Resilience and Being Thankful

COMMENTARY

A recent survey of 5412 adults conducted by the Centers for Disease Control and Prevention (CDC) found that 40% of people were experiencing mental health problems¹, most notably symptoms of anxiety and depression (approximately 31%). Furthermore, 13% of those surveyed had resorted to alcohol or drug use to cope with mental health symptoms and/or distress associated with the stress of living during the pandemic. In all, almost 11% of respondents had suicidal thoughts in the 30 days preceding the survey (Table 1). While some of these results reflect preexisting mental conditions—9.9% of participants reported preexisting anxiety and depression, and some (4.6%) had preexisting posttraumatic stress disorder (PTSD) symptomatology—the vast majority of individuals reported new onset symptoms (predominantly anxiety and depressive symptoms) in the wake of coronavirus disease 2019 (COVID-19).

Of course, this is hardly surprising. By any measure, the impact of the current—and inexorably ongoing—COVID-19 pandemic on our society has been profound. We have witnessed an extraordinary death toll (estimated at more than 216,025 lives and still climbing as of October 15, 2020) and a recent catastrophic constriction of the United States economy by one-third. The global impact of COVID-19 is even more devastating. We watched in horror as health care systems have collapsed in other nations as well as in the United States under the enormous burden of care posed by COVID-19.

Particularly poignant is the tragic story of Lorna Breen, MD. Breen was a high-functioning individual with a normal premorbid personality and no preexisting mental conditions. She was a valiant emergency room doctor (and alumnus of our medical school), who provided exemplary care in a New York hospital that was deluged with COVID-19.² After working long hours, she contracted COVID-19. Once she recovered, she temporarily returned to work; she later died by suicide. Thus, the specter of mental health problems related to COVID-19 is significant^3,4 and will likely endure well past this pandemic (Table 2).

Even in the middle of the pandemic, however, there are reasons to be grateful. “Gratitude makes sense of our past, brings peace for today, and creates a vision for tomorrow,” according to Melody Beattie, one of America’s self-help authors. How true these words are, and how well they resonate as we consider the human experience of the COVID-19 pandemic. While the death toll is terrible and the current situation globally looks grim as a consequence of this pandemic, there are still silver linings, both personal and professional. Some of these silver linings are highlighted in this article.

Health delivery and impact of COVID-19

The impact of COVID-19 upon US health care has been staggering, with an estimated $300 billion revenue loss and a projected -7% hospital operating margin in the third quarter.⁵ Overall, academic institutions have fared better than community hospitals during this pandemic. Additionally, hospitals that were financially strong heading into this pandemic have weathered this challenging period better than their less fiscally viable counterparts.⁵ At Virginia Commonwealth University Health System (VCUHS), we began the pandemic with an approximately 3.5% operating margin, which declined precipitously after March 2020 when we were then losing $2.5 million daily. Through the magnificent efforts of our health care team and the support of state and federal funding, we concluded this fiscal year with a remarkable 2.3% operating margin. Like others⁶, we have seen the effect of health care disparities in outcomes for COVID-19. We have also witnessed the consequences of delaying care for chronic, non-chronic, and COVID-19 medical conditions and a corresponding increase in mortality.⁷

Mental health has, of course, been challenging during the pandemic. Patients who are acutely disturbed experienced longer stays in the hospital emergency room. Early in the pandemic, this delay was complicated by COVID-19 diagnostic tests, which were needed to help security and clinical staff feel safer (they were naturally anxious about close contact with psychiatric patients who might have COVID-19). We transitioned quickly to using rapid testing for our patients with psychiatric illness. On the ambulatory care side, we experienced declines in outpatient visits until we ramped up our telepsychiatry access. This telehealth approach quickly led to outpatient daily patient volumes that exceeded overall pre-COVID outpatient volume levels. We also heard, as have other health care systems, stories of great personal resilience in recovery from COVID-19.⁸

All that said, we have experienced positive changes in health care. As noted, our use of telehealth has skyrocketed from an average of 80 visits pre-COVID to now about 4000 to 4500 visits per week. Moreover, we have witnessed unprecedented innovations in health care, from the rapid development of COVID-19 testing capabilities all the way through ultraviolet light re-sterilization of protective masks and more.^9,10

Perhaps, however, the most profound revelations have happened on a human level: that is, the demonstration of leadership and the expression of resilience. It is noteworthy that leadership and resilience have appeared during a tragedy, as they have surfaced throughout the ages in response to great calamities.

Reflections on leadership and human resilience

Notwithstanding the widespread effects and health care challenges of the COVID-19 pandemic¹⁰, the following represent my reflections on the potential good that can be taken out of this situation (Table 3).

Good health of our family. I am ever grateful that my family and I have remained healthy thus far during this pandemic. We had a scare when my older brother in Ireland was hospitalized with a heart problem, complicated by suspected COVID-19, at his care facility. All of us know families whose relatives have been affected by this virus. Good health is certainly something for which to be grateful.

Opportunity to work. Unfortunately, layoffs and furloughs have become commonplace during this pandemic. The chance to come to work and serve in health care has been more rewarding than ever. Additionally, service during this pandemic has been in itself gratifying.

Cohesion and individual talents of our multidisciplinary team. As in all health care systems, our team truly pulled together. Team cohesion was necessary to achieve the rapid mobilization of physical capacity, processes and procedures, and human resources that enabled us to mount a full-frontal health care attack on this virus. People put aside other priorities (and even personal differences) to function as a cohesive unit, and we all kept our heads down in preparing our health care system for patients with COVID-19. We have seen a remarkable expression of each individual’s talents, from nursing staff implementing pronation for COVID-19 patients through physicians collaborating with engineers to create novel ventilators. This is the essence of multidisciplinary team care.

The remarkable compassion, professionalism, and resilience of our team members. Throughout this pandemic, we have often heard the phrase, “health care heroes.” Our staff could see those words on billboards as they traveled home exhausted after a long day caring for patients with COVID-19. Our nurses (along with respiratory technicians, radiologists, and others) stood on the frontlines and provided exemplary and compassionate care to sick patients. For this, they were repeatedly and deservedly recognized, especially given that they were at risk of contracting the virus. The resilience shown through long hours and protracted crisis management (most health care crises are short-term) has been remarkable, especially as health care providers grappled with their own familial stresses.

Our innovations and impact as an academic health system. It is said that universities serve as anchor institutions within their communities. During the COVID-19 pandemic, it has been heartening to observe the real value and expertise our institutions have brought to each of their communities.¹⁰ At our institution, like so many others nationally, we have demonstrated our abilities to: conduct clinical research on COVID-19; make COVID-19 testing and successive testing innovations readily available; and provide expert information to other community colleges, universities, and regional businesses (Table 4). We have all witnessed the truth of the phrase “research is hope” as we advance both basic and clinical research to combat this virus. Research at academic institutions is providing knowledge, hope, and real solutions (including an imminent vaccine) to this pandemic^.9,10

Faculty and collective successes during—and in spite of—the coronavirus pandemic. Our research faculty submitted more research grants during May 2020 than in May 2019, even working from home. Our colleagues submitted manuscripts, mentored junior colleagues, supervised theses defenses, and served (virtually) on national organizations. Their perseverance and commitment to our academic mission, even in spite of this pandemic, was inspirational. Also, our health care system, during this pandemic, was named to Becker’s “100 Top Hospitals.”

Advancing the training of our students. The impact of this pandemic on our students has been profound. In March, we all scurried to reduce the human density and risk on our campuses, moving rapidly to online training for students. The resilience and flexibility of our students has been impressive and admirable. During June 2020, we brought about 1700 health sciences students back to campus to continue their clinical training and placements. Our faculty greeted their return to clinical training with joy. It was an affirmation of our fundamental mission: training tomorrow’s health care workforce.

Remarkable support from friends, from our Richmond community, and their (not so) random acts of kindness. In my 30-year career as a psychiatrist and academic health care leader, I have never experienced such an outpouring of support and appreciation for health care providers.

We have received donations, gifts, lunches, and innumerable supportive comments from every corner of our community. This has been an unparalleled and uplifting experience.

Things in life previously taken for granted now take on a unique/special meaning. Undoubtedly, this pandemic serves as a powerful reminder of our need for human contact and connection. As hugs have been replaced by elbow bumps, social distancing has (paradoxically) contributed to a greater appreciation of the joy and importance (well-known to psychiatrists) of socialization. Among the many commonplace activities that we might heretofore have taken for granted, a dinner out with friends is now a special treat! Several people have spoken of greater cohesion among families during this pandemic, with a return to more basic and shared human experiences.

Our personal and professional growth through these life experiences. The preeminent television personality and journalist Tom Brokaw refers, with pride, to “the greatest generation”: those Americans who survived and thrived after World War II. The proposition is that this generation’s exposure to war gave them a greater resilience, which served them and our nation throughout their lives. Our resident physicians have had remarkable clinical and human experiences over the past months. They will be a generation of great doctors, and that in itself is a gift to the future of American health care. Also, we have grown through our personal and professional experiences, likely in ways that will only become apparent over time.

These experiences are neither unique to me nor to my institution. Academic institutions all across America have clearly demonstrated their value to their communities, serving as a foundational resource for their public health state departments. The impact of academic medicine is admirable, and the role of psychiatrists has also been foundational, much as it was in the wake of the September 11, 2001 terrorist attacks. Just like that traumatic experience, we can anticipate continued adverse effects on mental health as a direct consequence of this pandemic. This pandemic will be with us, to some extent or another, for awhile. We will be further challenged and, hopefully, these experiences will further enhance our collective resilience.

In psychiatry, we are ever aware of the richness of human experience and of the transformative power of human resilience. Every day our patients battle the adversities of mental illness. Through their resilience and recovery from mental illness, our patients have much to teach us about the human experience, the joys and sorrows of life, and the potential for personal growth, even in the worst circumstances. Undoubtedly, we will ultimately prevail over COVID-19 and, in doing so, we will each strengthen our own human resolve, as well as our collective resilience.

For all of that, we can be grateful.

Dr Buckley currently serves as dean of Virginia Commonwealth University (VCU) School of Medicine and executive vice president for Medical Affairs at VCU Health System. He has also served as interim senior vice president for Health Sciences at Virginia Commonwealth University (VCU) and interim CEO of VCU Health System. Dr Buckley also serves on the Psychiatric Times^TM editorial board. The personal reflections herein represent his experiences while serving in these dual roles—and as a psychiatrist—during this pandemic.

References

1. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69
(32):1049-1057.

2. Knoll C, Watkins A, Rothfeld M. ‘I couldn’t do anything’: the virus and an E.R. Doctor’s suicide. The New York Times. July 14, 2020. Accessed October 8, 2020. https://www.nytimes.com/2020/07/11/nyregion/lorna-breen-suicide-coronavirus.html​

3. Moreno C, Wykes T, Galderisi S, et al. How mental health care should change as a consequence of the COVID-19 pandemic. Lancet Psychiatry. 2020;7(9):
813-824.

4. Chandran S, Kuppili PP. Necessity is often the mother of innovation: lessons from coronavirus pandemic. Psychiatric Times. June 3, 2020. Accessed October 20, 2020. https://www.psychiatrictimes.com/view/necessity-often-mother-innovation-lessons-psychiatry-covid-19​

5. Hall, K. The effect of COVID-19 on hospital financial health. Accessed 8/20/20 at Kaufmanhall.com. https://www.kaufmanhall.com/ideas-resources/research-report/effect-covid-19-hospital-financial-health​

6. Berkowitz SA, Cené CW, Chatterjee A. Covid-19 and Health Equity - Time to Think Big [published online ahead of print, 2020 Jul 22]. N Engl J Med. 2020;10.1056/NEJMp2021209.

7. Woolf SH, Chapman DA, Sabo RT, Weinberger DM, Hill L. Excess Deaths From COVID-19 and Other Causes, March-April 2020 [published online ahead of print, 2020 Jul 1]. JAMA. 2020;324(5):510-513.

8. Curran C. Family of first Westminster Canterbury resident to test positive for COVID-19 tell their harrowing story. Richmond Times-Dispatch. March 31, 2020

9. Castaneda R. Doctor MacGyvers Way to Disinfect N95 Masks. U.S. News & World Report. May 29, 2020

10. Pascarella G, Strumia A, Piliego C, et al. COVID-19 diagnosis and management: a comprehensive review. J Intern Med. 2020;288(2):192-206.❒