Second victim experiences and moral injury as predictors of hospitalist burnout before and during the COVID-19 pandemic.

BACKGROUND: The increasing number of physicians leaving practice, especially hospitalists, has been well-documented. The most commonly examined factor associated with this exodus has been burnout. The COVID-19 pandemic has put a unique and unprecedented stress on hospitalists who have been at the front lines of patient care. Therefore, the investigation of burnout and its related factors in hospitalists is essential to preventing future physician shortages. OBJECTIVE: This study examined the relationship between burnout, second victim, and moral injury experiences before and during the COVID-19 pandemic among hospitalists. METHODS: Two anonymous cross-sectional surveys of hospitalists from a community hospital in the metropolitan Washington, DC area were conducted. One was conducted pre-COVID-19 (September-November 2019) and one was conducted during COVID-19 (July-August 2020). The surveys were sent to all full-time hospitalists via an online survey platform. A variety of areas were assessed including demographic (e.g., age, gender), work information (e.g., hours per week, years of experience), burnout, second victim experiences, well-being, and moral injury. RESULTS: Burnout rates among providers during these two time periods were similar. Second victim experiences remained prevalent in those who experienced burnout both pre and during COVID-19, but interestingly the prevalence increased in those without burnout during COVID-19. Moral injury was predictive of burnout during COVID-19. CONCLUSION: While there were some factors that predicted burnout that were similar both pre- and during-pandemic, moral injury was unique to predicting burnout during COVID-19. With burnout as a contributing factor to future physician shortages, it is imperative that predictive factors in a variety of different environments are well understood to prevent future shortages. Hospitalists may be an excellent barometer of these factors given their presence on the front line during the pandemic, and their experiences need to be further explored so that targeted interventions aimed at addressing those factors may be created.

Fast and furious: flecainide toxicity presenting as monomorphic ventricular tachycardia.

A 63-year-old woman on flecainide, furosemide, and triamterene-hydrochlorothiazide presented with weakness and diarrhoea. She had profound hyponatraemia, hypokalaemia and a pre-renal acute kidney injury (AKI). Her ECG showed a regular wide complex tachycardia concerning for monomorphic ventricular tachycardia. She was haemodynamically stable and treated with aggressive electrolyte repletion and amiodarone. Flecainide toxicity can present as a variety of arrhythmias and early recognition is crucial. This case focuses on flecainide toxicity from multiple concomitant insults: diuretic use, diarrhoea, hypokalaemia, hyponatraemia and pre-renal AKI. We emphasise the importance of close outpatient monitoring of electrolytes in a patient on diuretics and flecainide to prevent life-threatening arrhythmias. We discourage use of multiple diuretics in patients taking flecainide.