Staying psychologically safe as a doctor during the COVID-19 pandemic.

Introduction

As we face the ongoing global pandemic of COVID-19, doctors, nurses, ambulance officers, paramedics and many other health workers answer the call to serve in time-pressured, unfamiliar, chaotic and often-traumatic environments.1 We know how to look after ourselves in an infectious physical environment, but it is equally important to look after ourselves psychologically at this time. We have all been exposed in different ways, for instance, the role of a General Practitioner (Family Physician) will vary in the different healthcare systems throughout the world—some will be at the forefront, others will be doing telehealth, or may find themselves back in a hospital situation.

With long hours, an often unmanageable workload, lack of personal protection equipment, distressed patients, fake news and the prospect of this continuing into the future, doctors are at high risk of burn-out.1–3 The features of burn-out are emotional exhaustion, low personal accomplishment and depersonalisation, and the consequences of burn-out on the doctors and their patients can be profound and long-lasting.2–4 In crises, doctors are also at risk of vicarious trauma as we listen to stories from our patients of illness, death, grief, hardship, unemployment, domestic violence and suicide.5 This is at a time when we are physically distancing from our family and friends, with little time to exercise and possibly without sufficient access to healthy food or fresh air.

Such an ongoing crisis is likely to leave us emotionally overextended, exhausted, feeling alone, afraid, insecure, hopeless, frustrated, have difficulty concentrating and unable to access our usual support network.3 5 In addition, we will often be called on to take more stressful leadership, advocacy or educational roles. Many respond to stress with irritability, a demanding tone, or hopelessness, which can ‘infect’ others.5 Alternatively, the responsibility of staying resilient at work may mean that our families are only seeing a dysfunctional side of us at a time when they also need us to support and comfort them.

It is imperative that we are intentional in how we look after our psychological health. The COVID-19 pandemic is ‘not a sprint but a marathon’, and we need to ensure that our minds and bodies are healthy enough to endure.3 Many of our usual social structures will be disrupted—we may not have our normal family and friends around us, or might be working from home and have lost the boundaries between work and home. It is a time of much ‘doing’, but we need to still find time to just ‘be’.6

It is vital that we maintain our self-compassion and prevent compassion fatigue. We can act as Neff and Germer advise ‘to extend compassion towards ourselves when we experience suffering’.7 Compassion fatigue occurs when we are no longer able to preserve our capacity and interest in being empathic and hearing the suffering of our patients.8 We need to develop protective mechanisms in order to reduce compassion stress and enhance resilience with adequate self-care, compassion satisfaction and social support.9

The five principles of self-care

We propose a helpful way to approach self-care using the principles of Preparation, Protection, Professionalism, Promotion and Pathway of care (table 1).

Table 1

Principles of Self care

Preparation	Maintain optimum sleep, diet and exercise, hobbies.Accept vulnerability in all spheres.
Protection	Monitor own physical and emotional health.Be attuned to any early warning signs.
Professionalism	Limit COVID-19 information to a few reliable sources.Don’t infect others with COVID-19, or with hopelessness.
Promotion	Be a role model for staff, patients and students.Keep calm, look after others and use self-compassion.This will flow to others.
Pathways	Ensure to see own family doctor as needed.

Preparation

As with any marathon, preparation involves optimum sleep, good diet and exercise.1 Avoiding fatigue and sleep deprivation is difficult, because of the long hours, heightened sense of responsibility and cognitive overload, but also because of the uncertainty of the situation, and the lack of ‘success’ experiences.3

Acknowledging the sense of vulnerability we are left with, and doing our utmost to switch off at night is incredibly important. There are many meditation and sleep apps available (eg, Headspace, Buddhify, Calm) and having a simple bedtime routine should be priority. It is tempting to use alcohol or smoking to ‘settle your nerves’ at the end of a long hard day, but this will be detrimental to restful sleep. Night-time wakefulness will be common, and in the current climate we will often want to quickly look at the news or social media, but the evening blue-light from TV, computer or phone screens, and sense of urgency or fear, are also very bad for healthy sleep.

Eating on the run will only sustain us for a short period of time. We need strong immune systems and good hydration. Storing food, cooking and freezing healthy meals, and taking fruit, nuts and vegetables as snacks during the day will keep us going longer.

For many of us, our usual gyms and swimming pools will be closed. There will still be online exercise programmes, outdoor gyms and local parklands.1 It will be difficult to find time to listen to music, read, knit, cook—whatever our usual hobbies are—but factoring this into our schedule will benefit us enormously.

Building up a ‘resilience schedule’ can be helpful, for example:

Listing the 10 ingredients in our ‘well-being recipe’

A gratitude diary, planning a joyful moment each day

A quiet moment of mindfulness regularly in the day

Connection to land or relationships

Appreciative reflection

Time with pets or loved beings.

As the duration of the pandemic becomes longer, we may become tired pushing ourselves to follow these steps. We need to persevere with these measures and to continue to cheer each other on.

Many of us will be juggling many new balls right now—social and community disruption, financial problems, childcare, elderly parents, caring for the household. We cannot do this by ourselves, so it is essential that we find help wherever we can.

Protection

This is about feeling confident that we are physically safe from COVID-19 as much as possible. We know how to do this at work, but we also need to look after ourselves and our more vulnerable loved ones as much as possible. We all have innate resilience and have survived many crises—personal and professional—up until now. Harnessing these skills can help with this new situation. We will be anxious and often distressed, but we need to focus on what is under our control, take it step by step, and not give our negative thoughts too much power.

Make sure you take your medication, have your COVID-19 and influenza vaccinations, and attend to your own health. Enacting our parasympathetic nervous system to counteract the overactive stress response is easily done with deep exhalations, attention to the digestive tract, hydration and muscular relaxation. Activating our endorphins will also help through combinations of music, laughter, singing, exercise, appreciation of nature and meditation.

Do not let your guard down because you are tired and stressed, and do not answer calls from sick friends and relatives to visit them. We need to protect ourselves first, or we will not be able to help others. Keep your boundaries clear in your mind around your own risk aversity and do not negotiate when asked to step beyond those.

If you are working from home doing telehealth, make sure the rest of the family know not to disturb you. A colleague made a useful sign on her study door at home saying: ‘Your mother is not here. The person you see inside this room is not your mother. It is a doctor working saving lives. She can perform no parental functions of any type for the time being (unless it is an emergency). Please do not disturb her until this notice is removed from the door’.

We should continue our physical separation, but we need to increase our social connectedness. Our friends, family and community are our greatest protection from stress and burn-out, yet at this time we may be isolated from them. For some there has become a stigma associated with being a healthcare worker and we have been cast out as others are afraid we may be infectious. Some doctors whose physical or mental health is more vulnerable may choose to stay at home, but there is a risk of being bullied by those who continue to work.

Some examples of staying connected online might be:

Building online communities and connections, even having coffee, dinner, or Friday night drinks online in a community is possible.

Many religious institutions, choirs and learning environments are now online. Our support communities are still there, and now might be a time to reconnect with them.1

An online Balint group or peer support group may be an answer, where we talk about our own doubts and anxieties related to our clinical work. These help us to build up our resilience, sense of coherence10 and self-efficacy.11

Find the small positives from the crisis, including that we are able to do something constructive to assist, whereas many are in lockdown with no employment.

Professionalism

It is easy to become caught up in the many unreliable claims from online information. Maintaining an evidence-based stance is important. Avoid looking at social media and the many news sites available. Choose only one or two reputable sources of information and only look at those. Especially do not start and end the day looking at the news.

Part of promoting hope is having a ‘growth mindset’ and not ruminating on our ‘failures’ or what we do not know.12 There are so many unknowns in the current situation. We are constantly learning and growing in our understanding or what we and others are capable of. In fact, the leverage of systems disruption could lead to culture and paradigm shifts that greatly enhance our collective resilience in the long run. Taking a systems-lens to these complexities can enhance our sense of agency and service.

Remember that hopelessness is infectious and try to maintain a calm and positive manner with colleagues—while allowing ourselves to fully embody the authentic emotions when we are in trusted spaces. We are not fully responsible for solving the current problems, but we can listen to the frustration and distress of our own inner voice and of those around us. We need to make sure we are fully present in the moment and accept our feelings without judgement or evaluation. It is important to accept what we have done well and the limits of what we can do under the circumstances.13

Doctors are renowned for ‘presenteeism’—going to work when sick. At this time we need to take particular notice of our own health and support our colleagues to stay home if they are unwell.3

Promote hope, self-efficiency and care for others

Whether we choose it or not, we are leaders and role models for others, especially staff, students and patients. At this time of crisis it is more difficult to maintain the balance between safety and allowing staff the independence they need to feel they have some control over their work lives.

Bringing everyone back to the core principles of working together and looking after each other will be helpful. Finding the core values that we share, reminding ourselves of these and moving forward together. Our own self-compassion will flow onto others as we practice self-kindness, have a sense of common humanity and mindfulness.5 7

If, as a doctor, we are required to self-isolate, it is important to continue to have a sense of being useful. It may be possible to consult by video-link or phone, or do telephone triage. Creative thinking will be needed as we are accustomed to being useful—examples might be:

Assisting older people who are not computer literate by doing online shopping

Writing journal articles

Running an online support group or tutorial group for students

Advocating for vulnerable communities.

If we see a colleague struggling, ask if they are okay and encourage them to debrief, look after themselves and seek help if needed. Listening and supporting can make an enormous difference. Acknowledging that as doctors we are used to trying to solve everyone else’s problems—but that this is actually an impossible task. We too are human, have human needs and human failings, and medicine is extremely complex and often unsupportive.

Those of us in leadership positions need to ensure that our staff are safe and that there is transparent communication with an environment where staff can speak openly about their concerns. It may be possible to adjust staffing schedules so that we can rotate workers between higher and lower stress functions and allow flexibility for those with who need to care for family members. More senior physicians can provide support and monitor the safety and well-being of junior colleagues and staff. Many studies have found that there is a high prevalence of depression, anxiety, burn-out, compassion fatigue, insomnia and distress in healthcare workers treating patients with COVID-19.2 3 5 14

Pathway of care

Many doctors do not have a consistent relationship with a Family Physician, General Practitioner or primary care team.15 Most doctors use a blend of formal and informal methods to manage their own health. But there are many who have ignored both physical and mental health symptoms, made an incorrect self-diagnosis or endured unnecessary treatment delays because they did not seek timely, formal healthcare from an independent practitioner. Being a patient, and not the doctor, is not easy but the current circumstances can be an opportunity to access good healthcare for ourselves.

We should be clear about our needs, as well as acknowledge when treating a colleague that shared decision making, different referral pathways and informed consent are of the utmost importance.16 There are online courses to learn how to be a doctor/patient and a doctor for doctors.17

The treating doctor should:

Allow sufficient time

Maintain their professional stance as the treating doctor

Not discuss what has happened in the consultations at social events

Reassure us that records are completely confidential

Be thorough and prepared to ask the usual uncomfortable questions

Maintain good records, recalls and preventive care

Show empathy.

Many colleges, hospitals and organisations have Physician Support services to account for psychological needs.3 Now is the time to solidify your connection to a person who can hold space for the myriad emotions that arise during a traumatic event. Even if you are feeling resilient and emotionally regulated, there will potentially come a time where you may strain to cope with the trauma witnessed or experienced. Having a solid and attuned relationship established with a support person, agreeing on appropriate interventions, and knowing you have an existing supportive framework is a worthwhile pathway.

There are multiple modalities when it comes to psychological support, including cognitive and somatic frameworks (some examples in table 2). Many physicians relate to the thinking-brain’s ‘top-down’ approach and are used to engaging the neocortex in sorting through critical thought processes or cognitive schemas. However, for many, trauma is embodied in our tissues,18 and it might take a physical act to unlock this tension (‘bottom-up’ phenomenon). Participating in movement such as dance, yoga, or Qigong can be deeply healing—it is impossible for the amygdala to host trauma in a calm physiological state.

Table 2

Resources

Allen C. 16 March 2020. How to protect your mental health during a quarantine	Https://news.virginia.edu/content/how-protect-your-mental-health-during-quarantine
AMA. Managing mental health during COVID-19	https://www.ama-assn.org/delivering-care/public-health/managing-mental-health-during-covid-19
Australian Psychological Society. March 2020	https://www.psychology.org.au/getmedia/38073179-4701-48bd-afd9-988c560ee2f9/20APS-IS-COVID-19-P1.pdf
Black dog Institute. 10 tips for managing anxiety during COVID-19. 20 March 2020	https://blackdoginstitute.org.au/news/news-detail/2020/03/20/10-tips-for-managing-anxiety-during-covid-19
Headspace	https://www.headspace.com/health-covid-19
International Balint Federation	https://www.balintinternational.com/about-us/
Doctors Health SA	http://doctorshealthsa.com.au/covid19
National Academy of Medicine	https://nam.edu/clinicianwellbeing/
Mental Health at Work	https://www.mentalhealthatwork.org.uk/toolkit/coronavirus-and-isolation-supporting-yourself-and-your-colleagues/
WHO. Mental health and psychosocial considerations during Covid-19 outbreak. 12 March 2020	https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_10
WHO. Psychological first aid: Guide for field workers. 2011	https://www.who.int/mental_health/publications/guide_field_workers/en/
Vital talk. COVID-ready communication Skills	https://www.vitaltalk.org/guides/covid-19-communication-skills/

Conclusion

For many health professionals in the world, this crisis is the first time we have had to deal with severe disruption to our personal and professional lives.2 For others, this adds to already stretched resources, compassion and resilience. We need to care for ourselves and our colleagues as we are also at risk of ‘post-corona stress disorder’.

Hopefully, on the other side we will be more aware of the importance of our relationships and our small objects of gratitude. We will find new strength, meaning and courage in ourselves and have a deeper awareness and respect for our collective resilience.

Let’s do this together.