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

July 6, 2020

In this Joule COVID-19 Learning Series webinar, host Dr. Jillian Horton talks to Dr. Michael Kaufmann, a specialist in addiction medicine and physician wellness. He spent more than two decades as the founding director of the Ontario Medical Association’s physician health program and is currently the physician wellness director at William Osler Health System.

Dr. Kaufmann shares his own experience with addiction and red flags health care professionals can look out for in their own lives in this time of prolonged uncertainty.

tweetable: “Recovery from substance use disorder has got much more about it than not using and 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 of relapse prevention.” — Dr. Michael Kaufmann

 

KEY TAKEAWAYS

You became interested in physician wellness after embarking on your own recovery. Can you share that story?

  • Dr. Kaufmann began his career as a family doctor in a rural setting.
  • He brought with him a strong family history of substance use problems, and he did not have the toolkit of coping strategies he needed for an all-purpose, rural family practice.
  • To help him cope, he found comfort from opioids and discovered that he could access them easily.
  • It didn't take long before the disease took hold, but he’s grateful he had the opportunity to get well quickly.
  • He says he has a lot to be thankful for in that whole experience.

 

Through the process of recovery, what were some light bulb moments in recognizing your risk factors for relapse?

  • Dr. Kaufmann learned one of the keys to recovery is proper self-care.
  • He says everyone in the recovery community will recognize H.A.L.T. — it’s one of the first things they’re taught. The acronym stands for four self-care principles to fall back on to get well and stay well:
    • Hungry: Don't let yourself get hungry. It sounds obvious, but a lot of doctors get busy and skip meals.
    • Angry: We can’t afford to let ourselves carry around strong negative emotions like anger and resentment ― we must deal with them in a healthy way.
    • Lonely: Addiction can be lonely because we tend to isolate ourselves from important relationships. The secret to recovery for Dr. Kaufmann was to do the opposite: restore his existing relationships, make new healthy relationships, go to recovery meetings, surround himself with people in good recovery and emulate good things that they have to share.
    • Tired: What doctor doesn't know about getting tired? Through his training and early days of practice, Dr. Kaufmann was tired most of the time because of working late at night or into the next day. Opioids helped him with that fatigue, and that's one of the main things that got his addiction going.

tweetable: “Living a life of addiction can be a very lonely one. We tend to get sick in secret, behind closed doors, and isolate ourselves from important relationships like family, friends, colleagues. The secret to recovery for me was to do the opposite.”

The pandemic has forced many of us into a prolonged, high-stress state. How does that interfere with assessing our own risk factors and vulnerabilities with addiction?

  • Dr. Kaufmann says it takes time, effort and practice to develop self-awareness and vigilance about coping.
    • People in recovery practise and work on it every day.
    • To others, it may not seem quite as natural to do.
  • He says doctors typically are resilient people, but many of them were already overburdened and facing burnout symptoms before the pandemic.
  • Considering the energy required to self-assess and be vigilant, it’s not surprising to Dr. Kaufmann that doctors let down in that area.
  • Dr. Kaufmann explains that this is due to allostatic load, our physiological adaptation to chronic stress.
    • We all know that “fight or flight” is a natural response to stress, but our bodies need to return to baseline homeostasis to function well again.
    • When we don't have a chance to come back down to the baseline, we're chronically stressed by that physiological state of allostasis.
    • This negatively affects our cognitive capabilities and other systems.
  • The conditions health care workers have been facing lately can contribute to allostatic load, which puts us at increased risk.

tweetable: “If COVID-19 is pandemic, then burnout is endemic. A high proportion of doctors, sometimes 50% or more, were already experiencing some degree of burnout.”

How do you counsel physicians who are struggling with vulnerabilities from various disorders?

  • Dr. Kaufmann says we all have personal vulnerabilities that can be activated by unrelieved stress.
  • Because they want to protect themselves from relapse, people with chronic conditions (people with mood or anxiety disorders, physical disorders like coronary artery disease, or substance use disorders) usually recognize what’s at stake more than others.  
  • One of the main ways to protect ourselves is to be mindful and check in on changes in any of these areas:
    • Lifestyle: How are we doing with our home life, nutrition and exercise, hobbies and life-enriching activities?
    • Relationships: Are we spending enough time with loved ones?
    • Moods: Are we feeling irritable, anxious, sad or depressed?
  • To prevent relapse, it’s important to pay attention when there are negative changes in life-enriching activities or behaviours, or when we pick up new maladaptive behaviours.
  • Checking in with yourself and the people around you is an effective way to do this.

tweetable: “Hats off to you for being able to say ‘you know what, I notice I'm having an extra drink or two when that wasn't what I would have normally done, and that's something I should give attention to.’”

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

  • Dr. Kaufmann says it's useful to have a sense of when an everyday behaviour becomes riskier.
  • Alcohol is socially acceptable, readily available and part of a lifestyle for most people who aren’t in recovery.
  • Diagnostic criteria for a substance use disorder do not focus on how much or how often someone uses the substance ― the diagnosis has much more to do with our relationship with the substance and its impacts on our life.
  • When we depend on a certain substance to bring ourselves to a state of ease we can’t find elsewhere or when we use a substance to treat pain or cope, that’s a slippery slope. These are problem indicators Dr. Kaufmann that looks for.

tweetable: “An insightful person might notice they can't wait to get home and have a drink or two. Before my own illness really took hold, that's what I did. I would come home and have a couple of bottles of beer and chug them down fairly quickly because I knew that it would make me feel better. Then I start looking forward to that more and more each day ― and now we're beginning to think ‘okay, is this a red flag?’”

COVID-19 isn't going away anytime soon. What can individual physicians do in the short term to move from simply identifying risk factors to building a meaningful blueprint for their own self-care?

  • Dr. Kaufmann says that even under good circumstances, it can be difficult to establish a lifestyle in which self-care is a priority.
  • Medical culture, including medical training culture, doesn’t lend itself to a healthy personal lifestyle. Many workplaces and training programs are addressing these realities now, but culture can be slow to change.
  • He’s hoping the pandemic can help accelerate this kind of change.
  • Compassion toward others needs to start with self-compassion.
  • He says we need to reframe the way we think about self-care as an act of self-preservation and an extraordinary act of loving kindness toward ourselves.

tweetable: “If I can convince anyone that our patients don’t get the best of us and may even suffer when we aren't looking after ourselves, then I might be able to convince them that looking after themselves is worth it. [It can mean] pausing to get something to eat during a busy day, to have a rest or to have something to drink. Or when you get home, instead of drinking, you can go downstairs and jump on the elliptical for a few minutes ― the good feeling you get from that is healthier and lasts longer. Why not? Why not do that?”

_

This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule.  Feel passionate about this topic? Please connect with us at jouleinquiries@cma.ca.

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