One of Dr. Riva Kamat’s most jarring memories from the past year was an 11-year-old patient struggling to breathe.

“He was COVID-positive, he was doing initially quite well, and then he started going downhill very quickly from a respiratory standpoint,” said Kamat, a pediatric hospital physician at Inova health system in Northern Virginia. Before the patient was rushed to the pediatric intensive care unit, he left a note for his medical team: “I don’t want to die. Please help me.” (The patient recovered and left the hospital three or four days later, according to Kamat).

National data is shedding new light on how the COVID-19 pandemic is affecting medical providers and their mental health as they balance the emotional and physical demands of a sometimes deadly virus. For frontline hospital workers, it’s often the visceral jolt — and exhausting work — of caring for critically ill patients. But primary care physicians are also reporting fears of infection and ongoing stress that comes from a radical shift in how their businesses operate.

In Virginia, there’s growing concern that burnout and extreme stress could lead more providers to leave the field or grapple with long-term mental health problems. On an individual level, it’s bad for doctors and their patients. But on a systemic level, there’s also worry that COVID-19 could make an existing physician shortage worse.

“One of the things we always talk about is physicians, nurses, support staff — they’re taking care of patients every day,” said Taylor Woody, the communications manager for the Medical Society of Virginia. “But who’s focusing on taking care of them?”

A medical worker with Neighborhood Health, a chain of community clinics in Northern Virginia, swabs a resident for COVID-19 at a testing event in Alexandria. (Photo courtesy of Neighborhood Health)

Currently, there’s not much data to assess the scope of the problem. Diane Powers, the director of communications for the state’s Department of Health Professions, said doctors in Virginia renew their licenses on even-numbered years. The department doesn’t track retirements, so those renewals are one of the only ways it regularly updates workforce numbers.

In 2018, DHP sent out 37,436 renewal notices. A total of 33,293 physicians — nearly 90 percent — renewed their license. In 2020, the most recently available data, the response was roughly equivalent. Of 38,702 notices, 34,899 renewed their license, or just a little more than 90 percent.

But there’s also evidence that mental health concerns are growing. Virginia was the first state in the country to establish a “Safe Haven” legislative program — laws that offer civil immunity for providers who seek treatment for burnout or career fatigue. The legislation was expanded this year to include nurses, pharmacists and medical students, and ensures that participants won’t be reported to the Board of Medicine unless they present a danger to themselves or their patients.

“Before that, physicians were truly afraid of seeking help or raising their hand to say they were burnt out,” said Jenny Young, MSV’s director of membership. “For fear of losing their medical license, losing their job, or having anything discoverable in a medical malpractice trial.”

MSV has also developed a network of mental health resources through the program, provided through the company Vital Work Life. Over the last six months, roughly 20 percent of doctors in states where the company operates have used the company’s services, Young said. In Virginia, it’s been around 35 percent.

“It’s still very early,” she said. “But we’re encouraged that allowing physicians to seek help without fear of repercussions really will move the needle.”

When it comes to leaving the field, Woody said there’s less concern about young doctors (especially since most graduate with a level of student debt that makes quitting prohibitive). Kamat, who also chairs the provider wellness committee for the Virginia chapter of the American Academy of Pediatrics, said national data suggests that mid-career doctors, between the ages of 40 to 54, report being most affected by burnout.

Anecdotally, she said several of her friends have expressed an interest in transitioning to jobs that offer more of a split between administrative work and frontline care. For many, the decision has been driven by the high acuity of pediatric patients they’ve seen over the last year — not just with COVID-19 cases, but with worsening mental health symptoms and other medical conditions.

“But there are some people who say I am completely ready to leave practice and this is the best time to retire because acuity is really high and I can’t do this anymore,” Kamat said. Often, that decision comes from older doctors in later stages of their careers. MSV President Dr. Art Vayer said it’s not just the stresses of caring for patients, but financial difficulties and fundamental changes in how practices have been operating throughout the pandemic.

“I’ll cite one of my orthopedic surgery colleagues,” he said. “As the governor put a moratorium on elective surgeries, he still had rent, full-time staff to pay, but had no income coming in because he couldn’t schedule any procedures.” That doctor was already weighing retirement, according to Vayer, but it was the pandemic that finally convinced him to close his office.

There’s been a national spotlight on the struggles faced by frontline hospital workers since the start of the pandemic. In late April of last year, a New York emergency room doctor died by suicide while she was visiting family in Charlottesville — a tragedy that resonated with health care workers across the country, Vayer said.

But Woody said primary care doctors have often been left out of the conversation. National studies indicate that those practitioners may have faced the most risk of dying from COVID-19 (Virginia doesn’t provide public data on deaths among health care workers, but more than 26,000 have contracted the disease since the start of the pandemic). Vayer said one painful reminder was the death of Dr. Larry Monahan, who ran an established medical practice in Roanoke and died from COVID-19 in November.

In the early months of the pandemic, especially, private primary care practices were often excluded from statewide distributions of personal protective equipment and testing supplies. Dr. Sterling Ransone, a family physician in Deltaville, said the lack of resources put them at much higher risk of catching the virus, especially at a time when there wasn’t wide understanding of asymptomatic and presymptomatic spread.

“I talked to one physician very early on, and the day before she had been coughed on by a COVID-positive patient before she knew they were COVID-positive,” Young added. “It’s really clear the stress and the toll that it takes on community providers.”

Private offices were also forced to quickly adopt different methods of care and intensive safety measures. Before the start of the pandemic, Ransone said telemedicine had never been a part of his practice. But over the last year, he’s had to invest in new technology along with enhanced personal protective equipment and establish a new curbside waiting policy for patients. It also took some time for Medicaid and Medicare to reimburse telehealth appointments at the same rate as in-person or video visits — a particular barrier for physicians in rural parts of Virginia with limited broadband access.

Ransone said he’s heard of some colleagues who retired within the last year. But he’s heard from others who are waiting to leave the field until the pandemic ends and they don’t feel the same critical demand for their services.

“Once all this is in the rearview mirror, that’s when they’re saying, ‘That’s probably the time to hang it up and move on,’” he said. That’s left him nervously eying a future with fewer primary care doctors — especially in areas that are already experiencing a shortage.

“The worry is, where are we going to be in a year or two?” Ransone said.

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