Burnout for medical professionals during the COVID-19 pandemic in Greece; the role of primary care

KEYWORDS:

• Pediatrics
• COVID-19
• public health
• primary care

Introduction

The Greek state funded national health system is organized around tertiary care hospitals, with primary care being provided primarily by private practice physician. This leads to significant inequalities in terms of access to primary and preventive care, with financially disadvantaged citizens being de facto obliged to visit tertiary care hospital emergency departments even for minor ailments that could have been easily addressed in a primary care context [1]. In addition, due to the financial crisis, health promotion services were restricted to a bare minimum [2]. A need for health care system reform to allow universal access to state-funded primary care services has been echoed for years prior to the start of the COVID-19 pandemic [3].

The first cases of Covid-19 were reported at the end of February 2020 in Greece, and strict social distancing mandates were introduced swiftly on 7 March 2020. The strict lockdown lasted until 15 May 2020, and individual measures were repealed gradually [4].

Since the start of the COVID-19 pandemic, the national health system of Greece was protected from the surge of patients as consecutive lockdowns were imposed. However, lockdowns do not come without consequences as many people suffering from other diseases (such as acute myocardial infarction, chronic obstructive pulmonary disease exacerbations among others) were urged to stay at home, therefore leading to complications (i.e., heart failure, sepsis, or even death), as the primary diseases were left untreated [5]. A major issue that came up during the lockdowns was the indefinite suspension of elective surgery, leading to a deterioration of the quality of life of patients who needed them [6]. Furthermore, lockdowns had a major impact on the mental health of Greek people as the prevalence of anxiety and mood disorders as well as the suicide rate increased [7]. A recent paper [8] considers the public health measures imposed by the Greek government successful as early lockdowns reduced the mortality rate from SARS-COV2 infection. However, absolute mortality and mortality rates from other diseases are not addressed by the authors.

A great burden of work was placed upon resident physicians during the COVID-19 pandemic. Junior doctors in Greece are expected to work 35 hours a week (7 hours per day on weekdays) with a maximum of seven 24-hour call shifts per month. A minimum of 12 hours of rest for each 12 hours of active duty are mandated by European legislation, but due to staff shortages, this was never enforced in Greece, where residents had to work 24-hour shifts with no post call day off even prior to the pandemic [9].

Residents in Greece are required to have an unrestricted license to practice medicine, but in a hospital environment, it is expected that they work under constant supervision with the responsibility for all important clinical decisions falling on the attending physicians. There are significant discrepancies on the autonomy and supervision given to residents throughout Greece based on the requirements of the health care system [9].

Body

Between the consecutive lockdowns that were imposed as preventative measures of the pandemic, Greek hospital doctors were challenged. During this period, many doctors were working 24-hour shifts without taking the next day off as is mandated by European legislation, having to work 32−36 hours without rest [10]. Others were afraid to go home and come in contact with their loved ones fearing they could transfer the virus to them. As in other countries with more organized health care systems, doctors from surgical specialties were transferred to COVID-19 departments in order to help with the management of SARS-COV2 patients [11]. This measure was also applied to residents making their specialty training education deficient, as for example orthopedic residents were obliged to treat respiratory infections. At this point, it seems worthwhile to address the matter of Greek medical resident’s education more carefully as a study conducted before the COVID-19 pandemic reports that up to one third of the sample is not satisfied by the education offered during their residency [12]. Last, but not least, during the pandemic, doctors (both residents and consultants) were not able to receive their regular vacation time (20 days per year for new residents) due to an increased demand for staff. The situation became even worse when the government suspended the services of health care professionals who chose to remain unvaccinated [9].

Even before the pandemic, it was well known that Greek junior doctors work more than the 48-hour work week mandated by the European legislation without additional compensation for their services [10]. For example, a medical trainee may be required to stay at the hospital beyond their working hours in order to admit new patients as certain hospitals admit patients each day. Therefore, should a patient come near the time the shift is closing, the medical resident is required to stay at the hospital without any additional payment, even though it is required according to his contract [13].

It is known that primary health care in Greece is understaffed and has been struggling because patients have immediate access to the hospital without having to visit a general practitioner first [14]. This results in primary care for those unable to visit a private physician being assigned to state hospital emergency departments. In addition, emergency department triage lacks general practitioners as most medical graduates do not choose this specialty, opting instead for internal medicine due to a perception of increased prestige compared to general practice [15]. For this reason, patients present to the hospital even for minor problems that could have been dealt with in a primary care setting, including COVID-19 patients. As a result of this, emergency department visit rates are greater than most hospitals can bear, with disastrous delays and deficiencies in care provided. It is evident that if Greece had a more organized primary health care system, regional medical centers could admit patients with mild COVID-19 and offer them supportive therapy with oxygen for a couple of days.

Conclusion

Lockdowns may have led to a lower incidence of COVID-19 as they delayed the spread of the virus, at the cost of reducing access to medical care for patients with other serious medical conditions. If primary care was more organized and sufficiently staffed in Greece, hospitals would not have to deal with the majority of patients, and tertiary care hospitals would be able to focus on the treatment of those who actually required tertiary care. At this point, it is seems that the solution to the pandemic might have been a more organized health care system based on primary care providers and not on hospitals.

Disclosure of any financial/other competing interests

The authors have no relevant conflicts of interest to disclose. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

Gerasimos Panagiotis Milas: Conceptualization and writing of original draft; Vasileios Issaris: Writing the original draft; Nikolaos Zareifopoulos: Writing, review and editing.

Additional information

Funding

The authors received no direct funding for this research.