On literally working with COVID-19

Why are doctors being told to come to work while sick with COVID?

I’m an emergency physician and if—or, realistically, when—I test positive for COVID-19, the hospital where I’m employed expects me to keep coming to work without isolating because of what they say is a “critical staff crisis.” I will wear an n95 mask for my 12-hour shift, during which time I won’t be able to take it off safely to eat or drink. Any deviation, and I’ll spread COVID to other staff and to whichever patients might not have COVID already. I’m more likely to be exhausted, and to make mistakes. Have the administrators making these decisions ever put on a mask while they are ill, and then worked physically arduous 12-hour shifts?

There are two related crises happening right now: one is the COVID-19 crisis among the general population, and the other is the crisis among hospitals and healthcare workers. I’m at the intersection of those crises: I will, according to my employer, push through my own exhaustion to keep up with the constant onslaught of patients with COVID, and decompensated heart failure and COPD and cancer and diabetes, exacerbated by the pandemic's impact on outpatient care. The omicron surge means there are almost no beds for patients requiring critical care, but I’ll continue seeing the flood of patients clamoring for finite resources. If it sounds like emergency physicians aren’t being protected by the hospitals and groups that employ them, it’s because they’re not.

Most people don’t seem to understand what’s happening in hospitals, or why. I think my own story helps explain why: I’ve simultaneously been called a “healthcare hero” as I’ve been eased out of a job, in April 2020. I’ve been told I’m an essential worker, then found that my own health is expendable because of the flood of unvaccinated patients hitting the ER. I don’t think most people understand the psychology of healthcare workers right now, and maybe they don’t want to. I’ve been the person telling an unvaccinated patient they may die and need to be admitted, only to have the patient tell me “COVID isn’t real.”

Maybe it’s hard to feel sympathetic to the plight of doctors. I’m frequently told that we “signed up for this,” or that we are somehow “in bed with big pharma” or getting kickbacks making us rich off COVID—yet no one specifies the mechanism or mechanics of this. Depression and burnout are terminal for ER doctors, and, on top of that, my hospital group tells me I have to work sick. Even as I write about the systemic causes of our stress, it’s hard to truly internalize it. We’re trained by residency and employers to believe that the burden of success is on us alone, and if we are not meeting it, we aren’t working hard enough, we aren’t good enough. Merging your personal worth with your clinical performance is dangerous.  Pre-pandemic, 300 physicians died by suicide a year, the highest rate of any profession. In 2021, I can personally name two of them.

How’d we get here?  

The last two years have been a series of repeated, and failed, tests of hospital preparedness. Early in the pandemic, emergency physicians were expected by hospitals to work without appropriate personal protective equipment (PPE), forcing us to expose ourselves and our families to COVID. We came to work anyway, motivated by a deep obligation to our communities and patients.

At work, we struggled to understand a novel virus. We feared for our patients. We feared for ourselves. And we faced brutal choices—who got the last oxygen tank, or the last ventilator? The hospital made choices too, about how to risk doctors’s lives. We asked for the hospitals to reach into their pockets and purchase more vital life-saving PPE and were denied. Although we found PAPRs—air purifying devices that make intubation safer—and masks and face shields to buy,  they couldn’t be purchased  through authorized suppliers using the correct bureaucratic channels.  So, we reached into our own pockets and the pockets of friends, and paid exorbitant prices for whatever protective gear we could find so that we could keep coming back to the hospital to do our jobs day after death filled day.  For this, some colleagues were fired, with administrators stating it was against hospital regulations to bring PPE from home—even if it was CDC-approved gear. This, while the masks provided by the hospital were two weeks old, and meant for one-time use in a clinical setting. 

Early in the pandemic, shutdowns and PSAs imploring people to avoid the ER except for serious emergencies successfully flattened the curve and rapidly put an end to ER overcrowding. However, rather than using the temporary respite to help a ravaged healthcare system regroup and prepare, hospitals instead made “adjustments” that reduced staffing to reflect that current moment’s ER census. I was part of that adjustment. In March 2020, everyone pressed physicians' sense of moral and professional duty; physicians  were called to volunteer to help with the crushing influx of patients. We did. Some became critically ill. Quite a few died. Unable or unwilling to project future needs, these same hospitals fired, furloughed, and in some cases retroactively cut the pay of ER physicians, citing a lower patient census and difficulty affording consistently high levels of staffing. “Healthcare heroes” became unemployed. By May 2020, I wasn’t working: I’d become redundant, because there were too few patients.

Doctors and nurses are paying more attention to where the money is going: the average hospital CEO pay in 2020 was a whopping $9 million dollars, with thirty CEOs making more than $30 million each. We need greater transparency of hospital finances. If a hospital's CEO is raking in millions while their best solution to solve a healthcare crisis is to force sick doctors to work instead of offering incentives and per-diem staff as is being done to address nursing shortages, then the hospital has clearly stated that they value CEO reimbursement over physician and patient safety. I’m being told to work sick; how about offering me bonuses to work additional shifts? How about offering my colleagues bonuses to work more shifts, instead of telling sick doctors to come to work?

Emergency physicians are nominally the safety net of the healthcare system. We’ve been on front line the entire pandemic, and, unlike many other doctors, we’ve been unable to close our clinics, switch to telemedicine, or move patients to another day. If a patient refuses to wear a medical-grade mask, we can’t turn that patient away. Yet somehow, early on in the pandemic, it was implicitly decided that we were dispensable. After all, you protect a resource you think is valuable. We chose a high-risk career that puts us front row for a multitude of communicable diseases and violence, but did so with training on how to protect ourselves and mitigate those risks. The risks have become too much to bear. That’s a key aspect of the hospital crisis today: doctors and other hospital staff are exhausted by the whiplash in how we’re treated, and we’re exhausted by taking care of the unvaccinated, who won’t take of themselves.

Hospitals and physicians have different motivations. Most of us go to medical school with the vague notion that we want to “help people.” Now, many of us have learned people won’t help themselves through simple steps like vaccination. Being a good doctor to our patients is what drives us to make huge sacrifices of time and personal life: Did we get the diagnosis right? Did we choose the correct treatment? Did the patient’s symptoms improve?  But there are also other, more difficult to measure outcomes that make medicine such a satisfying, humanistic endeavor. Did we connect with our patient? Did they feel heard? Did we make a real difference in their life? Did they understand the instructions and follow up and are confident moving forward? A hospital wants to employ “good” physicians, but their metrics of success are fundamentally financial..

The motivations of  hospitals and large contract management groups, especially in the age of private equity takeovers, are financial. Medicine is a business, and the expectation is that you, the doctor, keep patients moving quickly through the department. A large part of residency training is learning how to safely manage over a dozen patients at a time, which, as you can imagine, is an organizational feat moreso than an academic one. 

Hospitals aren’t taking simple steps that could improve efficiency, and that contributes to healthcare system collapse. For example, a more efficient doctor makes the hospital more money, yet most hospitals aren’t paying for medical scribes. A medical scribe is a person whom is responsible for charting, watching for labs and images, and preparing discharge papers, and this person is not usually paid for by the hospital. A scribe's pay at most hospitals is directly deducted from the pay of the physician with whom they work. A doctor without a scribe usually charts for free after their shift is over, or is marked as inefficient and finds themselves fielding conversations about what they can do to better “move the meat”—slang for getting patients through the department more quickly. Even in the stress of a pandemic, there is no relaxation on receiving reprimands on long wait times or charts not completed within 24 hours. Effectively, paying for a scribe means paying your employer to keep you on the schedule, since doctors who do not keep up with their charts, or wait-time metrics risk losing their jobs. It’s easier to fire a doctor and convince them they’re not good enough, than it is to provide basic support systems.

So hospitals won’t hire medical scribes, because of money, but doctors can work sick? What? Why should we? We saw what happened at the start of the pandemic. We’re tired of being sacrificed. Hospital administrators care primarily about money, and patients aren’t protecting themselves. We’re getting it from two ends.

Missing from many conversations are questions of how “efficiency” correlates to “quality of care.” As long as the more efficient doctor isn’t being repeatedly sued, whether the less efficient physician’s health outcomes are better is rarely considered. No systems truly measure quality of care. Patient satisfaction scores are an inadequate replacement, the highest of which are actually linked with worse health outcomes.  ER doctors may be spectacular at task shifting, but with increased cognitive load and increased interruptions, avoidable errors become inevitable. Working sick is going to increase the total number of avoidable errors.

Lulled by the overall success of the efficient physicians, the metrics for “efficiency” shift with an increased burden of patients. Now, suddenly, even the fastest ER doctors cannot keep up with skyrocketing need. Details that would aid in diagnosis don’t have time to come out in conversation, and tests and treatments that are non life-saving but would have value to mitigate suffering are foregone because the patient is stable enough to hand off for a follow up with their primary doctor. 

There are a few ways to approach the problems this surge of COVID patients has caused. First, the hospital could double down on valuing efficiency above all else, and continue to marry a physician’s perceived quality to their ability to push patients through the department. The physician keeps up, or doesn’t. Errors are considered a personal failure on the part of the doctor, not an inevitable consequence of the system, leaving many emergency physicians depressed and burnt out. Instead of looking at the problems of the system as a whole, we blame the individual and ignore the role of the system. The second option would be to allow for a greater amount of focus and reduced cognitive load, by hiring additional staff to help see the same number of patients, with less risk, but in the same amount of time or potentially faster. The practical solution is somewhere in the middle, with the expectation that some additional help is hired or additional shifts for current employees are incentivized, and everyone pushes harder to keep up with demand, without sacrificing patient and physician safety. 

Many ER doctors are grateful to be working despite lack of support from the government, hospital, and their communities. Older ER doctors are retiring early, if they can. Additional help occasionally comes through temporary staffing agencies, but most often there is no additional help and no incentivization for current staff to pick up more shifts. At no point in the pandemic have I, nor any colleague I know, been offered hazard pay or overtime. If we missed shifts due to illness with COVID, we simply lost the money we would have been paid. An administrator I spoke with told me that they didn’t want to start giving physicians bonuses or increase the hourly rate when there is increased need, because it sets a precedent that will be hard to undo after the pandemic. The California Department of Health released a statement that they will soon allow staff to work with COVID “to keep the health care infrastructure running.” How about offering more pay to keep the system running?

Physicians’ sense of obligation has been an invitation to exploit us. Burnout, exhaustion, and demoralization isn’t just a doctor problem. It’s a patient problem. 

“Staffing” is a problem money can solve. This manufactured shortage isn’t about too few skilled physicians, but the way that leaning on the backs of healthcare workers is preferable for the bottom line. Most hospitals have chosen to remain constantly on the edge of crisis. On the federal and state scale, relief money could be earmarked to help hospitals create more beds in temporary locations during a surge and provide funds to bring in additional doctors and support staff. Putting federal state and hospital money into increasing support during surges would also expand opportunities for a variety of temporizing strategies. If more beds and staff were temporarily available, then we could better stem the tide of patients flooding hospitals from pushing us to crisis care standards. It would be safer for everyone.

A pandemic is a public health emergency. By definition, the public are the ones who affect and are affected by the situation most.  People are really sick of COVID. I get it, I’m sick of COVID, too. Unfortunately, pretending like it isn’t happening, isn’t going to make it go away. You can be “sick of COVID” and still spreading it. You can be “sick of COVID” and not be able to be seen by a doctor, because COVID patients are everywhere.  When people tell me that we should just get back to our lives, worry about ourselves and let others worry about themselves, I realize that we have failed to provide a clear message: the problems with a public health emergency there are no such thing as private choices. We’re interconnected whether we like it or not. Maybe it’s hard to believe it without seeing it. While the general public is told the statistics of increased cases and full hospital beds, in the ER we watch the actual consequences in scared, sick, human form.

The story that being “healthy” will alone keep you safe is a fairy tale. It’s not just the medically fragile, the old or those with comorbidities that are affected. You never know when you may have appendicitis, or a heart attack, or a trauma requiring an OR or an ICU bed, but the hospitals are filled. Delays in care can lead to death or morbidity that wouldn’t have occurred if the system wasn’t strained. Even if you don’t have COVID, a COVID surge may be responsible for your suffering or death. Anyone can be affected, and so everyone is potentially affected. “Don’t get sick right now” isn’t a plan, and yet it’s one I hear all around me.

An attitude of separateness is only sustainable as long as there are healthcare workers and hospital systems available to manage the consequences. I’m not here to tell you why you should care about other people, simply what happens when you don’t. Good luck getting seen expeditiously in the emergency room: our safety nets have been straining under the pressure of the last two years and have already cracked. The best solution is for a clearer message of collective action, with governmental and hospital support. Still, we may not get that. The onus of public health is, ultimately, on the public.  If this concerns you, I encourage you to reach out to your local representatives and ask what they’re doing to support a community whose medical system is in crisis. Ask them why they aren’t using tax dollars to improve the health and safety of the very people who are paying those taxes. 

What can you do?  Accept minor inconveniences for the safety of others. Don’t go out if you’re ill, wear a well-fitting medical-grade mask indoors, get vaccinated to reduce your risk of hospitalization from Omicron by up to 90%. Think about the ways you can better utilize the systems we have in place. Don’t go to the ER unless you are having an emergency. Go to urgent cares for mild illnesses. If you want to be tested, go to one of the many local free testing sites. If you do come to the ER, remember to wear a medical-grade mask to reduce your risk of catching COVID in the waiting area or spreading it to other patients. If we are sick, the n95 we keep diligently strapped to our face will protect you, too. And please, if you do find yourself needing medical care, please be kind to your doctors, nurses and staff.  A single appreciative patient encounter can be the motivation to help keep us going even when we’re ill. After all, now we may be a patient too.

You’re tired of COVID. Doctors are tired of the twin crises: COVID, and the hospital administration response to COVID. Who is working to help us?