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The coronavirus pandemic has been going on for almost two years, and there seems to be no end in sight. One strain replaces another, a new wave begins, and hospitals fill up again with patients. All the while, doctors have been fighting for the lives of patients in “red zones” – many of them already mentally and physically exhausted. Some have left the profession or changed fields, while others are preparing to do so.
What causes burnout among doctors in Russia and how do they deal with it? “I may be alive with you now, but when I get home, I will just lie down. I won’t talk to anyone, I won’t talk to anyone, I won’t read. I will lie down and wait for the next day. And I’ve been doing that for a few months now,” says 27-year-old Anastasia Protopopova. She found herself in the “red zone” at the very beginning of the pandemic – in the spring of 2020. She and her classmates, students at a medical university, were sent there for “volunteer” practice.
“We could refuse, but we have graduation courses, everyone wanted to go to the residency. They told us: ‘We will submit the lists of those who will not go to the Ministry of Health,'” the girl says. I think it’s nonsense, of course, but people in this situation didn’t want to test their fate. So the girl became a nurse in the intensive care unit of a large temporary center that housed patients with coronavirus. Anastasia admits she was “shocked” on her first day of work. Unlike most of her classmates, who were sent to help “milder” patients in intensive care, she was sent to the ICU: “When I started working as a nurse, I had almost no skills. Well, I could give my parents a shot in the butt. And here we come to the department, they send me to the ICU. I go in – everyone is on a respirator, something is beeping all the time, I look at it all with big eyes… I was even afraid to touch the patients, let alone work.
It took Anastasia some time to get used to the system. “A year and a half has passed and now I understand what to do and how to do it automatically. But the first time was very scary,” she says. Currently, the girl combines the position of a resident resuscitator in the “Green Zone” and a nurse in the intensive care unit COVID-19 in one of the Moscow hospitals. According to Anastasia, during the first year of working with COVID patients, she had the strength to mentally “distance” herself from the patients: “Of course, I didn’t disrespect them. But I could leave work at work. And home is home.”
But since the summer of 2021, the situation began to change, partly due to a family conflict. The nurse realized that she was starting to “take everything on herself,” worrying about every patient. She doesn’t know if she can call her condition “burnout,” but she knows “something is wrong.
Stories from doctors on the front lines of the coronavirus fight in New York, London, and Moscow. “Burnout in medicine is a common occurrence even outside a pandemic,” says psychotherapist Ekaterina Sigitova. “Burnout results from prolonged emotional and physical strain under conditions of constant work stress.” According to various sources, up to 40-50% of healthcare workers experience burnout at any given time. One psychotherapist highlights four core symptoms that can help identify burnout: We explain quickly, simply, and clearly what happened, why it matters, and what happens next.
In almost half of the cases, burnout is accompanied by depression, notes Sigitova. Often, overload leads to such a state of emotional exhaustion that during work a person “gathers and accelerates,” and then, when it is possible to stop performing their functions, the system shuts down, and nothing else fits in it – no worries, actions, desires, says psychologist Ekaterina Artemenko, community director of the online psychotherapy service “Yasno”. “Difficult situations lead to the aggravation of our crises. Sometimes, however, they allow us to be distracted from them and not notice them, and then the aforementioned disconnection occurs. But the crisis will catch up with us and we will still have to face important questions that every thinking and feeling person faces – why am I here, what is the meaning of all this?”, says the psychologist.
According to Sigitova, there are three degrees of burnout. In the first degree, workload reduction, meditation, walks and restoration of daily routine can help. In the second stage, a long vacation, sick leave, or a change of job usually helps, and in the third stage, psychotherapy and sometimes medication are required.
You can help yourself only if burnout has not gone too far, she stresses. “Classic recommendations for anyone who shows signs of burnout (including doctors): use all available stress reduction techniques, exercise more, maintain a daily routine, spend time in nature if possible, restore the boundary between work and personal life, seek support from others, consult a psychologist, reduce perfectionism,” explains Sigitova. However, she admits that all of this will be a “drop in the bucket” compared to the conditions of the pandemic and the working conditions that come with it.
“Some doctors and nurses, because of their personalities, simply cannot be less responsible and stressed; some have already missed the moment when something could have been done,” she explains. Sigitova says the only realistic advice she can give to doctors working during the pandemic who still do not want to change jobs is: “Wait out the hard times, they will definitely pass.” “The problem with medicine as an industry is that the causes of burnout are very rarely under the control of individual employees: in 80-90% of cases it is a result of poor organization of the treatment process,” says Sigitova. “Doctors and nurses are desperately trying to maintain a certain level of work quality and standards in conditions of chaos and uncertainty that they did not create. So without serious intervention from the top, it is unlikely that anything can be done to address burnout at the individual level.”
Denis Shoikhet, like Anastasia, was “called” to fight COVID-19 at the very beginning of his career – right out of college. He says he was one of the first to apply for a job as a nurse in a COVID hospital. He worked during the first wave from April to June, and with the start of the second wave, he finished university and started working as an on-call therapist in a polyclinic. At first, he says, he felt a sense of pride and involvement in a great cause: “In the very first wave, especially when everyone was saying on TV, ‘Doctors are heroes.’ It was very pleasant to realize that I was part of it.”
Relatives also reacted positively when they found out he was working with COVID patients, the doctor says. Other medical professionals spoken to by the BBC describe similar emotions during their initial work in the pandemic. Most of these medical professionals asked that their surnames and places of work not be revealed because they are not authorized to give official comments to the media.
At the temporary COVID hospital, Vadim, a cardiologist, had his first medical experience. “I felt something I had never felt before – no matter how difficult it was, I was needed by other people. It inspired me, and there was no talk of burnout,” he says of the first weeks of his work. “Here I was literally immersed in hospital life. And I liked it. I was drawn into it. It was what I wanted,” says Anastasia Protopopova about the beginning of her work in the Red Zone. “In my personal opinion, it was interesting for me to see patients with COVID,” says an anesthesiologist-resuscitator Dmitry (name changed at the request of the hero) in a conversation with the BBC about his experience working with COVID.
Many physicians note that they are motivated by the financial aspect of the issue – in the “red zone” they receive good salary supplements. But literally after a month or two, for most of them, the enthusiasm turned to frustration, and symptoms of burnout began to appear – much of it related precisely to problems of work organization.
For example, Vadim, after being transferred to the “red zone” of the hospital in Lyubertsy, encountered the indifference of the institution’s management to almost everything. “It was banal – there was no printer in the department, and we spent two weeks asking for it to be fixed. This led to conflicts and made it impossible to keep track of medical history,” he says.
He also worried about the overall instability of the job: “Right now you’re working every other day, and in a month you might not be working at all because some doctors are being laid off, and they say, ‘You’re not needed right now, but we’ll call you sometime.'” “Most of the work is done on a temporary contract. For me, this is a more significant factor in burnout than the patients themselves,” Vadim explains.
“Emotional burnout existed in my work before COVID-19, but in a milder form,” says Dmitry, an anesthesiologist-resuscitator. “But when I worked with these patients, a sense of the futility of my actions sometimes visited me, and it didn’t give me any energy.” He was burdened by the fact that the Covidh hospitals were built from scratch: “They were unstructured facilities, the processes were not fine-tuned, and the staff was not always optimally qualified.” “The efforts made under such conditions may not have yielded results, and that was certainly frustrating,” Dmitry explains.
The psychological state is strongly influenced by physical fatigue, says Anastasia. According to her, work in the “green zone” cannot even be compared to what happens in the “red zone,” where doctors and nurses are forced to work for hours in personal protective equipment. The doctors’ suits are impermeable to air, and it was very hot inside them, confirms Dmitri. Therapist Denis Shoykhet talks about the excessive workload of going out on calls: “During the epidemiological wave at home [during a shift], there are 30-40 patients, which is an incredible number. During a regular appointment in a polyclinic, where each patient is seen for 12 minutes, there are about 50-55 patients per shift. And at home it’s 40…”
Due to the indifference of the management, Vadim left the COVID hospital after working for less than a month. “I wasn’t afraid to go somewhere else, I had two other jobs. I just didn’t let myself get burnt out by doing meaningless things… To avoid burnout, it is important for me to engage in meaningful activities,” he clarifies. Today, Vadim works as a cardiologist in a private clinic and in a vascular center in the Moscow region and is feeling better.
The shochet continues to work with COVID patients, currently in the CT center and as a therapist on house calls, and says that he is already beginning to feel fatigue. “Last year there was hope that it would all be over in 2021, but this year I understand that it will most likely be over in 2024 or 2025…” he shares. “So far, I’m still hanging in there, I don’t know what’s next…” he says about his condition.
“Basically, all my efforts to do something for my patients are in vain. Because of those in intensive care, only a few survive,” Protopopova explains. “In our department, as far as I can remember, none of the patients over the age of 60 survived. And among the younger ones, there were those who survived, but the prognosis for life is a very long rehabilitation period, and it is generally unclear how it will all end”. Doctors say they feel helpless in the face of the disease they are fighting. There is still no effective treatment for the coronavirus, many continue to suffer severely, and the mortality rate remains high. In general, there are not many departments in Russia that are ready to take care of critically ill patients, says an intensive care specialist named Dmitry. “Treating such a patient requires enormous financial, human and labor resources,” he says. He speaks of many systemic problems related to a lack of drugs or insufficiently qualified personnel.
“What I was able to achieve in such conditions undoubtedly added positive emotions. But it is difficult to implement such a wish in many hospitals. It is really exhausting and does not motivate you to continue working,” he says. Now Dmitry, like many other doctors, has left the “red zone”: “Despite the fact that this job was quite well paid, there was a feeling of complete exhaustion, fatigue and lack of desire to continue.”
In such working conditions, the usual balance is lost, notes psychologist Ekaterina Artemenko. “Roughly speaking, even the dopamine from good work is produced less, because you have to deal with a much larger number of failures, the edges of which are not visible,” she explains.
The death of an 18-year-old boy who ended up in intensive care left the biggest impression on Anastasia Protopopova’s memory. “Everyone was running around him and… [pause] it didn’t work.” The girl was in medical school when the patient’s mother was informed of his death. “I will remember that scream for the rest of my life,” she says. Anastasia remembers another patient: “During my shift, I was given a child’s drawing for a woman on a respirator. She is about 50 years old. It broke my heart. I was supposed to just put it on her bed and leave. But I couldn’t help but stare at it and it made me so sad, so sorry for this child who draws pictures for her mother, but the mother is not coming back. It’s already clear that she’s not coming back. “I had a patient like that, already choking, intubated. And he said, ‘I should have been vaccinated. I said, ‘Well, it’s already too late. He didn’t survive,” Protopopova recalls.
The BBC physicians surveyed agree that the public’s skeptical attitude toward vaccination and protection also leads to a sense of meaninglessness in their work and, as a result, to burnout. “Now, thanks to vaccination, civic responsibility has emerged.
It has partly fallen on the shoulders of the population, and they did not like it,” Anastasia muses. “People like the way things used to be, when they could blame everyone but themselves. Now everyone blames the unvaccinated, and the unvaccinated blame the doctors.
At first, it annoyed Anastasia when people publicly called for refusing vaccinations. But then she had no strength left: “Drowning and suffocation, it seems to me, are the two most frightening deaths: when you can’t breathe. That’s what happens to our patients, they can’t breathe because their lungs are gone. Do people want that fate? Let’s do it.”
“Of course, when I saw the suffering of people who ended up in intensive care and couldn’t even eat because it’s difficult to take a break from breathing, there is… [pause] anger, maybe that’s not the right word, well, misunderstanding why many people are not forced to get vaccinated, to take some steps to stop the spread of infection,” says Dmitry.
But not everyone shares this view. For example, Vadim himself was against vaccination for a long time, because “in Russia it has become politics”. “The reluctance of Russians to be vaccinated is a protest not against the vaccine, but against the government. Because the government has done everything to be mistrusted,” Vadim believes. He calmly accepts the fact that not everyone wears masks in public places: “Even if a person doesn’t wear a mask, it’s their personal thing, they can get sick and die, it’s their choice. My job is to help.
Denis Shoikhet notes that working during the pandemic reduced his empathy and ability to empathize. “You just go about it as if it were work. Sometimes I have difficult patients, but I don’t feel anything. I don’t know, maybe that’s normal for our profession,” he says uncertainly. “Losing sensitivity is one of the psychological defenses. This is how we protect ourselves from overload,” says psychologist Ekaterina Artemenko. This is one of the symptoms of burnout mentioned by Sigita – doctors start treating people as functions or objects.
“At some point I started to realize that I don’t care anymore, I’m losing empathy,” says Vadim, recounting a similar experience. “I tell them [the patients] how to get treatment, how to proceed, but they don’t listen to me.”
He remembers one patient who was in the hospital for a week. Vadim came to him every day and talked to him, but when he was discharged, he realized that the patient didn’t even remember his name. “He stayed there for a week, I visited him all week… And I began to understand that I was also becoming indifferent. That is one of the reasons why I left that hospital,” he recalls. “When a young doctor feels a loss of empathy and compassion, it is necessary to leave, Vadim is sure”.
“The hardest year of my life”: How Regional Doctors in Russia Will Remember 2020 “Maybe the attitude to life has changed,” says Protopopova when asked how her experience with COVID has changed her. “In everyday life, no one thinks about death.” “And here, every day, every single day, you see how people die, how life ends,” she explains. “How they write notes with their last strength: ‘Tell my daughter not to take on burdens’. And you understand that there are only small things left. And you can’t really help them. It fundamentally changes your attitude to life.
She talks not just about work, but about life outside the hospital in general: “It also affects relationships. If it used to be that we’d fight and it seemed like we’d never communicate again – I’m exaggerating, of course, but still… Now I think it’s better not to fight at all, because who knows what tomorrow will bring”. Psychiatrist Ekaterina Sigitova says that those who have already suffered greatly should consider labor migration – either within the industry or to related industries. “This is not as terrible as it seems at the peak of burnout. You can and should take care of yourself in this way,” the psychotherapist notes.
Nearly 30% of those who work directly with coronavirus patients are on the verge of being fired due to fatigue, while 37% have experienced health problems due to emotional exhaustion, according to a survey of medical professionals conducted by the team behind the popular Doctor’s Handbook mobile application. According to a survey, physicians believe that society’s attitude toward them has changed significantly since the beginning of the pandemic: everyone has gotten used to doctors working in a constant emergency mode, they are no longer seen as heroes, and the extremely difficult work in “red zones” is now taken for granted. Respondents acknowledge that fatigue and emotional burnout are having a negative impact on their attitudes toward patients. The study included 2822 respondents, of whom the authors estimate that about 90% were physicians. At the time of the survey, 611 participants were working directly in the red zone.
“There is no such thing as what they show on TV. A doctor on discrimination and working conditions. Among doctors and nurses working in coronavirus hospitals and departments, only 12.6% are still “full of energy” and “go to work with interest”. Currently, there is a “negative balance” in the inflow of personnel into the health care system, said Deputy Prime Minister Tatyana Golikova at the end of October. According to her, doctors, more than any other group of people, are vulnerable to the consequences of COVID-19, which could be a reason for them to leave the profession.
The problem is not unique to Russia: WHO Director-General Tedros Adhanom Ghebreyesus noted in December that many healthcare workers were leaving the industry due to the difficult working conditions during the pandemic and the lack of adequate support. “Covid became a challenge for the entire healthcare system. At a time when we need to increase the number of healthcare workers – nurses and doctors – we are actually losing them,” he said. “Doctors and nurses have been working day and night for more than two years, and many of them are burned out with little recognition for their hard work,” said the WHO director-general.
“The absolute majority say they will not return to medicine after COVID. Now everyone in the ‘red zone’ earns money. They work for money, for children’s surgeries, for apartments, cars, grandparents and themselves,” Anastasia Protopopova shares her observations. Vadim is also confident that the people currently working with COVID patients are primarily motivated by money. “Everyone else is probably already burned out and gone,” he suggests. “Now I deal with completely different patients who are interested in their treatment, who have paid money, and who came to me specifically,” says Vadim, who works as a cardiologist. “They are also serious cases, but I help them, and I am very satisfied because I invest myself emotionally and professionally.”
“I am in a good mood because I feel I can help, people come back to me, I see the results of my work,” he says. The desire to leave medicine did not arise after a few seconds of reflection, says anesthesiologist-resuscitator Dmitry, who faced burnout while working in the COVID-19 ICU, but now happily works in the ICU of a regular hospital. “I’m interested in my work and have never wanted to quit, because I don’t see myself in any other profession,” he says.
Denis Shoikhet, who is currently working “in COVID”, says that after his residency, he will change his field of activity because this fight exhausts him. He adds that he plans to choose genetics as his specialty. Anastasia Protopopova had already considered quitting medicine before she was admitted to the COVID hospital because she was disillusioned with the profession. However, her opinion changed after working during the pandemic. “Now I understand that maybe I was born for this. Because I don’t see myself in any other field. I would leave medicine forever as the purpose of my life. With all the negatives, with all my ailments. I understand that I will go back there every day because that is where I am needed.
Illustrations by Magarram Zeynalov Editor Olga Shammina