Well-being as an internist is never easy, let alone during a global pandemic.
“I know that I personally have struggled with a lot of frustration, and anger, and fear, and grief,” said ACP Member Elisabeth Poorman, MD, MPH, a clinical instructor and primary care physician at the University of Washington in Seattle. “And those feelings are totally valid.”
Especially in medical education, physicians may believe they need to know everything in order to be competent, said Dr. Poorman. “But it's not possible to know everything in medicine, and it's certainly not possible right now in a pandemic. Information is rapidly changing.”
From patients dying to financial uncertainty, the consequences of COVID-19 for physicians are both professional and personal. Dr. Poorman and other wellness advocates provided their top 10 tips for staying well as the crisis continues.
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.”
This disease is also 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 (SIU) 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 Eileen D. Barrett, MD, MPH, FACP, an ACP Well-being Champion and former ACP Regent and Governor who spent six weeks in 2015 treating Ebola in Sierra Leone. “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. Embrace what you can do with telemedicine.
Telemedicine is “totally different than face-to-face care,” which makes for new intellectual challenges, said Dr. Hingle. “I didn't realize how much nonverbal information was provided by eye contact or body positions that you can't necessarily pick up on a phone call or on a video,” she said. “And the accuracy—internists, we're known for liking our data, and you can't listen to a patient's heart or lungs.”
Losing that therapeutic touch and connection from in-person visits can almost feel like losing a sense, said Tammy Lin, MD, MPH, FACP, an internist in private practice in Rancho Santa Fe, Calif., and Governor-elect for the ACP Southern California Region III Chapter. “But if you lose your sight or you lose your hearing, all the other senses become amplified, and you develop them further,” she said. “So perhaps this is an opportunity to further develop some skills and senses.”
One example is that telemedicine can sharpen your triage skills, said Dr. Lin, who is also an ACP Well-being Champion. “There are obviously things that you can't do via telemedicine, but I think what you can do over telemedicine has opened a lot of people's eyes in deciding who needs to be seen in person and what you may be able to take care of in other ways,” she said.
To maximize your telemedicine visits, remember what's called the “golden minute,” Dr. Poorman said during an ACP webinar on lessons learned from the front lines. “Traditionally, you may be familiar with that as the minute that you're walking to the exam room with the patient before you open the computer and launch into your questions, but on telemedicine, I think you can also incorporate that as well,” she said.
Precharting before a visit is an efficient way to help you customize your approach; in addition to the clinical agenda, consider making a note of the patient's job or some detail about the person that jogs your memory, said Dr. Poorman. “That moment of connection has been really important for them, but also really important for me. And many patients will actually ask me how I'm doing, which is unusual and has been really heartening,” she said.
Then, after a patient has told you the reason for the appointment, it can be helpful to ask what he or she is most afraid of or concerned about, she added. “I think that's probably always a useful question, but right now, the fear and anxiety is so high that that question really helps me better understand what the patient is looking for, make them feel heard, and oftentimes will reveal some very helpful clinical information, such as the fact that they may be living with immunocompromised family members,” Dr. Poorman said.
3. Keep financial concerns in perspective.
From pay cuts to layoffs to keeping the lights on, financial concerns are top of mind for everyone right now.
At SIU, the majority of patient care income comes from the outpatient setting, so the decline in patient visits immediately after the pandemic negatively impacted the financial bottom line, said Dr. Hingle. Effective in May, faculty were receiving 75% of their salary, with the rest of the money going toward payroll to avoid layoffs, she said.
Dr. Hingle advised keeping measures like this in perspective. “Physicians remain a very well-compensated profession. … It is definitely a big pay cut. But still, what I'm able to bring home at 75% is way more than what my staff get paid and way more than the vast majority of my patients get paid, and I don't have to worry about living paycheck to paycheck. I can feel comfortable that I can pay my bills without needing to make hard decisions,” she said.
No internist wants to hear about pay cuts, layoffs, and office closures, but reacting with worry and fear of the unknown can be paralyzing, said Dr. Lin. “Slowing down so you can get into a state where your mind can be clear and calm is helpful as you evaluate the situation, determine which resources you can tap into, and tackle one step at a time,” she said.
While you will likely have an emotional reaction, taking a moment to do some breathing and mindfulness techniques before going into problem-solving mode can help reduce stress levels, Dr. Lin said. “Those techniques will increase your capacity to be there for others and to find effective solutions—to respond instead of react,” she said.
For physician leaders, transparency with staff is key when salaries are on the line, said Dr. Poorman. While it's important to let them know you may be cutting hours or pay, be sure to work with them, listen to their concerns, and set expectations for the future, such as potential opportunities for overtime, she said. “In a few months, I think there's going to be a huge demand for our services. So how are you going to take care of your loyal and important staff?” she said.
4. Remember that you're not alone.
As the crisis began, organizations and clinicians were focused in solidarity on protecting and supporting the American public, which provided meaning and purpose, said ACP Member Read G. Pierce, MD, who is an associate professor of medicine at the University of Colorado Anschutz Medical Campus in Denver. But now that the country's trying to get back to normal, the realities of physician burnout are creeping back into the picture, he said.
“Now we have this environment where budgets are in bad shape for many health care systems, and support from the county, from the community, from the state, from the federal government is going to drop because of the economic impact,” said Dr. Pierce. “I think we're going to enter this period where there is an even more acute challenge of needing to do the same amount of work with many fewer resources, and that's going to put a ton of pressure back on the previous drivers of burnout.”
In these next phases of the pandemic, the onus is on health systems and other employers of clinicians, as well as the government, to make clinician well-being a priority, according to a perspective published May 13 by the New England Journal of Medicine. “Before the virus struck, the U.S. clinical workforce was already experiencing a crisis of burnout. We are now facing a surge of physical and emotional harm that amounts to a parallel pandemic,” the authors wrote.
While caring for patients, providing for your family, and taking care of colleagues and employees is a lot to handle at this time, remember that you don't need to do it all alone, noted Dr. Lin.
“I think to seek help, tap into resources and support, and not be afraid to do so is a really important point,” she said. “And also to not do it alone on a professional front. That is the role, in part, of our leaders and professional organizations and societies: to advocate for you in these times. That's why you're a member and you participate. We're all in this together.”
5. Stay connected.
The world can feel strange, foreign, and suddenly dangerous right now, Dr. Palamara said. But physical distancing does not have to equal social isolation, and video platforms offer a great opportunity for connection, she said.
Mass General hosts “water cooler breaks” through Zoom to allow staff to share good stories with each other, Dr. Palamara 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, she 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,” said Dr. Palamara.
It's also important to continue mentoring relationships during this time, said Dr. Lin, who helps run Med Mindset, a pipeline mentorship program affiliated with the University of California, San Diego (UCSD), where medical students mentor high school students from groups that are underrepresented in medicine. “Mentoring is not just the transfer of information, but it also serves an important social function too,” she said. “And you can help students, or whoever your mentee is, develop and grow in other ways as they encounter challenges.”
Although COVID-19 caused a significant disruption to the mentor-mentee relationships, the mentors have adapted by helping their mentees focus on tangible, attainable goals to help them feel productive and keep their minds occupied, said ACP Medical Student Member Alexandra Maloof, a third-year medical student at UCSD School of Medicine who leads the Med Mindset mentors. “Another point is helping mentees understand their new normal, which varies from mentee to mentee based on their personal experiences that they're having and how they're coping with COVID,” she said.
Another way to stay connected and share ideas is through online discussion boards, such as the ACP Member Forums. (The Member Forum for COVID-19 discussion is online.) As the pandemic escalated, 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.
“Part of their well-being was just being well informed about what's happening, so it was so crucial to make sure everybody knew what was going on nationally to inform their decision making,” she said.
In addition, connecting around difficult events can help clinic staff process the harsh realities of COVID-19, said Dr. Poorman. “We know that a lot of our patients are probably going to die in the next few months, and I think one thing that we have struggled with as physicians is thinking about ways to grieve,” she said.
Patients have relationships with the entire staff, from the front desk to social workers to nurses, Dr. Poorman noted. “So it's important, when we lose a patient, to think about how our whole team is affected by that and to think about ways to grieve together,” such as by calling families, writing notes together, and debriefing about difficult situations or concerns that something was missed, she said. “It's important when you debrief to think about psychological safety, which is where you say no one will be punished for speaking up,” she added.
6. Find gratitude.
Practicing gratitude is one of the most important ways to get through a crisis, said Dr. Hingle. “There's lots of terrible, terrible things happening, but there are also lots of positive things that are happening in the midst of all of this,” she said.
For example, many clinicians are learning to teach remotely and realizing in which situations video conferencing can be more efficient than face-to-face meetings, Dr. Hingle said. “We're also learning that our relationships are important and something that we need to pay attention to. … So look for those learning lessons and positive things that are coming out of this, because there is definitely a lot to be learned throughout the challenge,” she said.
Another area to practice gratitude is with your colleagues in the clinic, such as by writing thank you notes or giving kudos for a job well done, suggested Dr. Poorman. “And be kind. This is not the time to write an angry email,” she said. “Keep in mind that a lot of our bad coping mechanisms are going to be coming out in the next few months, so just give people some space.”
7. Be informed, but don't overdo it.
With information on COVID-19 constantly updating, “It's like a fire hose, 24/7,” said Dr. Lin. While it's important to stay informed, it's also important to put limits on what you take in, “just like you would, hopefully, watch what you eat and what you consume,” she said.
Dr. Wahi-Gururaj, also an ACP Well-being Champion and professor of medicine at UNLV, said when the crisis started, she was “nonstop” reading media coverage, reading scientific literature, and listening to podcasts about it. “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,” she said. “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.”
8. 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 and 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.
9. Nurture positivity.
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. 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, added 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.”
10. Remember to take care of yourself.
In addition to staying positive, mindful breathing and self-care are key tools to approaching a crisis with calm, experts agreed.
One technique called box breathing 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 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. “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.”
Dr. Poorman, also an addiction medicine fellow at the University of Washington, noted that a lot of people are using alcohol to unwind. “I certainly understand that. This is an incredibly stressful time and it's an easy thing to do,” she said. “But one thing I'd like you to keep in mind is that we are at particularly high risk for substance use disorders in normal times, and I think during this pandemic maybe even higher.”
At baseline, one of 10 physicians qualifies for a substance use disorder and one in five qualifies for hazardous drinking, Dr. Poorman reported. “Just be careful about that. Don't think you need more to the extent to which you will be wanting that alcohol to calm your nerves after work,” she said.
Remember that maintaining well-being is both a marathon and a sprint, said Dr. Lin. “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.”