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    Transcript for Preserving Well-being in a Pandemic

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    David Skorton: I'm David Skorton, President and CEO of the Association of American Medical Colleges. And I'm talking to you from my home because these are hard times right now. Living through a global pandemic like this one is tough on all of us, as I surely do not have to tell you. The emotional tolls sometimes in tragic ways as recent news of front-line care-giver suicides sadly reminds us. But you don't have to be a front-line health worker to feel immense pain, stress, anxiety, and grief during these times.

    All of us are under significant pressure, whether you're a small business owner, a parent, a child, a faculty member, or leader of a medical school or a hospital, a researcher and an educator, or in any other walk of life. And the causes of these emotions are not only linked to the lethality of the virus, but to the unprecedented economic conditions shaking the very foundations of so many lives.

    So let's talk about stress and how it's affecting all of us right now. And in particular, those of us like me who qualify as high-risk for this virus because of our age. Because we're feeling the emotional strain in different ways.

    On this episode of "Beyond the White Coat," I'm joined by Dr. Jonathan Ripp, professor of medicine, medical education, and geriatrics and palliative medicine, and chief wellness officer and senior associate dean for well-being and resilience at the Icahn School of Medicine at Mount Sinai in New York. Dr. Ripp and I are here to talk about the concept of well-being for all of us but especially for older populations too. Thanks very much, Dr. Ripp, for joining me.

    Jonathan Ripp: Thank you, it's my pleasure.

    David Skorton: It's a pleasure to have you here. Well, I hope this doesn't seem like too obvious a place to start, but tell me how are you?

    Jonathan Ripp: I'm doing okay, I'm doing okay, it's – we're a little past the month of the peak of the COVID pandemic here in New York City and it's certainly been a very intense period of time with lots of different phases and sort of issues that we've evolved through as we've gone according to that pandemic curve. And we're just – we're taking it very much a week at a time.

    David Skorton: Yeah, you've been through a lot, there's no question about that. And really around the world, people have been watching the bravery and the heroism really of people in New York City. Can you tell me what the mood is like at your institution at Mount Sinai? I know New York has been hit hard by this virus. How are you focusing on your colleagues' wellness? Tell us a little bit more about your approach and how that's working in this particular circumstance?

    Jonathan Ripp: Sure, I'm happy to. And it's not a question that I can necessarily answer quickly and probably should give a little bit of background as it relates to what I was doing before all of this started in a way to kind of inform my answer to how we're doing now. So as you mentioned, I am the chief wellness officer at Mount Sinai and a relatively new position in general. But much of my work, the focus was on looking at ways to promote meaning in work and professional fulfillment for a large workforce at Mount Sinai leading up to the events that we're speaking about now. Most of our efforts focused on looking at how the system influenced well-being and that kind of understanding the way in which the efficiency of the workplace and the culture of medicine all interplay to affect those of us that are learning and working within it. It was very much where our focus was.

    And we created a fair bit of infrastructure to try to engage and develop initiatives. To do that, not only because it's the right thing to do, obviously, there's – we're concerned about an epidemic, a burnout. But also because there's a good reason to believe that if you’re a health system and you wanna function optimally that there's a lot of important outcomes tied to well-being, whether it's quality of care, patient experience, the efficiency and productivity of a health system. So all those things that are important for a health system and, of course, the moral imperative to take care of our own was what was kind of infused all of our efforts leading up to COVID. So what's happened really in the midst of this pandemic is that we've kind of had to pivot our efforts a bit and we relied heavily on the infrastructure we put in place to help inform the way in which we would try to meet the needs of our workforce. And it's in this period that I think a lot of people are finding themselves processing just what it is they've been through and of course grieving.

    Grieving for the losses of our own, we've lost many of our own employees, and, of course, we've seen a lot of patients who've died. And I don’t think anyone here in New York – to finally come to the answer of your initial question of about how are we doing, how am I doing, I don't think any of us really feel unscathed by all this. We've all been touched very personally in one way or another. We have some preliminary data from a survey that we've done that suggests that many of our workforce have experienced the personal loss of a friend or colleague. So that's sobering. So that's where we are now and kind of where we came from.

    David Skorton: So the area of clinician well-being has been a great and growing interest of the profession for years, really way preceding the pandemic. And then now on top of the burnout and other issues that we've seen growing in recent years, there's the pandemic which is just clobbering us, especially but not exclusively those in so-called hot spot areas. What can you tell us about any other general thoughts about clinician well-being? Both related to COVID and just in general. At some point, this pandemic is gonna recede, at some point, we're gonna have vaccines. But give us your point of view, in general, about clinician well-being, where we are in 2020 related to the pandemic and even otherwise. We'd love to hear.

    Jonathan Ripp: I'd like to think that prior to the pandemic we had gotten to a point where clinician well-being had reached an appropriate – there was an appropriate spot-light placed on clinician well-being. And that's because for some of the reasons I already mentioned as it relates to not only the moral imperative to help clinicians who are – whose well-being may be suffering. But also because it just – it makes good sense if you want to optimally run a health system. We had also gotten to a place where there was recognition that it was really largely about the system that you could empower an individual with some tools to promote their own well-being and those tools are effective and there's evidence behind them and should be a competent.

    But really, the focus is on creating a system that enables our clinicians to do their work most effectively. And if we – kind of the premise is if we enable people to do their work efficiently they're likely to derive meaning from it by the nature of the work and if we promote a culture of well-being both of which really occur at the system level. That's gonna be at the heart of this and without getting deeper into it, that's kind of how we've approached it.

    All of that got disrupted and then if you layer in – so not only just eating, finding a meal, and getting to work, transportation, caring for your family. But they layer on that concerns around your own personal safely which I put into kind of your basic needs category. There all of a sudden emerged a very big area that became central and particularly early on when things were really getting disrupted and we had concerns around equipment and so forth which we have far less now.

    So in addition to meeting basic daily needs, the two other elements of our pandemic well-being response focused on things that made sense prior as well. But a real heavy focus on communication. So we recognized that communications are at the heart of promoting the culture of well-being. It's great if you care about people, but if they don't know it, if they don't hear it then they won't recognize it. And so I've never been more struck by the importance of just regular, transparent, authentic, humanistic, communication. And I think we've – I'm really proud of the work that our communications team has done and we've helped inform that process. And I hope that that – I expect that that'll continue. So communications has been central.

    And then, of course, the psycho-social mental health needs which were a part of what we were doing before but now have risen in level of concern because, of course, what we anticipate. Not so much what we've seen already, we've seen a slight uptick in utilization of resources, but we anticipate more. And the folks who study trauma can speak to the curve that there's sort of a honeymoon period, in fact, where you may actually be – have elevated mood because you feel like you've been contributing to an effort and doing some good. But that there – we do see this sort of disillusionment that follows. And so, of course, now we're concerned that – now that we are on that sort of downward slope of this initial wave of the pandemic, that we may be seeing more and more psycho-social mental health needs.  

    And have really centered our focus on providing crisis care 24-7 and one on one care, group debriefs and then screening in the longer terms for some of the more serious negative consequences. So that's kind of the before and the present.

    David Skorton: That's very, very interesting. There's been so much discussion of preparedness throughout the pandemic, national preparedness, and local preparedness. Just looking backwards a little bit you obviously were thinking about a day like this, maybe you weren't thinking about the magnitude of it. But you certainly were prepared in your own career and I'm quite familiar with Mount Sinai from my years in the city and know that that's a very well-prepared med center. Did you feel prepared when you were at the peak? Did you feel like those days and months and years of preparation got you ready to deal with what you had to deal with?

    Jonathan Ripp: Yeah, I mean I think the answer to that is yes and no. I think what we're experiencing, what we're all experiencing worldwide is a first. So for those of us living right now. So in that way, much of what we saw we have never experienced before. And so it's hard to say that we were fully prepared. But I do feel – I'm very proud of the way our health system has responded. And I think that's not just a platitude, I think there is a sense of inspiration that many of us have felt as having a role and participating in our response. And much of the sort of nuts and bolts of preparedness were very much in place.

    So in terms of the nuts and bolts of being prepared for something of this scope, I think the pieces were in place to enable us to be prepared. And yet, we're now processing what we've been through and realizing that this is something that is unprecedented.

    David Skorton: Your background in geriatrics really caught my attention because a long time ago I directed a division of general internal medicine which at the time had geriatrics within it. And we're learning that this particular virus is taking a particular toll on older populations as many illnesses do. And that's not as I understand it just because they're more vulnerable to complications if they get sick, but also in part because the emotional toll of all the social isolation. Can we talk a little bit about that, your thoughts about that?

    Jonathan Ripp: Sure, and I think I can comment on that more as a result of being – I still am a practicing physician and our – as it happens, our – my clinical work is with our home-based primary care and palliative care program the Mount Sinai visiting doctors. And most of our patient base, by virtue of the group that we take care of that are people that are ostensibly home bound, most of that group are geriatric. So, I'd like to think that that experience as a clinician can best help inform my answer to this question probably more so than my role as a chief wellness officer. I think there is multiple layers to the answer, one, of course, this virus seems to differentially affect that age group and so the toll, as we've seen from reports – or on deaths in nursing homes and so forth is particularly serious.

    There's also the issues around the isolation, so our population of home-bound elderly is already somewhat isolated but we can see firsthand that now a lot of – we're trying to decrease all of the interactions because – that people are having with our elderly patients because of our concern that probably the single most dangerous thing we can do is have them exposed to people in general. And so I think that's really hastened and exacerbated the isolation that our folks have seen. And then the other issues around geriatrics and sort of the tie to palliative medicine has been, as one example, a lot of the older patients that come into the hospital, and this extends to other age groups, of course, but that no visitor policy that so many hospitals have adopted for the safety of the patients and, of course, the people visiting has led to some really tragic circumstances. I did spend a month – I'm sorry, a week rather working on our palliative care service.

    And that was one of the most heartbreaking elements of all this is that when our elderly patients ended up coming to the hospital, they were there alone. I'm sure you've heard and seen stories about this where the only interactions they're having all day are with the medical personnel and those interactions are limited, again, because of the desire to reduce exposure. So just heart wrenching to see this. And I mean there's some – like a lot of what we hear there's been some silver linings of this whole thing. Certainly, leveraging technology to bring iPads into the room so that people can have video visits with their loved ones when they're – when they visit is impossible in person has been one< example.

    And also, I'd like to say that I think our policies have had to evolve quickly in recognition of some of these issues. So we're recognizing the – our no visitor policy very quickly had modifications to it, particularly for our patients who were at end of life which is largely our geriatric patients. And so the institution was responsive and kind of changed the policy to allow visitors at that critical time. And my personal experience is just being able to enable a family member to be there in those last hours of someone's life in the midst of all this was incredibly meaningful.  

    David Skorton: It's a beautiful thing and it's interesting, I'll share a bit of personal information with you. We have a loved one in our family now who is at a university hospital, distant from where we live in Washington, D.C. And we've been able to use Zoom and other techniques to stay in touch in the very same situation that you're describing. But I have to admit that it wasn't always easy to get the thing set up on the other side. I'm way too old to be a digital native, in fact, I'm old enough to be one of your patients. But it turns out that people vary in their ability to adjust to these new technologies.

    Are you seeing trends in how older people are adjusting to this new reality? Are there some potentially as we've heard in some reports more willing to just get out there and take more risks by being out in public? Just because they may feel, well, their time is limited or for other reasons. How are older people, in your view, making these kind of really life and death sort of calculations? I'd love to hear your perspective on this.

    Jonathan Ripp: Sure. And maybe I'll bring to bear my experience as a New York City commuter and [laughs] as seeing what it is that I see on the streets that can help to give insight to that question. I think pandemics, this has been described and our psychiatry colleagues are study this and really it's – you see a case study in human behavior I think. And whether it's – I often said as someone who takes care of older patients, when I was very early in my career I sort of had this notion that, well, as you get older you get wiser. And so there are lessons to be learned and then that will obviously influence behavior and lead to a lot of perhaps rational behavior. But I subsequently learned that people bring their personalities with them through their life.

    And so if your personality is such that you might be someone who throws caution to the winds when you're a 20-year-old, you might still be that type of person when you're an 80-year-old. And so I think we've seen sort of the full spectrum of human behavioral response as it comes to this on both ends. I mean I – we see people who – we hear of elderly patients in New York City who have not left their apartment in months. And, of course, there are ways of accommodating them and food delivery and so forth. And then there are those that are out and I'm wearing my mask on the street but they're not. And you kind of look and you sort of look quizzically and kind of try to understand what is it about this person that makes them take such a risk?

    David Skorton: So, Dr. Ripp, I have found in moments of pressure and stress for a long time, for years and years, that sometimes mindfulness is helpful. That mindfulness for me could be walking outside and giving myself the permission to notice things, visually and orally and smells on the wind, whatever it might be. And sometimes just in a quiet way doing a bit of meditation, even just focusing on my breathing, for example.

    I'll share with the listeners the way I use the mindfulness practice. I follow the work of Jon Kabat-Zinn years and years ago who did show, I believe, some broader medical advantages to mindfulness, just as you said, for those for whom it resonates.

    And I have a very simple practice where I sometimes have my eyes closed, sometimes open, but trying not to focus if you will and sort of sense my body's contact with the chair I'm sitting in. And then as that happens, I just become aware of my breathing and just follow the breathing for a while. Thoughts come into my mind that are distracting and I don't get upset or try to push them away, I just acknowledge somehow that they're there, let them drift away, and just focus on my breathing. And then maybe we can take just a few seconds to think about doing that right on this podcast. So if you're listening and you wanna give it a shot, either close your eyes or just allow them to not focus on anything in particular.

    [Moment of silence]

    If you're standing, if you're sitting, if you're lying, just feel the pressure of your body against whatever your being supported by whether it's your feet, your back, your arms on the armrest of your chair. And just become aware of your breathing as it comes in and fills up your lungs, as it goes out and empties and does it again and maybe try that for just a few seconds right now. And maybe the main point of the exercise is just to be aware of the present moment as opposed to thinking about all the stresses that have happened to us 10 minutes or 10 days or 10 years ago or what might happen in the future.

    David Skorton: Well, Dr. Ripp, this is all terrific advice for all of us to hear. I certainly learned a lot by interviewing you today. No matter the role that each of us is playing in this pandemic, whether as a health care provider, an educator, a community member, or as the personal support system for a loved one, or someone else in need, I think we can all be reminded of the importance of taking care of ourselves and others well-being during this very unusual time. Community and camaraderie are our best tools to strengthen ourselves and prepare for the still tough months ahead. So please, everyone, speak up and share your stories and experiences with your colleagues and with those closest to you.

    I wanna thank Dr. Ripp for joining me today. Your work to improve well-being for all students and residents and fellows and faculty and the patients you serve is really inspiring and I hope can be used as a model for others in academic medicine to follow. Thank you for being us on “Beyond the White Coat.”

    Jonathan Ripp: Thanks so much, it's been a real pleasure.

    David Skorton: I wanna leave our listeners with a reminder for all of us, let's remember that we are witnessing the realities of a deadly pandemic up close. And one way we can support each other is to reduce the stigma of asking for help by sharing our own stories of needing and seeking help. Others need to hear that seeking help is not a weakness but rather, a form of life-sustaining strength.

    I encourage you to reach out to me and to each other during this time. Be well, and I'll see you next time for another episode of “Beyond the White Coat.”

    If you or someone you know is experiencing emotional distress related to COVID-19, please call the National Suicide Prevention Lifeline at 1-800-273-8255. Or please, call your local crisis line, thank you.

    [End of Audio]