The problem

Even in the midst of a global pandemic, mental health in medicine is rarely discussed. And yet, the circumstances of our profession create the perfect milieu for darkness. The long work hours. The regularity of tragedy and loss. The nights, weekends, and holidays you miss with those you love. The constant pressure to be perfect — to be professional, to be composed, to be vigilant, to not make any mistakes. In rare moments away, the pressures of continued academic achievement and productivity are quick to take their place.

Over the past two years with the COVID-19 pandemic, all of this has been amplified. The work is more heartbreaking, and it breaks in new ways with each distinct surge. The system is crumbling. The beds are full. Essentials, including oxygen, blood products and even saline flushes, are in short supply. Health care workers are leaving in droves, with those that remain getting increasingly frayed at their edges. There is an endless stream of patients that we cannot help in the ways we envision. Many die in the hospital alone as visitation policies grow ever strict. We learn that a cruel truth of our work is that you can do everything right, and your patients can still die. Taken together, this leads to moral injury as we fall short of what we once hoped we could be.

Through one-on-one conversations with many dear friends in medicine, people have shared with me their own mental health challenges and how close they have come to the edge of their darkness. These conversations shake me to their core.

The proposed solution

I am writing this for those we have lost, hoping that these words can help even a single person feel more seen and cared for. I write this because the price of silence is too great. This is dedicated to Rose Wong, Justin Lemieux, Lorna Breen, Sean O’Rourke, and countless others that we will forever remember, love and mourn.

Check in on yourself. This first step and perhaps one of the hardest is: to be honest with yourself. How are you doing, really? Before we can work on a solution, we must acknowledge that there is a problem to be solved.

Allow others to look out for you. In medicine, we often use the adage, “do not worry alone” — I urge you not to struggle alone. Reach out to your support networks share your difficulties so that others can look out for you.

We must try to be vulnerable with each other — to speak openly not only about the tragedies and traumas we encounter at work but also about the personal events that affect us on a daily basis. Before we are health care providers, we are people. Life does not stop because you are in residency.

There will be moments that test us — when your child or loved one is ill, when you go through the end of a relationship, when financial or personal struggles arise, you may need time to care for yourself or to grieve. This does not make you weak; this means you are human.

This continues to be something I struggle with, as it requires letting your guard down. This past October, as I went through major personal losses and transitions, I worked to apply this to my own life. It was terrifying to let others in — especially in a professional context. I reached out to my program director, my mentors, and my loved ones for support and let them know about what was weighing heaviest.

I wanted those around me to know so that they could look out for me and catch me if it was needed. I am immensely thankful for this decision, as it allowed me to show up fully in the subsequent months for my patients on the hardest rotations and through yet another COVID-19 surge. It gave me the space to care for myself so that I could best care for those around me.

I take every opportunity to tell my interns and co-residents about these experiences with hopes that we can begin to model healthier ways of being and transform the culture of medical training.

Be kind with yourself. You can only do your best every day. There will be bad days. We all have them. There may be days where you had little to give and days where you feel like you fell short. There may be others where despite your team’s best efforts, there were tragic outcomes. Head to bed early, find nourishment and gratitude, and simply try again tomorrow. On days where this is especially hard, reach out to a friend who can show you the kindness you aren’t able to show yourself. Each new day is an opportunity to begin again.

Find what fills you up and protect it as best as you can. Start with the foundation. Sleep 8 hours a night if able. This can be challenging on demanding rotations, but it should remain a priority given its innumerable benefits for creativity, decision-making, learning, memory, and physical and emotional wellbeing. Ensure that you are eating well and enough. Make time for beloved activities and people. These joyful activities will sustain you in your relationships and in your work.

For me, this is toughest in winter, and especially with the pandemic, there was an added layer of isolation. Reading, writing, a daily gratitude practice, long walks and meals with friends, cycling, climbing, and strength training are activities that I prioritize to keep me well. Talk to those around you to see what works.

Process. Find ways to release tension. This is intricately related to the above, with more mind paid to the physical (and at times mental) sensation of tension and of stress. Rather than fighting it, find a way to move through the sensation. The way it manifests will be different for each person. Take a moment to figure out what it is for you. It may feel like heaviness in your shoulders, tightness in your jaw or chest, exhaustion that runs bone-deep, or even apathy. It may not be the same each time, but with it may come a sense of heaviness, a weariness that feels hard to shake. Try to see if you can.

There are many evidence-based strategies to complete the stress cycle — behaviors that show our bodies that we are safe and give us permission to turn off — to avoid burnout. This includes physical activity, positive social interactions, hearty laughter, deep breathing, physical affection, crying, and engaging in creative activities.

One technique to try is called the physiological sigh: a double inhale followed by an extended exhale — you may recognize this pattern in someone who is falling asleep or in the context of a good cry. I find release through strenuous workouts, laughter, massages, and rarely a cry in the shower (some friends find solace in the privacy of their car). There are countless techniques, and what works may vary from day to day. Continue to build and refine your toolbox of resilience. At first, it may be hard to recognize, but soon the intuitive shift that comes with letting go will become clear. You will find what works for you.

Check in on those you love. Take care to check in on those who you never worry about. Community is everything. Beyond our physiological needs, we all need a sense of safety, love and belonging to thrive. It doesn’t take much to send a message or give a call to let someone know that you’re thinking of them, but it can be so powerful in creating community, staving off loneliness, and creating a culture of support and connection. Take a moment today to remind your loved ones that they are cared for. It can make all the difference.

More difficult than noticing presence is being keen to absence. Take care to check in on those who always seem okay, as they are often those who struggle most and in isolation. Medical training tends to select for those who are self-sacrificing and skilled at compartmentalization — these coping strategies work great — until it crumbles.

Build your safety nets before you need them. Seek out professional help. Relationships are as much about being there for your people as it is allowing for them to be there for you. Hiding struggles and avoiding vulnerability is a sign of weakness, not strength. It takes courage to be open and to trust that you will be okay even if you let your guard down.

Safety has always been elusive for me. As a queer woman of color, raised with limited means in an immigrant household, the safety nets I inherited were sparse and somewhat frayed. Over the past decade, with the generous support of my communities, I have worked to build layers upon layers of reinforcement that I am confident can weather the worst of storms. Consider what it would take for you to feel safe, supported, and work toward slowly and gradually constructing it for yourself.

Last, and most importantly, establish with a therapist and a primary care physician. In times of darkness and significant stress, perspectives and possibilities narrow. Work through contingencies and create safety nets within your professional and personal networks with those who can help you reframe and broaden your views.

As health care providers, while we know the steps it takes to establish care, doing so in practice is entirely different. It is not easy to find time in your schedule to look for a provider, to schedule an intake and to put yourself out there. While it almost certainly is not what you want to do on your one day off each week, it can be life-saving. Do it before you need it. Do it for the ones you love, who love you.

Rosa Yu is an internal medicine physician.

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