Stanford Medcast Episode 66: Women in Critical Care Mini-Series - Psychosocial Challenges Facing Physicians

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Amanda Kore Schilling, DO: On behalf of the Society of Critical Care, anesthesiologists and women in critical care, I'd like to welcome you to our podcast miniseries. This Stanford Medcast mini-series is dedicated to women in critical care medicine, but really it's for all physicians and working professionals out there who may be listening. I'm Amanda Kore Schilling. I'm an intensivist and anesthesiologist who practices critical care medicine at Tucson Medical Center in Tucson, Arizona. In this miniseries, you'll also hear from my co-host, Dr Kirsten Steffner, a critical care physician and cardiothoracic anesthesiologist at Stanford. Our ultimate goal is to provide professional development content that puts a new lens on how we define success and quote, having it all. We'll talk with leaders in a wide range of fields, including organization psychologists and experts in physician wellbeing. Through these dynamic conversations, we hope to support and nourish the multiple roles that we play in our day-to-day lives.

When Kirsten and I started brainstorming about a podcast, we were able to pull our target audience, you guys, women in critical care. And these amazing, powerful women answered in the most vulnerable ways and chose topics that play into the psychosocial aspect of our lives that ultimately does affect patient care. Some of the interest topics that came up were personality struggles within yourself, strategies for being listened to as a female fellow or attending or working with leadership, whether that's male or female that you might not particularly like and how to deal with an overpowering or overconfident male colleague. Although these seem like very personal and professionalism related topics that might not have any place in medicine, stressful psychosocial interactions at work have the ability to negatively affect patient care, how physicians under stress are more likely to treat patients poorly. Today, we will touch just the tip of the iceberg when it comes to identifying and tackling various psychosocial issues that involve the diplomacy of medicine that ultimately surround patient care and who better to talk about it than a psychologist herself.

Dr Alaina Henry. Professor Henry is currently the clinical director at Refuge Counseling Center in Napa, Idaho. She has her master's in clinical and mental health counseling from George Fox University and a double bachelor's in biblical studies theology and communications from Multnomah University. She has trauma training in EMDR and has a history of working with both mobile crisis response teams and mental health assessments for children brought in with CPS. She currently teaches abnormal psychology and specializes in integration of spirituality and psychology when training her interns. Professor Alaina Henry, thank you for being here.

Alaina Henry, MA, LCPC, NCC: Thanks for having me.

Schilling: I have the privilege of knowing you outside of your professional life and other than all those accolades I mentioned earlier, you're a mom of three, two of those being very energetic twin boys. You work full-time, you teach and you're an extremely supportive spouse to a hospice chaplain who also has an emotionally intense job. How do you do it all?

Henry: Well, I have to keep really good boundaries with my schedule and understand my priorities. Something that I've been working on a lot this year is allowing my work schedule to become a little bit less intense, which in the past my priority was trying to pay off student debt and somehow hold that in an equal space with being a mom and a wife and having emotional health. And over the course of doing some pretty intense trauma work for nine years, I've realized that I need to prioritize my values a little bit differently. What that means is that I say no to people often if it's just not in my emotional or mental capacity at the time.

In order to understand my emotional capacity, I have to have really developed self-awareness, and that looks like going to counseling myself and taking advantage of the skills and resources that I have. Also asking for help. I have a supportive friend network and family network, and sometimes it's uncomfortable to ask for help, but I would say that's something that I've had to learn how to do more and more, especially as my kids' schedules have gotten busier, being willing to put myself out there, but also being willing to prioritize based on my values.

Schilling: There has been an increasing amount of literature and studies that are focused on burnout, and we actually had the ability to discuss burnout and wellness in a previous episode. However, there is such a strong element of finding and sustaining emotional balance that gets skirted around. Recent studies have found that emotional stability is tied to the ability to implement coping strategies. Positive interpersonal relationships can not only support but buffer 7us against trauma and stresses such as accidents, natural disasters, and disease outbreaks. I can speak from a critical care perspective how we jump from helping a family transition their loved one to comfort measures, and then 30 seconds later run to a code and then bounce back into teaching rounds.

From a practical sense, that can mean we are the support systems for families during their time in the ICU. When we run to codes, we end up supporting the staff during debriefing sessions, postcode, and then we're going back into teaching rounds where we're trying to support the future of medicine through residents and med students. So Alaina, how do you balance being that professional support system for your clients and still having the emotional capacity to support those you love and care for?

Henry: I have had to learn how to prioritize my values and understand that if I am not mentally and emotionally healthy, I am not showing up to work at my best. I want to honor who I'm working with. We all take the same oath to do no harm, and in my mind, if I show up to work distressed and frazzled because I'm not taking care of myself, then that is potentially harmful because transference and countertransference is a real thing. So I don't want my personal life to bleed into somebody else's story because it's not about me. What that looks like is when I have the ability to say no, saying no and also understanding the deep desire that I have to help others, but that I can't be a savior of everybody all the time.

Schilling: There was a qualitative analysis done that stated physicians relied heavily on their friends and family to cope with the pressures of the COVID-19 pandemic. However, what I found more interesting was that 50% of these physicians felt like their support network, made up of their friends and family did not truly understand the pure exhaustion created by their work. So how do you come home and talk to your spouse or partner or friend and really feel like they understand you? And Alaina, I think the tricky part is not how we talk to our support system, but how do we protect our support system in that we don't constantly emotionally dump on them as our surrogate therapist?

Henry: Yeah, that's a really good question. When I think about professionally, what I've sat through during the day or the things that I've heard, I have training to compartmentalize in a healthy way, to practice mindfulness, to practice things that I'm working through with my clients, so on one hand I feel like I don't want to traumatize my spouse by talking about some of the things that he might not be prepared to hear and vice versa. On the other hand, I do think that it is important to be able to share when it's been a hard day or if there is a case that I really just can't get off of my mind, we might discuss it a little bit, but it comes down to what we feel is appropriate and how we manage our inner world. If I expect my spouse to be my therapist, that feels inappropriate and unfair to them for various reasons.

Now, that's not saying we shouldn't be vulnerable and open with each other. That's where I feel like having a therapist or a colleague maybe in a similar field is really critical. So I'm not saying we don't share or that you shouldn't share, but it might be worthwhile to set expectations together.

Schilling: I think the importance of the interpersonal support system is so underplayed. When a traumatic experience happens in someone's lives, they immediately go to their support system, they reach out to their network and they seek help to somehow mitigate that emotional taxation of medicine, but let's be raw. We experienced things that the general population never even fathoms. The other day, I ran to a code and the patient turned out to be a baby, a 15-month-old. Being a new mom myself, I really had to choke back the tears and drown out the mother's wailing to be able to secure the airway. The rest of the day was a blur, and then I found myself at home holding my eight-month-old and just crying.

I didn't even have the words to articulate what I needed from my support system. There are so many physicians out there who experience traumatic events on a daily basis and have support systems and partners at home who are not medical. In scenarios like this, how do you truly utilize your network, your village, when they can't conceptualize and you don't want them to picture the things you go through on a daily basis?

Henry: Yeah, I think if you have a relationship with really open communication, if there's an understanding, if you say, I just coded a baby today and I need you to know that I'm triggered and I'm having a major emotional response, my hope would be that the communication and the expectations set are that's enough. That you don't need to go through the play-by-play unless for you that's really what you need in the moment. Something that I haven't said that is really important here is the way that we need comfort and that we share that we need comfort against a vulnerability and communication to say, when I'm triggered, this is what I need from you. Some people need a big bear hug and some people need to walk away and be alone. Understanding the way that you process, especially if you get triggered because of an event that happened at work. How do you guys develop awareness around each other in those settings?

Schilling: Shifting a little, let's talk about the diplomacy of medicine. We know we can't pick the people we work with. We can't pick our colleagues, and most of us will go through our day-to-day environments and come in contact with at least someone that rubs us the wrong way. What's your advice when it comes to conflict resolution and developing those communication skills in the face of adversity?

Henry: Having self-awareness is really crucial. My hope would be that most people have some sort of value on the fact that everybody is a human being, so whether that's from a faith-filled perspective or just a respect for humanity, my assumption would be that whoever I'm speaking with is another human being, and if you don't have that already established, then this is hard. The next step in my mind is self-awareness, is understanding what your identity as a person and as a doctor or as a counselor, what is your identity connected to that maybe it doesn't need to be connected to in the sense that I might have really strong opinions about things and I might come across somebody who has really strong opinions about things differently.

So am I so connected to my opinion that if somebody disagrees with me or somebody has a response that might be offensive that I am [inaudible 00:12:24] a blow because how dare they think differently because this is what's true. This is one of those spaces where if you understand yourself and what matters to you and what things set you off or get you emotional, the more ability you have to navigate when you feel those feelings.

Schilling: There was a study that found that patients treated by female physicians had lower mortality and readmission rates. These findings were also replicated. Despite these leaps that women have made in every specialty and subspecialty of medicine, it still feels like I need to prove myself just to get through the door. Can you shed some light on how to deal with this old school culture of medicine from a psychosocial standpoint?

Henry: I have some strong thoughts here, but this is where so often I run across people so concerned, especially as females to be sweet and kind because we don't want to come off as rude. We are specifically trained, all of us, but even more so as females to be aware of everyone's feelings. How are we impacting people? Keep a read on the room and be peace makers. Being direct and calling out inappropriate treatment or behavior with kindness is not being disruptive or rude. We are not willing to lower our standard of respect because we're female. This feels like an art form in a lot of ways that has been lost, which is the ability to have conflict that is not disruptive and dysregulated and blowing up, which unfortunately is the expectation nowadays that if there's conflict, it's going to be emotive and angry. We need to be able to have more direct conversations that are fueled with kindness and compassion.

Schilling: Can you give me an example of how I would be standing up for myself and being authoritative and assertive, but still doing it with kindness and not breaking a relationship?

Henry: Sure. Let's just pretend this surgeon's name is Dr Brown. I would say something like, Hey, Dr Brown, I want to talk to you about something that's just been on my mind for a while. It feels to me that when you and I communicate about our patients, I feel a little bit disrespected, and I am assuming that you don't intend that at all. I'm actually assuming that you might be in a hurry or that there might be something else going on, and I don't think your intent is to make me feel disrespected or mistreated, but I need you to know that when we communicate, that's what it feels like. I feel like you maybe forget sometimes that I'm a physician, that I have experienced and that I've been caring for your patient.

And so the impact of the way that you speak to me is pretty upsetting, and I'm wondering if we can figure out a way to communicate differently. So separating from that, in my mind, it's putting on the table that I'm going to choose to believe that your intention is not malicious. If we can give people the benefit of the doubt and put that in front of them and see how they respond, that gives you more information, at least as far as how to move.

Schilling: I feel like being a woman in medicine can be a double-edged sword. On one hand, a study found that patients conscious and unconscious biases led them to choose a confident female anesthesiologist to care for their loved one. Then you have the other edge of the sword where we find ourselves caring about how others perceive us and maybe rightly so. Is this double-edged sword universal or something more related to women in medicine?

Henry: I would say that I think it's a personality thing, but also it's a female thing as well. I have worked with men who are in first responder positions that have felt these sorts of ways, especially if it's a male who has a naturally softer, more emotional personality, but the stereotype exists for a reason. It's not just born out of nothing. Females are raised to be softer, kinder, and more aware of other people than men, and we tune and move around others' personalities and feelings more than men are taught to do so. We're nurturers and I think some of that is innate, but again, I would say I think it is also personality and it can happen with men as well. It's just more prevalent in the female world. Different settings call for different kind of expectations. If you're in a code, you're going to be barking some orders, and that is the expectation as the physician in charge. That's where we have to separate in our own self-awareness and identity that I don't need everyone's approval all the time.

Schilling: An article stated that physician level factors in difficult scenarios related to three things. One, psychosocial attitudes and self-awareness, two, communication skills and three practice environments, and all three of these were directly related to integrating mental health. As we mature and grow as people and physicians, we do develop this self-awareness to know that there are those personalities at work that we just don't mesh with, and these people have a knack for triggering our insecurities and flaring up past trauma. Knowing that the two components that are under their control, which would be psychosocial attitude, self-awareness, and communication skills, how would we go about implementing change in these areas today?

Henry: Well, again, this is where I would say therapy and self-care is critical to being able to hold in these kind of scenarios. If you know that you're going to be dealing with a surgeon who might belittle you and talk down to you, the emotional and mental preparation for that interaction is important, so you already have the understanding that this is triggering for you, so how do you set yourself up for this interaction knowing that this surgeon might trigger you in that way? Then when you go home, how are you decompressing on a regular basis? How are you confronting this background trauma so that it holds minimal space in your psyche when you're in these situations? This is a place where I would say you might be reminding yourself before they come on the clock that, Hey, I'm going to have an interaction with this person, so I'm going to take some deep breaths.

I'm going to calm my body down, and I'm going to tell myself that it's appropriate to speak back to this person more directly than I maybe normally would because one, it might mean that he would respect me more if I don't back down to him. Number two, I know who I am. I know my credential and I know what I did all night. I know why I deserve to be spoken to with respect. So when this person comes up to belittling you, I do think that it's appropriate as women sometimes to say, Hey, I need to stop you for a second, and I need to remind you that I've been working with this patient for the last 24 hours, and that feels harsh and that feels rude. But again, oftentimes when we have bulldozers in our life, when they are met with strength, they tend to shift a little bit. This is where it is appropriate to say, I have the ability and the flexibility to show up differently with different people based on how they treat me and also have different boundaries.

Schilling: It's no wonder that topics like conflict resolution, working with difficult personalities and articulating what you may or may not need from your support system are topics that women in critical care were yearning to learn more about. So a special thank you to Alaina Henry for taking the time to help our listeners learn the tools to expand on the art and diplomacy of medicine. We appreciate your time and expertise.

Henry: Thanks for having me.

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Ruth Adewuya, MD, CHCP

Managing Director, Center for Continuing Medical Education

Stanford University School of Medicine

Course Director

Alaina Henry, MA, LCPC, NCC

Faculty

Amanda K Schilling, DO

Intensivist/Anesthesiologist

Tucson Medical Center

Planner

Kirsten Rhee Steffner, MD

Stanford University

Planner