The COVID-19 pandemic has induced profound changes in the medical system within an astonishingly short amount of time. This has certainly been evident in the field of obstetrics and gynecology. Obstetricians increased the intense volume of their work, rushing to create protocols for management of pregnant patients and reorganizing prenatal care while continuing to provide care for a steady volume of patients. Gynecologic specialists and subspecialists sought to determine the definition of the term “essential” and to contribute to hospital-wide patient access crises. Medical trainees of all levels sought to contribute to patient care within the realms of their relative abilities. Health care professionals strove to balance their fear of work with the strong desire to contribute, at times creating a profound identity crisis and sense of angst. And most notably, patients were forced to face the unfortunate circumstance of fearing to enter the offices and hospitals where they had previously sought relief.
In the adrenaline surge that the pandemic has brought to all of us, there has been little time for group reflection about which elements of our rapid change should be continued and considered for long-term and meaningful change to the medical establishment. Discussions surrounding reimbursement for virtual visits scarcely scratch the surface of the depth of what could be gained from this moment in medical history.
Herein, we aim to review what arose in our midst from the COVID-19 pandemic that may be used to bolster the field of obstetrics and gynecology through the lens of three major themes: patient care, medical training, and physician well-being.
“My patient panels have half the number of patients but take twice as long…”
“My patient told me she would consider delivering at home, except she wants her epidural…”
“My patient said she’s scared that no one will pay attention to her while all the doctors are working on the sick COVID patients…”
At the very core of what a physician does is to treat, heal, and comfort. In our daily practice, our evidence-based algorithms and protocols provide us with a roadmap to guide our patients to safety. However, perhaps the most important role we play is to validate and reassure in the face of illness. Never before have we recognized the depth of panic that our patients are experiencing. Office and virtual visits take much longer than ever because our patients require contact with a professional who can transition their concerns from the realm of the emotional to the realm of the cerebral. By thinking and taking certain action, we can outwit the disease we fear.
Many of us have forgotten or failed to ever fully recognize that our patients are always, at all times, coming to us seeking reassurance and validation in the face of fear. The pressures over the recent era in medicine to increase patient volume and visits have minimized the time required to fully understand a patient’s unique fears and to bring them from panic to trust. Prenatal visits lasting five to 10 minutes to exclude the presence of preeclampsia, preterm labor, or stillbirth are not optimal to develop a strong relationship that demonstrates to a patient why an obstetrician is necessary to safely afford delivery of a baby. Such volume diminishes the trust that a physician has the best interest of the patient and child at heart in medical decision-making. Well-woman gynecology visits that feel rushed amid a busy schedule of procedures and consults may subtly convey that the patient’s concerns aren’t of sufficient import to be time-worthy and that the practice is more interested in volume than in patient care. Even physicians who are profoundly empathic to the patient experience have insufficient time to express that empathy. Rather, we err toward reassurance, minimizing the fear of the patient. It is of little surprise that patients who survive obstetric emergencies are at higher risk of post-traumatic stress disorder and express two related concepts: “my doctor didn’t listen to me” and “I didn’t know this could possibly happen to me.”
Consideration of practice scheduling, reimbursement structures, and assessment of patient satisfaction must change in order to regain some of the trust that has eroded with our patients over time. No moment before has more critically demonstrated the importance of this concept than the present. With forced physical distancing leading the charge, we may currently have smaller panels and ability to spend more time with each patient. This should not be lost in the charge to reopen to normal.
My medical school is offering to graduate me more quickly so that I can join the front lines…”
“I want to help but I don’t know how…”
“I’m scared that I’ll be in over my head with a patient who is going to die because I didn’t know what to do…”
The medical hierarchy, to its credit, has evolved to realize the folly of its traditional eat-or-be-eaten strategy. Increased supervision has improved patient safety at the reasonable expense of some measure of clinical autonomy. Algorithmic and evidence-based care has allowed increased confidence, as it has removed elements of complex decision-making from the purview of the as-yet incompletely trained individual.
Unfortunately, the limits of algorithmic care are brought into sharp relief in the time of a pandemic, when previously unseen emergencies stack immediately proximally to one another. The loss of the ability to think on your feet provokes an anxiety among trainees that they will not be able to provide appropriate care in the moment for patients in their care. This is paralleled with a strongly held understanding that the purpose of entering a medical profession was to provide healing help, leading to an intense feeling of guilt at the limits of ability.6-7 It is our role as faculty to support our trainees as they navigate this uncertain and winding course and as we ourselves are faced with our own anxieties and guilt. At this moment, our trainees require more support, attention, and validation than ever before. However, clinicians coping with their own limitations and insecurities may not feel they have the bandwidth or adequate expertise to extend their support to trainees.
Dedicated resiliency training and increased support for clinicians who specialize in medical education are critically important. We all, especially the younger learns, need to learn how to work with uncertainty and all the while remain uncomfortable while doing so. Medical educators should be credited with providing support and resources to trainees at all levels. Additionally, medical education should redouble its efforts to provide not only didactic and experiential knowledge but also support structures for autonomy, managing uncertainty, and emotional coping.
“My brain is only working at 60%...”
“I never feel like I’m doing the right thing, neither for my patients nor for my family…”
“I’m so tired of feeling guilty all the time…”
Physician burnout and well-being had been a contemporary focus within the medical community even prior to the pandemic. However, medical administrators across the country recognize the cognitive dissonance impacting all health care professionals in the face of the pandemic: on one hand physicians and other health care workers have stood up to honor their oath to provide care for the many sick; on the other hand, we live in permanent terror of potentially infecting and killing our children, parents, and other loved ones. This duality has led to incredibly high levels of anxiety and fear, impacting clear cognition and causing a sense of helplessness. The high rate of death by physician suicide was a prominent concern prior to COVID-19 and underscores the need for awareness and action to address the compounded mental health challenges associated with this time.
Virtual group wellness check-ins have suddenly become a new standard. Opportunities to commiserate and share are considered to be not only acceptable but also a good and healthy use of time. That which many would previously would have considered self-indulgent wastes of time has now become a highly valued component of pandemic response.
What is important to realize about these check-ins is the acknowledgment of the vital requirement for community. A feeling of intimate closeness with the other members of our community cannot necessarily be gained solely by proximity in grand rounds presentations and nearby office structures. The ability to honestly convey concern, self-doubt, and fear and to find understanding has the ability to heal. These opportunities should be perpetuated beyond the moment of the pandemic, as periods of emotional trauma will continue to be a part of the lives of physicians providing clinical care in the recovery phase and beyond.
Despite the unprecedented uncertainty with which the COVID-19 pandemic has forced us to wrestle, there are positives of this pause which we can and should capitalize on as physicians and obstetricians and gynecologists. For our patients, we can advocate to provide adequate time to more sufficiently address their numerous fears and concerns. For our trainees, we can serve as role models not only as regards clinical care, but also with how we demonstrate our mechanisms to manage our own uncertainty and anxiety. This may well provide a variety of frameworks for them to incorporate into their own coping strategies and ideally well-being for a lifetime of clinical practice. And finally, for ourselves, we can appreciate both the recognition and appreciation of the strength of community that this pandemic has brought to us as physicians and other health care workers. Though working in different roles, we all have universal goal of providing excellence in clinical care while grappling with—and sometimes suppressing—our own worries and fears. Taking time to personally recharge our batteries with our families, friends, and other support structures (although often virtually) amid our clinics, surgeries, and L&D shifts provides the strength to persevere. We must maintain a focus on compassion for our patients, our trainees, and ourselves so that the positives of the pause will not be forgotten.
Christina Duzyj Buniak, MD, MPH, Holly Khachadoorian-Elia, MD, MBA, and Lori R. Berkowitz, MD are physicians at Massachusetts General Hospital and faculty in the Department of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School in Boston, MA.
Disclaimer: The thoughts and opinions in the Frontline Voices initiative reflect experiences of individual ACOG members and do not represent official organizational opinions of ACOG.