Q&A: Neurologists navigate 'challenging' delivery of care during COVID-19

Qualitative interviews with community neurologists demonstrated four primary themes associated with the impact of the COVID-19 pandemic in this group, specifically highlighting “the unusual environment” in which these providers practice.

The themes identified included challenges of the political climate, lack of support for new models of care, practicing “on the front line of suffering” and clinician self-care. Taken together, the COVID-19 pandemic and “pandemic politics” resulted in an environment “that made care provision challenging for community neurologists,” Roman Ayele, PhD, MPH, a research scientist at Denver-Seattle Center of Innovation, Rocky Mountain Regional VA Medical Center in Colorado and assistant professor adjunct at University of Colorado, Denver, and colleagues wrote.

Healio Neurology spoke with Ayele to learn more about the results and the strategies they suggested to deal with these issues.

Healio Neurology: What prompted this research?

Ayele: We were interviewing clinicians as part of a larger multisite, randomized clinical trial of community-based, integrated, outpatient palliative care for patients with Parkinson’s disease and related disorders. As COVID-19 related changes were implemented, we observed that clinicians were navigating a new territory. But we had anecdotal data so we decided to further explore it by asking clinicians directly. We added additional questions to our interview guide focused on COVID-19 to understand its impact on clinicians, their patients and family caregivers.

Healio Neurology: Can you discuss the four major themes that emerged?

Ayele: The four main themes that emerged are described below.

1) Challenges of the current (pre-2020 U.S. presidential election) political climate

Community neurologists described observing the intersection of the COVID-19 pandemic and associated politics impacting their practice. Clinicians described wavering trust among patients. They connected this to patient skepticism about COVID-19 and the current U.S. political climate negatively affecting patient–clinician trust. There were serious concerns that patients may not trust them. One clinician said, “I think the question I would be interested in is: Do they trust providers less right now because sometimes they just seem skeptical of COVID-19? I do not know if that kind of turned into skepticism for doctors as well. It is definitely political; that is for sure.”

They also talked about patients living in facilities as being extremely isolated, creating increased stress and worry for those patients and their families. One clinician even said, “... They really have felt like prisoners for weeks or months at a time."

2) Lack of support for new models of care

Clinicians talked about using telemedicine as an opportunity, but also very much as a challenge because they were trying to figure out the “how” along with their patients. This created frustration and feelings of burnout and being overwhelmed. In addition, they were treating older patients who were not used to having serious conversations about their health via technology. One clinician said, “... People who are older ... find it very unnatural to have important conversations through a digital medium." There was no additional support for telehealth, though institutional support would have made that transition smoother.

3) Being on the front line of suffering

Clinicians had the front-row seat for observing human suffering, which created a heartbreaking environment. They felt like patients were just giving up and there was hopelessness. One clinician talked about how they felt there were more non-COVID-19 related deaths because people have just given up: “I feel like a lot of people are just sad and they have just kind of given up. They feel like, ‘Well, what’s the point?’ That is kind of hard because you care about these people."

4) Clinician self-care

Clinicians described a lack of self-care during the pandemic where they could not check out to get a break because everything was shut down. Their usual means of self-care, such as socializing, going on vacations and more, were not an option, so they kept working. That in turn created a cycle of burnout. In addition, they missed collegial interactions, which increased their isolation.

Taken together, the themes capture the unusual environment in which community neurologists practice, the lack of clinician trust among some patients, patient and professional isolation, and opportunities to support quality care delivery.

Healio Neurology: What were the primary take-home messages of your findings?

Ayele: Community neurologists experienced personal and professional losses, such as moral injury due to lack of trust, during the pandemic. Despite their best efforts to bring quality care to patients using telemedicine, technology was not a panacea. Telemedicine and the quick adaptation of it actually created additional stress for clinicians. In addition, the existing burnout prior to the pandemic was worsened during the pandemic.

Healio Neurology: What specific strategies would you suggest, based on your conclusions that efforts are needed to improve the delivery of care?

Ayele: Our findings call for better structural strategies to support the neurology workforce during the pandemic and beyond at individual, organizational and societal levels. We need a multipronged approach to curtail burnout, improve neurologists’ well-being and connect clinicians with resources that impact patient care. At the societal level, broad resources and funding are needed to enhance mental health programs and provide opportunities to mitigate the culture of silence around discussing and addressing clinician well-being. At the organizational level, efforts should address clinician isolation by building infrastructure to enable physicians to engage with peers and process moral injury to reduce burnout and associated negative impacts on patient care. At the individual level, neurology workforce burnout should be addressed by identifying and providing resources that are tailored to meet their needs.

Healio Neurology: Is there anything unusual or surprising about the results that you would like to elaborate on?

Ayele: Political rhetoric impacted the doctor–patient relationship. Clinicians are finding it difficult to maintain a therapeutic relationship with patients during a politicized pandemic and with the spread of misinformation and feel there is a lack of support for new models of care that were implemented in response to the pandemic.

Reference:

Ayele R, et al. Neurology. 2021;doi:10.1212/WNL.0000000000012363.