Physician Engagement and Morale During the COVID-19 Pandemic

On March 3, 2020, the Renaissance School of Medicine at Stony Brook University held what was to be, unbeknown to us, the last in-person clinical department chairs meeting for the pandemic season. At that meeting, our hospital epidemiologist gave a presentation about a novel coronavirus affecting the city and region of Wuhan, China. She explained that, given the scarcity and the celerity with which new information was made available to the medical community, it was apparent that this virus was highly contagious (with an R0 much greater than 1.0), likely had an asymptomatic contagious phase, and had no current effective treatment. She predicted, correctly, that the virus would be extremely deft in terms of spread, and that it would travel to the New York area with devastating effect.

Additionally, the epidemiologist issued a dire and extremely accurate warning that New York and the New York local healthcare systems were about to face an unprecedented and insidiously effective viral illness that would test the healthcare system and its components to the maximum.

Stony Brook Medicine is the only academic medical center in a largely suburban area outside of New York City (Suffolk County), serving a population of about 1.5 million people. As New York City grappled with the devastation of the COVID-19 pandemic, its adjacent areas, including Suffolk County, were swept into the pandemic vortex.

The only Level 1 trauma center in Suffolk County, Stony Brook University Hospital (SBUH) consists of 603 beds and 32 operating rooms, and performs almost 20,000 operations yearly. As the pandemic surged in New York state (middle of March to mid-May 2020), it came as no surprise that Suffolk County was one of the hardest-hit counties in the nation, with incidence and mortality statistics reported as some of the highest in the country.(1)

During the worst of the pandemic, SBUH had more than 400 COVID-19 patients in house, of which more than 100 were intubated intensive care unit patients. Through the pandemic months of March to June 2020 over 1,500 COVID-19 patients were treated as inpatients at Stony Brook University Hospital.

Recognizing the key role our academic medical center would play in the fight against COVID-19 and its strategic position on Long Island, SBUH wasted little time in creating an Incident Command Structure Committee that officially launched on March 2, 2020 to mount a response, in concert with the state of New York.

As the first confirmed case of COVID-19 was identified in our hospital, followed by a deluge of others, normal hospital function was disrupted beyond anything experienced by any of our healthcare providers in recent memory. The clinical departments, including the department of surgery, were called upon to maximally support our medical center’s task of addressing a previously unknown viral illness that produced excessive numbers of critically ill patients in accordance with rapidly evolving public health policies.

For an academic surgical department, the threat to healthcare providers’ morale and engagement under these circumstances has been significant and challenging, given the speed of change the pandemic precipitated. In a culture accustomed to dealing with challenging healthcare issues, COVID-19 brought a sense of distress, coupled with the earnest desire to provide excellent medical care.

Given today’s instantaneous worldwide communication, an avalanche of sudden, often chaotic information assailed the faculty via social and traditional media. For a surgery department, the fundamentally nonsurgical nature of the disease shifted normal surgical care and its usual importance to the side.

“Feeling part of a team” and “being recognized for good practice”(2) have been described as key to morale for physicians. Both concepts were threatened during the pandemic. “Team” was disrupted by altered physical presence and absence from the operating room. “Good practice” was threatened as normal care protocols were altered and bandwidth of attention focused on a disease that was primarily nonsurgical.

How do department leaders — division chiefs and the department chair — maintain engagement and morale in such an environment? The purpose of this review is to address these issues and to catalogue the experience of our department of surgery and its success in maintaining engagement and morale.

Department Impact

The pandemic had a widespread and profound effect on the functioning of the surgery department. Some faculty, particularly those in the division of critical care/trauma, experienced substantially increased workloads and were working assiduously for long hours fighting an unknown and dangerous disease.

In the Stony Brook Hospital structure, the surgical critical care/trauma team cared for roughly 50 percent of all the intensive care unit COVID-19 patients who were admitted to our medical center during the worst stages of the pandemic on Long Island, NY (March to May 2020). The demand for critical care of COVID-19 patients far exceeded department of medicine resources.

Stony Brook Medicine, as the region’s only Level 1 trauma center and as a tertiary surgical referral center, has developed a robust surgical critical care capability within the trauma critical care division. Throughout this difficult period, the surgical critical care/trauma faculty worked above and beyond expectations on the COVID-19 units, driven by a desire to understand the disease, preserve as many lives as possible, and provide great care under difficult circumstances. Meanwhile, other surgery faculty were confronted with disruption in patient engagement and care as their normal practices in the operating room and clinics were completely, or nearly completely, closed down.

To respond to the challenges of surgical clinics operating at reduced hours and with minimum personnel, the department of surgery rapidly adapted telehealth modalities and modified requirements for in-person patient clinical visits.

The pandemic created a need to adapt and respond as clinicians and as researchers. In this context, communication became paramount. As opposed to previous outbreaks in recent memory (AIDS, SARS, Ebola), COVID-19 has taken place in a fully developed environment of ubiquitous social media and immediate transmission of information via the Internet. As such, communication locally and around the world was instantaneous, multichannel, unfiltered, and unconfirmed. Communication occurred in a milieu in which clinicians knew little about the nature of this new disease or how to best render care — particularly critical care. Events were moving quickly amid an avalanche of information of questionable reliability.

The pandemic also affected the research mission of the department. Bench research was suspended. Clinical and outcomes research turned to learning and disseminating critical information about COVID-19. The formal education mission (in-person research presentations) and modalities of the department halted. Clinical medical students on their third-year clerkship were unable to attend on the surgical services. Grand rounds and all face-to-face conferences stopped.

The department’s day-to-day operations changed dramatically and immediately. Our surgery resident and fellow contingent was re-deployed to the needed COVID-19 care surge. Daily morning resident and faculty hand-off rounds were canceled and replaced by virtual sign-outs with far fewer available participants.

From an emotional standpoint, department members suddenly were faced with new concerns. Elective surgery, usually a critically important component to an academic medical center, was on the sidelines. Our faculty were worried about their health and the health of their families. Face-to-face and group meetings were moved to virtual online meetings or phone calls. The clinics emptied out as did the academic offices, with most personnel transitioning to remote work. Faculty covering urgent and emergency surgical care for the most part did so without the usual resident or licensed independent practitioner support structure.

In summary, uncertainty, fear, and loss of the normal mission threatened to upend departmental cohesion, sense of mission, morale, and engagement.

Department Responses

These sudden and dramatic changes were significant threats to the long-term emotional health of the department team in terms of morale, optimism, and engagement. These elements are critical to successfully addressing the emergent situation and the longer-term effect for the department. At the beginning of the pandemic, the faculty numbered 67. All 10 of the trauma and critical care faculty participated in the care of critically ill COVID-19 patients in existing and expanded intensive care units. These units were established and run by the trauma and critical care faculty, and at maximum census numbered three units with a total of 55 beds. The vascular surgery division, with eight personnel, established a line of service.

Throughout the rest of the department, deployment was on a voluntary basis. For instance, a breast faculty surgeon took on floor care of chronic trauma patients, a pediatric surgeon familiar with pediatric trauma covered some adult trauma, and others volunteered to assist as additional faculty on the COVID-19 ICUs being managed by our faculty. For a time, elective surgery was stopped, but emergency and urgent cancer surgery and trauma continued to require care in a constrained environment.

Survey Method and Results

The department faculty were intermittently surveyed as part of academic life before the pandemic. The survey questions were developed in conjunction with an outside consultant, but were not specifically validated, as this primarily has been a tool to guide departmental strategy and decision making. These surveys included questions that addressed engagement and morale.

Before the COVID-19 outbreak, the faculty were last surveyed Oct. 7–13, 2019. At that point, the department was implementing a new compensation plan and one of the goals was to provide a starting data point to evaluate the effect of the compensation plan on engagement and morale. However, the outbreak of the COVID-19 pandemic put the compensation plan on hold.

Between May 9 and May 15, 10 weeks into the pandemic as defined by initiation of our hospital’s incident command center, another survey was sent to faculty including the same questions as the survey in October 2019. In both instances, the Survey Monkey tool was distributed by the chairman, via email in early morning, five days running during a single week. Anonymity regarding individual comments and responses was promised and maintained.

Once collected, the data were downloaded to an Excel file and transferred to SAS statistical software for analysis. The survey results between the two time periods were compared, with each question having a five-step scaled response. As the survey was anonymous, identification of individuals across the two surveys was not possible, weakening statistical analysis.

The responses were compared using gamma as a measure of rank correlation, measuring the strength of association of the cross-tabulated data with both variables measured at the ordinal level. -1.00 is a negative correlation, meaning the answers were more favorable on the first survey, 1.00 a fully positive association, meaning the answers were more favorable in the second survey.(3) A value of 0 indicates the absence of an association.

Gamma, a form of rank order correlation designed for two-way cross-tabulations, was used because there were a limited number of response categories for each question and, as a result, a large number of individuals gave the same response.(4) The statistical strength of an association was measured by a two-tailed Z-test, with significance considered less than 0.05.

Based on the results from the Survey Monkey survey, the departmental response can be divided into four categories: communication, operations and operating room modifications, education, and research endeavors.

Communication

“The antidote to fear and uncertainty is transparency and timely, accurate information from reliable sources,” Robert Bartholomew writes in Psychology Today.(5) Instinctively identifying this need in a department affected by the uncertainties of the surge of COVID-19 cases in our region, the chair began a daily morning briefing using a “fireside chat”-style voicemail message that was sent by email to the department faculty and residents.

The chair transmitted critical information from our hospital’s incident command structure meeting, such as data about the pandemic (patient and ICU numbers) and timely policy information, then asked faculty and residents to forward to the chair any potentially important or interesting pandemic information from their information streams. These were shared as were notes of encouragement and thanks.

The chair sifted and vetted this information, shared highlights and materials verbally, and appended them to the emails with the voice messages to ensure that the entire department had a common knowledge base and understanding of the pandemic from both a local and international perspective.

In addition, a daily virtual Departmental Operations Committee meeting was established that included division heads as well as our key operational departmental and administrative personnel. The meeting organically morphed into a well-established rhythm.

The participants first received key updates from our surgical critical care/trauma team managing ICU COVID-19 patients, as this was the prime contribution of the department to the organizational pandemic effort.

Next, we reviewed any morale and health issues concerning the residents. This was critically important because our resident workforce was re-deployed early in the outbreak to care for COVID-19 patients. Surgery residents, with their highly valued and much-needed critical care skills, were central to the organization’s effort in fighting the daily surges of COVID-19 positive patients and patients under investigation (PUI). However, the deployment of the surgical residents to “the front lines” scattered them away from the department, deprived them of scrubbing in the operating rooms, and disturbed their normal team configurations. It was important for the department leadership to keep a finger on the pulse of the residents’ morale and health.

Next, the Departmental Operations Committee heard from our business administrator regarding any specific department issues or tasks that needed to be addressed. Each division then reported out any issues or challenges that had occurred since the previous meeting.

During these daily meetings, we discussed what the department was learning about treating this novel disease, which resulted in multiple clinical publications. If needed, outside resources were called to join the virtual meeting on the spot, such as the university’s information technology officer, the graduate medical education officer, or those managing the re-deployment. In these meetings, departmental human resources personnel were shifted in real time to support those working above capacity or to assist those with health challenges related to COVID-19.

Managing Operating Rooms

Early in the pandemic, it became clear that surge planning for the influx of COVID-19 patients would mandate a reduction of surgical operating room activity. Soon, New York state government official proclamations formalized the cessation of elective surgery. In our “stretched to the limit hospital,” surgical activity would consist only of emergency procedures and inpatient procedures to shift resources to pandemic care.

Early on, the Perioperative Executive Committee, consisting primarily of the surgical department chairs, met to create definitions and operational plans to wind down and eventually wind back up as necessary. As the COVID-19 surge began, a daily virtual meeting of the operations sub-committee of the Perioperative Executive Committee monitored the operating room schedules, modified internal policies as necessary, and matched resources available to emergent and urgent activity as allowed by state policy. As the patient volume began to return, this group also prioritized cases per state proclamation.(6)

Education

Weekly education sessions remained on the schedule but were repurposed to transmit critical pandemic information and educate the department on COVID-19 and the department of surgery’s role in managing the pandemic. Weekly sessions included online talks such as:

• The chief medical officer and the designated graduate medical education institutional official reported on likely scenarios and plans of action at the beginning of the pandemic.

• The departmental surgical critical care/trauma faculty detailed early learnings regarding clinical care of COVID-19 based on conversations with other United States and overseas COVID-19 surgical and medical teams.

• Education sessions included reports from our surgical critical care/trauma team and re-deployed residents regarding their activities and first-hand experience with COVID-19 cases.

These weekly meetings provided the entire department with a common framework of information regarding the pandemic and the department’s role within the organization’s overall pandemic effort.

Research

Formal laboratory research was paused because of the state’s mandated stay-at-home rules. Some aspects of clinical outcomes research, such as grant writing and financial management of clinical trials, continued remotely. Clinical trials that were about to start were postponed and the healthcare professionals and the research arm supporting the enrollment and follow-up of the patients in the already existing trials had to operate with heightened alert to ensure compliance, as well as to monitor the safety and wellbeing of the clinical trial patients.

Asking and answering questions regarding the pandemic became the focused research effort of our medical staff, given that a substantial number of critically ill COVID-19 patients were cared for by the department of surgery faculty. Reports from the frontline faculty caring for these patients during frequent departmental meetings sparked collaborative research. For example, the team learned early that the endotracheal tubes were becoming occluded and required replacement.(7) Additional publications from the department reporting discoveries important for COVID-19 critical care have been submitted and are pending publication.(8)

Survey Analysis

A subset of survey questions from the larger survey keying in on morale and engagement were compared from the pre-pandemic period in November 2019 (35 of 68 respondents) to the pandemic period on May 5, 2020, (44 of 67 respondents), four weeks beyond our peak pandemic activity and 10 weeks following the hospital incident command structure initiation. Table 1 lists the questions.

Age and gender were not queried to avoid impairing the promised anonymity. Since “sidelined” versus “reassigned” were not cut-and-dried choices or categories, we did not ask this in the survey. The distribution of rank, and therefore seniority, did not differ between the two surveys.

On nine of the 19 compared questions, the responses are statistically significantly more positive, or trended toward significantly better in the pandemic period survey when compared to the pre-pandemic survey (see Table 2). Those nine questions probed morale, communications, and relationships among faculty.

Several questions that did not see a significant improvement were answered favorably in both surveys (55 percent or more “Agree” and “Strongly Agree”). One such question, “How often do you look forward to going to work?” decreased from 80 percent to 75 percent “Agree or Strongly Agree.”

Two additional questions were answered less favorably overall in both surveys, with a small decrease in the second survey (“I regularly receive recognition for my work efforts” and “I feel valued by the organization”). The full results for two key morale questions as well as detailed histograms for the significant questions and answers are illustrated in Figure 1.

Figure 1. Histogram examples of key questions and answers

Discussion

Large-scale disasters with local impact can put the mental health of the population at risk.(9) Healthcare workers at the frontline of the COVID-19 pandemic are at high risk for burnout, depression, anxiety, post-traumatic stress disorder, substance abuse, and suicidal ideation.(10) Specific interventions to promote and address psychological wellbeing should be implemented as part of pandemic response efforts.

The COVID-19 pandemic has created an environment of stress and threat to morale and engagement. Attendings, residents, and staff were impacted by the magnitude of the viral spread and the number of hospitalizations. In Wuhan, China, the initiation site of the worldwide pandemic, the impact on medical and nursing staff was profound.(11) Among 994 physicians and nurses there, 36.9 percent had subthreshold, 22.4 percent had moderate, and 6.2 percent had severe mental health disturbance. Many sought help: 36.9 percent accessed psychological help materials and 17.5 percent participated in counseling or psychotherapy. These data speak to the importance of a proactive approach to morale and engagement at the departmental level.

The Gallup organization, near the beginning of the pandemic, proposed four key elements relative to morale during the pandemic: (1) setting a clear plan of action, (2) ensuring workers feel prepared to do their jobs, (3) keeping workers well-informed about what is going on in the organization, and (4) ensuring the organization cares about workers’ overall wellbeing.(12)

These steps were pursued as applicable to maintain engagement, morale, and therefore psychological health of our faculty and residents.

At the Mount Sinai Health System (MSHS) in New York City, the issue of maintaining the emotional wellbeing of the healthcare workforce during the pandemic was addressed early on at a system level on the premise that “the health system’s full support is required to address the needs of its workforce.” In this respect, MSHS created a task force that identified three priorities: (1) meeting basic daily needs, (2) communicating, and (3) providing psychosocial and mental health support options. At the departmental level, the identified deliverables were daily communication with information distilled to fit the group, and department/division conference meetings for free flow of communication.(13)

The Columbia Spine Surgery Group also addressed the appropriate response to the pandemic. They continued all normal educational conferences such as morbidity and mortality using teleconference platforms.(14) In our department of surgery, this was not possible from a resident point of view, as our residents were deployed across the pandemic effort and unavailable for such meetings. However, multiple strategies were used to keep the department at the cutting edge of pandemic knowledge. In this respect, we recognized that clear and frequent communication was critical.

The Columbia spine surgeons implemented a faculty “buddy” system for check in and emotional support. In our setting, these objectives were achieved through close interactions within divisions, including out-of-hospital support for physical and emotional health issues.

The current work demonstrates that use of a set of specific intentional measures was effective not only in maintaining morale, but also improving it. This is demonstrated by comparing results from a survey addressing morale and engagement three months before the pandemic that was repeated during the pandemic. Nine of the 19 compared questions showed a significant improvement in scores related to morale and engagement. In another set of questions, there was improvement that did not reach significance primarily because the early scores were already high, making robust improvement unlikely.

While our department of surgery was fully engaged in the direct care of COVID-19 patients, many of our attendings and residents specializing in critical care, vascular, emergency, and general surgery were deeply involved because of the clinical complexities of COVID-19 illness (coagulation issues and cytokine storm, for example). These faculty members worked long hours over many days, driven by the excessive volume, the enormity of the tragedy, and the opportunity to contribute to the understanding of a new and dangerous disease (personal observation).

A similar phenomenon has been described among nurses. Serin, et.al., describe a negative correlation between compassion and burnout in a cross-sectional study of 177 nurses.(15) Rothenberger suggests that a highly effective strategy for avoiding burnout among physicians is “enabling physicians to devote 20% of their work activities to the part of their medical practice that is especially meaningful to them.”(16)

In the case of our critical care surgeons, the effort with COVID-19 patients was meaningful, albeit difficult. Some faculty were briefly “sidelined,” particularly with respect to the normal rhythm of surgical procedures and clinic activity. Almost all continued patient care using telemedicine as an adjunct. As such, the department represented a spectrum of situations the faculty found themselves in. As the surveys were confidential, we could not match responses from survey to the other, limiting statistical power and the ability to analyze specific subgroup changes. Specifically, we could not dissect out busy and non-busy surgeons to detect differences in morale and engagement among these groups.

This analysis did point out some areas of significant opportunity. Feeling valued by the organization and regularly receiving recognition for work efforts disimproved by small margins between the two periods and show significant room for improvement. During the pandemic, substantial efforts were made to highlight the work of those on the “front lines.” Perhaps it is not surprising that those on the “sidelines” did not feel adequately recognized.

Conclusion

In an academic department of surgery in a hard-hit region of the COVID-19 pandemic, a set of intentional tools focused on clear and persistent communication was used to maintain engagement and morale.

Key elements of the program included daily voice messages, daily leadership meetings, and frequent department-wide virtual events to share information. Measurement of morale and engagement via a confidential Survey Monkey survey of the faculty demonstrated clear improvement in the department faculty morale and engagement despite the substantial disruption and stress of the pandemic.

Clear strategies can mitigate the potentially harmful effects of a significant medically focused disaster if employed early, consistently, and exhaustively.

References

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