It can be difficult to imagine a crisis until you're in it.
Whether it's shortages of personal protective equipment (PPE) or too many codes being called to respond to them all, hospitalists are facing challenges that they may have never considered. But that's only natural, said hospitalist Eileen D. Barrett, MD, MPH, FACP, an ACP Well-being Champion who spent six weeks in 2015 treating Ebola in Sierra Leone.
“It's really human for someone to say they can't possibly imagine not physically examining a patient every day with their entire team, because they can't imagine not having enough PPE,” she said. “Or they can't imagine having so many patients to take care of that you're essentially just trying to keep people alive.”
At Dr. Barrett's hospital in New Mexico, clinicians are not allowed in the room of a patient with COVID-19 unless they have appropriate PPE. At first, some thought it unthinkable not to do everything they could to provide lifesaving care—even if that meant exposing themselves to the virus, she said.
This is the wrong approach, Dr. Barrett explained. “I said, ‘Let me be clear. This isn't a competition for who's more committed. . . . This is a time to talk about what the worst possible scenario can look like and work backward from there.’”
In order to help get everyone through this pandemic, hospitalists must prioritize their own health. In a March study published by JAMA Network Open, front-line clinicians treating inpatients with COVID-19 in China had a higher risk of depression, anxiety, insomnia, and distress than their second-line colleagues.
To help hospitalists deal with these side effects of the crisis, ACP Hospitalist spoke with Dr. Barrett and other wellness advocates and collected their top 10 tips.
1. Be flexible.
Uncertainty is a major feature of the COVID-19 crisis, said Kerri Palamara, MD, FACP, director of the Center for Physician Well-Being at Massachusetts General Hospital in Boston and physician coaching services lead for ACP. “This pandemic is a terrible perfect storm of uncertainty, anxiety, rapid-cycle change, seeing things for the first time, and a lack of data,” she said. “And then you factor in a touch of social isolation . . . and you feel like you really have nothing to grasp on to.”
In addition, this disease is especially challenging because it is so novel, said Susan Thompson Hingle, MD, MACP, Chair of ACP's Physician Well-being and Professional Fulfillment Committee and professor of medicine at Southern Illinois University School of Medicine in Springfield.
“For a lot of things in life, we learn from people who have experience. That's where we get our comfort. They reassure us, ‘We've been through this before, and we'll get through this,’” she said. “This is so new and different, and the people who got through [the influenza pandemic] in 1918 are not here to share that wisdom with us.”
Since the only stable aspect of a crisis is the instability, being flexible is perhaps the most important skill in a physician's toolkit, said Dr. Barrett, who is an associate professor at the University of New Mexico School of Medicine in Albuquerque and a former ACP Regent and Governor. “We know it's going to be unstable and changing for a while, so I will anchor myself onto knowing that this will be the case,” she said.
2. Stay connected.
The world can feel strange, foreign, and suddenly dangerous right now, Dr. Palamara said. “I'm not used to walking out and being afraid of other people, and wondering if those people should be afraid of me,” she said. Although hospital clinicians may feel selfless, important, and appreciated while at work, those feelings might change when you leave the hospital and people are scared to be around you, she said. “It's like I go from savior to pariah in the blink of an instant.”
But physical distancing does not have to equal social isolation, and video platforms offer a great opportunity for connection, said Dr. Palamara. Mass General hosts “water cooler breaks” through Zoom to allow staff to share good stories with each other, she said. As an added bonus, taking a few minutes to check in with a peer can even increase productivity compared to burying yourself further in your work, Dr. Palamara said. “It doesn't feel like it would work this way, but this actually increases your efficiency and productivity, and there are companies that have designed their entire strategy of the workday around that.”
ACP Member Read G. Pierce, MD, agreed that building relationships with clinical colleagues can help one find joy and sustenance in work. In the spring, the hospitalist and associate professor of medicine at the University of Colorado Anschutz Medical Campus in Denver created an hour-long Zoom forum with his colleagues to connect and debrief. They call it “Fears, Beers, and Cheers.”
“People can drink beer in their backyard, if they're not at work, or whatever beverage they choose, and we try to blend enough space for people to talk about what's anxiety provoking (that's the fears part) and also to highlight what's going well or where they have tapped into some positive emotion over the course of the last week, which is the cheers part,” he said. “It's an uplifting thing we do every week.”
Online discussion boards, such as ACP Member Forums, are another way to stay connected and share ideas. As the pandemic started to escalate, the Association of Program Directors in Internal Medicine discussion board was invaluable to inform decision making around resident education, said Sandhya Wahi-Gururaj, MD, MPH, FACP, a former program director for 12 years and now associate program director of the internal medicine residency program at the University of Nevada, Las Vegas (UNLV), School of Medicine.
3. Be informed, but don't overdo it.
For ACP Resident/Fellow Member Banreet Dhindsa, MD, now a first-year gastroenterology fellow at the University of Nebraska Medical Center in Omaha, the biggest challenge during his final months of residency was the need to treat patients despite the lack of good evidence on the risks and benefits of potential therapies. “For example, a patient of mine might have passed away from one of the adverse effects of one of the medications touted as treatment of COVID,” he said. Nonetheless, Dr. Dhindsa said staying informed on the emerging data about the medical condition helps relieve anxiety about doing something wrong.
Information can also become siloed in a crisis, especially between partner hospitals, and that can increase clinician discomfort, said Dr. Wahi-Gururaj, an ACP Well-being Champion. To keep trainees up to date on hospital policies, the residency program leadership joined the hospital's COVID-19 task force. “Once we were all less siloed, I think that really helped us in terms of knowing what the policies are so that . . . we were well informed on preparing our ward teams and our trainees on what to expect and what was changing, because the disease is just so rapidly evolving,” Dr. Wahi-Gururaj said. “There's still the frustration of not knowing how to best treat our patients, and that's just the reality of the disease and what's happening currently.”
With so much new information to process at any given time, allowing time to debrief after a shift can help hospitalists in the same way that it helps soldiers, said Carter Sigmon, MD, MHA, MS, a physical medicine and rehabilitation physician who is in private practice in Rancho Santa Fe, Calif., and served in the military for eight years as the medical director of the Navy's Wounded Warrior Battalion. “Campfire debriefings came out of the Army after long shifts of being on watch or monitoring combat zones to ensure that when you come off a shift, you have a few minutes to psychologically release the kind of events that occurred,” he said.
Even when not on service, it can be easy to get overwhelmed by constant COVID-19 updates. “I was nonstop reading the media coverage, reading scientific literature, listening to podcasts about it—all important to stay informed,” said Dr. Wahi-Gururaj, also a professor of medicine at UNLV. “But at some point, I was drowning in it. And I realized I needed to give myself breaks from reading about COVID all the time to do other things. I've never made pasta in my life, and I made pasta with my kids.”
Twitter is another tool for staying connected, and the internal medicine community actively shares well-being advice (and challenges) at the hashtag #dontworryalone. However, Dr. Hingle found that limiting her Twitter use improved her well-being. “There was so much negativity, and it was getting to the point that it was creating so much anxiety that I really try to minimize it,” she said. “I try to insert some positivity when I can, but for a lot of people, it's just not a positive time right now.”
4. Be empathetic.
Patient care can be particularly rewarding at the moment, said Dr. Barrett. “It's a time to challenge yourself to be empathetic. . . . The patients often have so much fear, so this is a time that a small gesture of kindness means so much to the patients,” such as holding their hands, getting down to eye level (even in PPE), and reassuring them, she said.
In particular, groups who have previously experienced trauma from the health care system, such as African Americans, people of color, Native Americans, and those who are poor, may benefit from gestures of solidarity and cultural humility, Dr. Barrett added. “I think it's really important . . . that we say to them, ‘There is no information that I know that I'm not sharing with you or that I'm keeping from you.’ I say that very deliberately,” she said. “I also say that ‘There is no treatment that's available that we're not giving to you,’ and I also say, ‘If a treatment becomes available elsewhere that we couldn't get for you, we would send you there to get it.’”
Another way to humanize care is using a smartphone or tablet to communicate with patients while not wearing PPE, which also makes the work safer, Dr. Barrett said during an ACP webinar on lessons learned from the front lines. When such technology isn't available, one alternative is creating face sheets, she noted. “The patients receive a piece of paper with a photograph and the names of . . . everybody who's going into their room, so that they can know that there's a person behind that mask and also know that they are not alone,” Dr. Barrett said.
And don't forget to also offer empathy to your colleagues working in the hospital. “I'm so grateful to be able to work someplace where, as a hospitalist, I see the housekeepers and the lab techs and the dietary people, and I can say, ‘Thank you for taking care of the patients,’” Dr. Barrett said. “These small gestures of humanity to each other mean so much for all of us.”
5. Recognize what's in your control.
We all know we can't control everything, but it can be helpful to be more specific. ACP Member Narath Carlile, MD, MPH, a clinical informaticist, found a way for physicians to do that.
While assessing the utility of apps for measuring stress with his 12-year-old daughter, he came across a simple yet powerful diagram: an inner circle depicting what one can control and an outer circle depicting what one cannot control. But as he reflected on that paradigm, he realized that for physicians, there is a gray area in between the circles. “In addition to the things that I can and cannot control, there are areas where my actions can matter, where I can influence but not control the outcome,” Dr. Carlile wrote in an April blog post.
So he made his own diagram, customized to his clinical experience, which can be found in “COVID-19: An ACP Physician's Guide & Resources.” Without a cure or vaccine for COVID-19, physicians cannot stop people from becoming sick or dying; the best they can do right now is “try and influence the best possible outcome, and give the best care possible,” wrote Dr. Carlile, an associate physician at the Phyllis Jen Center for Primary Care and director of innovation for the internal medicine residency at Brigham and Women's Hospital in Boston.
But of course, every physician's circumstances are different. “I've been trying to find a way for people to easily make their own, or perhaps more easily for a small group of docs to create a shared understanding,” he said. To do that, Dr. Carlile recreated his diagram on the Google Jamboard app, where users can make a copy of the diagram and create their own by adding customized sticky notes.
6. Get creative.
One of the most difficult parts of this pandemic is that patients are dying alone in the hospital, but hospitalists are finding creative ways to provide some peace and comfort.
At the University of Colorado, clinicians have figured out how to get isolated patients on an iPad so that they can talk and see their family, even those in different countries, said Dr. Pierce. Spotlighting small feats like this can boost the morale of hospital staff. “Not just saying, ‘Well, that's what we've got to do, let's move on,’ but acknowledging how proud it makes us that we've been able to create human connection when the systems and structures are set up to try and keep people separated, because we're trying to keep people safe from coronavirus,” said Dr. Pierce.
Clinicians can also think of creative ways to support patients' religious or other practices at the end of life, such as using a tablet so that a priest can administer last rites to a Catholic patient, added Dr. Barrett. In addition, while many hospitals established no-visitor policies, she said hers allows one person to visit when a patient is on comfort care—under strict safety conditions. Visitors are screened for symptoms, have their temperature checked, get instructions on hand washing, and receive a mask when they walk into the hospital, as well as a gown and gloves when they get to the patient's room, said Dr. Barrett.
“We experience so much distress where people die terribly and they die alone, so I think that us advocating for ways that they don't have to and ways that people can have the gentlest death as possible is really important,” she said, adding that every clinician should be trained in end-of-life discussions. “It can put people's fears to rest because they feel more prepared, but then also we do better because the patients are more at ease.”
One creative way to put patients at ease is using the power of music. At New York-Presbyterian Allen Hospital in Manhattan, which in April lost an emergency medicine physician to suicide, Rachel Easterwood, MD, an ICU physician and trained musician, arranged for professional chamber music players to perform concerts for the wards and in the ICU. Selections from Brahms to the Beatles were broadcast to bedsides through video chat software and have even expanded to reach staff members, who have gathered together to listen around nursing stations and in break rooms. There was a somber cello performance for emergency department staff after news of their colleague's death, Dr. Easterwood told The New York Times.
7. Reflect on your purpose and what energizes you.
Not everyone has the opportunity to play a major role in pandemic response. “Doctors are one of the groups of people that get to make a difference every day,” said Dr. Hingle. “There are some people who are stuck at home who have ‘nonessential’ jobs who are just sort of wondering, what is their purpose? I think one of the positive things that essential workers have is they know that they're helping people through this.”
Focusing on that may make it easier to feel “good” tired versus “bad” tired at the end of a shift, said Dr. Pierce.
Clinicians who are “bad” tired are typically facing burnout and show signs such as cutting corners, being detached or depersonalized, taking unplanned days off, and cutting back on workload, he explained in an ACP webinar on optimizing well-being. In contrast, doing the work well, even when it's challenging, often leads to peak experiences that feel inspiring, “like the reasons we went into medicine in the first place,” said Dr. Pierce.
For some, thinking about purpose and passion and finding meaning in medicine can be too abstract, Dr. Pierce noted. To get more specific, he suggested paying attention to the parts of your daily work that are draining your energy versus giving you some sense of being alive and energized, and focusing your thoughts on the latter.
8. Stay positive.
Tapping into positive emotions, even for a few seconds, can both provide energy and balance the stress hormones and signaling in the brain, said Dr. Pierce.
“So part of what I think we can be working on, even at times like these, is [recognizing] little things we can do to tap into healthy amusement, pride, hope, gratitude, or interest in daily work, and when we can do that,” he said. “There are lots of opportunities to do that, if we look for them.”
As part of his own version of this practice, Dr. Pierce said he inserts frequent small doses of positive emotion by recognizing three good things that happen every day, and he's shared this with colleagues as well. “We've done simple things like at the end of a shift, people who were on share what recently went well or three things you're grateful for from the last six hours, 12 hours, just to put a spotlight on that,” he said.
Writing down three specific good things at the end of each day is one of the most evidence-based positive psychology techniques, in company with the expression of gratitude and random acts of kindness, said Dr. Palamara, who presented an ACP webinar on using positive psychology in times of crisis. “There's really cool data to show that if you even do this for three weeks, your overall depression scores over the course of three months, six months, and nine months go down, your efficiency in the workplace goes up, your subjective quality of life goes up . . . and it's free,” she said.
Dr. Palamara knows firsthand what the power of positivity can do. After her nearly 3-year-old son was killed in 2018 when he was struck by a car, she ran the 2019 Boston Marathon with a team of 11 runners and raised more than $100,000 to give back to other children and families in Boston. As it did then, “Positive psychology has helped tremendously during this time,” Dr. Palamara said. “This is not going to change this pandemic, but it can change how we feel in a moment. And no matter how awful things are in life, these still can play a role.”
9. Remember to take care of yourself.
In addition to staying positive, mindful breathing and exercise are key tools to approaching a crisis with calm, experts agreed.
One technique called box breathing is easy to fit into a busy lifestyle. It consists of a four-part cycle of four seconds each: breathing in, holding in, breathing out, and holding out, which can reduce anxiety and stress, said Dr. Sigmon. “We've had a lot of success with these types of techniques in many areas of the armed forces. . . . At first you have to initiate it, but after practice it becomes reflexive,” he said.
Meditation is also a useful practice, but it's not for everyone, said Dr. Palamara. “I'm more of an exercise-as-meditation person,” she said. Finding ways to exercise at home has been crucial for ACP Resident/Fellow Member Caleb Murphy, MD, MBA, a third-year resident at UNLV. “Most of our decompressing activities—hiking, going out to eat, going to the gym—are not options right now, which makes wellness tough,” he said.
With so many competing priorities, making time for exercise is difficult but necessary, noted Dr. Wahi-Gururaj. “I think you have to remember yourself and that your self-care is still important during this challenging time, because I think we often don't give ourselves permission to care for ourselves,” she said. “As a woman and a mom, I tend to put myself last. So giving myself permission to go on those runs in the morning and walks to get the exercise, even though I'm busy, has been really important for me.”
10. Connect with your resilience.
Connecting with your mind and body can help you tap into your inner resilience, said Dr. Sigmon. “You're trying to prepare your mind and body for peak performance under extreme stress, a battlefield-type mindset that can be useful to the front-line workers now,” he said. “Essentially, you're trying to have volitional control of the fight-versus-flight response by training your mind and your body into a reflexive response.”
One way to do this is repeating a positive personal mantra. Thinking or speaking a repetitive saying, such as “I have energy” or “I can cope,” or even repeating a word like “aloha” can train the body-mind connection not to allow the fight-or-flight response to become overwhelming, said Dr. Sigmon.
“These techniques must be routinely practiced to be effective, similar to how special forces train for deployment to combat zones,” he said. “If you're having a clinician go in and see a patient that is infected and putting themselves at great risk, doing these different techniques while they're washing their hands is a good time. It only has to be 15 to 30 seconds, maybe a minute, to start priming the body to develop internal resiliency to the inevitable physiological response to these extremely stressful situations, facilitating a clinician battlefield mindset.”
Remember that maintaining well-being is both a marathon and a sprint, said ACP Well-being Champion Tammy Lin, MD, MPH, FACP, Governor-elect for the ACP Southern California Region III Chapter. “Just like any muscle, these skills will get stronger and you will be able to call on them and depend on them the more that you activate them,” she said.
Finally, it's important to have hope, said Dr. Hingle. While physicians everywhere have worked tirelessly through many challenges during this pandemic, it won't last forever, she said. “I always liken it to when you're treading water and your nose is under the water,” Dr. Hingle said. “It's terrible, but once you get that head above water, even though you're still treading water, you can keep going.”