The Hardest Weeks of My Life: A Qualitative Study of Experiences, Practice Changes, and Emotional Burden of New York City Oncology Physicians During the COVID-19 Surge in 2020

Abstract

QUESTION ASKED: What were the experiences of New York City (NYC)-based cancer care physicians during the Spring 2020 COVID-19 surge, including practice changes, challenges, and emotional burden? SUMMARY ANSWER: The uncertainty brought on by the initial COVID-19 surge challenged many of the fundamental approaches of oncology physicians and hospi-talists, from decision-making strategies to patient contact. Practicing in the global epicenter, cancer care physicians experienced fears of exposure and decisional distress while striving to preserve quality oncology care. WHAT WE DID: We conducted a virtual qualitative study with a targeted sample of physicians from a dedicated cancer hospital in NYC. Participants included medical oncology physicians from two of the largest inpatient and outpatient services (gynecologic [GYN] and GI) and oncologic hospitalists who attended on these services during the first two months of the COVID-19 surge in NYC. Interview transcripts were analyzed using a thematic analysis approach. WHAT WE FOUND: Qualitative analysis identified fear and distress as the two most resonant emotions, organized around five major themes: (1) perceived patient fears of the hospital during COVID-19, leading to avoidance and delay of acute care needs before admission, (2) physicians' fear and distress delivering oncology care during COVID-19, (3) physician distress resulting from ambiguity in decision making, (4) distress and anxiety balancing the need for patient contact with the need to minimize infection risk, and (5) distress regarding impact of uncertainty and acuity of COVID-19 on goals-of-care discussions. BIAS, CONFOUNDING FACTOR(S): Our study is from a single institution and was limited to two services within that institution. Although we aimed to sample a mix of junior, midlevel, and senior physicians, there may be selection bias present within the sample. Nevertheless , the unique environment makes this an appropriate study setting for this research. By examining physician experience in the cancer setting, we were able to identify nuances in decision distress that may not have been detected otherwise. REAL-LIFE IMPLICATIONS: These data support recent hypotheses that moral distress may have intensified among oncology clinicians during the COVID-19 pandemic. Anxious reflection on the impact of clinical decisions and expressions of decisional regret raise concerns about the long-term impacts of COVID-19 on oncologist mental health and well-being. Given the fear and regret described here, institutions should consider ongoing assessment for stress-including post-traumatic stress disorder-among their workforce. Specific interventions to address burnout are urgently needed for oncologic hospitalists, given their role on the frontlines of inpatient care and persistent fears of COVID-19 exposure. Concerns regarding resource allocation and risk to colleagues confounded oncology care in unprecedented ways and fostered decisional regret. In planning for future COVID-19 surges, institutions should consider incorporating structured staff debriefing sessions into their hospital response protocols and group meetings to share both rapidly emerging knowledge and the burdens of uncertainty to reduce staff confusion and isolation as a pathway for integrating physician concerns and recommendations into institutional decision making. abstract PURPOSE The COVID-19 pandemic surge in New York City in Spring 2020 resulted in an unprecedented constraint on health care resources. This study aimed to explore the experiences of doctors providing care to oncology patients during this time. METHODS Hospitalists and medical oncologists from two large inpatient services at a dedicated cancer center participated in virtual in-depth interviews exploring how the pandemic affected their practice and to what extent it may have affected decisions for urgent evaluation or hospital admission, interventions, or goals-of-care discussions. Interviews also explored how the pandemic affected each individual physician's psychologic well-being. Transcripts were analyzed by three independent coders in Atlas.ti v. 7.5, using a thematic analysis approach. RESULTS Eighteen physicians were interviewed (n 5 6 GI medical oncologists, n 5 6 gynecologic medical oncologists, and n 5 6 hospitalists). Analysis identified five major themes related to fear and distress: (1) perceived patient fears of the hospital during COVID-19, leading to avoidance and delay of acute care needs before admission, (2) physicians' fear and distress delivering oncology care during COVID-19, (3) physician distress resulting from ambiguity in decision making, (4) distress and anxiety balancing the need for patient contact with the need to minimize infection risk, and (5) distress regarding impact of uncertainty and acuity of COVID-19 on goals-of-care discussions. CONCLUSION Insight into the experiences of physicians providing cancer care during a COVID-19 surge underscores the need for strategies mitigate short-term distress and long-term psychologic impacts. Findings can also inform practitioner training and preparedness for future pandemics in the oncology setting.