by Aekta Malhotra, MD, MS
Originally published in the January 2021 issue of the Dallas Medical Journal. Reprinted with permission.
There is a prospective optimism that a new year brings allowing a “start over” positivity that helps our collective need to shed and renew. Yet, before we burst out the Champagne, we should process how we got here as 2020 may well have been the most challenging year of our lives, with enough despair, wounds, and wisdom, such that we are Turning 2021, metaphorically speaking, of course.
We have been in the grips of a worldwide pandemic that has upended our personal and professional lives. Our nation’s soul lays bare amidst a fight for racial equality. As the pandemic rages on, our mental health has continued to take a hit. The chronic exposure to stress is causing a variety of issues. The uncertainty, lack of sense of control, and alteration in our values and routines have given way to anxiety. The successive, unexpected changes brought on by the pandemic have also been underscored by a series of losses—our jobs, how we work, our children’s routines, travel, finances, gathering with family and friends, and simple pleasures like eating out and entertainment. This sense of loss over life as we knew it has been a chief driver of depression. When attempting to suppress severe wildfire, there is a possibility for firefighting crews to be overrun by wildfire, known as entrapment and burnover. There are many metaphors that come to mind when we consider the toll of 2020 on our mental fitness. Move over burnout. We are suffering from burnover.
Turning 2021 might not feel like a moment to see the glass as half full, but a critical step towards restoring mental fitness, and a favorite tool in the psychiatrist’s toolbox, is perspective taking. This is not meant to minimize the harsh reality of an incredibly difficult 2020 with Pollyannaish optimism. Many of us have lost loved ones, friends, and colleagues. We are sad, frustrated, and exhausted. But as we reflect on 2020, taking stock of the losses and triumphs, there were unmissable silver linings:
Amidst the suffering, we witnessed heights of human spirit and ingenuity. Rising to the clinical and logistical challenges, we put on our problem-solving caps to make the most of a limited supply of Personal Protective Equipment (PPE), ventilators, and medications. When our hospitals reached capacity, we built makeshift hospitals and converted concert centers into giant negative-pressure rooms. We served our patients to the best of our abilities, embracing the steep learning curve and ever-changing guidelines and information on COVID-19. We held our patients’ hands to give them a dignified sendoff when their loved ones could not be there in their last moments. Our creativity wasn’t just limited to our professional lives; In addition to doctor, we added teacher, caregiver, coach, and other roles to our credit.
We went virtual. Sure, we went from one online meeting to the next and had to scramble for a bathroom break, but we found a great way to safely connect with our patients, parents, friends, and each other. When we ached for culture, we brought Hamilton, the Metropolitan Opera, and concerts streaming home. We virtually toured cities and world class museums, studying art masterpieces, closely zooming in and out.
We flexed our tech muscles and found other convenient ways to bring the comfort of nourishment and shopping for essentials to our doorsteps. It took a few months to get the hang of it, but we joined online gyms and live workout classes from home.
Our internet bandwidth made it possible to meet the combined needs of work from home, telemedicine, online school, and a dozen devices streaming online platforms simultaneously. We concurrently admired and doom-scrolled the Institutional and governmental COVID-19 data repositories. Most importantly, we had real time information about this pandemic on our fingertips, (at times—perhaps too much information).
We learned that gratitude and grief can coexist. Our circles got smaller by necessity and we became intentional about our connections, out of which came bonus time with family and pets (and plants). Without our usual external outlets and distractions, we turned inwards and made time for introspection. We came upon unexpected opportunities for nourishment—we took up new (and old) hobbies, games, books, podcasts, yoga. We made a commitment to support struggling local and small businesses. Even if the presidential election of 2020 delivered a powerful referendum on how divided we stand, we found ways to unite over popular fads and shows. We developed new coping skills, and when these were not sufficient, we leaned on our colleagues, family, and friends for support. Meanwhile, our scientific community also embraced the challenge of 2020 with a promise of a vaccine, which has been developed in record time.
There’s nothing quite like a pandemic to make us reevaluate our priorities. As physicians, we (finally) learned to say no as self-care became more critical than ever. We watched a third of the country burn in wildfires and came to appreciate the profound impact of our choices on our environment. A discussion about Turning 2021 would be entirely remiss without acknowledging the pandemic of racial oppression thrust into the forefront in 2020. The intersectionality of COVID-19 pandemic and social determinants of health has been underscored by the disproportionate and devastating impact of the pandemic on black, latinx, and indigenous people of our nation. So, we committed ourselves to the task of self-examination and intentional antiracism. Out of activism came a commitment to change for the better with more progress on equity and justice.
If 2020 was the ultimate exercise in improv, we gave a performance worthy of cheers and ovation. Even so, 2020 was especially stressful for doctors as we were stretched beyond our capacities in all spheres of our life, all at once, and for far too long. Published research on the impact of the pandemic on health care workers in the U.S. is limited at this point, but the data from China, Italy, France, and other countries impacted by COVID-19 earlier on in 2020 are telling. As a volunteer psychiatrist for the Physician Support Line, a free and confidential peer phone support helpline for struggling physicians and medical students, I have heard countless stories of physicians and medical students, I have heard countless stories of physicians who endured a risky, exhausting, and demoralizing milieu for much longer than the human body and mind were meant to tolerate—all the elements of not just burnout, but anxiety, depression, post-traumatic stress disorder (PTSD), substance use, and much more.
In his seminal book on trauma and its effects, The Body Keeps the Score: Brain, Mind, and Body in the Treatment of Trauma, Dr. Bessel van der Kolk discusses how trauma and chronic stress rearrange the brain’s wiring— specifically areas dedicated to pleasure, engagement, control, and trust—in a process known as neuroplasticity. The human response to psychological stress is one of the most important public health problems, and doctors are especially susceptible to it because of the nature of our work and the long hours, only compounded by the pandemic. Many of us are Turning 2021 psychologically wounded, exhausted, and mentally exhausted.
Taking stock of 2020, Turning 2021 mentally fit might seem like a lofty goal. Fortunately, there are evidence-based strategies that can help us ameliorate the impact of chronic stress as we pursue our goal of mental fitness in 2021.
We have endured a collective trauma in 2020 that has given way to a crisis of meaning. The chronic stress might make you feel irritated, impatient, angry, sad, and you might experience feelings of disconnection, difficulty concentrating, and a range of other cognitive effects. You might also be navigating anxiety, depression, or fatigue. These are all perfectly human, adaptive responses during such a difficult time.
● Welcome and honor the full spectrum of emotions that make you human, because they are here to teach you important lessons about your triggers, coping skills, and current emotional state.
● Practice Self-compassion – as physicians, we have several personality traits that lead us to pursue careers in medicine, including perfectionism and self-denial. While these traits can serve us well in doing our clinical work, they also give way to unrealistic personal and professional expectations, including denial of personal vulnerability. Some days your best IS enough. You are a doctor, but you’re also human. Acknowledge and accept your vulnerability.
● Seek Help – part of recalibrating normal is to also normalize seeking help. Extraordinary stresses cannot be overcome with ordinary measures. Although we all have the ability within us to heal, we sometimes need support in the journey to self-realization and optimal mental fitness.
Reflect and release
Unprocessed traumatic memories and stress can become sticking points that cause our mental and physical processes to suffer. As such, it is imperative that we reflect inwards and take intentional steps towards improving our mental fitness. The journey to recovery can be slow, intentional, and at times, uncomfortable, yet, immeasurably rewarding. As with any form of recovery, the first step is acceptance.
● Give yourself the permission to grieve the many losses of 2020, including loved ones, colleagues, and even your routines. This isn’t always at our forefront, but in addition to attachments to other people, we also develop powerful attachments to our work, things, and places.
We know that neuroplasticity and trauma go hand in hand. Just as traumatic events can forge neural pathways, so can positive and effective therapeutic experiences that help us cope and heal. The psychiatrist’s toolbox is equipped with evidence-based strategies to help you navigate this journey.
● Psychotherapy – if anxiety is the worst use of the imagination, psychotherapy helps us reestablish psychological safety and dial down the trauma response. There are numerous evidence-based therapies to help address anxiety, depression, and burnover, such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, psychodynamic psychotherapy, and Mindfulness-Based Stress Reduction. The undertaking of knowing oneself might be the most challenging yet rewarding experience of one’s life, with lasting results. In fact, suffering often brings with it the opportunity that drives emotional growth for a more mentally fit self. As with anything worthwhile, this process requires time and commitment.
● Medications and more – we enter the medical profession with many underlying vulnerabilities, including personal and family medical and psychiatric history, chronic stress from childhood, personality factors, social determinants of health, and much more. Moreover, the stress from medical training is associated with systemic inflammation, telomere shortening, and oxidative stress, findings which have often also been reported in major depression. Antidepressant medications, in particular, are associated with not just mood recovery but also recovery from oxidative stress on a cellular level. There are also several medication and non-medication augmentation strategies that can help you with your mental recovery. Most importantly, a good psychiatrist can blend psychiatric medication management and psychotherapy while empowering you with skills for self-management over time.
If the body keeps the score of chronic stress, then the symbiotic relationship between the mind and body becomes a critical target for recovery.
● Mind-Body strategies – we all know the benefits of exercise as a healthy coping skill to build our mental and physical fitness. However, when we are exhausted, the last thing we might want to do is run laps around the neighborhood with a mask on. Fortunately, recovery from stress does not require us to train like an athlete. In fact, routine, less intense activities, such as walking a pet, doing the laundry and dishes, gardening, and washing your car can be just as effective and give you a sense of accomplishment. One of the best strategies to facilitate traumatic release from the body is to engage in an intentional, slow, and mindful activity like yoga, which you can easily access over the internet from the comfort of your living room.
If you’re suffering from burnover from another discussion about mindfulness, you’re not alone. I had similar skepticism about mindfulness when I first took the eight-week Mindfulness Based Stress Reduction (MBSR) course. In fact, around the third week, I recall being quite frustrated with the process of completing the same body-scan meditation every day for an hour or more, but I stuck with it. Around week six, a sense of calmness came over me. My movements and actions became more intentional and I felt less exhausted, without any change in the rigor of my clinical schedule. My relationship with nourishment also changed as I learned to chew my food instead of my thoughts, which saved me precious mental energy to devote to other aspects of my life. When I wavered from this intentionality, I returned back non-judgmentally to the task at hand. One of the greatest misconceptions about mindfulness is that it helps us fight distressing thoughts. Quite the contrary, mindfulness allows us to change our relationship to the distressing thoughts that are a part of living.
As physicians, our careers have been shaped by the expectation of conformity married to the assumption that resilience and professionalism are in endless supply, particularly during a pandemic. Fittingly then, 2020 has been the ultimate test of our professional status quo. While the long hours and medical culture might make it seem that your personal identity is inextricable from your professional one, this is a perfect recipe for burnover. Along with recalibrating normal, Turning 2021 mentally fit requires that we reimagine work as an extension of what we do, rather than us as an extension of who we are. You are a person with many gifts, values, dreams, and talents, and one of them just happens to be being a hard-working doctor. This could be a variety of things, including spirituality, advocacy, mentorship, leadership, and other activities outside of your profession. Also, as much as possible, release yourself from the myth and burden of multitasking. Focusing on one task at a time and being mindful of the task at hand will improve your concentration and help you to be more mentally fit. Spreading ourselves thin depletes our battery faster than working on tasks individually. Like any of your devices, the more programs you have running simultaneously, the harder it is on the system. It is the same for our body and mind.
Mental fitness is not merely the capacity to endure, but also the capacity to recharge. Most of us forget the latter. Take the time to slow down and explore other aspects of life that fill your bucket and keep you mentally fit. Recreation, humor, daydreaming, connection with nature, your partner’s touch, and the simple act of doing absolutely nothing at all can all be ways to recharge your mind. Rather than spending your time on passive activities like binge watching shows, find a book or a podcast that teaches you something new. Monitor your screen time and disconnect digitally to give your mind a digital holiday. Be it while on a walk around the neighborhood or on your walk from the parking lot to your office—put down your phone, pull down your mask and stop to smell the roses. New experiences and new ways of doing old things can also set you on the path to mental fitness.
Most of all, remember that mental fitness is not a checkbox, it’s a moving goalpost practiced over time with intentionality. If at first you fail, get up and try again. And again. And again. Join me in the commitment to turn 2021 happy, healthy, and mentally fit!