All right. Well, we'll get started. So welcome, everybody. I am Lisa McClanahan. I am the co-chair for the Early Career Member Council for the AAPMNR. And for those of you who don't know me, I'm a pediatric physiatrist and assistant professor at Vanderbilt University. Today, I'm excited to have with me Dr. Carrie Kinney. She is a clinical psychologist and assistant professor at Vanderbilt University who specializes in anxiety disorders and other related conditions. She got her undergraduate degree from Northwestern University, followed by her master's and Ph.D. in clinical psychology at the University of Illinois at Chicago. She then completed her doctoral residency and postdoctoral training at the University of Mississippi Medical Center before joining us here at Vanderbilt. So welcome, Dr. Kinney. Thank you so much for having me and thank you for the introduction. OK, well, so today we're going to talk a little bit about mental health concerns, wellness, burnout in health care. It's a huge hot topic that's come up a lot more, especially since the pandemic. Mental health concerns continue to plague physicians and it's become more apparent with the COVID pandemic. Even starting to pervade a little more into pop culture and medical shows have started even presenting addressing it. So in your practice with clinical psychology and especially dealing with anxiety disorders or issues with burnout, something that you regularly encounter? Yeah, I would say I encounter burnout in a lot of my patients that I see and I also encounter it, I would say, even in colleagues at times. As you mentioned, like, you know, with the pandemic, there's a lot of new stressors that health care providers are facing, including risk of infection and social isolation, increasing economic stressors, increased use of telemedicine as well and work from home. That's just kind of increasing feelings of isolation, I think, as well. And there have been a lot of changes in the patient provider relationship that I think have contributed to a lot of the burnout that we see. And, you know, health care workers are really facing much more physical and emotional risks in their work that's very real. Absolutely. Definitely agree with a lot of that from the clinical side of things, too. So why is it so important that we address burnout? Yeah, burnout can have a lot of negative consequences in several different ways. So it can obviously really affect the physician themselves as well as patients in the organization. So we know that burnout when it's left unaddressed can place providers at increased risk of negative consequences like depression, even increased alcohol consumption, even all the way to suicidal ideation. You know, there's a lot of research documenting that physicians are at a much higher risk of completing suicide compared to the general population. And on average, 400 physicians die by suicide each year. So addressing burnout can be really important at catching it early because we know that chronic stress can lead to a lot of changes, including in the brain. So when there's elevated glucocorticoid concentrations that accompany stress, that can lead to damage or loss of hippocampal neurons, which can result in, I'm sure I don't have to tell you, but impaired learning and memory, impaired feedback to the stress response system as well, which means more stress and more neuronal damage, according to the glucocorticoid cascade hypothesis. It can also lead to shrinkage of dendrites and loss of spine throughout the medial prefrontal cortex, which is implicated in cognitive control and associative learning. And chronic stress can lead to expansion of dendrites in the amygdala, which is associated with emotion generation and processing. So more stress can actually lead to stronger emotional responses to threatening situations. So it kind of builds on itself, essentially. And it can weaken connectivity between regions of the prefrontal cortex as well and interfere in cognitive functioning. And all of that can lead to a lot of negative consequences for the physician, obviously. But then patient care tends to suffer as well when we don't address burnout and chronic stress. And then there's increased rates of medical errors, which places patients at risk as well as providers and institutions. So it's really important, I think, to address burnout. And the earlier we can address it, the better. Absolutely, because I know the goal oftentimes is to prevent burnout. So we're not even to the point of having to deal with some of these consequences and sequela of burnout. So I think one of the big questions is, how do we do that? What are some strategies that can help us prevent burnout? Yeah, there's tons of strategies that can be used, so you might need to kind of rein me in a little bit. I'll try and go one at a time. And feel free to interrupt me with any questions you have or thoughts that you might have about how this might apply to you all, since you're the expert on that. So one aspect is really just feeling like you're part of a team. We know that social connection is really important in preventing and reducing burnout. So, you know, I don't know entirely what that would mean for a physician. But, you know, having regular check-ins with other members of the team or the department, having common goals, clear communication and clear roles and expectations. And being able to seek help when you need it, I think, can be important. Those are just kind of some things that I've thought about. But I don't know, like, what do you think might be ways or, like, is there anything from there that physicians can do to kind of promote that feeling of being a part of a team? I think PM&R is unique in that we are often kind of part of a multidisciplinary or interdisciplinary team as part of our regular work structure. So I think kind of helping to foster more of that true team mindset and kind of everybody is in this together, you're all bought in on, you know, your group of patients and your program can really make a big difference. I feel like I personally have seen that in a few different areas, especially when you've had, you know, your whole team, maybe on an inpatient unit, has a really difficult patient. When you have that ability to get together as a team, debrief, kind of even vent a little bit, have that shared connection and that ability to process some of what you've been going through, I think makes a big difference in kind of creating and fostering those more meaningful connections and making you feel like, hey, I'm not alone in this. Yeah, absolutely. Communicating and feeling heard and seen by other people that you're teaming up with is really important. So I love that that's already part of PM&R. That's really nice because not all specialties have that, it seems. Probably for us, it's just more making sure we take the time to really do that, you know, to instead of just trying to get through all the topics of the day, putting aside that little bit of extra time to foster that connection. Yeah. Yeah, that makes a lot of sense. And I know that physicians are under a lot of time constraints, so that can be a challenge. So in addition to kind of building that team mindset and feeling like you're part of a team to prevent and reduce burnout, another major strategy that I would say is something that we in the therapy world called cognitive restructuring. It's part of cognitive behavioral therapy, but it's basically just challenging unhelpful thoughts and trying to generate more balanced or helpful thoughts rather than taking our thoughts as facts. And so I can kind of walk you through what that might look like, if that's helpful. Oh, yeah, absolutely. Great. And of course, feel free to jump in on any of this, but just to kind of provide a quick overview of like how you would even identify some of these thoughts that need to be challenged, because a lot of times these thoughts happen so automatically and we have done them for so long that we sort of just don't even question them or think twice about them. So some things to look out for, though, that can signal that this is a thought that maybe needs to be challenged are when we're applying what we would call like a mental filter, which means like only paying attention to certain types of evidence. So, for example, that might look like only paying attention to our failures and not our successes. So that's one common one that we see a lot. Another one is emotional reasoning. So assuming that because we feel a certain way, it must be true. So I feel embarrassed, so I must be an idiot, for example. But feelings are not facts. So emotional reasoning is what we would call a cognitive distortion or an unhelpful thinking style. Catastrophizing is another one that we see a lot. So blowing things out of proportion or assuming the worst, kind of jumping to that worst case scenario and ignoring the possibility of kind of everything in between all the other possible outcomes. Or all or nothing thinking, also called black and white thinking, is another one that comes up a lot. So an example of that might be if I'm not perfect, I've failed, or if I can't do it right or perfectly, then I shouldn't do it at all. So those are just some examples that I tend to see a lot, particularly in people experiencing burnout or kind of leading up to burnout. But there are other ones that can come up as well. And then once you identify those thoughts that are kind of getting in the way or really affecting your mood or increasing those levels of burnout, you want to challenge those thoughts. And there's different ways of doing that. One approach that I really like is really looking at the evidence for and against a thought. So, for example, with that thought, you know, I feel embarrassed, so I must be an idiot. Looking at what evidence we have that you're an idiot versus what's some evidence that I'm not an idiot or that I'm smart. And then developing a more balanced thought. And also, this is one thing I really push people on, because there's often this jump between, like, I make this one mistake, I am an idiot. Oh, yeah. One mistake does not an idiot make, right? So really looking at, is this actually evidence in support of this thought or is it not? And then developing a more balanced thought, like, I may not be perfect, but I'm doing the best I can, or I made this mistake and I have a lot of great qualities, something like that. And then when it comes to catastrophizing, I really like to have people think through, like, what are the actual possible outcomes in a given situation? What's the best possible outcome? What's the worst possible outcome? What are some other outcomes in the middle? And what's the most likely outcome also? So you can kind of think about, like, am I getting ahead of myself? And I also have people estimate what's the likelihood of that worst possible outcome? Because if it's, you know, less than 1%, which it often is, what's the likelihood of that worst possible outcome? Which it often is. Like, are we devoting an undue amount of time and cognitive resources and emotional attention to this very unlikely outcome? And then I also have people think about, you know, how might I cope if that worst possible outcome happened? And then, you know, what's the most likely outcome? How might I handle that? So that's, those are some examples of some things that I do to have people challenge thoughts. You can also challenge your thoughts using behaviors, like behavioral experiments. So particularly with that black and white thinking or that perfectionism, you know, instead of waiting until you can do something perfectly and saying if you, you know, buying into this thought of if I don't do it perfectly, then it's not worth doing. You can stop just taking steps towards doing that thing and seeing how it goes. Did you fail? So you're kind of testing that hypothesis as you go using your behaviors. So those are just some examples of ways that you can challenge your thoughts. I don't know. Does any of that seem like that might apply to PM&R or anything? I have to say, yeah, I think a lot of it, it's applicable, especially to not even just PM&R, but physicians, especially young physicians in general, we're coming out. We've been used, you know, to having kind of these safety nets behind us. And then all of a sudden you're out on your own and you're practicing and you don't have somebody that you go to to give them your plan and make sure that it's what they would do. So then it's right. You know, it's all of a sudden it's on you. So, you know, then there's a lot of, you know, anxiety and indifferent, I think, feelings that can come along with that. I think the one personally that I found that I probably resonate with the most is the more negative bias one where you think about me, I had a whole day of patients, you know, and maybe I had 10 encounters and nine of them went well. But I'm going to focus on this one that didn't go well and then, you know, just carry that with me the rest of the day. I think, you know, that's probably something people encounter a fair amount. Yeah. And that makes a lot of sense. We know that there's a lot of research supporting that all of us have a negative bias to some extent. And those of us who are maybe prone to feeling a little bit more perfectionistic or a little bit more anxious or whatever it might be, are especially biased towards that threatening information. Of course, it makes sense from an evolutionary perspective that we would tend towards threat, right, to keep ourselves safe. And that's really unhelpful in the modern setting. And one thing that I like to recommend to some of my patients is when they're really noticing that they have a hard time even noticing the positives is I'll have them write down just one positive thing a day. It can be anything. It can be small, like a sweet email that they got or that they got to spend a little extra time cuddling with their dog or whatever it is. And I especially encourage people to do that on the really tough days because then over time, people tend to find that, you know, they start looking for the positives a little bit more and noticing those more than they did in the past. So that's another thing that you can do. Another option to prevent or reduce burnout is something that we call behavioral activation. That's something that is actually comes from the depression literature. It's part of CBT for depression. And it's basically just about doing pleasant activities. And we define pleasant as activities that are fun or enjoyable. And activities that give a sense of mastery. So that can be like buying a special little treat for yourself. It can mean cleaning a room in your house, wearing some clothes that you like or that make you feel good. It can be really small things. And in fact, I usually recommend that most of the pleasant activities that people choose when they're setting these goals are really small activities that they can build into every day or most days a week. Because I also like to leave some wiggle room, especially for the people who tend towards the more perfectionistic tendencies. I don't want them to feel like they've failed if they've missed a day. But I think scheduling in fun is really important and doing those activities that give that sense of mastery as well. Yeah, so that's another option. And there's lists of pleasant activities out there that people can do just to give them kind of a starting point for brainstorming because sometimes when we're feeling a little burnout it's hard to even imagine like taking the time to do something fun and treating that as like an important part of our day. It feels like just another task to do. It's like where do I even start? So there's a bunch of lists out there that are really helpful I think in terms of kind of getting the gears turning on what are some really small ways you can build in those pleasant activities in your daily life. And then I also think kind of setting boundaries can be really important because it allows for you to build in that time for behavioral activation for those pleasant activities as well. Okay, one thing just thinking about the pleasant activities is I appreciate you saying it should be something little because as you said that my mind is over here thinking about like bigger things that in the end are probably pleasant but also create stress. Like things I've done personally like I'm going to take a pottery class and I'm going to learn how to make a bowl and then I'm frustrated at that. Yeah, that's a great point and I think those things can be really important too especially if they give you that that sense of fulfillment and meaning. And that's not the only way to get it and a lot of times I think starting small and noticing those smaller changes in your mood can help you kind of build up the motivation to do something else. Like sign up for this multi-week pottery class for example which does sound kind of daunting if you haven't done that before and if you're already feeling stretched really thin. Right, yeah. Coming back to what you the last thing you said with setting boundaries I mean one part of you know kind of setting that is protecting your time and that can be particularly challenging. I feel like for younger physicians who are trying to sort of practice or kind of prove themselves as like a young faculty member fresh out of training what advice do you have for these younger physicians that are kind of struggling to find that balance? Yeah, I think it's really tough for anybody who's kind of coming out of training and getting feel like you're kind of back at the bottom of the totem pole in some ways. It can be really hard so I do want to acknowledge that but I would start probably with like what's getting in the way of saying no or what's getting in the way of setting those boundaries? Like is it you know a thought related to if I'm not working 14 hours a day for my patients I'm not a good enough provider? Is it it means that I'm rude or aggressive or unkind or selfish or insert whatever adjective you want if I say no to this thing? Will I upset other people if I say no or set this boundary? So I would start there and figure out what it is in particular that's getting in the way of setting boundaries and if it's something like those thoughts I would kind of come back to kind of restructuring like we talked about earlier like you know think of other people that you know who have set boundaries like do you think that they're rude and selfish and bad providers whatever it is that you were thinking or you know sometimes it's really hard to be kind to ourselves and we're better at being kind to others oftentimes particularly those in the health related fields I think. So it can be useful to think about like what would you say to a friend or a colleague or a loved one if they came to you with similar concerns that can be really useful in challenging some of those negative thoughts and so starting with that and then if part of that is even finding the way to or part of what's getting in the way is even finding the appropriate way to set boundaries or say no like there's tons of information out there about assertive communication and a lot of people confuse assertive communication with aggressive communication those are two different things assertive should be clear and constructive and focused on the goal at hand aggressive is going to be something different than that so just really focusing on clearly communicating your needs so usually I recommend that people keep it really brief stick to the facts there's several different ways of saying no but in general you want to keep it brief and stick to the facts and be really direct and in terms of specific methods for saying no one is you can just directly say no another option is what we call the reflecting no so that's acknowledging the content and the feeling of a request but then adding your assertive refusal at the end so that might sound like you know I want I know you want to talk to me about organizing the departmental review but I can't do lunch today so you're saying like I'm acknowledging that you're seeking this and I can't do it you could give a brief reason a brief and genuine reason for why you're saying no so that might sound like I can't have lunch with you because I have a report that needs to be finished by tomorrow or I can't stay late because I need to pick up my daughter from daycare whatever it might be but if you feel so inclined you can give a brief reason for saying no there's also what we would call the inquiring no so that's not a definite no it's opening up the request to see if there's another way it can be met that doesn't interfere with your boundaries so if somebody says you know can I can you cover my shift today you might say I can't cover your shift today but is there another time you'd like me to cover for you so it's opening up the possibility of you know meeting their request in the future and then there's something we call the broken record which can be really useful for persistent requests so just sounding like a broken record so that might sound like can you cover my shift no I can't cover your shift today well I will buy you lunch if you cover my shift I still can't cover your shift today well I'll cover your shift another day if you cover my shift today no I can't cover your shift today so don't be afraid of just really asserting what you need and what your boundary is in that moment and as long as you're doing it in a you know compassionate and professional manner we should all feel comfortable hopefully asserting our needs so those are just a few examples of ways of setting boundaries so that we can make time for the things that are important to us like self-care because we know that that is so important I'm sure you've heard this a million times but that you know putting on your own oxygen mask first so kind of reminding yourself that I need to take care of my own needs and here's how I can do it in order to better serve my patients and the other people in my life and yeah does that answer your question about kind of setting boundaries I think so it's I think it's definitely like I said before something very difficult and challenging but I think those to me those sound like very natural ways to to start to set those boundaries in terms of just other methods for preventing and reducing burnout there are a lot of relaxation strategies from the therapy world that can be really useful so examples of that include just belly breathing deep breathing from or diaphragmatic breathing there's a lot of different names that goes by that's one method and there's a number of other ones out there there's plenty of apps as well that you can use that have like guided relaxation exercises as well so that's another thing to kind of keep in mind but those are kind of the main strategies for preventing and reducing burnout that come to mind for me I'm sure there are many many others that we could go into but I think those are some big ones that might be useful especially to health care providers ideally the goal would be to address all these concerns and prevent burnout but I know that often doesn't happen what are some signs that we can look for that would indicate burnout great question so I would say a huge indicator that someone might be burnout is low accomplishment so getting less done basically than your baseline and then oftentimes those thoughts start to kick in about I've failed I'm lazy whatever it might be which then kind of worsens that burnout but that can be a really clear indicator that burnout is happening other ones include emotional exhaustion which can just lead to a lot more cynicism um and depersonalization and uh difficulty empathizing with patients so almost like feeling more callous um so I would say those are probably the big um indicators as well as just you know fatigue um because that often follows that chronic stress okay and I know there's an association between burnout and the development of diagnosable mental health conditions which are not uncommon in health care providers I found one study reporting that 29 percent of physicians experience symptoms of depression and up to a quarter of physicians experience anxiety when do we typically see burnout kind of turn into those issues more into those issues more like consistent with you know depression or anxiety so uh we tend to see that that burnout places individuals at an especially elevated risk of depression anxiety and other mental health conditions when that stress that somebody's experiencing is chronic unpredictable severe and untreated um so when stress doesn't have a clear time limit if it's unpredictable or if it comes when you're lacking social support it can start to really feel like everything is kind of out of your control which can lead to greater sustained anxiety more vigilance sometimes we see increased impulsivity as well as depressed mood so those are going to be the times when someone's really at increased risk of developing a disorder like depression anxiety or another mental health condition and so doing things that can kind of increase that sense of control can be really useful so for example we know from the research that health care providers do a lot better when they have control over their own schedules for example so but when they don't which is often the case for a lot of physicians we know that that can place them at especially elevated risk of depression anxiety so it can be especially important to treat those symptoms sooner rather than later and i would also say you know if you're noticing some of those symptoms of burnout or chronic stress that we talked about earlier if you're noticing some of those in yourself and if you're maybe trying out some of the strategies we've talked about today and you're not really seeing a change or you're having trouble implementing some of those changes or just not leading to the effect that you want again i would seek help sooner rather than later from a mental health professional and i know there are a lot of different sources where people can seek out help for that so just doing that sooner rather than later it's going to be useful and have a better outcome than than waiting until it gets worse right and then i think the the point about control over your schedule is definitely an important one it's something that i think as you know young physicians are looking at you know contracts and jobs things like that that's an important thing to talk about with somebody when you're looking at a job is how much you know control do i have over my schedule in terms of how long my appointments slots are you know when how easy or hard is it to block slots for different things and if you do want to do some teaching or you know personal reasons things like that last question um and i just want to circle back a little bit to some of the assertive communication and just see if you have any extra thoughts or tips kind of when you're trying to deal with some of these boundary setting things or you know ways to protect your time when you're speaking to a superior versus maybe a colleague who's asking you to cover a shift but maybe you're speaking to a superior asking about like hey i need to change my clinic schedule for these reasons you know do you have any additional thoughts on that yeah um i think it really depends on the situation and i would i would think about um uh like what's your goal in that situation right so um with the colleague um and someone at the same level as you um you know your goal is to just maintain that boundary right um with the superior you kind of have some competing goals sometimes which is you want to maintain that relationship as well as not that you don't want to do that with colleagues as well but that relationship uh carries a lot more weight when it's someone um who is your superior um so uh i guess most of my advice would be the same like clearly communicating your needs um and also you have to kind of ways weigh the pros and cons of uh um of setting this boundary of communicating in this way with this person um and kind of pick your battles a little bit i think um which unfortunately isn't like the most useful advice i think but um because i think you know it's practical it's very practical yeah so it's like what's your long-term goal like basically thinking about what's going to get you closer to your long-term goals um and is this something that you're willing to sacrifice temporarily um like maybe your time you know this year or this rotation or whatever it is um is that a sacrifice that you're willing to make or is that too much um and then coming in with uh with the facts so starting with just describing the facts expressing what that means to you um and asserting your needs um but then i would also just add being willing to negotiate a little bit um because that's something that you're going to have to do um with somebody who's your superior i think the broken record piece still applies um but you do have to be a little bit more open to negotiation when it's a different situation like with a superior right right all right well great well thank you so much this has been a great discussion i hope everyone watching finds um this information helpful um we have a list of resources that we're also going to post to the group along with this talk um so you have those as well um for me it was an act of wellness to pre-record this session due to some other commitments i have um during this month of may um so i appreciate everyone taking the time to watch um and then a very special thank you to dr kerry kenney for volunteering her time and her expertise today thank you so much it was so great to chat about all this yeah thank you for inviting me this was great everybody have a great day thank you

mental health

burnout

healthcare

cognitive restructuring

behavioral activation

assertive communication

professional help