Without further ado, I'd like to introduce Dr. Rebecca Guest. She's the medical director of employee health and wellness at Memorial Sloan Kettering Cancer Center in New York. She's associate clinical member of the staff at Sloan Kettering. She's associate professor of medicine at Cornell, and she is the vice chair of membership for the MCOH section. Welcome Dr. Guest. So I'll start with my plug for membership. If you're not a member, please join MCOH. We would welcome you. This is the last talk of a long week for many of us. Some of you came just for today's curriculum. So I think it's not a great spot for me to be in, but there's not a lot of facts, which is good for you all. It's really more an approach and an attitude and sort of a willingness to address, think about, deal with this, these sort of taboo issues that come up that nobody else really wants to deal with. And you may, or you likely will, or have already encounter while doing medical center occupational health. I have no actual or potential conflicts of interest. And I'm speaking really based on my practice. I'm not speaking for Sloan Kettering or for Cornell, but these are the recommendations that I have. So I'm going to start by reading a passage from a book, which was written by Dr. Adam Hill, who is a pediatric oncologist and palliative care physician. He says, my name is Adam. I am a human being, husband, father, physician, recovering alcoholic, and mental health patient. I drank away the mounting problems in my life one night and one bottle at a time. I searched for any possible way for the ongoing pain to end in the midst of these struggles working in modern medicine. I was left a shell of the person I wanted to be. I had dedicated my life to medicine, but when my own life hung in the balance, medicine turned a blind eye to my suffering. So I'm hoping that, you know, after this talk, we'll be less reluctant to sort of look this problem in the face, and we will not be one of those individuals that kind of shirks from it and turns a blind eye. I think that many of us have the opportunity to help other physicians and nurses and healthcare workers who are in trouble that may come to us or may come to our attention. So this is our agenda. We're going to talk about substance use disorders, mental health conditions, and other related distress, barriers and facilitators to seeking help among healthcare personnel, and the importance of identifying good resources. And I have a list of some resources which I've curated, which will be in the handouts. They're not in the slides, but you'll have all of the slides, so you don't have to take pictures or take notes of the resources that I list. So not surprisingly, because we are human beings, we as healthcare professionals have the same problems that are common in human beings. So clearly we're not immune to things like anxiety disorders, depression, sleep disorders, PTSD, burnout, addiction, overwork, and a myriad of physical ailments as well as these. Often though, when these kinds of things come to our attention, working in employee health or in occupational medicine, it's really not clear exactly what's going on. It's not like you'll get the phone call from the chair of the Department of Medicine saying, you know, Dr. So-and-so has major depressive disorder and, you know, I think he's taking too many benzodiazepines that are making him sleepy at work. It doesn't come in a neat package at all. It's more often than not very murky and confusing. So I suggest that, number one, you take time, schedule an appointment for that phone call rather than sort of allow the curbside consult be sufficient, but actually if someone asks you about a colleague or someone that reports to them because they're concerned, schedule a phone call or a meeting face-to-face and talk about it, listen carefully, ask questions, make a history, don't sort of fall prone to hearsay, gossip. People are saying that so-and-so may be drinking too much. Really hone in on what's been observed specifically, if anything, and why the person is concerned about whether it be mental health or substance use problem. So OCMED physicians know that there's a distinction between impairment and illness, but it does bear saying that when we talk about addiction because we do have healthcare professionals who are dependent on certain substances, who function very well, but they don't have an impairment, right? So you know, they might be taking something to help them sleep, but they take it at the right time, and then when they go to work, they're fine, right? That's distinct from the misuse of substances, which cause difficulty at work. So maybe being sleepy while still at work, taking a pain medication at the wrong time of day, these kinds of things. So these things, just because somebody has a dependence, doesn't mean that they have an impairment. So you have to sort of sort that out, and it takes time, often. The second thing is to realize that if there is a substance use disorder or a dependency, it's important to know that substance use disorders, when not addressed, are the major reason for physicians to become impaired. So it can't just be ignored, oh, he's always been taking so and such and such, oh, he's got this script. You have to kind of really dive a little deeper and realize that it could progress, even if it's not right now. And the terminology has evolved to talk about physicians with potentially impairing conditions, and the reason why we use that, if we can remember to, is so that we're not overstating or causing panic or getting ourselves into trouble, quite frankly, with licensing boards where we should have reported an impaired physician or an impaired nurse, right? Because if they have a diagnosis, there are responsibilities for reporting, but if there's potentially a problem or potentially a dependency, or there is a dependency, that's different in terms of reporting requirements. In fact, you don't really have to report if there's no impairment. You're just looking into something, right? So what is addiction? As defined by the American Society of Addiction Medicine, it's a primary chronic disease affecting brain reward, motivation, memory, and related circuitry, leading to characteristic biopsychosocial manifestations. This is reflected in an individual pathologically pursuing reward and or relief by substance use and other behaviors, and here you can see on the right of the screen, there's three stages of the addiction cycle, where there's an abinge or an intoxication, then there's withdrawal from that substance, which might be like the hangover, and then there is the craving or the preoccupation with getting that substance again. And what is a substance use disorder? It's two or more of the following symptoms occurring within a 12-month period, and you can look at these later. We're not addiction medicine doctors. I mean, if there is someone here, then you should be giving this lecture, actually. But just, it bears to say, we don't need to make these diagnoses. It's just, if you're thinking it might be one of these things, look it up, right? So the prevalence of substance use disorders is high in our population, and all of these stats, which I'm not going to read, but you can look at, have probably increased after COVID. There were a lot of lectures about this during this conference, but among physicians, pre-COVID showed there was 10 to 15% alcohol use disorder, and 69% of physicians who abused prescription medicine said they did so to relieve stress, physical, or emotional pain. And these are all risk factors, comorbid psychiatric illness, which could just be depression, which is incredibly prevalent and has increased since COVID, stress, which many healthcare personnel have, especially the last 25 months, high expectations of work, disrupted lifestyle, well, most healthcare personnel have that, doing shift work or being on call, self-treatment which is a very tempting thing that many healthcare professionals fall prey to, writing their own prescriptions for themselves, easy access to meds, et cetera, and a family history of substance abuse. Yes? Is that 69% of the 6% or is that 69% of the physicians? The 69% of the physicians that, of the 6%, it's 69% of the 6%. Thank you for clarifying that, yeah, 69% of 6%, so most, the majority of physicians that use substances other than alcohol do so to relieve stress, physical or emotional pain. And the reason why I like that, that sentence, why I pulled that out is because I thought, you know, people who become dependent or addicted or misused or become, or abused don't usually start out doing so because they want to get high, particularly when we're talking about physicians and healthcare professionals. They often do so to relieve stress or pain. And these are some great articles that I hope you'll take a look at, but it did, it's just basically talking about how alcohol abuse and dependence is associated with a lot of these other things like depression, low quality of life, lack of career satisfaction, burnout, and of course, suicidal ideation. Many signs and symptoms of substance misuse disorder, and this gets back to taking your history, what is the concern? If you're getting a phone call from leadership, a chairman, a residency director, a nurse leader, what did they see, what are they worried about? And these things are really pretty important to ask about, but note that really very few of them are specific to a substance misuse disorder, right? Maybe you could say that slurred speech or the observation of alcohol on one's breath is specific, but many of these things overlap with depression, quite frankly, overwork, burnout, et cetera. So again, we don't often know what's going on, we just need to know something may be going on and it needs to be looked at further, okay? And I like to think of the positive, it's not all negative, I mean the prognosis for physicians and also nurses is better than the general population when these healthcare personnel decide to seek treatment and engage in monitoring after treatment, monitoring for the substance that they were dependent upon. So that's a good one to pull out if you're counseling or coaching somebody to get care, there's very positive success rate. Another really long list, which you can look at, but these are behaviors of concern, they're not pathognomonic, but inappropriate behavior, change in behavior, the person who was never argumentative is now incredibly argumentative, you know, being late all the time, things like that. But again, not pathognomonic, but important to ask, or you don't have to ask all these things, but just listen, and then you can refer back to this list if you're not sure. Okay, so let's talk about some mental health conditions other than substance misuse and other distress in healthcare personnel. And all of these images are from the AMA website, there's a really terrific section on clinician well-being, and these are photographs and art created by healthcare professionals. So this is a sobering statistic, which I think if you take away one point with this last talk of a long week, is that depression is very prevalent among physicians and nurses, and doctors have a much higher risk of death by suicide compared to most other professions, with three to four hundred physician suicides, or deaths by suicide in the U.S. every year, which is about one a day, right, that's a lot. So even this, in the last two years, there were two residents in New York area hospitals who died by suicide in the area that I work, which is, you know, just totally a tragedy, terrible. And there was a study in JAMA in 2015 which showed that 29% of resident physicians experienced depression or depressive symptoms. So really, really prevalent, and again, all this is done pre-COVID. PTSD is also a major issue, particularly in certain areas and subspecialties of medicine. Emergency medicine is one. Critical care medicine, you know, you probably could figure out the culprits of people who are on the front lines. One 2019 study showed 16% of emergency physicians met criteria for PTSD. And then in the fall of 2020, a survey showed as many as 36% of front-line physicians suffered PTSD. And I didn't put the DSM-5 criteria up for PTSD, but you can look it up. Again, we don't need to make these diagnoses, we just need to be aware that our employees, many of them are facing them. At the end of March, there was a really beautiful essay, I encourage you to Google it, in the New York Times, written by Dr. Seema Jalani, who's a pediatrician, a humanitarian, and an aid worker, as well as a Fulbright scholar. And here's an excerpt. My shift in the pediatric emergency room during my three-year residency training were a tour of human heartbreak for me. A 15-year-old needed a sexual assault kit. A three-year-old tested positive for the dad's meth. A man dipped his six-year-old's feet in boiling oil. I once had two children die within six hours of each other. After each death, I choked back the welling tears, picked up the next patient's chart, and soldiered into the next room. The culture of medicine discourages doctors like me from crying, sleeping, or making mistakes. Worse, we can even be punished for seeking mental health care. And, like, I guess that's why I wanted to give this talk, because I just, I felt like it was an opportunity to say, like, let's change this. Let's not punish one another for seeking support. Let's recognize it and welcome people with an open door. Let's not be part of the problem, but be part of the solution, because we have that opportunity in our positions doing medical center occupational health. And then, of course, the pandemic magnified stressors, magnified pre-existing mental health issues by causing, you know, new stressors, shortages of staff, poor morale, lack of PPE. A lot of fear and guilt was experienced, particular, and there were studies that showed it was particularly among women who were mothers, and they actually sort of documented the highest, I think it was about 50, more than 50% of women who had children at home had tremendous guilt and fear of bringing the infection home with them. I have a couple friends of mine who didn't go home for a couple months. They were staying in hotels because they didn't want to infect their children. So it was real. And then, of course, many people lost their jobs. Not many healthcare workers, but many other people's spouses. Lots of our nurses are married to other essential workers or people who didn't have work who were laid off because of the pandemic, which added a whole other layer of stress. So the culture of healthcare, we know. Patients always come first. Studies have shown that healthcare professionals often postpone or neglect their own self-care, physical and mental, and one study showed 35% of physicians do not seek regular healthcare for themselves. And the reluctance to seek treatment for mental healthcare is particularly pervasive. A study showed that 50% of female physicians did not seek treatment, despite feeling that they met criteria for a mental health disorder. Why is that? Well, some of our states still ask, are you under treatment or have you ever had treatment for a mental health disorder when we have to renew our licenses? Not all of them, that's changing, but that still exists in certain states. And even if it doesn't, we remember that. We sort of know that's not something you want to admit and you don't want to have a record for having a mental health disorder or let alone having a history of an addiction. So what can we do? So as I said, have an open door, be approachable, start out, you know, let's say you get the referral. If it hasn't happened yet, it will, but someone calls you, says, I'm worried about so-and-so. Often they don't say I'm worried about, to be honest. The call's more like, do I have to report so-and-so? I think this. But you want to change the conversation and the tone of the conversation to, let's have a conversation. Let's see what's going on. Not jumping to reporting, which tends to be sort of the knee-jerk reaction of certain people, maybe administrators or people who have to be risk-adverse, of course. So first off, you know, try to tease out what's going on. Have a meeting, take a history, do a physical. And then the other main thing to do is be there as a resource to assist somebody in getting care. And sometimes, often, that can be done without actually having a full diagnosis or even having a person totally disclose what's going on. So if there is not impairment at work, but there's concern, you're in a great spot, right? That's when you say, do you have a primary care doctor? Do you have an internist? No, oh, well, maybe you should have one so you can have a conversation and start taking care of your health. Or that's when you say, you seem like you're under a lot of stress. Anybody to talk to about that? And that's when it's good to have a list of, you know, mental health professionals that have experience working with clinicians, with nurses, with doctors, that you can, with confidence, say, you know, I know this person has seen doctors before. Why don't you give them a call? So you don't have to sort it all out. You can maintain privacy and respect and all that good stuff. But just have an open door. So this is my cheat sheet. Stop is what you shouldn't do. Or what we shouldn't do, right? Stop is what we, as a culture in medicine, should stop doing. Because we often perpetuate this with residents, medical students, et cetera. But let's stop sort of the fear and the stigma and the lack of awareness. And let's present ourselves as a nonjudgmental place where we can listen and provide confidential, supportive, and practical information to get people into care, if that's what they need, or further evaluation. How do we make it easy to get help? I recommend that you take a little time with good, old-fashioned Google and look and see what resources you have available to you in your community. And I'm going to give you an example of a list that I pulled together. Some are national resources, a couple international, but not many. But the local, I included a few, because they're really terrific in New York, in case you're a New Yorker. But each state should have resources, and even certain cities. And then go on the road and communicate this. And that's how we contribute to breaking down the stigma and getting people to get care. So here's an example. This past January, I spoke to our medical staff, which includes our doctors, our nurses, our licensed independent practitioners, so our physician assistants. Sorry, not our nurses, that was a separate meeting. The nurses have their own sort of group. But, you know, PAs, nurse practitioners, et cetera, registered nurse anesthetists. And we were invited, myself and a psychologist, to just talk about the situation, these kinds of things, and raise awareness. And I have to say, I got so many emails afterwards, which were so lovely, like, really lovely. So, like, I've been at this institution for 15 years, and nobody ever talked about this. Or, I struggled with this 20 years ago. I'd really like to share my story. Is there a place for me to do that? Like, people reaching out. I was like, wow. Really blown away by how grateful people were to get this taboo topic out in the open, you know, to talk about the elephant in the room, I guess. So, we started our presentation with this quote. These are the duties of a physician. First, to heal his mind and give help to himself before giving it to anyone else. Epitaph of an Athenian doctor. And then, I'm going to fly through these slides, because it's not really important for you to look at the details. But essentially, I want you to know that I put together about 10 slides, which I think all of us could do, of resources. And this is a psychologist who will see medical staff, health care professionals, as well as non-health care professionals. We have an employee assistance program. We identified one particular person that we like working with, in particular, particularly for our trainees. Our GME, SKI, SKI Sloan Kettering Institute, and GSK is the Gerstner School. So, this is a picture of her, making her look approachable, with her phone number, her email, and what she does, and that there's no charge. But I think people seeing like there's a human being, really just helps. And then, I just have learned from doing this job long enough, and my own personal experience of self-care neglect, meaning not getting primary care, that many of us don't have primary care providers, and don't do our routine care like we should, particularly in the last two and a half years. So, I just looked at the website for our benefits, and gave some essential information. Some of the smartest people don't know how to get a primary care doctor, and they don't want to look. So, this way, they could just look at the slide, with the phone number and the website, and not have to find it buried, you know, themselves. And then, I shared some other resources, like our wellness platform, and about time off, because we did talk about addiction, and what we really want is people to seek help on their own, right, before there's an issue. So, the way to do that is to say, oh, this is how you could get help yourself. And also, by the way, there are some wonderful sick leave policies in short-term disability, and if you take a leave of absence, and it's not related to impairment at work, when you come back, great. You've had some of the best medical coverage, and, you know, you don't have to tell anybody why you were out. I mean, outside of, of course, your return to work with our employee health, which is completely confidential. And I kind of threw in, for good measure, you could say you went out for a knee replacement, which got a good chuckle out of everybody, because the point is, is that it's really not everybody else's business. And I think one of the major barriers for healthcare professionals to seeking care is sort of embarrassment and shame. So, those were the internal resources, which you would have to do for yourselves, because they vary based on where you are. And then the rest of these slides are external resources, meaning resources that have nothing to do with a particular organization. Every state has a committee for physicians' health. Just raise your hand if you know what a, what CPH is, a committee for physicians' health is, because I don't want to bore you. It's called something different in each state. Oh, they do? Okay. So, essentially, it's called CPH in New York, but it's essentially a program which each state has for physicians and physician assistants to go. They can contact them anonymously and ask questions. And it's a sort of self-referral, or could be referred to, and it's a non-disciplinary program to support physicians with mental health problems or impairment or addiction. And they make referrals to specialists and will engage in monitoring once the person, you know, becomes sober or gets the care that they need. So, the CPH, I actually called the director of our CPH in New York, who I was sitting next to at a conference. I said, what's CPH? And he told me all about it. And I was like, wow, that's an amazing resource that I didn't even know existed. So, it's a good one. And there's the same thing for nurses in most states. Again, the names vary. And they sometimes refer to them as alternatives to discipline, ATD. So, it's not sort of reporting to the board in the case, one of the states that I looked at for nursing, a nurse who had a problem could voluntarily take a leave from work, give up her license for a short period of time to receive treatment, then voluntarily enroll in some monitoring. And this was for addiction. And, you know, over a certain period of time. And then this particular organization would advocate for her if she were to have some problem, if she were compliant with the treatment. It's kind of a good thing. Here's a curated list of resources. I think the National Academy of Medicine website is amazing. There's something called the Collaborative for Healing and Renewal in Medicine. There are whole conferences on physicians' health, where they delve deeper into this stuff. The National Suicide Prevention Lifeline, SAMHSA, of course. And then there's AA groups for recovering nurses, physicians, et cetera. So, I think because sometimes people feel more comfortable with their own colleagues participating in these things. And a couple more resources, hotlines, and that's sort of, that's it. And then I just wanted to close by saying, Dr. Lorna Breen was a emergency physician who committed suicide very sadly early on in the pandemic. She had had COVID. She was working on the front lines of New York City. She got COVID. She got sick. She came back to work pretty quickly. Then she left work, went home, and tragically died from suicide. And afterwards, there was her family, I think maybe her sister and brother-in-law, or it might be her brother and sister-in-law, I don't recall which, but they put a lot of effort together. Now there's the Lorna Breen Healthcare Provider Protection Act. And essentially, there's grants that have been established for funding, for increased awareness, for increased access to resources to help people with burnout and mental health problems, particularly healthcare workers, physicians, residents, etc. And this is my last slide. I think that in our position, we have an opportunity to change the culture one person at a time, to reduce stigma, to encourage prevention, and to improve access to excellent consultation and care with mental health professionals. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

mental health

substance use disorders

healthcare professionals

supportive environment

depression

PTSD

Lorna Breen Healthcare Provider Protection Act