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Issue 4: Care

By Dr HT Goh. First of all, please let me apologise to you for contributing to the tsunami of 'in these trying times' emails that have inundated my inbox, as I suspect it has yours. In my more uncompassionate moments I wish these companies could suffer my withering gaze as it casts over their final sentences, which inevitably have a sudden realisation that their very offerings, conveniently available as several subscription tiers (discounted!), may humbly assist you. These times are indeed trying for almost all of us, so it is important that we all do what keeps us well. Usually this is a combination of approaches like regular exercise, a healthy diet, or mindfulness, which are effective and which are therefore repeatedly recommended. This article addresses something a little different. Although I have tried to be careful that the content here is not written gratuitously, it may nonetheless remain distressing. Although everyone keeps recommending that doctors should be authentic and reflective, I think they are picturing me meditating calmly after a cup of camomile tea, not having a breakdown over buying oranges at my local supermarket while I ponder profound existential issues. While I think that what follows will be valuable in its own way, if you do feel that you are content with what you have in your toolbox and more will not help, or even worse, that such reflection will actively destabilise you, then you have my blessing (if you need it!) to offline immediately, and ensure that you are taking care of yourself. Now is not the time to gaze into your navel if it will allow an abyss to gaze back into you. Personally, as I become more senior, the more basic lessons I've learned are paradoxically more helpful. In making increasingly complex and high risk clinical decisions, I take lessons from Francis Peabody's inspirational lecture when he announced "the secret of the care of the patient is in caring for the patient" , or I try and follow exhortation that "it is much more important to know what sort of patient has a disease than what sort of disease a patient has", popularly ascribed to William Osler. The General Medical Council (the UK's medical registration body) agrees and directs its doctors to "make the care of your patient your first concern". We persistently chase this goal of medical deontology. But as the coronavirus has become a pandemic, the world has changed. I recall the thorny dilemmas posed as bioethics thought experiments at medical school, such as having to choose between two male patients for the last ventilator bed, one a 32 year old man with poor physical condition due to a severe drug use disorder and the other 88 years old but otherwise healthy. Well, now these avatars, once safely confined to the pages of my lecture notes, have leapt from the pages of my lectures into real situations. How should I be patient-focused when I am denying life-saving treatment to my patient? Are Osler's recommendations compatible with the monolithic entity of COVID-19? In affected parts of Italy, doctors had to adopt age cut offs for ventilator beds, and some emergency departments divided into two sections, one triage-focused, and the other for treatment, because having to both choose who could obtain treatment and then to treat them was too traumatising. For these colleagues who, like us, are dedicated to trying to save lives, this has been unspeakably distressing and I understand doctors have been extremely reluctant to talk about this, perhaps so as to not panic people, but also almost certainly because deciding who takes the last ventilator bed is essentially incompatible with our contemporary professional and moral identities. Such a strongly utilitarian standpoint conflicts with those deontological urges that we are encouraged to follow. More pointedly, for a doctor to say that they chose who would die seems so grossly perverse and stigmatising that it must carry an incredible burden of shame and guilt. This raises the concept of 'moral injury', which is defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code. The original concept was developed in military psychiatry to describe the emotional stresses that occur when, for example, you or your commanding officer chose to fire, or chose not to fire, or could not fire, and this resulted in the death of an innocent civilian, resulting in similar feelings of shame and guilt. The concept has been recently brought to wider consciousness as a contributing factor to healthcare worker stress during the pandemic by psychiatrist Prof. Neil Greenberg from King's College London along with some helpful recommendations (footnoted). In short, the pandemic situation has meant that we can often not say “I provided the best treatment I could, and it did not work”. Rather, “what I could offer and do for you was not of my choosing, and yet I had to choose, so here I am, apologising to your family about your loss”. Unsurprisingly, healthcare workers during a pandemic are at particular risk of being derailed by these particular feelings. Here in Australia, the healthcare budget has been a major part of both state and national elections, and has suffered from budget cutbacks long before COVID-19 appeared. In the USA, the cusp of elections in the era of Me Too and All Lives Matter has brought with it renewed interest in health equity and socialised healthcare, with the gaps made more visible by the pandemic. In the UK, progressive systemic de-funding of the NHS for years has been accused of 'radicalising' medical staff and has resulted in high levels of medical stress. The McKinley cross-sectional study from late 2018 reported that a third of UK doctors surveyed were suffering from burnout and secondary traumatic stress. That this has occurred in wealthy countries seems particularly unjust and morally injurious. How could I morally injure thee? Let me count the ways. With so many issues, accreting over time into injury after moral injury and grating against our increasing focus as doctors on the systemic and social factors affecting healthcare, how are we not to feel passionate and angry? I’m sorry to say that I can’t offer any easy solutions, as we both sit here in the vegetable aisle weeping, me trying to console you over the spinach. So in the spirit of helping you through these trying times, I present to you a one-time pass, a discount coupon if you will, to last for the entirety of this COVID-19 crisis, for you to do what you can to keep working and to keep taking care of yourself, never forgetting that despite all the utilitarianism you need in your current practice that Kant could still be proud of you, and that sometimes, in these trying times, the most compassion you can muster today may be for only one person, that one person may be you, and that you would still be doing your duty. References: The Care of the Patient, Francis Weld Peabody 1927 JAMA 1984;252(6):813–8. From a Harvard Medical School lecture in 1925. [PubMed] From <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3147198/> Managing menta l health challenges faced by healthcare workers during covid-19 pandemic Greenberg et al. BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1211 Junior doctors have been radicalised by Jeremy Hunt’s smears Rachel Clarke, The Guardian "Resilience, burnout and coping mechanisms in UK doctors: a cross-sectional study." McKinley, Nicola, et al. BMJ open 10.1 (2020). Dr Goh is a psychiatrist currently working in Tasmania.

Issue 3: Anticipatory Anxiety

by Dr Jeremy Smith These are strange and unsettling times. It can feel a bit like standing on a deserted beach watching the tide suck out and further out, wondering when the tsunami is going to hit. The waiting is hard. Patients with Panic Disorder tell us that the anticipatory anxiety can be more difficult than the actual panic attacks. Not knowing when it will hit. Tensing yourself as you wait. The background tension that sucks the joy out of your day-to-day life. I heard some people playing the Last Post at the end of their driveway at 6am on ANZAC day. I wonder what it was like for the young men waiting in the boats approaching Gallipoli, or crouched in a trench on the frontline. “They have to stay there while shell after huge shell descends with a shriek close beside them. Each one an acute mental torture; each shrieking tearing crash bringing a promise to each man, instantaneous, I will tear you into ghastly wounds...like these that you see smashed around you one by one to lie there rotting and blackening.” Charles Bean, Australian war correspondent Reading of war is sobering. The images of COVID-19 in Spain or Italy are sobering. You may feel like you are working on the frontline of a war. Our colleagues in the Emergency Department, in Intensive Care Units. When you started medicine, did you sign up to be a soldier heading into battle? I imagine some healthcare workers are not comfortable with the rhetoric of war. As doctors we are willing to make sacrifices for our patients, to work hard, do overtime, and put them at the centre of what we do at work. But we don’t usually head to work with the chance of contracting a novel and potentially life-threatening illness. We are all aware of the uncertainties about the effective use of Personal Protective Equipment. But this is not just about fear for our own safety. What if we unknowingly take this virus home to our partner and children? Just going to work every day can be a challenging decision. We find ourselves between a rock and a hard place - caring for our patients and caring for ourselves and our families. These competing priorities can leave us in a state of tension. An ED colleague of mine recounted the difficulty of responding to a Code Blue for a patient who had a cardiac arrest on the COVID-19 ward. Policy required full PPE prior to attending the resuscitation. I can just imagine the sweaty fingers fumbling with gowns as precious minutes pass, and the possibility of saving this patient’s life slipped away. I can imagine the frustration and even the guilt afterwards. Should we risk more for our patients? We all feel for the doctors in Spain, and the moral injury of denying care and allowing some patients to die. No wonder our hearts are in our throats. We see on the horizon the potential for this sort of trauma. Actual soldiers with PTSD are often most troubled not by the near-death experience as much as the actions they partook in that were morally compromising or the guilt and shame when they helplessly watched others die. I think there have been times in the last couple of months where some of us have felt like we have generals who are comfortably safe away from the fighting, telling us to charge on into the fray. Politicians and health management telling us that PPE will be adequate. Policies that allow ongoing exposure to risk in order to preserve resources, almost as if there is a calculation where it is ok to have a certain number of doctor 'casualties'. How do we respond? How do we 'hold the line' in the face of all this? I guess in writing this I want to start by validating the tension, the reality of the difficulty of facing up to work some days. I want to recognise the anxiety that can affect us even when we are simply waiting. I have heard from colleagues about the eerie q---- in many areas of our health system. Even now, when we seem to be winning and flattening the curve, we wait to see if new outbreaks will occur as the social distancing restrictions are gradually relaxed. We know it isn’t over yet. We acknowledge the anticipatory anxiety, but we don’t get paralysed. We turn this into a frenzy of activity as we prepare for the worst. In my workplace we have had strong clinical leadership, in touch with the ‘troops’ on the ground. There has been a pulling together of the multidisciplinary staff, all staff actually, from cleaners to the ADON. It is reassuring to have clear methodical leadership pushing forward with thorough preparations. I have heard this elsewhere. Some of the worst anxiety was when we weren’t yet fully engaged in getting ourselves ready. When we didn’t even know what exactly we needed to do to prepare. I think many of us are coping with the overwhelming scope of the worst-case scenarios by harnessing our perfectionistic, obsessional, driven, controlling doctor personality traits and focusing on really nailing the things we can control. There is some degree of relief from having had enough time in the last month to at least train most staff in correct use of PPE. I think many of us are now in a steady readiness. Some of us aren’t even particularly busy now, but we’re still feeling emotional, on-edge and stressed. As I suggested above, I’m sure you’d agree that great colleagues make a great workplace. This is only more true in these times. If we can trust each other, have a laugh together, communicate easily, do simulated practices together, then maybe we know we can make it through this together. I’ve seen the many helpful support networks that have popped up online. These are great. I’ve seen how keen your local GPs are to support you, and I know that we as psychiatrists want to be there for you also. If we can help, get in touch via Mentate. Dr Smith is a psychiatrist who is currently working in Tasmania.

Video: Staying well

Issue 2: Awareness

By Dr Michelle Adams For most of us, our professional reputation is incredibly important. It’s not just how we think our patients and colleagues see us, but also our own internal barometer of how competent we think we are that matters. Our perception of our competence is derived from the kinds of thoughts we have about ourselves and our practice. What influences the content of these thoughts? Much of it comes from external feedback: a positive response from a patient, the regard of a valued colleague, a positive report from a supervisor. Sometimes we receive feedback that is less than positive: perhaps we missed something important, or failed to respond empathically to a patient in need. How we make sense of these day to day set-backs and incorporate them into our larger internalised concept of ourselves as practitioners affects how well we bounce back, or in other words, our resilience. But what affects the way we make sense of, or internalise, the things that happen to us? In a nutshell it’s a product of the interaction between our temperament and our environment. Why is this so important now? Because we are all operating in a time of generally heightened anxiety in the community, and especially within the context of health care provision. We are uncertain. We don’t know what will happen. Many of us have been cut off from our usual sources of support and self-care. Many of us are caring for children at home, and many families are also trying to teach children whilst working from home. We are existing in a milieu characterised by anxiety and uncertainty. The messages we internalise about ourselves, our self-worth and our competence cannot help but be affected by this. For these reasons, it’s possible that you could find yourself feeling more vulnerable to stress at work and at home than you usually are. Or maybe you don’t notice that. Maybe for you it will be being unable to let go and move on from a mistake that you normally would. Feeling the need to check and double check your work, decreasing your efficiency. Or maybe it will be none of these things. Maybe things at work are alright, but you are feeling suffocated and frustrated by the extra time at home cut off from your usual social supports. My point is that the psychological consequences of COVID-19 are varied and won’t be the same for everyone. Not everyone will experience a readily identifiable sense of anxiety, accompanied by clear worries about the virus. It can be really helpful to check in with yourself and have a look at how you are coping in this difficult time. If you notice that your internal dialogue is less positive than usual, that you are feeling less patient with your family, that your sleep is poor or your alcohol use has increased, then some psychological support might make a real difference. Some doctors miss out on the support they need because of the fear of triggering a mandatory report to AHPRA. You may not be aware of the changes that have recently been made to the mandatory reporting legislation. In March 2020 the mandatory reporting notification for all states other than WA (they have no mandatory reporting obligation for health professionals) changed in relation to impairments. Under the amended legislation, simply having a mental health condition or some psychiatric symptoms, does not warrant a mandatory notification. To warrant a mandatory report, the assessing clinician must be satisfied that there is a substantial risk of harm to the public. This usually implies that a practitioner both has a serious mental health condition and has made no effort to modify their practice or engage in treatment. Even if a practitioner is affected to the point that they are unable to practice, so long as a plan is made for treatment and time off work is organised, this in itself need not trigger a mandatory report. I hope that this reassures anyone who may have avoided seeking help due to the fear of being reported. Dr Michelle Adams is a registrar currently working in Tasmania. In addition to Mentate, the following may be useful sources of information for you: Your state Doctors’ Health Advisory Service – they are able to offer confidential advice on Doctors’ health matters and help you figure out what you would like to do. Drs4Drs.com.au – a service to help you find a GP who has been trained in looking after other doctors. For urgent advice where you are imminently worried about your risk or someone else’s – your local emergency department or mental health help line. "Between stimulus and response there is a space. In that space is the power to choose our response. In our response lies our growth and our freedom."  Viktor E. Frankl

Video: Managing Panic Attacks Using Breathing

Issue 1: Connection

Dear Team, Welcome to Mentate. How connected are you? Consider this definition: “I define connection as the energy that exists between people when they feel seen, heard, and valued; when they can give and receive without judgement; and when they derive sustenance and strength from the relationship”, Brene Brown. How connected are you? In this time characterised by profound disruption, uncertainty, isolation and danger, we know that connection is a key to managing the impact events have on the self, in the now and in the future. It appears that connection mitigates the effects of trauma, as explored in the contribution below by Australian trauma authority Psychiatrist Dr Richard Benjamin. News about COVID-19 is everywhere, day-to-day life for every Australian is becoming increasingly restricted, and healthcare workers are at the frontline of the pandemic every day. Much of what is being written about and shared involves information about the virus and the associated illness, how to avoid it, and the effect of the virus on jobs and the economy. Fortunately, more is now also being shared about the effects on the community, and on mental health, which is incredibly important; most of us have never seen anything like this, and it is almost impossible to predict what will happen next. This unpredictability is particularly relevant for healthcare workers, who, by the very nature of their jobs, and their dedication, may be looking after people who are very unwell, frightened and isolated, while at the same time repeatedly exposing themselves and their families to the risk of infection, illness, and death. Additionally, they are now subject to a range of additional pressures regarding infection control and workload. When I was asked to contribute to this initiative, I was re-reading Ben Shephard’s epic history of Military Psychiatry, “A War on Nerves”; I am sure this was no co-incidence. The current pandemic and the responses required are, in many ways, much like a war. The scenes of chaos and devastation in Italy and Iran are difficult to comprehend, and the virus is spreading across many more countries at alarming rates. In response, command centres have been established, resources are being mobilised, and supplies are being rationed while new supply lines are under development; much of this is occurring within the healthcare landscape. And healthcare workers under these conditions – hospital doctors and nurses, GPs, specialists, allied health staff, and support staff - should be expected to experience a wide range of emotions. It has been pointed out already that fear is a rational and adaptive response, often leading to the development of creative solutions. Anxiety is, of course, completely normal, and it is important to also note that, prior to the pandemic, many healthcare workers were already under enormous workload pressure. Each healthcare worker also brings their own unique personal and family situation to this crisis, which will, by necessity, direct their perspective and responses. Rationing of medical supplies and treatment brings its own very difficult challenges for healthcare staff; this raises the issue of “moral injury”, where ethical and moral beliefs are compromised in the delivery of healthcare services. Availability of ventilators in Intensive Care Units is seen as the most obvious example in the COVID-19 setting, but confronting media footage, for example, of people struggling to breathe on city streets in neighbouring countries, also raises significant moral issues. Every healthcare worker feels a need to help, is driven to help, but it is not always easy to know exactly how to help, and there are always priorities to balance. I have worked in Australia for 30 years in the field of mental health. I have been particularly interested in the experiences of adults, and of the long-term and often hidden effects of childhood abuse and trauma in adults presenting with severe mental illness. What I have learnt is that sometimes we need to see past the disease model of illness, and to hear the personal stories of the people who present to us. The initial responses to all traumatic events in children, and adults, are adaptive. When the responses do not resolve over time, they are often seen as “symptoms” when a medical lens is applied, which leads to misdiagnosis. A more holistic perspective leads to reappraisal of the responses as repeated attempts to cope with the initial insult, or insults. When we are most thoughtful in our approach to people who have been traumatised, each person is understood and recognised in their own right, and every attempt is made to enhance feelings of safety, control and choice. Understanding the responses of healthcare workers to the inordinately challenging COVID-19 pandemic may benefit from a similar approach. Healthcare workers, fully cognisant of the virus and its potentially lethal effects, will be repeatedly exposed to dangerous and unpredictable situations, will have to negotiate significant resource constraints, and will often have little time to process an array of associated emotions. The “Mentate” initiative has come about to provide information and support for healthcare workers at the frontline of service delivery during the COVID-19 pandemic. Many experts will provide advice. Connection of all kinds will be of paramount importance, even more so in this era of substantial social isolation. In the military setting, “collective factors”, particularly unit cohesion, are often seen as critical with respect to mental health, and they too will be important in the current crisis, as the health professions unite in their response to the pandemic. In this context, I was reminded of the many Australian soldiers who returned home from Vietnam by sea journey, on the HMAS Sydney (III). The HMAS Sydney made 25 trips to and from Vietnam between 1965 and 1972, delivering over 16,000 Army and RAAF personnel, as well as many thousands of tonnes of equipment. The ship landed at Vung Tau in South Vietnam and was affectionately known as the “Vung Tau Ferry”. Each trip took between 10 and 12 days. On the way over, soldiers were prepared for battle. On the way back, after a lengthy tour of duty, soldiers were able to relax together, they had time to reflect on their experiences and to adjust to non-military life, and they were usually met by dignitaries on disembarkation, where their efforts were formally recognised. Soldiers who returned by plane, a much shorter 10-hour trip, were deprived of all of these experiences, and, anecdotally, did not fare nearly as well. Dr Richard Benjamin, Consultant Psychiatrist, Principal Editor of “Humanising Mental Health Care in Australia: A Guide to Trauma-informed Approaches”. How can you connect in the context of physical distancing and isolation? How do other forms of connection, like connection with the media, impact on making and sustaining human connections? Mentate sits (or is connected, if you like) within a larger framework providing support and care for frontline staff during the COVID-19 pandemic. Hand-n-Hand Hand-n-Hand is a group of doctors, nurses and allied health with a background in psychiatry & general practice helping to establish effective peer support for healthcare workers during this incredibly difficult time. Hand-n-Hand is a free pre-clinical service and does not involve any medical or psychiatric treatment, but rather is based on peer support and mentoring. Hand-n-Hand have brought together great minds from specialty colleges, beyondblue, MHPN, Doctors Health Services, Many Hats Network and the AMA. Their team have some terrific champions including Dr Kym Jenkins, Prof Brett McDermott, Prof Pat McGorry, Prof Samual Harvey, Dr Kieran Allen and Dr Tahnee Bridson as part of the broader #PandemicKindness wellbeing response. The link to receive peer support is here. The link to volunteer as a peer supporter is here. Mentate is a confidential referral network linking doctors requiring clinical assessment and treatment with psychiatrists. And finally, for good measure, our first YouTube video is a refresher on terminating panic attacks. Stay safe, The Team at Mentate “There is simply no pill that can replace human connection. There is no pharmacy that can fill the need for compassionate interaction with others. There is no panacea. The answer to human suffering is both within us and between us.” Dr Joanne Carriatore