Episode 49 of the Hope4Med podcast features Dr. Arlene Chung. Dr. Chung is the program director for Maimonides Medical Center Emergency Residency program in Brooklyn, New York. She is also a former chair of the ACEP Wellbeing Committee and recognized as one of the original EMRA 45 under 45 young physician influencers in emergency medicine. Dr. Chung talks about the importance of focusing on wellness for the future of healthcare and providing residents with the right tools to prioritize their wellbeing and reflect on complex emotions. We distinguish moral injury vs. burnout and discuss how we can change the culture in healthcare for the future generation of healthcare providers.

Transcript:

[00:00:00] Dr. JB: Welcome to Hope4Med.

[00:00:03] Hi everyone. Welcome back to the Hope4Med podcast. I am your host, Dr. JB, and today’s guest is Dr. Arlene Chung. Dr. Chung is the program director for Maimonides Medical Center Emergency Residency program in Brooklyn, New York. She is also a past chair of the ACEP Wellbeing Committee and recognized as one of the original 45 under 45 young physician influencers in emergency medicine. Welcome to the show, Dr. Chung.

[00:00:33] Dr. Chung: Thank you, thanks so much for having me. Good morning, this is so exciting.

[00:00:37] Dr. JB: Yeah! And you have a very impressive resume. And so I’m really excited to learn about your story and how you got to where you are. So please start from the beginning, share your origin story.

[00:00:48] Dr. Chung: Oh, goodness. It is always sort of interesting when you see it on paper like that, because it doesn’t seem all that remarkable, like living the life, right? I joke around that I had a very boring like pathway to medicine, so I’m a residency director in my day job and we actually just finished our interview season, so I got to meet like some 260, some amazing individuals and all of their journeys to get to emergency medicine. And I don’t know, I like, I just feel like for me, it’s like I did, I was like pre-med in undergrad, and then went to med school, and then I loved emergency medicine so I did a residency, and I feel like in some ways, I’ve had a very traditional sort of academic career. I did my med school at NYU. I ended up doing residency training for four years at Brown, and then I did a Medical Education fellowship at Maimonides. So that’s actually the first time I came to Maimonides, got my master’s in medical education, and then I was very much obviously interested in sort of education as a career, and so I took an assistant program director position at Mount Sinai, and then I became the program director here at Maimonides in 2018. So, that’s where I’m now in my day job.

[00:01:45] I had an interesting conversation, so I worked clinically yesterday, and I was working with a PA student and we were sort of chatting about, I was like, oh, are you interested in emergency medicine? And she’s like, I’m not sure. And I was sort of explaining to her, she’s like, oh, why did you pick it? And so, my dad was an emergency physician before he retired. And it’s sort of interesting, I saw it from that perspective growing up and so a lot of the things that I think sort of for some people, like the odd hours and the nights and the weekends, for me that was normal. And then when I got to med school, I loved the clinical diagnostic aspect and just this idea that you really can take care of anything anywhere, anytime. And I suppose the rest is history. So here I am.

[00:02:32] Dr. JB: Yeah. I mean, that’s very amazing because you came into emergency medicine with a good background in terms of knowing what exactly it is that you’re going to get into, through seeing your dad and his experiences.

[00:02:45] And it’s so true that emergency medicine, there’s such a wide array of possibilities. No two days are ever the same. And so, in terms of your interest in education, tell me what’s what has it been like being the program director?

[00:03:00] Dr. Chung: Well, so I became the program director in 2018 and then just as I was like getting settled into the job, it’s like, oh, wow enormous global pandemic that just like struck the world that obviously just completely shook the entire everything, everything, not just the healthcare system and education, but so navigating that– and now we’re kind of in this, I don’t even want to call it like post-COVID world where like, in this, you know, still COVID, but just different COVID in terms of like education and training and it is fascinating.

[00:03:31] Like I talked to, I talked, so, so for example, like– But, my father, when he was going through school, he never learned about HIV or AIDs, right? Because that was prior to all that knowledge. And so, for me, going through med school so many years later being like it was, like, how did you not know about this? or How did you not like learn about it in school? Now these trainees going through it are going to be like, how did you not learn about COVID in medical school? It’s going to be that same sort of process years from now, but it’s been a very– to answer your question, it’s been a very interesting journey, but nobody was prepared for it, right? It’s all kind of learning it as you go.

[00:04:06] Dr. JB: And so, when we think about wellness amongst residents, how has that been in terms of navigating this COVID pandemic with them, especially you had just started and now you are guiding the ship of residents through this COVID storm.

[00:04:23] Dr. Chung: I mean, I wish I could speak with a little bit more knowledge with sort of training in other specialties, nursing and dental, sort of all of the other, sort of, healthcare professions. But I really only, I can speak to the through medical training aspect and being a resident. And again, I don’t know if it applies in sort of other healthcare arenas, but being a resident is such a unique, it’s such a unique part of your training and that you’re not a student, right? You’re not a student, you’re actually a physician taking care of patients, you have ownership, can prescribe, you can treat, you can do procedures, but you’re not an attending, right?

[00:04:55] You’re not a fully independent practicing autonomous physician. And so, for a resident during the COVID pandemic, when we were sort of like, you know, the students were very obvious. It’s like the students, this is their education, we need to protect them. They do not need to be in a clinical arena. And a lot of them worked, were taken sort of out of the hospitals and moved to virtual learning. The attendings, it was very clear, like we need doctors, we need people to like do patient care, but like the residents, because on the one hand, you want to protect them because they are learning and they are training and you owe them that for that education. But they are also doctors in a global pandemic when you need people, right?

[00:05:33] You need people and emergency medicine is a particularly helpful skillset in that regard. That balance was very challenging. A very concrete example came up around sort of intubations. So this was very early on and was like March, April of the pandemic. And it wasn’t just our program, this was sort of everywhere where people were very concerned about aerosolization during intubations and how do you navigate this for the residents in terms of balancing their safety and their education? And I think ultimately, every program and every hospital settled on slightly, some slight variation of what they deemed was the most appropriate for their trainees and for their patient population. But I mean, like I said, being a resident is super challenging and a lot of this stuff, none of us had to navigate, certainly when I was learning how to be an educator, like I didn’t learn, there’s no manual like what do you do in a global pandemic? And how do you balance the safety of your training, is like we all kind of learned it as we went. So I don’t know. I don’t know if I have any answers for you, but certainly it was a very, it’s a challenging group, being a resident being a resident is tough.

[00:06:36] Dr. JB: That’s right. So being resident is tough at baseline, when you add on this unknown, right? This invisible enemy that we’re battling and, and I could just imagine walking into a patient’s room and seeing that they’re hypoxic. Alrighty, as a resident and being like away, what do I do? What do I do? So, yeah, that’s definitely something that was new for all of us. Even the attendings I’m sure. And then also, dealing with your own mortality and seeing others getting sick. So how was that for this resident?

[00:07:07] Dr. Chung: I mean, there’s this whole, it’s like such a multi, it’s still like a multi-layered issue. There’s this concept of moral injury that I think, before the pandemic, people were talking about moral injury, some and actually the term first, it actually, the term the has been around for a while. I think people first started using it around the Vietnam war. But it started becoming more popularized in the healthcare space a little bit before the pandemic, but then really sort of during the height of the pandemic, when really we were seeing people who are hypoxic to the thirties. We didn’t know what, you know, we had no treatments, we didn’t know, right? We didn’t have enough resources. And this idea that like you are either participating or you are witnessing or you are somehow contributing to some act that is against your moral values or your own compass, you know, your own internal value system, I think that plays a lot into, I think a lot of the emotional fallout we’re going to see now that things have kind of settled out like, oh my goodness. Like, the things that I did back then where there’s actually harming people, I think there were a lot of those questions then, again, like you said, there were a lot of young people coming in. A lot of young people with no comorbidities and that line between patient and provider grew very thin. And I think you have to sort of survive in this job. You have to have some distance, you know, don’t have too much distance, ‘cause then you just like have no compassion, but you know, if you’re so wrapped up in every single emotional life of every patient, you see every shift, it’s a lot of emotional lives to go through and it’s 12-hour period. And that gap grew very thin, I think, particularly as of March, April, May of ‘20.

[00:08:39] Dr. JB: Yes, but we do hear a lot about that term moral injury. You know what? I would love for you to elaborate a little bit more on that, in terms of your perspective of how this COVID pandemic is playing into this whole moral injury concept. So could you elaborate a little bit more about that and what do you mean by that?

[00:08:59] Dr. Chung: Yeah. It’s, medicine is such an odd career. I don’t know how many of your listeners are actually like maybe not in healthcare, sort of maybe healthcare-curious about what it might be like but it’s, becoming a physician, this is a very sort of unique cultural experience. So I teach I, I now teach first year medical students. So they’ve only been in school for like a couple of months now and quite refreshing, these men and women, but it reminds me that there are things that you learn from like your first day of medical school where it’s like this idea that we can diagnose, we can treat, we can fix people, right? And that’s embedded, not just in becoming a physician, that’s sort of embedded in this cultural idea that we have in America where it’s like, there’s a pill for everything. Or like there’s a, you know, we’re, we’re very much it’s sort of like fixing stuff like that. Like a magic bullet.

[00:09:47] And I think, you sort of become indoctrinated in that idea and then you get to something like the COVID pandemic where you don’t know. And then all of a sudden you’re like, I can’t treat, like I can’t fix, I can’t do the thing that has become intrinsic to my, you know, I’ve sort of adopted this professional identity of what it means to be a physician and I can’t do this. I think that contributes a lot of this idea of moral injury, where like you are not able, you’re either not able to do the thing that you know is right or you are actively contributing to something that you are concerned might be wrong. And I think that this idea of what it becomes, what it is to be a doctor, has sort of played into the pandemic with all of its unknowns and uncertainties.

[00:10:27] I do think in some ways it’s good that we had sort of become accustomed to this term before the pandemic. I mean, I think one of the reasons people really embraced it was that idea of burnout really in some ways put the onus, it sort of made people think like, oh, it’s the individual’s problem versus moral injury where it was this idea you are a player in a larger context, and so it’s not just like, oh, you need to fix your burnout. So I think in some ways that was good and it was a better way to think about it and certainly is much more applicable to what was happening before we had any treatments and before we really had any idea what was going on.

[00:11:00] Dr. JB: Do you feel like people are still experiencing moral injury now that we do have treatments and vaccines and things?

[00:11:06] Dr. Chung: It’s obviously different for different people, I would think that we are probably moving into like a slightly different emotional stage collectively in the health care force. I mean, I think the challenges are different now, so it’s less sort of medical uncertainty, you know, we haven’t– the PPE supply chain has come forward. Like, again, we have, it’s available, we have like monoclonal antibodies. We have an oral treatment now. Right? We have some of that stuff, then hopefully we have vaccines. But I think now some of those more, I guess, traditional burnout factors are coming to the force where, you know, burnout, I like to think about burnout as a mismatch between supply and demand. This idea that we don’t have the enough resources, whatever resources, time, energy, staffing, mechanical equipment, like whatever to do the job that we, to do a good job, to do the job that we really want to do. And that creates burnout. And I think now sort of two years, two plus years into it, we’re shifting back to that more traditional systems-based problem with healthcare systems burnout.

[00:12:08] Dr. JB: And so, in terms of like the wellbeing of your residents, how do you approach that? And what are some resources that you provide your residents to help with their wellbeing?

[00:12:18] Dr. Chung: Well, as I know wellness is a, it’s a very hard topic because it’s so different for everyone, it’d be so nice if we could just like, oh, everyone gets like a gift card to a spa. And then that like fixes everybody’s problem. Right? Unfortunately it’s just not, I mean, you know this, right? And I’m sure many of the people you’ve had on the podcast have spoken about how it’s so, it’s challenging because it’s so unique for every industry. The way that I philosophically try to approach it is that I think, I think one of the big– and this is sort of aside from the pandemic, this is just in general–I think one of the big contributors to burnout in residency is it’s not actually like lack of time. It’s not actually lack of sleep or even lack of money. And some people who are listening to this are just going to be like, what are you talking about? Well, I don’t actually think that those are necessarily the root cause, I think the root cause is a lack of autonomy. And then a lack of autonomy, like a lack of being able to have a say in what you do with your time, how you spend your money, right? Like, so, so I think the money, time, shift schedule, all of that comes as a natural extension from this idea of lack of autonomy.

[00:13:20] And I think that really is tough for a lot of people, just not having a say. And there’s some research out there that says like, it’s actually not the absolute number of hours you work. It’s this idea of having some control and flexibility over your schedule. And that’s not just in the healthcare literature that’s, regardless of what job you have. Again, in this time period when we didn’t have a lot, like I told the residents, it’s like, we are not going to send you into the ED wearing bandanas, like, I couldn’t create masks from nowhere. This time we didn’t have answers. And I think the biggest thing that we tried to give our residents was whatever amount of knowledge that we had and like transparency and communication so that they at least knew what we knew and then could make decisions accordingly and have some agency and some say in what they wanted. I think the important message that we sent for, again, all those months was that nothing was certain.

[00:14:11] Everything was changing every day, right? I would send out these sort of like daily updates that literally, they were like, I think it became like sort of nightly reading for some of their residents, but it was like– and just reinforcing this idea that like literally day by day, hour by hour, everything is changing. So we never developed like, I sort of hesitate to say, like we had a policy in place cause that sort of goes through multiple revisions, but I think fundamentally, what we tried to do was respect the autonomy of our residents while giving them all of the information that we had so that they could make an informed choice. So, and that included potential risks, potential benefits, ways that we could protect them, and ways that we could really protect their education, too. Because I think that is also really important. And that came into play a little bit later after the peak, but like with our patients, you want to give them, this idea of like autonomy of patients. We actually, I used to talk about this with my students, right? Patient autonomy. It’s the same concept where you want to give people all of the information that they need to make an informed decision that is right for them.

[00:15:08] Dr. JB: Yeah. I mean, I think I fully understand that, because there are so many unknowns and like I said, so many things were changing so rapidly, right? And of course our training is, hey, if you’re hypoxic, you’re in the sixties, you’re getting to, you’re getting intubated right away. And so there was a lot of innovations that were happening and then the more research came out, more we realized, well, maybe this isn’t necessarily the optimal treatment and, and it’s just amazing how quickly medicine changes. Because before this pandemic, it took so long for policies and procedures to change or anything to change in medicine, and to see that actually it’s possible to change pretty rapidly.

[00:15:47] Dr. Chung: Right. In response to the situation as needed. I mean, I think, I think there’s, I mean, there’s some bureaucracy obviously, but I think there’s also benefit in making sure the research is solid and all of those processes worked in a non-COVID time and we were not under any kind of time pressures. And then obviously we saw that when we needed answers, like immediately that system obviously was not adequate to meet the demands.

[00:16:08] Dr. JB: Yup. Yup. So, along those lines, What do you think, or when we think about training the future of healthcare and our healthcare professionals, what policies and procedures do you think could be put in place to really address their mental and wellness states?

[00:16:28] Dr. Chung: I mean, I think you have to give people tools, wellness is, you can’t sort of prescribe the end product because you don’t know what it is that people are going to need. And everyone’s going to come to this job with their own sort of unique experiences. But I think you give people different tools that they can use to navigate for it.

[00:16:42] I do think the schools are doing a better job now of sort of introducing like medical ethics and sort of this idea of professional identity formation, and even just, it’s something as basic as being able to reflect on what it is that you’re going through. I think schools are doing a better job at that, and there’s certainly a much more, there is certainly a much bigger push towards like a holistic sort of application process so that we bring in people who are maybe slightly more predisposed to be a little bit more reflective and a little bit more sort of in tune with what’s going on with their internal self.

[00:17:11] That can be like a very useful skill because even you don’t know what’s going to come up, right? And so the ability to at least evaluate like, ooh, this thing happened, how is that impacting me? And then how can I respond in like a good way? And having that ability to do so, but like again, sort of, you foster sort of this idea that it’s there’s tools that you can give.

[00:17:28] And then there’s sort of like normalization on top of that. And I, and again, I think we’re doing a better job of saying– We’re talking, you and I are here talking about this, like this probably wouldn’t have happened, however many years ago. And the fact that, in schools and residencies, people are talking about burnout and depression and like physician suicide and all these things that people are actually now, speaking about can be helpful from a normalization perspective. So I think in general, we’re doing a much better job. Takes a while for us to see it because for these students and these residents to then go out and practice and then become attendings, and then as attended kind of influence the generations that come after them.

[00:18:05] Dr. JB: So in the emergency room, so things move so quickly, and at what point do these residents have time to really process and reflect on what they’ve experienced?

[00:18:17] Dr. Chung: That’s a great that’s a great comment to bring up. And there are, I mean, quite frankly, some of it depends on where you practice, right? But most of the time, whenever there’s a critical event, usually there, there is very little space and certainly not enough space to deal with that emotional sort of all those feelings in the moment. Some places, so our shop included at Maimonides, but another, multiple other institutions that do this have instituted formal debriefing processes. That can be very helpful. So there, you know, some of them are triggered by certain events, so like a death, trauma or like, there’s certain very standard events that will trigger this. And other times it can be anyone who sort of provided in the case that feels like they need debriefing. Other times it’s just every standard recess patient or critical patient, but there’s this idea of a hot debriefing, a warm debriefing, and a cold debriefing.

[00:18:59] And depending on the time, the situation, I think there’s a role for all of them, right? So a hot debriefing being sort of immediately afterwards in the moment, you’re right there and it just happened. And then a warm debriefing might be that day, but like a little bit later. And then a cold debriefing, sometime much later. And I think there’s, it’s not like you would do one in the absence of the others. And I think there is some role for sort of processing in the moment, but then, also giving some time to reflect later. But I think the important part is recognizing that, as you said, there, there are really emotionally challenging things that happen in the emergency department, everywhere, everywhere in the hospital, and it’s important to give space to that. And I think, like I said, some institutions are doing great in terms of formal debriefing programs. I think other places there’s some room to grow. But I think I know there’s been a, there’s been a greater trend towards recognizing this is really important, right? We have to take care of the providers if we need to in order to take really great care of our patients.

[00:19:52] Dr. JB: And it first starts with addressing the issues and having these conversations like we’re having, right? And really making, emphasizing that there’s nothing wrong with not feeling like you’re okay, right? When you talk about mental health and depression, anxiety, and PTSD, and all of those things are sometimes, actually almost expected, emotional responses to certain events that you encounter in your day to day.

[00:20:22] And that there’s nothing wrong with you for feeling the way that you do, but knowing that there’s resources available to help you process is extremely important. And to let you know that you’re not at all alone. And so these conversations that we have on this podcast really highlight the fact that you are not alone and that we’re all in this together, really just trying to do what’s best for us or each other and our patients,

[00:20:46] Dr. Chung: You know, There’s this idea of the hidden curriculum. So I’m an educator, right? So there’s this idea of the there are three kinds of curriculum that that we encounter. So there’s the formal, which are like textbooks and lectures. And then the informal is all the sort of bedside teaching. And then the hidden curriculum is everything else, right? It’s like essentially, it’s culture. It’s like how we learn how to speak and act and dress. And like all the things that people like, we just learned through osmosis about becoming a doctor, or becoming whatever profession, but no one actually sat down and told you that, like, whatever, it’s okay to wear like a scrub top and cargo pants, ‘cause that’s what we do, right? I mean, there’s no other doctors who do that, but emergency physicians, stuff like that. But I do think one of the really powerful lessons that is taught through the hidden curriculum is this idea that as a doctor, you don’t show weakness, right?

[00:21:32] You don’t show weakness and no one, no one, we don’t sit down and tell our students this, but they– I think still again, we’re trying to fix that, you know, through this podcast and through mechanisms like it, but I think that message is still being taught implicitly in schools. And that’s what makes it so hard, I think, to come forward later on in your career to say I’m sad or, I’m, Like I’m grieving or like, any of these sort of like unacceptable, like weaker emotions. I think it’s very hard to admit that because somewhere along the line we’ve learned that, oh, we’re not supposed to show weakness. So if we show weakness, maybe we don’t actually deserve to be a doctor at some level. There’s that cognitive process that’s going on.

[00:22:12] Dr. JB: And then the other people are going to perceive us differently, right? When we show that, oh, we’re human, like, are we not supposed to be human beings as physicians. Is that, is there a class that kind of says, now that you’ve received your medical degree, that your humanism and your human emotions now have to be put aside and you are officially a doctor? Is there a class that, that talks about that?

[00:22:38] Dr. Chung: Well, there’s certainly not, it’s not a labeled class, but I think it is unfortunately this one of those lessons that it’s going to take generations to fix. And my hope is that the group that’s going through now that is really benefiting from all these conversations that like you and I are having will then eventually years later grow and become the educators sort of the group to follow.

[00:22:59] Dr. JB: No, that’s so true. And, and so many people have been so receptive to these conversations and, some people say, oh, it’s because of COVID and that these issues that we’re talking about right now is a result of COVID. What are your thoughts about that?

[00:23:14] Dr. Chung: Well, we were talking about this ages ago, like actually people were talking about burnout, like I don’t know, like decades and decades ago, it just never really got some traction.

[00:23:24] I will say like actually in the five years before the pandemic, so like maybe 2014 to like 2020 really did get some traction, and that’s reflected in things like the ACGME, for example, which is the big accreditation body for residency programs in this country, you know, modified it’s common program requirements to actually explicitly include requirements for every residency program across all the specialties. So it doesn’t matter if it’s emergency medicine, but like all of the other specialties as well to include dedicated training and support for well-being for their residents and faculty, right? So that reflected like kind of a larger sea change that was happening in medicine, actually even the predates the pandemic. And it’s good that actually, we were having some of those conversations before, as we have out there now, even more important.

[00:24:10] Dr. JB: And so, do you have any words of wisdom for your colleagues, for the residents in terms of wellbeing and wellness?

[00:24:21] Dr. Chung: Just like forgive yourself. I think most of us are very hard on ourselves and there’s a lot of sort of meta thinking that makes things even worse. A lot of self-flagellation that goes on that is an extra layer on top of the already difficult emotions. But just recognizing again, like you said, it’s okay to feel the entire spectrum of emotions because you’re a human being, right? No shame in that. And I think, you know, there’s a, I read a lot of Renee Brown and she does a lot, she’s a psychologist, she’s an author, so teaches, lectures, and she does a lot of work on shame and vulnerability. And, one of the things she says is that fear and courage are not mutually exclusive. In fact, we often feel the most brave when we’re the most afraid, right? And so, it’s not like, just because you feel something like sadness or like shame or guilt doesn’t mean that you’re a bad doctor, right? It, in fact, it might make you an even more compassionate physician than you think.

[00:25:15] Dr. JB: Yeah. Who says a doc can’t rap? D O C T O R J B. The greatest doctor to ever touch the mic. The greatest podcast ever broadcasted or prerecorded. Come learn some, each one, teach one. I’m done.