Physician Mental & Physical Well-being Strategies During Crisis

April 18, 2020

(The following information was contributed by panelists who participated in the Montgomery County Medical Society Collegiality Conversation on April 16, 2020.)

In this article…

Importance of Exercise – Aruna Nathan, M.D., Internal Medicine & Lifestyle Medicine

During this Covid-19 lock down, it is important to maintain a consistent exercise routine.   Dramatic changes in day to day schedules and overlaps between work and home activities can be tricky to navigate. Some of us are feeling overwhelmed and this may demotivate us to care for our body and our mind. As physicians, it is important to focus on our well-being to be able to better care and support others.

Those who are accustomed to regular physical activity and exercise should persist with their routines while others should use this opportunity to start. Here are a few pointers to help those who are starting this new habit or working on being more consistent.

Long term health benefits is the true motivator

Most exercise routines begun with short term goals to look good or to lose weight do not last. Studies show that focusing more on the long term benefits, about how you will feel when you are healthier, is a greater motivator to form the habit of regular physical activity.

  1. 150 is the magic number: All it takes is 150 minutes of exercise a week to deliver measurable health benefit.  Doing more is fine, but only adds modest incremental value.
  1. Join the party: Exercise is fun and motivating when done as a team or a group.  Humans are social beings by nature and we can use this to derive greater physiological benefits.
  1. Body and mind: A cluttered and unfocused mind leads to tired bodies and unproductive days.  Exercising requires focus on the body and this in turns tunes the mind.
  2. Failure to start: One of the biggest impediment to success is failure to start.  Start exercising, start low and go slow to stay safe and healthy.

Importance of Healthy Eating Habits – Marsha Seidelman, M.D., Pulmonary Medicine

This is a good time to evaluate the QUALITY of the food we can reach for.  We can use these choices to feel better and have more energy now, and come out on the other side healthy.

You can pretend you have the newest branch of CAVA or Chop’d and have a variety of ingredients, so each person can mix and match according to their preferences.

Prepare a large bowl of green salad; beans or lentils; hearty grains like farro, bulgur or barley; pastas made of lentil or chickpeas, nuts and seed; other proteins like tempeh / tofu, fish, eggs, chicken or others.  

Make soups or chilis that can provide a few meals; freeze any that won’t be eaten.  Top with cilantro, nuts, seeds, cheese, non-dairy cheese from Trader Joes.

Shopping – to avoid many trips – buy lots of dried goods (lentils, beans, grains); frozen fruits and veggies; fresh fruits at different levels of ripeness; tuna fish.

Snacks – healthy easy to grab things: yogurt – dairy or non-dairy; Kite Hill Greek style almond yogurt is better than the rest; apple or banana with peanut butter.  Sometimes grazing can be limited by having water instead, or brushing your teeth.

Substitute ingredients: try new recipes but can’t run to the store each time you need something.  Google for potential substitutes; use 1/4 to 1/2 teaspoon dried herbs instead of 1 tsp fresh. Substitute lentils for chopped meat.

Overall, try to increase whole-food, plant-based foods, and increase fiber to improve cardiovascular and cancer risk.  Feel better now and be healthier in the long run.

Watch Gamechangers – Netflix – an amusing documentary about the benefits of Whole Food Plant Based diet in elite athletes

Other references:

  • Nutrition Action newsletter – cspinet.org
  • Michael Greger – nutritionfacts.org
  • CookieandKate.com – vegetarian
  • Onceuponachef.com – general
  • ladydocscornercafe.com – especially the side dishes.

The Importance of Meditation and Sleep – Mindi Cohen, D.O., Family Medicine

Meditation is a practice using certain techniques to train attention and awareness in order to quiet the mind and support mental clarity. In doing so it helps reduce stress and anxiety, creating a better sense of well-being.  There are many ways to meditate to achieve the same goal. Meditation is to the mind what physical exercise is to the body.

  1. Transcendental Meditation or TM is a form of silent mantra meditation, developed by Maharishi Mahesh Yogi. The meditation practice involves the use of a mantra and is practiced for 20 minutes twice per day while sitting with one’s eyes closed. When the mind wanders you go back to repeating the mantra. Mantras are sounds that create vibrations examples: OM, Shalom, Hallelujuh. TM has been shown to relax the sympathetic nervous system, creating a sense of calm. www.tm.org
  2. Mindfulness Meditation: Mindfulness is the ability to be fully present in the moment. Thich Nhat Hanh, A Vietnamese Zen Buddhist Monk teaches to be mindful is to be truly alive. In his 1975 book The Miracle of Mindfulness, he taught the idea that mindfulness can be practiced when you are eating, walking or even doing the dishes. Resources: Peace is Every Step, Thich Nhat Hanh, calm app, headspace app, Mindfulness-Based Stress Reduction(MBSR) Jon Kabat-Zinn, www.palousemindfulness.com.
  3. Laughing Meditation is a practice using laughter to release stress. When you are laughing you are truly in the moment. Laughter meditation is best done in a group. Laughter reduces stress hormones which could support our immune system. Resource: www.mindbodypal.com/laughing-meditation-why-how-to-do-laughter-yoga
  4. Compassionate Listening is the process of truly listening to another person with full intention. You listen without judgment and without trying to fix the problem. In doing this you also learn to have self compassion. Resource: www.tarabrach.com
  5. Sleep: Meditation improves our relaxation response which improves our ability to sleep. A simple meditation for sleep is just observing your breath, counting your inhalation and exhalation. If you are feeling tension in any area of your body, you can tighten and then release the muscle in your body beginning with your feet moving up to your face. Guided meditations can also help with sleep. Resource: www.chopra.com

Strategies for Work Life Balance (or Harmony…) during COVID-19 – Annette Pham, M.D., Otolaryngology/Facial Plastic Surgery

  1. Communication is key: no one can read your mind (yet)
  2. Create a team approach: address the unique needs of your family, taking into account that different ages and different personalities have different needs
  3. Create a common schedule: work on it together and share it
  4. Check-ins to plan for the next day: almost like a daily huddle you do with your staff before seeing patients
  5. Build in ways to recharge, for yourself AND your family, eg. dedicated “Alone” time and then also “Family” time

Remember, it’s a marathon, not a sprint.  Invest time in yourself AND in each other because that’s what we have right now, time.

And lastly, how do you climb Mt. Everest?  Keep putting one foot in front of the other and so on

Tips for Managing the Stress of COVID-19 – R. Patrick Savage, Jr., Ph.D.

The COVID-19 crisis presents to each of us both danger and opportunity.  Danger that the demands we face as healers, parents, spouses, and friends can become overwhelming or debilitating.  On the other hand, if the stressors presented by this experience are well managed, this experience can offer us a chance to grow, heal others, and learn to care for our own selves: the later a task that many of us have not focused on and at times appear encouraged to overlook.  During this time it is just as important, perhaps more so, to care for ourselves as we care for others.  I would encourage each of you to put together a “Stress Survival Kit” that works for you.  The following are ideas for you to consider as you build your own kit:

  1. Awareness, Planning, and Pacing:  Develop an awareness of the way in which you experience stress (physical and emotional signs) and create a plan to help you manage your stress when you first begin to sense it.  Remember this is a marathon not a sprint so pace yourself by doing what you can and recognizing that there is more to do than any one of us can do.  Pay attention to those tasks and challenges that you can affect and let go of those you can’t.  For those who are inclined, the Serenity Prayer offers some guidance.
  2. Limit Your Exposure to Stressors:  It is important to be informed but being too informed can overwhelm you and make it difficult for you to focus on your plan and the things you need to do to keep your balance.  Setting boundaries with yourself and others, learning to say no, and taking breaks to restore yourself are examples of how to limit your exposure to the myriad of stressors present today.
  3. Break down large overwhelming tasks/experiences in to smaller more manageable tasks/experiences and learn to focus on what you are required to do in the moment.  For instance, I just need to address the patient in front of me, or the staff member or family member that needs me in the moment, enjoy a tree in full bloom, or the softness of the fur on you dog, cat, etc.  Become mindful!
  4. Restore yourself regularly:  Engage in any healthy activity that you enjoy or offers the opportunity to re-energize yourself.  Examples include:  slow and deepen your breath (4- square), exercise, eat a good meal, engage in a hobby or leisure activity, connect with others (colleagues, friends, support groups, or talk to a therapist), hang out with your pet, get a massage, practice meditation, guided imagery or prayer, take regular vacations (mini and regular).
  5. Forgive and learn to be optimistic: Let go of negative emotions that become toxic over time and feed anxiety and depression. Forgiveness is about you not the other whom you perceived has offended or hurt you.  See what you can learn and take away from even the most difficult experiences.  Practice patience, be playful, use humor, and post aspirational messages for yourself, your colleagues, your family and friends.

A final word. Many of the suggestions above require lots and lots of practice and time to really learn.  Set your expectations low so you can exceed them.  It is better to succeed then become frustrated and convinced you can never learn a different way of thinking or skill.  It is all doable one small step at a time.  A useful tool that can help in your endeavor is an app called “The Virtual Hope Box.”  It is free, downloadable to your phone, portable, and contains a place to keep many of the tools for a “Stress Survival Kit” all in one convenient place.

Red Flags of Crisis Stress – Bruce Smoller, M.D., Psychiatry

  1. Under the stress of long term semi- isolation, alteration in usual patterns of socialization and especially the open ended loss of control over one’s environment, preexisting affective and anxiety based conditions worsen.  It is important, as with most illnesses, to recognize “red flags” and to take steps to intervene before a “tipping point” is reached and a clinically florid depression, generalized anxiety disorder or other psychiatric syndrome ensues.  This can occur even in otherwise healthy people with no previous psychiatric history under these conditions.
  2. Some “red flags” to be aware of are:  Difficulty concentrating, difficulty learning or understanding new material, flattening of affect, heightened autonomic arousal, inappropriate affective discharge. Strained social relations, sleep and appetite changes, irritability, increased use of alcohol or drugs, withdrawal, tearfulness, shortened attention span, somatic analogs of emotional distress such as frequent upset stomachs, headaches, and sighing respirations.
  3. People react to unusual or overwhelming stress based on their previous history and their genetic and learned resilience to stress.  Under most circumstances, most of us fall into the “worried well” group and can deal with moderate amounts of stress.  Some folks have more difficulty based on prior history and need to pay a bit more attention to the “red flag” buildup.
  4. Interventions include: Regularity of sleep and eating.   Irregular, shifting schedules can play havoc with affective stability.  Impose structure on one’s schedule, but add novelty to your schedule…start painting, take up a musical instrument, take a Zoom course.  Use humor…binge on all the old episodes of Cheers (they are funny), send and read all the jokes you can.  Humor is a wonderful antidote.  Confide in someone…a spouse, a friend, clergy, a therapist.  Externalizing conflict and stress can help a great deal.   Limit alcohol to reasonable amounts.  Alcohol over an above moderate amounts is a depressant.  And all the great suggestions of the other panelists…they help. 
  5. For those people who are on or who need to start medication…absolute regularity is key.  SSRI half-life is 24 hours, and it is gone by 48 hours.  It may take 2 weeks or longer to stabilize after a lapse of even 2 days in antidepressants.  For short term use in anxiety states, benzodiazepines may be used, but anything longer than very short term, use antidepressants supplemented by prn (very prn) use of benzodiazepines.  The antidepressant effect of SSRIs is mediated through synaptic receptors and these take a few weeks to spin up to speed, while the antianxiety effect is cell membrane mediated and takes a much shorter time.  It may not be as “punchy” as benzodiazepines but works as well or better over time.  Most people, however, who experience “red flags” will not at all need medication.  I include this for those folks with a history of affective or anxiety based disorder, or who are in danger of developing their first episode under the stress of this pandemic.

If you or a physician colleague are interested in accessing no-cost, confidential counseling, it is available via telemedicine even during this time of crisis through the National Capital Physicians Foundation’s Physician Resource Netowork (PRN). To sign-up, visit www.dedicatedtohealth.org/prn. 

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