Impact of the COVID-19 Pandemic on Medical Students' Perceptions of Health Care for Vulnerable Populations.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic highlighted the shortcomings of our health care delivery system for vulnerable populations and created a need to rethink health disparity education in medical training. We examined how the early COVID-19 pandemic impacted third-year medical students' attitudes, perceptions, and sense of responsibility regarding health care delivery for vulnerable populations. METHODS: Third-year family medicine clerkship students at a large, private medical school in Philadelphia, Pennsylvania responded to a reflection assignment prompt asking how the COVID-19 pandemic impacted their thoughts about health care delivery for vulnerable populations in mid-2020 (N=59). Using conventional content analysis, we identified three main themes across 24 codes. RESULTS: Students recognized homeless individuals and Black, indigenous, and persons of color (BIPOC) as vulnerable populations impacted by the pandemic. Students reported causes of vulnerability that focused heavily on social determinants of health, increased risk for contracting COVID-19 infections, and difficulty adhering to COVID-19 prevention guidelines. Notable action-oriented approaches to addressing these disparities included health care reform and community health intervention. CONCLUSIONS: Our findings describe an educational approach to care for vulnerable populations based on awareness, attitudes, and social action. Medical education must continue to teach students how to identify ways to mitigate disparities in order to achieve health equity.

Burnout and Commitment After 18 Months of the COVID-19 Pandemic: A Follow-Up Qualitative Study with Primary Care Teams.

BACKGROUND: Primary care practice teams continue to grapple with the demands of the COVID-19 pandemic. Early in the pandemic, despite the increased demands and low levels of control, in practices where protective equipment were available and practice-level support was high, few team members reported burnout, and many described a greater sense of purpose. However, since those early days, burnout levels have increased and high rates of turnover have been reported across the health care system, and further qualitative studies are needed. OBJECTIVE: The present study is a follow-up to a qualitative study on the workplace stress during the pandemic. DESIGN, PARTICIPANTS, APPROACH: Fourteen primary care providers and staff completed 1-year follow-up semistructured interviews (approximately 1.5 years into the pandemic) about their workplace demands, control, social support, burnout, and commitment to primary care. PRIMARY RESULTS: Primary care practice was characterized as high demand before the pandemic but the additional demands of the pandemic were leading participants to consider early retirement, quitting primary care or health care, and expressing a profound need for health care redesign. Short staffing extended medical leaves for COVID-19 and non-COVID-19 needs, increased management of patient mental health and aggressive behaviors, and frustration that practices were being held to prepandemic metrics all contributed to ever higher rates of burnout. Troublingly, while many described high-quality relationships at the practice level, the majority of participants described their organization-level support as largely unresponsive to their input and as offering little support or resources, though a few acknowledged that this could reflect that leadership is also under immense strain. Despite challenges, a number of participants expressed continued commitment to primary care. CONCLUSION: Fundamental redesign of primary care is required to prevent further loss of health care personnel and to provide opportunities for these staff to recover during the grueling, ongoing crisis.

A Qualitative Exploration of the Functional, Social, and Emotional Impacts of the COVID-19 Pandemic on People Who Use Drugs.

Since 2020, people who use drugs (PWUD) experienced heightened risks related to drug supply disruptions, contamination, overdose, social isolation, and increased stress. This study explored how the lives of PWUD changed in Philadelphia over a one-year period. Using semi-structured interviews with 20 participants in a Housing First, low-barrier medication for opioid use (MOUD) program in Philadelphia, the effects of the first year of the COVID-19 pandemic on the daily lives, resources, functioning, substance use, and treatment of PWUD were explored. Interviews were analyzed using a combination of directed and conventional content analysis. Six overarching themes emerged during data analysis: (1) response to the pandemic; (2) access to MOUD and support services; (3) substance use; (4) impacts on mental health, physical health, and daily functioning; (5) social network impacts; and (6) fulfillment of basic needs. Participants reported disruptions in every domain of life, challenges meeting their basic needs, and elevated risk for adverse events. MOUD service providers offset some risks and provided material supports, treatment, social interaction, and emotional support. These results highlight how there were significant disruptions to the lives of PWUD during the first year of the COVID-19 pandemic and identified critical areas for future intervention and policies.

Burnout and Commitment to Primary Care: Lessons From the Early Impacts of COVID-19 on the Workplace Stress of Primary Care Practice Teams.

PURPOSE: The COVID-19 pandemic has dramatically affected all areas of health care. Primary care practices are on the front lines for patients seeking health care during this period. Understanding clinical and administrative staff members' strategies for managing the broad-ranging changes to primary care service delivery is important for the support of workforce well-being, burnout, and commitment to primary care. METHODS: Thirty-three staff members from 8 practices within a single health care system completed short, semistructured interviews from May 11, 2020 to July 20, 2020. Interviews were coded using a combination of conventional and directed content analysis. RESULTS: Themes emerged from the data that mapped onto the Job Demands-Control-Social Support model. Participants reported that every aspect of primary care service delivery needed to be adapted for COVID-19, which increased their job demands significantly. Several also described pride in their development of new skills, and in most interviews, they expressed that the experience brought staff together. Staff engaged in active cognitive reframing of events during the interviews as they coped with increased workplace stress. However, as the pandemic changed from an acute stress event to a chronic stressor, staff were more likely to indicate signs of burnout. CONCLUSIONS: Primary care teams absorbed tremendous burdens during COVID-19 but also found that some stress was offset by increased support from management and colleagues, belief in their own necessity, and new development opportunities. Considering high prepandemic strain levels, the ability of primary care teams to persist under these conditions might erode as the crisis becomes an enduring challenge.

Work Redesign for the 21st Century: Promising Strategies for Enhancing Worker Well-Being.

Work is a key social determinant of population health and well-being. Yet, efforts to improve worker well-being in the United States are often focused on changing individual health behaviors via employer wellness programs. The COVID-19 health crisis has brought into sharp relief some of the limitations of current approaches, revealing structural conditions that heighten the vulnerability of workers and their families to physical and psychosocial stressors. To address these gaps, we build on existing frameworks and work redesign research to propose a model of work redesign updated for the 21st century that identifies strategies to reshape work conditions that are a root cause of stress-related health problems. These strategies include increasing worker schedule control and voice, moderating job demands, and providing training and employer support aimed at enhancing social relations at work. We conclude that work redesign offers new and viable directions for improving worker well-being and that guidance from federal and state governments could encourage the adoption and effective implementation of such initiatives. (Am J Public Health. 2021;111(10):1787-1795. https://doi.org/10.2105/AJPH.2021.306283).

A qualitative analysis of third-year medical students' reflection essays regarding the impact of COVID-19 on their education.

BACKGROUND: The COVID-19 pandemic fundamentally changed every aspect of healthcare delivery and training. Few studies have reported on the impact of these changes on the experiences, skill development, and career expectations of medical students. METHOD: Using 59 responses to a short reflection essay prompt, 3rd year medical students in Philadelphia described how the COVID-19 pandemic affected their education in mid-2020. Using conventional content analysis, six main themes were identified across 14 codes. RESULTS: Students reported concerns regarding their decreased clinical skill training and specialty exposure on their career development due to the loss of in-person experience during their family medicine clerkship. A small number felt very let down and exploited by the continued high cost of tuition while missing clinical interactions. However, many students also expressed professional pride and derived meaning from limited patient and mentorship opportunities. Many students developed a new sense of purpose and a call to become stronger public health and patient advocates. CONCLUSIONS: The medical field will need to adapt to support medical students adversely impacted by the COVID-19 pandemic, from an educational and mental health standpoint. However, there are encouraging signs that this may also galvanize many students to engage in leadership roles in their communities, to become more empathetic and thoughtful physicians, and to redesign healthcare in the future to better meet the needs of their most vulnerable patients.

The impact of COVID-19 on healthcare delivery for people who use opioids: a scoping review.

RESEARCH OBJECTIVE: The COVID-19 pandemic disrupted healthcare delivery worldwide with likely negative effects on people who use opioids (PWUO). This scoping review of the original research literature describes the impact of the COVID-19 pandemic on healthcare delivery for PWUO and identifies gaps in the literature. METHODS: This scoping review of the original research literature maps the available knowledge regarding the impact of the COVID-19 pandemic on healthcare delivery for PWUO. We utilized the methodology developed by the Joanna Briggs Institute for scoping reviews, and content analyses methodology to characterize the current state of the literature. RESULTS: Of the 14 included studies, administrative database (n = 11), cross-sectional (n = 1) or qualitative (n = 2) studies demonstrated service gaps (n = 7), patient/provider experiences (n = 3), and patient outcomes for PWUO (n = 4). In March 2020, healthcare utilization dropped quickly, sharply increasing only for reasons of opioid overdose by May 2020. Service gaps existed in accessing treatment for new patients during the pandemic due to capacity and infrastructure limits. Physicians reported difficulty referring patients to begin an outpatient opioid treatment program due to increased restrictions in capacity and infrastructure. Patients also reported uncertainty about accessing outpatient treatment, but that telehealth initiation of buprenorphine increased access to treatment from home. Disproportionate increases in overdose rates among African Americans were reported in two studies, with differences by race and gender not examined in most studies. Fatal overdoses increased 60% in African Americans during the pandemic, while fatal overdoses in Non-Hispanic White individuals decreased. CONCLUSIONS: In summary, this beginning evidence demonstrates that despite early reluctance to use the healthcare system, opioid overdose-related use of healthcare increased throughout the pandemic. Service delivery for medications to treat OUD remained at or above pre-pandemic levels, indicating the ability of telehealth to meet demand. Yet, racial disparities that existed pre-pandemic for PWUO are intensifying, and targeted intervention for high-risk groups is warranted to prevent further mortality. As the pandemic progresses, future research must focus on identifying and supporting subgroups of PWUO who are at heightened risk for experiencing negative outcomes and lack of access to care.