COVID-19: what are you optimistic about?

THIS was the question I asked a number of my medical colleagues during the height of COVID-19. Here are some recent answers:

• “Public health”.
• “Australia isn’t America”
• “The funding of telehealth”
• “Reduced air pollution”

And from a GP in remote Australia: “I always live like this in isolation and I love it. We even have enough toilet paper.”

There was also valid pushback to this question with comments like: “Don’t talk to me about false or forced optimism.”

Many felt overwhelmed by:

• “Information overload, the rapid adjustment to telehealth and the disruption of referral pathways.”
• “Many patients are presenting with severe mental health issues due to isolation, unemployment, substance [misuse] and family violence.”
• “Increased bureaucracy and [human resources] issues such as termination of staff, employees taking sick leave, and many other practice management issues, which are distressing as we have previously been a happy family.”

Some brave colleagues also admitted to experiencing raw fear. Only a few weeks ago, we were reminded of the fragility of our own lives and of those we love, with dire predictions of mass deaths and mass palliation in ill-equipped hospitals and communities. Although these worst-case scenarios have been averted for now in Australia, many of us are grieving for the loss of family members, friends and colleagues across the globe and facing a long uncertain future of hardship.

With the relaxation of lockdown comes the risk of a second wave of coronavirus disease 2019 (COVID-19), as well as a tsunami of non-COVID-19 diseases including mental health problems in patients who have deferred seeking medical attention in the last few months. To respond to this enormous community need, medical and other health practitioners must stay well. However, indirect or direct traumatisation of health professionals is so common it’s now regarded as a normal reaction to this state of emergency (here, here and here).

How can we protect our mental health and maintain our optimism for the sake of our families, our patients, our communities, our colleagues and ourselves when the world is in turmoil?

“We cannot solve our problems with the same thinking we used when we created them”
— commonly attributed to Albert Einstein

Pre-pandemic, there were many attitudinal barriers compromising the mental health of medical practitioners. In the recent past, despite high levels of mental illness, suicide, bullying, sexual harassment and racism within the medical profession, unfortunately many doctors accepted burnout like a badge of honour and help seeking for mental illness as sign of a weakness or incompetence.

Formal and informal support was sometimes offered to doctors after exposure to severe traumatic events such as patient-initiated threats and assaults, suicide, child abuse or neglect and other forms of family violence. Little attention was given to interventions for vicarious traumatisation, particularly for doctors experiencing repeated triggering of their past adverse experiences.

Unfortunately, mental illness was commonly under-recognised and undertreated in doctors as many self-diagnosed and self-managed their condition, often while continuing to function well at work. Only about 50% of doctors had their own doctor, mainly because of fears of breaches of confidentiality and career repercussions. Not surprisingly, many doctors tended to battle on alone and seek help late during a crisis, partially self-medicated, resistant to treatment, prone to relapse and at risk of suicide.

It is time for new thinking, empathy and support for doctors with mental health issues. How can we make this happen?

“Be kind, for everyone you meet is fighting a harder battle”
— Plato

It is important to understand that some doctors quietly hide their inner turmoil and joyless lives, withdrawing behind their well-developed emotional masks. In contrast, others are unfairly labelled “difficult” to work with due to mental symptoms such as irritability, anger, poor concentration, hypervigilance, cynicism, pessimism or paranoia. In either situation, it is not easy to reach out and offer informal support to a colleague.

During the pandemic, when mental health issues are commonplace, we can normalise help-seeking colleagues inside and outside the workplace. All doctors, like other patients, require routine mental health screening, early intervention, optimal evidence-based treatments and postvention after any traumatic experience, particularly in the context of the devastating impact of the pandemic.

Now is the time for each of us to develop a trusted relationship with a caring independent practitioner, whether that be a GP, psychologist or psychiatrist. DRS4DRS is a network of doctors’ health advisory and referral services, which also offers an independent, safe, supportive and confidential service for doctors and medical students. There is a myriad of other clinical services for health professionals via videoconferencing, overcoming many of the traditional barriers deterring help seeking (here, here, and here).

A mountain of online information is available for treating doctors on how to manage mental health problems including the empty void of depression, the constant worry of anxiety, the avoidance of acute stress reactions, and the nightmare of post-traumatic stress disorder (here, here and here) in patients, including doctor-patients.

Some of the standout resources and tools for health professionals during COVID-19 are:

• TEN — The Essential Network, an app to help manage life and work;
• Hand-in-Hand peer support;
• myCompass, the Black Dog Institute’s online CBT-based program;
• Face COVID-19 ebook;
• Minding Healthcare Workers;
• AMA Victoria mental wellbeing advice.

However, individual strategies are not enough. If we are to prevent and manage the enormous scale of mental illness in the medical profession, we need to create cultural change.

“My colleagues will be my sisters and brothers”
— modified Hippocratic oath

Far from being a happy supportive medical family, parts of our medical culture have been described as soul destroying, dehumanising and demeaning by families of doctors who have suicided. The past pessimism surrounding the entrenched negative culture in many medical workplaces is being overtaken by a determined focus on tangible solutions to address workplace health and safety.

The power of a united medical profession in effecting change has been demonstrated recently through the collective advocacy of our medical colleges, member associations and other organisations on major issues including personal protective equipment, telehealth and improved access to health care for disadvantaged groups and people with non-COVID-19 conditions. By putting aside their political differences and working together on a common purpose, our medical leaders have alleviated many of the extreme stressors and improved the safety of our workplaces.

Our medical organisations are harnessing this sense of solidarity to solve many other intractable health systems issues to improve the lives of Australians and their doctors. For example, all health and medical workplaces are being encouraged to implement a mental health strategy, which addresses systemic discrimination, racism, bullying, sexual harassment and violence.

If we need any other examples of medical leadership, we only need to look around us. There are many stories emerging of doctors working together as grassroots movements to create a healthier medical culture, including Crazy Socks 4 Docs, the Pandemic Kindness Movement, the Hush Foundation, and Beauty within Medicine.

“Where there is no hope it is incumbent on us to invent it”
— Albert Camus

Despite the fallout of the pandemic, I am optimistic that we can be kinder. I am also inspired when I listen to the optimism of my colleagues in the face of adversity:

• “Despite the distance of facial masks, social distancing, contactless contact and online orders, there are unexpected joys in the peace of lockdown.”
• “Observing my community with fresh eyes and the resurgence of local communities with soul.”
• “Basking in the love of close family and virtual hugs with kind friends — where there is love, fear cannot exist.”
• “Watching the world slow down and people focussing on what is essential, especially family.”
• “The changing winds everywhere.”
• “The unbelievable sense of community and collegiality in many parts of healthcare.”
• “Finally talking openly about mental health in doctors and their feelings.”
• “Bureaucracy getting out of the way, letting clinicians lead, become engaged and getting things done well and at speed.”
• “The Australian community openly valuing health care workers and the outpouring of love and support towards us.”
• “A window to a potentially different way of working and we can seize that opportunity if we are clever, curious and act together.”
• “The love and belonging and kindness I have seen from Melbourne to Broome.”

What are you optimistic about?

Clinical Professor Leanne Rowe AM is a GP, past Chairman of the Royal Australian College of General Practitioners, and co-author of Every Doctor: Healthier Doctors=Healthier Patients, www.everydoctor.org

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.