The struggles of healthcare workers during – and before – the pandemic

Responsibility, burnout and depression

SHEBA MEDICAL Center’s Underground Corona Critical Care Unit with an ECMO (extracorporeal life support) machine, Tel Hashomer, Ramat Gan (photo credit: COURTESY - SHEBA MEDICAL CENTER)
SHEBA MEDICAL Center’s Underground Corona Critical Care Unit with an ECMO (extracorporeal life support) machine, Tel Hashomer, Ramat Gan
(photo credit: COURTESY - SHEBA MEDICAL CENTER)
"Every day we come, there are new patients. Things are changing all the time, and we have to keep up with all the changes, and the patients, and learn everything on the go,” said Levi Levine, a 40-year-old nurse working in the isolation ward for patients suffering from COVID-19 at Shaare Zedek Medical Center in Jerusalem.
“It feels like a movie,” he said. “But it’s real life now.”
Patients in the isolation ward are monitored by cameras. When the medical staff enters, they must wear full gear, which must be thoroughly examined beforehand by a nurse to avoid any risk of contamination.
“It’s a completely different ballgame. The patient cannot see my face. They can see only my eyes and hear my voice. It’s depressing at times,” Levine recounted. “I can’t take care of the patients as I want to. I can’t be there for them as I’m used to because we have to protect ourselves to continue our work. It’s frustrating. And this whole corona situation… it’s absurd.”
Nurse Levi Levine at Shaare Tzedek Medical Center in Jerusalem: ‘I see it as a mission.’ (Courtesy) Nurse Levi Levine at Shaare Tzedek Medical Center in Jerusalem: ‘I see it as a mission.’ (Courtesy)

Levine’s new work routine now includes four 12-hour shifts per week instead of the usual eight hours, including weekends and holidays, if needed.
“The changes were significant,” Levine sighed deeply, “for me and for the entire hospital staff. The workload increased because there is not enough staff.”
Healthcare workers on the front lines have volunteered to be there, Levine said. “The workload has gone up considerably since the outbreak of the crisis.”
With a reallocation of medical staff to deal with the COVID-19 influx, staff members have increased their hours to keep the overall hospital services functioning while minimizing potential exposure to the virus.
“We have the support from the rest of the medical staff, from our own team,” Levine said. “The patients themselves are constantly asking how we are doing. ‘I see you here all the time,’ a patient told me the other day. ‘Are you resting, how’s your family?’ People care. It’s a very emotional time for all of us.”
With a master’s degree in emergency and disaster management from Ben-Gurion University of the Negev, Levine is now seeing in practice what he has prepared for years in theory.
“It’s shocking, but that’s what I need to do right now. I see it as a mission.”
CORONA UNIT for psychiatric patients at Sheba. (Courtesy Sheba Medical Center)CORONA UNIT for psychiatric patients at Sheba. (Courtesy Sheba Medical Center)

Amid the new coronavirus reality, healthcare workers are finally gaining some well-deserved respect from the rest of society. During the pandemic, however, a less discussed, less popular epidemic is growing in the medical world: worker burnout.
Even though it is too early to tell, Israel’s rapid response to the crisis, in cooperation with the military, intelligence and hi-tech communities, could lessen the burden on the country’s hospitals.
Despite more than 5,500 cases as of this writing, and 450 hospital admissions, the already crowded and understaffed hospitals around the country are not yet being flooded with incoming patients. Hospital personnel and administrators say they were ready for the outbreak a month before the first case of coronavirus reached Israel.
The country has  shown a remarkable capacity for efficiently dealing with the coronavirus. Thus far, the state of calamity seen in other parts of the world has not – and it is hoped, won’t – become a reality here.
“We have managed to turn the mess published by the Health Ministry into a coherent plan of operation,” said Dr. Sagi Harnof, director of the Department of Neurosurgery at Rabin Medical Center’s Beilinson Campus in Petah Tikva.
“Specific wards of the hospital deal with patients infected with coronavirus while other departments take the necessary actions to avoid contamination and continue functioning. The main changes were surrounding meetings. We are meeting our colleagues only through video conferences, and surgeries that aren’t urgent were delayed. But the reality is, if someone has a brain tumor and needs treatment and surgery, it will happen with or without corona,” Harnof added.
To avoid overwhelming hospitals, extreme measures are being taken, such as bringing mild cases to “corona hotels” and keeping Beilinson open for additional coronavirus patients.
Hasharon Hospital, which is part of the Rabin Medical Center complex, has been converted into a 200-bed facility with 40 ventilators. Some 1,400 staff members have been trained to treat COVID-19 patients while they protect themselves against the disease. Upon its opening, 37 patients were already hospitalized, five in serious condition.
“All hospitals changed, based on the coronavirus. Across the board, the clinics were closed. But the goal of any hospital in Israel is to keep the hospital functioning,” said Steve Walz, international spokesman for Sheba Medical Center at Tel Hashomer in Ramat Gan. “Operations that are being done are done. People who need life-saving procedures, such as dialysis or to give birth, for example, or if their doctors sent them to the hospital, we will take care of them.
“We put together three teams of doctors who are dealing with corona patients. They work in separate shifts and they never come in contact with each other. The entire staff is protecting themselves each and every day,” said Walz.
As numbers change on a daily basis, rotating teams with dozens of doctors are assigned to deal only with COVID-19 patients, who now occupy more than 60 beds in Sheba.
“If the hospitals don’t take care of their doctors, the system will crash across the board,” Walz added.
“We’re fighting a war against an enemy we don’t see,” said Levine. “It’s scary. The patients are scared. We are scared, but we are all supporting each other. We are in the same boat together.”
NONETHELESS, THE coronavirus crisis might serve as an urgent wake-up call to solve chronic problems that hospitals have faced for years.
On March 23, the state comptroller published a lengthy report on the current situation of the Israeli healthcare system, warning that it was “not fully prepared” for such a pandemic. The report pointed out deficiencies that have long been voiced. These include underinvestment throughout the healthcare system, overcrowded hospitals, lack of intensive care beds, and shortages of medical staff and equipment.
The issue was brought to light earlier this year when at the Soroka University Medical Center in Beersheba, for the fourth time in a year and a half, an Israeli doctor committed suicide.
WORKERS PREPARE new wards at Tel Hashomer on March 17. (Flash90) WORKERS PREPARE new wards at Tel Hashomer on March 17. (Flash90)
“The health system finds itself in a tremendous and frightful budget crisis,” Dr. David Zeiger, medical director of the outpatient department at Soroka, told Ynet in January, after the suicide.
“And maybe one of the problems of the doctors is the feeling that no one is listening to their cries that say, ‘We are trying to give the best treatment and not always are we able to because we are lacking the resources,’” he added.
While there have been waves of praise toward physicians and hospital staff on social media, lauding their work at the front lines of the crisis – with videos of cities worldwide singing and thanking their doctors from apartment balconies – healthcare workers from hard-hit centers of the coronavirus, such as Spain, Italy and the US, are publishing heart-wrenching open letters about the traumatic experience of combating this little-known enemy.
“Every time I have entered a patient room with a potential COVID-19 infection, I have felt scared; scared that I will infect other patients, my colleagues or my loved ones,” wrote Prateek Harne, a resident physician at SUNY Upstate Medical University Hospital in Syracuse, New York, in a CNN op-ed. “I am a soldier in this battle and I am scared.”
Contamination among hospital personnel is a significant issue. According to the Health Ministry, more than 3,500 medical professionals are in isolation, including some 850 doctors and 1,200 nurses, at least 140 of whom have tested positive for the virus.
Hospitals have adapted their procedures for dealing with the virus. In China, reports say that 3,000 healthcare workers have become infected, and at least 22 have died.
“We [healthcare providers] all portray a version of ourselves to the outside world, one that is undeterred by the uncertainty associated with this pandemic, even as we all know that we are scared,” Harne said. “This act of gallantry comes at a deep personal cost. These heaping emotions chip away little parts of you without you even knowing, leading to suppressed turmoil and eventually – for some – burnout.”
Healthcare workers have been exhausted since long before coronavirus
In a study published in late March on the JAMA open access network, Chinese researchers assessed the magnitude of mental health outcomes of healthcare workers in China treating patients exposed to COVID-19. Data was collected from 1,257 healthcare workers in 34 hospitals, 60% of whom worked in hospitals in Wuhan, and 42% as front-line workers at the epicenter of the disease. The study found that 50% reported symptoms of depression, 45% anxiety, 34% insomnia and 72% distress.
This pandemic is exacerbating something that can no longer be ignored: If healthcare workers, who are already underpaid, overworked and exhausted, cannot stay mentally healthy and supported, the healthcare system itself will collapse.
“The health system is falling apart,” said MK Orly Levy-Abecassis, one of the leading voices in the call for a massive restructuring to the healthcare system, following the suicide of the fourth doctor at Soroka in January.
“Emergency rooms are falling apart,” she said. “The halls are full. Working hours have become unbearable. There are not enough beds, and now the physicians themselves are in danger. How did we reach this situation in which the most important people in the health system find themselves facing an abyss?”
This was already the reality before the corona pandemic paralyzed the world. Physicians and general hospital staff were already burned out and depressed before COVID-19 infected thousands of people. It seems it took a pandemic for us to fully grasp the essential role of today’s front-line soldiers – our physicians, nurses, and medical staff – in the battle against coronavirus.
“We understand that the nature of our job is that of pressure,” said L., a nurse at Soroka who asked that his name not be used. “It’s emotionally, physically and professionally demanding. But there is only so much we can do. I can’t describe the feeling of impotence when you have to attend to a patient but you don’t have the basic things at hand to provide the necessary care.”
According to the National Physician Burnout, Depression and Suicide Report published by Medscape in 2019, the highest rates of burnout (57%) were found, not surprisingly, among physicians who worked more than 70 hours a week. This was especially seen among those who worked in surgery for healthcare organizations.
Some 14% of the physicians surveyed reported that in a state of burnout they make errors they would not ordinarily make, and 26% admitted being less motivated to be careful taking patient notes in such a state. However, only 13% claimed to be currently seeking professional help.
A study conducted by Israel’s National Institute for Occupational and Environmental Health showed that 60% of general practitioners, 39% of pediatricians and 72% of clinic directors suffered high levels of burnout, with levels rising significantly throughout the course of the seven-year study. It also showed that burnout was closely linked to insufficient remuneration, and that in 2011, the average wage earned by doctors in Israel was NIS 40 per hour (approximately $11).
A study published by Harvard University visiting scholar Joel Goh showed that burnout is not only destroying the lives of one of society’s most essential professions, but it is also becoming extremely expensive, costing some $4.6 billion a year. That’s the cost in the United States alone of physician turnover and reduced clinical hours attributed to burnout each year, a researchers’ team led by Goh wrote in the Annals of Internal Medicine last year.
In a first-of-its-kind study, the researchers looked into the costs in terms of reduced hours, physician burnout and expenses associated with finding and hiring replacements. The figure, however, does not include other highly likely consequences, such as medical errors and the impact on other staff members who need to carry the burden, making the cost significantly higher.
“Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organization expenditures for burnout reduction programs for physicians,” the study stated.
The symptoms of burnout discussed in the study include emotional exhaustion, a feeling of detachment and a diminished sense of personal accomplishment, rates of which are twice as high among physicians than the general population.
Mental health, denial and suicide.
From 2000 to 2016, 50 physicians in Israel – 41 men and nine women – committed suicide, according to the Center for Suicide Prevention. Globally, the rate of suicide among physicians is twice that of the general population. Significant research on the subject has shown that reasons include the trauma of dealing with death, diseases and hardship, and the responsibility of relieving suffering and saving people’s lives.
There can be immeasurable frustration when a patient dies, and doctors are often left with the feeling of having failed. This only adds to the stressful conditions of the profession, such as the long hours, technical and intellectual demands, and the overall pressure.
Adding to the problem is a culture of silence and denial regarding the mental health of physicians themselves. For years, the medical world has discouraged physicians from asking for help. If doctors are suspected of being in crisis, their careers might be put on the line. Therefore, silence and denial have become commonplace.
Fortunately, there has been a shift in thinking regarding burnout, depression and suicide among physicians in Israel following the multiple suicides at Soroka. The hospital’s administration established a hotline for its physicians following the second suicide, and medical students and interns have begun discussion groups where they meet to discuss their own emotional struggles.
The US 2019 National Physician Burnout Depression and Suicide Report revealed that 14% of those surveyed said they had thoughts of suicide, and 1% said they had attempted it.
Yet suicide is not a straightforward cause-and-effect issue. Behind suicide there is often burnout and depression and an inability to approach these issues. Constant support, professional help, helplines and openness to discuss these subjects are of utmost importance.
Blaming is not the most responsible approach to the situation. Nonetheless, four doctors ending their lives at the same hospital in less than two years is not something that should be ignored. Nor can we ignore functionality, management, workload and working conditions at the hospital itself.
The main aspect that differentiates Soroka from other hospitals in Israel is the number of shifts worked by its physicians. In non-pandemic times, Soroka’s physicians often pull nine shifts in a month, compared to five or six shifts for doctors in the rest of Israel’s hospitals. However, there is no comparable facility to Soroka in the center of the country.
Private clinics and private doctors in the South are considerably less common than they are in the Center and North of Israel. This contributes to the hardships found at Soroka, increasing pressures on the hospital and its staff.
Private clinics can give patients the option of looking for other treatments, which alleviates pressure on public hospitals.
Soroka has been dealing with unforeseen and challenging situations from the start. Apart from a lack of resources and the overcrowded conditions, Soroka’s caregivers deal with a strikingly different and especially challenging population, the southern Bedouin.
Not only can diseases prevalent in the Bedouin community be different from the rest of the county, but overall Bedouin health is significantly poorer than among other populations. Reasons include poor sanitary conditions, lack of accessibility to periodic medical treatment, poor access to the hospital and healthcare services, and – compared to other populations – arriving later at the hospital in emergencies after conditions have become aggravated.
Soroka, however, is not the only hospital suffering from the ills that have infected Israeli hospitals for years.
“Corona makes the situation for every hospital that much more challenging,” said Sheba’s Walz, “because a lot of time and resources have to be devoted to these patients over periods of time. It’s a matter of how you use your existing resources. The hospitals’ limits have been stretched anyway.
“The reality is, there aren’t enough doctors and nurses in Israel,” Walz pointed out.
Medical staff often have to work around the clock, without being counted among reserve medical staff, in a country where the ratio of hospital beds is 1.78 per 1,000 people, according to the Health Ministry. Patients in emergency rooms are at risk of exposure to dangerous viral and bacterial infections due to overcrowding.
The system has long lacked sufficient specialization for specific sectors, such as geriatrics and family medicine. Lack of manpower and equipment also add to the long waits that have become common for urgent diagnostic tests. These were already acknowledged problems long before the current pandemic.
More than ever, change is needed
Providing appropriate working conditions for doctors, nurses and other healthcare workers is more than a budget issue to be dealt with by a Knesset committee; it requires the collective demand of all parts of society.
It might have taken a pandemic for Israel, and the world, to wake up to the fact that healthcare workers are not only extremely important – they are absolutely essential.
“At times, when we see that our cries are not heard, that hospitals are full, that beds are in the halls and they don’t provide increased budgets for us to work properly, we tend to forget our value,” said L.
“We believe in it, in our profession. Then come times like this, and we remember why we did it.”