Physician Burnout on the Front Lines
Sharp Index founder Janae Sharp sat down with experts Megan Ranney, MD, MPH, Jessica (Jessi) Gold, MD, MS, and Benjamin (Ben) Miller, Psy.D, to discuss the systemic nature of healthcare worker burnout both before and during the pandemic. Dr. Ranney is an emergency physician at Brown University, director of the Brown Lifespan Center for Digital Health, and a public health researcher. Dr. Gold is an assistant professor in psychiatry at Washington University in St. Louis, and clinically works with healthcare workers, their families, and college students. Dr. Miller is a clinical psychologist who works as the Chief Strategy Officer for Well Being Trust, a national foundation focused on advancing the mental, social, and spiritual health of the nation.
You can watch the video of their discussion or read the transcript from the video below.
Transcript:
Janae Sharp:
Thank you for joining me today. We’re sitting down with experts to talk about healthcare worker burnout and I think it’s really important to talk to everyone and talk about how that relates to the system that you’re in and how it impacts the systems that we’re in. So, I brought together some experts to talk about our nation and our healing and how this is impacting physicians so I was hoping everybody could introduce themselves and talk about you know briefly and talk about you work.
Megan do you want to start?
Megan Ranney MD MPH:
Sure, I’ll go first. My name is Megan Ranney. I’m an emergency physician at Brown University. I’m practicing clinically in our level one and level two trauma center. I’m also a public health researcher who in pre-COVID times focused mostly on the use of technology, social media, wearable apps, etc. to try and identify and prevent violence and related behavioral health problems among our emergency department population and among the world at large. In that role, I’m also the director of our Brown Lifespan Center for Digital Health.
COVID, of course, has changed everything. Over the last ten months I’ve become involved with work to translate that public health approach and that kind of innovative spirit around public health to our COVID responses. I co-founded and an organization called Get us PPE, which is a national nonprofit dedicated to getting personal protective equipment to those in need. I’ve become involved with the media around trying to translate the current science evidence into information that’s useful and usable by folks who are not scientists of physicians and I’ve also become involved in working with Dr. Gold and Dr. Miller an others on trying to address the long-term effects of this pandemic not just infectious but all of those behavior health problems that are affecting both the society at large and of course our health care workers which I know we’re going to be talking about today. I’m super excited to chat with you guys.
Janae Sharp:
I’m really looking forward to hearing more about that perspective like the long term what does it mean? Everyone wonders, you know and you hear, I hear a lot about it from experts and from you know my neighbors so I’m glad that you could make it here.
Dr. Gold, or Jesse. I know everyone on just so like for the people listening so you know so it’s hard to so please say whether or not I can use Dr. Gold, Dr. Ranney or your names whatever you’re comfortable with.
Megan Ranney MD MPH:
First names are fine. Thank you for checking
Jessica (Jessi) Gold, MD, MS:
First names are fine absolutely. I can introduce myself. I’m Jessi Gold. I’m an assistant professor in psychiatry at Washington University in St. Louis. Clinically, I see healthcare workers and their spouses and children and also see college student and graduate students so when I say their spouses and children, the children I see are often their college students who are still home because right now a lot of college students are remote and a lot of college students are not where they’re supposed to be which means they’re in St. Louis. So that is my population of choice which means right now I’ve been seeing a lot of burnout and a lot of this conversation pertains really strongly to the patient population I see in my psychiatry practice.
The other work that I do in my role in the Psychiatry Department is I’m the director of wellness engagement and outreach. Which means that I have been really since the start of COVID working on how our hospital is responding to the mental health of health care workers and have been helping us think out what we need to be doing in the short term and the long term to better address the mental health of the faculty, staff and healthcare workers so we also have the university population so have also been addressing faculty and staff at the university level as well and wo implementing hotlines and things like that to the long-term effects in expanding mental health services. What do people really want, that sort of thing so have kind of run the gamut of what that looks like from that perspective and currently kind of run around talking about mental health as much as possible on campus and trying to just destigmatize it and talk about it and normalize it in every space that I can including social media including writing about it so I do a ton of writing in the popular press about mental health so I’ve done that for a while. I’ve probably ramped that up substantially over COVID in part because I write as a coping mechanism but in part because it’s very necessary that mental health is in the conversation. I write really regularly for Forbes. I’m a contributor there but I also probably most regularly write for In Style and Self so you can see my stuff there as well.
Janae Sharp:
I really like how you’re very good at making complex conversations about mental health very simple. Which is hard to do like it’s hard to capture that complexity. Ben would you like to introduce yourself?
Dr. Benjamin (Ben) Miller, Psy.D.:
Sure. Well first of all I have to comment on what was just said by Justin and Meagan I mean Jessi and Megan. We are so much better off because of these two amazing leaders. Their voices showing up on our TVs in print as Jessie was just saying. She’s a prolific writer. The world is a better place because of them and I have to just kind of say my honor to be on this panel with them because we need good information right now. There’s a lot of bad information out there, disinformation, misinformation, you name it from everything from mental health to what you put on your face when you’re outside. I mean we’ve just not been given the street of it and I think that’s a challenger for a lot of folks. It leads into the topic today when we start going into this because when folks have uncertainty in their lives and they’re not able to make senses of it a lot of times the best solution is good factual information and we’re going to do that today hopefully.
So who am I? I’m a clinical psychologist by training. I’m really a musician at heart who likes to paint when I have time but what pays my bills is I’m the Chief Strategy Officer (CSO) for Well Being Trust. We are a national foundation that focuses on advancing the mental, social, spiritual health of the nation and the topic that we’re talking about today is something that we focused on for several years now. I’ve been pretty disturbed by this notion of deaths of despair. That’s the drug, alcohol and suicide preventable deaths that have been growing exponentially for the last 20 years. It seems like in 2020 with all that’s gone down as we’ll talk about it’s just a huge moment for us to really embrace this inseparable notion of mental health of public health of primary care of all these major drivers that we know could really contribute to the overall good mental health and well-being so thanks for having me Janae.
Janae Sharp:
Yeah, I’m glad you could make. I really care about deaths of despair too, both because of personal experiences but also I live in a state where suicide is one of the leading causes of death for youth and there aren’t enough services. There aren’t enough. There wasn’t enough to help them before and now with COVID they’re trapped and I have friends who work in that field they have emergencies with all of the youth that they deal with especially foster children or underserved populations and I’ve cared about physician suicide and that overall lack for a long time. That comes from my ex-husband died by suicide and we have three children together. When he died it just felt like no one really had the language to talk about it and after like a month they’re like, okay, but, like can we be done, like can we be done talking about this and I was like everyone says this is an unhealthy system so if it’s really healthcare and they really believe in it they can fix it you know. Except I’m editing the expletives out right now, but I was pretty angry and I’ve thought about this now that COVID has kind of brought things more to a boiling point because I’ve always wondered like what is it going to be that’s going to make a difference when people actually start doing something? Usually people start caring about mental health when it’s impacted someone they know personally of when they can’t ignore it anymore. My hope is that we’re able to come up with mental solutions or even positive directions without tragedy, which is kind of hard. So that’s kind of why I brought everyone here together because you are experts in my experience. You’re people who care personally and have that knowledge like making you expertise in public health. So, I’d love to hear kind of your perspective about mental health and how that has changed like Ben, you were talking about deaths of despair. Your organization even looks at that like the mental health of the nation.
Dr. Benjamin (Ben) Miller, Psy.D.:
I can start with some data and then I’d love to have my colleagues weigh in here on what they see day to day. I alluded to this in the opening comments but if we look at the last tranche of data in 2018 we lost 152,000 live in the United States to drug, alcohol and suicide, which again is classified as deaths of despair and when you look at preliminary data from 19 and even data that our reporter friends have dug up from 2020 we find that the trends are going to exponentially increase because of this pandemic. We, ourselves put out some projections on what we think might happen because of some of the social decline, disconnectedness, the economic problems that our nation’s facing including unemployment and then just this ongoing uncertainty that I’ve already mentioned and it’s not a pretty picture. It doesn’t mean it’s going to happen it just means that if we as a nation don’t wake up and do something about this then shame on us and the thing that really gets me going here Janae, and I’m so glad you asked the question is because this is not a new problem. This problem that we’re discussing today around burnout, I mean you go back to the historical roots of when burnout was initially mentioned it was in 1971 and it was air traffic controllers. You all probably have seen this and you think about the professions that oftentimes are just put under so much stress, so much challenges and adversity and yes our medical professions are under that right now but if you look at other professions that are really involved in death and despair outside of medicine it’s what I would in the literature would call like a low-skilled workforce. It’s folks that worked in mines that had their jobs that they lost and that aren’t coming back and that they lost their reason to be they lost what kept them going and that was where we saw an uptick in these deaths of despair. There’s a lot of solutions. I don’t want to talk only about the problems. I know we’re going to get to the solutions, but I have to say you know heading into you know 2021 when we’ve got some much new opportunity with the new administration it seems like if this is not front and center on someone’s agenda then shame on us.
Jessica (Jessi) Gold, MD, MS:
Can I ask Ben a question? One of the things that I know we’ve had this conversation a lot and you make data and people take the data and do what they want with your data and you know as someone that believes very strongly that interventions do work and actually understands what risks mean, what happens when you make data that might be about to be misinterpreted and it’s misinterpreted in a way that is used by people trying to make a point that you’re not trying to make or it’s like used to say something very catastrophic that you wouldn’t have wanted to say.
Dr. Benjamin (Ben) Miller, Psy.D.:
Yeah. That’s a great questions. What Jesse’s alluding to is that from the president to the secretary of HHS to the White House press secretary our data and reports got misconstrued. I don’t want to say misconstrued. It got used for nefarious purposes and if you read our report we actually say that
Janae Sharp:
It’s even stronger than misconstrued by the way.
Dr. Benjamin (Ben) Miller, Psy.D.:
Okay. Thank you. Yes, thank you. That’s a good point.
Megan Ranney MD MPH:
Actively manipulated.
Dr. Benjamin (Ben) Miller, Psy.D.:
Actively manipulated. We said in our report like we are not giving you these data and making these suggestions because we want you to use it to now open up the economy when we’re not ready. And yet that’s exactly what happened and so if you read the report we’re actually very clear on why we think the data should be seen for what they are and not misinterpreted or used in these kind of unique ways. And so, Jesse, to answer your question, I thank that it is a problem and that in the previous administration or almost previous administration this is something that happened on a regular basis where data were either suppressed or presented in a way that didn’t tell the whole truth and Megan can talk about this better than anybody. When we began to look at the percent of positive in the case rates and the way the data around COVID was just truly, um, it would put any professor that had ever taught statistics to just it would put them to shame. I mean they just, they did a horrible job, that’s not the right phrasing, but you guys get it. I think we have a responsibility to not only be at the cutting edge of consistently making sure that good data is out there but also what you two do every day of your lives which his put the data in context, not spin it, but explain it in a way that people can best understand so Jesse, that’s the best I’ve got because I’m still hurting a little bit from that one.
Jessica (Jessi) Gold, MD, MS:
Yeah, I mean I think it’s really hard right, like you did it you put out the report. You did the work. You tried right, but it’s not what you intended to do from it and I know Megan and I both wrote trying to you know we wrote a piece really trying to contextualize your work in a lot of ways too because we felt like politics aside you know that the doomsday approach to suicide also scares anybody who works in suicide because there are interventions. There are treatments. There are things you can do and if you put out data that implies this is the worst thing that’s ever going to happen, everything is horrible these are the worst. It just cares people and it makes it seem like everything is inevitable and problems aren’t solvable and we have nothing to do and what that means that people just die. Like I don’t want to live in a world where that’s the case otherwise why do I practice medicine where I can help and save people right?
Dr. Benjamin (Ben) Miller, Psy.D.:
Great point.
Megan Ranney MD MPH:
Jessi I actually want to put a finer point on that. That I think that that kind of inherent tension here that we’re seeing both with COVID and with all of the behavioral health problems the way that that data gets used by some folks is it’s going to happen. COVID’s here. We’re all going to get sick and we’re all going to get hurt immunity and there’s just going to be a lot of people who die. Oh lockdowns cause mental health effects we’re just going to have a lot of people dying of suicide and opioid overdose and I think that all three of us and Janae you as well, come to this from a very different perspective which is we know there are these potential bad things that happen but they’re not inevitable whether they happen or not is up to us. Just as whether my kids goes out mountain biking and wears a helmet of not is going to determine his likelihood of getting a head injury when he falls off. We may not be able to stop the initial crash. We can’t stop the fact that COVID is here. We can’t necessarily stop the fact that there are all of these ripple effects of COVID on our economy, on our mental health, on our social and emotional well-being, but we can do stuff to change the trajectory of that, to make those effects be a little less and to help us get through this with a little bit more hope, and as you said Jessi with those evidence-based interventions that we know can help. And Ben to your point about the science and I didn’t say this in my intro, when I do my work on violence, a lot of it is really around gun violence and firearm injury and firearm suicide and if you want to talk about a field where data has been suppressed and misused you can look no further than firearms which of course integrate into the mental health discussion and again Jessi and I have written on this is well. People will say, well you know, firearms suicides are just going to happen or it’s all about mental health and neither of those are true and I think that one of the things that all of us on this discussion hold dear is the idea that we can still kind of have nuance and that we have to bring that to these discussions in order to inform change that will actually work there. It’s not an all or nothing discussion.
Janae Sharp:
Right. When I look at data I think also think you can say from we’ve seen it on a national level where people take data and sort of twist it to fit their agenda, but I also think everyone does that. Like if I really want to go somewhere, I’m going to find the data to support that that is important so if and I think there are a couple of things at play here one of them is that people don’t really want to change so they’re going to sort out the data that supports what they’re doing in their life but also it’s interesting to me because I life in a place the narrative is very different and the data that people are looking at is very different. And I think that can be helpful in some ways because it make you realize how much the narratives that we search for and the solutions, the conversations even aren’t enough. They aren’t enough for the problem and they aren’t enough to address the gap between what people want and what their basic human needs are and science. Like we have a h -
Jessica (Jessi) Gold, MD, MS:
gap right now in science not really understanding human need and I think that’s playing out really strongly in COVID.
Dr. Benjamin (Ben) Miller, Psy.D.:
Well, I mean one thing that we know based on the evidence that is playing out during COVID is that we are such social creatures that the disconnection from each of us socially has not worked in favor of good positive mental health and it’s one of those things I know all of us talk about frequently but when the first and arguably one of the most important recommendations that care out early on in this pandemic was to socially disconnect to you know physically distance. You know it was an opportunity to us to educate folks on the importance of still being socially connected while physically distant. And so even changing the language that we use but when your most powerful intervention and we see this every day play out I mean I just was driving home last night and I was looking at the number of people that are still in restaurants in my town, okay there I don’t want to fault folks that go to the restaurant, even though I worry why they do right now but I think that there’s this reason that people continue to do these things like go to bars and restaurants is because they’re longing for that ability to socially connect. And it’s really hard, and Jessi could talk about this better than anybody, it’s really hard to cope with this onslaught of stress, emotion, anxiety, uncertainty, you name it, when you lose your number one most important coping mechanism which typically for most of us is another person. And that’s like so unbelievably hard to day so like I don’t know how we I mean we’re working on it right and the answer is not going to be just pick up you phone and text somebody. You know there’s this deeper connection that I think we’re longing for and Jessi I guess, I would look to you because I mean you talk to folks all the time that are going through this that want to be socially connected and that can’t. I mean what do you recommend to them? How do you address it?
Jessica (Jessi) Gold, MD, MS:
Man, that’s such a hard question. You know I see college kids and I think one of the things that’s really interesting is we could have learned a lot from them too because they’re so internet connected and so video game connected and they started at baseline socializing in a very virtual space and could have told you there’s a reason why they have the highest rate of loneliness. Like if you look generation to generation why are 18 to 24 year olds the most lonely? But they seem super connected, so we’re missing something with digital connection right. So we could have learned something just there in what people are experiencing and this is sort of like I’m super over it. I’m just going to go outside. I can’t deal with it anymore. There’s a little bit of like cabin fever-ness of it which is you kind of can’t handle it anymore and you weigh in your own ways, maybe not purposefully, not out loud, maybe not on a piece of paper but a bit of a risks and benefits thing where you go I don’t feel good and I know what feels good is outdoors and a person and a person makes me happy and maybe the tangible risk of COVID just isn’t as present as the feeling of being miserable and you just know the miserable will go away and maybe you won’t get COVID right? And so it just doesn’t work for people so the miserable leaves. Maybe you get over it so I think it’s really hard to explain that to people because they just weigh the risks in the moment and it’s really you know we did a disservice in a lot of ways because we kind of in part reacted quickly because it was a pandemic, in part because of kind of the ways that different people at different levels have been communicating and communicating was not necessarily a central message but you know we’ve had a lot of just say no approaches and then a little bit of like anger reaction and a lot of just say no approaches and then an anger reaction and not a lot of nuance and all three of us really like or you know like we’re all of us are four of us like really like nuance and believe people are able to understand nuance if given the time to understand nuance. But the time is required right and the conversations are required and the yes masks, maybe we didn’t understand all the evidence initially and then evidence changes but we have to explain that to you. People are not stupid inherently but they need to understand that science changes but you have to teach them. You can’t keep telling them different things. It’s confusing. I don’t understand half of what epidemiologists and infectious disease doctors are talking about and I’m a doctor. I don’t think that people understood that flattening the curve didn’t mean gone right. I don’t think that was like clear to people and so it’s hard that we weren’t able to communicate to people with a consistent message with people who could have don’t that in a way that would have picked them up and helped them emotionally and had tools in parallel because if you would have had someone with a psychological background or a psychiatric background or a trauma-focused background in parallel going you’re going to tell them to socially distance give them some idea. Like how are you going to save their mental health? Like you can’t just say no more friends you have to say there’s some ideas. We have to do that in parallel. Like colleges are we’re scrambling to do that because they’re like all of our kids are going to be miserable. We have to give them something right but they were scrambling like crazy to do that right so you have to be able to like put those messages in parallel or you’re just really at fault but you know we’re always arguing to have mental health in the room for the reason that you just said which is like if mental health’s no in the room this is what happens.
Janae Sharp:
One of the things that happened at the beginning of the pandemic is someone asked me like how my kids were because I have you know I have kids, lot so kids um and I felt like my children were more prepared in some ways because they already had the language of death. They already understood how to talk about those feelings and then I also think about the perspective of like this was not good for me like as what I always like affectionately say I do a total autonomy parenting like nobody gets mad at me for not doing the dished like but at the same time like when we’re supposed to socially distance, I’m like a super extrovert so it was lovely to be home with my kids and do school but it was unreal and I’ve come from a background where I’ve gone through trauma. I kind of understand the feelings that you’ll go through but it was very difficult to balance those decisions. Like the okay well my kids I have to figure out what to do with my kids because like uh I work too and that necessity was a really hard turning point and I think a lot of people kind of like adopted an us versus them mentality that could be true but I’d love to hear like Megan what you experienced or like what physicians are seeing. What would you say to a crazy mom like me, just kidding I’m not crazy but I do not like,
Megan Ranney MD MPH:
Hey, I’m a mom too. No it’s not. I mean I have two school age kids. My little guy is still in you know elementary school. It’s tough for him. It’s tough in a whole different way for my middle schooler and as a parent you want to do your best for your kids and you can talk separately about kinds of all the expectations that are put on moms right now and on parents in general even outside of COVID but man there’s no way to not fail at parenting during a pandemic and I think I appreciate you’re asking the questions about physicians but also other health care workers so I don’t want to be physician-centric so kind of also my nurses, my social workers, techs, housekeeping staff, everyone who’s out there. None of us have the option of staying home so at the same time that we’re dealing with all the other stressors there’s literally no choice about whether to stay home or not and then we’re kind of walking into the thick of things where we’re taking care of folks that are showing up with the disease that we still have that same cognitive dissonance that Jessi just explained where you know, knock on wood in my own life, yes, I’ve know people who have had COVID but personally in my circle of friends and family I’ve not had anyone who’s died. In some ways I feel that difference between what’s on the news and reality when I’m in my home life. Then I walk in the hospital and that dissonance shifts because here I go in the hospital and kind of what I’m hearing in the external world in the community about oh, it’s not that bad. I look around my ER and I go it’s just as bad and worse. I have 30 year olds and 40 year olds and 50 year olds who could be me. I won’t say which of those brackets I’m in but there’s right they could be me. They don’t have pre-existing conditions and here they are hypoxic going up to the intensive care unit with kidney failure or blood clots of kind of whatever. We were going in to this already in an environment where most healthcare workers didn’t feel supported and where as I know Jessi and Janae you have talked about a lot that we were already in the throes of burnout and then this is so much more than burnout though. There’s this so you know we’re in COVID and everybody says we’re a healthcare hero and you show up and you do this great work but you’ve still got your kids at home. You’ve still got you community members who are saying it’s a hoax and meanwhile you’re putting yourself potentially in the way of sickness and no one’s coming to say you. You’re just expected to show up and kind of give of yourself constantly and at some point that gives out. It’s been a really difficult moment and I know that you know. The four of us talked before this recording about kind of the systems issues that are mixed up with it. I’s love for us to discuss that a little because to me it takes it from this discussion that we were just having about the population at larger and creating individual level solutions and therapy and having social support and I think those are all critical and we need those for healthcare workers too and we just like everyone else are missing our social supports right now. I can’t go out for a drink. I can go out to a friend’s house and kind of hang out in the back you know in their house or in the backyard. But it’s also about fixing the bigger picture and so all those structural determinants that affect out patients affect us just as much if not more because we try to serve as the buffer between the systems issues and the people we take care of. So, I’d welcome that.
Janae Sharp:
That’s super stressful. I wonder maybe Ben you could start with that because you talk a lot about that. What are the systems within healthcare but also larger systems that you’ve seen?
Dr. Benjamin (Ben) Miller, Psy.D.:
Well, I want to I loved what Megan said because I think there’s a when we talk about burnout of any of our clinician friends or anybody that’s in the health care arena you know there’s this tendency that I’ve found for people and Megan did not do this she does this perfectly well. There’s this tendency though to blame the person and say oh you just need to learn a new skill. You know Dr. So-and-so you just need to figure out a way de-breath better and like that’s so problematic. I mean don’t get me wrong. I think that it’s great to give people skills and resources but if we don’t acknowledge this broader systems issue that is forcing our clinicians to do more and less time. I mean if you look at some of the reasons that physicians burn out and there’s a lot of data out there on this.
EHRs – electronic health records, they’re one of the top ones because if you’ve ever practiced any type of clinical services and you’ve had to document it’s some of the most frustrating and harrowing experiences that you will have like can I get it done in the next five minutes? I remember driving home worrying about all the documentation I didn’t finish that day and it’s a very real problem. But why do we have EHRs? Well EHRs help our system maximize on revenue you know, sorry to be a little glib but it’s true. I mean there’s a lot of reasons why health systems want you to do everything you can that’s a big driver for burnout. Two, is inflexibility. I mean you have to see you have to meet your RVUs you have to have certain number patients that you see per day or else we’re not going to pay you your bonus or we’re going to ding you on your quality metrics ow whatever it might be and so inflexibility that comes at the system level oftentimes drive clinicians to be just at the end of the day exhausted and then they have to go home and figure out a way to be a mom or a dad or a friend or a partner or a neighbor and it’s just very hard. I mean I could go on for days about this stuff but I think that what Megan was highlighting which I think is really important for us is that while we talk about increasing resilience and building skills and helping people understand how to cope let’s also recognize all these horrible things that we’ve done to put them in situations where they have to learn those skills. I’m all about teaching people skills. I mean I wouldn’t have done what I did as a profession if I didn’t believe that was a worthwhile endeavor, but there’s another finger that needs to be pointed in a different direction and with tremendous respect for out healthcare brethren and folks that are out there doing what they need to do with the systems level. I think sometimes we lose of how damaging we are at the system level on the people that are actually working for us.
Jessica (Jessi) Gold, MD, MS:
Every time I give a talk on this because I give lots of talks on these things, I use a slide that’s this cartoon of Humpty Dumpty and it’s like a psychiatrist being like I want you to pull yourself together again. I always start with that when I’m going to talk about skills because people often ask me to talk about skills because they want people to have acute management. I always preface it by saying I know there are systems problems and I’m not here to tell you to fix yourself. I don’t want you to think I’m here to tell you to fix yourself. I’m her to tell you how to survive the mess and the ick because I’m working to survive to help like fix the system and systemic change takes a really long time and I will get there and we will get there and we'll name it and we’ll talk about it and we can talk about that too, but I just want you to know that I see you and that’s a problem but we also need to like have ways to deal with your feelings. Because if you just stew and are angry at the system that takes forever to change you’re also going to be angry and burned out and sad so we need to think about that too. So I always preface all my talks with that because I think it’s really important so I’m glad that all of you brought that up. For me a lot of the systemic problems are medicine’s culture right. You can make appointments available as much as you want you can duplicate me 500 times if no one wants to go and it’s not something we’re like okay with talking about and it’s not something that people believe is a thing you should be doing, what’s the point? Why did we hire a bunch of therapists if no one’s going to use them right? So for me a lot of the systemic problems in medicine are how do we change a culture to believe mental health counts and matters in the same way that physical health does? Because it will help patients too and how do we get people to use appointments in a way that’s not stigmatizing or weak or going to make them made fun of or make it so they like can’t tell their supervisor that they need to go do that because they have to go once a week to therapy and once a week is so much time off work right. Like we need to fix that part and there’s a whole licensing aspect ow that too which is a whole systemic problem which is if you can’t get help because you’re afraid your medical license is going to get dinged and you’re going to be followed in a different way you’re going to be watched in a different way you’re going to be considered in a different way which is an actually valid fear because one-third of medical licenses are the only ones that ask questions that are acceptable. Which means they ask something that’s not like a historical have you ever in in your whole life ever seen somebody for medical like mental health treatment. That means you’re not freaking out for no reason which means we have to change that right that’s systems that’s not you. So you know those are the things I think about all the time.
Megan Ranney MD MPH:
Can I ask kind of throw a question back to you around that is around that stigma and kind of vulnerability issue and Jessi, I know you and I have written about this before and kind of glossed over it as one of many things around the trauma that our healthcare workers are sustaining right now but we know that part of our training is to stoic. We never admit vulnerability certainly as physicians and I would say for many of the other healthcare professions as well. We’re supposed to put our patients first always. I feel like that’s a hugh even that moment of saying I need help is something that’s I mean it’s tough for society at large but I would pose that it’s even tougher for us in healthcare and I have my thought about how to overcome it but you too are psych experts uh psychology and psychiatry and I’d love to hear your thoughts and then Janae yours as well. Your lived experience and what you think could have helped overcome stigma and allow admissions of vulnerability.
Jessica (Jessi) Gold, MD, MS:
Do you want to take a shot but you want me to try first.
Dr. Benjamin (Ben) Miller, Psy.D.:
You go first Jessi.
Jessica (Jessi) Gold, MD, MS:
Okay. I will say one of the silver linings of COVID which like was a little bit hinted at is that physicians, nurses, respiratory therapists are having emotions and openly. I don’t know that they would have wanted to. I don’t know if they’re because we are so traumatized that they come out? I don’t know if it’s because we want people to hear our stories so much that we just tell them and we can’t hide our feelings when we do and that’s just the way that it is but we have feelings and we’ve shown them. There’s been a lot of tears on television and I don’t think I’ve seen that before. There’s been a lot of happiness in a way that was odd right like when people got vaccines they danced like that’s not something doctors do right. So I think that this broad range of emotion capacity is very different. Even expression of stuff on social media has been different so we could take that and day these people did this, they’re okay. How do we go from that and change culture and say look this is who we are, we’re human. We need to bond with this connect with this, be able to say this stuff out loud and I think that that’s going to start on probably like a smaller level than a huge level. Like teams attending to super like a little like attending to a team or like to a mentee or something like that. I think leaders have to show vulnerability. I think vulnerability is very much in a Brené Brown kind of way a key to leadership. I think we don’t do that often because we’re again leaders are strong and stoic and that’s not what you do but if you see people you look up to say anything was hard you say oh I’m allowed to do that because they said that too and it’s the same way it works for celebrities in a sort of kind of similar sense those and the celebrities of our culture is the people who are our attending Right and so there’s a level of that that’s helpful and makes a lot of sense and leads to connection and when people realize that I think it matters. I think it’s also important that people realize being vulnerable does not mean hi, I’m Jessi I have this diagnosis. I take this medication and that’s what my whole mental health history because I don’t necessarily even care. It that’s who you want to be and that’s what you want to tell, more power to you because that’s great and we need some people who do that and we definitely benefit from people who write those pieces in journals and write those pieces in more popular press places and talk about it and we’re better off that they exist but for the most part we need to realize that mental health is the spectrum of feelings and is actually in everything we do so if we could say I’m tired, I’m stressed. I haven’t slept, it’s hard to be a mom and a doctor. It’s really hard to have lived through a pandemic. What was that like for you? And just have these open conversations where having these conversations doesn’t feel like such a heavy lift and we start on that level. I think that’s really important because we’ve made it such a big thing that we think the only way to do it is this huge big reveal and nobody wants to do it because it’s huge and it’s enormous and it feels so scary. But if we start on a level where mental health is a continuum and is very much integrated into physical health and is not like anything that make anybody scared like anxiety. Man is the most physical think in the entire planet. You know, I think it would make a big difference.
Dr. Benjamin (Ben) Miller, Psy.D.:
I just want to underscore on thin Jessi said because I love it and that was it was beautiful. We should have that as our highlight reel what Jessi just did but you know stigma is social and structural simultaneously. It’s social in how we respond to one another. I think Jessi just nailed that but then it’s also structural and how our systems are set up to respond to us when we come forward with a need. I mean there’s some really nasty examples out there that we don’t even need to go into but I mean I’ve had friends that have admitted that they’ve had issues around depression or anxiety and then immediately that particular you know whoever their supervisor was will say well you know you should take some time off. Well that’s not what I’m asking you for you know I’m actually just telling you that I’m having a hard time right now. I don’t think I need time off. Actually working is helping me more than anything. So we have to be careful. There’s a lot of structural impediments that reinforce stigma that I think that if we were to truly unpack, peel away, that we would find that a lot of our health systems, a lot of our institutions they reinforce this notion that you should not show any weakness. Which I think both of my colleagues just said exceptionally. So, if we’re going to get to the heart of this yes, I want more people to talk about it from the top down for the CEO of your health system to say, listen, I’m struggling too. That sends a powerful message. Those of you that are in academic relationships and you have mentees talk to you mentees about how to talk about their own emotions. Show them what it looks like. Modeling matters. But don’t forget about those other things that reinforce why we don’t talk about it to begin with. I think if we address that and that’s going to be a big thing I think for us for the near future. If we address those two things at the same time maybe mental health will be that foundational element that we all know it is.
Janae Sharp:
I’m glad, um, I think that’s yeah we have to practice those things. I also um I’m glad you asked me because this is kind of like a pet peeve of mine a little bit like the messaging around mental health. I think we can teach people a lot of language but I don’t think that’s sustainable almost. Maybe I’ll tell you what like the experience behind that. When John died like it was a lot harder mentally than I expected and I was just like a mess. I think I got 500 text messages that day. It was so overwhelming and I just sat there. I didn’t really want to talk about it because I didn’t have that language but also I don’t know that that was helpful and then it continues to be hard and people kind of get sick of you being continually being hard and you’ve probably all had experiences with people who have continuous ongoing illness or ongoing mental health issues. I remember once in the suicide prevention world and there are these chats and someone shared something really important that was like you don’t die by suicide on your first attempt of reaching out. Like this is after you’ve been turned down hundreds of times. So, if we have physicians that are sharing and we have people that are sharing their stories like they really shouldn’t have to like you already know it’s hard especially from a systems level. You know it’s hard and you know you should be reaching out so every time you post something like oh reach out if you need help call this hotline like you’re actually, I always think those are like throwaways. Like don’t share those like if you really want to help people I don’t need a phone number. You call someone who you know. You know what demographic wise that’s going to be a difficult thing because they’re a physician. Like so you could call them and volunteer to help and I think it really has to go the other way. We can’t just offer to be there for people we have to actually be actively reaching out and saying look this is what I’m going to do to help or this is what we can do. And that’s some of why we’ve been able to work with health systems be like look you need to proactively reach out like I don’t care how many times you are say you’re available. You’re not available unless you’re calling someone on the phone and showing up at their house. It’s like when someone in your neighborhood’s like let me know if I can do anything for you and you’re like that’s not even a real offer. So I kind of have also take the perspective of whenever someone asks me I’m like I will think of something and I’ll give them an assignment every single time. I think that relates a little bit like physicians, leaders and everyone don’t just say I’m available like here are the tools which are necessary to survive and necessary for people. Leaders need to say this is what we’re doing and is that enough? And if you don’t show up then obviously maybe you just don’t have that capacity but I think that has to happen. Sorry, I might have ranted a little because I’m passionate.
Megan Ranney MD MPH:
I really loved the rant because it give us it’s much needed and needs to be heard. I mean it’s like there was that um there’s an article going around about when someone has chemo you know it has cancer and is getting chemo to not send them the email of what can I do for you but rather here is the list of things that you can do and I think that’s a great analogy here.
I’m going to bring it back to the COVID discussion which is I think that one of the really big challenges right now is that everyone in our society is just spent. No one has the emotional energy right now to reach out to their friends and family and say hey, just checking in how are you doing because we all need someone to check in with us right. I will say Jessi occasionally will send me texts and being like I haven’t hear from you just checking in you know um and I think that we all thy to do that but the emotional capacity is minimal. I had a discussion with a woman named Wisdom Powell who talks a lot about the idea of radical healing and that we have to acknowledge our trauma. We have to acknowledge kind of the fault lines and the fractures in order to create the possibility of us even reaching forwards into this healing space and when we talk about trauma-informed care you have to start by healing the healers and I feel like so Janae it like yes a hundred percent but I think that one of the barriers right now is that no one even has the reserve to do that reaching out to each other which is I think one of our most urgent tasks in this post-pandemic world is to find ways to allow each other to heal and to grow together whether it’s in little virtual pods you know some of the work I do is with like for all that you’re saying about being lonely through video games Jessi we’ve got like these online support networks for people who are in recovery from opioid use disorder that folks love because they can to go AA or NA right now so it allows them to get that peer support when and where they need it no matter where they live regardless of physical distancing rules and I think that has a place but there’s other stuff too and I think there may be even more radical ways that we can allow ourselves to realize Janae’s plea of let’s all reach out to each other but in a way that transforms the system and doesn’t rely on my being a good person with a little bit of emotional reserve.
Jessica (Jessi) Gold, MD, MS:
Yeah, you know thank you for that because the there’s thing that’s like when 2020 is over we’ll be great right and there’s a thing that’s missing in that which is acknowledging what 2020 was to us. When people do trauma therapy they write their trauma and speak about it and control the narrative and try to understand how they felt through it and try to understand what it meant to them and what they learned and what it was like and how they felt. If we don’t do that what was this? So maybe not everybody needs that because maybe some people are fine and resilient but there is a large portion of us that do and if we ignore that especially as a culture where we haven’t admitted like right now I mean 300,000 people have died. We haven’t grieved out loud. We’re at really at fault because we are just brushing trauma under the rug that will emerge somehow. I don’t know what that looks like because it’s super hard to predict. People ask me this all the time. What will mental health look like if we don’t address it I mean I’m not a I don’t have a ball um but like you know in a lot of ways you know it can look like a lot of things like when people hide things it comes out as crises most of the time right worse or you know mental health shows up as physical illness. Those are the two things that I would say are the most common but we need to find ways to say that this was not easy. This is what I learned. This is what it was like. This is what I felt like including in families including for children because I don’t think you can just close a chapter of 2020 and say well that was that book. I don’t.
Janae Sharp:
I think you’re right. We’re almost out of time. Maybe to wrap up everyone could say kind of like what, short, could like what has this meant for you as a physician and in your role? What has 2020 meant?
I could start. Should I start?
Megan Ranney MD MPH:
Model if for us Janae.
Janae Sharp:
No, I feel like I’m going to be a terrible example because from one perspective it was hopeful to see that maybe people would care about physicians and understand that like if people nee we need to take care of the people who we trust to take care of us and from a personal perspective too, 2020 is interesting because I had a lot of health problems in my family and I was able to help them but also 2020 has been like just kind of surreal. See I’m good at trauma right? It’s just like really does this have to be this way? It’s been exhausting to be like ugh, we have to keep trying and keep reinventing and keep pivoting and that’s exhausting. I think it’s been kind of like a pause for me trying to figure out if have the energy to pivot and what that even looks like. So, I’m not good at that but you guys can do better in answers so that’s good. Now you know the bar has been set. Okay, who starts? Then Ben should go next because he’s always staying to the end and giving great, great summaries!
Dr. Benjamin (Ben) Miller, Psy.D.:
That just means one of Jessi or Megan gets to wrap it up and put the period on it here. I’ll be very brief. I think that 2020 for me has allowed us an opportunity as a nation to really embrace what mental health feels like and what it is. I think it’s really hard to ask people to understand the importance of something that they haven’t experienced or at least they can’t put a name to this epidemic, this pandemic, excuse me, has given us that moment. I found from reporters, neighbors, people are talking about mental health which I find to be extremely powerful and encouraging. Now what we do with all that talk and what where we put it into action I think is the 2021 challenge but I’ll say this has been a tough year for everybody. It’s been a slog and I will not be you know unhappy when the next year’s around but to Jessi’s beautiful point before COVID wasn’t working so well for most people in this country. Just because we’re going to get through it we get vaccinated and we get to go to restaurants, we still have a lot of work to do as a nation to heal from racism to climate change everything in between. We have a huge amount of pain that like the trauma that gets swept under the rug if we do not address we’re not going to heal. I think that’s our challenge and that’s what I’ve been really trying to focus on for this year and then hopefully do something about next year. So thank you Janae.
Jessica (Jessi) Gold, MD, MS:
I’ll let Megan go last because I want to hear like a good summary statement from Megan. I think for me 2020 has been really interesting. I think I’ve had my own experiences with emotions while being a caregiver in ways I didn’t expect to have which has been really interesting. It’s hard to be a mental health provider for health care workers that have a lot of similar experiences to your own life and not be able to create distance as much as you used to be able to and realize it affects you and you need a break more than you used to. I think I’ve had to reevaluate my own coping mechanisms, rely on my therapist a lot more and realize I’m a health care worker and say that out loud some too. I think that’s important for me a lot of the self-care stuff has been something that has taken front and center for my own life in a way that it probably need to and I’m glad that that was part of it. I similarly agree with Ben in that people ask and talk about mental health in a way that they hadn’t before especially physician mental health. Reporters could have cared less you know and I think physicians could have cared less. Hospital systems certainly could have cared less even though we were supposed to be talking about it and it was well, well know before you know they’d be fine with a burnout lecture you know and I think we’re at least moving towards this being something that someone wants me to come to their department to talk about. I think that is important even if what I’m saying is just hear some data think of that it’s at least something and I think that‘s important and I’ll go to anybody who wants to talk to me about it because I’m happy to start the conversation and it’s really important to start the conversation. But, you know, I think what 2021 brings for mental health is worse and that’s the part that kind of makes me a little bit nauseous and a little bit sick inside. Because I think what happens for mental health, especially for health care workers, is once the sort of like apocalypse starts stops and like the bleeding stops you kind of breathe and go how do I feel? And you haven’t actually done that. There’s some people who’ve done that. I did that when I had to but the people who haven’t will realize that this has been really hard and they’ll need help and we actually have horrible services for physicians but for the world right the mental health system, I mean Ben could talk about this better than anyone is a mess and has been a mess at least since de-institutionalism but you could put that way further back because institutions were a mess. We don’t have a system that’s built to support what is going to be tremendous need in a population. That part worries me because to change anything quickly is impossible. We have to think about mental health, invest in mental health, and care about mental health on par with every one of these conversations we’re having at a national, local, individual, system, school, hospital level or we’re really, really not helping people because it’s not going away. This is a year’s thing it’s not a month’s thing and the changes take a long time. We’ve got to start that soon. So that’s where I’m at with the 2021 super rosy look from Jessi Gold to close that out.
Megan Ranney MD MPH:
I love it with the like drum roll um that is a super depressing but also honest view. So I think about 2020 in kind of two ways. One is that it is a year in which we have very obviously watched this struggle between a reactive system and a proactive system. And the reactive system has for the most part won this year. It’s a source of many of our failures whether with COVID or with mental health or with any of the other things that we’re watching. The few times when we did invest proactively we saw great results. We invested proactively in creating vaccines. That was great. We have a vaccine. We weren’t proactive about thinking how to distribute it but that’s a topic for another day. So I think that’s one thing with 2020 is that I watch that struggle and my hope is like Ben’s that we can take that, we can take the losses, the trauma and the failures of this year and use them as a moral imperative to force the system in pro-activeness. We have done some investment in public health and mental health and systems that had been completely missing. And we have the possibility of cementing those investments and growing them. The other way I think about 2020 is that it was a time of reckoning. It was a time of pulling Band-Aids off. It was a time of confronting all of these as Ben said structural issues which have been swept under the rug, the racism, the lack of investment in again preventive health care, the food insecurity of so much of our nation, the economic and gender inequities, the lack of primary care, the lack of a data infrastructure and we’ve reckoned with the results of that. We’ve watched the whole system go up in fire because we couldn’t keep it smoldering under you know any longer. Sometimes fire can be really, really bad but sometimes it can also create a possibility for healing and for right, yeah that rising from the ashes. My kids are super into Harry Potter, got to talk about the phoenix you know. I think that to me is the potential is how do we have this not be just a house fire but rather have it be the fire that allows the phoenix to rise or the forest fire that allows new growth to come out you know um that I think I take as my challenge for the coming year, for all of our challenges but we know that that new growth can’t happen if you don’t first sit with the destruction and the things that caused it.
Janae Sharp:
Thank you. I want to thank everybody for being part of this and for those stories. I love that like the new growth needs to happen. I hope that everyone who listens to his gets to also write down like kind of what it’s been for them and ask any question they have and
Megan Ranney MD MPH:
Janae, can I say one more really quick thing?
Janae Sharp:
Yes.
Megan Ranney MD MPH:
I just talked a lot about systems. I think one of the other things that 2020 has highlighted is the power of the individual. I don’t want people to go, oh my God, I have to wait for the government change, my state, my federal, that we each have a role to play and I will say that 2020 with that reckoning has been the power of the individual drive it and create hope in this terrible year. So, write down those things but also write down the little things that you can do and have control over and how you can make a difference.
Janae Sharp:
I love that because everybody can. Everybody can make a huge difference so thank you all and I hope you have a fantastic day!