Study shows pandemic has adversely affected clinicians in safety-net practices

We've heard many times how the COVID-19 pandemic has stressed our healthcare system and clinicians on the frontlines caring for hospitalized and emergency room patients. Clinicians are exhausted, and their work has not been "normal" since the pandemic started two years ago. Most of the reporting and research on the topic has focused on intensive and emergency care clinicians who have heroically withstood wave after wave of overwhelming sickness bringing uncertainty and death. Generally overlooked have been the pandemic's effects on outpatient clinicians, and most notably those working in safety-net practices around the country whose patients have been most at risk for grim outcomes due to COVID-19.

In a recent article in the official journal of the U.S. Surgeon General, Public Health Reports, UNC Family Medicine's Donald Pathman, MD, MPH, UNC Social Medicine's Jeffrey Sonis, MD, MPH, and colleagues assess how the pandemic has affected clinicians in outpatient, safety-net practices. The study involves data from 1,800 National Health Service Corps (NHSC) clinicians in 20 states during the first nine months of the pandemic and includes clinicians in primary care, behavioral health, and dental health.

"The COVID-19 pandemic has affected all communities in the United States, but infections, deaths, and financial and social disruption have been most severe in low-income, socially vulnerable, and predominantly racial and ethnic minority communities, both rural and urban," the authors say. "Among all outpatient practices, those that serve these communities may have been disproportionately affected, including federally qualified health centers (FQHCs), Indian Health Service (IHS) and tribal health centers, community mental health and drug treatment centers, and other safety-net practices."

Watching their patients struggle

People's health and well-being have suffered in many low-income communities, with most study clinicians reporting that the pandemic had adversely affected the physical health of over half of their patients and taken an even greater toll on patients' mental health. Many clinicians noted increases in patients' alcohol consumption and misuse of other substances, and reported most of their patients' financial situations had suffered due to the pandemic.

Work upheaval

In the first year of the pandemic clinicians saw upheaval in the care they could provide to patients and in their day-to-day work. Patient visit numbers dropped precipitously, and most care moved to the telephone or telehealth. For patient and staff safety, the scope of services they could provide for patients was narrowed and many clinicians were shifted to different clinics. Dental health clinicians, whose work cannot be performed remotely, were especially impacted, with more than 40% seeing a reduction in pay and temporary furloughs.

On top of disruptions in their work, many clinicians reported a lack of support from their safety net practices, which have limited resources, to help them practice safely. Half of primary care clinicians did not have the option to work even partially from home or relocate to a lower risk area if they were in a high-risk group for complications if infected. Compounding the matter was that most lacked any support with stress management and few were given any help with childcare despite the new requirements of their jobs and three-quarters being women.

Clinician well-being suffers

Given these challenging circumstances, it is not surprising that the study found many clinicians' well-being had suffered significantly. More than three-fourths were found to be "at risk for mental distress," including feeling overwhelmed, fatigued, burned out and depressed. These findings bode poorly for their continued resiliency in the face of an ongoing pandemic, as well as the future retention of these clinicians in important safety-net practices. To help with current and future needs in safety-net practices, the article calls on legislators and administrators in these agencies to build a culture of listening to, caring for, and supporting clinicians and staff to support their mental health.

Moving forward

"The long-term impact of adverse effects of the pandemic on clinician mental health is unclear," Sonis said. "However, ongoing stresses due to new COVID variants raise concerns that the effects may be long lasting."

Pathman added, "Practices in low-income, socially vulnerable, and predominantly racial and ethnic minority communities have not normalized. Our healthcare system is still overwhelmed, and clinicians have been stretched thinner and thinner. Millions of healthcare workers are being affected. Given that most people receive most of their care in primary care and other outpatient practices, all of us will be impacted in the care we receive, but especially those most vulnerable."