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 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 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 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 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 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 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.
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.
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.
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.
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?