For most frontline physicians and healthcare workers, the Omicron surge at the beginning of 2022 was the hardest to manage. It seemed that the public cared less than ever before. Those who refused to get vaccinated or boosted, or to wear a mask, were even more indignant, and the escalating stress and exhaustion as the pandemic continued were reported by countless media. Today, mental health crises have become a secondary pandemic (Parker-Pope T, et al. Why 1,320 Therapists Are Worried About Mental Health in America Right Now. New York Times. Dec. 17, 2021).
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March 2022The significant impact on patient volume and the corresponding decrease in revenue had dire consequences, including layoffs, salary reduction, the expectation to work more with fewer resources, and less of the individual flexibility I had once intentionally created for my team. My core values and advocacy for well-being and resilience were in stark contrast with health system realities and financial imperatives. (A shout out to my fellow pediatric otolaryngology chiefs, who joined weekly and monthly calls to share information and ideas, and provide peer support.)
Through it all, I’ve asked myself, “What has it been like for other otolaryngology leaders?” With safety and stability nowhere in sight and endless changes inflicted upon our daily workflow, how are our leaders doing? Above all, I’ve wondered, “Are leaders human?”
Our otolaryngology leaders often seem infallible, tenacious, unflappable, and gifted with foresight and omniscience. They seem to never tire. The weight of leadership often isn’t visible to others, but stress can and will take its toll, even among the strongest of leaders.
Leaders shield us from the tsunami of health systems’ pressure to generate income and rush to centralize resources and decision making. They’re warriors who battle for individual and group autonomy, advocating for patients and care providers. Amidst COVID-19 risks, they have ensured that patients received high quality, safe care that’s aligned with our values, not just measured by metrics and patient survey responses.
Why should we care deeply about those who lead us? Because the well-being of physician leaders is associated with their leadership effectiveness—and our own well-being. In a 2020 study on the “association of burnout, professional fulfillment, and self-care practices of physician leaders with their independently rated leadership effectiveness,” 9.8% of the variation in leaders’ aggregate leadership behavior scores was associated with their own degree of burnout (JAMA Netw Open. 2020;3:e207961). After adjustment for age and sex, each one-point increase in leader burnout score was associated with a 0.19-point decrease in leadership behavior score (P = .02), whereas each one-point increase in their professional fulfillment and self-valuation scores was associated with a respective 0.13-point (P = .03) and 0.15-point (P = .03) increase in their leadership behavior score.
I asked a few otolaryngology academic chairs and chiefs to share their reflections; I hope to increase our awareness and gratitude for those who continue to serve. Below are their authentic responses, edited for clarity and length.
JW: What were your most difficult pandemic- or nonpandemic-related challenges?
Maie St. John, MD, PhD, chair, department of head and neck surgery, University of California, Los Angeles: In March 2020, when we didn’t know the full implications of COVID- 19, except the challenges from transmission and high mortality risks, I was faced with the realization that I wasn’t afraid of dying but afraid of leaving my three children motherless. I recall a conversation with my father about the uncertainty of my safety as reports of otolaryngologists dying from COVID-19 came to light. My father stated, “If you’re meant to go, you’ve done a lot of good.” Not having knowledge-based answers on how to protect our trainees and even my own children was difficult.
Partnering with chairs and chiefs across the country to gather and share accurate information critical to our department and helping people manage truth vs. narratives were challenging. I also didn’t want our people sitting around during the mandatory shutdown, so many were encouraged to write about their experience and be academically productive. Resource allocation was incredibly challenging, as personal protective equipment (PPE) was scarce. A grateful patient of mine who owned a huge toy company shifted his manufacturing to make powered air purifying respirators for our residents. We made sure our donors supported getting PPE for our residents, and I focused on making sure no one felt alone.
Gene Liu, MD, MMM, president, Cedars Sinai Medical Group: During the start of the pandemic, I served in several leadership roles: president of a 300+ provider multispecialty group including primary/ urgent care within a large health system, a member of the AAO-HNS Infectious Disease Committee; and program chair of a new residency program starting the inaugural class in July 2020. Once the pandemic hit, I also served as the surgical airway director for our 886-bed medical center. The number of decisions required in each of these areas seemed like full-time jobs in themselves. Trying to contribute effectively to each role felt impossible.
On the day the mandatory stayat- home order was implemented, I moved into an apartment to minimize the risk to my family as I worked in our COVID-19 clinic and set up urgent cares. PPE was sparse, safety protocols were just being developed, and very little was clear. Within a week, I fell ill with COVID-19, with moderate symptoms and remained in isolation for two weeks. Managing the physical symptoms and emotional and psychological fears about the unknown, while still assisting in the early pandemic response of our system, was definitely overwhelming.
Although nothing since has come close to those early pandemic days, ongoing frustrations continue to escalate. Each surge comes with sudden, all-consuming, frenetic work that feels like it should have been avoidable.
On a personal level, I always swore I wouldn’t become the stereotypical physician/surgeon/father who was never or rarely present for his children’s activities. I had started to carve out more time from professional obligations just before the pandemic hit, but since then I’ve been derailed with ongoing challenges related to COVID-19.
Daniel Choo, MD, division chief, pediatric otolaryngology–head and neck surgery, Cincinnati Children’s: Figuring out the proper prioritization balance between the safety and well-being of our patients, faculty, and staff was the most difficult challenge. For patients, it was prioritizing who needed to be seen and managed and who could be deferred. Life-and-death decisions on care were obvious; quality-of-life clinical decisions were more difficult.
For faculty and staff, it was how to keep them safe while managing their different risk tolerances—some didn’t want to see patients in person, others were happy to see everyone as normal; some wanted full PPE, while others thought that was ridiculous. And as things dragged on, it was hard to keep everyone financially whole when they were seeing a fraction of their normal patient load. I sidelined two of my older faculty members for a couple months due to their risk factors—but if I had them stop working, wasn’t I financially penalizing them at the same time?
The ripple effects were striking. Short term vs. immediate term, it was all about safety. Everything was disrupted and different. Nobody was acutely worried about how we would return back to normal. In the intermediate term, we shifted a bit to figuring out how to adjust to COVID-19—how we reintroduced aerosol-generating procedures into our clinics, how densely we scheduled patients, how we redeployed people to maximize safety and reduce exposure risks, etc. Long term, we integrated vaccination and booster status into our plans as we resumed operations. Our schedulers, pre-cert staff, and administrative assistants have all been working remotely from home, and that may or may not revert back to pre-COVID workflows. The cultural landscape has changed a lot.
JW: How were you able to accommodate increased demand on productivity amidst reduced resources and centralization?
Dr. Choo: We temporarily and partially shifted to a “generic physician” mode during COVID-19 peaks. Patients might see one MD in clinic but have another MD perform the surgery. Unlinking some patients from a particular physician allowed greater scheduling efficiency in the clinic and the OR. It was a big hit to patient–physician relationships and care continuity, but desperate times called for desperate measures.
Dr. St. John: During COVID-19, not everyone worked equally and some worked more so, risking their lives to greater degree, so our compensation plan was based on productivity. The model highly incentivized people to work late and do Saturday clinics. For two quarters in 2020, I made sure our overhead was split fairly among all 31 faculty members. In order to still be able to hire staff and support our academic mission, especially because we aren’t a hospital-based clinic model, we asked our donors to give what they could to our Head Neck Innovation Fund because we were being hit hard. Philanthropy is an important source of funding for our department.
JW: What were the most difficult decisions you have had to make since the start of the pandemic?
William Armstrong, MD, chair, department of otolaryngology–head and neck surgery, University of California, Irvine School of Medicine: The biggest challenge for me as chair has been deciding how long I’m willing to do this job, and sorting out why. The number one factor is that the job has changed profoundly over the last decade. Leadership has been seriously diminished, and management has significantly increased to the point where the chairs at our institution are relegated to [the role of] middle managers. I feel like the night manager at McDonald’s who has to focus on staffing and operations but has almost no role in shaping the direction of the department. This is because all the decision making has been centralized, and meetings with the C suite and dean are “informational” meetings. This is a national trend, and I think it’s unhealthy for medicine as a whole.
A second factor is that I’ve been doing the job for 14 years, and I’m trying to figure out how much of what I’m experiencing is that it’s becoming routine. I love patient care and teaching; administration is a burden I tolerate, although I do get satisfaction out of seeing the department grow and faculty and residents succeed. The ability to influence has decreased significantly, however.
The third is age dynamics. I’m heading toward 60 this year and thinking about what I want to do in the last productive decade of my career. Do I want to bang heads with administration? How long do I want to fight for the faculty, and am I being an effective advocate?
Mark Gerber, MD, division chief, otolaryngology, Phoenix Children’s Hospital: “In the beginning, it was splitting the team in half and keeping each of the teams isolated from one another. Now, here we are in the midst of a more infectious variant and the teams are mixing every day. We’ve delayed plans for adding more pediatric otolaryngologists who will ultimately be needed in the region due to the reduction of primary pediatric otolaryngology needs, and we’re unable to add support staff until more people return to the job market. Just this week, due to sick staff call-outs we’ve had to convert back to telehealth for most of our elective visits, at least for the next one to two weeks.”
Dr. Liu: We were in the process of a compensation plan redesign even before COVID. Trying to change how physicians are paid in the middle of the pandemic was unsettling for all. Ultimately, we still moved forward to better align our compensation model with the academic focus of our organization. Additionally, we were ready to hire a phenomenal surgeon–scientist when the pandemic hit. When everything shut down, we had to put a complete stop to the process and put our expansion plans on hold. It was tough, but the right decision in March 2020.
Dr. Choo: Early on, balancing the greater good vs. individual needs/ desires was consistently difficult. PPE was an easy example: There weren’t enough N95s to go around. Some faculty procured their own, but that left nursing and anesthesia staffs inequitably protected. Having discussions with faculty about compromising their own safety for the institutional good was very difficult.
JW: Given the weight and pace of evolving changes, what has been the impact to your own well-being, energy, and mental health, and what do you do for self-care?
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Dr. Choo: I truly never experienced any depletion of energy or sense of well-being. My saving grace was engaging more people to help lead and carry the load. My refueling was accomplished by watching people step up and demonstrate new skills, new leadership, new boldness, and new maturity as they were charged with new responsibilities and opportunities that probably wouldn’t have arisen without COVID-19. Candidly, more than 80% of the ideas that we implemented were conceived and developed by my COVID team. We had daily meetings during the peaks that were my recharge. Then, as things waned, we shifted to weekly and bi-weekly meetings. If anything, I miss the very close contact I had with that team and the active, high-energy decisions that we were implementing on a day-to-day basis.
Dr. Liu: The pressure to model the right behavior has meant that I’ve spent the last two years living a lifestyle with a very strict interpretation of safety precautions and recommendations, while everyone else seems to be having dinner out, going to concerts, and seeing friends. It can definitely feel very isolating at times. Self-care? At least there’s golf.
JW: How would you rate your job satisfaction now compared to three years ago?
Dr. Choo: High. Being engaged, relevant, and impactful are key drivers of my satisfaction. Making a difference hugely determines whether I’m enjoying my job. If nothing else, COVID-19 presented many of us with an elevated opportunity to make decisions and changes that were significantly impactful in people’s day-to-day and longterm lives. Through original COVID-19 and subsequently Delta, none of my faculty ever caught COVID-19, and only one administrative assistant developed significant illness requiring transient hospitalization. I’m not sure how many of my people have gotten Omicron, but I’m hopeful and confident that we won’t lose anyone to this variant before it starts waning. Reflecting back on that kind of end result, I can glean a lot of satisfaction.
Dr. St. John: I have higher job satisfaction now. The pandemic gave unique opportunities me as chair. I’ve brought in endowed chairs and feel positive as we’ve continued to build momentum through the COVID era.
Dr. Liu: Moderate. I feel great about the direction of our group and feel supported by the institution as we continue to rapidly grow. I do feel very frustrated by the ongoing pandemic, in part due to people’s continued refusal to vaccinate or wear masks.
Dr. Gerber: High. I still love what I do and have a great team. I’m disappointed that COVID-19 came around shortly after my arrival here, but it hasn’t beat the love of my job out of me yet.
Dr. Wei is chair of otolaryngology education for the University of Central Florida College of Medicine. She is also an associate editor on the ENTtoday editorial advisory board.