University of Wisconsin–Madison Medical College of Wisconsin

Mental Health, the Impact of COVID-19, and More

Sarina Schrager, MD, MS, WMJ Editor-in-Chief

WMJ. 2021;120(4):256-257.

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The quadruple aim, described in a seminal article in 2014 by Bodenheimer and Sinsky, establishes clinician health as a key metric for measurement of quality of care.1 And as Fojtik articulates in his commentary in this issue,2 the previously well-defined triple aim (enhancing patient experience, optimizing population health, and reducing health care related costs) is not attainable unless the health care team is healthy. Burnout, or the feeling of emotional exhaustion and inability to feel effective in daily practice, is rampant and is correlated with decreased quality of care.3 High electronic medical record responsibilities, patient volumes, and heightened acuity have all contributed to the high levels of burnout among clinicians. And when clinicians are unhappy and feel ineffective, patients are less healthy. Thus, health systems around the world are working to find ways to support clinicians and mitigate the ever-increasing pressures of patient care.

Meanwhile, the COVID-19 pandemic has further stressed health care providers. From the vast unknown about a brand-new virus, to shortages of personal protective equipment at the beginning of the pandemic, to frustration with unvaccinated patients now, clinicians have been continually challenged over the last 2 years. New clinical processes and personal safety issues have pushed many clinicians out of the field. Since February 2020, almost 18% of all health care workers have left their jobs.4 Some data suggests that of those who remain, about a third have considered leaving.4 Unfortunately, as more clinical staff leave, the pressure on everyone else intensifies. Clinicians have demonstrated higher levels of anxiety and depression as well as posttraumatic stress disorder.5,6

A paper in this issue by Jewell et al looks at coping strategies by emergency department (ED) providers during two waves of the COVID-19 pandemic.7 Data suggests that burnout is very high among ED providers at a baseline.8 In the Jewell study, around 70% of people noted increased stress due to the pandemic. The researchers categorized coping strategies as being positive (“approach”) or negative (“avoidant”). The respondents described more approach coping than avoidant coping with some interesting distinctions. Women tended to use more approach coping strategies than did men, and residents tended to use more avoidant coping strategies than faculty.7 The physician assistants who responded to the survey described more excess stress than any of the other groups.

Another paper in this issue by Glisch et al looks at burnout rates among a group of academic hospitalists at the Medical College of Wisconsin.9 This study found an overall burnout rate of 62% among the 43 respondents to the survey. Burnout rates were higher among women (78%) and were related to high patient volumes and unrealistic workload, which also interfered with the clinicians’ ability to teach medical students. And there’s little doubt hospitalists have been increasingly stressed due to the high COVID patient volumes that continue in Wisconsin.

Multiple programs to address clinician well-being have included enhancing team-based care, improving communication, and prioritizing wellness—as well as specific process issues that overburden clinicians.10 Health care systems need to focus on these measures to successfully recruit and retain an excellent workforce.

The pandemic also has heightened mental health issues in the general population,11 a topic addressed by authors of two papers also in this issue   – one on the therapeutic effects of yoga12 and another about the efficacy of a culturally adapted intervention for depression in African American adults.13 Hampton and Bartz reviewed the literature, looking for evidence that supports the use of yoga to treat certain medical and psychological conditions. They found that yoga improved both depression and back pain and served to promote overall health and improve mental health.12 Ward et al found that a structured, culturally adapted class improved depression in a group of African American adults.13 This study challenges the health care profession to adapt interventions for diverse populations of people.

Finally, as the COVID-19 pandemic has shaken the health care environment to its core, the WMJ continues to publish content on clinical and system issues related to this virus, including a papers in this issue regarding COVID management and cultural practices in the Hmong community14 and more. To access a curated collection of all the papers WMJ has published regarding myriad aspects of COVID-19 in Wisconsin, visit our website.


  1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576. doi:10.1370/afm.1713
  2. Fojtik JE. The three confounding elements of the triple aim. WMJ. 2021;120(4):260-262.
  3. Tawfik DS, Scheid A, Profit J, et al. Evidence relating health care provider burnout and quality of care: a systematic review and meta-analysis. Ann Intern Med. 2019;171(8):555-567. doi:10.7326/M19-1152
  4. Masson G. About 1 in 5 healthcare workers have left medicine since the pandemic began—here’s why. Beckers Hospital Review. November 17, 2021. Accessed December 14, 2021.,survey%20research%20company%20Morning%20Consult.
  5. Carmassi C, Foghi C, Dell’Oste V, et al. PTSD symptoms in healthcare workers facing the three coronavirus outbreaks: What can we expect after the COVID-19 pandemic. Psychiatry Res. 2020;292:113312. doi:10.1016/j.psychres.2020.113312.
  6. Galbraith N, Boyda D, McFeeters D, Hassan T. The mental health of doctors during the COVID-19 pandemic. BJPsych Bull. 2021;45(2):93-97. doi: 10.1192/bjb.2020.44.
  7. Jewell C, Vandivort C, Patterson B, Schnapp BH. Coping strategies utilized by emergency department providers during the COVID-19 pandemic. WMJ. 2021;120(4):262-267.
  8. Rodriguez RM, Medak AJ, Baumann BM, et al. Academic emergency medicine physicians’ anxiety levels, stressors, and potential stress mitigation measures during the acceleration phase of the COVID-19 pandemic. Acad Emerg Med. 2020;27(8):700-707. doi: 10.1111/acem.14065
  9. Glisch C, Yadav S, Bhandari S, Jha P. Perceptions of burnout among academic hospitalists. WMJ. 2021;120(4):268-272.
  10. Rotenstein LS, Sinsky C, Csael CK. How to measure progress in addressing physician well-being beyond burnout. JAMA. 2021;326(21):2129-2130. doi: 10.1001/jama.2021.20175
  11.  Xiong J, Lipsitz O, Nasri F, et al. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. J Affect Disord. 2020;277:55-64. doi:10.1016/j.jad.2020.08.001.
  12. Hampton A, Bartz M. Therapeutic efficacy of yoga for common primary care conditions. WMJ. 2021;120(4):293-300.
  13. Ward EC, Brown RL, Sullivan-Wade L, Sainvilmar S. A culturally adapted depression intervention for African American adults: an efficacy trial. WMJ. 2021;120(4):273-280.
  14. Lor M, Xiong P. Lessons learned: COVID management and cultural practices in the US Hmong Community. WMJ. 2021;120(4)316-320.
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