This Podcast Will Kill You - COVID-19 Chapter 17: Frontline Mental Health

Episode Date: April 27, 2021

This pandemic has certainly taken its toll on all of us, but one group that has been particularly hard hit are those who have been on the front lines, continuing to take care of patients even when PPE was running low or nonexistent, even when there were no more ICU beds available. During both non-pandemic and pandemic times, physicians and other healthcare workers experience a tremendous deal of stress and pressure that can lead to depression, isolation, anxiety, moral injury, and other mental health issues. In this episode of our Anatomy of a Pandemic series, we seek to understand the factors contributing to the prevalence of these mental health issues among healthcare workers, the stigma that often prevents the seeking of treatment, the role that the COVID-19 pandemic has played in exacerbating these issues, and the ways in which the medical system has done or can do better. We are very excited to be joined by Michael Myers, MD (interview recorded March 29, 2021), psychiatrist and Professor of Clinical Psychiatry at SUNY-Downstate Health Sciences University in Brooklyn, NY and author of several books, including his latest, Becoming a Doctors’ Doctor: A Memoir.As always, we wrap up the episode by discussing the top five things we learned from our expert. To help you get a better idea of the topics covered in this episode, we’ve listed the questions below: How did you become interested in the field of physician mental health, and what made you choose to pursue it? Can you talk us through some of the challenges healthcare workers face and what impact they have on their mental health? Does this field experience things such as depression, anxiety, substance abuse, and suicide at higher rates than the general public? What does the stigma surrounding mental illness look like in the medical field and how does it contribute to the high rate of mental health issues in healthcare workers? Can you talk a bit about where these mental health issues among healthcare workers originate and how each step of medical training and beyond contributes to the problem? How much of this is a problem unique to the US and how much of it is universal? What are some of those changes you have seen throughout your thirty-five year career as a psychiatrist primarily treating other physicians? How have we gotten better, and what are the areas in which we have failed to make improvements? How do these public health crises, especially COVID-19, amplify the issues that physicians are already facing in terms of mental health? Can you talk a bit about the “healthcare heroes” narrative and how damaging it can be? What is some of the fallout you think we can expect to see in the long-term from the COVID-19 pandemic? As family members or friends or partners of healthcare workers, what are worrying signs that we can look out for? How do we recognize these signs in ourselves as well? For those who maybe have friends or partners or family members who are frontline health workers, what are some of the ways in which we can help and provide meaningful support during these times as well as in non pandemic times? What do you feel are the biggest failings of the medical system in terms of emotional and mental health support for those in medicine? How can we begin to change things? What role should medical school play? Hospitals? Other physicians? See omnystudio.com/listener for privacy information.

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Now your plans refined. Run a smoother business when you're all aligned. Do that with Acrobat. Learn more at adobe.com slash do that with Acrobat. Hi, everyone. Before we begin this episode, we just wanted to issue a content warning that this episode does contain discussions surrounding depression, anxiety, substance use, self-harm, and suicide. So my name's Dr. Kratika Kapali. I'm an infectious disease physician at the Medical University of South Carolina. My background is in emerging infections, biosecurity, and global health. And over the past 10 years since I finished my training, I've spent half the time living internationally

and the other half of the time living domestically. And the time living internationally has been spent really working on emerging infections and pandemic response, I was in West Africa during the 2014 Ebola outbreak, whereas the medical director of an Ebola treatment unit. And after that, I was part of a U.S. government initiative helping to develop a clinical trial capacity for therapeutics in the event of a high-consequence pathogen outbreak. I've also worked in numerous disaster zones in the aftermath of natural disasters. And I feel like all of that background really has helped prepare me to work during this public health crisis we're facing here in the United States and in the world because of the COVID-19 pandemic.

And this has been a really challenging year. Sometimes I, for you, yet that it's only been a year and a half because it feels like it's been 10 years. And there are days when I am walking into the hospital that I'm exhausted and I feel empty and I don't want to hear the word COVID anymore. And I think that sometimes I hear people use the word, a hero and it makes me cringe because I don't feel like we are heroes. I feel like we are really lucky that we are trained to be able to take care of patients that are sick and need our help and that I'm just doing my job just like anybody else would be doing if they were in this situation. And I feel like that label at times puts undue pressure on us to do something. To do

some superhuman type of thing that we may not be able to do when all we need to do is just treat our patients with the care and compassion that they need. And I worry about how this pandemic is going to affect our health care workers. I feel like I have some insight because when I returned back from West Africa after the Ebola outbreak, it was really difficult for me. I had visions of some of the patients I took care of, some of the situations I had been placed in, continued to run through my head, and it took me a long while to work through that. And I fear that some of our healthcare workers who have been in extremely intense situations are going to have the same problem on top of the fact that this pandemic has been drawn out for so long.

And I feel like every time we see another surge, it's just another layer of exhaustion that people feel. And I hear it from my colleagues. I hear it from my friends who are just really tired. And I'm starting to see it as well. I see personality changes in people that I never even used to hear a crossword from. I've seen people who are older thinking about retiring or stepping back. And this will affect our entire profession. I think for myself, some of the things that I worry about is when I came back from West Africa,

I noticed that I had somewhat of a more disconnected feeling. And I noticed that I have that now. It's not so much that I don't care about my patient or I don't care about people. But there's definitely some sort of detachment. And I think that part of that is to protect myself. And I think other people do that too as a way to protect themselves. And I think we should all be cognizant of that because this has been a very difficult time for all of us in the healthcare field. We don't just have the same stressors as everybody else.

But then we also have the increased demands of trying to care for our patients. And since this has been going on for over a year now, it's felt like a marathon. And it's a marathon that for some of us, we don't see ending anytime soon. We need support just like everybody else. And I hope that people who are out there listening to my story and everybody else's story remembers that. And hopefully, as we see this small light at the end of the tunnel with our vaccines, which are wonderful, we can all remember that and remember that we need to come together as we try to end the coronavirus pandemic. Thank you.

I work as an ER nurse in a regional hospital, Montana. The second wave of COVID was really our first. And while we were not nearly as devastated as places like New York or Houston, we were pretty battered. You know, it was a series of crises of, you know, short staffing because coworkers were getting really sick. a huge surge of patients from all around the region that needed hospitalization with our capacity well above 125, 150 percent. I mean, it was wild. Holding vented ICU patients in the ER, dealing with the just rampant misinformation,

but, you know, just worst of all is just, you know, dealing with how sick these patients could get. I wanted to share specifically my experience with two patients. I think they're both good representations of what COVID can do to people and what we've been seeing at the bedside. You know, patient number one, she was my mother's age in her 50s, and I had started my shift with her on two liters nasal cannula, which is basically just bare minimum oxygen requirement. And I ended my shift calling your family to let them know it did not look good. She had progressively worsened throughout the day with her work of breathing getting worse and worse. And she entered that third stage of COVID that we all so dread. And she went to carmort of pulmonary arrest four times after we had intubated her.

And then she arrested four more times in the ICU before they finally called time of death that night. Patient two was a 30-something year old that, you know, had started again with just bare minimum of oxygen required. it's just three days prior. I mean, she was borderline send home, you know, when she'd come to the hospital. And I assumed care of her as an ER inpatient a few days later. And I just, I knew in my heart when I walked in her room, I was going to interbate her by the end of my shift. Within four hours of that shift, no matter how much proning we did, how much oxygen we gave her, you know, how much support there was, I could never get her above about 78% saturation.

normal being of course 95 to 98 at one point she dropped to 30 percent a true real life 30 percent of the monitor and I have only seen that a few times in my career pre-COVID within that time the hospitalist had transferred her care to the ICU doctor whom I called down saying you know it's it's time she's we're it's this or nothing you know it's this or she dies and we intubated her and then eventually I got her transferred upstairs. For a time, I had heard that she was making some recovery. I do not know, though, how things had turned out. And, you know, sorry, these guys really, they tug at my heart. Because they just, there was particular things with these patients that, you know, got kind of close to them. And you, it's a sense of failure in a way once you get to that point, once, you know, you start intubating.

Because we just, we know, we know that there's nothing more we can do. And I'm really tired. I'm so tired of COVID. I have spent time as an ICU ER nurse. I'm no stranger to death. Bad, bad flu seasons in the past have of course been devastating. But you get used to saving 30, 40, 50, even 60 and 70-year-olds. You know, it was a well-established expectation that for that age group that for the most part,

barring complications, patients with respiratory illnesses have a good chance of making recovery with, you know, careful with the right care and, you know, ventilator management. Just now there's no such expectation. And if we have to put a patient on bi-pap or, God forbid, yet they intubatim, it's like a sinking feeling of loss. And in all my years of nursing and nursing education, I've just, I've never seen anything like it. Hello, my name is Christy and I'm a registered nurse in New York City.

I graduated in May 2019 and when the pandemic hit, I was still in a fellowship training to become an ER nurse. I remember the panic that started hitting all of us as we saw more and more patients show up to the ER with COVID symptoms. And what really shocked us was how young they were, how unpredictable this thing seemed to be. In April, I got a phone call that I was being reassigned to a makeshift COVID floor that had been refashioned from an outpatient surgical center. The first night I arrived to start my shift, I saw a giant truck outside the building. It reminded me of the trucks you'd see around New York when they were filming a movie. I was later told that this was the refrigerated truck to hold the dead bodies that were outpacing the hospital morgue. Every shift began that way, walking past that truck, like a symbol of what felt like the futility of trying to save the people who were dying.

Working on the floor was a type of nursing that I hadn't trained for and that I never planned on doing. Most of the patients where I worked had do not resuscitate and do not intubate orders. So I was there to provide them comfort care as they died. The image of these people gasping for air as they slowly slipped away as an image I can't erase from my mind, and I think it will hold onto my whole life. I spent 12-hour shifts in this windowless floor and layer upon layer of protective gear. I saw patients die, and I saw other patients have emotional breakdowns from being sequestered from their families. I think most people that become a nurse do so

so that they can help comfort and heal people. And for so many of us, we didn't feel like we were able to do either for our patients and that more than anything has broken our spirits. Eventually, when the surge lifted, I got to go back to the ER where a new normal has set in of wearing protective gear for entire shifts, always concerned that any patient could be carrying this virus.

I'd say at least half the staff has gotten COVID, and many are dealing with long-haul symptoms such as brain fog and shortness of breath. I was able to get my vaccine on the second day it was available in the United States, and although I was nervous and had my concerns, I had seen the devastation and the long-term effects of COVID enough that I was willing to take the chance.

I thought it would give me some sort of peace of mind to be vaccinated, but work is still full of anxiety and fear due to the variance. So many patients who are now testing positive admits taking vacations are going to large underground parties in New York, and there's nothing that frustrates us of health care. workers more. For a brief time, the world was clapping for us, and everyone seemed to tire of that and tire of trying to stop this thing from spreading and mutating. I've started attending therapy for my sleep issues and have been told I have PTSD from the last year of work. I'm haunted by the

faces of people I watched die, but I also try to remember the rare beautiful moments of the last year. I had one patient who wanted to watch baseball last spring, and I had to explain to him that the sport had been canceled for the season. So instead I pulled up an old Mets game on the the iPad and sat with him for a couple of minutes to watch it. He told me he wished he could buy me a hot dog. A year later, baseball is happening again, but he is dead. I like so many people, desperately want this thing to be over, but part of me doesn't know if I see an end date any time in the future. Thank you again to everyone who provided a firsthand account. Those were incredibly powerful, and we really appreciate you taking the time to share your story with us, and for also

everything that you're doing to fight this pandemic. Yeah, definitely. Hi, I'm Aaron Welsh. And I'm Aaron Alman Updike. And this is, this podcast will kill you. It sure is. Welcome to the 17th episode. What? It's a lot of episodes. It's a lot of our anatomy of a pandemic series. In each episode of this series, we've been taking a closer look at a certain aspect of this pandemic, from virology to economics, from spillover events to schools. And in one of our earlier episodes, we discussed some of the mental health impacts that this pandemic has been having on the general public, as well as some coping strategies for how to deal with the stress and anxiety that a lot of us are feeling. With this episode, we wanted to revisit the mental health impacts that this pandemic is having,

but on a very specific group of people, frontline healthcare workers. Yeah. But before we get into that, it's quarantine time. It's quarantini time. What? What? are we drinking this week? Well, Erin, Quarantini 17. Yep, Quarantini 17i. Oh, I like that. The Quarantini 17 or 17i is essentially a Clover Club, which, if you don't know what that is, it is basically gin, grenadine, or raspberry syrup, lemon juice, and egg white, and you kind of shake it up and it looks quite beautiful, I must say. It is so gorgeous. I think it's one of the prettiest quarantinis ever. I think so too. Yeah. We will post the full recipe for our quarantini 17 as well as the non-alcoholic placebo rita on our website. This podcast will kill

you.com as well as on all of our social media channels. Yeah. Any other business, Aaron, our usual suspects. Yeah. Why don't you take us through it, Aaron? All right. We have a website. You can find everything you need there. Yeah. Basically, we have a website. We have a website. It's this podcast. We'll Kill You.com. Check it out. There's a bunch of fun stuff there. Okay, moving on. Moving on. So let's get into the actual meat of this episode. You led us. Frontline healthcare workers, doctors, nurses, respiratory therapists, NPs, PAs, MAs, so many people have been involved since day one in the direct care of people sickening and dying from COVID-19. And since so much about this virus and disease,

especially in the early months was unknown, it's been a really difficult road, to say the least. Providers have been dealing with overloaded hospitals, a lack of adequate personal protective equipment, and watching patients die alone without family or friends there for comfort. And we've heard a lot of this, you know, health care heroes narrative in the media, but healthcare workers are human beings, not superheroes. And this year has put an incredible amount of stress on the health care system and on our providers as individuals. Yeah. And that is on top of a system that is already stretched, where health care providers are already suffering from things like burnout and depression at higher rates than the general public,

and often with little or no support for their mental health from the health care system in which they work. So we wanted to focus today on the impact that this pandemic is likely having. in the immediate and the long term on the mental health of frontline healthcare workers, but also we wanted to take a broader view to examine what kinds of structural issues in the health care system contribute to the problem to begin with. Yeah. And we were fortunate enough to interview an expert on this topic, Dr. Michael Myers, a psychiatrist who specializes in treating other physicians and health care workers, and who is also professor of clinical psychiatry at SUNY downstate Health Sciences University in Brooklyn, New York. His newest book,

titled Becoming a Doctor's Doctor, is a memoir of his journey, and he joins us in this episode to answer so many of our questions about the underlying issues that contribute to mental health struggles in health care providers, as well as how the COVID-19 pandemic has exacerbated these. This interview was recorded on March 29, 2021, and we also wanted to mention that there were some sirens that went off a few times while we recorded, so you may hear those in the background. So just keep that in mind. And we will let him introduce himself right after this break. Dinner shows up every night, whether you're prepared for it or not. And with Blue Apron, you won't need to panic order takeout again. Blue Apron meals are designed by chefs and arrive with pre-portioned ingredients, so there's no

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Text lift to 32 32 32 32 32 32 32 32 32. Text lift to 32 32 32 32 32. Lift to 32 32 32. My name is Michael Myers. I'm a psychiatrist. I'm a professor of clinical psychiatry actually at SUNY Downstate Health Sciences University in Brooklyn, New York. I'm a former training director in psychiatry, but since I've semi-retired, What I do now is that I'm the ombuds person for our medical school, meaning that I investigate any complaints that our students have about mistreatment. And I also serve on the Medical Student Missions Committee. So I'm a specialist in physician health. I've written extensively on that, and I'm excited about my most recent book, which is called Becoming a Doctor's

Doctor, M.M.R. Excellent. Thank you so much for taking the time to chat with us today. We're really excited to speak with you. So our first question is just if you could tell us a bit about how you became interested in the field of physician mental health and what made you choose to pursue that as a kind of career. Well, this started with a tragedy, actually. In 1962, I lost one of my roommates, his name is a pseudonym, Bill. It's his first name to suicide. And that was over the Thanksgiving weekend. We were both first-year medical students. I was the last person to see him alive. And it was awful. I was young. I mean, I was only 19. I had never been exposed to suicide before. But I think what really struck me the most was how much his death was,

I don't know what I would say, perhaps covered up. The stigma associated with any kind of perceived flaw or whatever you might call that in medicine back in those days was so. profound. So we didn't hear anything from the dean's office. I'm the one who made the announcement to my classmates. We didn't attend this funeral. We didn't send flowers. And I thought over the years how different this would be, they were killed in a motor vehicle accident, night of cancer or something. And I think that that got me thinking about the stigma associated with psychiatric illness and medical students and physicians. And then fast forward a few years when I was in training that in psychiatry in the early 70s. I saw my first physician patient on Christmas Day,

1970, the pseudonym is for Dr. Monroe. And that's how I started my book, actually, about my memoir, because I really wanted to capture how captivated I was really by his story, looking after him and his family. And through the rest of my training, which is four years, I got to actually look after some other members of doctors' families so that by the time I graduated and opened up my halftime private practice, I felt I had a little bit of a leg up. I wasn't quite as intimidated about looking after my peers or whatever as maybe some of my colleagues were. So that's kind of how it all got started. So even in non-pandemic times, physicians and other health care workers experience a multitude of challenges such as burnout or

isolation that can have a substantial impact on their mental health. So can you talk us through what some of these challenges are and what impact they have on the mental health of health care professionals? You know, does this field experience things like depression, anxiety, substance abuse, and suicide at higher rates than the general public? I'm going to do this in two ways because I like to think of like the bigger factors, what we call the systemic factors of the situation in medicine today here in the United States, because that seems to be driving a lot of the concern that so many of our physicians today describe as burnout.

Some are unhappy with that term, and it's now being called moral injury. But then it can get worse, though, too. And you touched on that error in that sometimes individuals then wonder, is this burnout or perhaps have I fallen into depression, or something like that. In other words, the illness of depression, things like that. So the systemic factors are felt to be the things that are really driving this in physicians themselves.

So in other words, you could take the healthiest doctor and he or she is going to succumb at some point with a system that is so demanding of them. And some of the things that you hear about so much are the electronic health records, for instance. or the increasing corporatization of medicine so that there's less time with the patient, and having to gather so many things on the computer, and having to do so much work that feels like bureaucracy. And there are a number of other factors that doctors describe. It varies a little bit on the branch of medicine. And so that can really make doctors.

feel demoralized. And, you know, when we look at the definition of burnout, it's got to do with a loss of agency and control over your life or doctors felt they're on a treadmill. And they describe this kind of exhaustion, an erosion of their spirit. Those are the terms that they'll often use. They'll talk about depersonalization, for instance, that sort of numbness or detachment from their patients and each other, like a loss. of compassion and that's very very bothersome and at the end of the day the other thing that they described is a sense of futility even though they really are helping people that's not necessarily they don't really feel gratified that you're experiencing that so that's the big systemic piece but

the one thing i never want to be left out is what we bring to the table ourselves as individuals so in other words we could be going through just stuff on our own personal life having to do with who we are as individuals, our particular vulnerabilities, whether or not we've suffered from anything in past in terms of health challenges, or there could be things going on in our family. And, Aaron, I think you were kind of trying to get at maybe whether or not there are particular things that we might be prone to in Madison because there has been quite a lot of research on this. It's mixed. But he's generally felt that, especially during training in medical school and residency and beyond, that our rates of depression are a little bit

higher than age-matched cohorts in other professional schools, for instance. So there's that piece. The second is also, we don't know so much about anxiety disorders because I think that they've been underdiagnosed in the past. Like, for instance, PTSD, which we're hearing about so much since the COVID-19 pandemic, we were hearing about it before, but I would say only in the last, maybe five, seven, eight years before that, I think it was not being picked up or not being talked about. This has probably always been there at some level. And so, but the other one that they're most concerned about is suicide in physicians. And that was the substance of the book I did just before the memoir called Why Physicians

Die by Suicide, Lesson Learned from Their Families and Others Who Careed. And that's my post-vention research interviewing family members and friends and colleagues of doctors who have ended their lives. And what we found is that the research varies, but it's been felt, though, for one doctor a day dies by suicide in this country. We don't know whether those rates are going up or going down or just how accurate we're. But even if it's that or something like that, that's very serious. there tends to be a gender difference that the risk of suicide and women doctors compared to women in general is much higher than it is for male doctors as compared to men in general, for instance, those kinds of things. So I think I'm getting back to your question that even before COVID-19, you know, we're a group of human beings, you know, with some pre-existing volesisting. vulnerability. And that's the so-called humanness that I'm trying to communicate in my memoir.

Absolutely. And so although it seems like in a lot of ways, we've made some strides over the past few decades, there still is quite a lot of stigma surrounding mental illness, not just in society in general, but also very specifically, like you mentioned in the medical field, especially even in terms of things like licensure, like having to mark that little box to get your medical license. So what does the stigma look like and how, in your opinion, does it contribute to the high rate of mental health issues in health care workers? Okay, Aaron, thanks for that question. I try to always break this down into what we call interior internal stigma and what's called enacted or external stigma. So with regard to the former, that internal stuff is what we feel

when and if we develop some symptoms suggestive of a psychiatric illness. And usually that's pretty negative. You feel horrible. You just feel frightened. You feel less than. You feel embarrassed, dreadful that this is not something that is generally accepted that easily in society, as you mentioned, especially in the house of medicine and the culture of medicine. So there's all of that piece where we beat ourselves up and delay going for help. The external stigma, and you touched on really the most profound example, is when we're judged or discriminated against externally. And the two areas that I think that's most manifest has been with regard to our application for medical licensure or their renewal, as well as credentialing applications for hospital

privileges, medical cyber privileges, and things like that. Where this is problematic, then, it's twofold. Doctors get frightened that, oh, my God, if I go see a psychiatrist or get some help, I'm going to have to report this when I go to get a medical license or when I renew my license. So they avoid going. They don't get treatment. And doctors should be able to get the same kind of care that they so selflessly give to others. So with regard to licensure, that varies tremendously from state to state. I happen to practice in New York. We're one of, I think, about 12 states where no questions are asked at all of us when we apply for a medical license. No health questions, nothing. And contrasts that with some states, which will remain unnamed,

where the questions are draconium. They violate the Americans with Disabilities Act. The good news, though, is that this has been looked at very strategically and carefully over the last five years, the last two to three years, there's been a recommended template for what's called the Federation of State Medical Board. If you feel you do have to ask a question

about a physician's health, this is what we would recommend. to a doctor, are you currently suffering from any illness that is affecting your ability to practice safe and competent medicine? If so, please explain. So there's three things about that that we feel are, you know, for those states that feel that they need to ask that that are acceptable. The first one is it currently. So this is just about a current illness. The second one, because it's current, it's about possible impairment as opposed to just having an illness. The third part that we like in my field of psychiatry is it doesn't partition off psychiatric illness and substance

use disorders from, say, general medical conditions like diabetes, high blood pressure, multiple sclerosis, something like that. So that's kind of where that sits. And more and more state licenses are modernizing their questions or perhaps moving to not ask. any questions at all. Yeah, yeah. So the higher rate, as you mentioned, of these mental health issues among health care workers is well known, though maybe not as widely discussed as it should be. It's been measured quantitatively and studied qualitatively, but these measurements don't often tell us about the roots of these issues. And you've touched on sort of the bigger picture of what some of these, you know, issues at the root are. But can you talk about where these bigger picture problems

originate and how each step of medical training and beyond contributes to the problem? Okay. Yeah. And I'm going to largely put a positive spin on this because it's been worked on over the decades. And I'm going to confine my remarks to medical students and physicians. What's happened in medical schools, though, is applicants to medical school are making up their list, Sometimes the bottom line is to say, I want to go to a school that really does seem to be a place that cares about its students for four years. Not just that we're going to get a first-rate education, but that indeed this feels like a big home or something for four years. Or they found the other medical students friendly, a little less competitive with each other. So when you have a culture that starts with the dean who's setting a tone or an example for the entire medical school, that makes a huge difference.

then all the associate names. Okay, then you've got peer wellness groups where the second year medical students reach out to the first year medical student, where you've got free services, mental health counseling services for your students, where there's stuff that just sort of built in on the website, where you've got people like me who have a possession

of being an obfitz person because mistreatment is not on. You know, it's tough enough going through four years of medical school. You don't need to be experienced. this treatment at the hands of a resident or a professor or something like that. So when you can create all of that, I like to believe that that guarantees like more of a safe passage. And even if there's a tragedy in the medical school, for instance, say, where or if a medical student dies by suicide, we now have national, basically a toolkit that I was

instrumental in consulting on through the American Foundation for suicide prevention that walks you through what you do on day one, day two with regard to the other students, to the professors, to the family, to the media, all that sort of stuff, all meant to reduce copycat suicide or things like that. So it's making a whole change in the culture of medical education. And then after medical school, it's kind of, of the same thing through residency training, which could be anywhere from four to six years, again, making sure they don't neglect the health of your trainees, offering services, for instance,

seven days a week, perhaps, or in the evening, because of the long hours that they work, you reduce duty hours per week. Again, built-in services, changing the whole culture, having to do with microaggressions and micro inequities that women's students have faced, that LGBTQ students have faced, that Asian and black and other minority medical students have faced. Yeah. So kind of looking at all of this big picture, how much of this is a problem that is unique to the United States and our medical training and how much. much of it is something that we maybe see among health care workers more universally. And if there are other countries or other places that are doing a better job when it comes to the mental

health of health care workers, what can we learn from them? Okay, that's a very good question. In my lecturing around the world, I've certainly visited some countries where my area of expertise in physician suicide is pretty frightening for some countries. that they're looking at physician suicide as sort of just an unusual outline event due to the individual that's got nothing to do with the system. Like we're fine, she wasn't. On the other hand, I visit countries or I receive, now I get on conference calls with physicians in various parts of the world that are really open to learning some of the advances that we have here, for instance, in the United States. They wouldn't necessarily want our system because it's a confusing system with all the insurance. For instance, and I spent the bulk of my practice years in Canada where we have a universal health care system.

But we weren't without our problems as well in terms of with physician health. The one piece, though, that I can sort of speak clearly about it so proudly of was that I could see, I could treat a medical student. I could treat a physician or the family member without ever having to worry about insurance. I think one thing that is universal, though, is this increasing perception that people in medicine for too long have been sort of treated as workhorses. And, you know, they're used to hard work. So just pile more work on them. You think what we're seeing is that that's not working.

Right. So your most recent book, Becoming a Doctor's Doctor, is a memoir of your 35-year career as a psychiatrist primarily treating other physicians. So over that time, you must have witnessed a lot of change in the way that we talk about or in the way that we deal with mental health in physicians. So can you talk about some of those changes, what some of those changes are, you know, and have we gotten better? Or what are the areas in which we have failed to make significant improvements? Okay, there's lots of good news, and there are some things that I would like to see happen. The one thing, even though we've been talking a lot about stigma, it's much less than it used to be, but unfortunately, it's still there.

There's much more research on these systemic and personal vulnerabilities that, you know, we've been talking about. The other thing that I'm excited about is that we have more and more role models who self-disclose in both scientific and lay journals that they've suffered from depression, an alcoholism, an eating disorder, for instance, something like that. And we've got more resources for doctors to, through the various state physician health programs. It vary a little bit from state to state, but largely, though, you're out there to certainly help physicians in their hour of need and then to offer sort of follow-up in advocacy,

and that's very important. There's less sexism and abusive teaching, but yet we still have a Me Too movement in the House of Medicine as well. Duty hours are less. There are dedicated rest breaks, sleep breaks, strategic napping, for instance, is something that it's called. Areas that need more work, we've talked about the licensing and credentialing applications. far too many doctors are still leading no very unbalanced lives. This is now getting to the personal piece, where I feel it's altruistic,

but they are working way too hard, and they're not building in enough time in their life for exercise, for nutrition, for just, quote-unquote, taking time to smell the roses, for relationships, for kids, you know, I don't, I never mean that in a judgmental way because there are some individuals in medicine and say, look, I'm not interested in relationships. I just love my work. And that's fine. But I said, but at least also, if you're going to keep doing it, then at least

take some trips by yourself or something, you know, go to a yoga class or something, you know, things like that, just so you can protect your individual health. there's still too many doctors, even with COVID-19 going on, and how we've normalized all of the stress associated with being on the front lines, still so many doctors through kind of just suck it up. Or it's that sort of macho rigor or something that is still very much a part of medicine. I mean, it's commendable at one level, but it should never, ever feel like a weakness if you go for mental health care.

You don't feel weak if you start to have blood in your urine. I mean, it's scary. Or if you notice a lump in your breast, that's scary too. But you go and get help. And I would like to see more physicians have primary care doctors. Too many don't. And one final thing I'd like to say is that, I would like to see more psychiatrists who are kind of sort of dedicating, at least part of their week, to look after their colleagues, you know, if they're so inclined.

Because there's some science to it, and there's things that you need to do. And that person opposite you is a fellow physician as opposed to perhaps an attorney or a realtor or teacher or something like that, just because you're in the same. field. You're both in medicine, that sort of thing. So those are the kinds of things that, and with that, I think that that doctor-patient, you know, gets a higher level of care. When the doctor looking after her or him is comfortable looking after her in the doctors. So I do a lot of teaching in that whole realm, you know, in my day-to-day work. Yeah, absolutely. So COVID-19 is not by any means the first public health crisis. that a number of physicians have had to deal with.

There are a number of physicians out there who might have worked during other outbreaks, such as Ebola or even during the early years of the HIV-AIDS epidemic. So how do these crises, especially COVID-19, amplify these issues that physicians are already facing in terms of mental health? Okay, let me comment on that. In my memoir, that's why I put a whole chapter in in my book on HIV-AIDS, because that was occurring through the 80s into the 90s and that first decade where it was so, so much,

you know, on everything on the front lines. There are some differences, though, because one thing is that there isn't the same degree of stigma associated with patients with COVID-19, although at the very beginning, though, there were some patients who somehow felt stigmatized that they got it and somebody else didn't. And people, of course, were afraid of them.

we knew less about the virus than even than we developed, much like HIV at the beginning, but even doctors who looked after patients with AIDS were stigmatized, that sort of thing. So, you know, there, and other than that, there are also lots of differences, but it really calls to the four of physicians. And so I've seen doctors through the COVID pandemic because my colleague that I, Dr. Fiss, we started support groups at University Hospital, Brooklyn, our teaching hospital, This is our first year anniversary of starting weekly support groups for hospitalists and for emergency docs. Then we had groups for residents, for medical students, all for the nurses, and things like that too.

I remember a couple of physicians saying that I was kind of burned out before the pandemic, but I don't feel it now. Even though this is very scary work, and we're not exactly sure what we're doing because we're still learning about this virus, I do feel that I'm doing what I was trained to do, to look after critically ill people. Now, again, that's in the face of concerns of our PPE and all of the, you know, the masking and the gowning and the gloving and that depersonization that you feel. And this is, of course, when relatives were outside the hospital and they've got dying loved ones in the hospital and the health care professionals having to communicate on way of FaceTime with them. And, oh, my gosh, when I think back on all of that, it was just unbelievable. So that called to the fore, though, so many things in health professionals themselves.

And now is when I think people are more concerned about the long-term effects of this, which perhaps we could come to. The one thing, though, if there's any silver lining to all of this, I have heard people say that there's been a more humanistic interpersonal space developed. I've heard doctors talk openly about feelings that you would never expect that they would talk about before, that they're talking with their trainees about what they're feeling in their heart, for instance, the sorrow they're feeling or the fear that they're having, things like that, where they're dropping at least some of that intellectual jargon,

medical ease that we use in our health centers, just to be human with each other. So I think there has been more of that sort of community of caring. So that, in a way, I think is a good thing. Yeah, yeah. And so, you know, as you mentioned, during COVID-19, we have seen disillusionment and despair in health care workers. And this might be especially pronounced as public health measures are ignored or belittled by these large swath of the country. And yet, especially in the media, this narrative of the health care heroes seems to be perpetuated,

seems to be constantly put forth, you know, putting a rosy spin on this pandemic or on the actions of health care workers during the pandemic, which in some ways maybe allows us as people who are not directly involved on the front lines to sort of ignore or, you know, look through rose-colored glasses at this excess stress, at the lack of PPE. And so can you just talk a little bit about how damaging this healthcare hero's narrative can be? The hardest part, I think, and this is where it gets back to moral injury, especially for all of these healthcare professionals, the ones who have been interviewed, these first person stories that you listen to, of the nurses, and this one's working in emergency room, the intensive care, you know, nurses, doctors, and then you're exhausted,

after a shift, then they get in the car, they drive home and see people out partying with no masks on, things like that, or, and I'm not going to get political, but the fact that it's become political, also so tragic that we have to follow the science. And I know that sounds like a hackney phrase, but it is essential until we really are clearly, you know, really out of the woods. And so that's where sometimes the healthcare professors will say like, yeah, it's nice to be called a hero, but, you know, do something yourself in terms of prevention so that we're not having to be in this kind of heroic job. The other thing, too, is that I really like this, when these health care workers

you say, you know, I don't like being called a hero. I just, ooh, it just doesn't, I just don't feel right. I'm a doctor. I've trained to do this work, but, you know, I'm not a hero. So what I've always said to them, I said, look, I just try to say thank you. that what it is is that people are just so touched and honored by the work that you're doing and putting yourselves at risk for others. And I said, and that's really because they do see you as heroic.

And even if you don't feel that yourself, I said, you are doing extremely important work. Then, of course, they say, yeah, but most of my, as the beginning said, but most of my patients have died. I said, but that doesn't mean, though, that you didn't do something. You were there with them. You showed up. You held their hand because their actual loved ones can't do that. They're outside the hospital. I mean, it's very granular.

These are the basic, you know, the basic covenant of the health professional patient relationship. Yeah. What do you think might be some of the false? fallout that we might expect to see in the long-term future from the COVID-19 pandemic in terms of its effects on mental health. I'm just going to confine my remarks to more of the medical, psychological fallout. The first one is PTSD. And this is not a shock even to most people who are suffering from it. And certainly, I'm looking after some people at the hospital trainings who are feeling that and having symptoms of PTSD.

but they're getting better. And time is passing, and there are, you know, we've got so-called CPT, cognitive therapy, medications that can help, and things like that, support groups. The other, though, is probably broader, and that has to do with grieving.

And sometimes, I think, when we can articulate that for an individual who's feeling something, but they're not sure what to call it, they are grieving. And if they're not asking, actually grieving the physical loss, say, of a family member or friend to COVID or something else, is all of the other losses, though, they've had the loss of, well, maybe attending their niece's

first communion or their nephew's barmets or an in-person funeral, for instance, or, you know, a wedding with that, there's all forms of grieving what we once have, you know, that type of thing. And preparing for the, quote, unquote, new normal as these things sort of evolved through this. There's a lot of loss and this isolation, of course, that we've all had to live with. People in relationships, that's been really different. Sure, there's a set of problems there, you know, too much time with each other. You've heard of an uptick in domestic violence and in dysfunctional families because the kids are remote learning and, you know, all of that stuff. We're hearing about physician moms.

And what they're all dealing with, they're trying to run a practice at the same time as, you know, homeschooling their kids or hybrid schooling or not having available childcare as they once had. So that's all in that kind of, all of the loss that even probably many of us aren't even exactly sure really what that is right now. But it'll unfold. And again, I always try to be positive, though. I really follow things like post-traumatic growth. And my experience with that was long before COVID-19. That's through my bereath network, the families who have lost someone to suicide. And yes, they look back and say, this has been a complete nightmare.

But now that I've been my seventh year since losing my son, I'm seeing a bit of a silver lining to his premature death. I know that I'm a better person. I'm kinder and more giving. I've got more emotional intelligence. I'm wiser. I'm more gracious toward families who do have a son graduating in university and I don't. people are just so amazing and so full, I think, of strength and grace and dignity and courage and love. Yeah, I think it'll be interesting to see, you know, in the next year and the five years from now and ten years from now sort of how we look back on this.

And, you know, maybe some things will have emerged that we didn't expect or, you know, both good and bad. But, yeah, hopefully a lot of it is more good than bad. Yes, exactly. Yeah. And so as family members or friends or partners of health care workers, what are some worrying signs that we can look out for? And as someone who might be, you know, one of these frontline health care workers or just a practicing physician anyway, how do we recognize these signs in ourselves as well? Okay, so I always tell people, look, just look for things if there's any change. And I sometimes tell people that behind the crankiness, or something of a loved one,

your partner and your spouse, or their withdrawal, or their displacement, or unworked criticism, can sometimes just be a lot of pain or a lot of anxiety or whatever. The key is to kind of get at that and say, look, we need time out.

Okay, so we just need to talk about it. I need to reconnect with you in some ways. I've always told spouses and partners, of doctors, especially, that you have as much right to a whole, range of feelings that your work, whatever it might be, is just as important. It's defined differently. It may not get the sort of kudos or something that people in the health professions got. You're doing, whatever you're doing, it all counts in the same degree. And so,

and so I think to just kind of stuff it and to try to always be strong and comforting and caring, you can get burned out or something and also resentful. The other thing, of course, always tell people that your bottom line is you're trying to protect family life. And for some of you, it may also include spirituality or religion. Not always, but there's got to be other types of family rituals that will work. Yeah, absolutely. So going back to sort of this big picture questions, and we've touched on a lot of these throughout this interview. But what do you think are the biggest failings of the medical system in terms of emotional or mental health support for those who are in medicine?

And then maybe most importantly, how can we begin to change things? What are the changes that we should make at the medical school level or at the hospital level or what role do other physicians have to play in terms of providing or helping to provide this emotional or mental health care workers? Well, so in addition to so many of the things that I think we've already talked about, the basic rule, though, is that all health professionals are human too. And I know that sounds so simple, but I think that, you know, we're kind of drawn to the field like all health professionals because they care or want to make a difference or something like that, which is laudable, wonderful, et cetera, et cetera. but yet, you know, we're still human beings. And so I've always felt that health professor, they're used to hard work. But the fatigue if they feel after a 12-hour shift, it's been a good day, is a different kind of fatigue than they feel if it's been 12 hours, but half of it's been a nightmare or something where they just feel that this is such a dysfunctional place on working, that kind of thing. I mean, they need to feel valued.

It's not always just so much from, you know, sort of patients or their family members or something, but from the system itself. And again, that's, that gets into all of these, all of the stakeholders, the CEOs of hospital systems. But yet when and if people feel that, it gives, it gives more meaning or purpose, you know, in your work. Can you get through these these tougher days because you feel that there's, you know, just sort of an ethos here. And because without that, though, we know from the work, for instance, it's coming out of Stanford led by Dr. Tate, Shannonfeld. He's always writing about making the business case for burnout prevention. And he's done it in space that if the CEOs don't get out. on top of this, they're just losing so much money because of attrition and turnover, staff.

People just don't stay. They can't. Loss of life, for instance, long-term disability that your workers go on because they're ill. You listen to a humane model for a healthy workplace. There's a strong business model for that too. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands

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weeks and ISSA guarantees you'll get a job. Text train to 32 323232. Text train to 32 32 3232. Train to 32 32 32 32 32 32. Hey, this is U.S. Olympic gold medalist Tara Davis Woodhull. And I'm U.S. Paralympic gold medalist Hunter Woodhull. As athletes, our lives are about having a clear path. And a team that you can absolutely trust.

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So burnout often stems from a loss of agency or control. Many physicians became doctors because they wanted to help people, and our current system has them spending hours of their day dealing with bureaucracy, insurance battles, paperwork, medical charts, things that don't have anything to do with patient care. It can make their work feel exhausting and futile. And on top of that, working in health care can be emotionally challenging in its own right. But one thing that's often overlooked in these conversations about burnout is that every healthcare worker is a person, an individual human that brings to the table all their own personal challenges that might have nothing to do with their work at all. And this is, of course, true for everyone in every job, but we often expect that physicians and other healthcare workers are superhuman and expected to ignore or suppress these personal challenges in the face of their challenging work environment.

Yeah. And number two, in the realm of health care, workers experience both internal and external stigma that can contribute to mental health challenges. Internal stigma can make it difficult for us as individuals to accept or even acknowledge that we are facing a difficult time and need to seek help. This often results in a delay in seeking care or, at worst, not ever seeking help. And I think this is something we all deal with to one degree or another. and it can be so difficult to overcome. Internal stigma can also be compounded by external stigma. External stigma can come in so many different forms, but essentially is the societal or workplace pressures

that may make it so that someone who could benefit from mental health services who is experiencing something like depression or anxiety or any other mental health issue feels as though they can't seek help because of external pressures. In medicine, one of the most egregious examples of this is having to document previous or current psychiatric treatment or conditions when applying for state medical licenses or hospital credentialing. This is something that used to be completely ubiquitous and is now fortunately changing and vary state by state, but is one very strong example of a practice

that really has the end result of preventing physicians and other medical professionals from seeking help or treatment because of this fear of repercussions. Yeah. Number three. Let's consider all of these systemic issues in the context of COVID-19. Physicians and other healthcare workers, especially those on the front lines, are facing an incredible amount of additional stress and pressure due to this pandemic. Early on, many were working without proper PPE, with constantly changing recommendations and regulations. And as the pandemic progressed, ICU's reached capacity, and yet cases continued streaming

into hospitals. Some report feeling invigorated as though this is what they have trained for their entire careers. But others say they're overwhelmed and frustrated at being called a hero when they don't feel heroic. This pandemic may be the first time in which many healthcare workers have had to watch more of their patients pass away rather than recover. Or the first time they've held up an iPad as patient after patient says goodbye to friends and family, bearing silent witness to counter. countless tragedies. And then if after a long shift in the ICU, they drive home to see lines outside bars or crowded sporting events on the news, this can lead to a feeling of, what's the point? Moral injury can come into play yet again. This healthcare hero's narrative can in some

ways allow the rest of the public to fail to acknowledge their own personal responsibility for their role in slowing or speeding up the pandemic, instead relying on these heroes to step in and save the day. Of course, those who have fought and continue to fight so hard against this virus are incredible, and we should all be extremely grateful for their efforts. But we need to be careful not to let the healthcare heroes narrative rid the rest of us of our responsibilities, or make us forget us get or overlook that the conditions many have worked under are unacceptable. Yeah, absolutely. Number four, as of the time of recording this, the pandemic has slowed, especially compared to

the big winter wave, but in the months or years to come, we can expect to see a lot of fallout from COVID-19, especially in the form of things like PTSD and grief. And grief, not just as in the loss of a family member or friend, which, I'm sure many of us have experienced, but also the loss of the life that we once had and having to transition to this new normal that we all have to live in now. If you have someone in your life who is a healthcare worker right now, or if you are a healthcare worker yourself, recognize that this year has been a ridiculously trying one, and it's okay to need help. It's okay to need support, especially right now. Essentially, it's okay to not feel okay or to not be able to be able to

to take on all the extra things you maybe used to take on. It's okay to say no and just turn everything off. Turning off and focusing on connection with each other, with our loved ones, can be really helpful for your mental health. And I think this advice applies in some way to all of us. It's also important, as Dr. Meyer said, that we may someday be able to recognize growth within ourselves through this experience. Number five. The good news, though, is that things are changing for the better in many ways. The first is that more and more states are not requiring any questions about health status, mental or physical, for licensure, or if they are, they're at least refining the questions.

Another trend is that when making their decisions or their rank lists, applicants to med schools and residency programs are taking into much greater consideration the way that students and residents and faculty are treated. So medical training is no longer viewed as strictly the quality of education, but how well a program is going to support students and residents? Do they actually comply with new work hours, regulations, and restrictions? Do they have confidential counseling services? Do the students and residents and faculty actually feel supported or even happy?

Also, today there are many more resources available to all of us, not just health care workers. So even though the stigma isn't gone by any means, it has at least decreased in recent years. In part, we can really thank the physicians and healthcare workers that have self-disclosed that have told their stories, whether in magazines or journal articles on social media, or even by providing a firsthand account on a podcast. So thank you again to everyone who has shared their story, not just with us, but in general. And for anyone who is struggling, whether you're a healthcare worker or a teacher or a bartender or a grocery store employee or a stay-at-home parent or anyone at all right now, know that you are not alone. And if anyone is suffering from suicidal ideation, the National Suicide Prevention Hotline phone number is 800.

273-8255. And we have a link to their website as well as other mental health resources available in the U.S. and worldwide in our show notes and also on our website. Yeah, we do. Well, we want to thank you again, Dr. Myers, for taking the time to chat with us for this episode. We really appreciate it. Yeah. Your expertise was very welcome. And thank you again for everyone who provided a first-hand account. It's been incredible to hear from all of you, and we really, really are grateful to everyone that has sent in a first-hand account. Yeah, really. Thank you also to Bloodmobile, who provides the music for this episode and every single one of our episodes. And thank you to the exactly right network of whom we are a very proud member.

And thank you to you, listeners, for listening to this episode. This is, we're getting towards the end of this COVID-19 series, so we appreciate that you listen. Yeah. Well, until next time, wash your hands. You filthy animals. Success starts with your drive, and American Public University is here to fuel it. With affordable tuition and over 200 flexible online programs, APU helps you gain the skills and confidence to move forward.

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