Flattening the curve of COVID’s emotional impact [PODCAST]

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“Based on the evidence of the effects of trauma, we can predict that our health care teams, patients and families will exhibit signs of this assault through a variety of symptoms–sleeplessness, apathy, depression, and anxiety. The warning signs are already here. We read the desperate accounts and pleas of frontline workers describing the indescribable, holding the hands of patients dying alone, communicating with stunned and distraught families isolated away from death beds of their loved ones. Dr. Breen is symptomatic of a larger undercurrent of the fatal moral injury of the system currently at work. We need to face it head-on or risk additional losses as tragic as this.”

Mary R. Talen is a psychologist. Deborah Edberg is a family physician.

They share their stories and discuss their KevinMD article, “Flattening the curve of COVID’s emotional impact.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Mary Talen and Deborah Edberg. They are co-authors of the KevinMD article “Flattening the curve of COVID’s emotional impact.” Mary and Deborah, welcome to the show.

Mary R. Talen: Thank you, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but Mary, first let’s start with you. Can you share your story and your journey to where you are today?

Mary R. Talen: Yeah, so I am a psychologist by training, and I have been working in family medicine residency programs for more years than I want to share. I have been privileged to work side by side with family docs and residents and just learn about the stress and strain of their training experience. And I think what brought me into this work is really seeing the burnout and impairment of physicians from the stress of the system and the moral injury that they encounter, and what a toll it takes on them. And in this COVID time, it just has exploded for all of us. And so Deb and I have worked together on physician wellness and kind of wrapping our heads around how we take this on from a systemic point of view, and that’s where we kind of got to this article.

Kevin Pho: Wonderful. And Deborah, you’ve been on the podcast before. You’re my first repeat guest. But share with my audience a quick paragraph about your story and your journey.

Deborah Edberg: Yes. So Mary and I were essentially partners in crime. We started a family medicine residency focused on underserved medicine on the West Side of Chicago about 10 years ago, and like Mary, I have just recently transitioned out, and I’m now working for Rush University to help them start a similar program, also on the West Side of Chicago, to help address health disparities.

Kevin Pho: Wonderful. I’m so happy that you guys wrote this article. The topic of burnout has always been a previously taboo topic when it comes to physicians and residents and medical students, and I think that the pandemic has certainly exacerbated those symptoms. So Mary, I’m going to start with you. Can you walk my audience through your article for those who haven’t read it and share the story, in depth, of why you decided to write it?

Mary R. Talen: So I want to go into the, I mean, just being a witness to what our health care systems and our providers have been experiencing in the hospital is certainly the first impetus to writing. But also, the article about Dr. Breen and her suicide has been so moving and telling. It was just a riveting experience of seeing what happens to our providers, and someone who’s so competent, having resources, and yet being able to mitigate against this sense of loss and hopelessness and disempowerment. That has really brought us to the point of saying, “What are we going to do in the midst of this crisis?”

Kevin Pho: So by Dr. Breen, you’re talking about Lorna Breen, the emergency physician in New York City, the tragic case where she was on the front lines of the COVID pandemic, and despite her best efforts, she tragically committed suicide and had a thorough write-up in the New York Times.

Mary R. Talen: And there was a recent follow-up to that article that we were referencing in our article that gave more details about what happened for her to get treatment and the support of her family. And even in the midst of that, the potency to counter the impact of what COVID has done was just not enough, and it’s so tragic.

Kevin Pho: So Deborah, when you heard the story of Dr. Breen and her tragic suicide, what was your reaction, and what was the reaction of your colleagues?

Deborah Edberg: I think that even before this happened, most of us were anticipating that something like this would happen and will continue to happen, just because what we were experiencing was unprecedented in many ways. And I have written about this before. I think as physicians, we are trained to deal with a certain amount of humanity that most people don’t get to see, and that can be an enormous emotional burden in a lot of ways. But this pandemic added on layers of stress and trauma that were not something that any of us were prepared for, that we should not have had to deal with: the lack of PPE, the overwhelming volumes of cases, the fact that we were so unprepared, and kind of this narrative that, “Oh, this is what we signed up for. We are the health care heroes.” And none of that is true. I mean, nobody signed up to be risking our own lives and the lives of our family to face down an illness that nobody knows how to treat, and just watching people die over and over again.

And I think that what happened to Dr. Breen was horribly tragic, but not unexpected. It was just kind of a symptom in that arc of how horrific this entire situation was. And I think for Mary and me, we are very much “What can we do?” kind of people, and “How can we help to support?” I was hearing from so many of the residents that I helped train who were floundering and just feeling very overwhelmed, very helpless, sort of being forced into this role that they hadn’t anticipated and weren’t sure that they wanted to be a part of. And how could we help them navigate that in some meaningful way? And that was how Mary and I came to sit down and try to write this article, to offer some type of a road map that people might be able to refer to.

Mary R. Talen: And I just had lunch with my new residents here, and they were in the hospital describing a situation of very long hours, code after code after code, and death after death, and it just came at them and kept coming at them. And today was one of the first days that they’ve been able to sit back and say, “OK, now I can start to talk about this. I just had to push on in the face of this urgency, this emergency.” And being able to be in a place where the leadership says, “Indeed, we have got to attend to what this is doing internally to our physicians,” is a call to arms for all of us.

Kevin Pho: So Mary, what are some of the symptoms that burnout manifests as? So if you’re a physician in training or if you’re a physician, how do you know when you need help?

Mary R. Talen: Yeah, so classically, it’s detachment and depersonalization, the sense of “I just don’t feel. I have no empathy anymore. I don’t feel anything. I don’t want to engage. I can go about my work like a robot.” And that kind of experience of feeling like “I am not really part of this. I don’t want to emotionally be part of it” is one of the classic signs.

Kevin Pho: And Deborah, you and Mary talked about a framework to help address this. Can you share with my audience a little bit about that framework?

Deborah Edberg: Yeah, and Mary and I had kind of thought through something like this even before the pandemic hit, all the different areas to ward off burnout in this type of situation. Obviously, number one is get the resources that the physicians and the health care workforce need. Make sure they’ve got PPE, make sure that there’s enough staff, that there are enough ICU beds. The public has to do their part and try to flatten the curve, obviously. And I think that what we were seeing were a lot of individual resources. There are hotlines, there’s “Call your therapist,” “Get help,” those kinds of things, and I think that that’s very helpful. I think that individualized therapy can help somebody process what they’re going through personally.

But the biggest part to me is that there needs to be space to share the experience, to discuss the shared trauma that everybody is experiencing, and I think that is often what is lacking. I think that organizations need to make space. I think it’s important that it not be optional, because as physicians, a lot of us feel very heroic, that we shouldn’t need help, that we shouldn’t come to something where we feel like, “Oh, we’re just doing this touchy-feely thing.” With our residents, we would have them sit down and do Balint groups and sort of process together. And I think that if it’s more an opt-out as opposed to an opt-in.

There’s nothing quite like sitting in a setting where you feel like you’re the only one who’s experienced something or feels something, and to say it and to have three or four or five people say, “Oh my gosh, I felt the same thing,” or “I saw the same thing.” There really isn’t a substitute for that, to feel like, “All right, I’m not alone. I have this experience that other people have too.” And you can’t really get that from people who haven’t been in it with you.

Mary R. Talen: And that is really drawing on the community of providers, and there’s something that is a natural bonding together to be able to face this. There is a part of our human nature where being together and sharing a trauma bond, if you will, brings some kind of relief and a sense of support. That should be second nature to the way that our health care systems work and the way that we allow for that kind of space and healing for our providers, and that isn’t there, and it needs to happen. Otherwise, we have a festering of the moral suffering that all of us encounter.

Kevin Pho: One of the things that struck me in your article was a concept of personally protective emotions. Mary, can you explain a little bit more about what that is?

Mary R. Talen: So it’s this idea, I mean, it’s a play on words of PPE, of course, but it’s a sense that we have to do something proactively to protect ourselves from the avalanche that you could experience later if we don’t start attending to it now. So being able to have that protective sense of “I can process this emotional experience in a safe place where people understand me and support me, and I’m not ostracized or judged for this, or I’m not reported as an impaired physician,” which is a huge barrier for so many of our providers. This is a way that we have to infuse into our system this sense of “You need to debride the impact of the experience, the traumatic experiences that you’ve gone through.”

Kevin Pho: Deborah, I have a lot of hospital administrators and CEOs who listen to this podcast, so you have a direct line to them. So what are some of the ways that they can help the situation?

Deborah Edberg: So I think they really need to make space for this type of processing based on what their health care workers think that they can do. It doesn’t have to be a large, blocked-out, two-hour sit-down. I mean, obviously, that could be what people need, but it can also be worked into rounds. It can be worked into the end of rounds, to have five or 10 minutes to say, “Let’s share an experience with a patient, something personal.” Personalized check-ins, to make sure that somebody is checking on every single person. I know that in the first responders literature, there’s some evidence that just having a buddy system, where your buddy checks on you to say, “Hey, I saw you had a really tough shift last night. You lost a few patients. I want to see how you are. Let’s sit down. Let’s talk about it.” So there’s a multitude of ways that it can get done.

So I think each organization can figure out what it is that works for them, but it needs to come from the providers themselves. It can’t be administrators deciding, “This is what we’re going to do.” They need to offer a menu of options and then hear back and make the space for it. I think that people feel like if we try to invest time in this or resources in this, it’s a money suck or whatever. We’re already hemorrhaging money from a pandemic in general. But it’s an investment for the future, because if they don’t pay attention to the mental health and the well-being of the people on the front line, they’re going to lose them. Six months, eight months from now, who’s going to be left? And so it’s absolutely worth the effort to be attentive to the mental wellness and well-being of the workers who are providing the care that they need.

Mary R. Talen: And it needs to come from the seniors, the attendings, and from the leadership, where people who are on the ground can say, “We are going to take the space and the time to talk about what just happened to you or to our team.” And also to be able to, if you see someone who has not taken a break, that person says, “No, we’re going to cover for you. You need to go and get something to eat, and you need to take this next 45 minutes to step away.” Those kinds of recalibrating and watching out for each other are how you build that sense of cohesion, and “I’m not in this alone, but I have other people watching my back.” And that needs to come from people who have the power to make it happen.

Deborah Edberg: Yeah, and days off. I mean, I think that is critical. There needs to be a limit to the number of days you work in a row, and then you need to have, if at all possible, an equal amount of days just away from the situation, because you’ve got to have a space to process.

Kevin Pho: We’re talking to Mary Talen and Deborah Edberg. They co-wrote the KevinMD article “Flattening the curve of COVID’s emotional impact.” Now I’m going to ask each of you for your take-home messages. Deborah, we’ll start with you.

Deborah Edberg: So I think that for me, being attentive to the emotional impact of what’s happening right now is critical, to take a step back to recognize this is a very strange and horrific experience that we were all experiencing. And it is just as important as anything else, as any PPE, to be attentive to the emotional impact and to do what you can to protect it.

Mary R. Talen: I would ditto that, and to look for the things that are already in place that you can build on, that this isn’t something where you are referring out, but you are taking what’s already there and being able to foster that natural kind of cohesion and connection, but giving more space and time for people to have that kind of emotional outlet and support from each other.

Kevin Pho: Mary and Deborah, thank you so much for your time and insight, and thank you both for being on the show.

Mary R. Talen: Thank you, Kevin.

Deborah Edberg: Thank you, Kevin.

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