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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER (HOST):

Welcome to Central Line. I'm your host and editor, Dr. Adam Striker. Today, I’m going to share more of my conversation with Genie Blough, principal for G Blough Associates, who does consulting work exclusively on anesthesia and pain management issues for a variety of groups and settings, and Dr. Patrick Allaire, staff anesthesiologist with the McFarland Clinic in Ames, Iowa, and who currently serves on the State Board of Directors. Dr. Allaire has also been involved in a number of committees for the ASA and in his own practice.

In the first half of our conversation, recorded in December of 2020, we discussed preparing for and managing disasters and disruptions. Today, we want to shed light on the human toll disruption can cause, also stress management, as well as suicide prevention. We are fortunate enough to have both a practicing physician and an executive both with expertise in practice management here to help us.

Dr. Allaire and Ms. Blough, welcome back to the show.

MS. GENIE BLOUGH:

Thank you for having us. We appreciate being here.

DR. PATRICK ALLAIRE:

Thank you, Dr. Striker.

DR. STRIKER:

Well, let's start off when it comes to stress management, what policies should practices have in place to deal with their staff's anxiety, stress, depression, et cetera? Let's start with you, Ms. Blough.

MS. BLOUGH:

Well, you need some basic policies and resources. An employee assistance program is something that's available, and prior to the pandemic, I would say it's used for chemical dependence and more serious issues along that line. But we refer to this as the EAP, is something that would be help someone that’s struggling and will have a protocol for handling. And now that we know about COVID and the related stressors of that, of the pan, pandemic, we need to talk more about managing stress and building resilience. And part of that is awareness. You want to make sure that the group and its leaders are in communication. So you can't just live in isolation. And the interesting thing is that with anesthesiologists as opposed to perhaps a pediatrician, you're not operating in the same room with another anesthesiologist in most cases. You're in a room doing your job with your patient, maybe with a CRNA, but it's not like you're constantly in practice in a building with just other anesthesiologists, as you might if you were a practicing pediatrician.

So you want to know how to build this resilience and manage the stress. You need to manage your own stress, to start with. And from a personal standpoint, I do kind of every now and then have the checkpoint and say, how am I doing? How is my stress? And physicians and all of the providers have both clinical stress and work stress, but they probably have personal stress as well. You need to work with people in your group. You want to make sure that you have an eye out for them. Look for the unusual behavior. You need to always be aware of how others are handling the work, how there may be things that you're not aware of that they're struggling with. Are they having personal problems at home, in addition to the work stressors? Clinical people are well adapted to recognizing those kinds of behaviors. But we need to really tune into that. I think a discussion within a group of having, let's keep an eye out for each other, let’s check up on each other. Even if you need something like a buddy system, how do you go about doing it? So get people to talk. You could do a Zoom once a week with, with a CRNA, or Zoom once a week with staff have small groups. In addition, have a large group meeting, a town hall, maybe with open discussions and talk about what's going on. In my family, we always had a, a dinner conversation around good thing, bad thing. And you talk about the things that happen good in the day, and one thing that happened that was bad, and, and how you feel about it now. And that same family kind of relationship can be carried over to a group to have those kind of discussions in a town hall. And it, it starts with maybe a, a key leader who can say, I'm feeling stressed, I'm feeling these stressors, because that opens the door for other people to come in and step up with that.

DR. STRIKER:

Well, Dr. Allaire, how has the uncertainty of all this affected the mental health of your staff? And, and how has your practice evolved to deal with all of it?

DR. ALLAIRE:

Well, you know, the, the short answer is that it's been exhausting. You know, for most professionals, you reach a point in your career where you know, you've, you've got sort of this slot for all of the things that you deal with at work and then you come home and you go about your life. That’s probably true in all professions, whether it's police work, firemen, anything that, where professionals are involved.

But, you know, COVID, interestingly, travels home with you and sort of insidiously, before you know it, you, you spend more time you know, reading about clinic, I found, I probably found myself reading more clinical articles than I had years. But you're constantly trying to digest this pandemic. And in the Midwest, when, you know, we sort of had a hyper reaction to what was happening on the coasts, you know, we had a lot of people sitting around without an actual action plan. They were, they were prepping for a disaster, it was almost like getting ready to go to war, but there was no battle yet. And I think, you know, the first couple of months probably were, were the hardest on our people. They, you know, just all of the unknowns and uncertainties. To a certain degree, once we sort of figured out a, I guess, a more graduated response to the pandemic and what was happening in our region, in our state, and people were able to resume some normal work, but also, you know, to a certain degree, start taking care of COVID patients. I think I saw the palpable stress start to go down because there, there was an action to go with sort of the anxiety.

So like I said, we've tried to come up with the individual plans in terms of staffing and hourly commitments, and that's at all levels, nursing, facilities, workers, advanced practice nurses, physicians. And so we have found that we've had to sort of insist that people actually use their time off when there's no place to go. Everything's closed. There's this natural desire to, to, to sort of just keep coming in and punching the clock. But, you know, we know from, from sort of what experts tell us and anybody that has, you know, had a fairly draining and busy job knows that that time away is important, even if the time away is to just take five days at home and rake your leaves.

In my case, I cleaned up after derecho and cut, cut logs for a couple of weeks after we had a, an inland hurricane. And at the end of it, I actually felt better than I'd felt all year just because I took my mind off of it. So we've been en, encouraging and reminding people that they need to step away.

And, and another health, healthy step that we took in many of our lounges, we turned off the news. A lot of lounges, nursing lounges, staff lounges have television sets, and I think there's a tendency for those to play CNN and Fox News and whatever other type of news almost all day long. And that constant barrage of the doom and gloom, you know, adds a heaviness to what is already hard work. So in many of our staffing environments, we've, we've sort of all agreed to at least take holidays from the constant news feed at work. You know, stay, stay focused on work, stay focused on each other, support one another, and, you know, if anything, turn off all of the, the talking heads for a while. In a nutshell, that's been our, our experience.

DR. STRIKER:

And, Ms. Blough, what action steps should practices be taken to make sure they're supporting their leadership, as well as creating a culture that gives staff and community the care they need?

MS. BLOUGH:

Well, the, the meetings certainly are a big help, but I think buying lunch, having lunch, set out if you know someone who's really struggling in the group. I think there, this is a time to really take care of the group as a whole, but also reach out to the individuals. I think a buddy system even, which you know, is, a lot of this sounds like we used to call this pink everything is pink, we need, let's talk finances and money. But this is the thing that's going to keep our group together. If you've got that strong culture, you can, we care about you, and it’s, it’s not just chatter. It's, it's action of things that we're doing. And I think is, Patrick may have been the things that you do in the community, standing up and, and, you know, whether it's around the holiday or you get together and have a collection for someone who’s struggling. I think that if you do things for other people, it helps you more, it helps you personally get through this. So anything that can be done with the group as a whole.

Keep everybody talking and emotionally engaged and certainly being aware of them, of you've just got to really focus on that individual and look at them in the eyes. This person that you've worked with for years and you may not know a lot about their personal life, this is the time to kind of help draw them out and to understand what they may be going through.

DR. STRIKER:

Well, I'm wondering about some outside support or guidance for setting up mental health protocols and where listeners can turn for that. What work resources have, have you both relied upon? And let's start with you, Dr. Allaire.

DR. ALLAIRE:

Our organization has turned to our State medical society actually a, a great deal. That's both for anesthesiologists we’ve, you know, the Iowa Society for Anesthesiologists been helpful, but on a much, on a, more broader view, the Iowa Medical Society has had a lot of resources that they've dedicated, particularly to the mental health and resilience part of this. And so we found them to be very helpful, at least referring us to more specified resources. So in terms of finding a template that sort of says you've got a stressed out organization, you may have mental health issues starting to emerge, certainly your State medical society is a good place to start. I think most of the State medical societies and certainly your national organizations, whether it's you know, if it was the American Society of Anesthesiologists or the American Society of Orthopedic Surgeons or whatever specialty medicine you might practice, they also are a good resource.

On a, on a more local level, we have actually engaged a, a third party source that provides confidential counseling and sort of what I call life management opportunities or assistance. If your organization is of a size that you, you want to individualize a, a service to your, your employees and your partners, then you could, you could look into a third party. We use a company called Vital Work Life, and every employee and their families are invited to engage with, you know, both an online platform and a call center that allows them to request confidential counseling. They can request help with scheduling a college visit for their, their high school student. There's concierge opportunities there. If, if somebody is wanting to plan a special event, we have found this third party vendor to be very helpful.

And interestingly, I might have been one of the biggest skeptics of this when we subscribed to the service, interestingly, just ahead of COVID, which was a total coincidence, but, you know, with an organization with about fifteen hundred members, all that's, that would be all employees, doctors, nurses, all in, you know, we may have started with referrals to the service in the tens in a given month initially, but after it's been up and running, now it's in, in the one to two hundred sort of what we call client interactions with the service on a monthly basis. So, that is, that's certainly been the temporarily a helpful adjunct to our sort of mental health of the staff that we've used.

MS. BLOUGH:

I would add to that, that ASA has an excellent white paper that came through the Committee on Professional Development and it's focused on stress and resilience, and I believe that's available through the ASA website.

DR. STRIKER:

Great. Excellent. Thank you both.

Tragically, we've seen the risk of suicide increase during the pandemic. And from the perspective of your practice, Dr. Allaire, have you dealt with staff or patients who've expressed suicidal ideation because of the pandemic?

DR. ALLAIRE:

Well Dr. Striker, un, unfortunately, besides dealing with patients, families who struggle with suicide, our organization actually lost a physician to suicide at the end of May of this year. And even though, you know, I would say we're a modest sized organization, it's still a very fairly tight medical community, and, and it was devastating. It's devastating for that phy, clearly for that physician’s family. It was devastating for the organization, the department. And so we've unfortunately had that suicide followed up by a suicide in, in the family, the immediate family of a, one of our beloved retired physicians. Know I, I can speak about it because I know the family members of our physician past have said, you know, if there's anything that can be done so that this never has to happen again, feel free to, to sort of leverage this experience. And so it was very important to support the staff. And, you know, you need to be attuned to people's emotional health.

And oddly, in this case, where we lost the physician, everybody thought he was a, just a little off for several months. But who hasn't been a little off with COVID? And I think, you know, from that, you know, there comes a, a responsibility to just sometimes ask somebody how are they feeling and reach out to them. Surprisingly, that's one of the most helpful steps, according to some of the psychiatrists that have debriefed me, or the psychologists that we've spent time with talking about this tragedy.

DR. STRIKER:

That is truly tragic. And I am so sorry to hear that you and your community are, are grappling with that and obviously more common than we want to admit. How did you all deal with it? You and your team, everyone?

DR. ALLAIRE:

Well, certainly you need to come together and you need to talk honestly about it. When this happens, there's no reason to hide the truth, certainly amongst the staff. That just leads to a lot, to a lot of back door conversations and, and theories and whispering. So we honestly told people what happened. We gave them time to talk about it. We’ve, we have circled back on it and we specifically created time in the work environment to let people talk about it. You know, we are in a mid-size suburban city, so fortunately there is a adequate supply of psychological professionals. So we were able to engage them to come into our organization and give us time. You know, and, and based on how much you interact with somebody that, you know, in some instances was fairly time intensive. And in other instances it was just, you know, a discussion to sort of check in in your department for the, for the people outside of this physician's department to just sort of check in, look everybody in the eye and engage and say, you know, is everybody here doing well enough to that, we don't need to be worrying so much about something this tragic.

Moving forward, we're going to be focusing more on suicide prevention and awareness, and, and you know, that's going to involve some learning modules and some, you know, as we can get together, not necessarily electronically, you know, we’re going to have some speakers and some engagement also. But it's a national problem. You know, this is, you know, our loss of a physician was the third physician suicide of a physician that I know in my career. And I think that's tragic. And I rather doubt that most private citizens know three suicide victims. So it tells me that there's a lot of stress, a lot of, a lot of internalization. Some of this may go larger in terms of as a workforce or sort of a “don't ask, don't tell” about your mental health. Most licensing applications ask if you have had a mental health issue, sort of implying that if you have, you're not going to get your license renewed. So the house of medicine, and it’s true for, for all levels of medicine, you know, all, all levels that require licensure has a bit of a problem here of having a double standard of what we, of the services and the care we provide for others and what we expect of ourselves.

DR. STRIKER:

Yeah, absolutely. Great points. And you know, the issue of burnout and stress, it's, it's all apparent and we're all aware of it. But, boy, you don't really get a sense of the, the reality of it until you hear these stories and or unfortunately, have the experiences you have where, you know people personally affected in that way. I mean, it affects a lot of us in different ways but boy, those, those stories really, really hammer home the, the importance of dealing with this issue.

Ms. Blough, do you have anything to add to that in terms of a broader perspective? We obviously know that the effects of suicide are wide and deep, but if you could talk a bit about tools or tactics families and communities can use to deal with this issue?

MS. BLOUGH:

Well, I think Patrick's really covered a lot of very practical instances of this. I think when suicide does occur, how are we going to forgive ourselves and keep moving? And all of the modalities that he referenced, to whether you get support, maybe you outsource this and have something set up so it makes it easy for people to talk with. Personally, you know, when I think of what he's been through with three people that he knows to have committed suicide, the personal guilt or the personal what could I have done to make a difference to this person, what could I have done to stop this, is something that giving people the resources to handle that. And I do think that they don't sweep it under the rug is excellent because it's not a dirty thing. It's something that happens in families. It happens all across the country.

And, you know, we may not ever figure out exactly what it was that, that triggered in that person that caused the suicide. But all the people that are close to it are going to need support. You're going to need for the family, I think a group can support a family that has gone through that, reaching out to them, including them. The overarching feeling for that family that you're not alone in this, that this person, this individual who committed suicide was a part of us as well. So forgive yourself and then find ways of talking through it. And en, encouraged that these groups looking at focusing on suicide prevention, talking about it so that you can get an idea of when people are struggling.

DR. STRIKER:

Well, Ms. Blough, great advice for some of our listeners.

MS. BLOUGH:

One thing I'd like to acknowledge is the vulnerability of anesthesia providers in particular. Other specialties are affected as well, but the anesthesiologists are quite often right there in the perioperative area as patients are dying. And it's very difficult for them to survive through this. Throughout all the training, the residencies, fellowships and active practice, providers are trying to make decisions. They're trying to be the leaders in the perioperative arena. They are supposed to be the strong leaders. They've been trained to do this. And this background of training becomes a weakness when it comes to recognizing and acknowledging their own stress, mental fatigue and perhaps depression.

So the challenge really is, and I think Dr. Allaire alluded to this, is to look at each other, to keep in touch, to acknowledge the, the, the struggles that we're going through. Confess your own struggles, confess your own worries about being depressed, and that encourages others to be open and discuss it as well. Gone are the days where the physician has to be so strong and, and stalwart in these kinds of situations. And we're just seeing so many people affected, physicians and then physician families as well. So to the extent that you know the people you work with and that you're around, and to be able to look them in the eyes and have those honest conversations I think are just critical.

DR. STRIKER:

Well, Dr. Allaire, what kind of programs does your practice have in place so that they're monitoring mental health of your staff?

DR. ALLAIRE:

I think we have some, some rather good programs. You know, first of all, we have a mentoring program with any new clinician that enters our organization, they're paired up with an established generally senior person, in their, in their same field. And, and there's, there's some required meeting time. They, they’re the person you reach out to if you're, if you're just trying to get your feet under you in a practice, you don't understand anything.

And we mentor all of our new clinicians for about two years. And, at which, and that’s, you know, it does coincide with a probationary period for employment generally. So there's at least the level of, of engagement right from the start that sort of puts you in somebody's space that you're accountable to, for, you know, you hope it's going to be mostly minor things. But as you meet with somebody periodically on a monthly or bi monthly basis, you, you start to get a feel for their personalities. You start to read them. And so on the front end, that's, I think that's kind of where our engagement starts on, on this level.

We have an employee assistance program. That's a whole other type of modality that really directs some of our resources to the employee or clinician or physician who is struggling with a personal problem that may affect their licensure in particular. So let's say chemical dependency or, or a financial strain. And so the, the employee assistance program is a confidential program that allows a clinician who thinks they have a problem or maybe sometimes these problems are brought up by a spouse, you know, you know, a gambling problem, for example, that allows them to sort of enter into that with some confidentiality and some additional resources that hopefully can help them better themselves or work through whatever that issue is.

DR. STRIKER:

Well, before I let you go, I'd like to ask you both one final question. What's the one thing you think physician anesthesiologists should do today to make sure they're attuned to the mental health needs of staff, patients and their community? If you had to distill your thoughts into one piece of advice, what would it be? Ms. Blough, let's start with you.

MS. BLOUGH:

I would say let your guard down. Be human, lean on others in your group, hold your family close and take care of your physical well-being.

DR. STRIKER:

And Dr. Allaire.

DR. ALLAIRE:

I would encourage everyone to, you know, take a lot of time for themselves, take their allotted time off. Don't be taking any more work home than is absolutely necessary, and if that means turning off the cell phone, stop reading the emails after dinner. Stop listening to the news after a certain hour. Try not to take all of these stresses home. You need to lean into your family. You need to lean into the things that you like to do. And sometimes you may not feel like doing either. You know, you may not want to be with your family. You may want, not want to go golfing or fishing or whatever historically, it is that you've enjoyed. But sometimes you need to just step through the paces of doing those things and you'll actually find that there, there's comfort in those activities and, and they're going to reduce your stress. You know, I want everybody to remember that, you know, we're in the, the healing arts and we take care of people, but we have to be healthy ourselves to take care of other people's health.

DR. STRIKER:

That’s great advice from both of you and I just want to thank you both for joining us for this incredibly important and engaging conversation. And covered a lot of ground, but I, I think these issues are need to be addressed and are incredibly important. So thank you both again for, for joining us today.

DR. ALLAIRE:

Thank you.

MS. BLOUGH:

Thank you.

DR. STRIKER:

This is Adam Striker thanking everyone for tuning in again for another episode of Central Line. We appreciate it, and, and we'll see you next time. Thanks.

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