It’s OK to be not OK

Why mental health care should be required, or at least strongly encouraged and incentivized.

Do you know that meme – the one with the cartoon dog surrounded by fire saying, “This is fine, I’m fine”?

If you haven’t seen it, you can understand the sentiment. The Emergency Department can be a chaotic and under-resourced place, and that was even prior to COVID-19. Then our experience showed that in many cases, the additional workload and stress of the pandemic could not be borne completely by the current system. The cry of ‘flatten the curve’ wasn’t to prevent the disease itself, it was to prevent our health care system from being overwhelmed.

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For a time, there were hero flags put in front of our workplaces, community gestures of support such as the shift change honking and sirens for our NYC colleagues, and even some free food to fuel our tired bodies, while our crafty friends and neighbors began sourcing and creating PPE.

These wonderful gestures of support and humanity helped fuel us for a sprint, which was great!  The truth is that we are not in a sprint, we are in a marathon. An Iron Man marathon!  Barefoot. Carrying a lead backpack. And the backpack is on fire! You get the idea.

But we are superheroes, right?  Aren’t we supposed to do all of that and take care of our partners and families, homeschool our kids, have high clinical and academic productivity and still look happy, energetic and Instagram-worthy in our hero capes?

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I call bullshit.

This is not fine. I am not fine. Many of us are not fine.

According to the literature, more than 50% of clinicians treating patients reported that they had experienced burnout pre-COVID.[1] I’m sure the post-COVID numbers are much worse. During the pandemic, 80% of practicing clinicians expressed concerns for their own health and safety and 83% expressed concerns for the safety for their family and friends due to the virus. [2]

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And there are at least 400 physician suicides per year, much higher rates per capita than the general public.

Emergency physicians treat anyone who comes through our door, 24/7/365, regardless of if they are insured, violent, unwilling or unable to speak – we are their voice and we provide care to the best of our resources. We are the safety net of the health care system in this country and the system needs to change. Corey Feist, the brother of Dr. Lorna Breen, an amazing NYC EM physician who died by suicide, noted that Dr. Breen was a canary in the coal mine and aptly stated “We don’t necessarily need a stronger canary. We need a new coal mine.”

Here’s the current situation for physicians.[3]

• 65% cite concerns for the job, financial security due to COVID-19
• 80% expressed concerns for their own health and safety and 83% expressed concerns for the safety for their family and friends due to COVID-19
• 45% — nearly half of Emergency Physicians — hesitate to seek mental health treatment
• 73% feel there is stigma regarding mental health in their workplace
• 57% are concerned for their job if they seek mental health treatment
• 27% have avoided mental health treatment for fear of professional repercussions
• EM Physicians cited these reasons for why they avoided mental health treatment – job security, professional stigma, future job opportunities

Physicians should not be penalized for seeking mental health care by their jobs or licensing bodies. In fact, I boldly state mental health care should be required, or at least strongly encouraged and incentivized.

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Here is a starter wish list of things that can improve our lives:

• Destigmatize seeking help for mental health issues
• Encourage physicians who are suffering to seek mental health care
• Improved workflow and efficient work environments
• Meet the needs of emergency medical practice including appropriate staffing, PPE, supplies, resources, space, etc.
• Smart and healthy scheduling practices
• Minimize or eliminate unnecessary administrative burdens
• Strong and sustained self-care practices
• Excellent peer support systems
• Organizational commitment — not just with mission statements, but walking the walk with robust administrative support
• Leadership accountability to ensure these things continue to improve

We can start changing the coal mine if we have the energy to do it! Here are some strategies we can employ on a personal level to EMPTY some stress out of our lives so we can save healthcare.

E: Eliminate – what can you eliminate, automate or delegate from your life that is taking time or causing unnecessary stress?  The pandemic certainly taught us how many things were unnecessary (like dress pants!) and how many meetings could have simply been an email and saved us a lot of time.

In your personal life, what can you eliminate, automate or delegate?  I was cleaning up dog poop in my yard (courtesy of my two big rescue dogs) despite the full email in-box, talks to prepare and wanting to spend quality time with my kids. So, I paid someone to do it for me.

I’m not grossed out by dog poop (we see way more gross stuff than that!) but I decided that the $12 dollars I paid someone to do it was more than worth an hour of my time!  Which helped me realize, what other (ahem) crap should I not be doing so I can do the things that bring value into my life?  What’s your time worth? What in your life needs to be done, but not necessarily by you?

Consider this concept in the emergency department: we could certainly change bedpans and scrub floors, but that would keep us from spending time using our education and expertise providing excellent patient care. The teams run smoothest when everyone is working at the top of their skill level.  By eliminating unnecessary things, automating recurring things and delegating appropriate things, we have more freedom to work and live at our highest level.

M: Minimize – there are some people, situations and things we, unfortunately, cannot realistically eliminate from our lives. In these cases, anything we can do to minimize them as much as possible will help!

In addition to minimizing our total time spent in those stress-inducing situations, it is also helpful to minimize the impact that they have on us. Think about the “energy vampires” who constantly complain and could suck the happiness out of any room. Too much time in an energy vampire’s presence, and we start feeling negative.

Unfortunately, we can’t eliminate all energy vampires from our lives. Instead, it helps to prepare to “minimize” the energy vampire’s negativity by creating a positive mindset. Do an energizing workout, listen to your jams, play something fun with the kids…anything to get into as positive a mindset as possible. After any negative interaction, continue shedding any leftover negative energy by doing something you find enjoyable and doing everything you can to diminish their effect on you.

Many emergency physicians prepare to minimize negative energy before and after shifts as well. Get pumped up with some great music, eat a nourishing meal, put on their doctor outfit and have a robust pre-shift routine to clear their mind and get ready for whatever comes. Then the shift comes, good or bad. Then the post-shift self-care and unwinding to minimize the damage from any frustration, exhaustion, abuse, moral injury, or witnessing of human suffering that occurred. What you do pre and post any difficult thing can substantially affect your mental health.

P: People – This is my 5-People-Type adaptation of famed EM educator Tracy Sanson’s principles of the 12 people.

Having these five types of people in your life will significantly bolster your mental health.

1. Luminaries – these are your role models. The people you learn from, look up to and emulate. They might be peers, mentors, authors, famous people or historical figures. They light the way for the kind of person you want to be and the life you want to live.
2. Fail friends – these are the ones you can get real with. Really real! When you missed something, messed up, didn’t handle a situation the way you wanted, or had a crap day, these are the people you can call with the un-pretty things in your life. They listen and support you without criticism and judgment. We all need people that we can vulnerable and imperfect with.
3. Tribe – these are your people! Your friends, your golf buddies, your volleyball team, your parent group, your family, your travel gang, etc. The people you have things in common with, feel a sense of shared community and belonging, and enjoy spending time with. Humans aren’t meant to be solitary creatures. Having your crew makes a big difference!
4. Ride or die – these are the people you can call in the middle of the night for bail money. The ones who would take a bullet for you. The number and quality of these deep relationships you have is an indicator for how you are showing up for other people.
5. Mentees – who are you lighting the way for? How are you reaching out and helping the people that look up to you and want to learn from you? These could be your peers, staff, learners, and even family and friends. By you living your best life and role modeling to others, you give people permission to grow and thrive.

T: Thankfulness – Remember when you really wanted all the things you have right now?  It is easy to forget where we were when we are where we have gotten. And it is easy to take things for granted until an event happens. We don’t appreciate our ankles until we sprain one and it interferes with our day. We don’t appreciate electricity until the power goes out. We forget to be grateful for our wellness until we are sick. We aren’t bad people, we are just human (busy humans!).

Having a regular gratitude practice can increase our happiness. There are apps and fancy pre-printed journals, or you could just write or type on a blank document. Every day, list things you are grateful for. The practice is most effective when you do it at both the beginning and end of your day. It trains you to look for things throughout your day to be grateful for and strengthens this neurocognitive muscle.

Angry at your spouse?  Kids being monsters?  Job getting frustrating?  Computer being slow?  Pets made a mess?  Taking the time to write out the things about our partners, kids, jobs, electronics, and pets that we are grateful for can help mitigate a lot of the anger and frustration that we have towards them. It doesn’t mean we have to like every single thing; it is an exercise in finding perspective and finding the good in real life situations. These kinds of things will occur throughout our lives, we can choose how we react to them.

Y: You time – Self-care isn’t selfish! You can’t fix the world with broken hands. You can’t carry the weight of the world with a broken back. I tell my trainees that they will be better doctors with a full stomach and empty bladder. Medicine can be a bit macho and we all love our trophy for suffering, but the truth is, we perform better if we take care of ourselves.

Think of how much easier a shift is when we’ve had nourishing food, energizing exercise, restorative sleep, stress release and meaningful connection!

Think about what fills your bucket. What do you like to do to relax, unwind, have fun, and nourish yourself mentally and physically? Do more of that! Self-care isn’t selfish. The stronger and healthier we are as individuals, the more energetic we are to change any parts of the system that are causing us harm.

The more stress we EMPTY out of our lives, the better our mental and physical health will be, the more we can fill up our buckets and make our lives and health care better places.