Physician burnout is a significant challenge for the health care system, affecting the quality of patient care and the well-being of medical learners and physicians. This self-guided learning on health and wellness introduces core concepts and provides a common language and framework to understand, assess and improve physician wellness.

Foundations of Physician Wellness

Featuring national and international experts in physician health, this interactive course will take you through key wellness concepts, organizational factors that contribute to burnout, and evidence-based findings on the interventions shown to protect against burnout and foster well-being.

This course is open to all physicians and medical learners, and is:

  • Online, self-led
  • 30 minutes
  • Accredited
  • No fee

Please note you must create a account to register and access the learning portal; a CMA membership is not required.

Coping during COVID-19: expert webinar series

Coping during COVID-19, a learning series hosted by  Dr. Jillian Horton, is intended to provide expert support and guidance to help physicians and medical learners manage the stresses of the pandemic.


Managing isolation and building resilience

Length: 25:16

Dr. Bob Thirsk

Many front-line physicians are self-isolating to avoid potential infection of their families and colleagues. Former Canadian Space Station astronaut Dr. Bob Thirsk will share approaches used by the Canadian Space Agency for dealing with isolation during high-stress situations.

Read the show notes

Dr. Jillian Horton: 

Welcome to the COVID-19 Physician Learning Series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. I'm a general internist, writer, medical educator, and podcaster. And I'm your host for this series. 

We've always known that our jobs as physicians are uniquely stressful. But now, we are anticipating clinical experiences that will surpass the highest levels of stress that the majority of us have ever faced. Furthermore, many have been or are considering self-isolating from our families and are cut off from normal sources of personal support. Our intention with this webinar is to explore and reframe our fear and our mindset as we prepare for an unprecedented clinical experience. 

Today, I'm joined by Dr. Robert Thirsk. A physician who has the lived experience of long periods of isolation and of working in situations characterized by high personal risk. Dr. Thirsk is a former astronaut with the Canadian Space Station. And he holds the Canadian record over 204 days of time spent in space. Dr. Thirsk, thank you so much for joining us on the webinar today. 

Dr. Robert Thirsk: 

Dr. Horton, it's my pleasure. 

Dr. Jillian Horton: 

So before we talk specifically about the challenges that doctors face around COVID-19, I'd like to ask you to set the stage. Can you tell us about the training that you went through to prepare for your mission? Not just the technical training, but also the nontechnical aspect of it. 

Dr. Robert Thirsk: 

Well, in a nutshell, training for spaceflight-- training for the astronaut career is like drinking from a firehose. We all come into the astronaut program from a variety of professional backgrounds-- aviation, science, engineering, medicine. Even recently, some astronauts have an educational background as well. 

And for the first two or three years of astronaut training, we all raise our skills up to a common level of a basic understanding, knowledge and skills, and attitudes that's required for spaceflight. So physician astronaut is going to learn how to fly a high-performance jet aircraft. And a pilot astronaut is going to learn how to take a blood pressure, and how to start an IV. So we all develop this common level of basic skills. 

And then, the next few years are spent in advanced training. So we learn the technical skills. The technical skills for an astronaut are spacewalking-- EVA we call it-- robotics, rendezvous and docking procedures, and assembly and repair procedures as well. So that takes many years. 

But you also said nontechnical. And I'm so glad you said that because some of these nontechnical skills, I think, are just as important as the technical ones, especially, for long-duration spaceflight, especially, for isolated and confined environments. So those skills we consider to be self-care, self-management teamwork, group living, leadership but also followership, and then the cross-cultural skills as well. 

If you're going to be living in an isolated, confined environment for a long time-- in my case, it was six months-- with international crewmates who represent a variety of nations, a variety of cultures, problem-solving techniques, political ideologies, religious beliefs, it's important to have those nontechnical skills in abundance. So that we can be an efficient-- we can be a productive crew. And we can maintain our intra- and our interpersonal relations. 

Dr. Jillian Horton: 

We talked yesterday about teams and some of the lessons that you've learned about teamwork in space. And so what aspects of team performance are we going to have to prioritize in order to get through the months ahead? 

Dr. Robert Thirsk: 

Well, there's a number of things. A space mission is not too much different than what we're undergoing here during the COVID-19 self-isolation that we're doing here. We have a mission objective. We can consider ourselves as astronauts on Spaceship Earth. 

And our mission objective right now is to minimize the infection rate so that health care practitioners and patients around the world have a fighting chance against this nasty virus. So there's a number of things that we need to do. Social distancing, of course, self-isolation. But living at home with loved ones can be challenging. So there's a number of things. 

First of all, make sure that the living environment is good for everyone. I have personality quirks. My wife reminds me of that all the time. And I have to be attentive, be aware of those quirks that can irritate people who are living in my face 24 hours a day. And I'm willing to change my behavior so that the mission objectives during spaceflight or during an infectious outbreak can make the living environment pleasant for everyone. 

Onboard the space station, there are the challenging tasks that we do. Robotics and spacewalking are probably the most challenging task that we do. But there's also the communal housekeeping tasks that we do as well. They're not glamorous tasks. They're not heroic tasks. But they need to get done. 

And so we all need to take our turns changing out the human waste container that's part of the toilet system. It's not a scheduled activity. No one's going to ask you to do it. But you just realize that eventually, it becomes uncomfortable to use the human waste facility. 

So you just find 30 minutes in your time, and you go and do that change out. Taking care of the garbage, wiping down the walls, keeping the station tidy-- those are all tasks that are not scheduled. But we just know that we need to create a thriving environment for all the crewmates. 

Same thing at home. There's a lot of unheroic tasks that need to be done at home-- cleaning up after dinner, taking the garbage out to the curb, mopping the floors, doing the dusting. Especially, during this time, where we're all trying to accomplish this world mission objective. Take care of the small things at home as well. 

Personal conflicts inevitably arise during the course of every space mission. Thank God, in my two missions, they were only minor issues. But it's important to address the elephant in the room. Don't let these conflicts fester on without someone stepping forward and bringing everyone together. 

Air your expectations, communicate. Maybe the misunderstanding is due to a cultural difference or to a Russian or English the second language kind of problem. So make sure that you communicate well. 

And then, like a good marriage, compromise. So I guess in general, group living is-- be flexible and make sure that you don't do things that annoy other people. If it's for the sake of the mission, I'll comb my hair the other way for six months. That's minor to me. What I want to do is I want to come home, as a crew, thriving, happy, healthy, and having accomplished all of our mission objectives. I'll make small changes in my behavior in order to make sure that the crew thrives and that the mission is a success. 

Page Break 

Dr. Jillian Horton: 

So you mentioned something that I think is really important for us to talk about. And you know as a physician that the medical community has not always modeled quality self-care. And in fact, self-neglect has been a touchstone for us. 

And I was sharing with you that I saw a post on social media about a well-intentioned resident in the United States who was saying, he was coming for duty. And he was staying on service until somebody forced him to go home. And I wonder if you could talk about why that classic physician attitude could actually impair our ability to respond as well as possible to this crisis. 

Dr. Robert Thirsk: 

Well, when I arrived aboard the space station, I remember the first dinner that we had that evening. And my crew commander at the time-- his name was Gennady Padalka from Russia. And he said to me, Bob, you've flown in space before in the shuttle, correct? And I said, yes. 

And he said, what's the difference between a space station expedition and a shuttle flight? And I said, well, a space shuttle flight is a sprint. And a space station expedition is a marathon. And he said, that close. A space shuttle mission is a short-duration flight with a hectic, aggressive timeline. Space station expedition is a long-duration flight with a hectic, aggressive timeline. 

So he was just telling me what I was going to experience for the next six months. It's going to be going, going, going every day. Gennady is a master of making sure that he controls his workload. And he always has reserves. 

In the course of every space mission, there's going to be contingencies. There's going to be something that goes wrong. Equipment is going to fail. Someone is going to get sick. There's going to be a crisis to deal with. And it's those astronauts who are not working at 100%, who have reserves to deal properly with the crisis when they arise. 

A lot of young people come up to me, and they say, I'd like to be a physician. I'd like to be an astronaut. What can I do? And first thing I tell them is to pace themselves. If you wish to soar with the eagles, to be a top astronaut, to be a top physician, then you need to take care of yourself first. Eat properly. 

How many of us have grabbed a quick calorie bar just to get some calories in and then head back to the emergency room? You can't do that. You need to get in your proper caloric intake-- the fruits, and the vegetables, and the protein, and that as well. Get exercise every day. 

I religiously do an hour and a half of exercise every day. That's an hour and a half investment of my life. But it pays off in big dividends because I have endurance that exceeds most of my colleagues. Because I take that time for exercise. And then, the same thing is with sleep as well. Make sure that your body has enough time to recuperate and be ready for the next day. 

We're all the same. We all have the same physiology. You're deluding yourself if you think that you are a superwoman or a superhuman and that you can do an 18-hour shift in the emergency room or the ICU with no consequences. You're deluding yourself. If you wish to soar with the eagles, take care of your self-management. 

I want to talk for a moment about fear. So many of my friends, and residents, and colleagues have confided to me that they are afraid that they are going to acquire COVID-19 in the line of duty and that they're going to die. And specifically, many are afraid that they are going to acquire it because of inadequate personal protective equipment. You and I spoke a little bit about fear yesterday as we prepared for our conversation. And I wonder if you could talk about some adaptive ways of working with fear in the context of a job where there is profound personal risk. 

Well, to be an astronaut is to take on risk and to live in a background of fear. But I'm the kind of person-- my astronaut colleagues are the kinds of people who think the small chance of injury or death in this occupation, which is just fine. I think each flight has probably got a risk of less than one in 100 of not coming back home. 

I've lost seven dear friends in a shuttle disaster. And I think that we've lost about 18 astronauts and cosmonauts altogether over the half-century period of human spaceflight. But I think that small chance of risk in injury and death is small compared to the opportunities that I have to get satisfyingly out of my comfort zone, to fulfill a childhood dream-- a dream that I've had since grade 3. 

The opportunity to test myself, not only intellectually, but test the limits of my being at my physical, my emotional limits as well. The chance to bring pride to my country. The chance to represent my country on the world stage. The chance to work with the top individuals of the world in the top organizations like the Canadian Space Agency and NASA. 

For an astronaut-- for me, those benefits greatly outweigh the small risks. Yeah, there's risk in everything that we do in life. It's always risk versus benefit. So what I do when I face fear is I do the recalculation of risk versus benefits. 

And then, another trait that I seem to have developed is some trait called compartmentalization. What that means is that when you're sitting on a launch pad aboard your rocket, 2 million pounds of high-explosive propellant below you, could be the last thing that you do at liftoff-- that's the most risky part of spaceflight-- is I'm focused on my task. I have a checklist. I have some duties that need to be performed during the eight and 1/2 minutes of ascent to orbit. 

And my crew is relying on me to throw those switches properly, to inform them about milestones that we've accomplished along the way, to pull out the emergency procedure checklist. If something goes wrong with the ascent, we have to return back to the ground. So I focus on the task. 

And that's the best thing that I can do. Get rid of all those other distractions that would cloud my ability to perform well and to be on top of my game. So compartmentalization. Focus on the task at hand. And that's the best way that I've developed to deal with my background here. 

Dr. Jillian Horton: 

I know that personal protective equipment is not the same as a space suit. But it still poses significant barriers to communication. So I wonder what advice you could give us on creating and maintaining the best possible communication when we're providing care in full PPE. 

Dr. Robert Thirsk: 

That is one of the most original questions I've ever been asked. That's wonderful. You're right. When we wear our flight suit to go outside the space station-- it's a 100-kilogram space suit. It's got our life support system in there. And it's got a rudimentary communication system as well. And you're right. 

When we listen to each other talk on the air-to-ground or the space-to-ground loops, the quality is not very good. Even on board the space station, just in our shorts and our T-shirts, it's hard to understand what some of our crewmates are saying because in some places of the station, the noise level can be up to 70 dB. And we've got life support equipment that's running 24/7. So pumps, compressors, motors, fans that are running all the time. 

And sometimes, verbal communication is not the best way to communicate. So this sort of thinking about some of the ways to communicate, I guess, you could do a lot of pantomime in space. Astronauts are good with hand signals. We developed a number of hand signals that beam things to each other at a distance. 

We use common terminology. So "copy," "concur," "Roger that," words that are expected. And then, also I probably have one or two Mediterranean genes. Some of our stereotypical Mediterranean colleagues use their hands an awful lot. So using hands is a good way to communicate as well. Be a little bit like Marcel Marceau. And that's a good way to communicate. 

And maybe the last thing is the smile on your face. That's important. That communicates that you're in control of things that are going on. When I review some of the videos and the images from my past missions, all of the crewmates, we all have this big goofy smile on our face. And it's because we were enjoying ourselves. And we were communicating to each other that we were enjoying ourselves. 

So through the PPE, make sure you use your other body language modalities to let people know. And keep that smile on your face to let everyone know that you're thriving and that you're in control. 

Dr. Jillian Horton: 

As I hear you talk about that, I just find myself thinking about how easy it is for one teammate, one crewmate to bring everybody down if they're not engaging in that kind of behavior. 

Dr. Robert Thirsk: 

Yeah, it's important to develop and to express a positive approach on orbit. That's one of the first things we learn in self-care, self-management. Occasionally, there are times, during our day, when someone says something to you or makes a gesture, and we interpret it the wrong way. And that bums us out for the next hour or so. 

And the other person didn't intend that same meaning that you interpreted. Again, it could be English as a second language problem or a cultural gesture that was misinterpreted by my Canadian culture. So it's really important to-- if you have any misunderstanding about what someone is communicating with you, go and get clarification on what they were saying. And in most cases, it's a miscommunication. It's better to maintain a positive outlook than to immediately jump to the negative outlook on someone's words or deeds. 

Dr. Jillian Horton: 

Bob, we're almost out of time. But before we go, I know and you know that our colleagues are dealing with many complicated emotions right now. And you have seen this planet from the window of the space station. You lost friends when Columbia exploded. And you have a perspective that, I think, pits mortality and risk against timelessness. So we're part of an historic event in medicine right now. What final thoughts do you want to leave with us as we enter into our mission? 

Dr. Robert Thirsk: 

Spaceflight is not just a professional experience, it's also personal experience. So we do have professional mission objectives to accomplish-- robotics objectives or assembly objectives. But being up there for six months with the opportunity to work in an international setting with other crewmates, other organizations, and to look out the window at this beautiful planet down below-- the first few days that I was up there in orbit, whenever my hometown in Canada passed by underneath, I call a crewmate over and say, hey look, that's my hometown down there. 

But after a few days, that didn't seem important to me. I became aware of my home continent. And then, maybe after two or three weeks up there, all I saw was just one humanity. I'm proud to be Canadian. But I just felt primarily to be a citizen of planet Earth. From the orbital perspective, we see that everything is one. Everything is connected. 

When I say connected, I mean that not just geologically or meteorologically. If there's a forest fire in Siberia, sometimes, you see a smoky pall from that forest fire rise up pass all the way across the Pacific Ocean, and impact the quality of air in North America. The same thing that you can see a small weather depression start in the South Atlantic, and then migrate up northwards, and develop into a category 4 hurricane, and impact the lives of those people that live along the Texas Gulf Coast. 

So you can really see that our natural ecosystem-- the air, the land, the oceans, the floor, the fauna-- they're all connected. And when something happens in one part of the world, there's going to be a repercussion somewhere else. That's the way the human body works, of course. If you have a patient whose beta cells are not working very well, it can have an impact on their vision, on their central nervous system, on the cardiac system, on the renal system. All because one tiny, tiny group of cells no longer produces insulin. 

At individual level, there's a myriad of interconnections that control this human system. And on the world planetary level as well, there's a myriad of interconnections that control viral infections, but also the world economy. And what became most apparent to me is that a lot of the issues that I focused on prior to flight-- Canadian Parliament, my community activities-- were less important. And the big problems are survival of the human species. And those are dependent on overpopulation, poverty, inequality, environmental damage. 

And when you look out the window from the orbital vantage point of the International Space Station, that seems so clear. I wish that everyone on the planet had the opportunity to go up to space and just look out the window for three days. Don't do anything. Just look out the window for three days. And I think that would give us a new perspective on what civilization is all about, what humanity is all about, and the promise of international collaboration. That's how spaceflight changed me at the personal level. 

Dr. Jillian Horton: 

And it sounds like I can extrapolate from that by assuming that after we get through this event, as horrible as it already is, been as challenging as it is going to be, there may be advantages in the new perspective that we are going to have about both medicine, and how we fit into the bigger picture. 

Dr. Robert Thirsk: 

That's another trait that you've touched on. One of the practices that I've incorporated into my life following my space career is debriefing everything. Everything that I've done, I've learned lessons from. When I returned from a training session, we spend a half hour debriefing my performance. Some things went well. Some things didn't go so well. But it's an opportunity for me to improve. 

After every mission, again, as I said, there's been no perfect mission that's ever been flown. But there are weeks' worth of debriefs that we allow us to recount to other astronauts who will follow us, flight controllers instructors. That we can take our game to a higher and higher levels. 

Yeah, the COVID-19 world phenomenon is unprecedented. We've never seen something of this scale before. It behooves us to sit and debrief all aspects of it. And we weren't quite ready for the COVID-19 outbreak. It took us by surprise. The magnitude of it took us by surprise. But another one is going to come in the decades that follow. And we'll be ready for that one. 

Dr. Jillian Horton: 

Well, I want to end by thanking you for sharing your experience with us today and for helping us all to see things just a little bit differently. If you can handle 204 days in outer space, I know that we can do physical distancing for as long as it takes to save lives. 

Page Break 

Dr. Robert Thirsk: 

Yeah, we have mission objectives, Jillian. And each crew member can affect the quality of life on our spaceship, planet Earth. So let's follow those self-isolation measures. Thanks to everyone. All my friends out there on the front lines as health care practitioners under this tough mission, I respect you and wish you strength and health. 

Dr. Jillian Horton: 

Well, thank you so much. I've been speaking with physician and astronaut, Dr. Robert Thirsk. I'm Dr. Jillian Horton. Thank you for joining us for the second installment of our COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon. Bye for now. 

Maintaining high performance in times of stress

Length: 27:49

Jason Brooks

Join us for a conversation with Jason Brooks, a performance psychologist who works with physicians, to learn some ways physicians can sustain their energy − both mentally and physically − during times of crisis.

Read the show notes

Dr. Jillian Horton: 

Welcome to the COVID-19 Physician Learning Series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. I'm a general internist, medical educator, writer, and podcaster. And I'm your host for this series. We know this crisis is going to play out over months, if not years. There may never have been a time in our history as a profession when so much rested on our ability to perform under challenging circumstances. 
In this webinar, it's our intention to help you focus on the criticality of having, and implementing personal strategies for fatigue and stress management. Joining me is Dr. Jason Brooks, a PhD performance psychologist. And long time performance coach to acute care physicians and others in high pressure professions. Jason, thank you so much for making the time to join me today. 

Jason Brooks: 
Thank you Jill, pleasure to be here as always. 
Dr. Jillian Horton: 

So Jason, you've infiltrated the psyche of our profession, and you have a very deep understanding of what drives us as performers. Can we start by talking about the characteristic parts of the physician mindset that are going to be strengths versus weaknesses when it comes to our personal and organizational approach to getting through the pandemic. 
Jason Brooks: 

Well, I think obviously the logistical analytical nature can be useful in terms of the fast and the furious way in which procedures and policies are changing. People being very apt at adapting to that and making sure that they stay on top. I suppose that I also can get in the way. The idea of just consuming too much information to the point where it might impact on recovery and detachment time for people away from that. 
I think that we have great teams in place that are very good at following instructions and working well together. But I think the emotional climate has changed significantly with this COVID crisis. And so, perhaps the teams and the communication needs to be strengthened even more. I mean if ever there's been a time in the history of being a medical professional where collegiality, and encouragement, and civility, and overcommunication are absolutely essential. I mean, I think this is the time. 
So I think those are skills and attributes that people can learn quickly on the fly. Because I think as much as anything, it's just about being consciously oriented to bring that. So we're going to have to make sure that we are stepping into our shift each and every single day perhaps motivated and anchor to do a few different things. Making sure we take care of one another, making sure we slow down. And perhaps those are things that aren't quite as common as we'd like to think day to day. 
Dr. Jillian Horton: 

Just to follow up on that. We know that there are aspects of the physician identity that can go from adaptive to maladaptive very quickly. When you look at the situation, what do you identify as some of those personality issues? 

Jason Brooks: 

I think one of the biggest things is when you consider that so many professionals are in this profession because they want to provide care. And with some of the decisions, and some of the new wave policies that might be forcing people to make decisions that are against the grain. Of the way that they would want to do things ideally, that can be a source of tremendous fear and anxiety for people who care and are so compassionate for what they do and the way to which that they serve people. 
So I think getting ahead of some of those feelings and having a plan, and making sure that we stick together. And there's sort of a united front to support one another, is going to be absolutely vital to ensure that we get through. And we heal effectively in the process while we're going through this together, supporting one another. And I think that's going to be really important consideration. 
Dr. Jillian Horton: 

So Jason, you've worked with a lot of physicians already around issues of performance anxiety. And under normal conditions, what's your approach to dealing with physician anxiety in the workplace? And how do you see that translating in the face of this crisis? 
Jason Brooks: 

Well, it's interesting. I mean, if you had let's say fear and stress on a scale, a Richter scale. On any given day, there's a lot of that that physicians and medical professionals have to face, but we're dealing with something unprecedented now. I think in any given day, always risk. There's always the possibility of poor outcomes, there's always the possibility of errors that can lead to deaths. 
The difference though, is that now that might actually impact the medical provider his or herself. So that's a whole different ballgame when it comes to fear, and stress, and anxiety. And so again for me, the thing that I would advocate then, that I would advocate now, is there are certain things that we can do with fear to get in front of it. To allow it to become something that we can utilize for its value. 
I would not want to be in this COVID situation and not have some degree of fear. Fear mobilizes you. Fear is an emotion that can keep you sharp. And keep you safe, and keep you from making mistakes. But of course, if it's at too high of an intensity, it does the opposite of that. It can impair us, it can sap our energy, it can destroy our ability to make effective decisions. And so, we have to meet fear by doing a few certain things. 
The first thing that I would recommend is-- and people might accuse me of recommending a split personality, I'm not. Talk to your fears. Talk to it, it's part of you. OK. It's part of your personality. We have this built in defense system to keep us safe, it's just doing its job. So we can help ourselves by when we see fear as the signal that it is. Just pause, have a conversation. 
I've even encouraged people at times to put it in the image of something. Put it in the image of an imaginary friend or one of your kids or something that's a part of you, but outside of you because now I can have a conversation with it. And let me ask you this. If you had fear, that signal, let's say in the image of someone you love. What would you do to someone you love if they were afraid? You'd show compassion. You'd ask them what it needs. 
So have that conversation with your fear, what does it need? Fear needs two things for it to dissipate or reduce in terms of its intensity. It needs to know that you hear it, that's its primary job to keep you safe. And that it needs to know that there is some reason that you can provide to allow it to feel a little bit more at ease with whatever the threat is that it's picking up on. 
So that's the second thing that we can do to meet our fear is, can we add some certainty to in this case, an incredibly uncertain set of circumstances. We will not be able to come up with answers to the global questions, when will this end? can I be certain that we're going to all be OK? And that sort of stuff. And that's the questions that we wish we had answers to. We can't. 
But there's a lot of things that when we're in a fearful state we're not focusing in on, that if we did, would bring a lot more certainty and a lot more confidence. These are basic things. Your experience doing what you do. The COVID situation is intense, but the actual doing of the job has not changed. The tasks, the procedures, they're still the same. And everybody who's doing this is very well trained and has a ton of experience. 
We have different procedural things we have to be mindful of for safety and such, but the tasks in the job at hand is the same. And we're good at what we do. Think of the team that you have around you, people who are bringing great energy and supporting one another. There's so many things. Think of the experience of getting through tough times and facing fearful experiences in the past. We've all been there, we've all found ways to navigate through. 
So when you start to meet fear by shifting your attention towards certain things that you can be certain of. And that in the bringing and creating of those things, it does increase our degree of confidence, it does increase the degree of safety that we can assure for ourselves. That's another huge step. 
Another thing we do with fear is plan. Fear does not like a plan. And yet that's what it's asking for, right? So when you step back and you consider, what are the things that I'm really fearful of? I know in talking to so many physicians over the past couple of weeks. Primarily, it's their own safety and of course their family's safety. And still, have those conversations. 
Don't allow the what if? What if fear's to predominate? Work the what-ifs through to a resolution. I was having a conversation with a physician not that long ago, who was concerned about the risk of exposure for their family-- obvious-- and I said OK, well let's process that. Let's work backwards. 
Do you know the point at which that it would be too much for you and you'd have to pull away? And they kind of had a sense of what that was. I said OK, in the worst case scenario, what would that look like? What would you do? What would be the plan? Would you leave with your spouse and kids leave? Where would you go? And you don't want to think about these things, but guess what happens when you start to think about these things? 
You reduce some of the anticipatory anxiety. Astronauts do this all the time, that's their job. They spend the worst possible situations and figure out solutions in advance. Such that if and when those things were to occur, they respond, they don't react. And secondly, I don't have to worry about them as much in the lead up. 
So with this person, we just worked backwards and we got to a point where they were still concerned about here and now. And I said well, what could you do? And they thought, they started getting creative. I could set up a bed in the basement. I could practice different ways in which I'm served my food, et cetera. And all the while you just saw this person feeling a little bit more at ease, why? Because they had a plan. 
And the other thing that fear doesn't like is facts. Fear, it doesn't look too far beyond itself. It senses danger, and it does not want to look at the other facts that are counter to that. So it's very helpful to increase a sense of confidence and peace of mind to inject some of the facts. You know, you've heard of the saying "Facts Over Fears." It's a great concept. Look at some of the facts that are happening all around us in lightning speed. 
We have so many companies that are volunteering to produce the absolutely essential PPEs. So we can say with some certainty that there is a movement coming down the wire to ensure that you have the stuff that you need. There's been changes globally in places that have had the outbreak before us, New York notwithstanding, that are beginning to show some measures. We have had some at this time here in Canada, in comparison to other places to get plans in place. 
All of these things, all of these things some degree as a [AUDIO OUT] what we do. And that's not even considering our individual capacities. Like I said, our personal experience stepping in, and doing this job under very challenging circumstances before. We're not coming into this thing completely unarmed. Everything that we would need to stay safe, as effectively as we can, we can leverage. 
And I think the final thing Jill, with the fear of uncertainty is focus on what you can do. Right now the mind is racing and focusing on the stuff that we wish we had and isn't in place, and what about this? And if you cannot answer those questions effectively, you're just creating undue suffering for yourself. 
So step back. Again, reel it in, put your attention in the directions of the stuff that you can do and you can bring every single day. That contributes to effectiveness. Contributes to safety of you and your team. And when we start to put our energy there, days feel a lot better. And I think it's sort of a practice … and the art of acceptance, this is a stoic philosophy principle. When you accept the situation as it is, and that doesn't mean we like it. Of course, not. But when you accept that as it is, there's an efficiency there. 
I need that extra bandwidth. I need that extra emotional energy for the long haul. This is going to be a marathon, not a sprint. And so, if I'm not attaching and resisting to things that no amount of spinning them in my head can help resolve, what a difference for you mentally and emotionally to release from some of that. 
And again, focus on the things that matter that you can bring. Good attitude, good energy. Good teamwork, good communication. Being safe. There's a lot more that we can do here to step in front of and get ahead of the feelings of fear of uncertainty that when we're in that state, our mind isn't [INAUDIBLE]. We have to shift our attention to those things. 
Dr. Jillian Horton: 

Jason, long before simulation was popular in medicine, you and your colleagues were talking about rehearsal. So can we talk about the role of rehearsing. Not just in the same lab, but rather the role for mental rehearsal in what we're facing right now? And what that looks like when an individual tries to use rehearsal. 
Jason Brooks: 

Sure. I mean, I think the role right now is primarily for safety sake. And I'll tell you why. Again, when you think of all the policies and procedures around PPEs, this is new to people. We're not used to having to take the extra time and consideration to follow very specific protocols. So we need to ensure that we're getting as many mental reps doing that as is possible because we have not had the luxury of doing a lot of training with this. 
So we can take advantage of as you alluded to the simulation center that we were born with, the one that floats between our ears. And so, if I use that particular example. The way that that would look to me is I would imagine myself stepping into a situation whereby let's say it's hectic and chaotic, and I am bouncing from one thing to the other. So there's the possibility I could be distracted. 
In the first wave of playing that scene through, I just want to gather the data. I get a sense as to what I would [AUDIO OUT] might be interfering with my ability to be more present and focused because that is what's my enemy. If I'm either aroused or if I'm too distracted, it might make the difference between a moment's error with putting on or taking off something properly. 
So I collect the data, and then I get a sense. So now when I'm playing that scene through again in my mind, priming my mind to respond rather how I want. I anticipate as I'm going from one week to another, that I might be experiencing some internal distraction. And so, I visualize seeing myself slow down. Seeing myself take a moment's pause. Maybe I cue it with a word that says just [AUDIO OUT]. Something along those lines. 
I see myself putting the equipment on properly. I see myself ensuring it's fastened and secured in whatever way it should. I see myself executing a procedure and then at the end I see myself take pause and doing the same routine in reverse. And maybe just maybe to add additional safety. I would visualize having a reflective statement that I say to the team that just says look, before any of us do anything, let's just take a moment. Let's take a breath and think about what we are about to do as far as taking off this equipment. 
And so, when I create this mental image, this story in my head. And play that seen through, the mind doesn't know whether what I'm doing is "real," air quotations, or perceived. And so, I'm getting those valuable mental repetitions. I'm training the mind to respond, and to behave, and to execute in a very particular kind of way. 
And if I spent two minutes doing that at the beginning of my day, before I step into a situation. Or maybe at some break in my day. I'm getting that valuable mental repetitions that's going to strengthen that neural pathway to remind me and to cue my mind to do the thing that I need to do to stay safe and be effective. 
Dr. Jillian Horton: 

Jason, let's talk about transitions. So, you see these as other found moments in the day that can help us create intentional change. So, tell us how we can use transitions to help us work through this pandemic? 
Jason Brooks: 

Well, I think the transitions in the moment, during a shift let's say, that just allow us to ensure that we are not allowing an otherwise busy mind to do something without the forethought that could put us at risk. So, taking a breath. Moving slower than normal, ensuring that we are mindful, that if we feel heightened in some way. Distracting thoughts, a bit more fear than usual. That should be a signal that says, hang on a sec, I need to take a little proverbial mental time out right now. 
And so, I step back. I take a deep breath. I quickly observe what it is I might be thinking or feeling. If there's some solution, I can bring to that at the moment, terrific. If I have to put it away for later fine-- later fine. But just taking that pause, I want some of that initial anxiety or intensity of emotion to drop down ever so slightly, which means I have more presence, more bandwidth available for the task. 
Those are the moments that you can happen 100 times a day during your shift. I also think it's important to manage the transitions in terms of leaving work and going home, and conversely going back to work. When you go home, I think the ride home is a great opportunity to do perhaps some of the processing of the day. 
And when you get home, I would encourage people to alert the team that is their family, whoever is going to be receiving them at home, as to what it is that they need to transition [AUDIO OUT] and emotionally. You might find that people want to be received in a certain kind of way. Maybe they need 15 minutes to vent about all of the challenging, difficult things that they experienced in the day. 
Maybe they want the exact opposite. They want to just be left alone for 15 minutes. Whatever the case is, if we have those conversations ahead of time and your family can actually support you in making the valuable psychological transition from the stress and strain of the day to be able to immerse more effectively and fully into our personal time. That's going to make [INAUDIBLE] in terms of long term recovery. So have those conversations. 
And I think be very careful with where you put your attention. I think part of ensuring that we recur at the end of a tough shift, especially under these conditions. I'm concerned about the flow of information. All the physicians I've talked to, their emails are beeping every 5 seconds with some new update as to way they should be doing things. You know what? If you're going to spend your entire evening glued to your phone waiting for the latest update, that will interfere with your ability to transition. 
Set aside a time for that. Let that thing buzz to its heart's content. If you're not working until the next day, I only have to be ready for the most current update when I start my shift. So, if you give yourself a half hour at the end of your evening just to check in. And then get up. And a little bit earlier the next morning to ensure that you can go sort of through the backlog of updates. They're going to be changed anyways. 
So we don't want to make sure that we're allowing the constant change to interfere with our time. And as I said to you in the morning, the transition to work. Get up and get ahead of the thoughts and feelings. Imprint to your subconscious what it is that I need and want to feel today. What do I need to bring that will be helpful to my team? What am I a little bit scared and anxious of solving? And can I do something with those thoughts and feelings right now. 
When we do that, we sort of put fear behind us to mobilize us. And we can be much better than at starting the day with better focus and better energy because we have a plan, that's like a mental warm up. If you went to the gym you would warm up your body physically before you put it under tremendous stress and strain. 
Now [AUDIO OUT] more than valuable strategy to do when we start our day, to make sure that we're switched on and dialed in as effectively as we can because that's what's going to ensure safety and effectiveness. 
Dr. Jillian Horton: 

I'm going to ask you to talk about contagion as it applies in your world. So can we spend a few minutes talking about how it lift's up or brings us down? 
Jason Brooks: 

Well, and it's just so interesting given that we are dealing with a global contagion if you will. And it functions in much the same way psychologically. If you think about the attitude and the energy, and the communication that we bring to our work, it in and of itself it has a contagion effect. 
So I think it's a just a simple approach, you step back and you ask yourself what is it that my teams need? That all of us are going through this same thing together. What can I do just by virtue of the way that I communicate, the support that I bring, the empathy, the understanding, the civility, et cetera. When I bring that and make a conscious effort to be that, that's the kind of energy that's helpful. Especially, as people are stressed, and tired, and with no end in sight and with all the anxiety. 
Conversely, the opposite is true. If I bring negativity, and anxiety, and panic and fear. That is what's going to infect if you will, the emotional climate of the environment. So ask yourself what is the energy that is optimal? And for me, the two things we need right now more than anything. We need calm, and we need courage. 
And so, if I can make a pointed effort to be and bring that every single day, that is the energy that is uplifting. And I'll tell you what, given that this is going to be such a long and arduous process, we need to be doing anything we can to ensure that we're optimizing and sustaining our energy for the long haul. And something so simple as bringing the right emotional currency that helps people. If we all did that, that in and of itself can be so uplifting and help increase our sustainability factor. 
Dr. Jillian Horton: 

So Jason, the last question I want to ask you for today. You know, and I know that physicians hate generic prescriptive wellness advice. But what would you like to see front line providers doing for themselves when it comes to both fatigue management and self care in the months ahead? 
Jason Brooks: 

Well, I mean again. I think that if you look at the idea of recovery, it is absolutely essential when you connect the dots. If we are fatigued and distracted, we are at a greater risk of making errors. Errors right now impact not only patient safety, they impact provider safety. So anything that we can do to recover effectively is going to contribute to better safety and better performance. 
So some of the things are the most basic things. And it's so interesting because it's all the things that all of us should be doing a better job of in non-COVID times. Making sure as best as possible we get as much rest. Making sure as best as possible our nutrition and hydration is well. Making sure as much as possible we get some form of exercise. And I think specifically, exercise that involves movement. 
I'm a big believer in under stress, stretching, yoga, Pilates, movement based exercises. Because again, just the way in which stress manifests physically in the body as muscle tension, people will be clenching their jaws a lot at night. So, allowing some physical release from this is incredible to ensuring that we can stay sustainable. I think finding moments for stillness. And I say stillness as compared to meditation because meditation is but one option that one can do to practice stillness. 
I feel that there would be just as much a benefit for someone listening to their favorite rock music while they vacuum their carpet. I mean that in and of itself is a form of stillness. We're not having ourselves attached to all things, stress and strain of this crisis. And I think simple strategy to help let's say with sleep, conscious breathing. I've heard many instances where this is a sleep aid that has been really beneficial for people under stress. 
So in essence, it's just thoughtfully breathing through your nose for a count of let's say two or three. And the key here is the exhalation also, through the nose just needs to be twice as long. Now, the physiology and the neuroscience behind that is quite clear. When we exhale, that is cuing the parasympathetic nervous system. That's the relaxation response. 
So we are literally bypassing whatever we are thinking going straight to the brainstem, and cuing it to begin to relax. Less physical tension, less mental tension et cetera. And feed your mind what's going to help. We have to be really mindful of what we're allowing into our subconscious right now. And I would suspect that most of the thoughts are not on the positive, and the encouraging they're on the fear from the anxious. 
So, make sure that you spend some time looking at some of the encouraging developments that are also happening at the same time. And what an opportunity this is to lead, and to serve, and to literally bring your skills and talents to the world in a way that matters more than ever before. And I look at some of the things that are happening in other centers. You get goosebumps seeing people applauding medical providers from their balconies in New York and in Vancouver. 
And I was speaking with an emerge doc in New York City just the other day. And that was the thing that he said to me more than anything he wanted to make sure that a message is being sent that says, look, we also, there's some good things happening here. The amount of recoveries, the amount of people being together. The way in which teamwork and collegiality has never been higher at the hospital. 
He says these are things that we also need to be talking about because there are a lot of another side of the story. And I suppose another key wellness thing then would be-- this might sound funny, but avoid CNN or news of that type. If you've been on the front lines of this crisis all day, the last thing you need to do when you come home is to be looking at ticker counts of deaths and cases and listen, I'll summarize the mainstream news media for you. It's not good, the number's on the rise et cetera, et cetera. We don't need that. We need to make sure that we detach and recover. 
Dr. Jillian Horton: 

Well, I want to end today by thanking you, Jason, for spending time sharing your knowledge and your expertise around performance with us today. 
Jason Brooks: 

Thank you Jill. I appreciate what you're doing here so much. It's so invaluable for those folks. And everybody who's out there facing this thing, thank you so much. I mean, I've said it before. The 1% of you are facing this thing while the 99% of us are silently sitting in the background. Sending every ounce of love and support we can. So thank you so much. 
And thanks for everything you do to support us. 
Thanks Jill. 
Dr. Jillian Horton: 

I'm Dr. Jillian Horton. Thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon. 

Running on empty: Staying healthy during difficult times

Length: 20:51

Maryam Hamidi

As a member of the Stanford Medicine WellMD & WellPhD Center team, Maryam Hamidi leads initiatives that promote well-being and a culture of wellness. She will share practical tips on how to manage nutrition and sleep during times of high stress and heavy workload.

Read the show notes

Dr. Jillian Horton: 

Welcome to the COVID-19 Physician Learning Series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. I'm a general internist, medical educator, writer, and podcaster. And I'm your host for this series. 

When it comes to health, physicians are often a primary source of information for patients. But we all know that the challenges inherent to practicing medicine can make it very difficult for us to maintain health-promoting behaviors in our own lives. And those challenges are about to get greater. 

It is therefore even more critical that we all work to adopt practices that are both realistic and high value for us during the months ahead. Joining me today is Dr. Maryam Hamidi, a member of Stanford Medicine's WellMD team where she leads initiatives and conducts research into promoting well-being, self-management, and wellness. Maryam, thank you so much for taking the time to join me today. 

Maryam Hamidi: 

Thank you. It's a pleasure being here. 

Dr. Jillian Horton: 

Maryam, during the COVID-19 pandemic, many physicians are prioritizing frontline critical care over everything else in their lives. Can you start by telling us how nutrition has been shown to affect physician performance under real life conditions? 

Maryam Hamidi: 

Sure. One of the biggest things that happens when we are really busy, we often stop attending to our own basic needs such as sleep and also nutrition, hydration. And we know that being dehydrated or even having mild hypohydration can result in deficits in our attention, in our reaction times, in our judgment. 

So for example, pilots who are dehydrated make more mistakes when they're landing. Or [INAUDIBLE] they make poor judgements when they're dehydrated. There are studies that have shown that. For physicians, their short-term memory would be affected. 

So it is important to keep hydrated. That's one of the simplest, easiest things to do. And often it can be achieved by carrying a water bottle if possible and having sips of water any chance you get to keep hydrated. 

Ideally, we want to have a urine color that looks like lemonade, not apple juice. If it looks like apple juice, we need to keep-- to increase our hydration and having more fluids. The other thing is that would be helpful to keep in mind is that if you're a habitual coffee or tea drinker, it doesn't necessarily result in dehydration. So that all counts towards fluid intake. 

Fruits and vegetables, if you get a chance to have them, are high in vitamins and minerals that are helpful in general for health. But also they have fluids and water in them that can be released over time. So they act like a time-released fluid. 

In terms of how we could do that is carrying them in little Ziploc. So things like grapes, cherry tomatoes, blueberries, baby carrots, things that are small, and they can be even easily, well, like cut apples. If you don't have time for cutting things, then it would be things that are already small, that grapes or berries. 

And for other foods, things that, for example, we know having a diet that is high in added sugars and saturated fat can really impair mood, in particular, over time. But it also can impair the quality of the sleep. We said it becomes a vicious cycle. 

We did an observational study with some of our outpatient physicians, and we saw that the ones who had diets that are higher in green, leafy vegetables and other vegetables, berries, nuts, legumes were low in added sugars and saturated fat tend to have less sleep depriving impairment during the day. So we also know that sleep deprivation can lead to us engaging in behaviors that are rewarding. 

Also when we are feeling tired, we're more likely to crave things that are high in sugar and saturated fat. So overall, the combination, it becomes like a vicious cycle that we feel tired, then we eat poorly. We eat poorly, it affects our sleep. So nutrition is one way to break that cycle. 

In terms of healthy things, I know that's a huge challenge to get access to healthy foods in COVID time. The good thing is a lot of the food organizations or food industry are supplying donations for healthy snacks and healthy drinks to frontline health care providers. So that's one way of reaching out to those organizations to ask for donations in particular during these times so there are always healthy snacks available. 

Sometimes depend if the patient load in the hospital has become less because the elective surgeries, for example, have been canceled, the hospital kitchens might have more bandwidth to serve our frontline physicians and provide them with healthier meals, deliver meals in their workrooms. So we are all in this together and in any way that we can support each other in taking care of patients and ourselves. That's all I had to the whole effort. 

So some cities are in full-blown crisis right now. And there's no question, there will be a tendency for physicians to work 24 or 36-hour a week shifts just the way many of us did when we trained. Could you talk about research on how sleep affects performance and why we should question the wisdom of returning to those practices as opposed to using other schedule models? 

So in terms of sleep, we know that, again, earlier studies have shown that being sleep deprived is similar to being drunk. And the problem with that is our attention comes and goes. So we have this micro lapses in attention. And at some point, people actually do fall asleep. 

I've heard from residents that they have woken up examining a patient and their head is on the belly of the patient. Because they're so tired, they don't even realize they have fallen asleep. But before that, there are these micro lapses in the attention that we are not aware of. 

And then all of a sudden and then we are alert again. And we are more likely to make mistakes. And that can do more harm than good. So any way that we can reduce that extended shifts and allow people to have at least 12 hours of rest between one shift until the other one would be quite helpful both mentally and physically for people to have enough rest to be able to perform at their best. 

And again, that seems to be very difficult, especially if there are not enough staff. So working, coming up with strategies where other staff or physicians can come and help. So for example, we hear that there are, for example, in ENT division, there are people who are board certified for internal medicine. So using those resources so we have more people, fellows. 

So basically pulling in everybody so then we can give a break to those who are affected more so they can just recuperate. And also we know that sleep is huge in the immunity. So sleep deprivation can decrease our immunity. 

And there are studies that show that we do need at least seven hours-- majority of people need at least seven hours of sleep for good immune health. And that's another factor that in this particular case is important to attend to. Perhaps the most important thing even before nutrition and hydration and anything else. 

Dr. Jillian Horton: 

You and I have spoken about this elsewhere, but could you review the strategic use and timing of both caffeine and green tea to ward off fatigue? 

Maryam Hamidi: 

All right. So that's another strategy. So use of caffeine can basically reduce drive for sleep and also up to 36 hours. So beyond 36 hours, no amount of caffeine can prevent falling asleep. There are strategies in particular for caffeine that can be helpful. So one is what dose is helpful. 

Some people are very sensitive to caffeine. So if all of a sudden they start having a lot of caffeine and they also already-- so caffeine enhances every mood that we are in. So if someone is feeling anxious or very tensed or stressed, and all of a sudden they increased the caffeine intake, that increases that sense of anxiety. And that can be-- that can make things more difficult. So knowing how to titer our caffeine intake is important. 

And again, it would be similar to having like a bottle of water maybe. If you don't mind your coffee being cold or buying cold coffee, or if it's available at all times, having cold shots of espresso can help to kind of having smaller doses so that we don't cross that threshold of going to full anxiety, feeling heart palpitation. That's one thing to keep in mind. 

Caffeine can also increase our core body temperature. So if we are working during nighttime, it can increase the core body temperature and we would be less likely to feel sleepy and tired. There is also a time lag between the time that we have coffee for it to be effective. 

That can be from 30 minutes to 90 minutes, depending on how much we weigh, what food we've had before. It's kind of similar to alcohol. So that can give a window of-- so let's say, if caffeine takes about 30 minutes to 90 minutes to be effective and you have a short opportunity to take a nap, then you can combine that together. 

So you can take your nap-- you can have a cup of coffee, take a nap, and then by the time you wake up, then caffeine has kicked in and you've taken a nap. We know that when people are sleep deprived and if they take a nap, then sleep inertia or that grogginess after sleep becomes a lot more intense. 

So another advantage of having coffee before taking a nap is that it will reduce their sleep inertia. So if you have short periods of sleep, then as soon as you wake up, you want to have caffeine to get over that grogginess. At the same time, if you are doing a 12-hour shift, you want to have caffeine ideally at the beginning of the shift and maybe in the middle of the shift. 

And then try to limit your caffeine intake about at least six hours prior to the time that you're planning to go to bed. And if for some reason your shift extends, then you can have another one. And the reason for that is caffeine can keep us alert for about three hours. And after that, it doesn't necessarily help with our alertness or reducing our reaction times, but it does impairs sleep. 

And then the other thing with caffeine is it's been shown in the meta-analysis that it can reduce the risk of errors in those who do shift work. So when sleeping is not a possibility, caffeine can be helpful. In terms of in what situation coffee is better than tea, caffeine is, like I said, it enhances whatever mood we are in. 

So if I'm feeling anxious or feeling jittery, then coffee may not be a good option because it has a higher dose compared to tea, for example. The other one is coffee is good for things that require attention switching. Or if you're moving a lot, let's say if you kind of think of an emergency medicine physician, coffee might be more helpful for them. 

Whereas green tea has something called L-theanine. And the amount of L-theanine in green tea is higher in particular in matcha tea compared to black tea. And L-theanine itself sometimes is use as something that as a supplement to reduce stress or for relaxation. 

And the combination of L-theanine with caffeine and green tea, there are some studies that show that it enhances the effects of caffeine, so we need less of it. But it also can provide a sense of, concentration or focus. So if you need to do something that requires attention and detail, let's say in pathology lab then you may want to do green tea more than you would use coffee. 

Other options for caffeine would be energy drinks or colas that have caffeine. They are not-- again, depending, not everybody can take them. Some of them have taurine. Taurine can really make us crash afterwards. Because it is helpful for sleep as well as to lesser degree, alertness. 

So one suggestion is to avoid the energy drinks that are higher in taurine. And the other one, if people don't use caffeine, would be things like-- minty has been shown to have some alerting effects through different pathways. Rosemary, sage, these are herbal things that can be helpful. 

Rooibos tea tends to be a little high in iron. Iron has been shown to be effective in improving alertness. Matcha is another one that has caffeine. So there are different, different sources of caffeine. 

And there are chewing caffeine in the chewing gums that some residents use. And they find that to be also helpful if they don't want to have coffee or they have acid reflux, for example, that can help in that instance. And a lot of times, that is the combination of the mint flavor and coffee so-- I mean, in caffeine. 

Dr. Jillian Horton: 

Maryam, everyone is interested right now in how to boost their immunity. Are there any foods that you would urge physicians to prioritize in order to boost immune function? Any evidence that you could recommend? 

Maryam Hamidi: 

So in terms of evidence, in general, it goes all back to healthy eating. Having a diet that is high in fruits and vegetables, healthy protein, healthy whole grain carbohydrates, all of that. Every single nutrient that-- the more energy dense our diet is, the healthier we would be. 

In terms of particular foods, not really. And also COVID is a really new virus. We don't really know what it does and what happens. But there are, like in the news, you hear that vitamin C, intravenous vitamin C might be helpful, taking vitamin C supplements might be helpful. 

Intravenous vitamin C is different. I'll leave that to our critical care physicians and dietitians to decide on. But in terms of taking vitamin C supplements alone, one challenge of vitamin C is that high doses of vitamin C can cause kidney stones. We know that low doses of vitamin C, it doesn't really change immune function. It's usually higher doses of vitamin C that help with that. 

And a lot of times, our health care professionals don't have enough fluids. So the combination of having high vitamin C and not having enough fluids can lead to kidney stones. So you don't want to show up in the emergency room at this time because you are afraid of getting COVID or being infected by COVID virus and then also having a kidney stone at the same time. 

So I would avoid large doses of vitamin C and try to get that from food. In particular, things like kiwi fruit, oranges, bell peppers, red bell peppers, green bell peppers, broccoli, melons are high in vitamin C. So that's one way of making sure that we do have enough vitamin C. 

Having enough protein, sources of protein can help with making sure that we do get enough zinc in our diet. So that's, again, something that it is helpful for immunity, zinc supplements. One challenge is that sometimes some of the supplements that can be helpful for prevention of, for example, cold or flu are not helpful when the symptoms have started. So they can make things worse. 

So staying off supplements as much as possible would be-- might be helpful, unless it's advised by a health care professional to take supplements, specific supplements for your particular situation. Otherwise, I would suggest having lots of green leafy vegetables. 

If someone is not feeling well, then often having cooked foods are more helpful. Or avoiding things that irritate the throat if they have a cough could be helpful. Keeping hydrated is very important. 

Again, it goes back to all the basic things that we talked about nutrition. Making sure that you have enough water, having enough protein, having enough carbohydrates for the B vitamins, and also having whole grains that is, and also healthy protein. And as much as possible avoiding added sugars and trans fat, saturated fat on processed foods. 

Dr. Jillian Horton: 

Maryam, I have one final question for you today. Can you talk about some of the literature around how physicians can use chewing gum to manage stress while at work? 

Maryam Hamidi: 

Yes. So actually I remember I forgot to mention one of the strategies to keep awake and not make errors. Some studies have shown that it is best to avoid food after midnight to 6:00 AM. Because when we eat during times when we should be sleeping, we're more likely to make mistakes. So in that situation, if we feel like we need something, it can either be a small snack or sometimes chewing gum. 

So chewing gum can also be used at other times as well. So one benefit of chewing gum that has been shown in some studies that it can reduce stress. Or if we are feeling sleepy, it can help keeping us awake, and some mechanisms like by increasing the blood flow to our brain or some other mechanisms that are still under investigation. But it's been shown to be helpful to have chewing gum. 

And another thing that might be helpful in that is that it means we know that it does have an alerting effect as I mentioned before. So that might be another-- I mean, flavored chewing gum might be helpful for both coping with stress and also not feeling sleepy, or if you're trying to avoid food at night and you still want to have chew something or have something that can help you cope with the stress and the busyness. 

Dr. Jillian Horton: 

I want to end by saying thank you to you, Maryam, for taking the time to be with us today. You've given us so many practical, actionable tips that we can use to begin to address our performance via nutrition, hydration, and other mechanisms. 

Maryam Hamidi: 

Thank you. Glad to be here. 

Dr. Jillian Horton: 

I'm Dr. Jillian Horton, and thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon. 

Moral distress: When core values are at stake

Length: 29:26

Roméo Dallaire

Throughout the COVID-19 pandemic, physicians may be faced with overwhelmingly difficult decisions. Retired Lieutenant-General Roméo Dallaire will share his perspective on how to approach moral distress in times of crisis and strategies he used in his military career to protect his core values.

Read the show notes

Dr. Jillian Horton:  

Welcome to the COVID-19 Physician Learning Series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. I'm a general internist, medical educator, writer, and podcaster. And I'm your host for this series. 

As this crisis evolves, some of our health care systems are being flooded with staggering numbers of critically ill patients. Doctors and nurses describe those scenes as war zones and battlefields. And while this experience may be foreign to us, its overtones have sounded all too familiar to Lieutenant General The Honorable Roméo Dallaire. 

In today's conversation, it's our intention to highlight powerful emotional and moral lessons learned from General Dallaire's distinguished military career, including his time as force commander of the United Nations Assistance Mission for Rwanda during the 1994 genocide. General Dallaire will also offer us key insights into managing our post-crisis risk of PTSD. General Dallaire, it is a privilege to be speaking with you today. 

General Roméo Dallaire: 

That's all mine. Thank you very much. 

Dr. Jillian Horton:  

For anyone who's younger, and perhaps, not familiar with what transpired in Rwanda, could you briefly talk about the absolutely impossible circumstances under which you served there? 

General Roméo Dallaire: 

I was nearly going to say, I hope they read my book. But I won't say that. 


A UN mission was sent in with the hope of assisting a nation, resolve a civil war, and ultimately, bring peace. We were there simply to assist and to provide a sort of referee job. But ultimately, extremists on both sides, but mostly, on the majority Hutu side decided that they felt peace agreement was not in their favor. And they ultimately commenced a civil war that also incorporated a genocide. Essentially, they decided that by slaughtering all the opposition, they would be able to maintain power. 

So what happened was an ethnic genocide in Rwanda. To which, I fear the international community before, during, and even in the ebbing parts, was simply not interested in engaging in providing the resources to-- one, prevent it, two, to stop it, and three, ultimately, to negotiate a much more appropriate solution to the conflict. 

That being said, a small force that I had was reduced because of casualties. And we, essentially, witnessed for three months the slaughter of over 800,000 human beings. And the realization that the international community was easy to blame the UN for failing but essentially forgot that every country making up the UN is the UN. And every country refused to provide us with the help we needed to prevent it, let alone, stop the slaughter. And as such, they are all culpable of being complicit in letting a genocide run nearly its full course. 

Page Break 

Dr. Jillian Horton:  

After I saw your powerful address to health care workers on social media, I had the chance to read one of your books, Waiting for First Light. And it struck me that part of understanding our own experiences is being given the right language to describe them. And we don't have that language in medicine because we don't have experiences on the scale of what you witnessed. How can framing our experiences in military language help us to get through this? 

General Roméo Dallaire: 

This is an extraordinary question because you absolutely must adopt a completely different lexicon to what is happening around you than a scenario that we are used to in a society like ours that hasn't seen war on its territory since for nearly 250 years, let alone, seen catastrophic failures of the scale that we're talking about. So with that, those who are in the front lines-- because we have front lines. We've got people facing the threat. People who are engaged in trying to stop it, to help the casualties, to reduce the impact of this threat-- they are part of our ensemble. 

That is to say, we're all in it. It's not as if it's only them, and we'll see how it works out. We're all part of it. We're all locked in and doing all kinds of restrictions and the like. And so we are in a campaign with a whole bunch of different battles being played out in different hospitals, in different health care centers, in the political structures, where they feel embattled. 

And so campaigns are run within the context of a war. And so we're in a war against a threat. We're all in it. There's no exception. And in so doing, we must use that similar atmosphere, that tone to what's going on. Versus a tone of well, let's sort out the problem here in our little local area or in our hospital. And we're achieving the aim. 

No, you're not. You're just one small part of the whole ensemble. And as such, you can gain strength by knowing everybody's in it with you. Or you could feel overwhelmed by saying, how are we going to get out of this? Because we're all caught in it. 

Dr. Jillian Horton:  

You were sent to Rwanda with totally inadequate supplies. And you talk about the UN start from zero system, where you are required to figure out what you need, and order it, and hope that it comes instead of having it provided. And as a result, you were totally under-resourced. And I found myself thinking about the parallels between that experience and health care workers caring for patients with inadequate, or in some cases, no personal protective equipment. What moral guidance would you give to doctors and other health care providers about their duty both to others and self when they are faced with this same mismatch? 

General Roméo Dallaire: 

It's very interesting that in the video you referred to earlier on when I spoke about supporting the first responders, the health care personnel, a minister got back to me from our government rather displeased that I mentioned that there probably won't be enough resources. And that it's going to exacerbate some of the moral and ethical dilemmas that the first responder, the medical people, the doctors are going to face when they're going to be-- potentially, if not-- overwhelmed, but certainly, in the midst of the full weight of the crisis. And it was a reaction of, well, this is not a very positive statement. 

Well, the first thing is, is that you've got to tell the troops the truth. And I think that what is essential for the medical staffs, the doctors, and so on is to recognize that they are in the front lines. When they will not have all the resources needed, they're going to have to make choices that are going to be even more complicated because of the lack of resources. 

And the near isolation that that creates to the individual-- in having to save a life or not being able to save a life, or seeing a life that he couldn't save, or alleviate the pain and the suffering of people because they know that either resources are somewhere else or they're simply just not been planned for or not acquired in due course-- that is going to bring about a near sense of guilt of saying, I'm there to do that, but I don't have it. I've been doing everything I can, and it's not enough. 

And so many years back when I came back from Rwanda, I was told, you did what you could, and nobody can expect more. That provided zero solace. Zero. Because you saw them. You smelled it. You touched it. You felt it. You lived it. You heard them cry. You could see in their eyes the pain and the suffering. And so the fact that you did everything you could will not alleviate the potential sense of guilt that it didn't happen. 

That's where it is crucial. That the profession and that the teams do not let people isolate themselves. That they sense that they are part of an ensemble. That it is a big scenario in which they're playing a part. And that their part, it may be not always successful. Other parts, may the same be in certain circumstances. 

But they're working within the construct of a massive involvement. And that they cannot hold themselves responsible or guilty for not having all that is required. Nor should they even hold themselves accountable for saying, well, doing all the best I can, just wasn't enough. No. That's wrong. 

You must communicate with colleagues. You must exchange. You've got to be communicating constantly between yourselves to sustain these pressures, sustain these stresses. And to be able to not let this sense of both rage-- on one side-- and of a sense of near guilt take hold because we need you for the long haul. We don't need you as a casualty in the early parts of it or in the throes of it because that's just going to weaken the whole team. 

And that's why you must be able to exchange with colleagues. And you've got to face the fact that this is of such significance. That you are pulling your weight. Then, that's what we can only hope for in this time of crisis. 

Dr. Jillian Horton:  

You share a story early on in Waiting for First Light that struck me as oddly familiar. Your executive assistant on the mission commented that you had concern and kindness to direct towards everyone other than yourself. And medicine is also a profession where we are not known for self-care. We have a high suicide rate, and a tendency to be martyrs, and to brand people who try to set boundaries as inferior. How is that going to be a liability to us? 

General Roméo Dallaire: 

Anybody who's part of an organization or profession, particularly, when they wear a uniform-- and you, guys, wear uniforms of varying types, of course-- or work within a very organized structure, hierarchical, or whatever, you come to realize that your organization is often very Darwinian. It doesn't tolerate not being able to give 100%. It has a serious problem with anybody that might be suffering that is not overtly physical but maybe psychological, and as such, is not able to perform to a 100%. 

And so what is direly, direly important is that we don't need commanders, leaders, heads, doctors who are in the most responsible positions to enter a role of-- as you say-- martyrdom or risk-taking that will put them in a position of not being able to sustain the whole campaign. You will lose some battles. But losing some battles doesn't mean you lose the campaign. And it certainly doesn't mean you lose the war. 

But if you irresponsibly put yourself at risks by thinking that going flat-out and not ensuring that you're sustaining yourself in an appropriate way, then yeah, the people might think you should be doing a bit more. But you cannot because it's not just today you got to worry about. You got to be there next week. You got to be there in weeks to come. You're going to have to keep that thing going. 

And as such, taking the hero-ish type of position, that win a couple of medals. No. That's not the way to do it. Not within the realm of responsibility that you have. Because what you ultimately will be held accountable for is taking decisions that have put you in jeopardy. And as such, you're abandoning the people that need you. The people that still haven't come to your door that will be needing you all the more into the future. 

And so how you fight that is by the institution-- the individuals in the institution-- of recognizing that they must be there for the long haul. And they've got to sustain this thing. And the only way to do that is to ensure that they take decisions that are, yes, responsible, of course. But that they commit themselves to the extent that they can work it for the long haul and be capable of sustaining the pressures, and strains, and the ethical decisions, and wearing down that that will have over time. 

If they're not doing that, then the central conclusion to that is that they weren't very professional about it. Professional means not just taking care of today. A profession means ensuring that you've got an eyeball out to the future also. And you're anticipating, and you've got foresight on what's still coming down the road. 

Dr. Jillian Horton:  

You talk so compellingly about re-entering the world after your time in Africa, and the discord between what you'd seen, and the absurdity of abundance in the life that you came back to. Can you make some predictions for physicians working through this crisis about what those transitions might feel like? And how we need to try to handle them? 

General Roméo Dallaire: 

It was uncanny that I'm in the midst of a genocide and waist-deep in bodies, with the smell, and the gore, and the destruction, and the pain, and suffering, and so on, and the depravities of resources, and what we've seen on the ground. And yet I took a small one-hour flight out of Rwanda, and I'm in Nairobi in a bustling town as if nothing's happening. And people are looking at it from a detached perspective, trying to be objective, and wanting to help, but not really living it. 

And so there is going to be a shock. It's going to be a shock that all of a sudden, you're going to walk out of the environment in which you are under so much stress and so much demand to see that other people are simply doing their thing. And that doesn't necessarily push you to want to explain what has happened because you come out of that with a feeling that they just won't understand. 

They've never been in combat. They've not been there. They've not smelled, and touched, and felt, and heard what is happening. And so how do you describe that? And do you want to describe it again? Do you want to relive it with them? And so you internalize this. And that's going to be nearly fatal. 

In fact, one of the great causes of suicide is the fact that we internalize it, and isolate themselves, and ultimately, we self-destruct. There is an absolute critical need to find a reference out there. And references will come to you from peers mostly. Peer support. People that you've known. People you trust. People you've seen who are willing them to listen. 

And that you know they'll listen. And they won't ask a bunch of stupid questions and won't interrupt. And just let you vet. And let the pain out, and the rage out. And let it live in the presence of another human being. And that that other human being is simply listening, smiling a bit, crying a bit, but listening, and letting you grasp the truism of an outside world that will never really understand that you hope you will be able to inculcate some elements of what happened. 

And that they have enough empathy and skills to be able to assist them in, at least, comprehending that you're injured. That you're hurting. That you're a walking wounded. That it's been honorable to work on those-- and to be hurt. And that there is not a shame there. And worse, there's no stigma in having lived that. And if that can be passed on by that community around through the family, and community, and professionally, then you're going to build strength. Because they won't feel as if they're the only one that's hurting, and as such, isolate themselves, and ultimately, make some pretty stupid decisions. 

Dr. Jillian Horton:  

You have concerns about the mental health of our profession after this is all over, and how that actually may be the phase where we are going to incur the most casualties. How else can we, as a profession, begin to mitigate that risk right now? 

Page Break 

General Roméo Dallaire: 

In the part of the leadership of your organization, the professional collegial milieu that you have, there is an absolute need of being very conscious and making people very conscious. That when this overt enemy is defeated, the effects of the war may raise exponentially on you, and on your team, and on the demands of you. Because the wounds that have been acquired during the campaign, you don't necessarily feel them to their full strength because you're going flat out, and your professional instincts often take over as they should. And they can fill the time. 

And I used to make my guys work till they drop so that they didn't dream. They didn't have time to think. They just slept. And then, bingo, they're back into it. But as this campaign goes down, and as we look at transitioning into the post crisis, then all that adrenaline is going to disappear. And it happens fairly fast. All what you've seen, all those wounds that were cut open in your minds, and so on are now going to start to hurt, which is different than simply when they happened. 

And because of that, it's going to ask for more support, more help. So just as foolishly as we saw governments at the end of the war cut all resources and everything, particularly for people. And I remember after Afghanistan, when I was in the Senate defense committee saying, hey, when Afghanistan ends, that's when the real number of casualties will start appearing. And that's exactly what happened. 

And so preparing yourself for a second round. That the first round is defeat the enemy. The second round is to bring you back to a level that you can sustain, and ultimately, evolve into a new future. And that means being able to handle those wounds. And those wounds need professional help. You can't do it alone. It's Impossible. 

And so the entity, the corporate body, the sisterhood, brotherhood of the profession, be it just colleagues, be it also those who can be close to you that love you and that are willing to sustain the impact that this have and seeing you all of a sudden hurting overtly. Because the operational demands of the job won't be the same, yet the impact of the injuries will have escalated. And so that's when you become exceptionally vulnerable. 

And so you prepare people for that. You said there's going to be another round, and that round. So where are the tools to be able to handle bringing those walking wounded back down to a certain level of normality? They'll never forget what happened. But then they live with it and continue. That's what you got and work towards. 

Dr. Jillian Horton:  

General, you talked about how the experience of being in Rwanda made you care more about humanity. What kind of social change or transformation might you predict coming out of this experience for us on the other side? 

General Roméo Dallaire: 

I think this can evolve into an extraordinary transition for us into a far more mature society. That we've all been in this together. And we've all hurt to varying levels. But we've all lived it. And it's not going to disappear. 

And so it's a reference point that our society can refer to and say, did we grow with this? Or did we fail? Or did we fall apart? Or in fact, did we have the right leadership? And will the future leadership be able to handle such scenarios because of the experience of this? 

I think that's one significant overriding element. There are two-- however-- groups in our society that I think are going to take on a different perspective. And I hope we're smart enough to realize it. The first one-- and not necessarily in the order. 

But the first one that I want to speak to is the youth under 25. This enemy is attacking the older people. The younger people are not being attacked in the same scale. Yet it is an opportunity for those who are young to hold the generations between the 25 and the 70s accountable for doing things right. 

And they should be engaged, and committed, and vocal, and pulling all the revolutionary skills they have of the communications world-- social media [INAUDIBLE]-- to keep the pressure on. They can come out as a new leading force within our society. So that's really, really important. 

And the second one is women. The front lines are just chockablock with women. They are fighting that battle in the majority. And so it is an opportunity for the male-dominated societies that we still have to realize that there's no way that that can continue. That the women must be perceived as a full-fledged, totally committed, and willing to take casualties to keep our society going just as much as men, and probably, better in certain circumstances than men are. 

And so there is an opportunity with this. That women grow within our society. Not that they are not themselves having to grow, but that their stature, that their ability to sustain our society will grow with this. And that the society will adjust. 

We could shave 25 years off of the gender problems and the glass ceilings with this experience if we're smart enough to realize it. And I do hope that the men come to the full realization. And that women use this as a pivot for their future. 

Dr. Jillian Horton:  

General Dallaire, I am so honored and-- 


--profoundly moved and uplifted after speaking with you today. 

I'll stay at it and keep me in mind as you start thinking about the post crisis, as I want to be engaged. And I'm talking with the political people. But I think I can be maybe of assistance of helping people explain what the hell is happening to them, and how they can evolve into the normalcy after being injured on this campaign. 

And before we go, I also want to extend my deepest thanks and gratitude on behalf of my colleagues everywhere for your wisdom and for your service to our country. 

I'm just an old soldier. Thank you very much. 

I'm Dr. Jillian Horton. Thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon. 

Grief and loss: lessons from a war zone

Length: 30:32

Roméo Dallaire

As hospitals become flooded with critically ill patients, health care professionals are witnessing extreme levels of loss and grief. In part two of a conversation with Retired Lieutenant-General Roméo Dallaire, he will reflect on his war zone experience and what he learned about surviving suffering.

Dr. Jillian Horton:  

Welcome to the COVID-19 Physician Learning Series brought to you by Joule and the Canadian Medical Association. I am Dr. Jillian Horton. I'm a general internist, medical educator, writer, and I'm your host for this series as well. 

As this crisis evolves, some of our health care systems are being flooded with staggering numbers of critically ill patients. Doctors and nurses describe those scenes as war zones and battlefields. While this experience may be foreign to us, its overtones have sounded all too familiar to Lieutenant-General The Honorable Roméo Dallaire. I am privileged today to have the opportunity to have a second conversation with him, this time, in French. 

In today's conversation, it's our intention to highlight powerful emotional and moral lessons learned from General Dallaire's distinguished military career, including his time as force commander of the United Nations Assistance Mission for Rwanda during the 1994 genocide. General Dallaire will also offer us key insights into managing our post-crisis risk of occupational stress injury and also PTSD. General Dallaire, it's an honor to be speaking with you again today. 

General Roméo Dallaire: 

The pleasure's all mine. 

Dr. Jillian Horton:  

We discussed this in our English interview last week. But for anyone who's younger, and perhaps, not familiar with what transpired in Rwanda, could you briefly give a sense of the absolutely impossible circumstances under which you served there? 

General Roméo Dallaire: 

Well, Rwanda was supposed to be an easy mission. A classic peacekeeping mission if you like. But what we fail to understand was that the extremists didn't want peace. So the situation degenerated over a space of about six months. There were negotiations during that time, murders, riots, and at the end of it all, the president's plane was shot down. And then, we ended up in a civil war and a genocide situation as well. 

The UN mission was not equipped. I didn't have a mandate to react. We lost soldiers right from the outset, right from the first day in fact. And countries taking part in that mission decided to withdraw the troops. So I ended up with about 450 troops facing off against more than 10,000 militia. And they had been brainwashed to kill all Tutsis across the country. 

So for three months, with no support from the outside, except for 12 Canadians who came in as reinforcements, we tried to mitigate the impact of the civil war. On the one hand, of course, there were truces along the road as well. And we tried to protect more than 32,000 Rwandan citizens from being massacred. But in the meantime, there were more than 800,000 who were killed. And more than 4 million, actually, became refugees. 

Page Break 

Dr. Jillian Horton:  

We're seeing an endless stream of doctors and health care professionals on social media and in the news putting forth their stories for public consumption. There are stories about what's happening in hospitals right now. In your writing, you talk about a phase in your life, where telling and retelling the story of the genocide and your role in it became an obsession. How can we work the most effectively with the public sharing of our experiences without it veering into a territory where maybe that impulse is not so healthy? 

General Roméo Dallaire: 

Well, it's essential for people not to ignore the experience that they're going through, and the experience they've gone through. Be it ordinary people, on the restrictions, the lockdown, even after they've gone back to their regular lives. But also, for those on the front line, in the firing line, if you like-- medical professions, more specifically, security forces as well. But especially, those working in the health service. Especially, those who face moral conundrums because they're overwhelmed. And we're seeing this already. 

And also, because they don't have the necessary resources to deal adequately with what patients need. So they have to make decisions. That complex and emotionally charged period and experience, where physicians are required to continue to do their job. Well, during that period, physicians will need proper communication. They'll need to be able to talk to their peers, but also, to society at large. So their organizations must also be able to allow them to speak out about what's happening, about their experience. 

And then, after the event is over, they must be able to actually work through the experience without throwing them into crisis. But they can't close down. That has to be avoided. They can't just close down and keep everything inside because they'll never deal with what they've gone through. 

If they do that-- if they quite simply close down and refuse to talk about it, throw themselves into the job, just say, well, I can deal with it. I can take care of myself. I'm the only one going through this. I'm not going to talk about it. That type of approach, it has to be stopped and prohibited. You have to encourage them to talk. 

Dr. Jillian Horton:  

In Waiting for First Light, you talk about a powerful moment where you were gazing at a child who was the same age as your son back home. You say in your heart, you had already brought him home and added him to your family. It made me think of how doctors are often taught to cope with the loss through nonattachment, and how toxic and suppressive they can be in the face of great suffering. Especially, as many of our colleagues in other centers are supporting patients who are separated from their families during critical illness and death. What counsel can you give on that front, working with the grief and loss in front of us when it's of this magnitude? 

General Roméo Dallaire: 

Well, the situation I went through was awful. I saw so many people dying far from their families. They suffered greatly. And very often, they never ever saw their families again. Survivors never saw their families again. And there was also a lot of psychological injury that was caused as well. 

But in terms of physicians, and those working on the ground, those who find themselves in this professionally demanding situation, and those who have strong values, who have a strong unshakable faith, which comforts them-- well, even for those people, it's impossible to expect human beings to be impervious to those emotions. And I think if physicians focus too much on trying to dampen down those thoughts, it'll make them battle-hardened. It'll put them on the wrong track. All they're doing is storing up more issues for the future. 

It's likely they'll become frustrated. And that they'll lose their desire to serve. So it can make things actually worse after the event is over. Undoubtedly, they'll start feeling guilty. They'll feel that they didn't do everything they should have done. 

So I think that as Dr. Orbinski at Doctors Without Borders said, you have to actually experience the event with people. But at the same time, you have to recognize that these events are ephemeral. They have a limited duration. And physicians will have to continue to do their job despite the heavy emotions that they feel. 

They shouldn't try to neutralize those emotions. But they have to realize that these emotions are normal. But at the same time, they can continue to do their job. It's almost as if they had to harness those emotions to demonstrate sacrifice and their dedication to their profession. And also, to demonstrate the strong values of that profession as well. 

So basically, you shouldn't hide from the emotions. It's an ephemeral experience. Of course, emotions will build up. And when the adrenaline fades, when the crisis is over, that's when it's crucial to help them to deal with what they've gone through, with the experience that they've been hard hit by. 

Dr. Jillian Horton:  

We talked in our other discussion about the struggle the medical profession faces to prioritize self-management and to discuss invisible wounds. You talked about the intolerance of professions that wear uniforms towards things that aren't absolute. I think you used the word "Darwinian." Can you say more about that? 

General Roméo Dallaire: 

Well, any organization with a strong identity, organizations that have clear symbols of what their organization does, be it uniforms, clear standards, its status in society-- well, those organizations put huge indirect stress on individuals to give 100% or even 110%. Now those organizations are very intolerant of suboptimal performance because they believe that all members of the organization must work together to ensure the success of the organization. The intolerance becomes even more pronounced when injuries or wounds are invisible because they tend to be very visual organizations. Like physicians, for example, they're very visual. 

So in that type of context, where there's a drive for high performance, well, individuals can be driven to not reflect outwardly any weaknesses. And that's why it's crucial the physicians be able to voice their issues in a group setting. They must be able to talk to other members of their group. They must feel supported by their colleagues. There must be an ability for physicians to communicate. 

And physicians must be encouraged to say, listen, I'm tired. I need to rest. And the group around them must support them, must encourage them. And even say, well, no, enough's enough. You need a rest. We can't jeopardize care to patients. 

That takes leadership. Leaders must be able to see these individuals for what they are. They're basically walking wounded. And individuals must be given the opportunity to speak about their experience, about their issues. It could just be a chat between peers, a quick coffee, something like that. 

But physicians must feel supported. They must feel supported by their peers because they won't be able to deal with their issues alone. And they shouldn't be encouraged to think that they have to go it alone. They have to feel supported by the team. 

And secondly, they have to feel that the country and their families are behind them as well. That the country is supporting them, is thinking about them, is concerned about what's happening to them. They have to feel that. It's something that has to be tangible. They must feel that. So that their morale can be maintained. 

Dr. Jillian Horton:  

After you served in Rwanda, you took over a role looking after troops' quality of life, and what was being done for them. And this was very personal work for you. I saw an interesting parallel between the relatively young movement of physician wellness, and how it has often been a subject of disdain, contempt among the old guard. What is the tone you want to see our leadership adopt when it comes to creating a culture where caring for ourselves isn't seen as a weakness? 

General Roméo Dallaire: 

Well, it goes without saying that the organizations we're talking about are very, very conservative. And leaders in those organizations often take an old-fashioned approach. They take the stiff upper lip approach as the British would say. What does that mean? You hide your feelings, your concerns. Individuals are encouraged to conceal their concerns to show they're in full control of the situation. 

Well, those leaders must be sidelined. They must even be muzzled. And they must be replaced by other leaders. Leaders who recognize that invisible injuries exist. People get injured inside. 

Those injuries are invisible. Those injuries are real. But at the same time, they can be managed during a crisis situations out of a sense of duty because adrenaline kicks in. 

But leaders have to realize that they are pushing physicians to the limit. They have to realize that physicians face ethical dilemmas. And that there's low morale. Leaders must be clued in to what's going on with their staff. 

We lost many of our soldiers to suicide post operation. Why? Well, when they were in theater, they had constant support. But as soon as they came home to civilian life, well, that care was delegated to their families and to physicians. 

And there were times of crisis for people returning from operations. They weren't getting appropriate support. And their emotions bubble to the surface. And those emotions basically dragged many of them down into the depths of a living hell. 

So leadership has to closely monitor their staff. They have to give these people a helping hand. They have to listen to them. They have to realize that some need support. They have to create an atmosphere where communication is encouraged. It shouldn't be seen as a weakness to open up about your feelings and say that you're injured. 

And that was a great innovation in the military. Having soldiers realize that it was honorable to be injured on duty. And to have soldiers understand that they shouldn't try to hide their feelings. That they should talk about it, open up about it, and they should seek treatment. And then, go back to work in the knowledge that the issue or the feeling would not go away. That it would only be dealt with after the end of the mission. 

Dr. Jillian Horton:  

I want to talk about the specificity of our experiences. You share a scene from your life where you were assigned to an all-comers therapy group with a therapist, who you say, you weren't even sure could spell the word Rwanda. And you talk about the criticality of shared knowledge. 

There is going to be a huge variation in the experience of doctors dealing with this crisis. Some of us will be in operations. Some of us will be on the front lines. How do we avoid putting our people in a terrible situation you found yourself in when you first sought help? 

Page Break 

General Roméo Dallaire: 

Well, there's no doubt that if leadership does not recognize that it takes a team effort to help an individual deal with their issues and their feelings-- well, if they don't realize that, it'll create divisions. And those divisions will be very, very harmful in many cases. Some will say, I've done more than you. Some of you dragged your feet. You haven't been as involved in dealing with this situation. 

So then, there has to be a coming together-- reconciliation. That's essential. At the Canadian Legion, I saw situations where First World War veterans refused to speak to World War II vets. The ones that had been in Dieppe, for example, who had fought for 24 hours and then taken prisoner. And the First World War vets refused to speak to them because they felt that because they had been taken prisoner, they had a comfortable life compared to those who had continued fighting. 

So those divisions do develop. But those who have influence over our teams through their leadership role or because they're an expert, a therapist, for example, they really must fully understand the culture of the organization. They must be able to fully articulate the impact of the issues on the individual physician. They must understand those issues within the context of the culture of the organization. 

It's not good enough for those therapists to have to continually be asking questions to understand the culture. No. They must fully understand the profession that physicians work in already. They must understand the setting. And they must be able to pinpoint the wounds that the individual feels. 

They can't be flailing about trying to understand what's happening because that'll lead to a loss of trust from the physician. And the adverse effect of that is that physicians will be deterred from reaching out for help. They'll turn inward. They'll stop talking to their colleagues or co-workers. And they'll self-destruct basically in the end. 

Dr. Jillian Horton:  

There's interesting literature in medicine to show that doctors, who are perceived as the most compassionate by patients, are also at the highest risk of burnout. I suspect that this is true in general on any mission. Yet those are the people who preserve the soul of our profession. But sometimes, they do what you talk about, which is suicide through work. What guidance can you give to that portion of our population specifically? 

General Roméo Dallaire: 

Well, I think humanity and compassion are crucial for any person doing a job where they come into contact with other human beings. Administrators, technicians, perhaps, they have more clear-cut roles and jobs I think. Well, for them, it's easy not to become emotionally involved. But for physicians, for example, well, they deal, on a daily basis, with other human beings. 

These human beings are either alive, sick, or deceased, right? So they can't withdraw. They get emotionally involved. You have to recognize that physicians are above all human beings. 

First responders have human emotions as well. They need support. Support that's specifically targeted to the trauma they've experienced. The trauma they've experienced during the situation that they've gone through. The event if you like. 

I think it's also important to realize that some physicians will be very adept at concealing their need to talk about what they're going through. And that's especially true if the organization has not demonstrated humanity or compassion for its employees and patients. If physicians also feel that their colleagues don't demonstrate humanity, it gets even harder. What happens is that they'll start working harder and harder to conceal their issues and their feelings. 

The issues that their community sees as weaknesses. So they're going to throw themselves into their job. They're going to work harder, and harder, and harder. And why do they do that? They do that to self-destruct but with honor. They give it their all. That's basically what happens. That's what happened to me in fact. 

At one point, I realized that I was working 22 hours a day. Why was I doing that? I was doing that to really mitigate the feeling of guilt that I had and also to avoid having to spend too much time thinking about what happened to me. 

So that really endangers physicians themselves. And one of two things can happen here. They'll self-destruct-- they might commit suicide-- or they'll just burn out. And then, they're of no use to anyone. Because basically, what they've done is they've upended all the normal standards governing work. Therefore, they're not able to support the team effort. They're not able to support their colleagues. 

Those on the front lines-- physicians, health care workers-- are in the same situation as soldiers. Soldiers train constantly to keep them fighting fit. Why? So they're able to support the team effort, to support their co-workers. So basically, physicians in that situation have to be encouraged to reach out for help. When they feel that their objectivity has been compromised, they must be encouraged to reach out. 

At the end of my mission, I asked to be relieved of my duties. Not so much because I was a threat, but really, because I didn't have the necessary objectivity to continue to command. I realized my objectivity had been compromised. 

Leaders must be sensitive to that. And they must take action. But also, individual physicians. Individuals must really be constantly monitored. So that leaders realize, in fact, that doctors are going through ethical dilemmas. And that they're trying to self-destruct by working harder and harder literally. 

Dr. Jillian Horton:  

General, before we finish, is there anything else you'd like to say directly to physicians and health care workers in Canada? 

General Roméo Dallaire: 

Well, at the outset, I think physicians have to recognize that they want to have everything they need to do their mission, to do their job. Secondly, they'll have to recognize that they're working in a country at war. And what they're doing will have an impact on all Canadians. So they have to be able to continue to do their job, to make things better for Canadians. 

So they have a huge responsibility. But they have a huge asset as well-- professional instinct, gut feeling. They're professional Canadians working. And they have to follow their gut feeling. That's very, very important I think. That gut feeling is vital. 

If physicians feel that they've lost the ability to quickly take the measure of a situation, I think it's time for them to take a break. So that they can rest and recover. It's the only way that medical professionals will be able to deal with the feelings of guilt that they'll have. 

They're bound to feel they haven't done enough, they could have done more. But basically, they're doing everything in their power to help. But the odds were quite simply against them. 

Dr. Jillian Horton:  

General Dallaire, I want to extend my deepest thanks and my gratitude both for your wisdom and your guiding hand and also your service to our country. 

Well, I remain focused on the time after the virus has been beaten back because that's when the wounds will surface. They will. And I hope to be of some use at that time. Thank you very much. Thank you to you. 

I'm Dr. Jillian Horton. Thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. And thank you for all that you do. I'll 

Building resilience in times of uncertainty

Length: 28:43

Dr. Ron Epstein

Grounding his work in academic theory, mindfulness expert Dr. Ron Epstein will explore how mindfulness practice can be used by physicians to manage stress and build resilience in times of uncertainty.

Read the show notes

Dr. Jillian Horton: 

Welcome to the COVID-19 physician learning series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. I'm a general internist, medical educator, writer, and podcaster, and I'm your host for this series. The clinical applications of mindfulness and patient care are well described, but there's also a significant body of work showing that health care providers can enhance both their quality of care and their quality of life by learning how to apply mindfulness for their own practice. 

Dr. Ron Epstein has been at the forefront of this topic for more than 20 years. With this session, it's our intention to provide you with a deeper understanding of how you may be able to employ mindfulness, to mitigate some of the stress and distress that you are undoubtedly experiencing in response to current events. Dr. Epstein is joining me today from the University of Rochester. Ron, thanks for taking the time to be with us today. 

Dr. Ron Epstein: 

It's really a pleasure. Good to see you, Jillian. 

Dr. Jillian Horton: 

You, too. Ron, just to begin, can you remind everyone of what we're talking about when we talk about mindfulness? 

Dr. Ron Epstein: 

We're talking about an attitude of mind, a purposeful attentiveness to things that are the most important, and all with the idea that you can actually regulate your own attention. You can regulate your reactivity to situations, pleasant ones and unpleasant ones. And it's a quality that we all have. But we can often cultivate a bit more of it. 

Dr. Jillian Horton: 

Some people will say that mindfulness right now is irrelevant. And I can just imagine, and I know you can too, colleagues saying these people are out to lunch, I don't need mindfulness, I need ventilators. I need PPE. So can you talk for a bit about why that kind of reaction misses the point of mindfulness and our need for other techniques for self-regulation, especially during times of crisis? 

Dr. Ron Epstein: 

I'm not going to debate the importance of having ventilators and supplies that keep us safe, but there are other ways of keeping ourselves safe and healthy and connected that are equally important. One is understanding what your own reactions are to a situation. You'd think that in a situation that's difficult, aversive, gut-wrenching, nauseating that you'd want to turn away from your feelings. 

But we all know that eventually our feelings catch up with us, and they direct our behavior in ways that may or may not be the kinds of reactions that we want to have to those circumstances. So mindfulness is a conscious and purposeful turning towards and examining being curious about and being present with those experiences of distress to the point that they can actually direct us to do the things that are in the best interests of our patients and best interests of ourselves. 

So why now? I think that we're all facing a tremendous amount of uncertainty. And in fact, we're even uncertain about how uncertain we should be. It's what's called epistemic uncertainty. A sarcastic uncertainty is the kind of uncertainty that you would have, for example, if you know that in a certain situation, 70% of people will benefit from a treatment and 30% don't. And you just wonder whether you're in the 70% or 30%. 

But with the current situation, we're in a situation of epistemic uncertainty. We just don't even know what the rules are, what the bounds are. And so trying to figure those things out through problem solving work only up to a certain point. And at a certain point, we have to recognize that there is going to be parts of this uncertainty that we just can't-- we can't get rid of, we can't put away. 

So in my view, a healthy reaction to that epistemic uncertainty is curiosity. It's an opening up. It's trying to understand, trying to see this exceptional patient that does well why is that happening. And it's only with a certain kind of openness that you can actually begin to see and appreciate and act on those observations. So we're not talking about the kind of mindfulness that we all think about sitting by a still pond, Lotus flowers, beautiful scenery, warm day. We're talking about the kind of mindfulness that during a cope or during an incubation or during assessing a patient who you know is not going to do well, and anticipating talking with that patient and their family. And so what is the attitude of mind that will be your best guide during those kinds of circumstances? That's what we're talking about. 

Dr. Jillian Horton: 

I wonder if we could talk about mindfulness and some of the literature around it. Can you talk about the evidence for its application in high stress medical environments? 

Dr. Ron Epstein: 

There is a little bit of evidence on mindfulness training, for example, of CPR teams, and showing that when you train teams to be more mindful, the outcomes are better, and also the communication among the teams seems to be improved. And we know that that resuscitation can often be quite chaotic. People don't always listen to each other. It's hard to know who's in charge. Information transfer often gets lost. So people are able to stop and pause before reacting and focusing collectively on that, which is most important. Then the outcomes, it would seem would be better. 

There's better evidence from other places outside of medicine. For example, among first responders and also in the military. And the military has really jumped on using mindfulness as a way of preventing irrational behavior in the face of extreme stress. So to not have repeat performances of some of the horrors of war and rather have teams or units or individuals be able to stop, take a breath, assess the situation, achieve a certain degree of focus, attentiveness, and calm, and presence before proceeding. 

It's not that this all takes a long time. When you practice mindfulness techniques, you can bring them to bear on situations that require very quick decisions. Surgeons know this. I mean, you have to cultivate a certain degree of mindfulness in order to deal with the unexpected in the operating room. And that's really the test of a good surgeon. I'm not a surgeon myself, but I do know that learning the technical skills, learning how to operate instruments and suture and those cuts are really only part of the picture. It's that moment to moment decision making that distinguishes a good surgeon from a great surgeon. I think it's the same thing that's true of us confronting the uncertainties during this current time that if we're able to step back understand our own thoughts and feelings a little bit more in touch with those, it allows us to listen to others better and act better in patient-- on patients' behalf. 

Dr. Jillian Horton: 

I want to talk for a few minutes about resilience. And we both know that resilience is sometimes a word that makes physicians and learners bristle because it's perceived as an accusation or problem with us that we're not strong enough to withstand a very challenging or stressful work environment. But there are other ways to look at resilience, and I wonder if you could talk about your definition of the word and why people shouldn't resist the concept of working even now to increase their own resilience. 

Dr. Ron Epstein: 

I'll start off by saying that by virtue of surviving organic chemistry, medical school residency, and whatever came after that, we all as physicians are intrinsically very resilient. And I would say that that's also true of nurses and other people who are on the front line of health care, social workers that resilience is just-- and we have that propensity. What I notice, though, is that there is kind of resilience in the short term getting through an acute crisis. And there's also this more long-term resilience of not letting the stresses of clinical care wear you down over time. 

So the short term resilience, I think, we generally do pretty well versus long-term resilience that concerns me more. Long-term meaning more than an hour or a day when things start going on for days or weeks. So resilience was an idea that was first developed by engineers. And you think about it the-- you're building a building and there's a strong wind, the building will actually bend a little bit, but what you want is for the building to actually restore itself to the shape that it was in previously. So it's a restoration to a previous stage of stability. But living organisms don't work that way. Living organisms are growing. They're always regenerating in a way. 

And so embedded in resilience is the necessity for growth. So if you were under a stress and just simply return to your previous resting state but didn't regenerate the cells in your body that were somehow damaged in the process, you wouldn't really be a resilient individual even though superficially things seem-- would seem to have gone back in balance. So although it may seem pollyannaish to say that in the midst of a crisis like what we're experiencing now, we all should experience some form of growth. In fact, if we didn't, we would start to crumble. So embedded in this idea of resilience is that it is to find those things that help us grow, and not just grow physically, but also emotionally and spiritually that the things that sustain us that help us increase our potential as humans. 

And I think in terms of mindfulness, that falls into four categories. One is attention. We want to grow our capacity to pay attention to the right things. Growing the ability to be curious, especially when situations are stressful, and we feel like shutting down. That capacity of opening up. So I'm a palliative care doctor and frequently deal with situations in which there's tremendous conflict within families or between families and clinicians. And it's so tempting to want to kind of shut that conflict down, and just speed up and to try to resolve things quickly. But in fact, if you slow down and listen, and don't act quite as quickly, often things actually resolve themselves more quickly. So that really has to do with opening up and being more curious. 

The third has to do with a beginner's mind, and especially important in situations that are unanticipated and novel so that if we're trying to apply situations from the 1918 flu pandemic to the 2020 of COVID pandemic, we're going to be right some of the time, but a lot of the time we won't be. Obviously technology has changed, but if we go back a decade and look at SARS and try to apply those sorts. So we need to actually have that ability to see the situation for what it is, which is something that's unique. And in fact, to see each human being is unique. So that's attentiveness, curiosity, beginner's mind. 

And the fourth thing is presence. And that's perhaps a bit harder to define, but we all know what it feels like when we are present with someone else. And we know what it's like when someone else is present with us. And in health care, that's always important, but especially important when things are so overwhelming that we just want to withdraw into ourselves. And there are lots of ways of being present, and some of them are pretty simple. 

So one thing that I've been doing since this all started is just making a point to call or email or text or send a brief message to a friend or colleague that I otherwise might not have. So it's creating a sense of virtual presence. It doesn't have to be an hour long Zoom session, it can be a two line text. And just that sense of connectedness with colleagues creates a sense of collective presence. 

With patients, the more complex and difficult the situation we find ourselves in, the more important it is to take 30 seconds or a minute or a minute and a half at the beginning of every encounter just to listen. Even though you might have an agenda, even though there might be some urgency, say, OK, what's going on with you? And just stop and listen. That has a few effects. One is it helps you be more attentive and curious and open to what's really novel about this situation. 

And the second thing is that the person you're with is actually feeling hurt, and we know that that will reduce their sympathetic activation. They will think it'll help them to listen to what you have to say. So just investing 30 seconds or a minute in the beginning. 

Another way to be present is to find ways of taking brief pauses during your day. By brief, I mean, two seconds or three seconds. So you've just finished up with one patient and you're going into the next cubicle to see the next patient, what do you do? Ron, we wash our hands. You draw your answer. But what do you do mentally during that time? 

So we know about cleansing your hands during that situation, but what do you do to be able to set aside what's just happened in the previous encounter so that you can actually listen and be present and best serve the needs of the next person? So something that I do habitually is just when I touch the doorknob, the door handle, I take a breath. I mentally set aside what's just happens. I don't suppress it. I know it's there. And then with that breath feel a sense of openness when I'm about to see the next patient. 

There's always a tendency to deny and minimize. And I guess the extreme of that would be to sugarcoat the situation. And especially now people see through that pretty easily. And I would ask-- and we all have that tendency. I kind of want to make things better, right? It's a human tendency. We don't want to see people suffer or want to anticipate seeing them suffer. But by sugar coating, it creates a sense of distrust and falseness because we all know that this is serious. 

Now you don't have to hang crepe and talk about doom and gloom. That's where the idea of beginner's mind comes in because when things are uncertain, especially in that situation of epistemic uncertainty, we don't know what's going to happen next. And whether that not knowing there's always hope. There's always room for optimism. And so it's just by confronting that catastrophe of the situation that we're in, it actually opens the space for real hope as opposed to pretend the situation is somewhat different. 

And the final thing that I'll say is that one of-- some of the best advice I've ever been given is never to worry alone. So don't worry alone. So when you're feeling afraid, and all of us are going to be feeling afraid. Afraid for ourselves, afraid for our families, afraid for our jobs, afraid of something. Two things, seek out connection with yourself. We are all resilient. We are all robust. We're all strong. And so seek out knowledge of that part of yourself. We've all dealt with adversity before. 

And then aside from seeking out connection with yourself, seek out connection with others. And think of those who nourish you. There are people who need you, and it's important to reach out to them. But at these moments when you're feeling very afraid, think about the people who nourish you the most. Again, it could be a two line text, it can be a brief phone call. It can be an email. It could be whatever. But just even establishing that bridge, that connection is important. 

Dr. Jillian Horton: 

Ron, you and your colleague, Mick Krasner, have been running mindfulness retreats for many years. And I've participated in them, and my experience was so transformative that I went on to train to teach with you. But it strikes me that in addition to mindfulness, one of the core restorative aspects of that experience was peer support. And can you talk about why peers and community have proven to be such an integral aspect of doctors learning mindfulness? 

Dr. Ron Epstein: 

As important as it is to be mindful, it's also difficult. Looking at the dark side of things, looking at your own difficulties being unflinching in your willingness to see situations as they are as opposed to how you like them to be is hard work. And part of the reason that people do this in communities and classes and in collectors as opposed to alone is because even if you're not necessarily talking about the struggles that you're having yourself, you know that other people are approaching the struggles they have with that same intention, that same sense of purpose, that same commitment to doing the right thing, to being compassionate, to being clear, but to being effective. 

And that's incredibly powerful. You can kind of feel it when you go into a room of people who share a common purpose. And when you leave that room, that sense of common purpose doesn't disappear. And now you need ways of maintaining connection around that. And now that we have so many ways of doing that, even though we have to be two meters away from one another, and sometimes have meetings at long distance, it's still possible to maintain that sense of connection. 

Dr. Jillian Horton: 

It's our goal in this series to leave listeners with things that they can deploy right now to improve their locus of control in this situation and their sense of well-being. So could we spend our last few minutes talking about active listening and how we can employ it in an online format? 

Dr. Ron Epstein: 

Well, I think the virtual presence that we created online is generally more powerful with those that we've actually had some kind of physical presence with. So I would say that there are really two categories of maintaining that sense of online connection. When it's with people that you-- Like example, I have a young grandchild, now three months old in Los Angeles. I have been there twice before the whole COVID thing happened. And doing Zoom or various other online platforms, the translation between the physical presence and emotional presence is much more possible. 

When they're with people you don't know, when it's a work meeting or with people you don't see very often, there are some few tricks, one, is don't talk for too long. Talk for 30 seconds or a minute, leave a space so that other people can talk because it's so much easier to tune out in an online format. It's so much easier to flip your screen so you're checking your email. And so making a conscious effort to be more interactive. 

It is possible to make eye contact. It's tricky because you have to look at the camera and not necessarily the face of the person that you're talking to, but periodically, glancing at the camera as if that were the face is another way of maintaining a sense of virtual connection. Trying to understand what the other person's intention is. So we get a lot from gesturing and posture, and we can see a little bit of that on screen, but it's not quite the same as if it's three dimensional. So trying to visually imagine. And I guess frequency and familiarity with the medium. So it feels kind of odd at first, and then after a while, it feels familiar. 

And then finally, know your saturation point. It's interesting because-- for me because the physical distance has actually made my connections with family and colleagues stronger. I'm actually communicating with colleagues more in depth than I would do in my everyday life when I'm rushing around doing other things. But I think there was one day when I had six straight hours of Zoom meetings, and I just couldn't-- I mean, six straight hours of in-person meetings is difficult enough, but I think that our tolerance for online formats is much just recognize. So now I schedule my meetings for 50 minutes rather than an hour so I actually have some breathing time in between. I think we'll all figure out our way through this. It's not the way we all wanted to have had to learn. But I do think it's a way of increasing social connectedness while physical distance is mandatory. 

Dr. Jillian Horton: 

And Ron, before we close today, could you talk about vagal activation and breathing and leave our listeners with something simple that they can do going forward starting today? 

Dr. Ron Epstein: 

Yeah, so I've mentioned two other simple things previously, one is what you do when you go from one room to the next, and what you do when you touch the door handle [INAUDIBLE] taking your breath. And then spending the first few minutes of any encounter listening. But the third thing I'd like to leave you with is just a brief breathing exercise. And we can actually control vagal tone. So this exercise has been one of many things of ways of actually helping you lower your own heart rate, lowering your oxygen to the end, lowering the speed of your thoughts so that you can actually not feeling quite so overwhelmed. And it's really simple. It just involves taking an in breath for a count of four, holding your breath for a count of four, and breathing out for a count of four. And then take a few normal breaths, and then do that again. 

And this is something that you can do while you're on rounds, while you're going about everything-- your everyday work. Doesn't have to be a particularly deep breath, but just consciously regulating a few breaths will actually lower your vagal tone. So you could do and try that now. So I can guide you through it. And then, again-- and just to see what it's like for you. 

So when you're ready to take an in breath. Do so counting to four, one two, three, four. Holding for four, one, two, three, four, and then exhale for four, one, two, three, four. And then taking a couple of normal breaths, and then at your own pace, doing it again. OK, and then maybe take a couple of other normal breaths, and a third time, one, two, three, four. Hold, one, two, three, four. Exhale, one, two, three, four. 

It sounds ridiculously so simple, but as with many, I see mindfulness as a practice. It's not just a thing. And so finding one thing that you can practice every day, and do it over and over again. It's like learning a piece of music. It's like learning to play tennis. It's like learning to be a good surgeon. It's the acquisition of habit. And if you practice a simple breathing exercise like this, you'll find that it comes back to you at the times when you're afraid of stress, the times when you are in a cold situation or some other acute situation. 

And you-- there are so much that you can't control in those situations. But you can control your response and your reaction to that situation. And if that response is to be more present, to be calmer, to be more available, to begin to see the novelty of that situation and that particular unique solutions of that situation requires, then your day will have been better than it would have otherwise been. 

Dr. Jillian Horton: 

Ron, I want to thank you so much for setting aside the time to spend with us today sharing your knowledge and experience. 

Dr. Ron Epstein: 

It's been a pleasure. Thank you.  

Dr. Jillian Horton: 

I'm Dr. Jillian Horton. And thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon. 

Keeping children safe

Length: 19:53

Dr. Jared Bullard

Dr. Jared Bullard, paediatrician and infectious disease expert, will share advice on discussing COVID-19 with children, reducing their anxiety, and tips on helping them safe and healthy.

Read the show notes

Dr. Jillian Horton: 

Hello, and welcome to the COVID-19 Physician Learning Series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton, a general internist, medical educator, writer, and podcaster. And I'm your host for this series. 

Many physicians will concur that family life is a balancing act at baseline. COVID-19 has thrown our usual routines into chaos. And not only are we working to care for patients under new conditions and trying to ensure we don't bring home a highly infectious disease, if we're parents, we're also supporting children through a physically and psychologically difficult time. 

Today I'm joined by Dr. Jared Bullard, a specialist in pediatric infectious diseases at the University of Manitoba. Dr. Bullard is also married to a hospital-based physician and is the father of two young children. Jared, thank you so much for making the time to join me today. 

Dr. Jared Bullard: 

No problem at all, my pleasure. 

Dr. Jillian Horton: 

Jared, children of all ages, even very young children are now aware of COVID-19. They're not in school or daycare. And they can't play with their friends. And for children of physicians, the older they are, the more they realize that their parents are in positions of special risk. Can you talk, first as a pediatrician and then, perhaps as a parent, about principles you would advise us to use when talking to kids about COVID-19? 

Dr. Jared Bullard: 

No, absolutely. I think this is a common concern that I've had as an infectious disease physician. When I think about COVID-19 and that risk of bringing something home to my family, absolutely. And as a pediatrician, certainly we've received training on how to talk to children at a bunch of different developmental ages, right, because what you say to a toddler or a preschool child is very different than what you would approach a teen with, right? 

And I would say at this point, I have seen some really good resources coming out of the Canadian Pediatric Society that give some guidance on how to talk to children specifically about COVID-19, but also give some guidance as to how to talk to them about disasters and how to kind of approach that because this is certainly completely unique in our lifetime. 

And what they're thinking about it I can imagine is challenging. And certainly there's many, many different factors that have to come into play. When I think about it, you really have to go with the appropriate developmental age. 

So I think that when you're talking about infants, they just really are a bit confused with the situation in general. But I don't think they're absorbing it the same way. I think that they realize that their parents or one of their parents is home a lot more than they would expect. And they're probably relishing the attention that they're getting. 

And I think that that does transfer a little bit when we get into our older children and the preschool age group as well. They have a little bit more understanding. And I think that they are more likely to pick up on the stress that their parents might have, whether that's a physician parent or any parent that you can imagine. So you really have to get a sense of how and where on the spectrum of understanding your child fits because one recipe is not going to work for all of them. 

And then, again, once you get into more of the school age children, they have a lot more understanding. And I think they're a lot more connected to the world in general. They're on-- they're are at the social media platforms or watching the news. They're hearing a lot of different conversations. 

And then teenagers, that's even the next level because they are intimately connected with all of their friends and their peer groups. And so they truly do appreciate that something is going on in an epic proportion. And then they also are having to deal with not having that in-person social connection with their friends to really hash things out. And they're also going through that emotional turmoil that's pretty typical in the adolescent years. 

So I said, it's really going to be a combination of one, know your own child and know how to approach them and second, to really appreciate that the question that they have, too, might be different than what you think they would want to know. 

Dr. Jillian Horton: 

I hear colleagues telling me that they can't sleep because of anxiety. So putting your clinical hat on and thinking again about children, how would you advise parents to support kids who are struggling with anxiety or manifesting appropriate reactive symptoms like a change in behavior? 

Dr. Jared Bullard: 

So I think it's finding out what exactly is causing them the anxiety. What is the root cause? And so I'd say that when it comes to physician parents, right, we're not always aware of what we're talking about in front of them at the dinner table because talking about all sorts of nasty things that are entertaining for us might translate into their head very differently, I think, than you would find parents-- or children of doctor-- or children of nonmedical parents, right? 

So you have to be aware that their fears are a little bit different. I mean, they have the exact same things that they're dealing with in terms of all the news and all the conversations going on with their friends. But in addition, they have this legitimate concern, I believe, that their parents are going to work every day. And they could be exposed to this. And I think that's a relatively fear. 

And certainly, like you said, I can appreciate that there are the physicians amongst us who have had trouble sleeping. And I was one of them, for sure, for the first two weeks, thinking about everything that had to be done and trying to shut off my mind. 

And so it's very important to kind of make sure you get to that root cause of what is causing their anxiety because it could be that they're really worried that you're going to go into the hospital or your clinic. And you're going to come back with this disease. 

And they're not necessarily thinking about their own safety, though they may be. They're more concerned that what happens if you get sick and how are you going to make sure that we're able to take care of you because kids often do think about how can they take care of their parents. 

And then they're also considering because they only hear the bad news on this high case fatality rate that, could you die from this? And I think that it's important to have a real and honest conversation with your child regardless of their age and trying to just make sure that you address those things. 

I mean, I can give examples of what my wife and I have done. OK, I mean, it's sort of a little bit different. My son for his grade for science project did a presentation on SARS coronavirus 2. He had a good resource, I guess, available to him. So certainly I think that there's a lot of background knowledge that he already had. And so he certainly had a fair amount of anxiety knowing that. 

But he also did appreciate that we were telling him, you know what? When we go to work, we are going to do everything we can to stay as safe as possible. We are going to make sure that we wash our hands carefully. We're going to make sure that when we're interacting with the patient, we're doing all of the things that we should, so putting on gloves, making sure we have gowns and goggles and a surgical mask, and those things. We said we're going to do that every day. 

And then my wife and I also talked about-- and made sure that we practiced-- and made sure they knew that we were practicing to remain as safe as possible. It's not unusual for some infectious disease to come into anybody's household. And we're no different. And it's something that we practice anyway, like usually when we have a norovirus infection in my house, I'm usually the last man standing because I'm probably the most careful. 

But it's important because it's what I do day in and day out. And I can appreciate that when you have a two physician family. It's not necessarily the same. So my wife and I actually went over like doffing and donning of PPE, practice that over and over until it's routine. And you don't even have to think about it. 

And then if you realized that you broke what you should be doing with PPE, stopping and performing hand hygiene are going to correct your step. So we talked about that. We went out of our way to order in special clothes. And we both have a set of surgical scrubs. And our kids know that. And we have as well a lab coat. We have our own goggles. And we've said that we're going to make sure we stay as safe as possible. 

We've also said that, you know what? When we come home, we take all of the clothes off. We wash them, throw them in the dryer. And we make sure that we also take those precautions to have a shower and clean up as best as we can. And even when we go out and it's not related to health care, we'll come home and immediately wash our hands. And they see that, right? And I think that reassures them a fair amount, too. 

In addition, the other thing that we've done for their anxiety is we've been a lot more cognizant of what we talked about at the dinner table and when we're doing just casual conversation. We make sure that we leave work at work as much as we can. And when we come home, we're as engaged as we possibly can with our kids and say, what was important in your day? What was good? What could we do different tomorrow? 

And kind of get them to be invested, too, in kind of the home process and normalize everything for them. So I said it's not straightforward. I think that this is something that we're going to be learning a lot more as we go forward, too, right? 

Dr. Jillian Horton: 

So, Jared, for anyone who wants to reinforce their skills of donning and doffing at home, recognizing that in different jurisdictions, depending on disease activity at that moment, the protocols may be different. Are there still overarching resources that you could direct people towards if they want to reinforce their skills of donning and doffing at home? And also, what does that look like for you? How have you conceptually broken that down to really master that and feel comfortable doing? 

Dr. Jared Bullard: 

Sure, I would say that it is important to look at the different jurisdictions in terms of what they're advising. And more often than not, you're going to find they draw on the same sort of resources. So here in Manitoba, I mentioned there is a shared health COVID website that actually goes over that. But like you said, it's really something that you have to conceptualize as well and something that you make a routine practice. 

So what my wife and I sat down and talked about in practice is really like once you have all of your gear off, you have to remember that the danger zone is your face, right? Any time that you are going to touch your face, you, well, one, should avoid it as much as you possibly can, which is easier said than done. 

I think that when you have goggles and a hairnet, which doesn't apply to me, or masks, et cetera, that you want to avoid manipulating those as much as possible because any time you have contamination on your hands, that's going to be an issue, right? 

So going through your workday, making sure that you minimize the contact of your face and head is going to be really important. When you are choosing to take the PPE off, one of the first steps is going to be making sure that you take your gloves off and proceed to remove your gown carefully. 

What I often suggest is that you kind of undo it from the back, making sure not to get anywhere near your face, bringing your hands around to the back on time and then hunching forward, so that this kind of falls off of you. And that way, you're trying to minimize any additional contact that might occur. Once that's happening, you've got yourself free from the gown. 

Performing hand hygiene is going to be important before you can leave the room typically of a patient that you're with. I often do a second step because I don't believe anybody is doing all the things they need to do. 

So I will wash my hands or perform a hand hygiene again. Before, I'm very cognizant of how I take off my goggles, making sure I don't reach for the center of my face, going on the side, leaning my head forward and taking the goggles off very carefully. 

And likewise with the mask, the same thing, making sure I'm not grabbing from the center, leaning forward and taking off of the elastic band, so that everything is kind of falling forward. If you lift your head or keep it up, it's probably not quite as ideal. And then I perform hand hygiene one more time just because it's an important thing to do. 

In addition, what we talked about was our phones. Our phones are filthy. Like if you're-- the best thing to do is try to not even touch your phone during the day if that's possible and at the end of each day, wiping them down. You can find any number of different products in most hospitals and clinics where you would wipe down your stethoscope on a routine basis. That will work just as well for your phone, too. 

So I'd say that those are kind of the key steps. And, again, it's practice. It's the more you do it and the more consistently you do it, the better your family is going to be. 

Dr. Jillian Horton: 

Jared, just to switch gears for a moment, for anyone who doesn't have family providing child care, which, of course, isn't perfect either unless it is in a truly closed loop, what can you say about the fear that many people have of putting their children in emergency daycare or child care with the children of other healthcare workers? Help us walk through the level of risk that you perceive there and how we should be asking those care providers to mitigate it. 

Dr. Jared Bullard: 

So that's a very good question. I think that my wife and I have had the luxury of having a long standing nanny dedicated to us. And we trust her that she really is just going to be going home and then coming to stay at our house and provide child care. But certainly not everybody has that. And I completely appreciate that. 

I mean, you have to consider to some degree that we, as a society, have to be responsible for each other, right? And I think that most people are getting the message in general when they are social distancing. And they're trying to avoid going out of the home as much as possible. I think that applies to daycare workers as well. I think that you have to find someone that you trust. And certainly there are a variety of options. 

Like you mentioned, there are daycare providers who are provided specifically for healthcare workers. In addition, I know there's a number of medical students throughout the country who have been looking for all sorts of excuses to do really good work. And they have included child care. And so I think that, again, you have these people who are very dedicated to helping physicians do the work they need to do. 

It's also important to go over the exact same thing with those child care providers. So our nanny-- we have gone over that it's important that when you go out, when you come back, first thing, you wash your hands. And that she has a bottle of hand sanitizer that she also uses before she gets into the car. 

So it's going to be kind of those common sense approaches and just making sure that we look out for each other because I think that's going to be important. But I appreciate fully. And it's hard to trust people with your children. That's your most important investment. But finding that person you can trust is essential. 

Dr. Jillian Horton: 

Jared, another question for you. Many people are weighing the pros and cons of self-isolating in the absence of a clear indication to do so, so for example, exposure to a known case of COVID-19 in the hospital. I know of many physicians, and I'm sure you do as well, who just by nature of providing face-to-face care with patients have made a decision to self-isolate within their homes. 

Can you share your thoughts on that? How necessary is it? And what should that look like if people are going to undertake that kind of isolation in the absence of an exposure or illness? 

Dr. Jared Bullard: 

I think everybody has an abundance of caution, right? They do not want their family to get this. And I think they're very concerned about it. In the absence of knowing that you were exposed to someone with COVID-19 or any infectious disease, to self-isolate doesn't make a lot of sense necessarily, right? 

I think that what would end up happening especially if you have children is they would appreciate that. And I think they need to have their parents at home and freely available. That being said, it is prudent. And if you are exposed to someone who is known to have COVID-19 and you think that there is some sort of breach or concern, yeah, maybe it's important to consider that isolation, but day-to-day practice where it's very low risk, probably not required. 

I mean, again, it's something that my wife and I have talked about. That in the event we are exposed to someone with COVID-19 or we developed symptoms, I think we've come up with a plan as to one of us basically staying in the bedroom the entire time and having the other provide any support that we can, at the same time, making sure that we don't ignore our children using FaceTime within the same house, which is somewhat ridiculous. 

But still it provides that contact time that I think they really need while minimizing the risk to them. But by and large, I'd say the vast majority of clinicians probably are not going to have that high risk COVID-19 exposure that you would expect in an ICU, emergency or maybe OR setting. 

Page Break 

Dr. Jillian Horton: 

Well, Jared, my last question for you today. 

Dr. Jared Bullard: 


Dr. Jillian Horton: 

Kids are naturally pretty resilient. And we talked a lot about the apex of the COVID curve. But what about the coping curve, parents whose kids are struggling right now in the absence of underlying behavioral or medical challenges? What's your prediction for what the next phase of this looks like for families? When do kids begin to settle into this? 

Dr. Jared Bullard: 

I think one of the things that drew me to pediatrics was exactly that children are so incredibly adaptable. And they're very plastic. And they become used to changes so much faster than you or I do. And it's admirable. I wish I were more like them. 

I think that what it's going to come down to is that schedule and routine. Children really do need that in their life. And that doesn't matter what age they are, right? As long as they kind of have that go to routine and that they do it day in and day out, I think that they'll adapt to this. 

And they'll kind of appreciate that, you know what? This is temporary. But, at least, I know this is going to be my day for the most part. And they can kind of look forward to that. It's important that we make sure that we reinforce that sort of scheduling with them and say, it's important to do your schoolwork. You're going to have to get up at the same time. You're going to have to make time to have fun, right, not too much fun, not too much screen time, but enough. 

And then make sure, too, that they've got that family time at the end of the day because it's going to be good for them. And most importantly, it's going to be good for you as a practicing physician. You're going to get the bond and get some perspective. And then also have them involved in making that routine, right? The more invested they are, the more likely they are to follow it and more in control they're going to ultimately feel with the whole process. 

Dr. Jillian Horton: 

Well. I want to end by thanking you, Jared, for helping walk us through these conversations and the practical issues that many of us are having with the children in our lives. 

Dr. Jared Bullard: 

Oh, you're very welcome. My pleasure. 

Dr. Jillian Horton: 

I'm Dr. Jillian Horton. Thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon. 

Preparing for the unknown: mental readiness lessons from the military

Length: 23:27

Dr. Stephanie Smith

Building on her crisis care experience in the Canadian Forces, resident Dr. Stephanie Smith will explain the mental readiness model she learned in the military, and how it can be used to manage the stressors facing physicians today. 

Read the show notes

Dr. Jillian Horton: 

Hello, and welcome to the COVID-19 physician learning series brought to you by Joule and the Canadian Medical Association. I am Dr. Jillian Horton, a general internist, writer, and podcast, and I'm the host of this series. We know that COVID-19 is pushing many physicians into the unknown. Working in new ways, under extreme pressure, against a virus that we have never seen before. 

Today we're going to take a page from the Canadian military and learn how its program to plan and prepare for the unknown can help reduce the stress of crisis care. Joining me is Dr. Stephanie Smith, a resident doctor in Calgary with personal experience in crisis care. 

Before medical school, she spent more than a decade as a critical care nursing officer in the Canadian armed forces, serving two deployments in Afghanistan and one in the Philippines following Typhoon Haiyan. Stephanie, thank you very much for joining me today. 

Dr. Stephanie Smith: 

Thank you very much, Dr. Horton. It's a pleasure to be here. 

Dr. Jillian Horton: 

So you have just started your residency. And I actually can't imagine a more challenging time to be entering this profession. What are you hearing from your fellow residents about coping during COVID-19? 

Dr. Stephanie Smith: 

That's a really good question, Dr. Horton, and it certainly has been impacting residents as it has been impacting many health care providers. I would say some of the stresses that have been impacting residents have been related to the unknown not knowing if they will get the clinical placements, they need to be prepared when they're going to be finished residency and going into practice, and concerns about when exams will be written. 

And also some stresses related to the finances associated with the situation as many others are going through when your children can't be in school, and you need to get a daycare or a nanny to help look after your children and adds a financial burden. And certainly, residents are in a unique situation where they are impacted by this like many others, but there is a bit different unknown for sure. 

So I think that the residency programs are trying their best to help keep us informed. I know my residency program is offering wellness sessions every week to make sure we have the opportunity to talk about what our concerns are. We also have opportunities to talk with our program director to let them know our concerns from a clinical competency standpoint. 

We understand there are challenges, and there are certain things that need to be done to both keep patients safe and to keep residents safe, but certainly, that does impact our day to day function from what it was only six weeks ago. So I think we've been doing a lot of collaboration with one another to really help support each other, and we know we're all in this journey together. But it certainly has been an adventure, to say the least. 

Dr. Jillian Horton: 

So I wonder if we could talk for a minute about how your previous training and your deployments in the Canadian Forces prepare you for what we are dealing with here today? 

Dr. Stephanie Smith: 

I would say that my experiences in the military have taught me to be comfortable with being uncomfortable. And often, I've been in situations where we have had limited resources. We've had limited individuals or clinicians available to provide the care. There's been a lot of unpredictability with the patient injuries that we would see, the volume of patients that we might see, and often there's a lot of responsibility for collaboration with New individuals that you might not have worked with in the past. 

So I think it taught me that you have the opportunity to really pull together and try to make the best of a really challenging situation, recognizing that everybody is also going through the struggles, but it's better to do it together and work together as a team. I would say my experiences on deployments have taught me that the camaraderie and the teamwork is certainly something that I really value from my experiences with the military. 

But it's also something that I see day to day working the health care field. So I think that ability to continue working together and recognizing that if we work together, this will be better to get through it than getting it done on your own. 

Dr. Jillian Horton: 

In medical school, you worked to take a model that was developed by the military called STRIVE, and you adapted it for medical school training. Can you talk a bit about why this model is so valuable to medical students? 

Dr. Stephanie Smith: 

I think that the program is really valuable because when I got to medical school, I realized that medical students were being exposed to some pretty traumatic events very early on, and I think it was unique to my experiences I had as a nursing student in the past because I wasn't expected to shadow as a new nursing student, but as a medical student, I'm trying to find out what specialty I want to work on or apply for in residency. 

So very early on, people are trying to get exposure in a variety of areas. And often with very little understanding of what that clinical experience might be like. So many of my peers in medical school would come to me and talked to me about their traumatic events, maybe experiencing death for the first time or witnessing something very traumatic from an injury and just trying to figure out how to process that. 

And so I found taking my experiences from the military and understanding that I was never 100% prepared for what I had to deal with, but I found my chain of command and the leadership always said that they were there to help prepare us the best that they could, and to give us the resources that would help us through that journey. 

And the military had provided me with resiliency training based on the road to mental readiness program. And so taking that model and bringing it to medical school through STRIVE really allowed me to take the experience I had from the military and help my peers work through those challenging events, give them an opportunity to be exposed in a simulated experience, where they could experience those emotions and learn how they would deal with them, and potentially talk about what they were feeling, and also develop a plan of action to help manage what they were going through. So I saw it as an opportunity to give back a little bit of the skills I had learned along my journey in the military. 

Dr. Jillian Horton:  

So the model itself has some key elements, and they are referred to as the big 4 plus. So I wonder if you could walk me through them one at a time. And maybe we could start with box breathing. 

Dr. Stephanie Smith: 

Sure. So box breathing or arousal control, sometimes, is another word used for this. I find is a really easy one for people to use. It's something that many of us are taught by our parents when we're younger, when we feel really overwhelmed, we're told to take a nice deep breath in and to calm down, and it can be very helpful. 

With box breathing, in particular, it uses a cycle of four where you take a nice deep breath in for four seconds, then you hold that breath in for four seconds, then you breathe out for four seconds, and then you hold the breath out for four seconds. And the goal is that you will do that four cycles in a minute, and so 16 seconds a cycle. And then ideally you do that for two to four minutes. 

And what that can do is really help calm down our sympathetic nervous system. When we get that flight or flight response, we're feeling anxious or overwhelmed by the environment we might be in, whether it's a direct clinical experience in the moment or just the overwhelming situation as a whole. 

Having that ability to take some deep breaths and actively bring down our heart rate, calm us down, and our breathing rate can be really therapeutic. And I find that this is something that's very easy to do regardless of the setting and it doesn't take a lot of concentration and I also find it really good to help us fall asleep at night. So it's a bonus as well. 

Dr. Jillian Horton: 

And how about now if we move on to goal setting and to talking about that? 

Dr. Stephanie Smith: 

I really like the goal setting portion because it can be broken down into two different ways. So there can be the smart acronyms so the specific, measurable, attainable, realistic, and timely goals that can be developed, which many people are familiar with. And you can use those for big picture goals on how you're going to make it through this challenging time and thinking about what things are going to look like in the future. Or you can use another acronym that's called win, what's important now. 

And they find that it's very easy to use in thse clinical environments when we know a patient's coming in. And we're anxiously preparing for that if they're significantly injured or, in the case of COVID, not really knowing what that experience will look like and how others are going to respond. Having the ability to really narrow in on what is most important and then trying to take away all the external things that really don't have any bearing on what really needs to be achieved. 

So whether it is a short term or an immediate goal that you want to take on or a long-term plan, I think goal setting is something we do day to day. In a way, it's even a mental checklist that's often something we've developed over time to achieve a task that we do regularly, but we might not even know that we're doing it. So I think the more you practice doing that skill, the easier it is to implement it in practice. 

Dr. Jillian Horton: 

And perhaps now we could talk about visualization. How do you employ that? 

Dr. Stephanie Smith: 

Well, Dr. Horton, I would say that visualization is probably one of my favorite of the big 4 plus, and as a competitive athlete, this is something that I have used many times in preparing myself to achieve the task. And, for example, in a triathlon, where I can think through every specific task that I have to do and how it's going to feel. And that's easily reproducible, specifically when you're going through a process in the health care environment. 

So if I wanted to visualize a patient coming into the emergency departments and then them having symptoms that I was suspecting could be COVID related. How would the team respond? How would we activate that? What would that look like? What would that feel like for me? And how would I respond to that? And I think visualization is a really great skill that you can use going through everything going well. 

But then the more comfortable you get doing visualization, you can challenge your brain to take different routes and going through it not working out optimally, and then how do you troubleshoot that challenge so that you can get back on the right track to have the positive outcome. 

We know in health care, we don't always have positive outcomes. But having the chance to go through those experiences in advance and being able to walk through, talk through those things and imagining how you might respond or helping yourself learn the best way that you could respond, I think gives a bit of peace of mind to help you prepare for those types of things in the future. 

Dr. Jillian Horton: 

And as we move our way through the elements of the program, I wonder if you could bundle up self-talk and attention control and talk about both of those? 

Dr. Stephanie Smith: 

If there was one more that was my favorite, it would be self-talk, as we can say many things to ourselves in our heads about the challenges that are coming our way. And maybe we don't think we're prepared enough or capable of taking on the challenge in the moment, and it's easy to really talk ourselves out of it. But I think really focusing on a positive mantra one for me has been, you are so enough, something my father taught me. 

And saying that can get me back on cue and remind me that I can accomplish what I need to do. Maybe I don't have the training or the skills that I wish I had or maybe have been exposed to this more, but given this situation, if I say to myself positively, you can get through this, I'm more likely to have a better experience and more likely to get through it feeling that I've done the best that I can. 

And then using that with attention control, we have very challenging environments in the clinical setting, we have our internal monologue, which I just mentioned and many natural characteristics that impact us and even how our bodies feeling, I'm I tired, sleep deprived, hungry, do I need to go to the bathroom? All these internal things are impacting me and my ability to maintain my focus. 

But then there's the external factors as well. How upset is the patient or the family that I'm dealing with at the time? Is it very loud? Is the lighting not easy to see the technique that I'm doing? Is the environment I'm working in safe? Am I concern that I might potentially be exposed to a pathogen that could get me sick or my family sick? 

So I think the importance of attention control is recognizing there are all these competing demands that impact my ability to maintain my attention. So being able to recognize those different factors can allow me to have a sense of control, and recognize which of the factors I have the ability to change, and then recognize which ones I don't have the ability to change so that I can then take that off my plate and recognize I can do the best with the things that I control. 

And often, we have to shift from a very focused perspective. And then do a specific skill. And then sometimes we need to take a step back and see the big picture and evaluate how multiple patients are being evaluated. So attention control takes a few different domains of you being able to adapt in the different environments that you're exposed to, depending on the expectation of the situation. 

Dre Jillian Horton 

And then I think there's one final element of the program that we haven't come to yet, which is progressive muscle relaxation. 

Dr. Stephanie Smith: 

So this a specific skill, in addition, to attention control, were the two newest to the big 4 plus. They are the pluses. And the progressive muscular relaxation allows us to recognize what tension feels like in our bodies. So when we're getting stressed, our body might manifest in a way of bringing on that tension. So if we can practice the skill in advance, we can recognize that our body is feeling stressed and use some of the other queues we've already discussed today to help you work through and manage that stress. 

So a really simple way to do it is even just grabbing your hands and squeezing them really tightly for five or 10 seconds. You can even look at the color change in your hands, and then relax, and then looking at your hands and seeing as the color changes and comes back. You can then go through your arms, your chest, down through your legs, and you can use this just to recognize. That's what it feels like to have tension for me. 

Many people will experience tension in their upper body and their shoulders, but some people will feel it in other locations. So doing a body scan by doing the muscle contraction for 5 to 10 seconds, and then a release where I actually feel like a release the catecholamines response and a flush that happens, this can be very therapeutic when you're doing it outside of a stressful event, but it really does help recognize our body's response in those types of events and allows us to be able to respond in a more positive way. 

Dr. Jillian Horton: 

Both in terms of the literature and your own experience, are some of these techniques more useful in crisis situations than others? 

Dr. Stephanie Smith: 

I think to best answer that question. It has to do with which ones connect with you the best? We all are going to be drawn to some-- more than others. We'll find them easier to remember or easier to utilize. I think for me, it's very easy to do deep breathing and positive self talk on the fly because I notice my breathing go up, or I notice my handshake or my heart starting to beat faster. 

So then saying, OK, take a couple of deep breaths and try to calm yourself down. I'm easily cued. And also the self talk if I recognize myself saying, Oh, no, I don't know if I'm ready for this situation. It's a lot easier to cue myself to do those things. I think for some people, visualization is a skill they use on the flight every time they're going to go in and do a specific skill set. I've met surgeons that say, when they're scrubbing, that's their time to do visualization as they prepare for the case they're going to encounter. 

So I think a big thing is practicing all of them, seeing which ones resonate best for you, and then trying those out, and recognizing that others might like different ones more than you do, but I don't think there is a right or wrong answer. I think it's really about what connects best with you and makes you feel is most beneficial. 

Dr. Jillian Horton: 

So we both know that there's a difference between theory and practice. How do you think that individuals can best ensure that they're able to deploy these techniques when they need them the most? 

Dr. Stephanie Smith: 

That's a really good question, Dr. Horton, and it's actually come up in the many times that I've taught this course in the past. People have said things like having on their name tag. Putting little cue notes can be there, like take a deep breath. Or that positive mantra I had mentioned earlier, it's just do it, or something a smiley face on-- on the back of their name tag can be helpful. 

I think practicing it more regularly will make it easier to pull on the skills in the moment, but I also think if the culture itself is supportive of doing these types of things, it will become more natural. So if the team says is there preparing to transfer a patient, if they were a code team or respond to a code, for example. 

If the team says to each other, everybody just take a nice deep breath, remember that we're going to do the best that we can do, and just think through in the next couple of minutes while we're getting prepared, the positive response that's going to happen. 

Maybe even make some specific goals of what you want to accomplish during that time, and then remember that doesn't matter what's going on in your life right now, anything else in your head, just try to put it to the side and focus in on the job that needs to be done. And I think having those cue statements can really help us in the moment because as we know, many other things are happening as we're feeling overwhelmed. 

It strikes me that in the military, it was probably an advantage that everyone had this training. So what advice do you have for physicians who are trained to use these types of techniques when the people around them don't necessarily have the same skills. 

I think the military has done a great job at teaching me how to manage my own personal stress response. And I don't think there is one perfect solution, but I do think we all need to develop a tool kit of skills. And many other people might use a different approach to managing their stress. I know we can all think of that one person that's always cool as a cucumber in a stressful event, and we often think, how are they doing this so well? 

And afterwards, they might say, you have no idea how stressed I seemed inside, but I have an ability to show on the outside that I'm managing this well. I don't think there is one perfect approach, but I do think what the military has taught me is that we have to have some approach. You have to talk about the realities of what you're going to be experiencing. 

You need to sometimes even talk about the worst case scenario, maybe not even the probable scenario, but just thinking through if it got really bad, how would we handle this? So that you can feel safely prepared in the process. I think creating that environment where everybody has an approach to deal with stress and supporting people in that role is really important, especially from a leadership side. That's something the military has taught me that you can't prepare everybody the same way. 

You can have a general approach to do this, and that's something the military has tried but by implementing the road to mental readiness training and resiliency training within our basic training now, something that I actually didn't have initially in the military and did get later on. I've since learned that it's such a helpful strategy to get through the challenging times. 

There are many things I've been asked to do that I have absolutely no technical skills in doing, like develop a rope bridge. That's not something I have technical skills in, but when you're given the task, and the military gives you a timeline to achieve it, and they're evaluating you, you have to try your best, so having skills that can help you work through a challenging situation, regardless of the resources that you might have at hand. 

I think just having that mental fortitude and that ability to recognize that you might not always have the experience, but you will have the support. And I think that is something that helps people sleep at night knowing that they're doing the best that they can and that it is the responsibility of the organizations working to really loyally support us and prepare us the best they can for the jobs that we have to do. 

Dr. Jillian Horton: 

Well, I want to thank you for spending time with us today, sharing your knowledge and experience with crisis care, and providing such an excellent roadmap to the STRIVE technique. 

Dr. Stephanie Smith: 

Thank you very much for the opportunity, Dr. Horton. It's a pleasure to do this today, and I'm hopeful that the things that I've discussed today will bring some positive light towards individuals going through challenging times right now and just knowing that we're all in this together, and we're all having to be comfortable with being uncomfortable, thank you. 

Dr. Jillian Horton: 

I'm Dr. Jillian Horton. This has been a webinar in the COVID-19 learning series powered by Joule. Take care of yourselves, and I'll see you again soon.

Compassionate leadership in times of crisis

Length: 17:01

Michael West

COVID-19 has upended health systems around the world. Organizational psychologist Michael West will explain the principles of compassionate leadership, and how medical leaders can use this model to overcome some of the hurdles they’re facing.

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Dr. Jillian Horton: 

Welcome to the COVID-19 physician learning series, brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. A general internist, writer, and podcast, and I'm your host. Over the past few weeks, COVID-19 has upended health care systems around the world. Today, we're going to explore how compassionate leadership can help organizations overcome some of the hurdles they're facing and tap into the strengths of their staff. 
Joining me is Michael West, a professor of organizational psychology at Lancaster University management school and a senior visiting fellow at the King's fund in London. He spent 30 years focusing on organizational culture and leadership and worked directly with a number of health agencies to develop compassionate leadership models. Michael, thank you so much for joining me today. 
Michael West: 

It's a pleasure to be with you Jill. Thank you. 
Dr. Jillian Horton: 

Before we talk about your actual work, can we just talk for a moment about how you became interested in this particular field? 
Michael West: 

I was always very interested in how teams and organizations can function most effectively. I did my PhD when I was in my 20s on the psychology of meditation. And in the middle of that work, I ran out of money. And I was living in Wales at the time when I went and worked in a coal mine for a year as a laborer. And I was astonished by how important the team that you worked with was in terms of your safety and your well-being. 
So I became very interested in teams and organizations and how they functioned, and how their structures and processes affected performance, and safety, and the well-being of people at work. And so, my research took me into health care organizations back in the 1980s, and I have been fascinated by the functioning of health care teams and organizations and deeply impressed and inspired by the work of health care professionals ever since. 
Dr. Jillian Horton:  

The stresses on the health care system are immense right now. Now you're in the United Kingdom, what are you hearing from health care leaders there about the challenges that they are facing. 
Michael West:  

So, of course, these are completely unprecedented times, and the challenges are enormous. I think that there are four that I keep hearing from health care leaders. The first is staff shortages. When we started in the middle of this pandemic, we were already in England 100,000 staff short in our health care system, that's [INAUDIBLE] staff were missing, and now we have staff shortages because of COVID. Staff who are unwell, staffing-- staff who having to self isolate. 

So that's added to the burden on our staff already under huge pressure and under more stress than they have ever happened in the history of our health service since 1948. Secondly, there has been an enormous problem of access to personal protective equipment. The demand for PPE has gone up 5,000% in the last five weeks. 

So staff are being asked to work in conditions that are frankly terrifying at times and very upsetting and discomforting for everybody involved in health services. That is the problem of testing for staff. Our testing regime in England has not been prepared for a pandemic like this. So many staff are not able to get tests or having to travel very long distance to get tests, to see whether they're positive for COVID-19. 
And fourth is the importance then of helping those we lead by removing obstacles to them doing their jobs effectively or acquiring the resources. So 
Utilizing their knowledge, their skills, their abilities, their motivations to be compassionate and caring so that we manage in these unprecedented situations, and we manage those particular challenges 
Dr. Jillian Horton: 

You've used the ABC acronym to describe the elements of compassionate leadership. So their autonomy, and control, belonging, and competence. Can you take us through each of those three elements? 
Michael West: 

So if we're to lead effectively, the best of times, let alone in a situation like this, then our leaders must understand what are the needs of those they need in the workplace. And we have an abundance of research that tells us there are three core needs that people have to maintain their well being at work and to maintain their motivation. And they are the ABCs of people's needs. 
The first is the need for autonomy and control. That doesn't mean that people need to be independent and do whatever they want in the workplace. It means that they need to feel they have a voice and insurance that they can influence how the work that they need to do is done. That they're not simply being coerced and directed, and that they have some degree of control and that extends to control not just about how their work is done, but very simple things like having access to hot food on night shifts, to having places to rest being able to go and get a drink when they need to. 
Things very basic control factors within our work environments. And belonging, the importance of belonging is about feeling that we're part of a team where those we work with care for us. We care for them. Seeing that we work in an organization, which is part of a larger caring home where the culture is one of compassion, after all, the core value of health care staff is compassion. 
So they want to feel that they work in organizations where that value is shared by those who lead them. And the third is the importance of the sense of competence in the workplace. I need to be able to feel I do-- I can do my job well in the context of health care that I can provide, the quality of care that I need to provide. 
And that means ensuring that obstacles that get in the way of me doing my work are removed, that I'm not dealing with a chronic excessive workload, which undermines my ability to provide the quality of care that I want to provide, and also diminishes my own ability to work in a way that ensures I don't make major errors and to ensure also that I'm getting the training that I need to do my job effectively. 
So in the context of the pandemic of COVID-19, it's making sure that in these really unprecedented situations, staff feel they have voice and control. They have a huge workload. And we know that a deeply toxic combination is a high workload and a very low sense of control. So it's vital that we're hearing the voices of our skilled, motivated staff in helping to solve the problems that face us, staff are afraid, and we manage fear to a great extent by being connected with others who care for us by a sense of belonging. 
So building effective teams where people feel supported, where they feel listened to, where they feel that they can voice their problems, their concerns, their difficult feelings makes a huge difference to that. And in terms of competence, the most and I talked about four factors, or four behaviors of compassionate leadership, listening, attending, understanding, empathizing, and helping. 
We know the most important skill of a leader is listening, and the most important task of a leader is helping people to do their jobs effectively. In other words, helping them to feel competent so they don't have a profound sense of moral distress. And not being able to provide the care they wish to provide. 
The example I gave earlier of the ICU nurse facing so many deaths, it's absolutely vital that we are focused on the core needs of the people who are working in health care. And we're providing that compassionate leadership as a supportive context in these enormously challenging times. 
Dr. Jillian Horton: 

Michael, are there some other practical ways that leaders can put the principles of compassionate leadership into action right now? 
Michael West: 

So I think one of the really important insights leaders should have is that we know that in crises-- research from other sectors and at other times has told us that in crises, leaders tend to revert to a threat rigidity mode of leadership, which is very much focused on directing people, Command, and control and it's therefore important that leaders make sure that they are not slipping into that. 
They're taking the time to listen to those they need, to understand the challenges they're facing to feel for them, difficult as that is, and then to help them. It's also I think really important that leaders exercise self compassion because in order for them to have the resilience and the ability to be compassionate. 
It's really important that they take care of themselves too, and that's about paying attention to ourselves, understanding the challenges we face in our work at this time-- empathizing with ourselves, caring for ourselves, and then taking intelligent action to help ourselves, in order that we can be the best leaders we can be and provide the support that health care staff need at this time. 
Dr. Jillian Horton: 

Michael, health care is often understood as having a very specific culture. And as we both know historically, it has sometimes been a culture that has pitted itself against compassionate care and leadership. So for organizations that don't make that pivot to compassionate leadership now, what do you think lies ahead of them both during and after the pandemic? 
Michael West: 

It would be a tragedy, if this time, organizations didn't value that that core commitment to compassion. Compassion is the most powerful intervention that we know of in health care. And compassion is the core value of virtually all our health care staff. And the role of leaders in organizations is to embody the values of organizations and ensure a fit between those values and the values of staff. 
So when staff feel our organizations are not sharing their values, of course, it creates a sense of dissonance of lack of commitment, of lack of connection. At this time, there is so much fear and uncertainty amongst our population at large and amongst our staff. And those four behaviors, which we know from decades of leadership, research are the most important leadership behaviors regardless of whether you label them compassionate leadership or not. 
They are the most important behaviors in ensuring effective leadership. If we want to respond effectively to this crisis, if we want our staff to be at their most effective, if we want them to have the highest levels of well-being possible during this time, then those four behaviors of compassionate leadership are absolutely fundamental. 
And it's not just our health care organizations but our countries as a whole. There is a loud background hum of anxiety, of fear amongst our populations. The most important institution in our country right now is our health care system. And we see that globally. We see the outpouring of relief from the population of gratitude of honoring those staff. 
And it's vital, therefore, we create compassionate cultures that enable staff to deliver compassionate care because health care staff constitute probably something like one in 20 of the working population in most countries. If they're experiencing compassion in their cultures and in their leaders, they will practice compassion in their treatment of patients. They will take that compassion back out into their communities and reinforce. 
I think the collective commitment to compassion and the gratitude of the population. We have to honor what our health care staff have sacrificed, what they've committed to. What they have been doing during this period, not just now but in the way that we manage and organize our health care services in the future, the level of innovation that we've seen in health care as a result of the actions of staff at the front line has been astounding in our country. 
The level of commitment the level of courage and the sacrifice, and we have to honor that not just during this time, but after we get through this pandemic and we create new institutions that are appropriate homes for these people who have made such sacrifices and saved so many lives and inspired us all. 
Dr. Jillian Horton: 

Well, I'd like to end this session by thanking you, Michael, for your time and your insights into compassionate leadership. You've offered a very important window into a particular way that health care can harness this moment for change as well. 
Michael West: 

A pleasure and a privilege for me Jill. Thank you. 
Dr. Jillian Horton: 

I'm Dr. Jillian Horton. Thank you for joining me for this COVID-19 webinar brought to you by the CMA and powered by Joule. Take care of yourselves, and I'll see you again soon. 

Taking stock during times of high stress: identifying risk factors and red flags

Length: 27:46

Dr. Michael Kaufmann

In times of high stress, it can be difficult to remember what “normal” feels like. A specialist in addiction medicine and physician wellness, Dr. Michael Kaufmann shares strategies for recognizing our own vulnerability, red flags and risk factors and when they can lead to problematic behaviours.   

Read the show notes

Dr. Jillian Horton: 

Hello, and welcome to the COVID-19 physician learning series, brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton, a general internist, writer, and podcaster, and I'm your host for this series. It's been more than 13 weeks since this pandemic began. And for health care professionals, this has meant either a long period of intense demand or quiet but prolonged uncertainty about what will happen next in our clinical lives. And it can often be hard to remember right now what normal even feels like. This can make it hard to recognize our own risk factors or vulnerabilities, and as a result, those who have overcome addictions or particular behavioral challenges may find that they are struggling again. 

Joining me to talk about how to take stock in times of high stress is Dr. Michael Kaufmann, a specialist in addiction, medicine, and physician wellness. He spent more than two decades as the founding director of the Physician Health Program at the Ontario Medical Association, and is currently the physician wellness director at William Osler Health System. Michael, thank you so much for being here with me today. 

Dr. Michael Kaufmann: 

Thank you, Jillian. My pleasure. 

Dr. Jillian Horton: 

You became interested in physician wellness after embarking on your own recovery. Can you start by sharing a little bit of that story with me? 

Dr. Michael Kaufmann: 

Sure. I'm happy to. Yes, it's true I began my career in our profession as a family doctor in a rural setting, it's where I actually still live. But I brought with me a certain amount of, let's call it, predisposition with a strong family history of substance use problems and perhaps not a full toolkit of coping strategies as maybe I should have had for an all purpose rural family practice. And it really didn't take very long before I discovered the kind of ease and comfort that opioids provided, and discovered also that I had a pretty good access to those drugs. And thought that I was smart enough and clever enough to use them to cope. And it really didn't take very long before the disease took hold and got the better of me. Although I am grateful that I was also given the opportunity to get well pretty quickly also. So I actually have a lot to be thankful for in that whole experience 

Dr. Jillian Horton: 

Michael, through that process of recovery, what were some light bulb moments when it came to recognizing your own risk factors for relapse? 

Dr. Michael Kaufmann: 

Light bulb moments, boy, it's hard to call them light bulb moments, Jillian, when recovery becomes a way of life and along the way, you can lose sight of living out of sight that way of life. But let's just say I learned skills that really were the kinds of things that a person ought to know. There were common sense kinds of skills, yet I lived life largely without them. 

Let me give you an example if I can because for all of us in the recovery community, what I'm about to say that everybody will recognize this acronym, which is HALT, HALT. But that's one of the first things that we were taught. And by the way, just to be clear, recovery from substance use disorder has got much more about it than not using and not drinking any more or being free from the symptoms of the substance use disorder. It's about living a good and proper life after that. A life of integrity, and a life indeed of relapse prevention. 

So back to the acronym, HALT stands for hungry, angry, lonely and tired. And basic principles that we fall back upon at times that we need them. And if I can elaborate just a little bit, I mean, hungry simply means don't let yourself get hungry and that sounds pretty obvious, but a lot of doctors practice a day at work and may skip meals. And even my own staff at my office, my family practice office years ago, they knew that, and they knew I needed a snack at about 11:30. And they set out a little cup of soup and some crackers for me every morning at about 11:30. I could just skip those and eat that on the fly. And so I didn't get hungry. 

Angry, the A, it stands for-- we can afford to let ourselves carry around strong emotion, anger, resentment, that kind of thing without dealing with it because there's too much at stake to carry that kind of burden, that kind of pain, and not deal with it in a healthy kind of way. The L is for lonely, and substance use disorders living a life of addiction tends to be a very lonely one. We tend to get sick in secret, behind closed doors. And more and more, we isolate from important relationships, family, friends, colleagues and so on. And the secret to recovery was to do the opposite, restore the relationships, make new relationships, healthy relationships, go to recovery meetings, surround ourselves with people in good recovery and emulate the good things that they have to share with us. 

And the T is tired, and I mean, what doctor doesn't know about getting tired. And certainly through my training and through my early days of practice and beyond, being tired all the time was the norm. Working late at night, working on into the next day from residency onwards, we were all subjected to penetrating, painful fatigue. And I did learn very early that opioids helped me with that fatigue. And that's one of the main things that got my addiction going. And so we learned that proper rest, proper sleep, proper self-care that's the key to recovery. And those elements are just a summary of the many strategies that we need to learn. 

And I learned that there was no choice. Those were the things that I had to do in order to get well and stay well. And as I've said, I'm very grateful for that. I didn't say at the outset but I have two things for which I'm extraordinarily grateful. And the first is that my wife, Judy, whom I met in high school we're still together. And we've had a wonderful life together. Thankfully, she's stayed with me through everything. But it's through addiction and the recovery that's enabled all of that. So those two things everything good in my life that's flowed from that. And I'm pleased to share some of those lessons with you today. 

Dr. Jillian Horton: 

Pandemic has forced many of us into a prolonged high stress state. What does this do to our ability to assess our own risk factors or even the state that we're in, in terms of what you just mentioned with HALT? And how does it interfere with our ability to perceive our own particular and personal vulnerabilities or our weak spots? 

Dr. Michael Kaufmann: 

Well, that's a good question for which I'm not sure that there's any ready or scientific answer, but there's certainly an intuitive answer. And it takes time. It takes effort, takes some practice to be vigilant at a high level in terms of our own self-awareness and coping. For those of us in recovery, we've practiced that, and we work that every day. For people without of that tradition, it may not seem quite as natural or as second nature. So I think that's the first point to think of. I do want to acknowledge, though, that most doctors understand resilience and are resilient people. Let's be clear about that. 

But at the same time, and I know that you know this, and I know that many of the watchers, viewers of this podcast will know this, if COVID-19 is pandemic and burnout is endemic, and that was a condition for us going in. High numbers, high proportion of doctors, sometimes 50%, sometimes more are experiencing some degree of burnout or other. So there's coming into this already more than overtired. They're coming into this already deeply fatigued. They're coming into this already feeling cynical and disconnected from themselves and their patients, and so on. They're already coming into this feeling depleted and feeling like what they're doing, even the good work that they do, may not be making a difference. And that's kind of a jaded place to be. 

When you put all of that together and consider the energy required to self-assess and to be vigilant, it doesn't surprise me that we can let go or let down in that area, and maybe even then fall back to another approach that we might be more accustomed to, which is giving our all. That's what doctors do. We want to be there for our patients. We want to be there for our colleagues. And if we're not sure what else to do, well, we'll do that. 

There's this thing called allostasis and allostatic load. Allostasis been the physiological adaptation to stress. We've known about that for a long time even if we didn't call it that, but that's when the hypothalamic pituitary adrenal access kicks in. That's when our adrenaline levels go up and our cortisol levels go up, and that's normal and natural. We all know that fight or flight. But the supposed-- we're supposed to have relief from that. We're supposed to recover from that. We're supposed to be able to restore our baseline homeostasis. Then everything's working as it's meant to be working. 

When we don't have a chance to come back down to the baseline, we're chronically stressed by that physiological state of allostasis. That's not good for us. That can affect our cognitive capabilities. That can affect our bodies, and all of our systems in negative ways. All of these things put together, I think, may well indeed put our colleagues at some extraordinary stress and extraordinary risk with respect to their vulnerability going through these times, whether they're on the front line or whether they're a step back from the front line experiencing vicarious stress. Or whether they're redeployed and they're not familiar with the work that they're been asked to do. Or they're underemployed and they're at home and frustrated and stressed and wanting to help. All of these things can contribute to the extraordinary stressor which puts us at increased risk. 

Dr. Jillian Horton: 

So just to follow-up on that Michael, how do you counsel individuals, perhaps those who are in recovery from various disorders or even more generally looking at those who have not struggled with issues related to addiction, but perhaps know they have weak spots of vulnerabilities, how do you begin to counsel those individuals when it comes to identifying as physicians their own weak spots? And why is this so often a struggle for us as doctors? 

Dr. Michael Kaufmann: 

Well, OK, Jillian, let's first agree to use the term vulnerability or risk, and set that the idea of being weak or weak spots aside for now because that's what I'm dealing with. That's what I've always been dealing with is vulnerability because we all have our vulnerabilities. And then the risk of activating those or what might happen as a consequence of unrelieved stress. So we're all in the same boat in that regard. The difference is some of us know what's at stake or immediately what's at stake. So those of us with mood or anxiety disorders, or maybe physical disorders, coronary artery disease, what have you, certainly, substance use disorders, we already know that we don't want to relapse into those chronic conditions. We don't want them to become active. We don't want to suffer the negative consequences of having those disorders overwhelm us. But we know they're there, so we also know how to protect ourselves. 

And as I said, it's not rocket science and we can use the same principles for any of us. And let's just be mindful, watch for the signs. When we interview our doctors in recovery for those that we do follow, we just ask them a lifestyle questionnaire. How's it going at home? How's it going with your appetite and your nutrition and your exercise program? Are you getting to your meetings? Are you spending time with people? Are you spending some time with your spouse and your kids? All of those things. Are you having fun? What about your hobbies and special activities? What do you do with all that stuff? And we can all be watching for the same things. Those of us who already have mindfulness practice, I think we're on it. We have a way of checking in with ourselves in how am I doing mood wise? How am I doing with my irritability? Am I feeling anxious? Am I feeling sad? Am I feeling depressed, whatever? It's all fine, but we pay attention to those things. 

And if you're not of that mind or not of that [INAUDIBLE], pay attention to what's happening in life, pay attention to whether we're feeling irritable or not, pay attention to the life-enriching activities that we're accustomed to, and are we letting them go, are we giving them up. Pay attention to any activities or behaviors that may not be such a great idea for us. I haven't heard of this happening lately, but I certainly, over the years, I've heard of cases, believe this or not, where doctors in midlife or at a time when they really, really should know better have actually begun to smoke. Can you imagine that for the first time? 

These days, I get concerned about people maybe smoking cannabis for the first time, being relatively recently legitimatized and made available readily. So we need to watch out for what I would think of as being some maladaptive behaviors too. And most of us know what those are. And if we're not sure, and you've got anybody who cares about you around you, just ask, how am I doing? And check in with the people that care about you, a spouse, or a family member or friend, or even a colleague, if you have a relationship that permits that. So there are lots of ways to check in with yourself and to check in with the people around you. And to those who are able to notice these things, I have a lot of respect for you, for them. Hats off to you for being able to say, you know what, I notice I'm having an extra drink or two, when maybe that wasn't what I would normally have done. And that's something I think I pay attention to. 

Dr. Jillian Horton: 

So on the subject of alcohol, let's assume that an individual does a personal survey and goes through these steps and realizes that since the pandemic started, they've gotten into a routine of drinking every evening, but they don't think they've ever had a problem with alcohol use before. Is this a red flag? 

Dr. Michael Kaufmann: 

It might be. It's useful to have a sense of when an everyday behavior becomes a risk-related behavior or bring some risk with it. Certainly in the field of addiction medicine that we're aware of when the use of a substance is risky or not risky. Alcohol, of course, being socially acceptable and readily available and part of a lifestyle for most of us. Certainly those of us not in a personal recovery. And there are guidelines, and the guidelines do refer to how much and how often. And I won't necessarily go through them here, the readily available. But those same guidelines would tell us that drinking every single day may not be a good idea, so we look at whether that's safe or not. Drinking more than a drink or two might not be a good idea for drinking occasion, it depends on the circumstances. But there's really nothing in the diagnostic criteria for a substance use disorder that even refers to how much or how often. It has much more to do with our relationship with the substance and its impacts upon our life. 

So in thinking about having an extra drink or two, an insightful person might notice, gee, I can't wait to get home and have a drink or two. I mean, before my own illness really took hold, that's what I did. I would come home and have usually a couple of bottles of beer chug down fairly quickly because I knew that it would make me feel better, or even better a Manhattan or two because that would work better and were sweeter, tastier, and it would be faster. I'd feel better quicker. And then start looking forward to that more and more each day. And now we're beginning to think, OK, is this a red flag? 

Beyond that, Jillian, if we're starting to use substances but be it cannabis, be it alcohol, be it over-the-counter, and it just means or anything or prescription medications inappropriately are on somebody else's, in order to feel better, in order to bring ourselves to a state of ease and comfort, we just don't seem to be able to find, otherwise, or aren't willing to find other ways to get us there, to treat pain, emotional, physical, to cope. This is the thin edge of the wedge. This is the slippery slope, whatever you want, however, you want to think of it. These are problem indicators. And then when I'm interviewing somebody, I'll be looking for all of those things. And that requires a little more thought, little more explanation or exploration. It requires some thinking. 

Dr. Jillian Horton: 

So it's obvious that COVID-19 isn't going away any time soon. And when we look at what we need to be able to do in the immediate future, how can the average physician move from simply identifying risk factors to building a meaningful blueprint for their own self-care? 

Dr. Michael Kaufmann: 

That's a really good question. It's hard enough to establish that as a lifestyle in good times. I mentioned the onslaught of the epidemic or endemic condition of burnout out before. Personal resilience is an important part of that. And I just want to acknowledge this before we return to it, our culture the culture I grew up in and that is to in any way during my training, the culture for arts and in training, for the most part, our cultures and conditions in our workplaces, they don't necessarily lend themselves to the healthiest of personal lifestyles. We were realizing that now to our credit and many workplaces and training programs are addressing these realities. But a culture can be a pretty slow thing to change. Maybe this is a time of opportunity that will help speed up that change. 

Nonetheless, if we haven't come into these times with a robust practice of self-care and a high regard for it, it might be hard to get there in the midst of all of this. But if I can convince anyone who listening to me right now and listening to us right now that self care is as important, dare I say, may be even more important than the other care that we provide. If I can convince anyone as the science is doing that our patients actually do not get the best of us and may even suffer when we aren't looking after ourselves well. And first and foremost, if I can convince people of that, then I might be able to convince them that looking after themselves is worth it. 

So pausing ever so briefly to get something to eat during a busy day. Time out to have a rest or have something to drink. Or when you get home instead of one two or more drinks in rapid succession in the same amount of time, you could go downstairs and jump on the elliptical for a few minutes. I mean, the good feeling you get from that is this healthier and last longer, why not do that? A lot of us might have a tendency to isolate, to go in a room and close the door when feeling tough. OK for a few minutes, but probably it's a good idea to find someone to talk to. A peer or somebody else that you know, love, trust, what have you. All of these things, all of these behaviors, hungry, angry, lonely, tired, I've written about them elsewhere and I've called it the basics, and I've looked at-- that's another acronym. And I've looked at the six domains of looking after ourselves up to and including a spiritual practice of taking a walk and remembering how wonderful it is in nature, or to hear the birds sing in the morning, or whatever it happens to be. These are all life-giving. 

Usually when I think about these things and talk about these things, I also want to think about compassion because we do talk about compassion these days. And we do talk about compassionate leadership. And I think you may even have an interview or two on that subject. But we also need to remember that compassion starts with self-compassion. And I think looking after ourselves in a robust way, dare I say it because I have said it, in a radical way, radical self-care. That's an act of loving kindness directed towards ourselves. And it's something that I think we ought to embrace and we ought to adopt as though our lives depended upon it. That's what I do. That's what I've always done since I got into recovery. That's what we teach everybody else in recovery to do. Do this as though your life depends upon it because it actually does depend upon. 

The chronic condition that we have in relapse, people die. And people may also die from any other condition that any of our colleagues are experiencing right now. Whether it's the malignancy yet to reveal itself or the coronary artery yet to clog or the stroke to have, or dare I say it, the depression or the suicide that they might be facing. God forbid. There are a lot of ways unrelieved stress can bring us to the brink or beyond. And so if we reframe the way we think about self-care as an act of self-preservation and an extraordinary act of love and kindness towards ourselves. And if we put that up there as being equally important as the kindness and compassion we have for our patients and others, then I think we're in the right place to justify looking after ourselves. And that's what I would done. That's what I would wish for all of our colleagues. 

Now and even better when this is finally over, we don't lapse back to some kind of status quo. I hope that this pandemic is the opportunity for ourselves as individuals to adopt and embrace these resilient practices, and even more for our organizations and institutions and cultures to say, yeah, this is what we want you to do, this is what we must do. Let's come together and support each other in looking after ourselves and looking after one another because that's also part of it. 

Dr. Jillian Horton: 

Michael, you have made so many critical and beautiful and salient points today. I want to thank you so much for taking the time out of your busy schedule to join me. 

Dr. Michael Kaufmann: 

My great pleasure Jillian. Thank you for inviting me. 

Dr. Jillian Horton: 

I'm Dr. Jillian Horton. Thank you for joining me for this COVID-19 learning series webinar, brought to you by the Canadian Medical Association and powered by Joule. Thank you for all that you do, and I'll see you again soon.