Q&A With Physician Well-Being Director Gaurava Agarwal, MD
November 20, 2020 | 10 min. to read
Here, Director of Physician Well-Being and NM Psychiatrist Gaurava Agarwal, MD, shares his insights for navigating COVID-19 fatigue and the new challenges for physicians and healthcare providers facing a second wave of patients.
As we enter the second surge of the COVID-19 pandemic, the protracted nature of the crisis may be contributing to a heightened level of stress and anxiety, not to mention exhaustion, especially among physicians and healthcare providers. What is different this time around? Naming emotions is really important. Based on what I have heard from colleagues on the front line, one of the major differences between the initial surge and the resurgence we’re seeing now is the emotions we are experiencing. Anxiety and worry were the dominant emotions for April and May, but now, while there is always an undercurrent of anxiety and worry, there are additional emotions of exhaustion, as well as some disappointment, frustration and even anger. Being cognizant that there are multiple emotions that our healthcare providers are experiencing right now will allow us to acknowledge these emotions and come up with ways to address the needs those emotions are speaking to.
How should physicians and leaders think about well-being during this second surge? From an organizational perspective, we used the same evidence-informed six-pronged approach to well-being many of the leading healthcare organizations around the country adopted. That framework from the spring is still applicable today but with some modifications. The six-pronged approach identifies six basic needs to help mitigate healthcare provider anxiety:
Care for me
Hear me is always central. There is nothing you can do until you listen to your people and provide timely, transparent, compassionate communication. In the spring, in terms of our organizational response, the most valuable anxiety mitigation tools were around protect me and prepare me, as we worked to ensure our workforce had appropriate PPE; contain the spread of the virus to protect our providers, patients and families; and prepare for the care of patients by developing new protocols, teams and COVID-19 units.
At that time, our Physician Well-Being efforts focused on care for me, support me and honor me, and in these domains, we benefited from the tailwinds provided by society’s focus on healthcare workers as heroes. There was a great deal of gratitude and appreciation coming from external sources outside the organization, and this support helped to sustain and bring us together to fight the common enemy of COVID-19.
The surge this time around is going to be different because the general population is no longer focused as intensely on this issue. There is COVID-19 fatigue all across society. While we feel much better about prepare me and protect me in terms of knowledge of the infection and organizational readiness, we will have to generate more internal support around care for me, support me and honor me.
We also need to address the other emotions of exhaustion, anger, frustration and disappointment. In April and May, we were starting fresh, but now, we are not starting fresh. It’s been a tough summer with not only COVID-19 stress, but other stressors around child care, the election and social justice issues. There has been a cumulative stress burden, so we need to be mindful of recognizing that exhaustion and monitoring our team members proactively to see who’s running out of steam.
How can this understanding help physicians and providers manage the ongoing stress? Step one is self-awareness. Take a temperature check by asking yourself, “Am I just running on fumes? Is this adrenaline, but really there’s nothing left in the tank?”
Sometimes, our self-awareness can be lacking during a crisis. I encourage people to get additional data from trusted sources to help increase self-awareness. So ask others, “How am I doing? Am I being short? Am I more irritable? If you notice anything that seems different, let me know.” We also need to provide this service to others, as peer support and buddy systems are some of the most useful strategies to remain connected.
The second biggest thing that’s a barrier to managing stress is giving yourself permission to rest. There’s a culture in medicine that does not value the idea of rest. There are feelings of weakness and guilt associated with rest, a feeling that I’m letting down my colleagues and patients. This is a time when we need to remember that we are human and give ourselves permission to take a break.
We have made stress the boogeyman. It’s not stress itself that is harmful. It’s our conceptualization of stress. When we think of stress as only having a negative impact, that’s problematic. A lot of the negative health outcomes come from that conceptualization of stress. However, stress also can be conceptualized as positive. One of the best examples of this is working out. When you’re lifting weights, you’re intentionally stressing your muscles, because the only way to build muscle is to stress them.
That analogy holds true both emotionally and mentally, in that we are under a great deal of stress, and there is an opportunity for growth because of that stress. However, to realize that potential growth, you need rest. To grow and be better — to be your best self, to provide good patient to care, to be the physician you want — you must take this stressful time and incorporate a little bit of rest so the muscles can heal and grow back stronger. Stress plus rest equals growth.
I am not Pollyannaish, and I know that rest is hard right now. But remember, perfect doesn’t have to be the enemy of the good. One minute in an hour, five minutes in the morning, a few hours one day a week to disconnect, finding little times to rejuvenate yourself may be enough to sustain you during this mini-marathon.
Since we have some experience with the virus from the spring, some physicians and providers may still worry about what is yet to be discovered. How do you recommend they cope with the unknown? Fear of the unknown has been here throughout the entire process, and it’s a central concern. There are a few concepts we talk about when we think about fear of the unknown during a crisis. One is the concept of bounded optimism and being mindful that we try to achieve that when we communicate. If you come across as if everything is OK, as if there is no challenge, or no grief and loss, you lose credibility.
So what you want to do is generate hope and this idea of efficacy, and that means talking from a place of bounded optimism, which is a delicate balance of hope and realism. For example, saying, “We don’t know what’s going to happen, but I do know that I believe in myself and I believe in this team, and we will work it out. We are going to get through this. It may not be perfect, and everything won’t be done ideally, but I am confident that we are going to get through this.” This is bounded optimism. The reality is that most people will do well, this will end, and we are going to look to the other side where we can plan to experience a great deal of learning and growth.
I also like to encourage people to continue to focus on what’s in the circle of their control, staying present and not trying to think too far ahead. We have no idea what January is going to look like and especially next summer. The real problem with how we often respond to uncertainty is that we get so focused on what we don’t know, that we stop controlling what we do know and can do something about.
Do all the same wellness and coping strategies that we employed during the first wave of the pandemic apply to this second surge? Yes. This is about basic human needs right now, and the things we need are always the same: sleep, companionship, water, food, meaning and purpose. So it’s important to stay focused on those basic needs. And again, it’s about controlling what we can control. I can still control getting my six glasses of water today. I can still control getting some sleep or rest today. I can still make sure that I have a snack bar in my pocket so if I miss lunch, I don’t go 12 hours without eating. I can control how often I have the television and news on, and how much negative information I’m consuming. This isn’t Game of Thrones time; this is about consuming soothing media. It’s important to recognize that all of these inputs into your brain can make a difference in how you calm your brain. If you can’t calm your brain, if you can’t sleep, you have to figure out what you need to settle your brain down.
What advice and tips can you provide to help calm the brain and reduce stress? All stressors are cumulative. Your brain cannot differentiate between COVID-19 stress and any other stress. While this might be an unprecedented time, stress is not unprecedented. This is not the first time you’ve experienced stress in your life. So to calm the brain, remember a time in your life when you managed other highly stressful situations, and the same strategies can apply here as well.
The biggest challenge right now is that many of the strategies that we used in the past may not be available. We can’t go to a restaurant to hang out with friends, we can’t go to sporting events, and we might not be able to go to the gym to work out. So we may have to learn new strategies and techniques that in the past we may have found unpalatable, such as practicing mindfulness, trying yoga and listening to soothing music. We need to be psychologically flexible and open to trying new things.
As physicians and leaders, what do we need to know to help not only our patients but our colleagues and care teams navigate the emotional impact of the months to come? We need to be mindful of some of the concepts of crisis or grief leadership. We need to recognize the importance of being present, whether in person or virtually, and communicating transparently in terms of demonstrating compassion and empathy. Instead of saying, “How are you?” perhaps try, “What is one thing I can take off your plate today?” That’s how leaders build trust, by demonstrating that you’re trying to make people’s lives easier on a practical basis. As leaders, we also need to recognize that sometimes we can’t “do anything,” but authentically listening and helping people feel heard is doing something, and oftentimes, it is the most powerful gift you can give someone.
Modeling is also important. Everyone is tired, including leaders. If your team never sees you take a break, then how can they give themselves permission to take a break? If your team never sees you struggling, then they don’t have the psychological freedom to express their own struggles. Modeling vulnerability and normalizing the feelings of your team will help you develop deeper connections and be a better leader.
Finally, be sure to honor the sacrifices, address grief, appreciate and recognize hard work, show sincere gratitude, and always remember to exude hope and bounded optimism. All of these are free.
What are some steps physicians can take to help support their teams, care for their teams and honor their teams during this second surge? Be intentional about honoring your teams and showing appreciation, such as giving hand-written notes, sending a quick email, starting an end-of-the-day ritual where you talk about what went right today and who was helped. Build in those processes to make sure they happen. They may sound cheesy, but those little things really matter. During dark days, they keep the light shining at the end of the tunnel.