Mental health and the pandemic

Writing is my therapy. I am not a mental health clinician. I am just a surgeon who grapple with these issues within myself, my colleagues and the patients I see daily. Many of you are much more experienced and better trained to speak into this space. I will not do justice in this blogpost to the breadth, depth and complexity of the spectrum of human mental health conditions. We will never be able to delineate and break things into neat compartments, because we’re humans and that’s what makes us unique.

The words “mental health” have been used a lot during this pandemic. Sometimes to the point of being used as a political weapon. When I ponder and meditate on my big emotions during this pandemic, I realise that there are differences between stress, exhaustion, burnout, moral distress, compassion fatigue & mental illness. What do I mean?

Stress

Stress is a natural physiological and psychological response to a challenge. Work is stressful. COVID is stressful. School is stressful. Weightlifting is episodic stress on muscles to build muscle resilience. Life is full of stresses. There is a spectrum of normal stress. Some stress is good for you. Exam stress and work stress train your mind to excel.

Exhaustion

Exhaustion is a natural physical side effect of working hard. Training and exercise, long working hours, consecutive shifts, lack of breaks, prolonged exercise, etc all result in physical exhaustion. It’s normal to be exhausted after a marathon at work. You can be exhausted, but be absolutely satisfied as I often experience after a whole day of operating.

Burnout

Burnout is an occupational psychological state characterised by cynicism/disengagement, emotional exhaustion and lack of efficacy. This is often due to poor work environment or toxic workplace culture. You can be stressed and exhausted, but be happy at work and not burned out. Similarly, you can be burned out in a low productivity job if there was significant prolonged negative culture.

Moral distress

Moral distress (moral injury or anguish) is the state of knowing the right thing to do but the inability to do it because of restrictions. You want to help a patient, but you can’t because there’s no ICU bed is moral distress. Not burnout. Needing PPE but having none is moral distress. Knowing the horrible state of affairs in your institution but being unable to change it is moral injury. Seeing a patient needing oxygen but being unable to offer higher level of respiratory support is moral injury.

Compassion fatigue

Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring. Sometimes referred to as secondary traumatic stress. This is many of us who have seen hundreds of COVID patients turn up in Emergency, ward or ICU. We plug them on oxygen and we move on to the next one without compassion because we know the next patient just needs the same thing again and again.

Mental illness

Mental illness is a medical/psychiatric condition with strict categorical definition based on DSM-V and ICD10. This is a diagnosis made by a mental health professional or a GP/Family Physician much like other medical conditions. I cannot define depression, anxiety, PTSD for you. It is the domain of the GP and mental health professional.

Interconnected

Of course, the above experiences are all valid and interconnected. You can be stressed without having compassion fatigue. You can be diagnosed with depression and not have burnout. You can be burned out but not have moral distress. They are different shades of the human experience. COVID is stressful for all. Health care workers are experiencing stress, exhaustion, moral distress, compassion fatigue, burnout and some even reach a diagnosis of depression.

The solutions?

Stress: manage the amount of work and consider breaks. Exhaustion: rest, sleep, nutrition, exercise. Burnout: occupational cultural change. Moral distress: ethics of resources. Compassion fatigue: rest, social support. Mental illness: mental health professional. The solutions to these challenges are unique. Antidepressant will not fix a toxic workplace. Lack of PPE will not fix compassion fatigue. Cutting workload down will not completely fix depression. Target the right solutions to the right challenge. We’re all humans. The solution to one isn’t the solution to the other. When I’m exhausted, I sleep. When stressed, take a break or call for help. Last year having proper airborne PPE gave me a massive boost against my moral distress. Having close colleagues with similar values and many others who work in the space of cultural change protected me against occupational burnout. We worked collectively to improve occupational health, and I saw purpose at work. My colleagues & team replenished me and protected me against compassion fatigue. Pandemic was stressful, exhausting and pushed us to moral distress and burnout. But these things in themselves did not meet the criteria of mental illness diagnoses.

Grief

One other big emotion that we do not often talk about during this pandemic is grief. Grief is mental or emotional suffering or distress caused by loss or regret, usually the sorrow from a death of a loved one. Millions of lives have been lost, and the grief is truly global. In addition, there is also the grief of losing your plans, hopes, dreams, jobs, routines, aspirations, and the fundamental grief and sorrow of losing normality. All of our plans have been cancelled by COVID. That’s been one of the hardest things for many of us to articulate.

Mental health

I share these non-professional thoughts as a human being on the same journey with all of you. There are many causes of our negative emotions and there are unique solutions. Being able to articulate accurately what we are feeling is the first step to finding an appropriate solution. Stress, physical exhaustion, burnout and compassion fatigue affect our mental health but they are not considered mental illness.

Chair of Wellbeing

A simplified way for me to think about my personal wellbeing is considering that my wellbeing is supported by a 4-legged chair. These 4 legs need to support my overall wellbeing. Do not disregard the importance of any of the other legs. These 4 domains and the listed suggestions are the things that have helped me stay healthy. You may have your own unique stool to stand on.

And one more thing,

This blogpost was initially a series of tweets on a Sunday morning. Following the discussions, Dr Nathalie Martinek PhD added her wisdom in this space. She suggested that there are also other things worth considering: Trauma, Moral injury, Burnout, Vicarious trauma, & PTSD. I have attached her article here which brings out some really important concepts of care. Pages 38-39.

Hope this has been a primer for your consideration. Please reach out to your local helpline if some things here have triggered you. I am not a mental health professional so this article is not definitive or exhaustive. I really sincerely just want to share the journey with you. As I have alluded to, there are many things we can do formally and informally to improve our general wellbeing. How are you feeling today? What changes would you implement this week to improve your wellbeing?

Do I need an online presence?

Do I need an online presence?

Short answer: Yes.

Long answer: It depends on the purpose.

Asking if any clinician needs to have an online presence is akin to asking in the 1970s if one needed a fax machine, in 1980s if one needed an email address or in 1990s if one needed a mobile phone. Online and social media engagement is the natural progression of communication technology and media interaction. It is now the norm not the exception. Of course when it all started we did not have a manual, so some of us used it effectively and others poorly. Institutions, legal entities and patients were also learning how to draw boundaries around the use of social media and online communication in the sacred doctor-patient relationship. Social media was once since as a frivolous marketing façade amongst clinicians. We now understand its powerful effect to inform and even influence health outcomes.

As of Jan 2020, 3.8 Billion people use social media. Facebook reports 2.45 billion users, YouTube 2 billion, Instagram 1 billion, TikTok 800 Million, Twitter 340 Million. If you are not a citizen of any of these online nations, you will lose real estate and therefore you are not searchable by your current and future patients. Worldwide average of daily internet use is 6 hours and 43 minutes (!), and 2 hours 24 minutes of that is spent on social media platforms. How do people access the online world? 53% of the time through smart phones, 44% via laptops/desktops, the rest through tablet devices and others. Full article here.

So, do I need an online presence as a clinician?

Short answer: YES. Because your patients are already there. Your patients are likely to have a social media account, spend hours daily on social media and by the time they walk into your office, they would have googled you, your institution and their medical condition on their smart phones. Embrace that. Being aware of the average patient online behaviour prepares you to be a better assistant to their health needs. If your patient cannot find you anywhere on the internet to check your credentials, then you may well be considered less accessible than another clinician who details their expertise.

One of my biggest reasons for being online is this: my patients and my trainees are already there. I need to understand where they’re coming from.

On the other hand, the longer answer to that question is: it depends on what your purpose is in having an online presence. As clinicians and human beings, we can all have a social media account for personal use. That’s where we connect with our high school friends and relatives. However, if we were going to use our online presence and social media activity professionally, then can I suggest 3 levels of social media usage that you can consider?

Basic

At its most basic, your online presence is your virtual real estate. It is to be used to inform patients and other health care providers of your presence. You can have a basic website (free from many website providers), or homepage (linked to your University Departments, Institutions or Private Practices) or a Facebook page (A Facebook personal profile is different to a Facebook public Page). The contents simply need to include your prior training, current practice and specialty interests. You just need to show the world that you are a legitimate clinician expert who can be contacted in real life. The contents can be similar across several platforms (Facebook, Blogsite, Website, Twitter, Instagram, etc.). This is to help patients to find you when they google you. The information is basic and static. For most clinicians, this is sufficient, depending on your geography and local referral processes.

Intermediate

For those who want to take it up a notch, you can turn your static presence into a more dynamic engagement. You can be an educator who could engage the community. Your website can be regularly updated with information specific to your specialties. You can have an interactive dialogue on the Facebook page. You can comment and like, retweet and engage with others. Facebook, Instagram, TikTok, LinkedIn and Twitter all have unique target audiences and therefore require different strategies of engagements. There are pros and cons on using each platforms. Your specialty and your patient will define your method. Doing social media well takes time. Putting up information and expecting the engagement from the community takes time. But the rewards are also great because you will find that as you connect with others, you gain knowledge and network. If you are an educator, putting up good information online would be important for our trainees and our patients. As doctors, we have the privilege of our training and position. Our presence online matters and in this day and age of fake news, I sincerely hope more and more of us would stand together online as a scientific community to continually present reliable and practical information. Whenever there is information vacuum, bad news tend to fill it. We have a moral obligation to our community to be present in this online information market to represent clarity and certainty.  

Expert

Finally, a few of us over time will end up being expert users of Social Media. This does not happen overnight and require long term strategy and time investment. You know some people with such great presence online who are powerful influencers. They have refined their presence over many years and reliably present clear information and therefore they become influencers and the go-to individuals. It is not how many followers you have. It’s how you influence them that matters. You can be followed by a handful of news reporters or other specialty clinicians and you can become the point person to connect and mobilise experts. The online connection crosses specialty boundaries, geographical limitations and timelines. You can connect with clinicians from other countries to collaborate on projects. You can be invited to speak at conferences or collaborate on manuscripts through the online networking. Social media is a catalyst and an accelerant when used well.

Some Practical Ground Rules to Note

You are a clinician and therefore the community holds you to a higher standard. Everybody’s watching and recording. Nothing gets deleted. The internet, like taxes, is forever permanent. So total RESPECT has to be first and foremost. You can provide opinions, but the information you provide online and the discussions you engage in has to be guarded by total respect because your words can be printed on the local newspaper and they can be sent to your Department Chief. This also means that jokes on other specialties or stereotyping people has to be done with care.

Never ever talk about patients. You can talk about conditions, but you must never talk about patients. Patient confidentiality rules in any country will be identical. Never break confidentiality, unless of course there is an expressed written permission. You can discuss, applaud, encourage a generic patient, but I would strongly advice against any specifi identifiable entries.

Be human. Be a social and a professional one. You do not have to reveal anything personal at all. You define your limits. Social media is a place where doctors can reveal their human side and engage in some non-medical interests and causes.

What about advertising?

Many clinicians would actually have an online presence for the primary purpose of advertising. In some countries that is normal and expected. In other countries, it is legally not allowed. I have worked in Australia, Canada, and New Zealand. When I flew for several conferences in the USA, I was surprised to see the inflight magazine full of medical advertising from big Institutions and personal doctors. That was foreign to me, but normal and accepted in the US. For the US clinicians where advertising is accepted, having a social media online presence is even more critical for your career. Check your local regulations and you might even engage an advertising company to design an advertising campaign for you. There are multiple measurements and return of investments measures that can be applied.

For those of us in Australia, on the other hand, here are the boundaries set for us:

Section 133 Health Practitioner Regulation National Law on Advertising

A person must not advertise a regulated health service, or a business that provides a regulated health service, in a way that–

(a) is false, misleading or deceptive or is likely to be misleading or deceptive; or

(b) offers a gift, discount or other inducement to attract a person to use the service or the business, unless the advertisement also states the terms and conditions of the offer; or

(c) uses testimonials or purported testimonials about the service or business; or

(d) creates an unreasonable expectation of beneficial treatment; or

(e) directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services.

It’s all fair and logical, in my words:

  • Can’t fake your service. You can’t say you’re the best.
  • Can’t offer gifts or enticements. Can’t say “do facelift and I’ll throw a discount rhinoplasty.”
  • Can’t use testimonials. Can’t get your mum to say nice things about you.
  • Can’t say this surgery or medicine will fix everything.
  • Can’t offer unnecessary treatments.

How do I maneuver around these reasonable practical limits? Education. In health industry, education is the best form of marketing. You can’t talk about patients, but you can talk about conditions. You can’t say how awesome you are, but you can talk about the procedures you do for certain conditions. Ultimately the more educational materials you put up on your Facebook, YouTube, Twitter, LinkedIn, Instagram and even TikTok, the more likely it is for the google algorithm to discover you. All these things are generally free. The main cost is time and effort. The internet records activities. The more active you are on any platform, the more likely you will rise on search engine rankings.

So there you go. Do you need an online presence?

The answer is “yes”. But what for?

I hope the answer to that is “for my patients and my trainees.” Our greatest satisfaction is seeing people get better. Help them get better information and better health.

See you online.

Tips for Virtual Presentation

Thanks to COVID19, we now live in a physically-distanced virtual world. Online virtual conferences and meetings are becoming the norm. This is a great opportunity to increase our worldwide connectivity across geographical lines. Virtual meetings mean that more people can attend and less unnecessary travels are undertaken (good for the earth!). Of course the social connections are missed but with every major change there will be positives and negatives.

Here are 5 pointers to help you increase the value of your online presentations. These are by no means exhaustive, prescriptive or conclusive. These are things I’ve learned as I have spent hundreds of hours in meetings, conferences and listening to talks. Virtual conferences are different to real live conferences and therefore we need to modify our techniques: Ready, Set, Lights, Camera, Action!

  1. Ready. Get ready by simplifying your content. Focus on 1, 2 or 3 key points. Most of your listeners are listening in an office between activities, lounge room, or even while they’re driving. No longer do we have the full attention of a conference hall. Most of us are juggling parallel activities while listening to talks. So leave one big message if possible. Keep slides to a minimum. Keep words on slides to a minimum as people may well be watching on a phone. (Seriously, no one is going to remember your talk details in 3 days.)
  2. Set. Set your timer. The most respectful thing you can do for your listeners, meeting organisers and other conference speakers is to stick to time. Speaking beyond your allocated time is basically rude. When time is up, speak forth the big message and drop the mic.
  3. Lights. Have light shining on your face from the front. Background lighting results on your face looking dark. Either have your desk light behind the computer you’re speaking to (like my pictured set up above) or get yourself some cheap “selfie” light you can buy and attach to your computer.
  4. Camera. Keep your camera level with your eyes. Elevate your computer on a platform or a box. Looking down to a camera below your eyes means that your listeners are going to look up at your nostrils. Also watch your background and sound. Headphones/earphones may improve the clarity and gain of your speech. Careful with bluetooth headphones and virtual background as it adds workload to the computer processing, which may delay connectivity or quality of your presentation.
  5. Actions. Maintain the tone of your talk as conversational. The elevated public speaking volume that we use when we speak on a big podium will not work too well on virtual conference. Remember that you are now talking directly to one person sitting in their lounge room, office, or car on their headphones. Facial expression matter even more now as they are almost face to face with you. Speak not with the tone of a quiet chat but that of an excited conversation so as to maintain engagement with your listener. Make them feel that you are talking to them directly.

Hope that helps!

Tell me if you have learned other helpful presentation tips too.

Artwork on my screen is a mural at the Royal Children’s Hospital Melbourne by Elizabeth Close.