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Taking stock during times of high stress: identifying risk factors and red flags

CMA

In times of high stress, it can be difficult to remember what “normal” feels like. A specialist in addiction medicine and physician wellness, Dr. Michael Kaufmann shares strategies for recognizing our own vulnerability, red flags and risk factors and when they can lead to problematic behaviours.

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About Dr. Michael Kaufmann

Dr. Michael Kaufmann spent more than two decades as the founding director of the Physician Health Program at the Ontario Medical Association and is currently the Emeritus Medical Director of the Physician Health Program (PHP). Trained as a family physician, he specializes in addiction medicine and is a diplomate of the American Board of Addiction Medicine and a Fellow of the American and International Societies of Addiction Medicine.

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COVID-19 wellness resources Self-care Stress

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Taking stock during times of high stress: identifying risk factors and red flags

Dr. Jillian Horton:

Hello, and welcome to the COVID-19 physician learning series, brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton, a general internist, writer, and podcaster, and I'm your host for this series. It's been more than 13 weeks since this pandemic began. And for health care professionals, this has meant either a long period of intense demand or quiet but prolonged uncertainty about what will happen next in our clinical lives. And it can often be hard to remember right now what normal even feels like. This can make it hard to recognize our own risk factors or vulnerabilities, and as a result, those who have overcome addictions or particular behavioral challenges may find that they are struggling again.

Joining me to talk about how to take stock in times of high stress is Dr. Michael Kaufmann, a specialist in addiction, medicine, and physician wellness. He spent more than two decades as the founding director of the Physician Health Program at the Ontario Medical Association, and is currently the physician wellness director at William Osler Health System. Michael, thank you so much for being here with me today.

Dr. Michael Kaufmann:

Thank you, Jillian. My pleasure.

Dr. Jillian Horton:

You became interested in physician wellness after embarking on your own recovery. Can you start by sharing a little bit of that story with me?

Dr. Michael Kaufmann:

Sure. I'm happy to. Yes, it's true I began my career in our profession as a family doctor in a rural setting, it's where I actually still live. But I brought with me a certain amount of, let's call it, predisposition with a strong family history of substance use problems and perhaps not a full toolkit of coping strategies as maybe I should have had for an all purpose rural family practice. And it really didn't take very long before I discovered the kind of ease and comfort that opioids provided, and discovered also that I had a pretty good access to those drugs. And thought that I was smart enough and clever enough to use them to cope. And it really didn't take very long before the disease took hold and got the better of me. Although I am grateful that I was also given the opportunity to get well pretty quickly also. So I actually have a lot to be thankful for in that whole experience

Dr. Jillian Horton:

Michael, through that process of recovery, what were some light bulb moments when it came to recognizing your own risk factors for relapse?

Dr. Michael Kaufmann:

Light bulb moments, boy, it's hard to call them light bulb moments, Jillian, when recovery becomes a way of life and along the way, you can lose sight of living out of sight that way of life. But let's just say I learned skills that really were the kinds of things that a person ought to know. There were common sense kinds of skills, yet I lived life largely without them.

Let me give you an example if I can because for all of us in the recovery community, what I'm about to say that everybody will recognize this acronym, which is HALT, HALT. But that's one of the first things that we were taught. And by the way, just to be clear, recovery from substance use disorder has got much more about it than not using and not drinking any more or being free from the symptoms of the substance use disorder. It's about living a good and proper life after that. A life of integrity, and a life indeed of relapse prevention.

So back to the acronym, HALT stands for hungry, angry, lonely and tired. And basic principles that we fall back upon at times that we need them. And if I can elaborate just a little bit, I mean, hungry simply means don't let yourself get hungry and that sounds pretty obvious, but a lot of doctors practice a day at work and may skip meals. And even my own staff at my office, my family practice office years ago, they knew that, and they knew I needed a snack at about 11:30. And they set out a little cup of soup and some crackers for me every morning at about 11:30. I could just skip those and eat that on the fly. And so I didn't get hungry.

Angry, the A, it stands for-- we can afford to let ourselves carry around strong emotion, anger, resentment, that kind of thing without dealing with it because there's too much at stake to carry that kind of burden, that kind of pain, and not deal with it in a healthy kind of way. The L is for lonely, and substance use disorders living a life of addiction tends to be a very lonely one. We tend to get sick in secret, behind closed doors. And more and more, we isolate from important relationships, family, friends, colleagues and so on. And the secret to recovery was to do the opposite, restore the relationships, make new relationships, healthy relationships, go to recovery meetings, surround ourselves with people in good recovery and emulate the good things that they have to share with us.

And the T is tired, and I mean, what doctor doesn't know about getting tired. And certainly through my training and through my early days of practice and beyond, being tired all the time was the norm. Working late at night, working on into the next day from residency onwards, we were all subjected to penetrating, painful fatigue. And I did learn very early that opioids helped me with that fatigue. And that's one of the main things that got my addiction going. And so we learned that proper rest, proper sleep, proper self-care that's the key to recovery. And those elements are just a summary of the many strategies that we need to learn.

And I learned that there was no choice. Those were the things that I had to do in order to get well and stay well. And as I've said, I'm very grateful for that. I didn't say at the outset but I have two things for which I'm extraordinarily grateful. And the first is that my wife, Judy, whom I met in high school we're still together. And we've had a wonderful life together. Thankfully, she's stayed with me through everything. But it's through addiction and the recovery that's enabled all of that. So those two things everything good in my life that's flowed from that. And I'm pleased to share some of those lessons with you today.

Dr. Jillian Horton:

Pandemic has forced many of us into a prolonged high stress state. What does this do to our ability to assess our own risk factors or even the state that we're in, in terms of what you just mentioned with HALT? And how does it interfere with our ability to perceive our own particular and personal vulnerabilities or our weak spots?

Dr. Michael Kaufmann:

Well, that's a good question for which I'm not sure that there's any ready or scientific answer, but there's certainly an intuitive answer. And it takes time. It takes effort, takes some practice to be vigilant at a high level in terms of our own self-awareness and coping. For those of us in recovery, we've practiced that, and we work that every day. For people without of that tradition, it may not seem quite as natural or as second nature. So I think that's the first point to think of. I do want to acknowledge, though, that most doctors understand resilience and are resilient people. Let's be clear about that.

But at the same time, and I know that you know this, and I know that many of the watchers, viewers of this podcast will know this, if COVID-19 is pandemic and burnout is endemic, and that was a condition for us going in. High numbers, high proportion of doctors, sometimes 50%, sometimes more are experiencing some degree of burnout or other. So there's coming into this already more than overtired. They're coming into this already deeply fatigued. They're coming into this already feeling cynical and disconnected from themselves and their patients, and so on. They're already coming into this feeling depleted and feeling like what they're doing, even the good work that they do, may not be making a difference. And that's kind of a jaded place to be.

When you put all of that together and consider the energy required to self-assess and to be vigilant, it doesn't surprise me that we can let go or let down in that area, and maybe even then fall back to another approach that we might be more accustomed to, which is giving our all. That's what doctors do. We want to be there for our patients. We want to be there for our colleagues. And if we're not sure what else to do, well, we'll do that.

There's this thing called allostasis and allostatic load. Allostasis been the physiological adaptation to stress. We've known about that for a long time even if we didn't call it that, but that's when the hypothalamic pituitary adrenal access kicks in. That's when our adrenaline levels go up and our cortisol levels go up, and that's normal and natural. We all know that fight or flight. But the supposed-- we're supposed to have relief from that. We're supposed to recover from that. We're supposed to be able to restore our baseline homeostasis. Then everything's working as it's meant to be working.

When we don't have a chance to come back down to the baseline, we're chronically stressed by that physiological state of allostasis. That's not good for us. That can affect our cognitive capabilities. That can affect our bodies, and all of our systems in negative ways. All of these things put together, I think, may well indeed put our colleagues at some extraordinary stress and extraordinary risk with respect to their vulnerability going through these times, whether they're on the front line or whether they're a step back from the front line experiencing vicarious stress. Or whether they're redeployed and they're not familiar with the work that they're been asked to do. Or they're underemployed and they're at home and frustrated and stressed and wanting to help. All of these things can contribute to the extraordinary stressor which puts us at increased risk.

Dr. Jillian Horton:

So just to follow-up on that Michael, how do you counsel individuals, perhaps those who are in recovery from various disorders or even more generally looking at those who have not struggled with issues related to addiction, but perhaps know they have weak spots of vulnerabilities, how do you begin to counsel those individuals when it comes to identifying as physicians their own weak spots? And why is this so often a struggle for us as doctors?

Dr. Michael Kaufmann:

Well, OK, Jillian, let's first agree to use the term vulnerability or risk, and set that the idea of being weak or weak spots aside for now because that's what I'm dealing with. That's what I've always been dealing with is vulnerability because we all have our vulnerabilities. And then the risk of activating those or what might happen as a consequence of unrelieved stress. So we're all in the same boat in that regard. The difference is some of us know what's at stake or immediately what's at stake. So those of us with mood or anxiety disorders, or maybe physical disorders, coronary artery disease, what have you, certainly, substance use disorders, we already know that we don't want to relapse into those chronic conditions. We don't want them to become active. We don't want to suffer the negative consequences of having those disorders overwhelm us. But we know they're there, so we also know how to protect ourselves.

And as I said, it's not rocket science and we can use the same principles for any of us. And let's just be mindful, watch for the signs. When we interview our doctors in recovery for those that we do follow, we just ask them a lifestyle questionnaire. How's it going at home? How's it going with your appetite and your nutrition and your exercise program? Are you getting to your meetings? Are you spending time with people? Are you spending some time with your spouse and your kids? All of those things. Are you having fun? What about your hobbies and special activities? What do you do with all that stuff? And we can all be watching for the same things. Those of us who already have mindfulness practice, I think we're on it. We have a way of checking in with ourselves in how am I doing mood wise? How am I doing with my irritability? Am I feeling anxious? Am I feeling sad? Am I feeling depressed, whatever? It's all fine, but we pay attention to those things.

And if you're not of that mind or not of that [INAUDIBLE], pay attention to what's happening in life, pay attention to whether we're feeling irritable or not, pay attention to the life-enriching activities that we're accustomed to, and are we letting them go, are we giving them up. Pay attention to any activities or behaviors that may not be such a great idea for us. I haven't heard of this happening lately, but I certainly, over the years, I've heard of cases, believe this or not, where doctors in midlife or at a time when they really, really should know better have actually begun to smoke. Can you imagine that for the first time?

These days, I get concerned about people maybe smoking cannabis for the first time, being relatively recently legitimatized and made available readily. So we need to watch out for what I would think of as being some maladaptive behaviors too. And most of us know what those are. And if we're not sure, and you've got anybody who cares about you around you, just ask, how am I doing? And check in with the people that care about you, a spouse, or a family member or friend, or even a colleague, if you have a relationship that permits that. So there are lots of ways to check in with yourself and to check in with the people around you. And to those who are able to notice these things, I have a lot of respect for you, for them. Hats off to you for being able to say, you know what, I notice I'm having an extra drink or two, when maybe that wasn't what I would normally have done. And that's something I think I pay attention to.

Dr. Jillian Horton:

So on the subject of alcohol, let's assume that an individual does a personal survey and goes through these steps and realizes that since the pandemic started, they've gotten into a routine of drinking every evening, but they don't think they've ever had a problem with alcohol use before. Is this a red flag?

Dr. Michael Kaufmann:

It might be. It's useful to have a sense of when an everyday behavior becomes a risk-related behavior or bring some risk with it. Certainly in the field of addiction medicine that we're aware of when the use of a substance is risky or not risky. Alcohol, of course, being socially acceptable and readily available and part of a lifestyle for most of us. Certainly those of us not in a personal recovery. And there are guidelines, and the guidelines do refer to how much and how often. And I won't necessarily go through them here, the readily available. But those same guidelines would tell us that drinking every single day may not be a good idea, so we look at whether that's safe or not. Drinking more than a drink or two might not be a good idea for drinking occasion, it depends on the circumstances. But there's really nothing in the diagnostic criteria for a substance use disorder that even refers to how much or how often. It has much more to do with our relationship with the substance and its impacts upon our life.

So in thinking about having an extra drink or two, an insightful person might notice, gee, I can't wait to get home and have a drink or two. I mean, before my own illness really took hold, that's what I did. I would come home and have usually a couple of bottles of beer chug down fairly quickly because I knew that it would make me feel better, or even better a Manhattan or two because that would work better and were sweeter, tastier, and it would be faster. I'd feel better quicker. And then start looking forward to that more and more each day. And now we're beginning to think, OK, is this a red flag?

Beyond that, Jillian, if we're starting to use substances but be it cannabis, be it alcohol, be it over-the-counter, and it just means or anything or prescription medications inappropriately are on somebody else's, in order to feel better, in order to bring ourselves to a state of ease and comfort, we just don't seem to be able to find, otherwise, or aren't willing to find other ways to get us there, to treat pain, emotional, physical, to cope. This is the thin edge of the wedge. This is the slippery slope, whatever you want, however, you want to think of it. These are problem indicators. And then when I'm interviewing somebody, I'll be looking for all of those things. And that requires a little more thought, little more explanation or exploration. It requires some thinking.

Dr. Jillian Horton:

So it's obvious that COVID-19 isn't going away any time soon. And when we look at what we need to be able to do in the immediate future, how can the average physician move from simply identifying risk factors to building a meaningful blueprint for their own self-care?

Dr. Michael Kaufmann:

That's a really good question. It's hard enough to establish that as a lifestyle in good times. I mentioned the onslaught of the epidemic or endemic condition of burnout out before. Personal resilience is an important part of that. And I just want to acknowledge this before we return to it, our culture the culture I grew up in and that is to in any way during my training, the culture for arts and in training, for the most part, our cultures and conditions in our workplaces, they don't necessarily lend themselves to the healthiest of personal lifestyles. We were realizing that now to our credit and many workplaces and training programs are addressing these realities. But a culture can be a pretty slow thing to change. Maybe this is a time of opportunity that will help speed up that change.

Nonetheless, if we haven't come into these times with a robust practice of self-care and a high regard for it, it might be hard to get there in the midst of all of this. But if I can convince anyone who listening to me right now and listening to us right now that self care is as important, dare I say, may be even more important than the other care that we provide. If I can convince anyone as the science is doing that our patients actually do not get the best of us and may even suffer when we aren't looking after ourselves well. And first and foremost, if I can convince people of that, then I might be able to convince them that looking after themselves is worth it.

So pausing ever so briefly to get something to eat during a busy day. Time out to have a rest or have something to drink. Or when you get home instead of one two or more drinks in rapid succession in the same amount of time, you could go downstairs and jump on the elliptical for a few minutes. I mean, the good feeling you get from that is this healthier and last longer, why not do that? A lot of us might have a tendency to isolate, to go in a room and close the door when feeling tough. OK for a few minutes, but probably it's a good idea to find someone to talk to. A peer or somebody else that you know, love, trust, what have you. All of these things, all of these behaviors, hungry, angry, lonely, tired, I've written about them elsewhere and I've called it the basics, and I've looked at-- that's another acronym. And I've looked at the six domains of looking after ourselves up to and including a spiritual practice of taking a walk and remembering how wonderful it is in nature, or to hear the birds sing in the morning, or whatever it happens to be. These are all life-giving.

Usually when I think about these things and talk about these things, I also want to think about compassion because we do talk about compassion these days. And we do talk about compassionate leadership. And I think you may even have an interview or two on that subject. But we also need to remember that compassion starts with self-compassion. And I think looking after ourselves in a robust way, dare I say it because I have said it, in a radical way, radical self-care. That's an act of loving kindness directed towards ourselves. And it's something that I think we ought to embrace and we ought to adopt as though our lives depended upon it. That's what I do. That's what I've always done since I got into recovery. That's what we teach everybody else in recovery to do. Do this as though your life depends upon it because it actually does depend upon.

The chronic condition that we have in relapse, people die. And people may also die from any other condition that any of our colleagues are experiencing right now. Whether it's the malignancy yet to reveal itself or the coronary artery yet to clog or the stroke to have, or dare I say it, the depression or the suicide that they might be facing. God forbid. There are a lot of ways unrelieved stress can bring us to the brink or beyond. And so if we reframe the way we think about self-care as an act of self-preservation and an extraordinary act of love and kindness towards ourselves. And if we put that up there as being equally important as the kindness and compassion we have for our patients and others, then I think we're in the right place to justify looking after ourselves. And that's what I would done. That's what I would wish for all of our colleagues.

Now and even better when this is finally over, we don't lapse back to some kind of status quo. I hope that this pandemic is the opportunity for ourselves as individuals to adopt and embrace these resilient practices, and even more for our organizations and institutions and cultures to say, yeah, this is what we want you to do, this is what we must do. Let's come together and support each other in looking after ourselves and looking after one another because that's also part of it.

Dr. Jillian Horton:

Michael, you have made so many critical and beautiful and salient points today. I want to thank you so much for taking the time out of your busy schedule to join me.

Dr. Michael Kaufmann:

My great pleasure Jillian. Thank you for inviting me.

Dr. Jillian Horton:

I'm Dr. Jillian Horton. Thank you for joining me for this COVID-19 learning series webinar, brought to you by the Canadian Medical Association and powered by Joule. Thank you for all that you do, and I'll see you again soon.

Taking stock during times of high stress: identifying risk factors and red flags

About Dr. Michael Kaufmann

Topics

Compassion fatigue: Signs, symptoms, and how to cope

Physician Wellness: Burnout Among Rural and Remote Physicians is a Significant Issue We Can Help With

Physician wellness: New 2021 National Physician Health Survey findings — burnout, short-staffing and an overburdened system take their toll

Sample script for approaching distressed physicians

The Intrinsic Practice

Are you in distress? Get help now.

Taking stock during times of high stress: identifying risk factors and red flags

About Dr. Michael Kaufmann

Topics

Related resources

Compassion fatigue: Signs, symptoms, and how to cope

Physician Wellness: Burnout Among Rural and Remote Physicians is a Significant Issue We Can Help With

Physician wellness: New 2021 National Physician Health Survey findings — burnout, short-staffing and an overburdened system take their toll

Sample script for approaching distressed physicians

The Intrinsic Practice

Are you in distress? Get help now.

Taking stock during times of high stress: identifying risk factors and red flags