Clinician Wellness During the COVID-19 Pandemic: Extraordinary Times and Unusual Challenges for the Allergist/Immunologist.

The global spread of coronavirus disease 2019 (COVID-19) has caused sudden and dramatic societal changes. The allergy/immunology community has quickly responded by mobilizing practice adjustments and embracing new paradigms of care to protect patients and staff from severe acute respiratory syndrome coronavirus 2 exposure. Social distancing is key to slowing contagion but adds to complexity of care and increases isolation and anxiety. Uncertainty exists across a new COVID-19 reality, and clinician well-being may be an underappreciated priority. Wellness incorporates mental, physical, and spiritual health to protect against burnout, which impairs both coping and caregiving abilities. Understanding the stressors that COVID-19 is placing on clinicians can assist in recognizing what is needed to return to a point of wellness. Clinicians can leverage easily accessible tools, including the Strength-Focused and Meaning-Oriented Approach to Resilience and Transformation approach, wellness apps, mindfulness, and gratitude. Realizing early warning signs of anxiety, depression, substance abuse, and posttraumatic stress disorder is important to access safe and confidential resources. Implementing wellness strategies can improve flexibility, resilience, and outlook. Historical parallels demonstrate that perseverance is as inevitable as pandemics and that we need not navigate this unprecedented time alone.

Introduction

Despite global awareness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) since December 2019, coronavirus disease 2019 (COVID-19) has become a global pandemic that caught the world unprepared in the early months of 2020. It is now clear that SARS-CoV-2 is highly contagious, capable of causing severe pneumonia, acute respiratory distress syndrome, and death, particularly in vulnerable populations such as older adults and those with chronic medical conditions, such as cardiovascular disease, diabetes, respiratory disease, hypertension, and malignancy. , Strategies are being implemented to “flatten the curve” of the pandemic to preserve capacity and not outpace the availability of precious health care resources. The current supply of personal protective equipment (PPE), intensive care unit beds, and ventilators may not be able to keep up with projected demands. , This nightmare scenario has been experienced internationally, with countries such as Italy and Spain overwhelmed, and looming concerns that this may occur in certain parts of the United States. For example, the percentage of symptomatic patients with COVID-19 requiring intensive care unit care has been between 9% and 11%. Demonstrating the rapidity of spread, the first recognized case of the pandemic in Italy appears to have been a young man admitted in the Lombardy region with atypical pneumonia on February 20, 2020, and health care resources were overwhelmed within a few weeks. The timeline of the Italian experience illustrates a major reason for COVID-19–induced anxiety around the world (Figure 1 ).

Figure 1

The coronavirus pandemic in Italy. Reproduced from Livingston and Bucher.

Attempts to mitigate the impact of COVID-19 have disrupted core aspects of society. Social distancing is central to efforts to control the pandemic. However, to be effective, social distancing must be rapidly and universally adopted across a society, which sadly has occurred to varying degrees across the globe. Risk perception is likely a significant lever on the degree to which populations embrace a social distancing approach.

During a pandemic, both medical experts and governmental authorities require a high degree of accurate knowledge and trust to execute effective policies. Tragically, there has been a vacuum of unified societal knowledge and trust throughout this pandemic. For example, a recent cross-sectional survey of the general public in the United States and the United Kingdom found that, of 2986 US and 2988 UK adults, 23.9% and 18.4%, respectively, believed SARS-CoV-2 to be a bioterrorist weapon. When asked between February 23 and March 2, 2020, 61% of US and 72% of UK respondents thought the number of people who would die of COVID-19 in their respective country would be fewer than 500 persons.

In response to the medical community, local government, and concerned citizen frustrations with currently available policies and demands for detailed accurate information, our knowledge of COVID-19 is rapidly expanding. Unfortunately, the spread of the virus also continues to rapidly increase, with the Johns Hopkins Coronavirus Resource Center listing 607,965 total confirmed cases and 28,124 deaths as of March 27, 2020. The case-fatality rate (CFR) of COVID-19 is being scrutinized. Early data from China estimated the CFR to be 2.3% of symptomatic patients presenting for medical evaluation, with rates as high as 15% in vulnerable elderly populations. , In patients with critical illness, CFR has been reported to be as high as 49%. Although CFRs may actually be much lower when mild and asymptomatic cases are considered, the Italian CFR is 7.2% (Figure 1). Much of these data are hindered by lack of knowledge regarding the total number of cases. Health care worker fatalities were noted early and continue to rise in the United States. , In an early report from China, 3.8% of cases occurred in health care workers, and 14.8% of these were classified as severe, with a CFR of 0.3%. , In Italy, more than 50 physicians have died of COVID-19 as of March 27, 2020.

Despite this rising tide of illness, there is room for hope. Although the pace of change demanded in our response to COVID-19 is disorienting, it is important to note that, globally, 145,625 patients with confirmed cases have recovered as of March 29, 2020. There is a growing awareness of the need to protect health care workers from SARS-CoV-2 infection. However, in addition to an urgent need to prevent infections related to patient care, there is also a growing need to address broader aspects of wellness among health care workers.

The COVID-19 pandemic has created sudden stressors across many domains of our lives that become apparent when viewed through different lenses, including the theory of knowledge (“you don't know what you don't know,” information vs misinformation), appreciation of system capacity (both health and economic), understanding warranted and unwarranted variation, and human psychology. To survive COVID-19 and its aftermath requires care directed toward our patients as well as ourselves and our families. Although tending to personal wellness is always important, it has become even more crucial during these extraordinary times. Understanding risks and consequences of burnout magnified by COVID-19; identifying historical parallels of the pandemic while appreciating new challenges of social media; leveraging new technologies to care for patients, staff, colleagues, and ourselves while managing responsibilities at home; and using wellness resources at the American Academy of Allergy, Asthma & Immunology, the American College of Allergy, Asthma & Immunology, the Canadian Society of Allergy and Clinical Immunology, and state physician health programs as needed can help each of us navigate uncharted waters together, even while practicing social distancing.

Clinician Wellness

Clinician wellness involves a number of factors including stress and burnout. These factors can impact negatively on patient care and lead to increased medical errors, malpractice risk, and early retirement. Greater clinician stress may lead to higher rates of drug and alcohol addiction, divorce, and suicide. Clinicians are more likely to have burnout symptoms than the general US workforce and are more likely to be dissatisfied with work-life balance. Even before this pandemic, burnout rates among US physicians overall were estimated to be at around 46%. Female physicians have higher rates of burnout. A recent survey revealed a burnout rate of 35% among US allergy and immunology physicians in the United Ststes.

Higher rates of burnout may be associated with certain clinician attributes, including belief in service and sense of duty, perfectionism, and personal internalization of patient outcomes. Day-to-day office-based stressors include clerical burden (eg, electronic medical record documentation), excessive nonclinical and clinical workloads, and practice inefficiencies. , Although medical practice demands may contribute to burnout most significantly, personal and family stressors may add additional pressures. The current COVID-19 pandemic has disrupted the health care system worldwide. A prolonged response to the pandemic will lead to additional stress for clinicians and their support staff and further permeate throughout the health care system. Consequences of burnout are shown in Figure 2 .

Figure 2

Health state transition and outcomes of burnout. A listing of state physician health programs is available at the Web site of the Federation of State Physician Health Programs.

COVID-19 Challenges to Wellness

In the setting of a global pandemic it is normal to be frightened for one's own personal safety (and potential mortality), particularly with data emerging about airborne and fomite transmission, exposure risk from asymptomatic carriers, limited testing, and well-publicized issues regarding conflicting advice about what level of PPE is necessary or available. Finding evidenced-based PPE recommendations is difficult; however, over a 2-week span, the Centers for Disease Control and Prevention downgraded the COVID-19 risk from airborne to droplet (outside of an aerosol-generating procedure). Changing recommendations have been a cause of anxiety for clinicians, compounded by employment termination concerns in some instances for wearing precautionary PPE.

In a crisis, physicians may feel their medical oaths tested when confronted with ethical dilemmas that are intrinsic in rationed care due to equipment shortage or institutional policy of universal do not resuscitate status for COVID-19–positive patients. As the psychological stressors are evolving day by day, non–intensive care unit/emergency department physicians may be redeployed to less familiar (and critical) clinical areas. Questions regarding the ethics of providing care outside of one's scope of practice, and the associated liability, are evolving. The American Medical Association released an update to its code of medical ethics on March 20, 2020, specifically addressing these issues in Opinion 8.3 and Opinions 11.1.2 and 11.1.3. These may help provide an ethical backdrop on how to approach such situations, though this still may not do much to leverage preserving one's own wellness and ability to persevere in such circumstances. In New York state, Governor Cuomo has introduced legislation limiting any malpractice liability to physicians practicing outside of their scope, except in cases of gross negligence (which remains nebulously defined). However, outside of New York, such liability protection is unclear and may cause justifiable concern.

Many hospitals and health care systems are recognizing the stress and strain on their clinicians. Some have made counselors available and have been offering free access to online tools for meditation and relaxation. A plethora of such online tools exist, and sometimes a quick breather may serve as a way to recharge and regain some wellness, at least momentarily, when under stress. Multiple businesses have recognized the heroic efforts of the medical community and are offering free services—sometimes just a free coffee and donut may be enough to show that one's efforts are being appreciated. The real concern is that in stressful times, there is a temptation to self-medicate or resort to less productive and more self-harmful solutions—drugs and alcohol in particular, which may increase the risk for suicide and domestic violence. Physicians at baseline work high-stress jobs and are already prone toward issues, including marital problems, and substance abuse, that may become magnified in this particular crisis.

Change, Loss, Guilt, and Grieving

Change is difficult, and during COVID-19 change has been rapid and associated with both uncertainty and with varying degrees of loss. Guilt and grieving are also major considerations for our wellness. Elizabeth Kubler Ross defined 5 stages of grieving: denial, anger, bargaining, sadness, and acceptance. More recently, these stages have been updated to disbelief, yearning, anger, depression, and acceptance, with the depression peaking at approximately 6 months postloss, and acceptance not until 24 months postloss (Figure 3 ). Some of these stages may be more identifiable, though loss in the midst of this crisis may be harder to define, and may vary considerably on the basis of personal experiences. When the disease was abroad, there may have been denial/disbelief as to the severity and yearning for limited effects on our society. As testing kits and PPE have been deficient, anger at the government and administration is being felt. Physicians may find themselves bargaining for any way out as they are called to make life or death decisions.

Figure 3

Stages of grief. Elizabeth Kubler Ross defined 5 stages of grieving: denial, anger, bargaining, sadness, and acceptance. More recently, these stages have been updated to disbelief, yearning, anger, depression, and acceptance, with the depression peaking at approximately 6 months postloss and acceptance not until 24 months postloss. Reproduced from Maciejewski et al.

Undoubtedly, how we practice allergy has already changed, and in addition to health risks physicians face the looming reality of economic loss and associated anxiety. As COVID-19 becomes pervasive around us, there is a need to appreciate the potential for our own countertransference in considering our own personal and familial needs versus the needs of our patients and colleagues. This may be more difficult for some than for others. Naturally, we will all likely experience some degree of guilt and grieving for a number of potential reasons. However, as we may all cycle through these aforementioned stages, there is the final stage of acceptance as we find our way forward. Remind yourself this is a normal, healthy part of wellness, and things will hopefully change for the better.

A Historical Perspective

Historically, one can draw an analogy to tuberculosis (TB). In the 19th century, tuberculosis was responsible for 1 in 7 deaths. Like COVID-19, TB mortality also significantly impacted physicians. It was not until 1882 that Dr Edward L. Trudeau discovered the TB bacterium that caused the disease, and in 1896, when he opened the first sanatorium at Saranac Lake, NY, patients sat outdoors on the wide sun porches to take the “fresh air cure” and receive state-of-the art management of that era. Unfortunately, fresh air did not cure TB, and it was not until simple public health social distancing that TB declined sharply in the 1920s and 1930s. The societal struggle with TB demonstrates several parallels with the COVID-19 pandemic. Foremost is the clear and present danger posed by an infectious agent for which curative therapy is currently unavailable and for which only symptomatic management can be provided. This creates challenges to both health and wellness, because fear, anxiety, and frustration can threaten to overtake a rational approach to managing the situation of the moment.

A second parallel with TB is the temptation to embrace unproven therapies. For example, in the early 1880s, interventions used to treat TB included “collapse therapies,” in which physicians performed an elective pneumothorax, with the rationale for this procedure being to deprive the aerobic Mycobacteria of oxygen, in an attempt to kill them. This procedure involved injecting oxygen or nitrogen into the chest cavity with increasing pressure until the lung collapsed. However, this collapse was not permanent, and it required repeating the procedure every few weeks. It has been estimated that more than 100,000 patients underwent this procedure in the 25 years after this technique was developed, despite the fact that there were no rigorous studies conducted at the time to confirm its effectiveness. It was not until 1943 that Albert Schatz discovered streptomycin, which initially proved successful as TB monotherapy, but, over time, combination therapy was required. Similarly, trials are actively ongoing to treat COVID-19, including new antivirals, the use of hydroxychloroquine with azithromycin, anti–IL-6 agents, and the development of vaccines to name just a few.

We can learn from our past and realize that, even in the darkest times, there will be a bright future someday. As physicians our calling is to care for those in need. Ultimately, validation of effective treatments will lead to greater physician empowerment. In the meantime, wellness tools and strategies can help to manage our fears and anxiety while we practice medicine with the tools we have in the moment.

Social Media During a Global Pandemic: The Good, the Bad, and the Ugly

With billions of active users across various social media platforms such as Facebook, Twitter, and Instagram, the manner in which we communicate and receive information has fundamentally changed. We have unprecedented instant access to information on a scale the world has never seen before. Before the introduction of Facebook in 2006, including during the early stages of the internet, we relied on a limited number of vetted resources for information, namely major media outlets or the daily newspaper. In 2020, however, we live in the age of “FakeNews,” and internet users need savviness and knowledge to identify factual information and ignore misinformation. The opinions of celebrities, accounts with large numbers of followers, and online influencers are artificially equated with those of actual medical experts. This constant stream of information (and misinformation) can be overwhelming for anyone, let alone clinicians already facing stressful challenges in their professional and personal lives. Before COVID-19, internet addiction was already recognized as a growing problem contributing to social anxiety, attention deficit/hyperactivity disorder, and other aspects of wellness, which may only intensify during these trying times that are constantly reminding us of the stakes we face. During a global pandemic, social media utilization can be beneficial for updates of important information related to current precautions and best practices and provide connections to needed resources. It can also help to connect physicians with loved ones across the globe who are having similar fears and are socially distanced. There are simple, yet effective, strategies that merit review for all medical professionals who use social media in order to maximize benefit and mitigate risk (Table I ). More information on managing social media during the pandemic is included in this article's Online Repository at www.jaci-inpractice.org.

Table I

Tips to maximize the benefits of social media as a medical professional

Mindfulness	• Turn off all social media notifications—do not let your device dictate your life • Schedule time each day to interact with social media at a time when you are engaged and not distracted • Recognize when you are forming an emotional response and take time away when necessary • Develop habits to reinforce not interacting with electronics first thing in the morning or before sleep
Productivity	• Follow professional organizations to receive up-to-date vetted information • Follow journals of interest for the latest publications • Follow leaders and mentors in the field
Reaching a target audience	• Provide valuable content • Use common hashtags when posting information • Incorporate links to longer format articles or online resources • Use pictures, videos, gifs to increase engagement • Comment on posts from other accounts • Repost interesting or important information from other accounts • Answer questions when posed
Professionalism	• Maintain patient privacy at all times • Never provide individual medical advice; can direct toward general information or recommend contacting one's personal physician • Avoid cursing, strong political statements, or religious affirmations • Think twice before posting—once you hit send, it can never be completely deleted • Your opinions DO reflect your employer, even if stated otherwise; be aware of existing social media policies at your workplace
Balancing clinician wellness during COVID-19	• Engage in non–professional-related online endeavors, ie, podcasts pertaining to areas of interest • Find social groups of similar interests to your own and engage or simply follow • Seek out groups and friends with positive, uplifting messaging • Implement social media to share resources, such as PPE access • Use social media to promote kindness to others and connect with those who are socially distanced

Depression, Substance Abuse, and Suicide

There is a relative paucity of data and unknown prevalence regarding physician depression. Systematic reviews of medical students and residents showed depression prevalence at 27% and 29%, respectively. , , A 2020 Medscape survey of approximately 15,000 physicians revealed a rate of depression of 15% to 18%. Unfortunately, clinicians likely have incentive to conceal symptoms of depression for fear of putting hospital privileges or medical licenses in peril. Thus, the prevalence is likely to be underestimated.

Suicide rates for physicians are estimated to be higher than for the general public, and higher in female versus male physicians. , Physicians are more likely than nonphysicians to succeed in suicide attempts. The 2020 Medscape survey revealed that 21% to 22% of physicians had suicidal ideations and 1% to 2% had attempted suicide. Risk factors for suicide include depression, being single, not having children, substance abuse, access to drugs, and associated stress and burnout. , This has unfortunately also affected our field of allergy and immunology.

Although the exact prevalence of alcohol and drug addiction among clinicians is not known, physicians are not immune to substance abuse or exempt from personal tragedy of the current opioid epidemic. Unfortunately, stigma remains among clinicians reporting depression, substance abuse, addiction, and those attempting suicide.

With the increasing stresses and uncertainty regarding COVID-19, the clinician may be at an even greater risk. In fact, more than 70% of health care workers in China during this current pandemic reported psychological distress including insomnia, anxiety, and depression. Addressing these issues with a mental health care professional may be needed, and it is important to understand warning signs of depression, anxiety, posttraumatic stress disorder, alcoholism, and substance abuse. Besides detection, understanding how to access safe and confidential resources to get help is key. In fact, most states have resources for clinicians seeking help through self-referral for depression, alcoholism, and/or substance abuse, and accessing these resources is confidential and does not need to interfere with licensure or medical practice. A listing of state physician health programs is available at the Web site of the Federation of State Physician Health Programs.

Promoting Wellness While Maintaing Oupatient Practice During COVID-19

COVID-19 is adding to nonpandemic stresses of allergy and immunology physicians in practice, regardless of the clinical setting. For example, allergic conditions and COVID-19 symptoms have some overlap. Lack of information regarding COVID-19 testing also can increase anxiety of both clinician and patient. Allergy and immunology services such as biologic therapy and immunoglobulin replacement therapy are medically necessary and keep patients out of the emergency department and hospital, potentially saving resources for the care of the COVID-19 patient. However, recent guidance has suggested approaches such as telehealth when service reductions are required. Appropriate triage during the pandemic allows for effective social distancing; however, economic realities of service adjustments are inescapable, and the consequences of managing reduced revenue will create challenges to staff retention and maintaining a practice. Federal stimulus legislation may provide some relief of economic pressures during the pandemic. Advice to improve resilience during this time is outlined in Table II .41, 42, 43, 44 More information on wellness at work and cost-effectiveness of physician wellness is included in this article's Online Repository at www.jaci-inpractice.org.

Table II

Tips for allergy and immunology practice resilience during the COVID-19 pandemic

Use telehealth
Postpone nonessential patient visits and procedures
Create a practice task force for addressing and implementing changes
Train staff on implemented changes
Collaborate with other allergy and immunology colleagues
Review practice finances and plan for income changes
Overcommunicate with patients

Working at Home with Children

During the pandemic, school closures add a layer of complexity to finding a work-life balance. In addition, there are different family units, including single physician parent households, with various custody arrangements. Parents of older children are coping with a unique set of stressors trying to help them navigate an uncertain landscape. High-schoolers currently applying to college are concerned because standardized college admissions tests and advanced placement examinations are being canceled, and they are unsure as to how this will affect their college admissions process. Many college students are anxious about whether their summer internships will be canceled, whether graduate degree programs will understand and accept that many colleges and universities are only providing pass/fail grades this semester, and how they will complete courses that depend on face-to-face interactions, which range from the performing arts to chemistry labs. Many seniors are grieving the loss of graduation ceremonies or are worried that their postcollege full-time job offers will be rescinded. Across the spectrum of pediatrics, children with special needs require increased supervision, and parents may need to work in shifts to provide one-on-one attention. All these factors translate to added stress on clinicians and patients alike.

Working from home while supervising clinical and/or research activities is challenging and requires new workflows. In this setting, clinicians must balance electronic medical record communication and respond to urgent and routine messages. First, it is important to establish frequent, consistent video and/or phone communication with staff and assign bite-sized tasks. Breaking larger assignments into smaller concrete blocks can prevent overwhelming colleagues, increase empowerment, and nurture a sense of accomplishment and satisfaction. Second, it is important to realize that everyone is adjusting to new pandemic realities. Additional advice on working with kids at home is depicted in Table III .45, 46, 47

Table III

Suggested strategies for being productive at home with children of different ages

• Have a daily schedule and stick to it. Kids do better when they know what to expect • Post this schedule where everyone can see it. You can use pictures instead of words for younger children • If you have another adult at home, one method would be to alternate work and childcare hours for each of you • Older children can do their school work if they have it while you are “seeing” patients. Older children could also supervise younger children and help with educational activities • If you do not have help at home, another approach would be to work when the children are sleeping or safely engaged in a quiet activity. Schedule meetings if possible during nap time • For younger kids, bringing new or special toys can help keep them engaged for longer periods of time. Movies are another enjoyable option • Allow kids to socialize remotely with friends and family via FaceTime, Skype, etc • For older children, set daily goals and reward them. Allow them to play outside with siblings while maintaining social distancing • Have children do chores and help out around the house • Use the mute button during conference calls and have a silent do not disturb signal for when you are on important calls. You can also post a sign that signals that you are working • Being proactive and spending quality time with kids, during which you provide undivided attention, will also give you more uninterrupted time to work • Schedule times to get physical activity for you and the children, ideally together

Coping and Wellness Tools

Now more than ever, health care providers need to practice self-care. Coping with rapidly changing recommendations can become overwhelming, while stress and anxiety can become insidious bedfellows escalating a cycle of tension both at home and at work. Paradoxically, at a time when social distance is strongly encouraged, we can all find ourselves more interwoven with one another in a common struggle to persevere against an unimaginable global challenge. While we face the defining moment of our time, resilience, compassion, and serenity may be great assets.

Many of us are filled with a mix of complicated emotions at this time. Strategies that have worked for us in the past, like getting together in person with friends, family, or colleagues, are not available while practicing social distancing. This loss of personal connectivity leads to further struggles for many. At this time, we need to look for ways to connect virtually and ensure we are attending to clinician wellness. This pandemic is unlike anything most have experienced before; however, we are able to draw from our collective experience with previous tragedies and struggles, including September 11, 2001, Hurricane Katrina, severe acute respiratory syndrome, and H1N1 flu epidemics.

The Strength-Focused and Meaning-Oriented Approach to Resilience and Transformation, which is typically used by social workers after a crisis to help survivors develop resilience to get through and transform and grow in the process, can be used today in our present crisis. The framework uses mind, body, and spirit approaches to foster awareness, develop strength, and discover meaning. It addresses this through “emphasizing growth through pain” by focusing on what personal strengths may develop through the experience. It “teaches the mind-body-spirit connection” in recognizing that by taking care of our physical needs we can boost our mood and mental strength. Furthermore, “developing an appreciation of nature,” we are encouraged to appreciate the small things in life, appreciate our own life, and those of loved ones around us. By “facilitating cognitive reappraisal” we can develop new perspectives and remember resilient experiences during other crisis and past successes. “Nourishing social support” allows us to improve and enhance our development and resilience while simultaneously having a sense of acceptance and connectedness while learning to recognize and appreciate the support offered from those around us. The final tenet of this approach includes “promoting the compassionate helper principle” in which we learn from traumatic experiences by extending compassion to ourselves and others.

Even in the best of times, health care professionals often do not seek assistance when they are experiencing stress, burnout, depression, and suicidality because of concerns regarding confidentiality, cost, time, licensing and career concerns, and stigma. Pospos et al selected and evaluated several Web-based resources according to the American Psychiatric Association “app evaluation framework” to be used as a starting point to address depression, stress, and suicidal ideation, noting that ideal interventions would be effective, “convenient, accessible, affordable, and confidential” and ideally would be used in conjunction with direct professional care. The resources chosen would inocorporate the treatment approaches used to address burnout among health care professionals: meditation, breath work, relaxation techniques, mindfulness training, cognitive-behavioral therapy, and suicide prevention. The applications it recommended include Breath2Relax, Headspace, MoodGYM, Stress Gym, Stay Alive, and Virtual Hope Box. Of note, the only one that has been assessed for efficacy in health care professionals was MoodGYM, which was shown to reduce suicidal ideation among medical interns. Mindfulness-based therapy platforms can allow for a sense of community, connectedness, and a platform to share successes and promote resilience. Additional wellness resources are outlined in Table IV .

Table IV

Physician wellness resources

Online resources
AAAAI Physician Wellness Toolkit53
AMA steps forward54
Stanford WellMD55
Institute for Healthcare Improvement56
Alliance for Academic Internal Medicine (AAIM), Collaborative for Healing and Renewal in Medicine (CHARM)57
Meditation and mindfulness apps
Art of Living - Online Happiness58 Program for Healthcare Workers (no charge during COVID-19)
Headspace59
Ten percent happier60

AAAAI, American Academy of Allergy, Asthma & Immunology; AMA, American Medical Association.

At this time of social distancing it is important to maintain a schedule and your morning routine even if you do not have to leave the house. Enjoy nature while maintaining social distances. Take the time to connect with others virtually if you are feeling lonely via phone, email, and video platforms. When feeling overwhelmed by the number of people in the house, take some time for yourself in another room or go outside. Use the resources mentioned in this article to get support digitally. If this does not suffice, please reach out for professional help. Supports may be in place from local universities, the American Medical Association, and state and local professional societies. Limiting your news and social media consumption that you find upsetting may also reduce stress. Avoid using alcohol and other drugs to deal with your emotions—instead, use the skills that have enabled you to get through difficult situations in the past. Practicing compassion with yourself and others is also helpful. Initiating a gratitude practice has been shown to improve a sense of connection, quality, and amount of sleep and has improved well-being. This can be achieved through a gratitude journal in which you write daily entries about someone or something you are grateful for or listing 3 good things daily, which has been shown to reduce symptoms of depression and improve well-being. Engaging in a religious or spirituality practice has been associated with improved coping, strategies of acceptance, and less burnout in internal medicine and pediatric interns. Finally, allowing time to debrief, meditate, or discuss challenging situations and grief can be helpful to prevent burnout.

Governmental and health care agencies, institutions, and professional societies can help by sharing and continually updating information and resources. Communication that is concise, clear, transparent, timely, and thoughtful will help build a sense of control in health care providers. Data from the H1N1 pandemic revealed that sufficiency of information was associated with reduced worry. Freeing providers from administrative tasks will allow peak performance for longer periods of time. Leadership should encourage all providers to strive to live the tenets of physician wellness.

Conclusions

“World War V” is clearly upon us, with all the attendant anxieties and disruptions one might imagine when fighting an invisible enemy on home turf. We are faced with a new reality that has changed our culture, implicit assumptions, and basic underpinnings of our daily work. Mandated “stay-at-home” orders and self-quarantine social norms seem to have arrived overnight in some areas of the country, but a patchwork of inconsistency adds to a dizzying assessment of risk—and if we as medical experts find ourselves occasionally off balance, it is certain that our patients likely feel the same.

Clinician wellness can be an overlooked and marginalized aspect of our lives. In the daily hustle, self-care may often be a last priority as we continue to practice in a field of self-sacrifice and service to others. But if we do not realize it in the beginning, we will certainly realize it in the end that without self-care we will have nothing left to offer to anyone. The caregiver must take care of himself or herself if they want to do a good job taking care of others.

COVID-19 has arrived, and life is different. As we realize that we are in a seminal moment, that future generations may refer to “pre-COVID” and “post-COVID,” we must also pause to reflect, to breathe, and to care for ourselves and our loved ones. This COVID-19 pandemic will pass, and although SARS-CoV-2 may see a slow burn with seasonal encores in the next several years, the practice of allergy and immunology will continue to provide critical services, even as our infrastructure is temporarily reorganized during social distancing. As a specialty, allergy and immunology will continue to lead, and as our community comes together, we will persevere. Take care of yourself.