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Dr. Maddux: The COVID 19 pandemic has taken a large psychological toll on physicians and other healthcare workers worldwide. This global crisis has brought mental health concerns into our everyday conversations. Today's guest, Dr. Felicia Speed, has seen firsthand the cascading impact of compassion fatigue on physicians, clinical staff, and patients. As Fresenius Medical Care's Vice President of Social Work Services, Dr. Speed has worked with the American Society of Nephrology to develop mental health modules for healthcare professionals and shares her insights with us today. Welcome, Felicia.
Dr. Felicia Speed: Thank you so much Dr. Maddux, I'm so glad to be here.
Dr. Maddux: I'm glad you're here as well. COVID-19, the Ukrainian crisis, a lot of things have brought issues of stress and impact on healthcare workers that are very different from what we've seen in prior years. Can you speak to that a little bit?
Dr. Felicia Speed: I believe that we look at it from a very different lens. Our perspective as healthcare workers, when we look at any crisis, any situation, we're always looking at the physical and mental wellbeing of the person. And so when the pandemic came through, it was very difficult for many of us to grapple with, because we're so used to fixing and helping and having solutions. And now we're in the midst of something that is not only impacting the people we care for, but it's also affecting our peers. We saw peers getting sick, peers dying, we also had family members and loved ones that were dying. We were in the midst of a whirlwind of so much, that it just became overwhelming, and taxing on... a person that their sense of wellbeing is to take care of others. So when you lose that, as a professional caregiver, you lose that sense of reality for yourself. It's just very difficult to navigate mentally. And when you're in the midst of all of that, the first thing that goes is your ability to take care of your own wellbeing. That gets pushed down. And it got pushed down hard. People kept talking about the waves of the pandemic, I was like, when did we leave the first one, when did that happen? And so we never felt coming out of a wave. It just continued. And it was overwhelming for us.
Dr. Maddux: Speak to me a little bit about the issues around our health care workers, whether their clinical staff, physician staff, they want to be able to create points of control. And in the pandemic, we were not in control in so many ways. And I'm sure that's true in the Ukrainian crisis, that we are just responsive and reactive. What does that do to people who are trying to create order where there is this somewhat chaotic situation going on?
Dr. Felicia Speed: It really comes from a place of "do you have resiliency?" And the resiliency is the ability to be able to get hit, and then bounce back. And also being able to compartmentalize what you're experiencing at that moment. Many times, in the midst of something like this crisis in Ukraine, where we're not only visibly seeing it, we understand it, but it taps into that core of who we are people who have empathy. And with that empathy, and like you said, the lack of control that we don't have, it makes you feel very helpless. It's almost like compounded grief or compounded loss, because we felt like we were losing in the pandemic. And now we feel like we're losing again, because we're having so many things happening that we can't control.
Dr. Maddux: That lack of control is one issue, but there's also just the fatigue that occurs from persistent long-term stress. You mentioned the surges in the virus occurred in sort of the incidents and the burden of the virus. But the burden of vigilance and so forth that was required for patients was just persistent for over two years with the pandemic. How do people deal with that? How did how do they deal with compassion fatigue?
Dr. Felicia Speed: Its important to understand what that really is. You actually have to have compassion first. So, before you have fatigue from compassion, it will help you to have compassion to begin with. At that moment, it is really a physical and mental exhaustion. There's a gradual erosion. During the middle of 2020, people were not yet experiencing compassion fatigue. They had to have a lot of stress. Stress was like an 82%, according to Mental Health America, with healthcare workers. Following that was anxiety and frustration. You didn't hear about the exhaustion until a Kaiser study that was in 2021. That's when you began to hear about the burnout, the compassion fatigue, because it's a gradual erosion of what connects us. So what happens you become extremely apathetic, you're there, but you're not present. It takes away my connection to hope, my connection to be able to empathize and to have that compassion. Even today, people are still grappling with compassion fatigue.
Dr. Maddux: Is burnout reversible?
Dr. Felicia Speed: Absolutely.
Dr. Maddux: Tell me how.
Dr. Felicia Speed: First of all, you need to recognize that you have burnout. And I can tell you what I have learned over the years, right? And I know you're a physician, but you all are the worst ones, at acknowledging that you actually do have burnout. It's really just, recognizing three things that Maslach identified, which was first emotional exhaustion, where you are completely depleted. That's when you become very apathetic, but then personal accomplishment where you're not able to solve things and do things that you want to do. Then the other one is really around depersonalization. And that impacts patient care. Because when you stop wanting to connect with the patient, because you're so burnt out, you become very cynical, and you blame the patient for everything. "Well that's why you ended up here". "Well, that's why you're in the hospital because you didn't come to treatment and dadadadada", so that cynicism spreads a lot. That's what we begin to see a lot with the burnout. The way to be able to help that is first to just acknowledge that you're there.
Dr. Maddux: When I was in training, and this was a while ago now. It was only a few years. We were on call all the time, there was a lot of physical exhaustion that went with mental exhaustion. And I'm just curious whether the physical impact of the pandemic and the degree of disruption to our healthcare systems has impacted not just physician burnout, but burnout of all healthcare workers, from the physicality of having lived through the pandemic and the things that we've had to do that are different.
Dr. Felicia Speed: Yes, it has, it has taken a toll on us physically. I hear a lot of people battling migraines, their immune system is very low. Because what happens when you're in stress and that stress mode, and you have chronic stress, there's something called the allostatic load. When you in that chronic stress where there's continued fight, flight, and freeze, then it takes a toll. And it you know, the cortisol and all those hormones, is looking for fat and sugar and then when it can't find anywhere lands in your stomach, right. That creates all these other types of illnesses. Then on a mental level, it's almost like it does the same thing. It finds a place to store it and it stores it in our thoughts. And just when we have a moment to relax, everything that we've went through rolls back in front of us again. So it's like we can't turn it off. And the ability to not be able to turn it off and to be able to disconnect to be able to unplug can often be very wearing.
Dr. Maddux: We've lost a lot of healthcare workers not just from the pandemic, although there's been that too, but we've lost people because burnout's driven them to where they just can't do this work anymore.
Dr. Felicia Speed: Yes, a mass exodus.
Dr. Maddux: What is the impact of that on those that are left to work, and how do we begin to recover as an organization to support people in this time?
Dr. Felicia Speed: What I hear is some resentment. Angry at those that didn't stay. Then also wanting to be recognized and acknowledge that I did. It's kind of like if everybody jumped off the boat, and four people stayed on, the Captain needs to identify the four that stayed. It's recognizing and celebrating the ones that stayed, but then also giving them the resources to be able to deal with their burnout, because it doesn't mean they're not burnt-out, it just means that they stayed. Because, they were like, this is where I want to be, even though I'm completely exhausted. Creating resources and keeping the resources simple. And making sure that everyone, even those on the very front line, have access to those resources in an easy way, and normalize it. We have to begin to normalize it from an organizational perspective, the community is doing their job, but are we normalizing it to the degree that we talk about it on a regular basis? Being transparent about ourselves if we've needed counseling or therapy. When we began to do that, as an organization, that's how we're able to support our team.
Dr. Maddux: You have done work in the area of anticipatory grief. Talk to me a little bit about that.
Dr. Felicia Speed: Yes. I just completed my dissertation. And it was on anticipatory grief with ESRD patients. It was a qualitative study. What was interesting is that I actually did it right at the beginning of COVID, so their responses did not include a lot of that. But what I found is that many of the symptoms and the signs that they had, were very similar to depression. I began to realize that we, as healthcare professionals in dialysis, are not having the conversations about their experience with anticipatory grief, like they're anticipating their own death. What I decided to summarize is that we cannot begin to talk about their quality of life, if we have not helped them face their quality of death. The more that they are able to have that conversation in a safe space, before we send them running through the fields, and getting on bikes, and walking again and playing with the dogs. Can we just acknowledge where they are? and the decline that they fear. That fear of the unknown was a common thread. And so it's interesting that that same thread lies with the healthcare providers as well, that's what we experienced in the pandemic. It was almost as though we were experiencing some anticipatory grief. Not necessarily of our own selves, but we were anticipating the death of those around us. Like, who's going to be next? that's when I began to see those common themes.
Dr. Maddux: I can recall when I was practicing that there were many times when a patient I was taking care of was near end of life, was, dealing with their own, expectations of death, and so forth. What I felt part of my role was, was to help with the patient and their family or their close, loved ones, how to choreograph that to be as positive an experience as possible, and realize that my role wasn’t to fix things. It was to just help them work their way through this part of life. I can only imagine during times of burnout, that's the kind of thing that gets lost in the ability to care for others. As a physician, the responsibility to try to help somebody figure out how to proceed to that stage of life. It’s probably a lot harder if you aren't in a place where you can actually deal with the emotions of it.
Dr. Felicia Speed: Exactly. Because it hits too close to home.
Dr. Maddux: Yeah.
Dr. Felicia Speed: It's like if I'm taking care of someone, and I don't have any countertransference, there's nothing there, then I feel like I'm able to help them. But when it hits close to home, and I know someone, then it makes it a little difficult to be able to navigate that conversation. You really have to separate yourself from it and say, Okay, I'm going to help you and I'm not going to think about how this is affecting me. That separation, that gap: they leave that room with that gap if they tried to navigate and help someone through that process, and they never bring the two back together. That separation creates that disconnect that continues and is very pervasive from one patient, and they take it home. They end up being disconnected at home. That's the biggest concern that I have with our healthcare providers is that their disconnect is remaining. They're connected to the phone. They're connected to the TV. But they're not connected to people. Because people, it's almost like I'm afraid to connect to people, because I've experienced so much loss, this is safer. It's safer for me to connect to the phone. It's more predictable, except when you're scrolling on Facebook, you don't know what you're going to see next.
Dr. Maddux: That's true. Let's talk about resources. What is it, as an organization, that we can be providing? Or where can individuals within our organization get someone to talk to, get help, recognize that they're not alone in the feelings they're having.
Dr. Felicia Speed: Within our company, we have invested so much into addressing our mental wellness and our mental wellbeing. The benefits that we have with the Employee Assistance Program, they actually increase the number of sessions that you can get free from 3 to 6.
Dr. Maddux: Let's be really specific about this. Why don't you just explain what the EAP is.
Dr. Felicia Speed: EAP is the Employee Assistance Program. They offer various resources, from financial, to wills to, sicknesses or preparing for anything, they literally help you through your life's journey. But a part of that life's journey is your mental wellness. They connect you with local providers or someone virtually, that you can talk to. To talk about what's going on with you, in your heart, and in your thoughts, and how you can reconcile that. That is so important right now. I really do encourage everyone who has access to these benefits to use them. I use them every single year. I don't believe there should be any caregiver that doesn't take three to six sessions at least . And go talk to someone, just to release, even if it's just talk therapy, because your family are tired of listening to you. Go talk to someone who gets paid to do it can also help you process it in a healthy way.
Dr. Maddux: How do you access it? Where do you find the EAP?
Dr. Felicia Speed: Just go right on the website. You go on the internet, you look up on the employee service center. It is right there, you type it in: "wellbeing". They not only help you with your mental, but your physical as well. So we have something like Real Appeal, there's Rally you can compete with people walking. Now we got physical therapy, that's virtual. I use it all myself. It has helped me mentally to be able, as a social worker, I'm listening to so much, I need a place to be able to release, those things are there. If you go up an employee service center, you're going to find the resources that you need.
Dr. Maddux: I understand you have some exercises we can do or that people can think about doing that to bring this to front of mind and help begin to acknowledge some of the stress that folks are working under.
Dr. Felicia Speed: There are several people that's going to go and get counseling, and go get the help that they so desperately need. But then you're going to have those that are just going to continue to be anxious and wired. One of the things I really encourage is that if you have a friend, if you have a coworker, and they're very worked up, a very quick exercise is called a grounding technique. And it's based on the five senses. I'm going to take you through that exercise. Are you ready? I'm sure you all worked up having to talk to me the last few minutes. So here we go. I'm sure I stressed you out. First thing is can you tell me the five things that you see.
Dr. Maddux: I see you. I see cameras and TVs around us as part of this. I see light. I see reflection.
Dr. Felicia Speed: Okay. Can you tell me four things that you can touch?
Dr. Maddux: Right now?
Dr. Felicia Speed: Right now.
Dr. Maddux: I can touch these little cheat sheet cards that I have here. I can shake hands or touch you, I can touch something that'll give me some relief if I get thirsty. And I can sort of feel the ground underneath us.
Dr. Felicia Speed: Okay, and tell me the three things you can hear.
Dr. Maddux: It's quite silent in here other than hearing you and be talking. I think that I can also periodically hear the general hum of sort of the environment of this studio.
Dr. Felicia Speed: Yes.
Dr. Maddux: I can hear movement when you move or I move, or something changes, I can hear the subtle movements
Dr. Felicia Speed: And two things you can smell.
Dr. Maddux: I can smell just the hint of the air we're in almost springtime here in Boston, so there's a little hint of a smell related to that. I can certainly smell that, in the environment, in the office, here, there is coffee, and there is food. So they're sort of occasionally food smells.
Dr. Felicia Speed: And the last one, the one thing you can taste,
Dr. Maddux: I think I can taste to the... to some degree that the memory of my breakfast this morning.
Dr. Felicia Speed: You always use taste as the last one, because if people are tasting five and six different things, I will be concerned. But that is the grounding technique. Yeah. Because when people's minds are racing-
Dr. Maddux: Do people that on their own, or do they do it with a partner?
Dr. Felicia Speed: Oh, no, if you have someone that you can just talk to. If you feel them getting very anxious and worked up, mad about the email, you know, just say, "Okay, let's just do a quick grounding exercise". It immediately just brings them back in and allow them to be mindful and to be present.
Dr. Maddux: How do you manage the load of information that comes our way? We deal in a world of information overload at times. I'm curious whether these same techniques that you're talking about, offer us a way to take a pause for a moment and think about how to manage the environment that we're in, whether it's too many emails, whether it's too many alarm bells on a machine, whether it's too many patients complaining of one thing or another, whether it's too many opportunities to, have a negative thought versus a positive thought. What techniques to use to address that?
Dr. Felicia Speed: For myself, I always look for the opportunities to unplug. For some of us, we can unplug for five minutes, and we're fine. But for those that are so connected to their phones, to having to look at something from technology, you may need 15 minutes. I really encourage that at least one hour a day. I feel like I'm advocating for your brain, and I'm advocating for your heart to unplug for one hour. Just to give them a rest to give them a break. During that one hour, you're not just sitting there looking crazy, just trying to breathe, but go sing, go dance, go do something fun. Go read a book that's actually enjoyable, go stand outside and let the wind hit your face. Take those moments that you completely unplug. And then I'm always encouraging people to be grateful. You cannot be grateful and complain at the same time. Your brain won't let you. So just take a minute and just think of two or three things that you're grateful for.
Dr. Maddux: This has been wonderful wise counsel from Dr. Felicia Speed. Thanks so much for being here with me.
Dr. Felicia Speed: Thank you. I’ve enjoyed it so much. Thank you.