AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.
In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger talks with Waguih IsHak, MD, a professor and clinical chief of psychiatry at Cedars-Sinai in Los Angeles, about the importance of addressing mental health issues in physicians.
- Waguih IsHak, MD, clinical chief of psychiatry, Cedars-Sinai
Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today I'm joined by Dr. Waguih IsHak, a professor and clinical chief of psychiatry at Cedars-Sinai in Los Angeles, about the importance of addressing mental health issues in physicians.
I'm Todd Unger, AMA's chief experience officer in Chicago. Thanks so much for joining us today, Dr. IsHak. The last two years have really taken a toll on everyone but, really, on this Doctor's Day in which we're recording this, it's important to recognize that the physician workforce has really had to bear a large burden. Are you seeing an increase in mental health issues among your colleagues, and what are you hearing from them?
Dr. IsHak: Yeah, thanks for having me, Todd and happy Doctor's Day, everyone. Yes, it's been tough. And it precedes the COVID pandemic, that we've seen a lot of physicians really having to juggle so many aspects of not just taking great care of patients but also focusing on making their own wellness also a priority, keeping their batteries charged so that they can give the healing power that everyone is in need of. And so it has been a struggle for physicians and then COVID just brought it totally to the front, where it became a lot harder to balance all the demands as well as keeping one's illness in check. I mean, wellness in check.
Unger: Seems to be a common theme we've been talking about here for a couple years during this pandemic is the things that were a problem before the pandemic were really made a lot worse. And I don't think anybody would've expected this kind of trauma level on physicians. I mean, some people have likened it ... The pandemic to a war and having tremendous casualties, not only among our patients but really long-term psychological impact on physicians, and some experiencing PTSD, maybe not now or even months down the road. Is our health care system equipped to handle that?
Dr. IsHak: Yeah. I mean, I think that the issue with our health care system is that it became a lot of demands that kind of fell on the front line, especially physicians and nurses right on the front line. It became more of a big struggle with adequate staffing. It wasn't just the long hours because people don't even mind working long hours but having to kind of lose control over one's schedule, losing control over how flow of taking care of people work, including also just really not a lot of reward systems that are in place. Not a lot of positive work environments are getting emphasized. Everybody's supporting and they seem to be supporting but when it comes down to the front line, you'll see that people are just almost doing it ... I hate to admit it but they're doing it all in a vacuum, they're doing it alone.
And the little rewards they got, like we loved the clapping at 6:00 P.M. and we loved the different things that communities came together to help health care professionals, yet the health care system itself and all health care systems, needed to make a lot more accommodations to enable the workforce to stay active and able to continue to not only fight the pandemic but also take care of normal situations that have been there all along. It's just the COVID pandemic was an addition on top of that.
Unger: Yeah. We've been thinking a lot about everything that physicians and these health care teams did to help this nation recover. It really is now time, as we hopefully emerge from this pandemic, to make sure that we have a good recovery plan for our doctors. And a big part of that is about the mental health impact and the toll its taken.
You are the author and designer of something called health education program for the public, which includes a number of online screening tools that help people determine if they have depression or anxiety or other illness or disorders. But since many physicians don't engage with this kind of self-assessment, what should physicians be watching for in themselves or in colleagues that indicate they might need help?
Dr. IsHak: Thank you for mentioning that. We started very early on with World Wide Web becoming mainstream in 1996 at NYU with the help of Ben Sadok and many icons of psychiatry, is to try to kind of value the whole issue of having to take a test in your own privacy that gives you a little bit of an indication to see if there is a need to pursue this from a professional point of view. Online testing had developed way more than our kind of moderate start in 1996, and to a degree that there are measurements now that people can take and score. They can really check not only anxiety and depression but also burnout. And even what we are coming to call now the whole issue of effort to reward imbalance. And there are scales for that that are available online. One of our favorites of all time for burnout has been the Maslach Burnout Scale but there is also ... the AMA had sponsored Mini-Z. If you just Google Mini-Z, you can get a scale to kind of get a little bit of a sense of your level of burnout.
So the signs are all over these questionnaires and they start by this triad of feeling exhausted, constantly exhausted. Telling yourself, "I'm so tired." You go on vacation, you sleep, you relax and you still can't shake this exhaustion off. That's the first warning sign. And it's not necessarily like all the alarms have to ring but it's kind of like an early recognition. And then with that, hand-in-hand, becomes this whole issue of cynicism. Starting to detach a little bit and disconnect from that healing power that we all have, that reward when a patient gets better or concern when they get worse. And I think that issue of cynicism starts to kind of ... Not a lot of things make a difference to the person.
And then last, for physicians, that third warning sign becomes this issue of being inefficient. Can't get a lot done, unable to get through, no matter how the tasks are being controlled in quantity and quality. And so these are very early signs of burnout. And when they come together with more intensity, then they kind of lead ... Because it is associated with feeling depressed and sad and dissatisfied with the work situation, and then anxiety kicks in because then, "Am I able to handle all the critical situations that are coming my way?" So yeah, these are some of the signs that we should be all looking for.
Unger: And as you mentioned, I'd encourage folks out there to check out their resources that AMA has in terms of assessing burnout. You mentioned the Mini-Z but our team here has put together a lot of resources and then in our Steps Forward modules that are online also, suggestions for ways to address those down the road. But kind of back to what you were talking about, you've also researched innovative ways to measure and improve the detection and treatment around depression. So why don't you tell us a little bit about that research and some of the key things that you found?
Dr. IsHak: Yeah. So first of all, I just want to say that depression's a very lonely place, even though the affect itself, the feeling of sadness is a universal feeling. We all know what that is, yet being depressed is a very lonely place because no one really feels that kind of pain the same way with the same intensity. Many times when you see people who are experiencing depression, are told by their people who are close to them or people who know them or people who converse with them, "Just be grateful, be grateful for what you have." Or they would say, "Just take a vacation," or "Take a walk," or "You need to change your healthy into more healthy eating habits." As if these pieces of advice are supposed to kind of fix the problem.
And depression runs a lot deeper than that because it runs with not only the feeling of sadness but also the feeling of nothing brings to the person, any pleasure anymore. That's the sign that we call anhedonia. So that person becomes indifferent to the joy. They're supposed to feel happy when good things happen. They're not really feeling that much. Their energy level is low. They might have trouble sleeping or they oversleep. They kind of use sleep as an escape. They might be not eating at all, lost their appetite or maybe they're just channeling their sadness into overeating. And so then it spirals because the depression don't just come and go and disappear like that. At times they start ... The person starts to question, "What's the point of continuing on?"
Because once you lose that kind of normal feeling that we all have is that, "Tomorrow's better than today. Tomorrow's going to bring exciting and new things." Once one loses this whole thing, it's ... I'm sure you've heard that when people say, "Same dot, dot, dot, just a different day." There's nothing that seemed to be changing and that kind of futility sense becomes more pervasive. So I think that ... Once one gets into these feelings and/or observe them in others, it becomes a call into action because we have very successful treatments. Medications bring down the severity, they don't wipe out the depression completely but definitely bring the severity down enough for the person to be able to think and problem solve and participate actively in therapy and engage in life activities that can get them out of depression.
So always the approach to it is a three-prong approach. It's a medicine, just to regulate body functions and reduce the severity, therapy or life coaching to kind of get reengaged back into life activities and that pursuit of happiness, and last but not least is wellness activities. So one would be engaged in healthy eating and gratitude and meditation and appreciate the environment and connecting with people who ... Developing these meaningful connections to people that we care the most about.
Unger: Okay. I couldn't help but think when we were talking about conversations I've had with Corey and Jennifer Feist who ... Sister and sister-in-law, Dr. Lorna Breen, died by suicide back in the beginning of the pandemic and their experience as they've dug into this issue about the barriers that exist in physicians seeking help when they're experiencing problems like this. Will you talk a little bit about what barriers you see in this process?
Dr. IsHak: Yeah. So I'm so glad that you are bringing up the barriers because they're huge. And many of them are ... I mean you can just divide them up into internal and external. There is internal barriers of that whole sense of pride when you have a wounded warrior. I'm the warrior, so now I'm wounded. How am I going to be seeking help? There's a lot of shame that comes with that. So that's a huge, huge barrier. It comes also with it sometimes denial. "There's nothing wrong with me, I'm continuing, this is just temporary," and a lot of physicians come from these kind of high-achieving backgrounds. They have to get through a lot of hardships to get to where they are in their career. And many times that sense of looking at that becomes ... A lot of it is self-blame and "How could that happen to me?" kind of piece.
The other external barriers continue to be the shame about getting help, revolve around the fear of reports to insurance or reports to things that can actually stop the physicians from practicing anymore. And I think we've done some steps towards making these accommodations true with Americans With Disabilities Act, and even identifying more what's a short-term disability and what's a mid-term disability to enable people to take time to recover, yet there is a lot more room for us to do in this area to accommodate physicians who had fallen just because of the normal course of action. Many of it is actually induced also by the hardship that they're finding in taking care of very ill patients.
Unger: And the volume of that, which must be astronomical.
Dr. IsHak: Yeah.
Unger: When you think about your experience at Cedars-Sinai and what you've been doing to support physicians during this time, is there anything that stands out as particularly helpful?
Dr. IsHak: Yeah, I mean, I think we've identified a very important paradigm that we've written about, about 12 or 15 years ago, which is this whole issue of physician wellness is not a one-way street. It's not just physicians taking great care of themselves. It's a two-way street, meaning that the individual, the person, has to do things to keep their hardware, their body and minds, in a good place but also their software, their approach to things, meaning to have more of a positive attitude. So that's the individual's responsibility. And the second one is very important is the health care system responsibility, the organizational responsibility in maintaining and preventing burnout and improving wellness. So we always see wellness as individual interventions, the things I could do as a person and things that the workplace could do as a place. And at Cedars-Sinai, we've been doing a lot of education about that. We've done really a nice series that runs actually every month, it's a wellness program. And we alternate, one time we talk about individual intervention, let's say meditation or nutrition or even using nutraceuticals.
And another one becomes picking one of the workplace interventions, whether it's management of workload, whether it's how you manage rewards, how you actually give more job control and how you do positive work environment. This is, I think, a culture at Cedars-Sinai that has been very admirable to me. I've been here for 20 years and the culture of dignity and respect has been there from day one when I got here. So as we all say, "Respect is earned," but no, now it's becoming, "Respect is a basic right of every person who comes to work," that everyone has to be treated by dignity and respect. And that's a high value of the organization itself.
Unger: Dr. IsHak, thank you so much for being here and what you've been doing to support physicians. That's it for today's episode and we'll be back with another Moving Medicine video and podcast soon. In the meantime, make sure to click subscribe on our YouTube channel, Apple, Spotify or wherever you listen to your podcasts. You can find all our podcasts and videos at ama-assn.org/podcasts. Thanks for joining us today and please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.