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Alex Raben: [00:00:08] Welcome to site, the educational psychiatry podcast for medical learners by medical learners. In today's episode, we're going to be covering wellness and Covid 19. For today's episode, we are very happy to be joined by Doctor Deanna Chacos. She's a staff psychiatrist at Mount Sinai Hospital in CL psychiatry. She's also, in terms of the Department of Psychiatry at University of Toronto. She's the wellness lead and an associate and the associate program director. So, Deanna, welcome to the show.
Dr. Deanna Chaukos: [00:00:44] Thank you so much for having me. I'm very glad to be here.
Alex Raben: [00:00:47] We're glad to have you. Uh, I'll be the host today. I'm Alex Rabin. I'm a Pgy five in psychiatry here at University of Toronto. I'm joined by three co-hosts today, and they're also the brains behind this episode. And I'm going to go through them one by one. So, grey, you you, um, quarterback this episode. Grey Mechling here is a CC3. Uh, and welcome to the show.
Grey Meckling: [00:01:11] Thanks, Alex. It's great to be here.
Alex Raben: [00:01:13] And we're also joined by William Caffyn, who's also a CC3 here in uh, at the med school in Toronto. And we welcome you as well.
William C: [00:01:23] Thank you, Alex. Happy to be here.
Alex Raben: [00:01:25] And last but not least, we have Randy Wang, who is also a CC three at Toronto. Welcome, Randy.
Randy: [00:01:32] For having me. Alex.
Alex Raben: [00:01:33] Thanks for being here. So before we jump into this very important topic and very timely topic, as we're all currently going through this pandemic as a global community and trying our best to cope with this and, um, and maintain our wellness, I want to go into the learning objectives we have for this episode. So this episode, we're really trying to get an idea as a group, uh, as to, uh, what wellness is and how it's affected by Covid and what we can do about that. So by the end of this episode, you, the listener, should be able to, number one, define wellness and burnout and their importance in medical education and how that relates to Covid 19 in our current time. Number two, understand strategies on how to maintain your wellness and prevent burnout, particularly during this difficult time we're in. And number three, understand strategies that you can use to help maintain or help others maintain their wellness and deal with burnout. So without further ado, why don't we jump right into questions? And we am. I'm going to throw to you because I know you. Uh, for our first learning objective, you did some looking, uh, research into what wellness means and what burnout means. And I'm wondering if you could define those things for us and how they relate to to each other. And then, uh, doctor Chacos could could also add to that as well.
William C: [00:03:14] Yeah. For sure. Um, so wellness is a time that I often heard, and it wasn't it was interesting for me to kind of find a definition for it. Uh, so according to the World Health Organisation, uh, wellness is defined as a state of complete physical, mental and social well-being and not merely the absence of disease. Um, and although it's a good definition that highlights that wellness is not just absence of disease, it has received a lot of criticism, um, because it describes wellness as a state rather than a continuum. So you're either well or you're not. Another definition that I found, it was proposed by the National Wellness Institute, and it defines wellness as an active process through which people become aware of and make choices toward a more successful existence. And that seems to be, uh, that definition is more is used more because it describes wellness as an active process rather than just a state.
Alex Raben: [00:04:08] So I'm hearing that it's not just the absence of disease, it's it's something more than that and that we have to work at this thing. Um, but we're we're used to in psychiatry, working from the DSM. How does this relate to that? Uh, that that large tome that we tend to work from? And why isn't wellness language used in that book, do we think, I wonder, Doctor Chacos, if you could maybe speak to that or elaborate a little bit about this definition and why it's not in the DSM or not, something we talk about as much in psychiatry? Psychiatry.
Dr. Deanna Chaukos: [00:04:47] Sure, I think. I think it's not in the DSM because the DSM describes pathology. And when we talk about wellness, I think, um, as William described, it's it's a pursuit. It's a pursuit of good health, physical and mental health. And it includes the behaviours and attitudes that are necessary for that. And so I don't think it's included in the DSM because it's. I think in many ways, as most medical specialities, psychiatry is no different. We describe the pathologies that we treat in a very specific way, and unfortunately the pursuit of health isn't included in that. Hopefully our practices include that, but unfortunately the DSM doesn't.
Alex Raben: [00:05:42] Right. That makes sense. And, um, we we chose to focus this episode on wellness and Covid, and I've seen the wellness perspective used a lot. Um, in other documents on social media around staying well during this time. Why do we think this perspective is helpful when thinking about Covid versus something like DSM, or another way of looking at the array of impacts that Covid could have on people and medical learners.
Dr. Deanna Chaukos: [00:06:16] So I think it's important to talk about wellness right now, because we are all experiencing an extraordinary stress in an extraordinary time, and our stress response as a result, though it might feel. Completely uncomfortable. I don't think that there's anything pathological about that. Um. Having said that, I think we need to keep an eye out and recognise when our stress response in a chronic way starts to cause additional negative consequences, and that's hugely important. But as we think about the general populace experiencing this stress, I think it's probably more helpful and more adaptive to talk about wellness. I also think burnout is part of that, especially as we as we consider our medical students and residents and other physicians. Um, I think burnout is a really important concept for us to consider as well.
Alex Raben: [00:07:26] Right. So the wellness perspective is particularly helpful because it normalises that this experience that really we're all going through, and that having stress and maintaining wellness are across the board important in this time. Whereas pathology may, may or may not come and it should be looked out for. But really the wellness perspective is more broad and it covers a lot more ground. And it helps us think in that more positive way of looking at health from a positive lens, um, which makes it useful in terms of how we can deal with this together as a, as a community. Danny also mentioned burnout there at the end. And, um, I'm wondering if I could shoot it back to you because I know you had looked into the definition of burnout and what that means. And then, you know, Doctor Chacos, you could you could, uh, elaborate on that perhaps as well.
William C: [00:08:24] Yeah. For sure. Uh, so, Bernard, uh, when I looked for definition, it was defined as a state of emotional exhaustion, depersonalisation, and decreased feelings of personal accomplishment. Uh, so that's how Bernard was defined.
Alex Raben: [00:08:40] And, um, doctor Chuck, you as a wellness lead, I'm sure, encounter this these concepts, uh, sort of in real life or in real time or whatever you want to call it. How do they, like, take that? Or if we take that definition, how does that actually apply? Like in the real world, what do you see with people who are burnt out?
Dr. Deanna Chaukos: [00:09:02] Thanks, Alex. Um, well, I think we all, we all encounter burnout in our practices. Um, I think that, statistically speaking, burnout is something that we will all experience in our careers medical students in their early careers, residents and and physicians as we go through practice. Um, the one thing that I would add to William's, um, definition is that. All those three components of burnout, those are experienced in a work environment. So burnout specifically describes a phenomena in the work environment. And that's really important because it also should should clarify for us how we tackle burnout. Um, because burnout is a work environment problem, we should be tackling it in the work environment and looking to the environment for solutions. Um, so we had talked about the DSM as psychiatrists clarifying the difference between burnout and, for example, other types of distress that a physician might experience, like anxiety or depression is super important because we know that we have evidence based treatments for anxiety and depression, right? And those treatments occur at the individual level. Um, whereas burnout is something that we know occurs in someone's professional context. And though there's a lot of overlap between these types of physician distress, anxiety, depression or burnout, um, we need to be clear about what we're trying to solve.
Dr. Deanna Chaukos: [00:10:44] And when we tackle burnout, we need to tackle it as a community. So you had asked me about you had asked me about how we encounter it in our medical environments. I think we encounter it, um, in a very real way. I think that we can each reflect on what we look like when we feel burnt out. Um, we can identify how our stress response impacts our interactions at work. Um, our emotional responses, whether it's through having a shorter fuse than usual, feeling less fulfilled by the interactions that we have with with patients, um, whether it's experienced as sort of an emotional numbing to the work or a depersonalisation, um, or a decreased sense of personal accomplishment with what we do. Burnout. Burnout, I think. Is such a big problem because it gets at the reason for why we're all here, and it it can minimise those rewards that we that we experience from the work that we do. And so, um. Similarly, I think many remedies for burnout are coming together as a community. Um, so that we can tackle the stressors in the work environment that propagate it.
Alex Raben: [00:12:12] Yeah, I think that that's a really important piece to add there, that burnout is dependent on the working environment that you're in and that community as well. And, you know, as the title of this episode, you know, is about Covid and that has had a huge impact on everyone's environment. And we're talking today about medical learners and residents and medical students who may be in in the hospital where things have changed, uh, drastically. How has Covid impacted these concepts? For medical, for residents, for for people, uh, for medical students?
Dr. Deanna Chaukos: [00:13:00] Certainly. Um, so I think I think that Covid well, I guess I, I think it's important for us to talk about the types of things that contribute to burnout at baseline, because many of those are exacerbated in the context of the pandemic. So so if we if we look at what are the main themes that contribute to physician burnout for for trainees and physicians alike? Um, some of those include that we work in potentially inefficient work environments. So that can include anything from a clumsy electronic medical record to lack of an electronic medical record, or all of the paperwork that, um, now comes along with the patient encounter. Another theme is inadequate support. So for trainees. Um, I like to talk about the responsibility expertise gap. That is a natural part of training. So I usually say to the pgy1 when they first come in, the only difference between you on day one of Pgy1 and you six months ago is that now you have a whole lot more responsibility. And if you don't have the support that you need in that new role, that can be that can be a source for burnout and trainings. Um, another main theme for physicians and trainees is loss of autonomy or lack of control. This one, I think, is probably one of the major contributors to burnout in the context of the pandemic. We feel an immense lack of control and uncertainty about the future. And for healthcare workers and trainees who are on the front lines, that is only exacerbated. Um. Another one of the main themes is problems with work life integration. I don't say work life balance because it never feels like a balance, but the way in which we can integrate our personal lives and our work lives, that can be a source of burnout. And then, of course, loss of meaning in the work. Um. And so as we talk about the pandemic, I think recognising that physician burnout and trainee. Medical student and resident burnout. Those were immense problems that required a lot of attention before the pandemic, and so many of those are only going to be exacerbated now, right?
Alex Raben: [00:15:41] Right. Thank. Thank you for taking us through. Um, a lot of the different elements of burnout and how things can impact our wellness in the workplace, and also how those things may be exacerbated further in Covid. You know, I'm also just reflecting on my own time as a trainee during this, this moment in in time and how these might apply, like you mentioned, you know, inefficiency, loss of autonomy, work life integration and loss of meaning in the work. Um. You know, I think, you know, just thinking about that inefficiency piece, I think that we've had to have so, so much shift in the way we communicate now, uh, in our clinical lives. That I think it's showing areas where the communication. Um. Maybe could have been improved before, and now it's like we're trying to figure out how to how to make that work. And that's definitely been at times a stress stressor for me personally, where you don't know where to get your information necessarily. And I think that, um, great efforts have been made to, to improve that and make such a difference for one's wellness, to know what's what's coming as best you can in a time of such uncertainty.
Alex Raben: [00:17:02] Um, you know, loss of meaning in the work. Um, I know a lot of colleagues and, and I think even myself, uh, thinking about what? You know, what does psychiatry, what role does psychiatry play in this pandemic? And some of my colleagues are being redeployed to areas that they, um, you know, did not set out to train in. And they may be on medical wards now. And, you know, what does that work mean to them? Is it different than their previous work? Uh, does it change the way they viewed their previous work? Lots of questions, I think arise from that. Um, just reflecting on my own experience and what I'm hearing from my colleagues. But I see so many. Yeah, so many things. Um, I also wanted to just open it up to the medical students as well, because I'm wondering how this has been impacting on you guys. Like, if you've noticed, um, any of these things. Um, any of these similar challenges during Covid times for you and your colleagues?
Randy: [00:18:06] So from what I've been hearing from my friends and a lot of what I've been feeling, my personal experience would be, it's just been really difficult for us to see everything that's happening in the world and what our resident friends are going through, and to not be able to do much. So we've been at home now for the past month or so, and sometimes you just feel so helpless, feeling like you should have a role in fighting the pandemic or contributing whatever you can. But at the same time, we're not allowed to go to hospitals. We don't have the expertise to help. So that's been really difficult. In addition to that, I think a lot of us have that kind of personality where we really been in control our entire lives. You know, that sense of having control and trying to maintain it, um, has really helped us, you know, get into medical school and to succeed so far in our training. Uh, so to all of a sudden have something this of, you know, this proportion happen to us. It's just shocking. So that uncertainty is definitely and lack of control is really hard to live with.
Dr. Deanna Chaukos: [00:19:13] Alex, I wonder I want to I want to hear from um, more from the students as well. I, as Randy was speaking, I think one of the concepts that you haven't asked me about, but I think is so important and infused in her response, is that, um, resilience is another component of what physicians bring to the table. And I think it's a worm that's gotten a really bad reputation in medicine. Um, because some feel that this worm has been used to put the onus of burnout on the individual physician instead of addressing the systems issues that propagate burnout. Um, so some people will say, you know, if only I think I think the reason why it's gotten a bad reputation is because is because it's understood that if only we were resilient as physicians, then we would not be burnt out. But I don't think I think this can't be further from the truth. Resilience is about having been through some hardship and persevering and thriving, such that you are able to generate meaning or become wiser or stronger from the experience. And medical students, residents and physicians represent a group that holds so much resilience. Um. Randy described that the medical students have been out of their clinical rotations in the past month. Um. But what I've heard the medical students have done in that time, you know, they were at risk for such a huge loss of meaning. U of T medical students have offered up their services to frontline workers, um, helping people with anything from like babysitting to picking up groceries, to helping all of these frontline workers who felt so scattered in the face of this pandemic to help them run their households and feel secure that their responsibilities outside of the hospital are are being attended to. What a resilient adaptation, right? Um, not only were med students at risk for losing this this source of meaning. Um, they actually helped frontline workers cope with the burnout risk that they were at.
Alex Raben: [00:21:35] Yeah. Terrific point. And something that definitely needs to be highlighted in this episode is just the amazing work that you guys, you guys are doing. Um, in this time with such a shift. Yeah. Thank you. Um, and I think we are going to spend like, some time at, like in the third sort of section of this, really talking about that altruism and, um, the impacts of it, uh, across the nation and I'm sure across the world as well. Um. I'm getting a little emotional even thinking about that. So thank you guys. Um, I wanted to turn now to ways in which we can, like, I think this is a nice segue into ways in which we can make the most of this situation. Um, and ways in which we can, uh, care for ourselves, ensure, ensure we're keeping our wellness, preventing burnout in ourselves. And, Randy, I know that you, uh, did some research on this, and so I wanted to hand it over to you to kind of take us through some of the highlights, and then maybe Doctor Chacos can elaborate on some of those things. Yeah.
Randy: [00:22:45] Of course. Um, so while there aren't many studies on pandemic specific wellness strategies for medical learners, um, I did find a lot of literature on medical learner wellness in general. Uh, so there was a really good systematic review from 2013, uh, that showed that meditation was, um, a significant stress reducer and that was shown across all the reviewed studies. Um, and in addition, I saw a study of first year family medicine residents, and the authors found that adequate sleep, physical activity, maintaining nurturing relationships, and spending time in nature were all protected from burnout. And then on the flip side, uh, they found that alcohol consumption was associated with higher prestige, stress, emotional exhaustion and depersonalisation. Um, so beyond what medical learners can try to do for themselves, I also read that, um, what government policies, um, how those can be changed to preserve wellness as well. And there was a study from the Lancet that suggested keeping lockdown as straight as possible, actively sharing information. Um, ensuring that there's always a good supply of household um, supplies and encouraging virtual communication amongst communities, and paying special attention to health care workers, that those strategies on the government level could also really help the population preserve wellness during this time.
Alex Raben: [00:24:26] Thanks, Randy. Uh, doctor Chacos, did you have anything to add to that list? Sure.
Dr. Deanna Chaukos: [00:24:33] Um. Actually I as I was listening to Randi talk about the different strategies, I wonder if it would if it would be helpful to think about strategies in response to some of the some of the. Problems that the pandemic has presented to us. And so, um, I've used this model before. It comes from one of my members, my mentors, Doctor Greg Fricchione, who talks about stress from an evolutionary biology perspective. And so I think it would be really helpful to think about pandemic stress in this context. So basically, as mammals, we're constantly trying to avoid separation threats. This is also an attachment perspective. Um, and as humans, our evolutionary resilience is that we seek attachment solutions. And many of the ways in which we stay well represent these attachment solutions. Um, so common separation threats for mammals, um, include loss of home and security. The pandemic, for example, has resulted in lost jobs for many people. Financial insecurity, um, another separation threat that we experience as humans is separation from health and the pandemic. Um, for health care workers, for medical students and residents who are who are on the front lines, um, not only have fear of being separated from their own health, but the health of their loved ones, and that represents another separation threat, separation from loved ones, from community, and from our sense of purpose. And so if we think about all of these limbic fears that we're experiencing as humans and as physicians right now, um, it's huge. This pandemic is causing us to experience separation on all fronts.
Dr. Deanna Chaukos: [00:26:36] Um, and so a lot of the things that we can do to remedy this very real threat, um. Comes from the attachment solutions. And so Randy talked about solutions like mindfulness. Um, mindfulness allows us to reconnect with purpose. It might also allow us to keep our head where our feet are. And think about what can we do in this moment to connect with the loved ones that we are physically separated from? Um. Similarly, I think that a lot of a lot of the stress right now comes from that separation, um, that we're physically distancing from our loved ones, and we're also working in different work environments that that make it so that our interactions with work colleagues are different. And so we're being forced to find new ways to connect, um, new ways to, to feel a part of the communities that we normally are a part of. Um, for for many of us, I think especially, um, the medical students who maybe moved to Toronto for medical school, many of the medical students and residents live alone. So many of the ways in which they connected with one another and stayed well before are not available to them right now because they can't go out for dinner after work, they can't meet their loved ones for brunch on the weekends. And so we need to really think about how do we continue to connect as a community when most of our coping strategies in that realm, um, might not be available to us?
Alex Raben: [00:28:27] Yeah, I think that's a really great point. This feeling of disconnection and how it relates to attachment and our, you know, our evolution, frankly, um, this is in us and it's important that we maintain it in some way. Um, how are people doing this? Uh, how are people maintaining connection? What are we recommending for medical learners with respect to this? And, you know, if any of you guys want to jump in with what strategies work for you, that'd be great too.
Dr. Deanna Chaukos: [00:29:02] I'll jump in while everyone is thinking about their own strategies. I think. I think now more than ever, maintaining connection is is hugely important. And so the example I know we're going to hear more about what the amazing medical students are doing. Um, but I think we've seen lots of lots of evidence of resilience from health care workers and from community members during this time. So we talked about one. Um, trying to find purpose where perhaps you were at risk for losing that purpose. I think we're seeing. We're seeing as you said, Alex. Um, these, these examples of our peers who are really stepping up. Um, whether it's to volunteer to be redeployed. Um, whether it's the care with which we see people. Um, caring for their patients on the front line, recognising that our patients are also separated from loved ones because they're not able to have they're not able to have visitors in the hospital. Um, and the tenderness and the compassion that we witness in each other, I think it's important to take a moment and notice those things. Um, one of idoukal psychiatry. So I've been in the general hospital lately, which in many ways has been a gift because I get to connect with my colleagues and see, see a lot of the positive.
Dr. Deanna Chaukos: [00:30:34] Testaments to resilience in our peers. But one of the social workers that I work with created a Covid bingo game. And she gave it to all of our peers. And the way that it works is that you have this bingo card, and on the card it has things like witnessed an act of kindness today, um, or observed someone give a air high five to a colleague. Um, or. Took a walk outside during a peaceful moment to get some fresh air, so it also includes wellness behaviours. Um, but what this card has done is it's required us to connect on something light-hearted. It's required us to to engage in humour. Um, one of the squares on the card was observed creative or unique ways of community members wearing masks. Um, and so I think like as, as health care workers, we see lots of very creative ways of wearing masks, including masks that are hanging around people's ears as they walk down the street. Um, and it's important that we engage humour as one of our most resilient, um, behaviours that we have as humans because, you know, we need to take the work seriously and, and learn how to be flexible with ourselves at the same time.
Alex Raben: [00:32:03] Know for sure. Yeah. I'm hearing, um, again, that sense of connection in there as well, along with the humour. Right. Having that back and forth and that sort of reciprocal moment and recognising those the great achievements and compassion that is happening right now, in addition to all the strife and difficulty. Um, yeah. Great. You had a point.
Grey Meckling: [00:32:29] I think there's. Yeah, there's just one thing that I could add, maybe to this discussion about how to maintain and support a sense of connection through this very difficult time. And one thing that I've been doing, and I've noticed a lot of my peers as well doing, is taking this opportunity of sheltering in place to really reach out to people that we may not have spoken to in a little while. I think there's very, um, or a lot of people feel like being inside can be very challenging. But, you know, a lot of us have moved on to zoom, and we're reaching out and scheduling meetings with other people. For example, I, I had a Skype call with some friends from high school just a week ago that I hadn't seen in a while. And so, oddly, as we are all sheltering in place, there has been sort of this different sense of community that we've been able to build online. And that's one thing that I've found really helpful during this time.
Alex Raben: [00:33:32] Such a good point, grey. And I've noticed that in my own life as well. Randy, it looked like you had a point to raise as well.
Randy: [00:33:39] Yeah, I was just going to echo what grey said, um, that I've been using this time to really connect with a lot more people who, I guess, you know, in the midst of all the busyness of medical school that I really neglected to do so. And some of those might just be my classmates who. Yeah, I used to see them a lot, and we used to talk a lot, but that was, you know, only in the context of academic things and clinical duties. But now we really get to open up to each other more. And you really do find that we do share so many similarities and just being able to talk to each other about, you know, the pressures we face during Covid, this, uh, expectation to stay productive during this time, it's, you know, just talking about it with someone who's going through the exact same thing. That's been really therapeutic for me.
Alex Raben: [00:34:29] Yeah for sure. So if I can summarise some of the things we've talked about in terms of helping with our own wellness as, as medical trainees, a lot of it has come down to connecting with others. Um, and this may be in different ways than we're used to, but it can still be meaningful. And it shows us even perhaps as grey you were mentioning in Randy as well, like other opportunities we may not have taken advantage of before, like reaching out to friends we haven't spoken to in a while. Uh, I also heard mindfulness. Just being aware of ourselves and what we're doing. Nature getting outside exercise in a physically distanced way. I know that has been particularly helpful for me. I'm fortunate to live close to trails where I can, you know, go out for a run and in a physically distanced way. And that really helps me reset, um, communication, just making sure we're, um, checking in and getting our, our information from trusted sources. Um, and then I think there was also a piece of staying away from the more maladaptive ways of coping, like alcohol, drugs, uh, things like that. Um, I've heard speaking of sort of information, I've seen a lot online around people talking about limiting their social media or their media consumption and that being perhaps a helpful intervention. Doctor Shawcross, do you have any thoughts on that as an intervention in this case?
Dr. Deanna Chaukos: [00:36:04] I've heard a lot of people describe that as well. Alex, one of the things that I've been involved in at Sinai, um, and I've feel it's been a great honour to be involved in this is resilience coaching of frontline health care workers. And in the early weeks, when the uncertainty I think about the pandemic was at its peak, one of the things that nurses and physicians talked about was that part of self-care was limiting consumption of some of the media about the pandemic, because there was this sense that other countries had been through what we were going to go through, and the anticipation of that was hugely anxiety provoking. Um, meanwhile, you're here in this moment trying to handle the stressors of this moment. And so I think limiting consumption and putting a boundary on that. I think maintaining healthy boundaries in general is another self-care behaviour that we haven't talked about. Um. Randy brought up that there's a big pressure to feel productive during this time for people who for the medical students who are sheltering in place or for other individuals who are working from home. Um, there have been studies that look at how people are working on their computers for more hours a day now, because the natural boundaries on work have disintegrated. And so thinking about self-care, yes, it's about exercise and healthy eating and sleep. Those are so important. And also maintaining healthy boundaries on something that, you know, work is a good thing. It gives us passion. It's a distraction, and we need to make sure that we have boundaries on that as well. Um, and boundaries on our consumption of the media right now.
Alex Raben: [00:38:07] Yeah. I think that that's a really good point, right? That it can be viewed as, uh, from a boundary perspective. Like at what point do you say enough's enough and I move on to something else? It's sort of that work life integration or balance or whatever you want wanted to discuss it as, um, if we're doing all of one thing all the time, that's not going to really keep us in a very balanced position. Uh, and I think just speaking personally, I felt like early on a lot of that for myself, like wanting to do more and looking for more and more opportunities. And then at some point it became a little bit too consuming. Um, and I had to find a, uh, a balance there. And that was, that was helpful. Um.
Dr. Deanna Chaukos: [00:38:52] Another, I think because now as we as we have progressed from the early weeks of the pandemic, we're now also getting to a point where the stress is becoming chronic. Um, and we talked a little bit about this and some of the helpful coping. But now more than ever, I think we need to really learn our own stress responses so that we can recognise what we each look like when we're stressed. Um, you described some maladaptive coping and how how those behaviours can be really harmful to an individual. Um, if we know our early signs of stress, the idea is that if we can recognise those, then we can maybe do something pre-emptively to intervene. Um, and attend to wellness. So like, for example, am I somebody who manifests stress? Um, cognitively, do I have a lot of self-deprecatory thoughts? Um, am I someone who manifests stress physically as muscle tension or fatigue? And when you're chronically stressed, it's important to also notice that stress response for what it is as a response, not as self. Um, because if we are chronically stressed for several weeks, it can be really easy to identify how we're feeling and how we're behaving as part of us. Um, and and not intervene appropriately with the wellness behaviours that we've been talking about with the self-care and the connection. Um. And then of course, noticing what about our stress response is particularly harmful drinking too much, eating too much. Um, and of course, the anxiety and depression that we're at risk for when we are chronically distressed.
Alex Raben: [00:41:00] Right. So really pay paying attention to the stress levels and also our response to them and not forgetting that this is still stressful. It's like it's as you say, it's almost becoming kind of our new normal in some way, but it's not normal, if that makes sense. It's very stressful. And so to not take that for granted either, um, and trying to reflect on how our adaptation to stress may be helping us or potentially hurting us.
Dr. Deanna Chaukos: [00:41:31] And having a stress response doesn't mean that we aren't also resilient. I think that resilience is sometimes equated to being made of Teflon, and that's not the case. Resilience isn't pretty. The path to resilience is experiencing the distress of this moment and of the pandemic. Resilience is, you know, being able to to actually sit with how we're all feeling right now, which is not not good. We are all so stressed by this. Um, and. I think a lot of the self-criticism that can arise from feeling chronically stressed can sometimes make us think that we're not doing this right. We're not handling it right. Um, and I just wanted to point out that the emotional experience of persevering is not a necessarily a positive emotional state. Um, but it doesn't mean that that you're not doing it right. Um, or that you're not doing everything you can in the moment.
Alex Raben: [00:42:47] Right. Which I think is a hugely important point, because we can add almost an extra layer of stress by being self-critical around this and, and thinking we're, you know, we're not doing it right. And that can spiral us, uh, in a negative direction, perhaps. And just being kind to ourselves and recognising we're all doing the best we can. Um, grey, I want to I want to turn over to you, because for this sort of third section or last section of our time together today, which is how do we take these lessons of what we know about wellness and how Covid has impacted us, and how we can help ourselves as medical trainees in this time? Um, and, and take all that and how do we help others, um, or our colleagues or like, how do we, you know, take what we've learned here and, um, put it to action in an altruistic way. And we had already discussed how you guys, as medical students, are doing this on a grand scale in this country and in others as well. Um, and, um, yeah. How do we what lessons have we learned there? Yeah.
Grey Meckling: [00:44:00] Alex. So I agree, it's a hugely important topic, and I think it's important to recognise that we can all play a role to help maintain everyone's wellness, especially in the clinical environments. And if we see others who are maybe struggling with burnout, there are some important steps we can take. So we'll be referencing a number of articles in the show notes. There was one that I found from the Canadian Medical Association, and they recommended a really nice approach. And so if you want to help someone with burnout, they recommended first noticing the signs of burnout. The signs and symptoms of burnout in our colleagues. And those can even be subtle things. We touched on some of them earlier, and I would encourage people to review those so we can really pick up on them in other people. And then if you do notice that people are struggling with burnout, there's this nice acronym. Um, it's called help. And so this acronym is really geared at providing peer support. And so the H is to really just ask someone, how are you doing? The E and the acronym is to remember to be empathic and show understanding. The L is to listen non-judgmentally and state your concerns about the situation or their wellness. And then the P is to plan the next steps. And that's really a key piece, um, either to encourage them to seek formal support or ask how you can help. So I really like that acronym. Um, I think it was a good place to start, and that would maybe be one tool that we can use to help people deal with burnout.
Alex Raben: [00:45:35] Yeah that's great. And I like how it gives you sort of a practical approach in the moment with a colleague, because I think that's where this may come up. Right. You're having a discussion, you're trying to connect with your colleagues and then you find out, oh, this person is maybe not doing as well as you had thought, or there's something that comes up as a concern. And this gives you sort of a, an approach to how you might tackle that. Uh, Dina, did you have anything to add to that approach? Like what? What what's your approach when you see someone like a resident in your office who's maybe struggling? Um, in this time.
Dr. Deanna Chaukos: [00:46:13] I think it's very similar to what grey described. Um. We, as I said at the beginning, statistically speaking, we've all experienced burnout and it's different for each of us. And so I think approaching our our inquiry to our colleagues with humility and with curiosity, meaning we want to understand what what we're each going through. Um, it can be really hard to initiate those conversations in medicine, because it's not traditionally the culture of medicine to allow for this kind of connection. And so, um, in my role, like one of the things that I think about a lot is how do we change the culture? How do we make it so that it's intuitive and natural for us to reach out to each other and check in to see how we're doing? And I think part of how we do that is by sharing ourselves, um, that burnout is this universal experience. Um, and part of the reason why it is, is because we see such challenging and painful, um, things in the work that we do. We bear witness to suffering. And so I think for us to take care of each other as a community is a really important culture shift. I think the ways that we can make that part of the culture is by making systemic changes to the learning environment. Some of some of how that's done is just by having conversations like this. Um, but making making these conversations a formal part of the medical school curriculum, um, which it has been over the past several years. Um, or having curricula that create a space for residents to connect with each other about how they stay. Well. Um, which naturally opens up an opportunity to talk about how the stresses of the learning environment impact us in different ways. These types of initiatives. Um. Are not going to necessarily change the experience of burnout on the individual level, but my hope is that over time, they'll change culture such that the learning environment can support more people to be. Well, um, does that make sense?
Alex Raben: [00:48:48] That makes a lot of sense. And it actually kind of feels like it ties back into that topic about resilience and how it's not necessarily pretty. And it can be, um, quite challenging, uh, for individuals. And the reason I say that is because, um, I think in this culture of medicine, sometimes we, we think of resilience as being as you were putting it, Deanna, being Teflon, and that if you're Teflon, you'll be okay. And so, you know, people who are in that, uh, mode of thinking are probably not going to be reaching out for help if they're starting to feel burnt out. Um, and so having these kinds of conversations, having an integrated into the, into medical education, I think is hugely important for shifting that idea to one where people can feel free to reach out more and, you know, go through this Help acronym that, uh, grey nicely talked about. Because if you don't get to that first part of the acronym, that how how are you feeling? And you can't really get an an honest answer to that, then you're not going to really have much impact, unfortunately for that person. Totally.
Dr. Deanna Chaukos: [00:49:58] We need to we need to challenge the culture of heroics and stoicism. Um, you know, wellness, it's wellness as a pursuit in medicine needs to be a dialectic, because so many of the things that we need to do to stay well are challenged or threatened by the busy schedules and the rigorous work that we do. And so we need to infuse some flexibility in how we approach burnout and well-being as physicians. Um, sort of living the full catastrophe.
Alex Raben: [00:50:34] For sure. This culture change also made me think about these amazing initiatives that our medical students are doing. Um, you know, they've taken this difficult time and turned it into an amazing opportunity, uh, to be altruistic and to show, uh, such compassion. Uh, I'm wondering, grey, if you could, um, maybe speak more to that because I know you, uh, had had done some looking, like, looked into that. Sorry for us.
Grey Meckling: [00:51:04] Definitely. And this is another thing we'll link to in the show notes. And we touched on it a little bit earlier, but as you say, there are just so many amazing initiatives that have been popping up really all across the country. I think every medical school now has numerous student led initiatives. And, you know, some of them are things we briefly touched on. There's students who are setting up Google Forms for child care, for, um, doing grocery runs, doing coffee runs and all these sorts of things. Um, some of our colleagues at the University of Toronto have also been collecting and donating PPE to local hospitals. Um, you know, collecting them from dentist's office that may be closed or any other health care setting that may have extra resources. So those are two really amazing initiatives. And I read about another one, um, where University of Toronto students were starting this program to stay connected with seniors. They were offering a call line, um, because there's a lot of seniors who are, of course, very vulnerable, and they may be sheltering in place at their their residential home. So just all of these different, um, resources, I think, really are an initiatives rather really are helping maintain this sense of wellness within the public and really among some of the most vulnerable, um, groups.
Dr. Deanna Chaukos: [00:52:25] It's amazing. It's really terrific. Um, when I read about some of these initiatives, actually, the way that I learned about the U of T initiative was from a physician Mom Facebook group that I'm a part of. And so many, so many people were so relieved. Um, and and touched by what the medical students have done locally. It's had a huge impact.
Alex Raben: [00:52:53] Yeah. Thank you guys. And and yeah it's just unreal what you guys are doing. And I and I've heard other initiatives across the country as well. I think out in Alberta they were medical students there were helping with testing and increase the capacity substantially and just unreal. Uh, the way that you guys have tackled such a difficult situation. Um, and, you know, in terms of a wellness, an additional wellness point, just recognising this, I think, is, uh, as you were saying, Dana, just recognising the good that is coming from this is so important.
Dr. Deanna Chaukos: [00:53:24] Yeah. The silver linings, I think noticing, um, noticing the things that we can feel gratitude for, we haven't talked about that as a, as an adaptive perspective yet, but I think, um, this initiative really manifests that.
Alex Raben: [00:53:42] Definitely. Um, grey, I want to go back to your acronym, the Help acronym, which is the, you know, how how are you doing, the empathic stance, the listening non-judgmentally to the person and then creating a co-creating a plan with them. And I want to go down to that last point, the co-creation of a plan. What are the practical things we can advise someone to do, or we could help co-create with someone? What are the resources they have at their disposal? I know we have a lot of international listeners and listeners out of province, so a lot of these will be probably more specific to Toronto, but I imagine that other jurisdictions have similar opportunities. And so hopefully that it's still something that's worth going through for for those listeners who aren't in Toronto.
Grey Meckling: [00:54:33] Yeah. Thanks, Alex. So one approach I found in the literature was to maybe think about addressing burnout or stress really in the acute phase, and then also thinking about sort of a longer terme plan to prevent burnout over the course of, say, a residency or over the course of a career. And so really, in the immediate phase, I read about something called psychological or mental health first aid, which may be useful in an acute setting. And I would love Doctor Chacos to elaborate on that a little bit more. And then maybe in terms of follow up and more long terme strategies, there was a lot of the same recommendations that we would use for ourself. We could recommend for other people. So these are things like staying well by eating, sleeping regularly, having a good diet, and all of the strategies we discussed earlier, um, that Randy pointed out so well. And then just finally, in terms of specific resources, I think each medical school or most, if not all in the country would have their own wellness offices. Residency programs, have wellness offices. And so those websites would be really important resources that people could turn to. And we'll we'll put some of those in the show notes. And I really encourage people to look up those, those resources in their, in their local jurisdiction. And then there's professional organisations that are putting out a lot of material, especially as it relates to Covid 19. So these are things like the Canadian Psychiatric Association, the American Psychiatric Association, Cam, for example, the centre for Addiction and Mental Health in Toronto. And so there's just a lot of resources that are available online now. And um, Doctor Chochos, if you had any to add or respond in this, um, in this conversation, that would be great.
Dr. Deanna Chaukos: [00:56:22] Thanks. Great. Those are are terrific resources that you've described. Um, you asked about psychological first aid, which I think is particularly relevant right now in the context of the pandemic. And if I try and summarise the principles of psychological first aid, it's basically to help to help individual individuals experience a sense of safety and security. And so that can be fostered by providing important information. So at the beginning of this pandemic, a lot of people had fears about, um, adequacy of PPE or supplies of PPE, for example. And so the Toronto hospitals, um, were able to provide their frontline workers with information about this, trying to help people understand, um, as much as they as they want to know about what their what their concerns are. And obviously, there's a lot of uncertainty with respect to the pandemic. Um, that can't necessarily be answered, but creating spaces where people can have their questions attended to is really important. Um, doctor Bob Maunder and and John Hunter have our attachment resource researchers and also have done some amazing work about health care workers under pressure from the SARS epidemic. And they've created a video that's called coping with Covid for Health Care Workers. And in the video, they talk about, um, dealing with the problems that can be dealt with and problem solving those. Um, so, for example, getting your questions answered about PPE, then for things that don't necessarily have an answer, attending to the emotional response, um, and developing coping strategies for those difficult emotions. And then the third part of the video talks about connecting to meaning and finding a way to feel purposeful in a setting that perhaps threatens your connection to meaning otherwise. And so the solutions that the medical students have found at U of T and across the country is an amazing example of that. Um, I can send you the video if you'd like. It's it's a really helpful resource. I think the other pieces that you, that you talked about really hit those three areas that we've talked about today self-care and maintaining healthy boundaries, recognising early signs of stress. Um, and then the connecting to meaning piece.
Alex Raben: [00:59:18] That's terrific. And I think. And, um. And I think that some of these things are also summarised in an infographic that, uh. Uh, here producer here at U of T and Diana. Were you involved in that, I think?
Dr. Deanna Chaukos: [00:59:31] No, I'm just a huge fan of it, so. Yasmine Nasser Zahedi and Nikita singal were involved in developing this, this gorgeous infographic that is geared towards residents and has been shared broadly because of how useful it is. Um, that infographic does a lot of psychological first aid principles. It gives residents information about safe donning and doffing of PPE. It answers a lot of questions that people have with respect to fears about the pandemic, and it also provides coping strategies for some of the difficult emotions that we're all feeling in response to the pandemic.
Alex Raben: [01:00:16] Yeah, I thought I think it's an excellent resource. And, um, um, Nikita, who co-created this, uh, is also part of the podcast and helps us with our infographics. So I know she does a wonderful job on these and so talented. Yeah. So talented. And we'll we'll be sure to link to that in the show notes. Um, a lot of Toronto specific stuff, but I think also very, uh, broad uh, applications as well. So please have a look. Um, we am I wanted to hand it over to you just as we're nearing the end here, because we had reached out to you guys, the listeners, um, to get a sense of how Covid is impacting you because you're also, uh, medical learners. And, uh, William, could you speak to that? And I know we had one person actually, uh, write in and maybe we could, uh, paraphrase some of what they had said to us and see if how we feel about it and what, you know, comes of that.
William C: [01:01:18] Yeah. For sure. Uh, as you mentioned, um, we here at psych, we post a question to our lovely audience, uh, to kind of ask how Covid 19, the pandemic, has impacted their wellness, uh, if at all. And, uh, we ask this question on various platforms, Facebook, Twitter and Instagram. And not surprisingly, uh, we we saw that wellness was affected by the pandemic by a lot of our listeners. Uh, I think depending on the platform, from Instagram to, uh, Facebook, for example, it ranged between 70 to 100%, uh, of our audience listeners has impacted where the wellness was impacted by the pandemic to different degrees. Uh, and at least 70% of the respondents on Twitter ranked that as being moderately or significantly, uh, affected in terms of their wellness.
Alex Raben: [01:02:09] So thanks for, um, for, um, for that. Yeah. I will talk more about this response that we got from a listener who wrote in to us. And yeah, please do write in if you have thoughts of how your how you know, how you're coping or strategies that have been helpful for you, feel free to write in to us. We always love to hear from you and get your feedback. Psyched podcast at gmail.com. So this listener, um, would like to remain anonymous, but I'll read some of her, uh, or paraphrase some of what she wrote. Uh, and what she had said is that even prior to Covid, she had been struggling. She had been in a difficult personal, uh, relationship. And she was seeing a psychologist. And essentially, when Covid hit, that office shut down. Um, and she was struggling even more because of that and didn't want to start over with someone new, which, you know, is a difficult thing when you're in therapy and you've formed a really close relationship with someone to move to someone else's, it's a challenge. Um, she, however, also, uh, found time to focus on the positive, uh, and doing things that she enjoyed.
Alex Raben: [01:03:25] And she had come to accept a lot of, you know, what was going on and that some days will be okay and some days will not be okay. She wrote us back as well, a few days later, to just say that she had done some thinking about her disabilities. She had some physical pre-existing disabilities and how that might impact her in terms of Covid. And, uh, she had she asked the question, you know, um, you know, because she has these disabilities, if she were to contract the virus, would her life be deemed worth saving? And that was kind of a chilling thought that she had and something that was bothering her at that time. I'm just wondering, you know, hearing from our our listener. Who's, you know, struggling and also showing signs of resilience, I think. You know, I guess what do we what do we make of her experience is this, you know, a common one, uh, and how might we help her? What what advice would we give to her?
Dr. Deanna Chaukos: [01:04:27] I think she brings up so many important points. Um. The first being that because communication has changed in its nature now. Um. There are so many individuals who are struggling with the fact that they can't access their health care providers, though I, I hope that most clinics are finding ways to connect virtually with their patients. Some might not be able to, and that's a huge additional stressor. I think another important. Point that the listener made is, is the experience of moral distress that that many physicians and individuals, um, might be experiencing as a result of the pandemic she brought up. The fear that. That when resources become scarce, would society be forced to make um. And in the example that she brought up the unsettling and morally distressing idea of of deciding whose lives are are to be saved over another. And I think that is is such a painful consideration. Right. Um, and it's one that I think physicians are worried about, of course, individuals. Um, who are who are coping with any number of, of, um, things right now are concerned about. It's pointing out. Aspects of our society that were problematic before the pandemic that are becoming problematic in a new way now. Um, specifically around, uh, prejudices, um, and disparities in our communities.
Alex Raben: [01:06:34] Yeah, absolutely. It it really ties in all the things we were talking about, right? That, you know, of course, life has its struggles, uh, even outside of a pandemic situation in this, this, uh, woman was experiencing that. And then it was compounded by what was going on, and, and just the change in dynamics that she had to face there. And these larger moral questions, existential questions as well. Um, and, uh, you know, I think, uh, as we were talking about before, like a lot of the strategies we were talking about, I think could easily apply in her situation, right, that she could have access to these resources as well, you know, paying attention to these new ways in which she can connect with others, uh, looking for those virtual opportunities for help. Um, even if it isn't what she had before, it may be something that can still provide care and provide for her wellness.
Dr. Deanna Chaukos: [01:07:34] At a systems level. I think it's also really important to point out that, um, this is important in the pandemic, but also for medicine in general. If we're aiming to create a culture of wellness that's also about creating safe environments free of intimidation and harassment, environments that support individuals regardless of race, gender, ability and socioeconomic status to thrive. And so if we think about wellness, Maslow's hierarchy of needs is applicable to write. Wellness can only be achieved when all of our other basic needs are met. Um, so safety and equity is part of that, right?
Alex Raben: [01:08:14] Absolutely. And, grey, I think you had a final question you wanted to end on, uh, so that we're ending on a positive note and looking forward to the to what comes in the future.
Grey Meckling: [01:08:29] Yeah. Thanks, Alex. So maybe on a final note, we were wondering if there are any opportunities or new developments, maybe reasons to be optimistic that are coming out of the Covid 19 pandemic in terms of mental health, wellness and burnout in general. One example that I can think of might be the increased media attention, for example, on health care worker wellness. So did you have any thoughts on that, doctor Chacos?
Dr. Deanna Chaukos: [01:08:58] Yeah, I think there's a few things, um, individually in my practice, a few of, um. My patients, and I know colleagues have described this as well, have mentioned that connecting with their providers virtually has actually created, um. A different kind of connection and comfort that if you're able to connect with your providers from home, an environment in which you feel safe and perhaps more reflective, it's allowing for a different kind of care to be fostered. And so I do think that we'll continue to learn about the ways that we've been providing care through telemedicine and virtually, um, in these more flexible contexts. I think that we'll learn that it might actually be more patient centred in some examples, not all, but in some. Um, I think that we're learning a lot from, um, from a psychiatric perspective, at least from these resilience coaching efforts that have been developed. Um, I told you a little bit about the one that I'm involved in at Mount Sinai Hospital, led by doctor Bob Monder and Doctor Leslie Weisenfeld, basically attaching psychiatrists to frontline health care units, um, to provide principles of psychological first aid and support. Um, and I think that I think that by attending to frontline health care worker wellness, as people are going through the pandemic is hugely important and shining a light on well-being in a way that maybe hasn't been done before. And cam is also doing that by creating a self-referral process for frontline health care workers to access. Their own treatment. Um, and I can send the link for that as well, so that you all have it. Um, I think there are going to be silver linings, and the fact that we're looking for them is part of our adaptive coping as well.
Alex Raben: [01:11:17] For sure. And yeah, and on that note, I do truly hope that this episode serves that purpose as well. Right? That I certainly feel, uh, nice and connected in this moment, seeing all of you on the screen and being able to have such an interesting and engaged conversation. And I hope the listener is able to feel that as well. And, and, you know, I hope that these recommendations and reviewing all of this, uh, serves that purpose, too. I want to thank all of you for being on the show, and I want to thank you guys for creating this episode. Uh, and of course, thank you to the listener, as always, for listening. We'll see you next time. Psyched is a resident initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was led by Grey Mechling and also produced by Alex Rabin, Randy Wang and William Sufian. This episode was audio edited and hosted by Alex Rabin. This episode was co-hosted by Grey Mechling, Randy Wang, and William Sethian. Our theme song is Working Solutions by Olive musique. A special thanks to our incredible guest, Doctor Deanna Chacos, for helping us navigate through this very important topic. You can contact us at any time at Psyched Podcast at gmail.com or visit us at Psyched Podcast. Org. Thank you so much for listening.