Physicians have been under an extraordinary amount of stress because of and related to the COVID-19 pandemic.
Although it is a labor of love, caring for people – either their physical or behavioral well-being – always can be stressful.
But COVID-19 has created a new level of stress: Long hours, uncertainty about how to care for and test potential and confirmed patients, and concerns about how to protect yourself, your staff, your patients, your family, your friends, and your community while caring for the sick. An ongoing lack of personal protective equipment adds another layer of frustration and stress.
Meanwhile, because of decreased patient visits and revenue, some physicians have had to make difficult business decisions to keep their practice afloat.
All of this can take its toll on you and your colleagues.
To help give you some perspective – as well as some insight and tips – into taking care of your own mental well-being, the Texas Medical Association reached out to Austin psychiatrist and internal medicine physician Thomas Kim, MD.
Dr. Kim, who serves on TMA’s Council on Legislation, Committee on Health Information Technology, and Subcommittee on Behavioral Health, spoke at length about what causes stress and ways to overcome it. The opinions expressed are those of Dr. Kim, not of TMA.
Listen to the entire interview via this recently published podcast, and check out the excerpts below. Dr. Kim even made a playlist, tapping into song to capture emotions that might feel familiar to physicians during COVID-19.
What about our current situation puts even the most resilient physicians at risk of wearing down mentally?
Our current reality during COVID-19 is so much more than an infectious disease pandemic or mass casualty disaster. We are all experiencing insecurity across every life domain including personal, professional, physical, psychological, social, and spiritual. I am at a loss for recalling a previous time when so many have experienced sustained insecurity and the end is not yet in sight.
What I know is that I am grateful to belong to a profession dedicated to the well-being of others. To borrow from (Austrian neurologist) Viktor Frankl, “Purposeful work is one of three paths to a meaningful life.” Purpose can bolster our resilience to overcome seemingly impossible challenges. Thinking about my colleagues in ERs and ICUs everywhere, I am humbled, but unsurprised. Having survived the rigors of medical training in an increasingly complex world, physicians are resilient by design. But this very resilience can also put us at risk. A friend of mine who is a critical care pulmonologist recently reached out to me to process how to manage 50 patients in need of a ventilator when his unit only had 16. Because the buck typically stops with physicians, physicians might be assumed to be the final arbiter in all situations, especially in a health care crisis. The result is that physicians are being relied upon for impossible decisions in equally impossible situations. This will undoubtedly have lasting effects long after the stay-at-home orders have lifted.
For all attention to the situation “on the front lines,” the warfront analogy seems to fall short in accounting for our colleagues practicing outside of hospital settings. I am especially concerned for small-practice physicians who are struggling to care for their patients in our new reality and don’t have the financial security of larger health systems. What they see are equally formidable challenges with no clear targets, no safe quarter in the rear, and the hits feel like they’re coming from every direction.
I’m certain that small-practice physicians are worried for their patients, but they now have the added concern for their staff, their families, and themselves. It’s important to remember that these concerns are not strictly occupational. How exactly are we supposed to balance caring for patients and ensuring our staff remain safe all while keeping the lights on? How is someone with small children supposed to navigate doing a more hazardous job while attending to their child’s well-being and education? How do you decide between running your practice at a loss in order to sustain your staff versus furloughing them knowing that staffing back up in the future might be far more costly? I imagine these are the questions that haunt many of us every day as we endure this pandemic. And to be clear, this is the reality for every small-business owner and employee in Texas and around the world.
How does the human body respond to intense stress?
I like to remember that the stress response is what keeps us alive. The stress response is what saved our forebears from tigers coming out of the jungle. The stress response is what helped me navigate running my first code in training. And the stress response helped me survive the first three months of my son’s life when I thought he was trying to kill me by sleep deprivation.
The stress response is also an elegant cascade of hormonal responses along our Hypothalamic-Pituitary-Adrenal axis. The result is our primary stress hormone, cortisol, which mediates a whole host of physiological “fight or flight” responses that influences most of our major organ systems.
Stressful situations are not by themselves a bad thing. But sustained chronic stress is very much so. There are a number of stress and trauma-based diagnoses such as PTSD or Generalized Anxiety. What these diagnoses share is a hijacking of the stress response, resulting in sustained and elevated levels of cortisol. And as with most things, too much of it is a bad thing. A helpful analogy I often share with patients is to consider chronic stress as the equivalent of driving on the highway in first gear. For those who don’t know how to drive a manual transmission, this may not resonate, but driving like this will burn out the engine.
Chronic stress negatively impacts every aspect of our lives both mentally and physically. Understanding and recognizing our own stress responses can help us develop ways to cope with it.
How can physicians prepare for a long, sustained period of intense stress?
Being prepared isn’t just for Boy Scouts, and preparedness can be enormously powerful to help ready ourselves against most anything. My thoughts on the value of preparing for intense stress are framed much like we frame the value of primary care: managing a heathy weight and diet is far superior to treating type 2 diabetes.
Preparedness starts with a readiness mindset; to respond rather than react. Most everyone around our state has been doing their best to be ready. Readiness leads to checklists, protocols, and aligned expectations which can mitigate the difficulties that lie ahead, particularly when things go wrong – and they will. Cultivating specific and practiced routines helps us maintain a positive challenge state with enhanced performance in the face of extreme stress and uncertainty.
The challenges we face may seem overwhelming and even paralyzing. Many physicians may be feeling lost in the enormity of everything that’s going on. And while no one can predict nor promise a specific future, there is only one way to eat an elephant: one bite at a time. Approaching momentous challenges step by step has gotten us to the moon among, other remarkable achievements, and it will help us persevere and overcome the current pandemic.
As our experience in the pandemic proceeds, stressors will begin to mount. What can physicians keep in mind during times of mounting stress to help maintain resilience?
When life inevitably hands us a lemon, finding hope in the positive aspects works to minimize negative distortions in thinking and identify constructive response strategies. The beauty of “making lemonade” is that it is a strategy most of us were familiar and have practiced before the pandemic, and something that we can build upon now.
Right now, most everywhere we look there’s a lemon. While our current situation is especially difficult, we may find there is still lemonade to be made. Staying at home has reminded us of the importance of familial and social ties. Many are turning to video chats to host virtual board game or puzzle nights, even at a distance. Without the crush of modern living pulling us in every direction, some people might have found occasion to rekindle personal interests, such as playing an instrument, exercising, or baking bread. On a more macro scale, our collective pause from life may be having a positive environmental impact. I understand Mumbai and Bangkok have never looked so beautiful.
But because of the enduring uncertainty and need for ongoing support, we may need to lead with the old-school approach of simply caring for each other. When I hear about people helping with food or medicine delivery so that a high-risk neighbor doesn’t needlessly have to venture out, I see a lovely and powerful benefit in both directions. Through simple acts of grace, we create a bit of security and hopefully remember that we get through these things together.
As a specific example, the challenge of educating our children is a particularly poignant example for me. I have discovered that I am a terrible middle school teacher. Despite finishing the 26th grade, fancying myself to be a lifelong learner, and having specific knowledge about brain development, it’s been tough for me to help my son continue his education in these uncertain times. That said, my wife, my colleagues, and my friends have been an enormous source of support for me. As a result, I have persisted, come up with new strategies, and we seem to be having fewer cross words and tears this week. I imagine next week will be better. And the week after better still. A big part of the strategy is continually reminding myself that we are in this together – and together, we will be OK.
How do you suggest physicians provide support to colleagues who may be struggling during this time?
Right now, it is so important for us to remember the ties that bind us. Expressing care and concern for one another is always the right call. Outside of a crisis, things go unsaid because the observer may be pre-occupied with their own life. They may be concerned about offending or alienating the person in distress. They may also hesitate to turn over this rock for fear of what they might find.
I suggest starting by simply asking “How are you?” or “Are you OK?” Borrowing from the literature around relationships, the two qualities that that have been found to support long-lasting romantic relationships are kindness and generosity. I think there is some generalizable value here with all relationships and recommend that we strive to be kinder and more generous with one another.
Of course, there is the concern of severe distress management. I wish to be clear that if anyone is unable to cope with their severe stress, please seek out or offer immediate assistance to the best of your ability. Do not hesitate to use or share the crisis hotlines, emergency mental health resources, and other supports available 24 hours per day.
As an example of “making lemonade,” what are your thoughts on the widespread uptake of telemedicine brought about by COVID-19?
We have remarkable technologic tools at our disposal that can support our continued work in caring for patients during this pandemic.
It took a global pandemic to re-evaluate some of the historic barriers preventing meaningful growth in telehealth, such as geographic restrictions and the lack of reimbursement parity. These desperate times have given us the opportunity to realize we have been holding on with both hands to a system of care that has limited bang while still costing a lot of bucks. Staying at home has freed up a hand to now grab for something potentially better.
Many physicians are likely to discover that telehealth improves health care delivery for patients and providers alike. It is my hope that expectations around care delivery will be forever changed for the better.
Alongside my enthusiasm is a gnawing sense of dread. This concern stems from the potential pitfalls of making decisions in a crisis. The current hullabaloo around Zoom security issues is an excellent example of why we should be more thoughtful and strategic around cultivating this new skill of delivering telehealth care. Another concern is around failing to see the true value of telehealth as connecting you to your doctor rather than simply a doctor. Mistakes will inevitably be made, and my hope is that when the dust settles, we strive to learn and grow from any missteps rather than try to put the genie back in the bottle and return to health care as usual.
I should highlight that the TMA has a wonderful resource page on its website that can be helpful in navigating the many strategic decisions to be made in order to provide telehealth services. If anyone should have a question not answered on the site, they are most welcome to contact me.
What is “mental health first aid” and why is this a beneficial skill set for physicians to have?
Mental Health First Aid is a training program designed to help people who have recently experienced a major trauma or are in acute crisis. It begins with teaching you how to identify mental illness and then how to supportive engage a person in crisis until such time they can access formal treatment, or the crisis resolves.
Even outside of a pandemic level crisis, being familiar with mental health first aid is a broadly useful skill much like CPR. This is because in addition to helping to overcome an acute crisis, mental health first aid has been shown to reduce stigma around mental illness by dispelling misconceptions and negative attitudes.
I would say that this is a beneficial skill for all physicians especially if they do not typically treat mental illness. Before the pandemic, I frequently joked that all physicians treated mental illness – just not well. Moving forward, I predict the need for mental health support will be greater than ever before, and mental health first aid can be vital to supporting everyone who needs help.
At some point, the immediate crisis will be over. What do you expect are going to be the long-term effects on physician mental health?
Mental health issues around crises typically follow a two-wave progression. The first wave peaks during the acute setting when everything is going sideways. Fortunately, the protective nature of our stress response and a challenge state of mind has been shown to blunt this phase as folks go into “crisis mode” and does what needs to be done. This is taxing work, and not everyone can be expected to manage this phase well. Attention to sleep, water, and food is critical to surviving this phase.
Once the crisis subsides, the second phase of mental health concern typically has a longer time of onset with a higher peak of intensity. The timing and intensity are directly influenced by how well-equipped the environment is to address the aftermath. If the infrastructure and resources are reasonably intact post-crisis, we can be more optimistic about recovery. If the environment has been critically devastated, recovery becomes more difficult and prolonged.
I don’t think we can currently speculate on how this pandemic will play out beyond epidemiologic modeling and evidence of when the pandemic surge will peak. If we remain in lockdown too long, the impact on essential and non-essential industries will leave us with limited capacity to recover quickly. If we end the restrictions too soon, we risk another round of infections with potentially more devastating impact in terms of loss of life and prolonged time course. And with no great potential futures moving forward, the challenge before us is formidable. What I do know is that we are all working towards better understanding the problem, which is the first step to finding a solution.
On the other side of this pandemic, it is likely that some of us will continue to feel distressed long after others appear to have gotten back to “normal.” In this situation, I would say that “normal” is largely an illusion. Following a crisis of significant magnitude, a return to normal – whatever that word might mean – is not a return to our best days of the past but is rather moving forward with intention and positivity. We will be bruised and scarred as a result of this pandemic. Those that get up off the mat will be the ones who are OK, and not everyone will find themselves in that group. The key takeaway here is that you do not have to do this alone. Asking for help is one of the hardest things a person can do. If anyone finds themselves struggling to find their path forward … we can and should rely on one another.
It’d be great to hear some of your thoughts on stigma. What can be done to reassure physicians that it is normal to need help processing this situation?
A helpful way to frame our new reality is to acknowledge that everyone is in the same boat. Regardless of history, status, or circumstance, we see rising levels of mood and anxiety distress in most everyone right now. This situational reaction to the pandemic reveals that we all experience symptoms associated with mental illness. I predict that this will have a positive effect on dispelling stigma long-term.
Being distressed in the face of crisis is not a character failing. Asking for help is an act of bravery. If we can remember these lessons once we get back to living our lives, we have an opportunity to address some long-standing societal challenges around stigma, mental illness, health disparities, and more. Once we see ourselves in each other, we will be better and stronger for it.
How can physician leaders help their colleagues and communities stay optimistic and resilient?
To be honest, I’m not sure my colleagues could do more. Both here in Texas and everywhere I look, I see my colleagues admirably fulfilling their professional oaths in some of the direst circumstances.
I hope that my responses have demonstrated a thoughtful balance of candid pragmatism and hopeful optimism. Lemonade isn’t made by ignoring the lemons. Lemonade comes from intention, effort, attitude, and other qualities that collectively boils down to choice. Choice always reminds me of the Cherokee legend of the two wolves. Put simply, a young boy learns that we all walk with two wolves, a good wolf and a bad wolf, who are constantly battling each other. When he asks his grandfather which wolf wins, the grandfather replies, whichever wolf you choose to feed. I choose to feed my good wolf as much as possible.
If I had one piece of encouragement for my colleagues, it would be to go easy on themselves. I would remind them that they are not alone and in the words of my son’s former PE teacher and archery coach: “We are all we got, and we are all we need.” I am confident that together we will make it through this pandemic.
Thomas Kim, MD, is a psychiatrist and internal medicine physician from Austin, who serves as principal for AGMP Telehealth. He has clinical expertise caring for a wide range of vulnerable populations including disaster victims. Dr. Kim serves on TMA’s Council on Legislation, Committee on Health Information Technology, and Subcommittee on Behavioral Health, and was also appointed to the governor’s newly formed Broadband Development Council.