Bearing the brunt
As health systems address the toll on employees’ mental health, they’re finding women to be most at-risk
I have experienced mom guilt more in the last three months than in my entire time of being a mom. This is such uncharted territory.”
Dr. Shikha Jain, oncologist at Rush University Medical Center in Chicago and co-founder of the Women in Medicine Summit
Because this virus is so new, there is an extra stress on my part of taking care of my patients, myself and my family.
Dr. Ma Carla Angela Evangelista
AT THE END OF 12-HOUR SHIFTS treating patients who have tested positive for COVID-19 at NYC Health + Hospitals/Lincoln in the Bronx, Dr. Ma Carla Angela Evangelista goes home to her husband and three young children, ages 8, 3 and 1.
Upon walking through the door, she tells her kids to go to their rooms. She then undresses, putting her scrubs in a plastic bag that goes into an empty hallway closet, to be washed later.
Immediately, she showers. Only after putting a fresh mask on does she tell her kids they can come out of their rooms. She cleans every object she touches in her home. “I think I’m a walking bug,” she says.
That’s how Evangelista has been interacting with her husband and kids amid the coronavirus pandemic. She didn’t want to live away from them, as some front-line workers have done during the pandemic, but she compares her thoughts to an endless roller coaster. “As a mom, you always worry,” she said.
With the pandemic exacting a significant toll on the well-being of caregivers, psychiatrists argue that female staff are likely going to be in most need of mental health resources and support given their heightened stressful duties at home and at work.
Health systems—particularly those hit hard with coronavirus patients over the last few months—are offering free counseling, support groups, mental health hotlines and other resources for their employees. The hope is that by addressing emotional well-being, fewer employees will get burned out and retention levels won’t suffer.
While health systems don’t target a gender when offering these resources, women are probably more vulnerable to experiencing trauma, depression, burnout and anxiety as a result of the pandemic compared with their male counterparts because of their magnified personal responsibilities and will likely use the resources more, according to psychiatrists and researchers.
Evangelista’s main fears are getting sick, forcing her to isolate from her family or risk giving the virus to her husband and kids. “At the baseline as a doctor, you have to be cautious of bringing stuff home but because this virus is so new, there is extra stress on my part of taking care of my patients, myself and my family,” she said.
NYC Health + Hospitals recognizes the toll the pandemic is taking on its caregivers and has established wellness rooms and assigned behavioral health personnel to units so they’re available to talk to staff.
Evangelista said they don’t pry, but she likes the idea of being able to talk to someone if she needs it.
“For now, it has gotten better … but if we experience a second wave or there are things that come up, it’s not a problem for me to approach one of them,” she said.
“Women take on extra burden in these times—child care, home schooling,” said Dr. Jessica Gold, an assistant professor of psychiatry at Washington University in St. Louis. “I think the extra burden of those unpaid responsibilities is going to be conducive to mental health challenges.”
There is little or no data in the
U.S. to support such a hypothesis, but a recent study published in JAMA shows that in China, where the coronavirus outbreak first emerged, women and nurses were more likely to report higher levels of depression, anxiety, insomnia and distress than men and physicians. Although the majority of study participants were women, which can skew the results, researchers and psychologists argue there might be compounding factors at play.
In addition to the environment and work responsibilities becoming more stressful during the pandemic, there is strong evidence showing that women continue to take on the majority of household responsibilities such as child care, grocery shopping, cooking and caring for elderly parents. Home life now has added stress points with children unable to go to day care or school due to stay-at-home orders and concerns about spreading the virus to family members.
“There are moms who are working as doctors and have someone sick at home,” said Dr. Christina Mangurian, professor of clinical psychiatry at UCSF School of Medicine. “The stresses on women and mothers are real.”
Money concerns
Economic strain is also at play. While most of the attention for mental health vulnerabilities has focused on those directly treating coronavirus-positive patients, some health systems have responded to thinner margins by laying off staff or cutting hours, which can also jeopardize emotional well-being, Gold said.
Layoffs can exacerbate the gender pay gap in healthcare, said Kellie McElhaney, founder of the Center for Equity, Gender and Leadership at the University of California at Berkeley. Research shows workers who re-enter the workforce after a period of unemployment earn 4% less than someone who hasn’t had a career disruption.
“There is a likelihood we will come out of this pandemic and we would have taken several steps backward in the gender equity space,” said Dr. Shikha Jain, an oncologist at Rush University Medical Center in Chicago who co-founded the Women in Medicine Summit.
Jain, who has a 6-year-old and 2-year-old twins, said she gets her work done between 8 p.m. and 1 a.m. because during the day she’s busy trying to home-school her daughter and run the household. Her husband, a gastroenterologist, helps when he’s there but at one point he isolated at a family home after exposure to a COVID-19 patient.
“I have experienced mom guilt more in the last three months than in my entire time of being a mom,” Jain said. “This is such uncharted territory.”
Women in medical academia face another issue. Professional journals in other fields are reportedly seeing fewer paper submissions from women, while those from men are rising amid the pandemic. This is likely because women are taking on homeschooling and other caretaker responsibilities with their children at home, said Dr. Nicole Sandhu, an internist at Mayo Clinic and president of the American Medical Women’s Association.
Such a phenomena can have long-term effects on the advancement of women in medical academia, McElhaney added. To receive tenure, an expected amount of published research is typically required.
Physicians also aren’t immune to intimate partner violence, which can escalate during times of crisis and stress such as this pandemic, said Dr. Kim Templeton, professor of orthopedic surgery at the University of Kansas and co-chair of the physician wellness initiative of the American Medical Women’s Association.
Since stay-at-home orders have been in effect, increases
in calls to domestic abuse hotlines have been reported.
There are already signals that women are using the mental health resources offered by their employers more than men. Henry Ford Health System in Detroit experienced a surge of coronavirus patients, and in response, the system began hosting virtual support groups for employees. They’re intended to allow caregivers to share their experiences during the pandemic in a safe environment.
Dr. Lisa MacLean, a psychiatrist and director of physician wellness at the system, said most participants are women. Calls to the 24/7 mental health hotline staffed by psychologists at Henry Ford have also been largely women. Additionally, most using the hotline aren’t physicians but other clinicians such as nurses and the nonclinical workforce.
“We definitely see more utilization (of those resources) by women, but is that because women are just more vulnerable? Is it because they are suffering more? Is it because they are just the majority of the workforce? We don’t know,” MacLean said.
There is also evidence that women generally express feelings of trauma or stress by sharing with others, more often compared with men, which might be another reason why women are more likely to participate in such support groups, said Dr. Katherine Gold, a family medicine physician and mental health researcher at Michigan Medicine.
“I have been running informal groups for faculty to just talk about what is going on for them during this pandemic and it’s predominantly women who participate in that,” she added.
In addition to mental health resources, organizations are addressing the stressors brought on b y the pandemic in other ways, such as offering hazard pay, childcare services, free meals and transportation.
Although the resources aren’t directed specifically at women, those with household responsibilities are likely benefiting from them, said Dr. Samantha Meltzer-Brody, chair of the psychiatry department at UNC School of Medicine. UNC Health has offered childcare and opened a food market where employees can shop after long shifts.
“We are absolutely trying to think as holistically as possible,” she said.
PTSD-like effects
Health systems are acknowledging the importance of dealing with the emotional trauma the COVID-19 pandemic has inflicted on their employees.
“As someone who has experience dealing with post-traumatic stress disorder, this (pandemic) was about as stressful as it can possibly be. It compares to being in combat or to what happened when the World Trade Center went down,” said Dr. Dennis Charney, president of academic affairs at Mount Sinai Health System in New York, which saw so many coronavirus patients that its flagship hospital was almost entirely a COVID-19 unit at its peak in early April.
Charney said he expects about 20% to 25% of the workforce on the front lines will experience post-traumatic stress disorder as a result of the pandemic.
The health system plans to open a center in June focused on addressing stress, resiliency and personal growth among staff. Mental health screenings, referrals to counselors or psychologists and resilience training will be among
We definitely see more utilization (of support resources) by women but is that because women are just more vulnerable? Is it because they are suffering more? Is it because they are just the majority of the workforce? We don’t know.”
Dr. Lisa MacLean, psychiatrist and director of physician wellness at Henry Ford Health System
the services offered.
Employers still face challenges as they offer additional mental health resources to their staff. Stigma around seeking mental healthcare is prevalent for both nurses and physicians. Depending on the state, physicians might opt not to receive treatment because they have to disclose it to the state licensing board.
In fact, several health systems said not as many employees as anticipated were using mental health services. That could be because it’s too soon, said Dr. Wendy Dean, a psychiatrist and founder of Moral Injury of Healthcare, a notfor-profit that works with providers on countering clinician distress. It takes time for the effects of a traumatic experience to settle in and the individual to process it.
Indeed, when coronavirus patients first hit New York City, most front-line workers expressed fear, said Dr. Michael Myers, a professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn who is leading mental health resources at the facility along with his colleague Dr. Ramaswamy Viswanathan.
They worried about infecting themselves or their family members and that they weren’t doing enough for their pa
tients. Now, as they have time to reflect, Myers said more clinicians are saying they have nightmares or trauma from their experiences.
There is also the pain of co-workers dying from COVID-19. Two colleagues of Dr. Bonny Baron, an emergency department attending at NYC Health + Hospitals, have died. “We are a very close-knit group in the ED,” she said. “This is our family.”
Health systems seem to recognize the long-term mental health impacts and don’t have an end date for the additional mental health resources. “We have to be there for our workforce for a long time to come and help people to keep moving forward,” said Dr. Philip Wilner, chief operating officer of the New York-Presbyterian Westchester Behavioral Health Center. Similar to other health systems, New York-Presbyterian has deployed its own psychiatry department to host support groups and individual counseling sessions with staff.
Ways to address stigma are allowing staff to remain anonymous when using resources or referring them to mental health professionals outside the system, which is what Mount Sinai Health System has done.
Leaders are also getting involved in alleviating the stigma of mental health issues. For instance, the CEO of Henry Ford’s medical group sent the workforce a message detailing the available mental health resources and encouraging staffers to use them. “Our thought is that if it comes from him, as a leader, that will be a message that resonated and hopefully we can break down those walls” regarding stigma, Henry Ford’s MacLean said.
Mangurian at UCSF said she disclosed during support groups with staff that she takes medication for anxiety, which she usually isn’t so open about. “I’m disclosing that with the intended goal that other people will see it and say, ‘It might be OK for me to do that,’ ” she said.
Loyalty questions
The consequence of not acknowledging emotional well-being can lead to professionals opting to leave the workforce. Besides the trauma of seeing droves of very sick patients, workers may feel betrayed or mistrust employers depending on how they have responded to this pandemic. At health systems that didn’t have adequate supplies of personal protective equipment or if layoffs occurred, feelings of betrayal are emerging, Dean said.
“When their existence is not expressed as valuable by their employers, it becomes very hard to be loyal,” she said. Nurses have expressed plans to leave the workforce as a result of the pandemic, said Liz Stokes, director of the Center for Ethics and Human Rights at the American Nurses Association. “I do expect nurses are going to leave the profession” because of the pandemic, she added.
In addition to offering mental health and well-being resources, health systems have other options that can help reestablish trust with staff, female employees in particular.
As systems explore restarting elective procedures that were held off, leadership should include front-line caregivers in discussions about how best to do that, Dean said. Clinicians working overtime treating coronavirus patients are likely exhausted. Flexible, lighter hours should be considered for those clinicians, she added.
In terms of decisions to lay off or furlough workers, leadership should keep in mind gender and pay, McElhaney said. Usually, the newest or least-senior employees are laid off first, and typically, women are in those roles.
“Instead of focusing layoffs on position and tenure, focus it on people and see who you are getting rid of,” she said.
Sponsoring women and inviting them to virtual conferences or speaking engagements is another way to help the careers of the female workforce during this time, Jain said.
“We could let COVID-19 set gender equity back or we could be intentional in our response and use this crisis to address the inequities that exist,” she said.
As for mental health, several psychiatrists at health systems expressed hope that the pandemic will break down stigma around mental health among physicians and nurses.
“A lot of our conventional ideas have lessened, and this will probably have long-lasting changes,” Myers said. “How can anyone see this as a weakness? You are having normal human emotions.”