Podcast Episode 21 | Taking Care of Doctors During COVID-19 and Beyond

Milad Memari:              00:00                Counting in the psychological burden and it's not just really the donning of the PPE and all of the stuff that from the outside can seem difficult, but we have a lot of folks who are dealing with something for the first time in their lives, it's a very scary thing.

Intro:                            00:19                From Spaugh Dameron Tenny, it's The Prosperous Doc Podcast, real stories, real inspiration, real growth, a show for doctors who are ready to improve their overall wellness in every aspect of life. Now here's your host, Shane Tenney.

Shane Tenny:                00:37                Welcome back to another episode of The Prosperous Doc Podcast. I am Shane Tenny and glad to have you with us today, whether you're working or driving or working out, I'm glad to be part of your day and talk about the topic at hand. We all know that our healthcare workforce, most of you are on the front lines of the pandemic sweeping the globe right now, COVID-19, and that's going to be part of the topic of our conversation today. I'm here with Dr. Milad Memari, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore, Maryland. We've actually been trying to get scheduled for a while now and in the process of trying to get scheduled, Milad actually contracted COVID-19, and so I thought we'd talk a little bit about a real life survivor story there, as well as the topic that really brought us together, which is just his interest in medical education and in particular resident wellness. So Milad, or Dr. Memari, thank you so much for being with us today.

Milad Memari:              01:38                No, you can call me Milad. Thanks for having me, Shane.

Shane Tenny:                01:41                Absolutely. Yeah. So glad that you're finally back in a condition to be able to be on a podcast again, I'm sure you're happier about that even than I am.

Milad Memari:              01:48                I feel similarly. Yes, certainly.

Shane Tenny:                01:50                Yeah. So the news is all around us, but let's maybe just start with the elephant in the room. What was it like? How bad is COVID-19 and how'd you come in contact with it?

Milad Memari:              02:03                Sure. So I guess the beginning of the story, Baltimore started having cases second half of March was really when things started. I was one of the first providers at our hospital to care for COVID patients on our COVID service. In the course of that time period, obviously there's no way to know for sure, but at some point myself and a couple of my teammates started having some minor symptoms. For me, it was a bit of a sore throat and a general malaise feeling. So I went and got tested. I was informed that I was positive. Over the course of the next few days after that, I generally felt unwell. I had chills one afternoon, but I never actually quite had a fever. I thought that it was a two-, three-day illness and I was over it.

Milad Memari:              02:52                So about a week after I tested positive, I was starting the preparations to maybe go back to work after our seven-day period of quarantine was over, and kind of right at the end of that one week, I started having some shortness of breath with moving around. One of my colleagues at the program was able to give me a pulse ox and I was monitoring my oxygen levels at home and they were kind of borderline. So essentially for the next four to five days after that, I was pretty short of breath whenever I was active and walking around. Spent a lot of time resting in bed, really had a very minor cough, but otherwise didn't have many of the classic symptoms. So for me, it was essentially shortness of breath, a little bit of hypoxia, difficulty getting oxygen, and then I would say probably around the two-week mark afterward, things cleared up.

Shane Tenny:                03:43                Did any of your colleagues also get COVID at that time?

Milad Memari:              03:47                Yes. A small number, but yes.

Shane Tenny:                03:50                Yeah. So I guess comparing kind of the protocols that were in place in March within your hospital, and now, were you doing the same thing then that you are now, or were things not quite as tightened up with the hazmat suits and everything else, that might've resulted in the increased exposure risk?

Milad Memari:              04:09                I think there was a lot that was still unknown at that time. Even then, testing was very limited initially. So a lot of the decisions were made not just by us, but in an emergency room when evaluating patients, some may have minimal symptoms. But the question was who do we test and who do we not? So that was a difficult thing because of lack of resources, specifically relating to testing. Relating to personal protective equipment and things of the like, I, at the time that I was there, we didn't have any limitations. I know that other hospital systems have dealt with that more, but I don't think that played any role in our hospital system.

Milad Memari:              04:47                However, in the time between when I was out the hospitals, the Hopkins system went to full masking, so that even when you weren't in a patient care area, you're with other providers, everyone was wearing masks. and then they created COVID specific units to where having to go in and out, you would have to don and off your complete gear and instituted some policies related to that. So this was all done kind of as people learned more about it and we got a sense for what resources were necessary. At our hospital, they opened a second intensive care unit, and so one of our medicine units is essentially blocked off for just patients. So I think these are things that as time passed and people learn more and saw best practices around the country, the protocols increased. I think as of now having been back on the service, things are really, really looking good.

Shane Tenny:                05:40                Are the overall things seem to be improving? Is the curve flattening or just the hospitals kind of system and plan for managing it is more turnkey?

Milad Memari:              05:50                I know that in terms of our hospital, the kind of peak numbers happened fairly recently and it seems to have already peaked and kind of be on the downtrend, but that was within the last couple of weeks. So I think it was fairly flat. I know a lot of the folks that have come in have been from nursing facilities and also minorities have been predominantly affected. In the area of Baltimore that our hospital is, there's a large Hispanic population in that area and so a lot of folks have come in, particularly, and of all age groups really having been affected disproportionately from what we see on the inpatient side. I do think that over the past few days as I was on service, the numbers did seem to be going down. In fact, we're decreasing the capacity of our COVID intensive care unit services and that's happened over the past week or so. So hopefully this continues and it continues to be a downtrend in cases.

Shane Tenny:                06:54                But what's your understanding of just the immunity around COVID? As a lay person, I feel like there's kind of varying messages that I hear and a lot of uncertainty. Either professionally, clinically, or just experientially, what's your take on kind of the immunity question?

Milad Memari:              07:07                Yeah. So at the front end, I'm certainly not a virologist. So take everything I say with a grain of salt. But through the way that I think about it, someone like myself who experienced the disease process and then improved, just based on different viruses that we know historically, that generally means that your body was able to mount some sort of immune response. I think the question that comes with COVID given that it is a novel virus and it hasn't been studied in depth is what kind of immunity is that and how long does that immunity last? I think just given that now we're starting to have more robust testing for antibodies, these kinds of questions will be answered once we're months out and folks are following up with people that have had COVID, seeing antibody levels, seeing how quickly those wane. I think we'll have some of these answers.

Milad Memari:              08:00                But I think a lot of what you may be hearing when folks say we just don't know is because any virus that comes kind of out of the blue and we haven't studied in depth, it's always safer to say we're not sure. And we question whether there is immunity just for everyone's safety, even if we have a high suspicion that if this acts like most other similar viruses, there should be some degree of immunity. I mean, the whole concept of vaccinations is based on the idea that you're able to mount an immune response and that immune response will protect you. So those that have had it, one would think we'll have immunity at least for a certain period of time. How long? we'll hopefully find out soon.

Shane Tenny:                08:41                Yeah. Kind of connecting some of this part of your story to the element that brought us together around just resident wellness, and hospital systems you mentioned a minute ago, just all the personal protective equipment. I call them the hazmat suits. I mean, just the exhausting schedule, if nothing else, the precautions that are now required of healthcare providers are just more exhausting. It just takes more time. It's more intense. It's more stressful. Do you observe or perceive that there's any difference in the exposure level between residents or those in training and attending physicians?

Milad Memari:              09:19                So kind of to address both parts of your comment, yeah, you're totally right in that it is fairly exhausting to go through the process, and I can talk a little bit if later we talk about, more about my specific institution. There have been things that we have done to try to minimize that burnout, knowing that it is exhausting. Specific to the second part of your comment, I haven't noticed any difference in between attending and trainees in terms of protective equipment and exposure. The only thing that I could think of is if potentially given that residents are more of the primary caretaker in a lot of these teaching services, we may go in and out of the patient room a little bit more often than folks that are more senior on the team. But in terms of specifics, whether it's protective equipment or any sort of safeguards being taken, I've not noticed any difference.

Shane Tenny:                10:13                Right. You're not being given the used PPE and the ones with holes in it and rust around the corners, are you?

Milad Memari:              10:19                No, hopefully not.

Shane Tenny:                10:21                Good, good. Since you are the frontline that most of us are counting on to help take care of this. I do want to ask you about some of the research that you've been working on and thing, but we'll plan to dive into that right after this break.

Will Koster:                   10:37                I'm Will Koster, bringing you this episode's financial wellness tip. Making financial decisions can seem routine to some, but paralyzing to others. We emphasize that financial decisions, big and small, are all interconnected. We call this philosophy the six money decisions. An individual's finances can basically be broken down into six components. You make decisions on how to spend, save, earn, borrow, give, and protect your personal finances. Let me give you a common example that I run into that highlights how these areas are connected. Remember that giving money can be voluntary like charity, or involuntary such as taxes. Here's the example.

Will Koster:                   11:27                A physician with federal student loans, here's the borrowing component, who is on an income driven repayment plan needs to make decisions around filing taxes with their spouse, the giving component. If the physician is part of a group that offers a retirement plan that they can defer money on a pretax basis to lower their adjusted gross income and thus lower their income driven repayment plan, the saving component, they to make decisions around whether that makes sense for them. What if the physician is an independent contractor? How does that affect their situation? That involves the earning component of the six money decisions because they would probably earn 1099 income.

Will Koster:                   12:09                The takeaway here is that even with a seemingly mundane part of an individual's finances, the impact or considerations are immense. Remember that if you need help in analyzing how a decision affects your personal finances, a professional can give insight from their experience. With his episode's financial wellness tip, I'm Will Koster.

Shane Tenny:                12:33                So Dr. Milad Memari, thanks again for being with us. I mentioned your background at the top of the show here as an internal medicine resident at Hopkins at Baltimore, and you have had a growing interest, I think, through your training in education and wellness, especially for your peers, for residents, for folks in training. Tell me a little, where did this interest start? What's the beginning of the story here?

Milad Memari:              13:01                Sure. Yeah. I'll take you a little bit back. So before I ever started med school, my job after college was I worked for Kaplan as an SAT tutor and teacher, and so there were these classes for these high school students and it was initially just a job and I did not think about this as a career. But I really enjoyed the idea of being in the classroom teaching. It was really inspirational for me. So I began, I applied to, and I went to med school down in Tulane University in New Orleans. When I started, I am looking at things I could get involved in. I gravitated toward things that have to do with curriculum development and education and I tried to take every opportunity I could to work on my teaching skills even then.

Milad Memari:              13:51                Then over time as I've gained more experience, both in that realm and as you gain more seniority working with learners at different levels, it's become clear to me that this is what I want to do. It's going to be a major part of what I do in addition to clinical care throughout my career. In fact, I'm currently in the process of applying for a fellowship in education, in medical education, which will follow my residency training. So truly it went from being something that was a summer job to something that's going to form hopefully a large part of my career moving forward.

Shane Tenny:                14:25                Interesting. So that has led, I guess, that growing interest or self-realization through medical school has led to some research that you've done within Hopkins, right?

Milad Memari:              14:37                Absolutely. Yeah. So this particular research project came into being a little bit before I arrived at Hopkins, and so I kind of carried the baton through. But there were a lot of different aspects of this particular study. The main question that was being asked was, what are residents doing when they're not at work? The secondary part of that question was, of the residents that we have here, and we had groups of internal medicine residents and psychiatry residents, are there differences in terms of the activities that folks are engaging in? If we break it down by gender, by residency year, by different programs, are we going to see differences in the kinds of activities that folks do with their free time?

Milad Memari:              15:20                A lot of that was brought about by the governing body for residency programs. The ACGME has been doing a lot of work specifically related to duty hours. As you may know, the duty hour restrictions in terms of how many hours we can work in a week, in a month didn't exist 15, 20 years ago, and my dad will often remind me of that as a physician. He'll tell me about the hours he worked back in his day. So we're fortunate to have a lot of limitations in terms of the hours that one can work, trying to limit burnout. But I think the interesting question is secondary to that was, okay, so we've limited the hours, what are folks doing in the rest of the time that they available? What makes that time special?

Shane Tenny:                16:01                What'd you find?

Milad Memari:              16:04                So when [crosstalk 00:16:05]...

Shane Tenny:                16:06                You're doing a great job leading me up to the edge of the cliff and leaving me waiting. Yes. How'd you conduct this study? What'd you find?

Milad Memari:              16:13                Sure. So the study was done through surveys. So we had 101 residents in the program kind of split between psychiatry and internal medicine. The survey had a list of activities that folks may choose to engage in in their free time. Just as an example, the questions included how often they got sleep more than seven hours consecutively, how often they exercise, how often they spoke to an old friend, read for pleasure, etc. So there were 16 activities and this was asked of residents. The question was, how often have you engaged in these activities over the past 30 days? So breaking it down between the internal medicine and psychiatry residents was an additional question based on the fact that as you may know, different specialties in medicine have differing levels of satisfaction with their work.

Milad Memari:              17:01                Internal medicine tends to fall a little bit lower on some of the satisfaction scales, while psychiatry tends to be higher. So that was an additional interesting sub question that we had. So in terms of the results, what we found was that there was no difference really in the number of activities engaged in based on whether they were in internal medicine or in psychiatry. There was no statistically significant difference based on gender as well. But where we did find a difference was one comparing first year residents to residents that were in the second or third year. For the purpose of our study, we compared that as first year residents are interns and the second, third and fourth year residents we classified as residents.

Milad Memari:              17:41                In that comparison, we found that there were some activities that were done more often. Before I get to the differences, I thought it would be interesting to see what were the activities that were performed most often. So for example, of all activities that were done, cuddling with another adult was done at a higher incidence, sleeping greater than seven hours consecutively was done more often than other activities. So the activities that happen less often included having a social night out or writing in a journal or doing reflective writing, things like that. But then in comparing those two specific groups in terms with residents, there was almost double the incidents of sleeping greater than seven hours consecutively in the residents group, which was statistically significant, and making a home cooked meal was also a statistically significant, 11 to seven. The sleeping greater than seven hours, the numbers are 16.3 to 8.2 in the comparison.

Milad Memari:              18:37                Then I think even more significantly, taken in aggregate, activities that can be performed alone and compared to activities involving others, the activities that can be performed alone were done more often by residents than interns with statistical significance. What I take all of that information to mean is that when time is more difficult and that is in intern year, you have less free time available, folks are still choosing with their free time to do those activities that involve others. Folks are making sure that they don't lose that. There wasn't any statistical significantly difference among residents and interns in that.

Milad Memari:              19:20                However, as people start to get more free time, as traditionally happens as residency goes on the second, third and fourth year, folks were getting back into doing those things that they like to do on their own. So taking an aggregate, those 16 activities represent a little bit more of that free time and the kind of activities that folks may have sacrificed during intern year.

Shane Tenny:                19:39                In the course of the study, I guess, you're looking at specific activities that people engaged in. Is there a way to quantify or do you look at the data and interpret overall, are these things or the quantity of these things, how are these contributing to their own sense of wellness or satisfaction or happiness? Do you have a sense for that?

Milad Memari:              20:01                Yeah, that's actually interesting that you brought that up. So this was one part of a study that other parts of which are also in review, and what the rest of the study was trying to try to come up with a wellness score to attribute to residents and to see whether certain activities correspond to higher levels of wellness. At our institution, there's been a lot of studies kind of focused on that concept of protecting against burnout if there are wellness promoting activities. So that was something that wasn't specifically studied within our published work, but it is something that we're looking into as part of the larger data set.

Shane Tenny:                20:40                You put words to what I was kind of thinking, which is like a wellness score at which almost seems, it almost seems crude to try to rank something like that, but it seems like it would be really informative to be able to say, "Wow, our interns are really struggling and we need to do some things to help them or the resident group," as you define it. You alluded earlier before the break to some of the things that Hopkins has tried to institute and put into place to care for residents and help promote their, I guess, emotional and intellectual and spiritual well-being. Talk a little bit about that.

Milad Memari:              21:14                Yeah, absolutely. So for those of us who are on the regular medicine service, the admitting wards team, we tend to work on average 12 out of every 14 days and then our blocks are 14 days. So that's the regular, that's the norm. For the COVID services, they made an adjustment to make it such that we work seven 12 hour shifts in the course of 14 days, counting in the psychological burden. It's not just really the donning of the PPE and all of the stuff that from the outside can seem difficult, but we have a lot of folks who are dealing with something for the first time in their lives. It's a very scary thing. We're coordinating with family members. We're trying to make sure that these folks are cared for at a level that is fair to them, fair to all people, making sure that just the fact that they have COVID in these isolated environments doesn't make it such that they're neglected or not getting the level of care that they need.

Milad Memari:              22:13                So making sure that that's the case and communicating with them and their family members takes a little bit more of a time and focus. So the COVID services that we have, we've limited the number of patients that can be on a particular team, and we've essentially doled out these shifts among more residents so that when we do work, it can be high-intensity shifts. People are at higher levels of, a little bit higher acuity of their illness that we can really focus on all of them and also not burn out in the process of doing that.

Shane Tenny:                22:47                Has that adjustment to the schedule, how's that been received? What's been the impact, as a recipient of that policy and as one who I'm sure has collaborated in the thinking about what we need to do to take care of each other and our patients?

Milad Memari:              23:01                Yeah, absolutely. I mean, one of my co-residents, Emily [Tang 00:23:06], she actually created a think tank that was just for us as residents to talk about our experiences, and this started right when I was still caring for patients in mid March. The idea was, let's talk about it. Let's come up with these plans. Our program leadership is terrific and they took a lot of our ideas and incorporated them into some of these things that you see. So for me, things are doing well now. I mean, as far as residents are concerned, I think a lot of these changes have been very well received. I think generally speaking, given that outpatient medicine has been a little bit less active now, a lot of the residents in our program have ended up doing a lot more inpatient work.

Milad Memari:              23:47                The fact that we've created new teams and new ICU just for COVID made it such that more residents are working more often. Making a system where there was a little bit less of a burden when you're inpatient was absolutely a good call. Having just come off the COVID service, I don't feel that it contributed to my burnout because between my three day shifts, I had four days off, then I had four nights with days off after. So that's manageable.

Shane Tenny:                24:15                Yeah. In wrapping up, I guess I'm thinking just given the time, given the interest you have around wellness, the time you've spent thinking about it, the efforts you've put into the research, is there a hypothesis that is beginning to form in your mind or an observation that you've made either within your hospital system or from talking with other colleagues from med school and things like that? What's the one thing that you think hospital systems could do at a macro level? I'm not speaking specifically about your institution, but at a macro level, what's the one thing that occurs to you that hospital systems need to be aware of or maybe adjust or accommodate or change to help improve resident wellness going into this next decade?

Milad Memari:              24:56                Absolutely. It's a great question. I think going back to what I took away from our study in particular and how that may relate to your question, I found it very interesting that different residents, as you can imagine, have a lot of different ideas of what they want to do with their free time. While I may want to go hiking and play soccer, someone else might take that time to read or pray or do whatever it is that they find gives them wellness. I think there's something interesting in that. Just one example from my experience, I may work 60 hours in a given week if I'm on a night rotation. While I may work closer to 80 hours if I'm on a days rotation. You may think that working on that night service, I might be less burnt out or less fatigued given that I'm working less hours, that would be I think a normal supposition.

Milad Memari:              25:47                But my experience and that experience of my colleagues is not that. So that made me think more about those activities, and to be honest with you, when you're working nights, the difficult part of it is that you're awake when your friends and colleagues and partners are asleep, and when you're awake and at home during the day, if you do have a couple of hours, everyone else is not around. Now, the COVID time it's accepted, but under normal circumstances, those folks that you may want to hang out with are not available for you. So I think one thing that's interesting to me moving forward is there has been a lot of focus on the total number of hours work and I think that makes sense. There's a certain limit to what the human body can do.

Milad Memari:              26:29                My question is beyond that, are there certain timings or shifts that different residents can do that would contribute to their wellness? For example, if I'm someone that spends a lot of time in solitude in my free time, maybe I will not be as affected by being on a night shift as someone who may have a partner, may have kids. Those hours during the daytime may be more precious to them. So it might be that this kind of one-size-fits-all approach to limiting hours can be buttressed by a more individualized approach to different residents' interests, and the ways that we all individually thrive. So that's going to be something that I hope to study a little bit more in the future and potentially if that can be implemented at some programs, I think that would be interesting.

Shane Tenny:                27:15                Really interesting. Milad, thanks so much for sharing your personal story, your professional story on taking care of yourself and your colleagues. Really appreciate it today.

Milad Memari:              27:24                Thank you so much for having me, Shane.

Shane Tenny:                27:26                Thank you for being with us today. We've got more great episodes of The Prosperous Doc Podcast queued up and rolling out in the coming weeks. We try to release some every other Monday. So don't forget to subscribe. Certainly we'd love any reviews that you have. Thoughts, questions, suggestions, you can email me shane@whitecoatwell.com. If you're looking for ways to prosper financially, we've got a free 54-page financial survival guide you can download, no cost for residents, fellows, or attending docs. So you can find that through our website as well. Thanks so much for joining us today. We'll see you back here next time.

Outro:                          28:03                This episode of The Prosperous Doc Podcast is over, but you're not alone on your journey. Spaugh Dameron Tenny has been helping physicians and dentists prosper through financial planning for over 60 Years. To connect with us, visit SDTplanning.com today and take your financial wellness to new levels. Join us on the next episode of The Prosperous Doc Podcast.