Podcast: Avoiding burnout, tending to mental health as pandemic enters year 2

Jim Dryden (host): Hello, and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri, the Show-Me State. As we continue to detail Washington University’s response to the COVID-19 pandemic, we focus in this episode on stress. We’ve been living in a pandemic for a year now. And that’s stressful for teachers, students and parents, and for first responders and health-care providers.

Jessica Gold, MD: Doctors, notoriously, are caregivers and not care receivers. We don’t think about ourselves as people who need treatment, but we think about the many ways that we can provide and help.

Dryden: That’s Dr. Jessi Gold, a Washington University psychiatrist and the director of Wellness, Engagement and Outreach in the Department of Psychiatry. During the pandemic, the doctors in emergency rooms and intensive care units aren’t the only ones who’ve been busy. Gold and other mental health specialists, also, have seen an uptick in anxiety, depression and other problems linked to stress. Developing a vaccine in less than a year seems very fast, but a year is a long time to go without seeing relatives or hugging friends, and there’s stress associated with those things.

Gold: I think anything you’re feeling is normal. I don’t think that there is a normal feeling at all right now. I think everybody’s just struggling. There are different times that we feel all sorts of things. There’s dancing health-care workers when they had the vaccine come out or when people were getting shots because it was probably the first time that there was any sign of hope. Any form of relief is, really, just a let go of what we’ve been holding in for a long time. I think we kind of look down the road, and it looks a lot longer still. So the disappointment that still exists and the sadness that still exists and the hopelessness that still exists, I think, will keep coming back around when you look at a calendar and you still can’t plan.

Dryden: Now, you, personally, have been part of the outreach offered to employees and students and others at Washington University who may need extra help during this pandemic. And I’m wondering, are you staying busy?

Gold: [laughs] Yeah. I’ve been busy. I’ve been busy the whole time. I think I’ve been busy more and more over time. I see people as a psychiatrist in my clinic. I see faculty, staff, health-care workers, faculty spouses and faculty and staff and health-care workers’ children, but people over the age of 18. So lots of their college and graduate-student children who are home, really, because a lot of people have been doing sort of the hybrid mix of schooling. And that has led to a lot of people staying around St. Louis who might not have done that otherwise. A lot of our employees have shifted to being home, which also includes additional stressors, like their family and their spouse working from home or their dog or all of the other chores and stressors that come with it. And I think it’s hard to balance all of that.

Dryden: But I’m imagining that there may be something cultural during a crisis like this. That some of the people who are at the greatest risk from stress and emotional problems may, also, be the least likely to reach out. And that would include, I’m imagining, people like first responders and, frankly, doctors.

Gold: That’s the understatement of the century. Doctors, notoriously, are caregivers and not care receivers. We don’t think about ourselves as people who need treatment, but we think about the many ways that we can provide and help. We end up in this place where we look at the person next to us and they are stoic and they aren’t feeling, so that’s just what we do. We don’t feel and we are, also, stoic and that’s just how it’s modeled. And so that’s what we do. Part of what my job is and part of what the job of the whole team and part of how we think this out as well is, how do you reach those people and how do you communicate in a way that you can find them? And this is something that I think about a lot. Like, “Do they even open their emails? Do they delete them? Is that the right way of communicating? How do you find them? Where do we go? How do we talk about it?” And I have been doing a lot of these — I’m on a tour, basically, where I go to a lot of the different departments and give five-minute, 10-minute, 20-minute, whatever people ask for, talks about mental health and coping with mental health over COVID and what’s been going on. But especially, it’s been a lot of physician groups because that’s who’s been asking. I think it’s been nice because they just listen. They don’t ask a lot of questions, frankly. But afterwards I get asked to do another two or three in some other spider-webbed way. And I think it does, eventually, get to more and more people and that’s the point. And within them, I talk about resources. And if even one person in there is listening and identifies with the symptoms and gets help, that’s the point, right? And so I think we’re trying and thinking it out, but it’s a hard thing to get people in for care because it’s not just competing against the medical culture, but it’s also competing against sort of like the entire American culture that has their own beliefs about mental health. So mental health is an uphill battle, in a lot of ways, for people.

Dryden: Now, a few weeks ago, it was a really a great presentation, Dr. Anthony Fauci gave Grand Rounds for the Department of Medicine. And toward the end of that — Fauci is 80 now, I guess — he talked about sort of reaching back to his intern and residency days because he hadn’t had a single day off, even Saturdays or Sundays, for the whole last year.

Anthony Fauci, MD, Director of the National Institute of Allergy and Infectious Diseases: Back when I was an intern, it’s just the resident and the chief resident. It was at a time when you were on every other night and every other weekend. There was some good things about that and some bad things about that.

Dryden: This is Dr. Anthony Fauci.

Fauci: But you really learned back then how to suck it up. You have three patients who are sick as can be, and the ER calls you up and says, “By the way, I have a bleeder coming up,” or “I have somebody who just had an acute myocardial infarction and arrested in the ER. He’s coming up.” You don’t say to yourself, “Excuse me? I’m too busy.” You say, “OK. Bring them up.” So it’s the same thing now. When you’re dealing with a crisis like this, just make out you’re an intern again and do it.

Dryden: So as Dr. Fauci reaches into his past to do what needs to be done, doctors and other health-care workers have been giving it their all for many months. But I hear you saying that part of caring for others also has to involve practicing self-care, especially when a health-care provider starts feeling burned out or depressed or anxious. I mean, doctors on call in the hospital are used to doing whatever it takes to care for their patients, but normally, those really hectic busy periods only last for a few days or a few nights at a time. This pandemic has been underway for a year.

Gold: Yeah. I mean, it’s like a light kind of switches on, right, and says, “Now I’m on call, and I don’t complain, and this is what I’m doing, and that’s what I need to do,” right? “They told me they needed me, and now, I work and I work and I work until I’m done working. And when they say, ‘Stop working,’ I will stop working.” And because we’ve done it and it was conditioned and we know we can survive it because we’ve done it before and we lived through it. Sort of like a panic attack, right? So lots of patients come in to me and they’re like, “I’m going to die of this thing.” And I’m like, “No, no, no. But if you could get over the curve — you won’t die of a panic attack. No one dies of a panic attack. You’ll be fine.” It’s sort of that. You’re like, “You’ve just got to get through it.” It’s like, “It’s a thing. You’ll survive it.” You just turn on that self which is like, “I know how to survive that. I can do no sleep. It doesn’t feel good. I don’t like it. But I know I made it through that and I was OK.” And so I think they’re just on autopilot, really. And it’s really hard because I think they have not had the break, and that’s the problem.

Mohit Harsh, MD: So my name is Mohit Harsh. I’m a resident in the Department of Internal Medicine.

Dryden: Mohit Harsh is getting close to completing his training at Barnes-Jewish Hospital in St. Louis, and in recent months, that’s meant rotations in intensive care units filled with COVID-19 patients. Last fall, his rotation through the ICU became more challenging.

Harsh: So in residency we rotate through the ICU for about a month at a time. And I had my, what we call the COVID ICU rotation, in September. The medicine was about the same. If someone is sick enough that they need a ventilator, the ventilator didn’t necessarily change. But what really changed was the never-ending cause of what brought people in and the never-ending feeling, like, “You’re not going to make a difference in that patient’s story.” Part of the reason why I like my ICU rotations, a lot of people enjoy it, is, yes, there are terrible outcomes that can happen, but a lot of the time we see that people, through and through, get better. But in that month, I didn’t see that so often. And on top of all of that, I wasn’t able to, necessarily, connect with the families when those situations occurred because of the isolation precautions, because no one’s allowed to visit. So all these hard, hard, challenging conversations, not just for the patients and their families, but for us, too, were happening all via phone.

Dryden: Now, as I understand it, you credit Dr. Gold with giving you some sort of a nudge that you needed to seek some help. Can you explain how that happened, exactly?

Harsh: Yeah. So Dr. Gold actually gave a Grand Rounds talk on mental health and physicians especially in the time of COVID. I was listening in, and a lot of what she was saying echoed with me. That we’re not in isolation, in terms of our own feelings. This is not something that I feel just myself. There are countless others who are feeling this way. Countless others who are probably seeking treatment or wanting treatment of some sort. And it made me kind of get away from this façade that, if I seek treatment, I am somehow weaker. If I seek treatment, I’m somehow not as good of a physician as I would be if I hadn’t. With all that, it made me, really, feel that desire to get therapy in that moment. But then also, beyond that, get rid of the stigma associated with it and feel like I should be as open as I can feel comfortable with that process.

Dryden: With your fellow residents, is it something that you talk about?

Harsh: Yeah. I’d say so. I can’t say that I necessarily bring up going to therapy often; it doesn’t flow into conversation. But when we talk about burnout, I’m very candid and open about the fact that I’m feeling burnt out. That’s not something I’ve hidden from my colleagues. That’s not something I’ve hidden from my attendings nor my program director. In fact, I actually emailed my program director and said, “Hey, I’m burnt out.”

Dryden: Now, Dr. Gold is listening in and she just completed her own therapy session. What do you think of Dr. Harsh’s decision, in deciding to seek help?

Gold: It’s amazing. I mean, listening to that makes me really happy. But I mean, that’s why I do what I do. Even getting one person to want to reach out and get help is an honor, to be honest, I think. When he told me that, I was really excited. And I save messages like that, so when I’m having a bad day I can look at them because a lot of what I do is really hard and really sad, too. And it’s nice to see people want to get help and want to feel better and want to know that this doesn’t have to be this way and that we can feel better while we do hard work. And it’s nice to see people get better, too, because it’s very central to my survival. It’s my primary coping mechanism. My therapist is the reason that I can get by in COVID, I think. It’s something I don’t miss. To me, talking to people about it has been really important because it just feels like the right thing to do. And I think if I was a patient, some of mine are health-care workers but some of them aren’t, but I would want to know that my provider was getting help because if I saw that, I wouldn’t see that as a weakness. I would see that as a strength. And I would see that as, “Anything that I’m going through, my provider can hear and deal with because they have their own stuff and own support.” And that’s kind of how most therapists are because, frankly, there’s just sort of like a train of support and we all go deal with it. And it’s very integral in therapy training and psychiatry training to have therapy be part of it, and to sort of understand your own darkness to deal with the darkness of others. But I talk about it as much as I can. And I mean, I love therapy, so I’m happy to talk about it.

Dryden: And I would imagine that it’s good to talk to anybody, but it’s better to talk to somebody who’s had some training in how to listen and what to look for. I mean, in other words, Mohit, you could talk to all of your fellow residents and you could all commiserate and maybe people would feel better. But maybe you could be directed better if you were talking to a professional who has been trained in how to listen and where to point you.

Harsh: I mean, I’d say both are important. I think there is a need for a support system among your peers, and I’m so glad that I have that. Having a therapist in isolation would probably not be enough, at least for me. And the same way, at this point, having just friend support in isolation is not enough for me. The other thing to Dr. Gold’s point about it, we need to normalize the fact that we all have feelings. That we all go through the same emotions that any other person would. Talking about it openly as much as you can really helps with it because then it gets rid of that imposter syndrome. That, “I’m the only one dealing with this,” or, “I’m the only one that can’t handle the situation well.” Well, that’s not really the case. I think everyone is dealing with it and and having a hard time with it.

Dryden: For you, was the issue more that you felt like you couldn’t help the patients? That it was just piling on day after day? Was it fear of getting sick yourself? I mean, what was driving some of that burnout for you?

Harsh: I think one of the biggest things that was driving it, for me, was the system as a whole and just the pandemic as a whole. That this was not something that I was, really, expecting to happen in training, right? Already residency training, no matter what specialty, is hard enough as it is with the amount of knowledge you have to gain. The amount of hours you work. The perceived sense or lack of autonomy that you can get. And then COVID comes around, and I feel like, for one, all of the education and efforts I need to take to build my own fund of knowledge got siphoned into this one disease.

Dryden: How are you doing now?

Harsh: Better than I was. I think still dealing with the day-to-day, but I think, through therapy, something that I’ve started doing that has helped is try to make enjoyment or find joy in just small things around me. And that was something that definitely took the back burner when I was really burnt out in September. October. November.

Dryden: But Dr. Gold, how hard is it to tell with a medical professional, especially? Because I mean, the rest of us you can say, “Well, are you sleeping regularly?” Well, you can’t ask him that because he’s got a cockamamie resident’s schedule, where some nights he doesn’t get to sleep. But what do you look for in a medical professional that might be different than somebody like me, who’s been housebound for much of this time?

Gold: I mean, you still have your schedule, right? So even if they’re bad schedules, you still know what your schedule is. You still need some amount of sleep. You need some amount of food. It might not be the amount that everybody would like you to have, but there’s still some amount that would be better than nothing. So you can kind of go from there. There would be a good baseline, and you’re not there. “How much is it interfering with your day-to-day?” is a really good measure, always. So anxiety that makes it so you can’t do things you want to be doing is, really, the problematic anxiety. Anxiety that you can function through is kind of the anxiety most of us have, especially right now in the pandemic, right? But anxiety that makes it so your friends keep asking you to go for a socially distant walk, and every time they ask you, you don’t want to leave the house, that’s not good anxiety. That’s anxiety that’s interfering with your life. Anxiety that makes you so irritable that you yell at your children or your partner, that’s not helpful anxiety either, right? So there are these things that you can tell where it’s really starting to affect your life or your job or your performance. And those are the things you really start to look at.

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Dryden: And she says you look at those things whether you’re talking to a teacher or a lawyer or a police officer, grocery store clerk, bus driver or a doctor. Gold says the world has been strange for many months now, and after a while it can get to anybody. She just hopes that the people who need help, like Mohit Harsh did, will ask for it. “Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and, maybe, teach you some things that will give you hope. If you’ve enjoyed what you heard, please remember to subscribe. And thank you for tuning in. I’m Jim Dryden. Stay safe.

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