Moral injury and practicing oncology during COVID-19 [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“As our office begins to return to pre-COVID operations, it has been uplifting to have a relative sense of normalcy, even though morale seems to be reduced. It is difficult to promote team building and improve morale when everyone has to maintain social distancing. I would love to go out for a meal with my staff, hug my patients, and lecture our trainees face-to-face in a classroom. While the hope is that all of these distancing measures are temporary, avoiding despair is another layer added onto an already heightened level of stress. I think all of us in medicine who have survived the pandemic thus far are grateful, even as we mourn the tremendous loss of life. There are signs that we can overcome this new normal moral injury involving fear, stress, and work-life imbalance. Several things that were burdensome pre-COVID such as licensing regulations, charting requirements, being unable to do telemedicine, for example, all were revised in some positive way as a result of the pandemic. In the same way that protests for social justice are rising, so are voices in medicine that will hopefully use this time of uncertainty to potentially change and improve health care systems. As we continually provide hope to our patients, perhaps there is hope for our profession to improve when we come out of this challenging time.”

Marc Braunstein is a hematology-oncology physician and can be reached on Twitter @docbraunstein.

He shares his story and discusses his KevinMD articles, “My new normal moral injury” and “Practicing oncology during COVID-19.”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

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 Marc Braunstein. He’s a hematologist-oncologist, and he wrote the KevinMD articles “My new normal moral injury” and “Practicing oncology during COVID-19.” Marc, welcome to the show.

Marc Braunstein: Great, thank you, Kevin. Thank you for having me. It’s really a pleasure to talk with you this morning.

Kevin Pho: So we’ll get into your articles in a bit, but first off, can you share your story and your journey to where you are today?

Marc Braunstein: Yeah, absolutely. So I’m an adult hematologist-oncologist. I’m assistant professor at NYU Long Island School of Medicine, but obviously, today my views are my own. I’m also a fellowship program director.

I grew up in New York. I’ve lived most of my life here and done most of my training in New York, and I’ve always had an interest in oncology due to family experiences and just scientific curiosity. My current clinical focus is in heme malignancies: lymphomas and multiple myeloma. I have a research focus in that area, and I really enjoy my practice in Long Island, New York, where I get to see a mix of really interesting cases and get to meet very interesting patients.

I’m also personally in a dual-physician family, and I think, like many of my colleagues, I’m just trying to keep my head above water in terms of balancing work and family life.

Kevin Pho: One of the KevinMD articles that you wrote is “Practicing oncology during COVID-19.” How has the pandemic affected your practice?

Marc Braunstein: So we never actually closed, and we had a duty to protect both our staff and our patients. Initially, during the peak in New York, our area in Long Island was the first area in Nassau County to be affected by the pandemic on the island. So we had to kind of fly by the seat of our pants to make adaptations to protect our patients, by screening at the doors and taking temperatures, all those things that weren’t yet established, that we had to do without much evidence to guide us.

So in the beginning, we were taking turns rotating through the office. We were being deployed to manage patients in the hospital, and we were trying to adapt our cancer therapies to anticipate protecting patients, not making them as immunocompromised where possible.

Now things have kind of gotten back to some semblance of normal. Almost as quickly as the pandemic came in, it’s gone down, but our patients are still wary about coming in, so we still have to take measures to reassure them about the safety.

Kevin Pho: Now, what are some specific challenges cancer patients face during the pandemic?

Marc Braunstein: Sure. Well, one article I wrote had to do with the mentality of the pandemic. In many ways, a new diagnosis of cancer has a lot of uncertainty, the same way that the pandemic has an uncertainty itself about the future, about how we’re going to get through this. I think looking to my patients for inspiration, for how they kept faith and how they looked for hope, gave me hope in terms of facing the pandemic.

Specifically, how it’s affecting cancer care is that many of our chemotherapy approaches make patients immunocompromised, and it wasn’t clear in the beginning exactly which patients were more susceptible. Data from China and Italy showed that patients who had recent surgery or chemotherapy were more likely to develop severe COVID infection, as well as patients with heme malignancies.

So we had to make a lot of modifications. For example, our operating rooms were converted into COVID units, so we didn’t have the availability of certain procedures or surgeries that would normally be standard of care. For example, patients with breast cancer who would have gone for surgery may have started adjuvant anti-estrogen therapy before they could get to their surgery. So there were many modifications we had to make due to logistical issues, as well as to protect our patients.

Kevin Pho: Now, in terms of these treatment modifications during the pandemic, what anticipation do you have in terms of that affecting potential outcomes?

Marc Braunstein: So I think one thing I’m concerned about is the delay in screening tests that were also kind of shut down, in primary care offices that were shut down that would lead to referrals for screening. So I think we may be in for a wave of new diagnoses, or even late diagnoses, of new cancers like colon cancer or even breast cancer, other cancers where there were delays in screening. I think that’s one downstream effect, as well as genetic screening and other offices that may not have been available at the time.

Now that the volume has picked back up, we’re almost seeing more volume than we did before the pandemic. So I hope that people will continue to do the appropriate measures, like preventive care, primary care, and screening tests that are really key to preventing cancer from even beginning.

Kevin Pho: Now, we’re speaking in mid-October, and we are potentially on the cusp of a third wave of COVID cases. Knowing what you know now, over the last nine months, from a cancer standpoint, is there anything that you would do differently going forward?

Marc Braunstein: So that’s a great question, Kevin. We have a moment right now where things are a little bit quiet, at least in the New York City area, where we can take a step back and kind of see what we did right and perhaps what we could do better.

At NYU, my health system where I practice is very well prepared. They’re doing drills to anticipate another rush of patients. There’s plenty of bed availability, ICU availability, and resources. Now that we know when we were constrained by limited resources, we now have everything in place to anticipate another rush of patients.

Likewise, from the point of view of cancer care, we now have a sense of which therapies are perhaps more risky to deliver in the setting of the pandemic and which patients are perhaps more prone to severe COVID infection. So I think with those things in mind, we’re well poised to face another wave. Hopefully it won’t happen, but I think we’re well poised to face that and try to anticipate the second or third wave of volume in the hospital.

Kevin Pho: Sure. Now let’s transition to the second KevinMD article that you wrote, “My new normal moral injury.” For those who haven’t read that article, can you walk my audience through it and maybe share the story of why you decided to write it?

Marc Braunstein: Sure. So I think the two articles actually led one from the other. When it comes to the pandemic, we’ve all had to make a lot of personal sacrifices and professional sacrifices. And when it comes to patients with a chronic, or even terminal, illness, they don’t have the luxury that many of us do to delay the important things in our lives.

When it comes to medicine, though, we’ve had to face this pandemic like people in my generation have never faced before. I trained at Bellevue Hospital, and I’ve seen infectious disease. I was there when the Ebola outbreak was going on in New York City, so I’m comfortable dealing with infectious diseases. But it was never the case where I could potentially infect my loved ones or my family.

So balancing that oath to medicine with my personal duty to my loved ones was my first kind of exposure to a kind of moral injury. Compounded by the stress on the health care system and the uncertainty of the pandemic, I just felt a new sense of stress that wasn’t there before, when I had my daily routine before the pandemic.

Kevin Pho: Yeah, I talked to a lot of physicians on this podcast, and that tension they describe, the duty to your patients versus the duty to your family, is very stressful for every clinician. How did you reconcile that, and what are some of the techniques that you use to help with that tension?

Marc Braunstein: Sure, absolutely. Like I said, I’m in a dual-physician family, and my wife is also a clinician. So one thing we tried to do is alternate the times in which we were working in the hospital or were on call, so that if one of us got sick, the other person could step in to take care of the family, and things like that.

We had a separate area in the house where we would come in, drop off our laundry, go right into the shower, and wash our laundry, and things like that. We tried to limit exposure to other family members when we were in the hospital or on call. And in our office, we kind of rotated different staff so that we could allow for distancing and not too much traffic in the office in terms of staff or patients. So those things helped, from a practical element, to try to limit our risk.

From a well-being standpoint, I think we tried to spend more time together as a family, to make the most of a bad situation, and to look for virtual activities for our children and things like that, just to try to get through it.

Kevin Pho: Now, in general, what kind of support services are available for clinicians who may be suffering from moral injury, maybe getting an increased frequency of burnout from the pandemic? What kind of resources do you recommend?

Marc Braunstein: Sure, that’s a great question, and I’m certainly not an expert on all the resources available, in terms of things like telepsychiatry and other things that may, in a positive way, come out of this pandemic.

I also think that, in many ways, while the stress level has increased, there has also been, and I wrote this in the article, a certain crescendo of revitalization of our interest in medicine and our purpose in medicine, and I think the public has seen that. So from one perspective, I think there’s more energy too, and we can try to direct that into changing medicine for the better.

But in terms of resources available for people who are dealing with an undue level of stress, I think, first and foremost, we have to look out for each other, right? So if you see a colleague who is just not acting normally, is coming in late, is just behaving usually in the setting of this pandemic, I think we have to try to reach out to them, talk, and help them, and in a non-punitive way look for resources for them where they can still function properly.

Many of my patients, for example, have gotten back into their bad habits, be it lack of exercise, bad diet, or even drinking, because their churches or their support groups were closed. So I also think, as fellowship program director, we do certain wellness activities for our fellows. I think trying to be creative about virtual activities and gatherings that are socially distanced, in a way to kind of connect, like doing a poetry slam or something that can allow you to express yourself and what you’re going through.

But ultimately, we have to look out for each other, and I think if someone is to the point where they’re truly depressed or truly clinically anxious, we have to try to direct them to the appropriate help. Maybe now that we’re in sort of a more virtual world, there are perhaps more resources to do teletherapy and things like that.

Kevin Pho: So that actually leads to my next question. I wanted to ask about the medical trainees that you see. How are they handling the pandemic? Because the tension that you talked about earlier can, in a way, be even amplified as a medical trainee, because this is really their first exposure to something that’s truly dangerous, like COVID-19. How are the trainees handling it?

Marc Braunstein: Yeah, Kevin, that’s a great question and an important one. We’re currently in the midst of doing our fellowship interviews virtually, and I try not to spend too much time not talking about oncology things, but I desperately want to ask them what’s been their educational experience. How has the pandemic impacted their training? Has it changed their motivation to pursue more training in medicine?

What I find is that residents and trainees were put in a very difficult spot, where many of them had their educational process turned upside down. They were deployed to take care of COVID patients for longer shifts and longer hours than they would have been otherwise exposed to, and with the same lack of clinical evidence-based guidelines that all of us dealt with.

I think many of them have benefited from excellent intensivists and mentors that have guided them through that and kind of supervised them, but I know that many trainees have also been thrown into situations they were not comfortable with, managing vent settings and things like that that might have been beyond their scope of comfort. So I think it’ll be a story that they’ll tell, when they’re older attendings, to their trainees about what they went through, and there’s going to be a lot of stories to be told when this all passes and the nightmare is behind us.

But I think we have to keep a special eye out for those trainees who, over time, may start to show signs of that stress and what they went through, and that impact on their training. In my fellowship program, we’ve tried to continue the educational didactics virtually and maintain some structure. I think certain organizations, like the American College of Physicians, have had seminars on stress and maintaining balance during the pandemic. But I know it’s taken a toll on a lot of trainees, and I really feel sympathy for them for having to practice and train at such a difficult time.

Kevin Pho: We’re talking to Marc Braunstein. He’s a hematologist-oncologist. He wrote a pair of KevinMD articles, “Practicing oncology during COVID-19” and “My new normal moral injury.” Marc, we touched upon a lot of topics during this conversation, and this could apply to any of those topics. Are there any lessons that you’ve learned over the last few months that you can share with my clinician audience?

Marc Braunstein: Dealing with the pandemic, to begin with, is a lesson for everybody in medicine, and in how we’re going to deal with something like this, God forbid it should come in the future. But one of the biggest surprises is how we’ve seen just activism in general during this time. A lot of the red tape in medicine, for example, a license and things like that, has been put to the wayside during the pandemic. And we’ve seen so much activism, for racial equality and gender equality, in the world outside of medicine.

I think it’s given us an opportunity within medicine to use that momentum to get rid of some of the stressors that were leading to moral injury before, like documentation, all these things. I think it’s given us more purpose in medicine, just to practice and realize how important we are in society, but also to kind of start taking more political action, and to start really interacting with our communities and the country as a whole, to understand what it is that we do, why our job is so important, and why we need to have a say in how health care is devised in this country.

I think the pandemic kind of accelerated the process we were headed towards in terms of taking back control of medicine, so that it’s patient-focused. So I think that’s been something that has really encouraged me, in terms of civil activism, but also the enthusiasm in medicine to kind of make changes for the better.

Kevin Pho: And my final question, Marc: What is your take-home message that you want to leave with the KevinMD audience?

Marc Braunstein: Well, first of all, thank you, Kevin, so much for what you do. I think social media is such a powerful tool for connecting us. It’s really essential for us to share our stories, our advice, and our experience, just for our general well-being, and also to help each other to get to where we want to go in our careers.

I didn’t really understand how much you could do with a medical degree, or even as a clinician in any subspecialty of medicine, and what a vital role you play in the community, until I started to go into practice. And when I’ve read blogs on your post and other social media groups like Physician Side Gigs, seeing the different elements of your life, that you can explore your passions in medicine, is just fantastic. So I really appreciate what you do and how you bring us all up together.

Kevin Pho: Marc, thank you so much for your expertise and insight, and thanks again for being on the show.

Marc Braunstein: Thank you so much. Great being here today.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes