Not only are they under enormous strain at work, they also face the fear of bringing the virus home to their families.
So what can help providers who are feeling exhausted, overwhelmed, or afraid during these difficult times?
Ron Siegel, PsyD recently sat down with Ron Epstein, MD to get his take.
Dr. Epstein: I think there are several, and the big one is uncertainty. There are really two kinds of uncertainty, there is one that we call stochastic uncertainty, meaning you know that, for example, 70 percent of your patients are going to do well and 30 percent aren’t, and you just don’t know which category people are going to be in because it’s such a new situation. The other is called epistemic uncertainty, we just have no idea even what the parameters are. The disease is evolving before our eyes, we just don’t know. So those two kinds of uncertainty interact and really make it difficult for us to predict anything, to be able to understand what’s going to happen to people, to counsel patients, or to even feel like we’re experts. The second is fear, and the fear is for ourselves as well as for our families. Balancing that fear is really tricky because, on a personal level, I’m 65, I may be called in to go into the hospital to take care of people at the end of life with COVID and I am going to be putting myself at risk and not only myself, but also my family, and balancing that, I think for many clinicians is terrifying. The third is really the absence of connection, the fear of isolation, the fear that you’re going to be alone, both for health professionals as well as patients, it’s a fear that we share.
Dr. Siegel: Ron, let me ask you a little bit more about that second issue that you mentioned. I’ve seen this also in my patients who are healthcare providers, that they really want to do a good job, they want to be a good person, they want to address the needs out there, but it’s scary. How might they somehow wrestle with this tension between being the person they want to be, the professional they want to be, and also protecting themselves?
Dr. Epstein: I think, for one thing, you’re not alone, and we’re sharing those fears and dealing with them in a way that’s principled and rational. What I’ve done, personally, is relied on people at the institution to say, “Okay, how are you handling risk based on age of healthcare professionals?” It gets people thinking, and we’re thinking collectively how to do that and what a reasonable risk is and what an unreasonable risk is. The second is to talk with family and I’ve done that personally, I’ve spoken with my wife. We’re aware that I’ve got an aging mother who might need my help, and we’ve made a decision about where to draw the line, in terms of my involvement. The third piece is to really take your own emotional temperature. Like, we’re taking our physical temperature every day, but where are you emotionally and how are your emotions either guiding wise decisions or getting in the way of them?
Dr. Siegel: Do you have any tips for what providers might do when they’re in the midst of a busy day, they’re exhausted, there are all these challenges, and they’re starting to feel super stressed out and overwhelmed? What might providers do when they’re in the thick of things?
Dr. Epstein: Well, I think the first thing is to figure out what you need to do to be physically safe, given the parameters of what’s possible. The second is, when feeling afraid, recognize that we not only have a fearful self, but we also have a robust and resilient self. If you survived medical school, if you survived medical training, you are, by definition, resilient, and we often forget that. The third thing is don’t worry alone. If you’re afraid of something, clearly there’s someone else who’s afraid of the same thing. Decrease your social isolation, even if you’re physically distant. So, call a colleague, call a friend, email a family member, but just try to create a web of connections so that you don’t actually feel alone. Think about ways that you can deal with uncertainty in a healthy way. First of all, don’t deny it. Second, recognize that there are limits to what you know and also what can be known, and try to be comfortable with that, because we’re all in the same boat. Sometimes compartmentalization is good, especially when you’re in the in the thick of things. But that only works in the short term, so we all need to find some way of integrating the horror and difficulty that we’re finding ourselves immersed in each day. A couple of very simple things you can do is find ways of taking brief pauses during the workday. So, when you’re between patients, what do you do mentally? Can you take a breath, can you stop and mentally set aside what’s just happened with a previous patient, so that you can be more aware attentive and present with a patient you’re about to see?
There are also some ways in which you can make a connection with colleagues and patients. Even before this crisis, I counseled physicians to spend the first 60 seconds of any encounter just listening. Just listen to what that other person’s experience is. Take it in, you don’t have to fix it, you don’t have to do anything, but it will enrich your understanding of that person, enable you to be more helpful, and also feel that you’ve made a human connection. Do that with family, do that with colleagues. It may sound paradoxical that when you need things the most, that listening is the thing that you can do the best. But, I would say try it on, see if it works for you. Finally, there are some breathing exercises that can be of help. One is what I call a vagal breathing exercise. It seems to raise parasympathetic tone and lower sympathetic tone. You inhale for a count of four: 1 2 3 4, hold your breath for a count of four, and then exhale for a count of four. It sounds almost too simple, but if you do that repeatedly a few times during the day, it may actually enable you to be your more calm, resourceful, and robust self, as opposed to just experiencing the fear, uncertainty, and vulnerability.
Dr. Siegel: Do you recommend trying that kind of vagal breathing in the midst of things, when you find your heart racing and you start to feel panicky about how to handle a situation?
Dr. Epstein: I would suggest starting in less acute circumstances, so you kind of get the hang of it. But it’s really useful to employ when you feel that the stress level is beginning to go up. And in that context, it’s good to have a little internal “stress meter” so that you don’t start to employ these strategies when the stress is 11 out of 10, you begin to employ them when it gets to about 5 or 6 out of 10. That’s a habit of mind that I think is pretty helpful. A lot of us develop that habit, I mean, surgeons in the operating room, anesthesiologists, ICU doctors, you can’t survive in environments like those without figuring out some way to manage your stress reactions. But you’ve also seen people who’ve managed those situations well and those who haven’t, and you want to be one of those who’s managing it well. I think this is just one simple exercise that you can do. Don’t just either take my word for it or limit yourself to that; think about ways in which you’ve dealt with stress and adversity in the past and bring those to bear. Sometimes, you know more than you think you know, it’s just a question of bringing to awareness those strategies which have been tried and true for you.
Dr. Siegel: Thank you. You mentioned that compartmentalization has a role, that there’s a time to put aside thoughts and feelings. But I’m assuming that self-care, particularly the self-care that we might do after work, when we’re not under the gun, when we’re trying in some way to work with the thoughts and the feelings and the images of the day that maybe were overwhelming at the time, I’m imagining that compartmentalization might not be the optimal strategy then, or is it? How do you advise folks to somehow process what’s happened during the day when they have a few minutes of relative peace at home?
Dr. Epstein: I can tell you what works for me, and I think we all have to discover that. In terms of talking things through, I would be judicious about with whom you do that. So, if your spouse is someone who’s ready to hear those stories from your day, maybe that’s the person, but maybe it’s not. Maybe it’s a phone call to a colleague or just a text message saying, “I had a tough day, just so at least you’re aware of that.” That kind of storytelling can be really useful but I think you need to decide who is the person who’s going to really be present and help you the best with that. For me, I’m a musician, I like playing music – that’s one way of connecting to something bigger than I am. For some people, that might be going out for a run, for some people, that might be hugging their kids. But in terms of the actual impact, there’s both a cognitive impact that is telling the story, what is it that happened, and also the emotional impact. The emotional piece can often be dealt with through social connection and through connecting to something that’s bigger than you are. The storytelling piece, maybe you need to write something, maybe you need to talk to somebody. But again, choose the right person at the right time.
Dr. Siegel: Thank you so much for sharing your insights, this is such a hard time for so many people, for patients, for providers, and I think these tips are wonderful beacons for how we might direct ourselves in these moments of stress. So, thanks so much for sharing them.
Dr. Epstein: Thank you.
Now we’d like to hear from you. How are you helping patients manage their stress and fear during the pandemic?
Please let us know in the comments below.