Photos by Ted Coakley III | Illustrations by Sarah Miller
On Monday, April 3, staff members working for the Tahoe Forest Health System showed up to work without wearing a mask, as did visitors and patients to the hospital locations in Truckee and Incline Village. So, too, was the case at Renown Health in Reno.
More than three years after the Covid-19 pandemic began, those on the front-most lines finally took a full-breath breather.
“I don’t know what people look like because I have not seen some of these people,” said Jan Iida, chief nursing officer with the hospital district, the week prior. “I don’t know what they look like because they’ve been wearing a mask for three years.”
In a way, the loosening pandemic restrictions are symbolic of relaxing pressure on healthcare workers’ shoulders. Yet they are also in stark juxtaposition to increased weariness in that same population since March 2020. A rise in burnout has been precipitously fast across the country, and according to survey results presented at an August board meeting, even more sharply so in our region.
Nationally, manifestation of burnout across physicians jumped by nearly 25% in one year, from 38.2% of physicians in 2020 to 62.8% in 2021. The information comes from a survey conducted from Dec. 9, 2021, to Jan. 23, 2022, by researchers at the American Medical Association, the Mayo Clinic, Stanford University School of Medicine, and University of Colorado School of Medicine.
At TFHS, burnout among clinicians — characterized by emotional exhaustion, cynicism, and a low sense of achievement — is following a similar trajectory, with particularly high rates among primary care and advanced practice providers, or APPs.
“We have pockets that are exceedingly high, exceptionally high, top-percentile high [regarding level of local burnout],” said Dr. Gary Gray, interim chief medical officer, last August. Gray has since retired, and hospital district representatives told Moonshine Ink they do not have the survey results on which Gray presented.
“I think every hospital, every health system in the United States, is either talking about burnout or exhaustion or whatever terminology they are using, or they should be, because I think it’s a significant problem nationally for not just physicians, to be honest, but many, many healthcare workers,” said Dr. Brian Evans, current chief medical officer at TFHS. Evans started his position in December 2022 after spending a significant portion of his career in Grass Valley at Sierra Nevada Memorial Hospital. Pointing to the national increased demands for healthcare staff since Covid-19, plus the added layer of Truckee/Tahoe having a rural hospital in a popular destination, “it is a very complex, challenging time for physicians.”
Staff at TFHS is actively working to improve the mood, with a heavy focus on increasing communication from the bottom to the top rung.
“People would like more of a clinical voice,” said Samantha Smith, a physician assistant who’s worked with the health system for nine years. “And we’re starting to see a lot of initiatives, especially even just in the last few months, about increasing our clinician involvement.”
Getting ahead of it
Clinician burnout is not a novel concept. A December 2017 study published in JAMA Internal Medicine noted “widespread burnout among physicians has been recognized for more than two decades.”
In fact, just before the pandemic began impacting the United States, TFHS medical staff created a group to address clinician burnout. The Joy in Medicine committee was formed as part of an American Medical Association recognition program. The first meeting ended up being virtual because the pandemic had just begun.
Smith was tapped to be chair of the committee. “When we first started, I remember thinking, wow, this is a really large task,” she said. “But … we had a great multidisciplinary committee, and we started developing some goals regarding how we can address burnout. It became clear that we needed some more information.”
The committee began utilizing the Mayo Clinic’s Well-Being Index to provide self-assessment opportunities for TFHS medical staff. “Clinicians can constantly re-assess as they choose,” explained Smith. “[We’d] like to do more formal communication to remind physicians and APPs to reassess, and we will be doing that in the next few months for 2023.”
The hospital district declined to share results of internal surveys tracking burnout as part of overall health and wellbeing, though multiple staff members told Moonshine Ink they resemble national data.
Exhausted and under-valued
Barbara Ferrero is a doctor of acupuncture and Chinese medicine who’s worked in Truckee for nine years. At the beginning of April, she began a joint practice with local chiropractor Dr. Thomas Clarke. While she’s independent of the local hospital system, many of Ferrero’s patients work there.
Ferrero’s pandemic experience was on an individual level: busy, but not stretched; she stayed open and relaxed her rates. She was anxious about regulations, she said, adding, “but it’s also my own personal practice, and nobody was telling me to do that. I had the opportunity to back down, and I had the opportunity to triage what was essential.”
The patients of hers who worked for TFHS told Ferrero about the stress of the virus’s unknowns on a system-wide level.
“Everybody was working too many hours, feeling afraid for their own lives, and then at the same time, there was just [a] lack of information,” she said. One of her patients working in the Covid-19 unit described the situation as shifting goal posts: “One week it was, oh, it’s a clotting disease and we’re treating it with anticoagulants and oh, it’s a respiratory disease and we’re intubating people,” Ferrero recalled. “And then two weeks later we don’t intubate anybody anymore because we realize that it doesn’t help them, and it will kill them.”
Iida, who’s worked for the district for almost 25 years, echoed Ferrero’s remarks as she recalled the first year of Covid-19’s impacts — treatment plans constantly changing and uncertainty about how dangerous the virus could be.
“I could really see the emotional exhaustion on their faces,” Iida said of the nurses she oversaw. “Just from the day-to-day of doing this and wondering, are you going to get it? What about your family? Are we going to take it home to our families? Everybody was basically changing out [of scrubs] at the hospital [to limit potential spread].”
As more and more people began moving to the region, patient loads doubled while hiring got scrappy. “[The district] has been scrambling to keep up with demand for new patients and also to manage the patients we already have had,” Evans said. “We’ve been adding a lot of physicians and also advanced practice providers, APPs, to help deal with the added demand, but I think we’re going to continue to need to grow over time to make sure that everyone has timely access to care.”
“There are issues across the country, but we’re in the first percentile; 99% of other health systems are doing better than we are on burnout, and that’s very concerning.”
~ Dr. Nina Winans, a sports medicine physician, at August board meeting
In addition to the day-to-day work under Covid’s cloud, frustration grew from team members who felt like their voices weren’t being heard.
At the same August board meeting at which Gray announced the exceptionally high local burnout, Dan Coll, an orthopedic PA for 21 years, the last 10 of which have been with TFHS, shared in public comment the frustrating workload impacts in light of rising demand. He mentioned increased shifts (over 50) without additional compensation, surgical assistance beyond orthopedic duties, and 40% of his coworkers resigning in late 2021 after suggestions to improve the work environment weren’t implemented by leadership.
“When we say other organizations have this problem,” Coll said during his comment, “I’m not aware of other organizations benchmarking at the level we do, which is the lowest percentile … We are the lowest scoring compared to our peer groups, and that should be very concerning for all regardless of the national trend of burnout.”
Dr. Nina Winans, a sports medicine physician, pointed with alarm at TFHS’s top percentile placement for burnout. “There are issues across the country, but we’re in the first percentile; 99% of other health systems are doing better than we are on burnout, and that’s very concerning,” she said last August. “To have medical leadership, we really need to have true empowerment. There has to be an openness to hear opposing views and to really have true, transparent discussions and to feel there’s a safety to bring in opposing views and see action items move forward.”
Three years out, and Ferrero has seen the urgency settle down for both her and her patients working for TFHS. “The faces that used to come being like, I am so over this, they don’t come in like that anymore,” she said. Some retired, others left, and others are taking part in the health system’s efforts to rectify low morale.
An apple a day
Since Evans’s arrival, and with healthcare stressors specifically under his purview to address, changes are taking hold.
To address the need for two-way communication, new roles have been installed: Medical directors are now in place for various district services (rehabilitation, behavioral health, acute care, etc.) and these directors participate in a partnership council to perform operational decision-making alongside Evans.
“Physicians need to be at the table hearing about and discussing, giving input to, and helping make plans for all sorts of things that are going on at the healthcare district level,” Evans said. “I am a strong advocate for elevating physician leadership and involvement in decision-making everywhere we function.”
Smith is the APP lead for the health system: the first ever. She’s held the position since last November, handing over her Joy in Medicine committee chair hat to do so. In her arena of outpatient services, she mentioned that they’ve begun holding huddles “that involve all of the staff, all of the clinicians, and managers to really increase the clinician and staff involvement.”
A wellness officer now exists, too, advocated for by the Joy in Medicine committee: Dr. Joshua Kreiss is a physician working for TFHS who serves as point person on physician burnout.
Beyond increased communication are attempts to improve operations, according to several staff members: Using Tegria, a healthcare consulting firm, to help with improving clinical operations; shifting more workers to help with administrative tasks; and providing leadership development opportunities.
Staff members told Moonshine Ink that while the proposed changes are hopeful, not all problems are over. Evans says he recognizes that.
“There’s a huge list of things that need to be done, and I’d really like to be able to say to you that everything is dialed, and I’ve got everything perfectly figured out right now,” Evans said. “I’d be naive to think that in just a few months I’d be able to get our entire medical staff of 175 clinicians to all feel like everything is perfect. But I’ve seen a lot of hope and I’ve gotten a lot of really positive feedback that we’re moving in a good direction, so I’m hopeful that we’ll continue that trend.”