal. The FIT/Early Career Webinar Series provides on-demand webinars on wellness, burnout and work-life balance.

One of these on-demand webinars has resonated with me. Morton J. Kern, MD, FACC, discusses specific habits that will lead FITs to successful and balanced careers. He encourages fellows to be available, affable, effective and dependable. For myself, putting patient care at the front of my mind helps me stay in an affable and effective mindset. When I consider the needs of the patient first, even late at night, I feel a connection to my work and a sense of well-being follows. Kern also talks about how prioritization becomes important as we are pulled in many different directions. Often this means prioritizing time and tasks not only at work, but at home too. I am married with two little boys and can say without a doubt that the best part of my day is spending time with family. At home, I try to stay undistracted and in the loop about their lives.

Time at home allows me to recharge and more readily reconnect with my patients and coworkers when I get back to work. Balancing home and work life is not easy. It requires that we identify what recharges us, recognize the limits to our time and attention, and be realistic when it comes to accepting extracurricular assignments.

Six systemic changes as the focus of wellness efforts were defined by the BOG Task Force in its Leadership Page.⁸ In relation to our institutions and fellowship programs, I think there are several areas on which to focus. Keeping a positive work and educational environment is key. We can accomplish this with social events outside of the hospital, inquisitive and nonjudgmental learning environments, and allowing space for fellows to cover for one another when "life happens." Additionally, I think the transition from residency to fellowship is a prime opportunity to welcome fellows into their new environment and focus on streamlining the transition through effective and efficient orientation.

During fellowship, we are forming the habits that will make up our daily practice. Now it becomes critical that we develop the skills to identify when we, or those around us, are struggling. We must begin using the resources available at our institutions and at the ACC level to mitigate burnout and promote wellness. The table shares actions we can take at the individual, institutional, organizational and societal level to combat burnout.

When the ACC Board of Trustees included the initiative to improve clinician well-being in the 2020-2023 Strategic Plan, I doubt anyone could have predicted just what a challenge COVID-19 would present. In July of this year, the ACC, American Heart Association, European Society of Cardiology, and World Heart Federation issued a joint statement calling for global action to improve clinician well-being.⁹ Specifically, they urged health care organizations to support their employees' psychosocial health, create an infrastructure where they can thrive, and give a space for reporting of mistreatment with emphasis on normalizing access to mental health resources. For medical societies, they asked for continued input on wellness and health policy change advocacy to health care organizations, creation of access to efficiency and knowledge toolkits, and focus on diversity, equity and inclusion.

As fellows, we are undoubtedly the future of cardiology. Training through the pandemic has left us changed, to be certain, but resilient as well. It is up to us to prioritize well-being for ourselves and our future patients and practices. 

This article was authored by Andrew D. Brown, MD, a fellow in training in the Division of Cardiovascular Diseases at the University of Mississippi Medical Center in Jackson, MS.

References

1. Judin N. 'A Raging Wildfire': Mississippi Now Top Global Hotspot for COVID-19 Spread. Mississippi Free Press. Available here. Aug. 20, 2021.
2. @EricTopol. Now leading the world in covid cases/capita (the U.S. state with the lowest vaccination rate). Available here. Accessed Aug. 18, 2021.
3. Mississippi State Department of Health. Mississippi COVID-19 Data Charts and Maps. Available here. Accessed Aug. 31, 2021.
4. Maslach, C, Jackson, SE, Leiter MP. Maslach Burnout Inventory. (1996; 3rd ed.). Palo Alto, CA: Consulting Psychologists Press.
5. Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ 2009;1:236-42.
6. Rao P, Diamond, J, Korjian, S, et al. The impact of COVID-19 pandemic on cardiovascular fellows-in-training: A national survey. J Am Coll of Cardiol 2020;76:871-5.
7. Lewis SJ, Mehta LS, Douglas PS, et al. Changes in the professional lives of cardiologists over 2 decades. J Am Coll Cardiol 2017;69:452-62.
8. Khandelwal A, Mehta L, Lilly S, Velagapudi P. The imperative of addressing clinician well-being. J Am Coll Cardiol 2020;75:118-21.
9. Mehta LS, Elkind MSV, Achenbach S, et al. Clinician well-being: Addressing global needs for improvements in the health care field a joint opinion from the American College of Cardiology, American Heart Association, European Society of Cardiology and the World Heart Federation. J Am Coll Cardiol 2021;78:752-6.