Episode 124: Physician Well-Being and Pandemic Burnout

Speaker 1: You're listening to Your Practice Made Perfect. Support, protection and advice for practicing medical professionals. Brought to you by SVMIC.

J. Baugh: Hello everyone and welcome to this episode of Your Practice Made Perfect. My name is J. Baugh and I'll be your host for this episode. Today's topic is one that has always been important to both SVMIC and physicians all over, but now more than ever after having gone through the COVID 19 pandemic, we see new challenges for our healthcare providers and the need to really focus on physician wellbeing. Stress and burnout for our providers has been around for ages, but it's inevitable that in a pandemic, which most of us never thought we would experience in our lifetimes, our frontline healthcare heroes have experienced a higher than normal level of stress. And we have an amazing physician here with us today to shed some light on pandemic stress and burnout. And so our guest for today's episode is Dr. Charlene Dewey. Dr. Dewey, welcome to the show.

Dr. Charlene Dewey: Thank you, J. It's such a pleasure to be here.

J. Baugh: Well, thank you for being with us today. Before we get started, could you give us some background information about you and your career in medicine?

Dr. Charlene Dewey: I would love to J. First I'd like to say that I'm a General Internal Medicine Physician by training. I trained in primary care at the Albert Einstein College of Medicine - Montefiore Medical Center, where I got to experience a wonderful program which is called the Social Internal Medicine Program in which we looked at not just disease and what we cure in disease, but we looked at individuals, their health, their family, their social settings, their cultures, and how all of those play a role. So I love bringing that into my career. I've been a physician now for a long time. I graduated medical school back in 1990, and I have had the pleasure of working at the Baylor College of Medicine in Houston, Texas for the first 15 years of my career. And I have been at the Vanderbilt College of Medicine here in Nashville, Tennessee for the last 15 years of my career.

In my career, I have had a background where I trained and taught many residents over the years. And I love teaching. My focus back at Baylor was really more of a clinical base and an education base on cardiovascular disease prevention. Always trying to bring the preventive roles to medicine. Here at Vanderbilt, I look and bring that same eye of prevention to physicians who provide care. So now I focus my attention on healthcare providers themselves. Our physicians, our nurses, pharmacists, dentists, and other healthcare providers. But the physicians is where I spend 99% of my time. Trying to help them with what we call their professional health and wellness. And so I do that. I'm also the assistant Dean for the educator development program in the medical school where I train faculty development type activities for our faculty. Help them learn how to teach our residents and patients and students better.

And I co-direct the Center for Professional Health, which is a center where we actually help physicians who've somehow gotten into trouble and need remediation training. And now again, focusing on the preventive side. How do we look at things that drive physicians to stress and burnout and how do we mitigate that stress and burnout?

I'd like to also say that that's not just me. Because I am also a physician who loves taking care of patients. I see patients half day a week. I also have a family. A wonderful husband who's a healthcare executive and leader and president of a medical center. I have two daughters, Erin and Alexis. One's in her master's program, the other one's a freshman in college. And I have a wonderful little black cat named Jasper. And that pretty much makes me.

J. Baugh: Well, thank you Dr. Dewey for that introduction and for all that you're doing. I know I speak for all of us when I say we're thrilled to hear from you today. So let's kick off our conversation this morning with a brief introduction to the Center for Professional Health. What is it and how does that help physicians?

Dr. Charlene Dewey: Right. So in our Center for Professional Health, this was developed by some wonderful physicians and giants here at Vanderbilt, 32 years ago now. And they recognized that physicians needed a place to help them. We realized that physicians could get in trouble for their behaviors, but the medical boards would actually sanction them for those behaviors. And Andy Spickard, David Dodd, Bill Swiggart and Ron Neufeld, which we call our founding fathers, had the insight to say that physicians needed education in this realm. And to start focusing on their behaviors and their professional interactions and relationships with their colleagues and their patients in ways that are a little bit different than what we're trained in medical school as. We had Bill Swiggart is a licensed professional counselor and a drug alcohol counselor. And Ron Neufeld is also a drug and alcohol counselor. Andy Spickard and David Dodd were both physicians.

And so the two worlds kind of met together. And when I got here about 15 years ago now, what I noticed when I started participating in the center was it was a unique way of helping physicians understand the sources of their stresses and their burnout and why those things lead to the behaviors that it leads to. So it very much took something that could have been very punitive, like being sanctioned by your medical board, but actually providing and empowering physicians to understand about themselves, to understand about their family of origins and how those behaviors translate into patients, and as well as relationships with their colleagues. And then they also learned how things like an ACE score, which is an adverse childhood experience, might influence their behavior or their propensity to substance use disorder. And so it was just this wonderful mix of medicine and the social sciences together to come and help physicians as opposed to be a punitive place.

For the last 32 years or so, we have run three programs. One is the mis-prescribing of controlled substances, the Distressed Physicians Program, and the Sexual Boundaries Program, to help physicians who have crossed professional boundaries find their way back to better professional practices. And in the last two or three years, we've been developing our Center for Professional Health and Wellness. I've been teaching the topic of stress, wellness, burnout, impairment for the last 15 years. And what I've realized is that a lot of physicians are unaware of the stressors, how it plays a role in their lives, how it impacts their families. I don't know if you've ever heard this J, but when I was a back at Baylor, my husband and I used to give one of the medical marriage presentations. And we used to talk about the evidence around physician divorce rates. And we of course went in and talked from our perspective of what stressors are like in a marriage when you have kids and things like that.

But what I didn't realize even at that time is how impactful the amount of stress and burnout played a role probably in that high divorce rate. So coming to Vanderbilt and kind of switching my focus to the health and wellness of physicians, I learned a lot about how we as physicians are trained, how we have to kind of hide our emotions and not really deal with our stresses in a safe environment and how most of us feel that there's, I'll say a stigma around asking for help. And so I have been able to try and take all of these lessons that we have learned in the last 30 years here and from my own experience as an educator, as someone who has taught physicians for the last 15 years, and we're taking that information, we're creating our new section for the Professional Health and Wellness in order to meet the needs of physicians before they reach any trouble points. It's the best I think preventive model we can probably use to help our physicians.

J. Baugh: Well, Dr. Dewey, that is certainly very helpful information for our listeners and we'll be sure to link the Center for Professional Health in the show notes of this episode. So now onto the COVID-19 pandemic. The pandemic's been a challenge all over the world and it's been especially challenging in the world of healthcare. So what are some of the challenges that physicians are experiencing?

Dr. Charlene Dewey: So, you know J, there's a lot of challenges, but the ones that I'm going to emphasize the most was probably the immediacy of which the pandemic came on, because that meant that there was the lack of preparedness. Physicians don't like ambiguity, right? We like being able to make the diagnosis, get people better. And so that initial paucity of information of what to do was definitely one of the initial challenging points. I remember sitting in my clinic around January 21st and said to my nurse, "What's the procedure if we get a patient that has the SARS COVID virus?" And she said, "I don't really know." So I looked it up on the CDC webpage and had to find that information and what to do and who in my organization was going to be the infectious disease contact person. And then of course it wasn't really but a month later when it really started hitting our colleagues up in New York. So that sudden onset, lack of knowledge, lack of preparedness, not sure what to do mode, was very jolting for most physicians.

I would also say as information started coming in, then it became the fire hose. I remember trying to look up all of the articles, trying to look up and listen to all of the news stations, trying to go to the CDC webpage, to the Johns Hopkins webpage, to my own webpage, to try and keep up with all of the information. And I wasn't sleeping, trying to get so much of the information in, because this is what I do. I have to teach these things and help my colleagues understand this. And it became overwhelming just trying to keep up with it. I wrote one of the first articles that was published on how to maintain physician wellness during this immediate startup of the pandemic. And we definitely all struggled with like, what do we do? What do we tell them? Because we didn't know how long it was going to last. We never had this experience. So we were suddenly jolted into an action which we weren't truly 100% prepared for. And then we had information coming in like a fire hose and didn't know where to get it.

The third thing is that physicians are ready to leap. They're ready to jump in. They're ready to grab someone's rope, help them, do whatever we can. But then we were faced with, but we might die in the process. And then not having enough PPE to protect us was probably the third big jolt that we got, which is as the patients started coming in. Now, my husband actually ran the COVID hospital up in New York in Brooklyn. So I was getting information from him that I was feeding to my colleagues down here in Tennessee and watching what was going on and listening to him and Dr. Fauci on the news. That part of it, and yet still going to clinic.

And so getting to the point of saying, every day I went to clinic, is this my last two weeks? Do I die in the next two weeks? And it was a huge emotional toll for people. Now, I did outpatient and I can only imagine what that was like for our colleagues that were the hospitalists and the intensivists, working with the patients that were actively sick. In my clinic it was always, we didn't know if someone was going to be sick, but for them, they knew they had patients with active disease. And I know I came home every day wondering whether this was my last two weeks and what was going to happen to my children? And thinking if the worst came to the worst, what are we going to do?

And so that was the immediate challenges that we had. Then we started to make it through the first and the second wave and PPE started coming. And I'll have to make the joke along with toilet paper, because that was definitely one of those social fun things that I found amazing. But we started making it through and we started realizing, getting more information from around the countries and around the world, what we could do to protect ourselves. And then I started getting into a habit. And so I made sure I knew exactly what I was taking in the clinic with me. I was only wearing scrubs. I was coming home decontaminating. I had developed a routine and it was starting to become habit by the time the fall months were coming. You started seeing people leaving I will say the jump in and help part to this is now what we have. Like the acceptance phase.

And then as things continued and we continued to watch the waves come, I think we started moving into that chronic phase. As we approached the year mark, everybody was, oh my gosh, I can't believe that we've gone through this whole year. So now we're looking at the chronicity and what starts to change with chronicity. Sometimes there was maybe, do I keep decontaminating or don't I keep contaminating? There's questions. Do we continue to do this, don't we continue this? Do I still need to live in a hotel or can I come home and live with my family? And those challenges then became, again, some personal challenges. And people started to master the clinical side. Physicians are smart, intellectual people. They pick things up very quickly if you give them the right information.

So then when you go through the more chronic phase, now we're a year and so into this. What I'm starting to see now is a little bit more of the psychological safety piece that they can care for the patients. But now we're starting to see more frustration because now we've just had a Delta wave. And could this have been prevented if everybody donned masks and did what they were supposed to do and social distancing? Would it have made a difference? There's that ambiguity that you want to say you know that mask can help. But at the same time, would it have changed anything? What if, what if, what if, and you start questioning all over again.

But then the frustrations when now we're starting to see patients get mad at physicians or yell at nurses, or even be physical with them, especially when they're trying to let them know that their loved one is ill and they're calling them liars. Meaning the patient family member is calling them liars. Or even the patients themselves, I've heard the stories, saying, "You're just making this up. This is fake, this isn't real." And then it becomes very disparaging and frustrating for physicians and I think that's where we're at now.

J. Baugh: Well, those are definitely some very challenging experiences that physicians and other healthcare practitioners are facing these days. So what can and should physicians be doing to help with their stress and burnout during the pandemic?

Dr. Charlene Dewey: Sure. I'm going to talk about stress first and then burnout because everybody perceives stress in different ways. And so I would never say there's one blanket way of handling stress, but the most important thing I think is understanding that you are stressed, recognizing how it manifests in you. Some people might clench their jaw, some people tighten their shoulders, some people have GI upset, bowel habit changes, sleep changes. They get short tempered and a variety of other things. We know that stress can manifest in a body in many physical ways, including the immune system and or heart attacks and things like that that might make physicians become more vulnerable to illness themselves.

And so the best thing I think is to figure out what works best for you. And so I know my favorite go-to is going for a walk, being outside or getting on the treadmill if it's rainy and I don't want to be out there. But that physical release is extremely helpful. But even emotional releases, just talking to each other, talking to a loved one, just letting the stresses out. Recognizing that it's there and talking about it.

Some people prefer forms of meditation, either Mindfulness Based Stress Reduction techniques, or prayer that can help get them into a space where they feel safe and comfortable. And other people might listen to music or read or watch TV. I've particularly become fond of Korean Dramas over the last couple of years and they help me unwind and just relax and let go of all the stresses that I'm dealing with every day.

So I would say, be self aware, figure out how it's affecting you and then find what is your best source for releasing and mitigating the stress. I think I used to always teach if there's a way to prevent it, prevent it. So that means if I know that there's going to be a stressor coming up, is there something that I can do to modify what that impact might be on me? And I use sometimes simple things that if it's a babysitter or leaving earlier if you can, in order to avoid the traffic. Simple things. Sometimes just anticipating them and trying to kind of put the stop on it before it can even happen.

So when it comes to burnout, burnout itself is a syndrome of depersonalization, low personal accomplishment and emotional exhaustion. And physicians unfortunately are almost at burnout already before the pandemic even hit. So the pandemic only added to that. Initially, you saw the rallying of the troops during that March through June period, where they wanted to help, they wanted to jump in. This is our duty. This is what we do. We were trained to help and that's what we do. But as time goes on and that feeling starts to wear off and the chronicity starts to set in, then those who were already at risk of burnout are still going to struggle with that and now it's going to be exemplified.

So burnout might look like someone who is depersonalized, and this is where they say, "F these patients, I'm done with this job." They're detaching. They're exhausted, they're detaching. They don't want to be involved anymore. And if someone is feeling like that, then I'm going to urge you to seek assistance. They're plenty of places that there are people ready to help you.

I will also say, when you start feeling like, one more thing, I just can't take one more thing. Oh, darn, this happened. And oh, this happened and now this is happening. I just can't take it anymore. That's when you're getting to that end of your emotional exhaustion and you also need help. Personal accomplishments reductions for physicians don't look the same as maybe for others, but it is manifested in slightly different ways in that physicians who are burnt out might actually have lower professional productivity if they get behind in charting or they get behind in housework and things that they would normally do, that they start putting off. They start doing stress relieving activities, and they delay other things which only compounds the cycle of stress.

And so when we start seeing that triad in people, we know that they are at burnout. And if you look at Shanafelt's evidence, just having depersonalization alone is strong enough to probably consider someone at burnout. And I often say, if you yourself say, "man, I think I'm burned out", then you might be. And that means you need to get help. Getting out of burnout is not impossible, but we need to know so that we can help physicians. And so it's overcoming that stigma and that barrier of asking for help. EAP programs, physician state programs, health programs, physician coaches like myself, our Center for Professional Health. The Mayo Clinic has programs. Stanford has programs. Columbia, some other schools. Mount Sinai in New York has programs. There are plenty of programs now that are out there to help physicians if they reach burnout.

J. Baugh: Well, thank you Dr. Dewey for that great information. And we will gather as many of those resources as we can and we'll put links to those resources in our show notes. So as of this recording, we have now been in this pandemic over 18 months. And since we are still dealing with this pandemic life, what are physicians experiencing now that was different from before when the pandemic first started?

Dr. Charlene Dewey: Right. So they are experiencing higher rates of burnout. When we start looking at the literature of the studies that are coming out and getting published in 2021 compared to the earlier studies in 2020, we're definitely seeing the rates of burnout go up. So it's becoming more prevalent. And I believe that's because most physicians probably teetered. At least 50% of us might have at least one portion of burnout, which is the depersonalization. And so we were teetering before the pandemic. And now that we're into this chronicity and we're dealing with much more of the frustration, the exasperations, the fatigue of doing this over and over and over again, I think that's what physicians are dealing with now. And again, the disruptive maybe behaviors of patients and family members.

J. Baugh: So given some of these concerns and challenges that you've just mentioned, how do physicians manage this, especially the frustrations that they are experiencing?

Dr. Charlene Dewey: Right. So one of the first things, I have a colleague who's a licensed professional therapist and she works with trauma. And so one of the things that we know is really important is to identify your emotions and realize that you're having them. So, are you frustrated? Are you angry? Do you feel hurt and disappointed at the way patients are treating you or your colleagues, the nurses, the medical teams and staffs? Do you have fear that's still persisting? Are you sad? Maybe feeling like you have some despair or hopelessness or content and discuss. So the first thing is to think about what the emotion might be. And maybe also reflect on how it might sound in your head because we don't just all the time say, “oh, the patient did this and now I'm angry”. What we might think is, “how dare they?”.

And so, we want to take what we might say in our head and shift that into the emotion and then recognize if you're getting what we call flooded. Some call it amygdala hijacking or some call it the fight and flight syndrome. But it's when your catecholamines all of a sudden start surging, because usually what comes with that is a disruptive or distressed behavior. And so if they're having something like that, then they probably want to step out of the situation and give themselves space from the patient or the patient's family. Or say, even because tensions are running high, colleagues can actually have these distressed reactions with each other. They're trying to get their service taken care of while a physician on another service is trying to get their service taken care of. And so they start to almost in-fight when the reality is, the common variable or monster here is the COVID. And what they're trying to do is the same, which is help patients.

So we want them to recognize if they're getting flooded, take a step back, go find a place to sit, to walk, to talk and to have maybe colleagues help each other with that emotional release and with that psychological safety. So they can quickly go for a walk. And I say, what physician's going to go for a walk during the middle of the day? They're busy. But what you do is when you're going from patient to patient, you can walk faster or maybe you take a detour and run down the stairs and run back up the stairs. It still might be enough to get your heart rate going and get you a little bit out of that stress zone.

If you have opportunity, and this is where I say places where the health system can work, because burnout is not just an individual problem. It's usually caused because between the mismatch of the person and the job. So if the systems that we work in provide places where we can go and de-stress, that would be amazing. That's one of the things we recommended to one of our departments here at Vanderbilt. Take one of the patient waiting rooms since patients can't stay there with COVID anymore and change it into a stress reduction relaxation lounge, where the lights are down low, where maybe there's a yoga mat or a Pilates ball or something where they could take a five or ten minute break to go in and do something to help relax themselves. That will help them release some of that stress and anxiety in the moment. And then of course, continuing to manage it and the system continuing to support them. Giving them affirmations, keeping them updated on knowledge and new information, making sure that they have enough PPE and things to do their job and do it well.

They can also talk it out. So this is where if physicians, especially in teams who work together, maybe there's physicians in ICU and there's nurses and there's a team. If they can create a place of psychological safety for each other where they listen to each other, and that really means be present, even if it's for a couple of minutes at the start of the day or a couple of minutes at the end of the day. But then they can just kind of talk about what happened today. How did it feel when we took care of Mr. So-and-so for 21 days and despite everything we did, he still died? How do we handle that? How does the team handle that? Talk it out. Making sure we encourage each other, I think is a really important one. We're working with a company called EncourageX in Texas, who happens to be my brother-in-law, but we love his process because he provides encouragements to people via email or text messages.

So in our center, we use that to encourage physicians and nurses and anyone who's one of our participants so that they can constantly get messages that are positive and that affirm who they are and that they're enough as they are. And then things like connecting, praying, meditating. Journaling, my partner always used to say that journaling is the best free psychotherapy that you can probably get. So is there a safe place to do some journaling for the physicians and other healthcare providers on the team?

And again, sometimes just breathing. Sometimes just walk out the room, take a deep breath in, hold it for a second, feel it come out of your mouth, realize that you're alive, that you have a purpose and that you're going to keep helping people. And that's what we do. That's why we come into medicine to help people. So I think those are some of the things that we can probably do in the short term. Again, system issues are the biggest problem that we have to deal with because most of the time that's administrative things that have to change, but that's where physicians can give good suggestions on what to do.

J. Baugh: So, Dr. Dewey, if you had one message of advice or wisdom for physicians, what would you tell them?

Dr. Charlene Dewey: I would first say thank you for everything that you have done. Not just in the pandemic, but how you've devoted your life, how you've sacrificed so much of your life in order to get to do the job that you get to do. I would say continue to have the passion and realize that patients are suffering, they get stressed, they get frustrated. So do their family members. And it's really not you. It's their stress and their frustration to have to deal with. But when you do get stressed, remember you're human, you're valuable, we need you, and to find whatever mechanisms help you either in your individual control or through your systems and organizations changes that help make your work environment a safe place for you to be.

J. Baugh: So, as I mentioned at the beginning of this episode, the topic of physician wellbeing has always been near and dear to SVMIC. But now with the COVID-19 pandemic, it's even more important. And we hope this episode and topic can provide insight and help those in healthcare who we at SVMIC hold so dear. So Dr. Dewey, are there any last minute pieces of information that you would like to share before we wrap up this episode?

Dr. Charlene Dewey: Sure. I'm going to say your health is your first wealth. Take care of yourself first. When you take care of yourself and you put into yourself, everything that you do becomes better. So I use the example of the drop of water and the ripple effects. The more you put into yourself, all of your ripple effects get better. So your ripple effect to your children, to your spouse and partners, significant others, families, extended families, patients, healthcare teams, everything will get better if you take care of yourself first. And I will say, our center offers some really great retreats and training programs, and you can check us out on our webpage and let us know if there's something we can do to help you.

J. Baugh: Well, Dr. Dewey, you have certainly provided some very important information for us today and we want to thank you for being with us and for the information that you've given to us today.

Dr. Charlene Dewey: Thank you so much, J. I really enjoyed being here and I appreciate that opportunity to reach my dear colleagues across the country.

J. Baugh: Well, you're welcome. Before we go, I would like to share that we appreciate Dr. Dewey here at SVMIC so much, and we know what she has to share is very valuable to our policy holders. So Dr. Dewey will be presenting at several SVMIC seminars in the future, and we'll link those seminars in the show notes as well as any other helpful resources for our listeners for them to reference. And we want to thank again our listeners for being with us today.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect. Listen to more episodes, subscribe to the podcast and find show notes at svmic.com/podcast.

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policy holders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state and change over time. All names in the case have been changed to protect privacy.