COMMENTARY

Psychiatrists Consider Emerging From Their 'Zoom Cage'

Drew Ramsey, MD; Sudeepta Varma, MD

Disclosures

July 27, 2021

This transcript has been edited for clarity.

Drew Ramsey, MD: Hello. I'm Dr Drew Ramsey. Welcome back to Medscape.

I have a lot of questions about what's going on today in mental health — my own and that of my patients. So I've invited Dr Sue Varma to join me in a conversation about what we're all experiencing now as we emerge from the pandemic.

You may recognize Dr Varma from her many national media appearances, but she is also an assistant clinical professor at NYU Langone Health and clinical assistant professor at Columbia University. Welcome, Dr Varma.

Sudeepta Varma, MD: Thank you so much, Dr Ramsey. So great to see you again.

The Signs of Burnout

Ramsey: It's really great to see you. You're one of the friends that I would occasionally bump into, and I realized I haven't seen you for over a year and a half now. It made me very nostalgic for earlier collegial times, where we would get together at conferences. That's something we've been missing, but it seems we're going to be returning to it again.

One of the reasons I wanted to talk to you is because I'm wondering, how do I figure out if I'm burned out or not, and what am I supposed to do about it?

Varma: It's a great question. All of us on some level are feeling the weight, because we are dealing with a lot of the same things that our patients are.

This is a really unique period. The last time I remember having an experience like this was maybe 9/11, where everybody was feeling some level of loss, grief, and trauma. We're holding space for our patients and simultaneously dealing with things at home. Both of us have families that were home-schooling. There's a lot going on, and we're wearing a lot of hats.

When we talk about burnout, the key things I look for are exhaustion (physically, mentally); a level of cynicism; irritability; and not really looking forward to the day or feeling that same level of joy, pleasure, and meaning.

That's tricky for us because we're so connected to the work that we do. I've had so many conversations with you, Dr Drew. I know you love what you do and get so much pleasure and joy out of it. So, it's hard for us to deal with these simultaneous feelings of wanting to be there for everybody but also wanting to maintain our own sanity.

Ramsey: So many of us in medicine and in mental health do take such a pleasure from our work. I often found that after an especially scary weekend during the pandemic, getting back into what I've called the "Zoom cage" and seeing patients was orienting. It surprised me how much that really was an essential part of my staying well during the pandemic and continuing on to now.

It certainly is a scary sensation, which I think all clinicians have, if you have one of those days where you're not feeling connected to the work. Having a day or two like that doesn't mean that you're burned out. But how do you start to try and shift that trajectory in your own life and practice?

Reestablishing Boundaries With Our Patients

Varma: There are a lot of clinicians who now exclusively practice telehealth. But what I miss is the face-to-face in-person meeting. There's something about telehealth, whether it's the screen time or sitting in front of that blue light, that has perhaps added to our issues with burnout.

For me, it was important returning to the basics, having some protected time between work and home. One thing that I was finding during the pandemic is that a lot of people really didn't have a separation, not only in their own lives but also with their therapists. They would say, "Well, Dr Varma, it's a pandemic. Where else would you be at 8 PM? Can you see me? Can you see me at 9 PM? Can you see me on a Saturday? On a Sunday?"

I take so much pride in being available. Honestly, I look at my patients in the same way I look at family; they take priority for me. I love what I do. To me, this is a calling. It's not necessarily a profession or a career.

And yet I had to set boundaries. Instead of telling my patients, "Yes, it's a pandemic, and no, I'm not going anywhere," I just say, "I'm sorry. I'm not available at this time, or the weekends really aren't great for me." I needed to do that so I could reboot, recharge, and give them the 150% that I'm used to giving. I had to have that work-life separation to get back to adequate sleep, exposure to daytime sunlight, and taking breaks in between.

It was hard. We may think when we're home that we have all the free time in the world. But we had added responsibility. Maybe we had young kids banging on our door asking how to get their computers working for school. There's a lot happening.

Setting boundaries and practicing self-care became important to me in a way that I don't think I was fully aware of before, when we had natural separation. We went to an office and our day ended when we left that office, in some regards.

Ramsey: That's been a big part of it for me. When I saw patients in person in New York for the first time in a while, I felt this real sense of relaxation. My kids and family were no longer just beyond the sliding door. I certainly have the ability to focus in telehealth, but being back in person provided just a little bit more sense of insulation around the experience and the frame of the work.

Deciding Between In-Person Visits and Telemedicine

Ramsey: At the same time, I've been trying to understand how practicing digital mental health can challenge boundaries and our notion of what we offer and when we offer it. I've heard of so many people coming up with more flexible and creative notions of how they're doing their work.

Are you going to go back to 100% in-person visits or keeping some level of telemedicine? How are you working through that decision?

Varma: It's tricky because I love seeing people in person. And at the same time, both you and I are unique in having professions where we have a lot of creative endeavors, whether that's appearances on television, writing, or speaking. Telehealth gives us the opportunity to really do our work anywhere. I love that, but I also do miss the in-person aspect.

I've decided I'm going to really leave it up to my patients. For a lot of patients, especially younger ones, telemedicine is how they prefer to communicate. And other patients feel like they must see you in person, that there's something very tangible that comes out of this.

Also, a lot of people still aren't working in their offices 5 days a week. I think that's going to be the biggest shift for a lot of them. Many companies have asked their staff to return in some form in the coming months, and they'll leave it up to the individual what that looks like; perhaps it's 1 or 2 days a week. And a lot of people who were working in the city have left or moved to the surrounding areas or even farther away.

So, it'll be interesting to see what happens. I think it's going to be in part driven by patients and also part driven by my own flexibility and the different hats that I wear.

Ramsey: It feels like my entire mental health practice has either bought or sold their house, moved somewhere else, maybe moved in with or away from a parent. It's such a tumultuous time.

Going through this with patients has really created an extra layer to the relationship. It's been very strange for me in the midst of some moves that have perhaps really changed the patients' experience of us. In the past, if you'd move towns or states, that would terminate the relationship. Now, there's more flexibility as patients move and we can continue their clinical care, if that's what you want to do.

It's also strange, as you're going through transitions yourself, in terms of what you disclose to patients. At one point, I had moved my family to Indiana, but I was still seeing patients in New York every week. At first, I was determined to not tell anyone because I didn't want to disrupt the frame with my personal stuff, but then that also felt a little inauthentic and kind of sneaky. It's interesting to contrast then to now, where everything we're doing is digital. If our Zoom cage background changes, then people are curious why.

What are you hearing from other clinicians in terms of how they're contending with adopting a mixed model of in-person and telemedicine?

Varma: I've had a few clinicians who made the decision very early on in the pandemic that they were going to switch to telehealth and make that move permanently. Some of it was driven by other factors, like they had rented an office, perhaps somewhere expensive like New York City, and were looking toward when their lease was ending.

So many different clinicians have had different ideas of going back and employing the hybrid model that we've talked about. Just as patients are having this hybrid of 1 or 2 days a week in person, and some days telehealth, I think clinicians are also doing the same thing.

The Growing Appeal of Group Practices

Varma: I guess the assumption is we're talking about the private practice clinician. However, one change I've noticed is that more group practices are forming, because so many of us are practicing in these silos and we're sort of isolated doing our own thing.

Ramsey: That's been the best part for me. Our group practice has really gotten me through the pandemic. We now have five clinicians meeting weekly and talking about our challenges in terms of either treatments or what's going on in our personal lives that's affecting our work. That has been really critical.

What's really shifted in terms of the digital model is that our clinical team is all over the country and licensed all over the country. We've never had that idea or flexibility.

Before the pandemic, digital health and digital mental health felt a little bit like the bastard stepchild of real in-person health. And I think the jolt of innovation that's happened has forced us to really reconsider, "How do we create a team? How do we create community?"

I miss in-person a lot, but I wonder how much of that comes at a cost of being able to engage more people with other models. That applies to both private practice and also larger medical systems. Consider the challenges of outreach, for example, in access, travel, and commuting. I'm in a community mental health program, and patients would sometimes have to commute 30, 40, 60 minutes. The idea that we can eliminate burdens for some things, but not everything, in mental health and not have it affect our treatment is very exciting to me and to patients.

Casting a Wider Net to Build Stronger Patient-Clinician Relationships

Varma: Absolutely. That gets me thinking about continuity of care, for example with patients traveling for work, consultants assigned to live somewhere else for 2 or 3 months, parents who can't leave home because they don't have childcare, those who are ill, or whatever the case might be. I love the fact that telehealth really allows us so many options there. I know some clinicians who are even seeing patients abroad.

It's so important just to find somebody that you connect with. So often people tell me, "I've been to therapy and had such a bad experience," which reminds me that you need to have a good fit between patient and clinician. And I say, "Keep trying, don't give up, just like you wouldn't if you went on one bad date that didn't work out." If a patient is very motivated and eager, it can form a very important partnership.

We can cast a wider net to find somebody who understands us in terms of cultural background, racial background, whatever it might be. Diversity is moving to the forefront of our conversations in this respect. How do we identify a clinician uniquely qualified to understand what we're going through? I think telehealth also allows us that opportunity.

It's really exciting. As you said, what used to be sort of the bastard stepchild is now a way of achieving these things.

Technologically Assisted Care: Once Taboo, Now Best Practice?

Ramsey: I think we're in a transition. A lot of us miss in-person visits but weren't forced until the pandemic to really understand what that model actually was, to quantify what its costs and benefits were. Now we have some ideas about that.

There's been an explosion of new models, some of which I think wouldn't work for mental health but the data say actually do, such as asynchronous texting. The idea that just sending text messages to patients, even if it's automated, can prevent suicide or improve medication compliance, is exciting. At the same time, that's a very new model, and I'm wondering how it informs my clinical practice.

I think we trained around the same time. At that point, it was a big deal to text with patients. Or if you saw the first resident who gave out their cell phone number, there was almost an audible gasp, like, "Oh no! You missed that note. You can't do that." And now you can text with patients. Even if you have great boundaries, your patients pop up as someone recommended to connect with on LinkedIn, Facebook, or other social media.

I think that's really challenged our notions of how we access patients, what services we can provide them, and what people want in terms of taking care of their mental health. Now there's a demand on mental health and psychiatry to really up-level our game. The competition that is out there, that's delivering better services in terms of people taking care of their mental illness, I think is quite significant. And I think a lot of folks are doing a better job with it.

Varma: It's so important to meet your patients where they're at. We have to evolve as technology evolves and time evolves. I think that's what people want now.

Ramsey: This cell phone I'm holding, this is where I'm at, any time you need me! Let's text! Let's have a call!

Of course, I'm teasing a little bit. But I do have a patient who is starting off as a young physician. We all remember what that's like. Our last session was the week before she was going to be wearing the long coat, and she was really struggling. It was nice to say, "I can see you later this week if you need to." It felt like the right thing clinically to send a text, which took something like 30 seconds, to essentially say, "Hey, I hope you're doing all right." Then I was able to fit the patient in again today because of the flexibility of telehealth.

To me, that feels like a great level of care, whereas it may have used to feel like people not having boundaries.

I appreciate what you said earlier, that part of you avoiding burnout was realizing in wanting to care for everyone, you hadn't set up specific times where Dr Varma was in and Dr Varma wasn't in. I'm wondering, where do you find that balance between being next-level available and having boundaries?

Varma: My default has always been to always be available. Because like I said, this to me is so much more than just a job, especially in the pandemic with sort of being plugged into the 24/7 news cycle.

Ramsey: And I'd like to raise a teacup and cheer all the clinicians out there who are on their own or in a small group, and on 24/7 call. Part of the reason I wanted to get together and talk was to recognize what an incredible weight that has been for all of us holding that space.

Your Doctor's Advice for You and Them: Take a Vacation!

Ramsey: I joked with you before this conversation about not knowing when I'm allowed to take a vacation. So many of you have been out there taking care of your patients, your families, and yourselves. We've been doing that as well, and I wanted to talk about some of the issues that are coming up for us as a result.

We need to find ways of bonding together to make sure that this next year includes, for you and for us, some recovery, some notion of reestablishing and understanding boundaries, and really taking that step back in a way that we used to be able to. And we kind of can't do that because some of us don't have a workplace. We need to really think about how this pandemic changed the workspace.

Varma: What you're also bringing to light is the fact that our patients for the first time are seeing us as people. Before this, you were a clinician — the neutral, objective blank slate. Now you're a human being.

Ramsey: Well, I wrote a sexy cookbook about kale years ago, so I think my patients got a dose of who I am. But I do know what you mean.

There's also so much that we learned about our patients. I met puppies, girlfriends, boyfriends, kids. My patients were like, "Come meet Dr Ramsey!" And suddenly you're seeing this 6- or 7-year-old kid on the screen who you've been hearing about their whole life.

Varma: Going back to what you were asking: How do I take a vacation? We're both on social media, right? So that already is a little bit out of the box, in the sense that there is a three-dimensional aspect that our patients can sometimes see too.

Ramsey: I loved seeing your last vacation on social media! I was living vicariously through you. It was refreshing for me. I was so happy for you.

Varma: Thank you! And it was much needed.

My patients asked me about it. A lot of my patients say, "Dr Varma, you practice what you preach and we appreciate it." Because I always tell them, take vacations. There's a 65-year-old couple that I treat, and the wife basically works 24/7 as a lawyer with her own practice. When I told her, "I'm going to be away," she said, "Good for you. I'm really happy to hear that." She can see that you're taking the same advice you give to her.

Ramsey: I tell patients, "I'm not trying to be harsh, but I think you're bad at this part of really enjoying all the success you've had so that you can have a vacation." People really struggle with that.

It's hard right now. Our kids aren't vaccinated, but we are. As we're planning stuff, there is this excitement. But you do feel that in getting on the plane, the risk is different than it was a year ago, and my kids are still at risk in a way. So, I think that we're all struggling with mixed emotions over what feels safe.

How did you feel being out and about with your family? And for those of us who are thinking about following your good example of taking a vacation, how was it?

Varma: You know, I have to say, it was liberating. I have a mask, and I'm vaccinated. There's risk involved, but it's a calculated risk. It was good weather, and we were outside the whole time. It felt restorative and much needed. At some point, you're going to have to continue living.

The 4 M's and Other Advice

Varma: I wanted to return to the issue of patients and boundaries. One thing that's really key in what you said about texting your patient is this idea of emotional attunement. If you're in tune with your patients, I feel like even when we set boundaries with them, they know, "My doctor sees me. They've got my back. They're thinking about me." I think that boundary doesn't then come off as harsh and punitive. It comes off as being out of respect and love for both parties.

Ramsey: That's a nice concept, which is that we sometimes think of boundaries as walls, and that's maybe not how they really exist. Boundaries are more like hedges. You can always walk through them if you need to find your way, and you want to be mindful if you do. But they are there to signal and demarcate traveling into a different territory or space. But a boundary is not a wall.

I hope that everyone hears your encouragement to take vacation. It's a liberating feeling. And it's one of the ways that all of us can really determine whether we're burning out, getting depressed, or are really affected by the pandemic in a way that we didn't pay attention to because we were holding space for so many people. You can determine that sometimes as quickly as a day or two away. Sometimes if I'm even on a 3-day vacation, I can't believe that it feels like I've been away for a month. To me, that's an indicator that I'm really quickly taking it in like a sponge, rejuvenating, and returning to the state that I know is me feeling well and doing well.

If you're not getting that and you find yourself still grinding and struggling, that's when it's time to double down on the 4 M's that Dr Varma talks about in terms of how to take care of your mental health, or eating some of the brain foods that I recommend via nutritional psychiatry, or using whatever techniques help you.

Varma: Just to quickly say what the 4 M's are, so nobody's left hanging: movement, mastery, meaningful engagement, and mindfulness. These are all things that you can do 10 or 15 minutes a day.

And like Dr Drew said, if you're not feeling well, talk to somebody. We are in this profession and can guide each other and give good referrals.

I did a check-in with a therapist whom I worked with many years ago during residency, when we all had to go to therapy. She's a cognitive-behavioral therapist, which is what I do in my practice. I did one session with her, and it was necessary and very helpful.

Even though I tell everybody about the 4 M's, it was nice for her to ask, "Sue, did you do the body scan meditation?" I'm a big believer in mindfulness-based stress reduction and doing the body scan every day, and I'm a huge fan of Jon Kabat-Zinn's book Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life.

It just took me back to the fact that I need to prioritize myself. And it was that conversation that told me, "OK, this is what I need to do." So don't be afraid to have a check-in with whomever you trust.

Ramsey: Or be like me. I've been in weekly treatment throughout the pandemic. My very lovely senior psychoanalyst was sure he wasn't going to go on to this silly FaceTime thing. And now he's been seeing me religiously by telehealth and is actually not going back to the office.

It could be seeing a therapist or something else entirely. As some of you who see me on social media know, I fell in love with horses, which is how I've taken care of my mental health. Each time, I feel a little more confident on the horse, I think about the way that that mastery is really helping fuel me and helping keep me mentally well.

Sue, thank you so much for joining us and chatting about your practice and your patients, and how you're taking care of yourself and avoiding burnout, as we all transition into this next state of our profession and what mental health looks like it's going to be.

Stay tuned. We'll see you soon.

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