Anger displacement during Social Isolation

-“Doctor…when I arrive home, I can’t help lashing out at the kids—feel so guilty.”

Verschiebung. This German term can be translated as “Shift” or “move.” It was used by Sigmund Freud to describe a particular psychological defense mechanism; it entails the shifting or displacement of an aggressive and potentially dangerous emotion from an important person or object into other ones that are less relevant and often lame. [i] Our patient had many situations of emotional frustration in her blue- collar job with her despotic boss and his unreasonable demands at work but she hid her anger towards him and the system, fearful of losing her job in tough  times. On many occasions, she scolded her children a little bit too much for not completing their homework or for just some obnoxious but inconsequential pranks.

This unconscious defense mechanism is an expression of what Freud had dubbed as the mortido—our basic aggressive drive. There are three basic mechanisms:

  1. Displacement of object
  2. Displacement of attribution
  3. Bodily displacements

A – Displacement of object

Some acrid emotions are displaced from one person into another one. Our patient’s anger toward her boss—who has authority and power to decide on her economic survival—had indeed been transferred into her  children—who are totally innocent and incapable of posing a threat to her as they are dependent on her. This situation will sadly become much more common in our modern societies because the SARS-CoV-2 pandemic has furloughed millions of workers worldwide and many of them will not be able to return to their old jobs due to inevitable closure of businesses. In the much more genteel days of Freud’s practice in nineteenth century Vienna, he put the example of children’s animal phobias; in order “to sanitize” their fears towards their parents, some children develop aversion to certain animals: dogs, cats, spiders.

B – Displacement of attribution

A personality trait that we might see in ourselves but that we consider as socially unacceptable or even reprehensible will be transferred to another person or entity. The typical example is a closeted homosexual who engages in continuous joking about gays or other LGBTQ individuals to perform a psychological projection. We can also find extreme examples in History like the horrific persecution of gays in Nazi Germany conducted by Ernst Röhm, co-founder with Adolf Hitler of the Sturmabteilung (SA); he was a barely disguised homosexual that was executed in the middle of an orgy by the German Army—fearful that his formations were gaining too much strength in the street—during the Night of the Long Knives in 1934. [ii]

C – Bodily Displacements

It consists of the attribution of a sensation experienced by one part of the body to another distant one; one of the commonest instances is when an oral sensation “is experienced” as coming from the vagina. John Cleland wrote a book in 1748 titled Fanny Hill or Memoirs of a Woman of Pleasure [iii]where he used funny euphemisms in order to refer to body parts that were not openly mentioned in prudish Albion; he dubbed the vagina as the nethermouth. He was a rebellious writer and some sources claimed that he finished it when he was serving a prison sentence for a bad debt. He printed it in two installments in November 1748 and February 1749; he was released from prison in March 1748 (he graduated from the University of Life…I like him)

“I picked two fights at work. One with a customer and one in a Slack [iv] queue with my colleagues, and I regret both terribly. They are possibly the first two fights I have ever instigated in my life. Wish I could have hashtagged those. #furstfightbearwithme.”

Ms. Chrissie, a lovely, clever, funny fellow writer and blogger [v], honestly shared her unfortunate event in a recent blog, which triggered this reaction from yours truly:

“The little anger that you inadvertently vented against two individuals is part of the humongous one building up in the street. It happened to almost all of us lately.

Unfortunately as we slowly come out of our forced Social Distancing and we interact more with our fellow human beings, we will discover that not only they, but us as well, are displaying a shorter fuse and we might snap at the slightest incident. We might be able to contain ourselves outside our homes, with an occasional “mea culpa” if we allow our emotions to get the best of ourselves in the survival frenzy.  What we have to keep clearly in mind that we cannot—absolutely cannot—bring that heightened state of alertness and potential aggressiveness to our dear families. Maybe we should go back to the old ways from our ancestors to vent off that stress.

Get the punching bag from the attic. Paste the image of your boss right up. 

Go. And do not pull any punches. Sweet.

(This article was based on our upcoming new book Emotional Frustration- the hushed plague)

References

[i] Sigmund Freud, New Introductory letters on Psychoanalysis, George Allen and Unwin, London, January 1940,

[ii] https://en.wikipedia.org/wiki/Ernst-Rohm.

[iii] John Cleland, Fanny Hill, Gray Rabbit Publishing, London, 2018.

[iv] Chrissie described this tool as a fast-paced messenger service that is commonly used in certain offices. https://slack.com/

[v]  https://chrissie.blog/2020/05/13/are-you-okay/

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Cherchez le fric

You cannot expect most mortals to excel in the über-byzantine ways of Modern Politics.

Except for the Brits. The inhabitants of a little island managed to rule the planet with wits.

Their top diplomats used few words adorned with plenty of elegantly suggested threats.

Why did the British born and raised CEO of Sanofi open his mouth a little bit too much?

In an interview with Bloomberg News on May 13, 2020, CEO Paul Hudson said: “The U.S. government has the right to the largest pre-order because it’s invested in taking the risk…(the U.S. expects) that if we’ve helped you manufacture the doses at risk, we expect to get the doses first.” The American government had expanded a public—private partnership by injecting U$ 400 to develop a safe vaccine faster; the company has a vaccine development facility in Waltham, Massachusetts.

The not-so-subtle words of someone that should know better than ruffling the already-excessively-ruffled feathers of the public servants assailed by the clamor of their constituents to bring a vaccine to the market that will deliver us all from this ordeal, landed as a cluster bomb in the elegantly baroque hallways of the French government. Président François Macron expressed outrage at that statement and countered that a good vaccine should benefit all Mankind and should not be sold in a private market.

We watched in Le Journal of France 2—the most popular news program in France—on May 14, 2020, as Serge Weinberg, President of Sanofis-Aventis, made a special appearance to calm the public uproar that his subaltern had maladroitly produced a day earlier. He said: “there will be no particular advance given to any country.” He explained that his company has a small vaccine facility in Waltham but a much larger one near Lyon. They are making arrangements already to produce the vaccine in those two facilities plus several other ones to meet demand in other parts of the planet.

In a Washington Post article, Christopher Rowland, Carolyn Y. Johnson and William Yan said: “Johnson & Johnson’s race to manufacture a billion doses of coronavirus vaccine is ramping up in a small biotechnology plant near Interstate 95 in Baltimore. But even as technicians prepare to lower 1,000-liter plastic bags of ingredients into steel tanks for brewing the first batches of experimental vaccine, international concern is bubbling about what countries will get the first inoculations.” That Baltimore facility is the first one of four company planned ones as the production of a vaccine for the whole of Mankind will take an unprecedented manufacturing effort.

Designing and manufacturing a reliable, safe vaccine for the SARS-CoV-2 virus is a task of biblical proportions with no margin of safety errors for three major reasons:

a) It’s a novel virus that produces multiple effects in various body systems, for which scientists and physicians are still learning “sur le champ” in a paranoid environment.

b) Pharmaceutical companies are developing new biotechnology techniques that had not been tested before and demand caution as there is hardly any long-term safety data.

c) Unlike other pharma products that are eventually consumed by sick people, an approved vaccine(s) will be given to millions of healthy people all over the planet.

Herd Immunity is the indirect immunological protection that is afforded to an entire population by the presence of a sufficient number of immunized individuals in their midst—after they had been infected; this has occurred for measles, mumps, polio and chickenpox due to the massive vaccination campaigns promoted by authorities. As long as the number of immune individuals does not go below a certain threshold, the whole population is safe. If there is a community with lower coverage—like it happened with measles in Disneyland in 2019—there might be an outbreak. Some viruses like the Flu mutate frequently and its immunity only lasts a few months, requiring almost yearly updates. So far, the SARS-CoV-2 virus has not shown that propensity to change frequently, which would extend immunity to several months or years. However, we still do not know much about it and we should be prudent.

There are two ways to develop the Herd Immunity: option A and Option B.

Option A

If we do not enact Physical Distancing and Social Isolation measures, the virus will infect millions of people in just a few months; experts agree that at least 70% of the population must be immunized in order to get the necessary Herd Immunity. This is the approach taken by Sweden, which has not put up any radical measures. We must consider that it is a small country of only a few million people, living apart both from a physical and social standpoint. Have you seen Swedes holding hands in the street? This approach can overwhelm the care facilities and exhaust the available material needed to take care of a surge of critically ill patients in the large urban centers.

Option B

If we do enact those drastic Public Health measures, the incidence of new infections will slow down, which will not overwhelm the already existing facilities and allow authorities to increase their resources, both human and material; this is what is commonly referred as “flattening of the infection curve.” New cases will rise slowly, then plateau over a period of weeks or months before finally coming down. This is the approach that has been taken by most countries in the world at the present time.

For both societal alternatives, the arrival of one (or 2,3) useful and safe vaccines will accelerate dramatically the attainment of a protective immunity shield for all people. That is precisely why many governments (especially if they have vaccine producing facilities in their territory) are fighting a sordid war of words and elbows to be in the pole position once the  frantic race for massive vaccination starts in the near future.

Development of an effective and safe vaccine for millions of people is usually a process that takes many years, even decades. The design of one ( or maybe two or three) vaccines for the SARS-CoV-2 virus is being fast-tracked by several teams around the planet, sometimes carrying out animal experiments and the initial phase of clinical trials at the same time. There are at least four major techniques to achieve that feat in record time:

a) Use of harmless viruses to deliver their genetic material inside the cells so they can form proteins, which will eventually alert the immune system to produce antibodies.

b) Use of killed or inactivated fragments of the virus to engage the immune system.

c) Use of a novel technique of viral messenger RNA in order to stimulate the human cells to produce the viral proteins that will trigger a response.

d) Use of viral DNA to produce the same effect as the above-mentioned technique.

The use of viral DNA or DNA is a completely new scientific approach and there is not any industrial experience about how to manufacture that kind of vaccine in a large scale; if we consider that in order to reach complete immunity, humans might need two doses of the vaccine, we are facing the real need of producing billions of doses on short order. Experts believe that eventually there will be more than one candidate, which will facilitate the tackling of this colossal production of good vaccines in a few months.

In order to dramatically speed up the arrival of an effective vaccine, the American government—breaking all the conventional wisdom and past experiences on vaccine development—has created a special project called Operation Warp Speed. In an article in Science, Jon Cohen said: “The project, vaguely described to date but likely to be formally announced by the White House in the coming days, will pick a diverse set of vaccine candidates and our essentially limitless resources into unprecedented comparative studies in animals, fast-tracked human trials, and manufacturing. Eschewing international cooperation—and any vaccine candidates from China—it hopes to have 300 million doses by January 2021 of a proven product, reserved for Americans.”

On May 21, an article in Bloomberg News detailed the U.S. administration whooping investment of 1.2 billion U$ in the joint AstraZeneca-University of Oxford project to develop a vaccine for SARS-CoV-2, which will start a large clinical trial in 15 days. The details are still coming out but there is already talk of a compromise for 1 billion doses.

If you are trying to guess which country will get the vaccine first, you must remember the answer of veteran sleuths to the question of what the motive of a heinous crime was.

Cherchez la femme!

Cherchez le fric!

Note – We have a little theory why Mr. Hudson committed perhaps the worst mistake of his life: he has spent too much time in the USA, the land of the brutish spitters of “truths.” Except for highly educated regions like New England and well-behaved ones like the Midwest, there are far too many spontaneous sauvages in this country who sincerely yet naively believe that just because something might be “correct”, it necessarily has to be “right.” We respectfully propose to the honorable Sanofis-Aventis board that they should grant their Demolition Paulie a leave of absence for a refresher stint in an English boarding school—with mandatory wearing of a good muzzle at all times, except in the refectory.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Is the SARS-CoV-2 pandemic starting to slow down?

In New York City, the number of new cases of infected people with SARS-CoV-2 and the daily death toll have been dropping for the past five days. The gory spectacle of health care personnel hastily talking to the reporters while they are sweating profusely in their Mertian protective gear is fortunately gone from our evening news programs. So are the makeshift hospitals to take care of the patients and the refrigerated trucks holding the bodies of the victims. Some of the hardest hit hospitals like Elmhurst Hospital in Queens and Brooklyn Medical Center in the homonymous neighborhood have much lower Emergency Room visits and less admitted patients for the infection, an unexpected phenomenon that has puzzled Public Health experts and hospital administrators.[i]

Today in an unusually optimistic article in Les Echos—the most respected financial daily of France—Yves Bourdillon affirmed: “the pandemic wave is coming to a close, apparently. The new cases of the Covid-19 atypical pneumonias and the associated deaths decrease in absolute number in al the countries of the world during the past few days. This daily flux only represents no more than 1.2% on average of the total number of the registered cases and 0.5% of the deaths, according to the reference sites of John Hopkins University and Worldometers.” [ii]

Amongst the developed nations most affected by this pandemic, the daily rise of new cases has been 0.5% in the USA,  0.3% in Germany and 0.2% in France, Italy and Spain. Even though they register almost two-thirds of the deaths, their daily rate has significantly slowed down, except for occasional peaks—like yesterday’s surge in the USA that tallied 1500 deaths. We must consider that there must be many more cases than the officially counted ones, but the trend is unmistakable and gives hope.

There have been many hypotheses about this phenomenon, including the benefits brought by a change of weather with the arrival of summertime; however, in New Zealand located in the Southern Hemisphere, the same trend is observed, with hardly any new cases. The Social Distancing and Isolation have certainly contributed to the betterment of the statistics but this trend occurs in countries with differing policies; it is observed in countries like Switzerland and Norway that have enacted a light version of Social Isolation and countries like Japan and South Korea with more draconian versions.

Some scientists are wondering if this “ralentissement” [iii] is really an expression of a mutation of the virus to become a different infecting agent. Less infectious or more? Veteran physicians and administrators are warily watching the sudden decline of clinical activity in their now eerily vacant hospital beds and the spreading calm. Is it just a temporary reprieve before a second wave hits them? Nobody really knows.

What do you think? Please tell us.

Don’t leave me alone.

Stay distant. Stay safe. Stay beautiful.

References

[i] https://www.nytimes.com/2020/05/20/us/coronavirus-live-updates.html?campaign_id=9&emc=edit_nn_20200520&instance_id=18629&nl=themorning&regi_id=57802664&segment_id=28532&te=1&user_id=459dba66f3e7ac37fa87a73994317eab#link-598d056

[ii] https://www.lesechos.fr/monde/enjeux-internationaux/la-pandemie-sessouffle-presque-partout-dans-le-monde-1204511

[iii] Term in the French language that means: “slowing down.”

Leftover victims of the SARS-CoV-2 pandemic

On May 8, 2020, the U.S. Department of Labor issued its monthly employment report, which showed that the national unemployment rate jumped to 14.7% in April, its highest level since the Great Depression of the 1930s; it said that 20.5 million people had suddenly lost their jobs due to the country’s lockdown, erasing a sustained rise of employment of the past ten years. A more detailed analysis of those that are abruptly working part-time instead of full-time and those that are not counted showed that the unemployment rate might even be higher. Moreover, the tightening of the federal, state and county budgets will inevitably furlough many more people.

In the previous recession of 2007-2009, the majority of lost jobs belonged to men, as the construction and manufacturing sectors ground to a halt; but this time the real losers are often women as thousands upon thousands of their positions as clerks, secretaries, hairdressers, health care aides, travel consultants, stewardesses, airplane and ship chandlers, restaurant servers and cashiers, dry cleaning employees, etc., evaporate. Once the lockdown is finally levied, albeit in various progressive stages according to the local public health characteristics, many of the once thriving small businesses that used to predominantly employ women will be gone. And there will be hardly any credit for entrepreneurial initiatives as the banks will be reluctant to lend.

Not only did women hold most of the positions offered in the Education and Health Care realms—the hardest hit sectors—but they were also furloughed in greater numbers than men. In a Washington Post article, Heather Long and Andrew Van Dam said: “Before the pandemic, women held 77%of the jobs in education and health services, but they account for 83% of the jobs lost in those sectors…Women made up less than half of the retail trade workforce, but they experienced 61% of the retail job losses. Many of these women held some of the lowest-paid jobs.” A large proportion of those workers are single women with children and members of the Latino and Black minority groups.

These disadvantaged single women usually lack a strong social or family support, for which they disproportionately rely on their children’s school services for their care, instruction, and meals. If they cannot take their kids to school, they will not be able to resume their previous positions, even if they are asked back to work.

In order to re-start our economies we must first help the women that sustain it.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

Thanks for your fabulous service

Dear readers and fellow bloggers;

Good afternoon. As a physician that has worked uninterruptedly during this terrible pandemic (even though we follow the Social Distancing protocols enacted by the City of Miami and State of Florida authorities) we must acknowledge that our dedication has been buttressed by the countless workers that have stood their ground and helped us.

Today we are introducing the beautiful Ms. Bre Wyche, star cashier at the Publix Supermarket branch at Mary Brickell Villlage in downtown Miami; last week she took care of us gracefully and diligently when we staged a quick foray to do our monthly shopping spree there. Today we went back for a refund and to buy certain items, for which we insisted on taking the opportunity to get her picture. (she is a very shy girl)

Beautiful Bre

Isn’t that smile bewitching?

After our incursion last week, we felt obligated to send an email to Mr. Todd Jones, CEO of Publix, to let him know what an outstanding service she had gently provided to us. According to his biography, Mr. Jones started in 1980 at the very low-end of the ladder (he was a front service clerk, a.k.a. bagger of groceries, in the New Smyrna Beach facility) and worked tirelessly until becoming the top executive of the largest employee-owned grocery chain in the USA. He should know a thing or two about merit-based progress.

We wrote to him: “when we were almost done, I suddenly said:’Oh, I forgot to pick up the garbage bags.’ You know what she said:’Don’t worry…I’ll go get them for you.’ And took off…She asked me what the specifications of what I wanted where and went out to get it. Can it get better? Yes, indeed. She came back with five variants of the perfumed Glad bags AND laid them out for me on the conveyor belt to chose from. I chose the lavender. This is what I call outstanding service. Please nominate her for employee of the month.”

Mr. Jones kindly answered my message, thanking me for sharing the anecdote as they love to hear that their committed employees are doing a great job every day of the week. As a front-end employee, Miss Bre is relatively exposed as she touches what we do.

Thank you very much to all the employees and administrative personnel of Publix Supermarkets for showing us, with big and little details, that they care for our families.

Stay distant.Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Multi-system inflammatory disease in Covid-19 infected children

On April 27, 2020, The Sun, a British newspaper with an American edition, published an article about a National Health Service warning about a new presentation of the Covid-19 infection in children; it even had flashy pictures of the new syndrome. The alert was sent to general practitioners in North London where the chiefs of health care delivery said: “there is growing concern that a Covid-19 related inflammatory syndrome is emerging in children in the UK…Over the last three weeks, there has been an apparent rise in the number of children of all ages presenting with a multi-system inflammatory state requiring intensive care across London and also in other regions of the UK.”

On April 27, 2020, the Pediatric Intensive Care Society of the United Kingdom issued a statement warning health care providers and parents that there was “an increased number of novel presentations of a multi-system inflammatory disease in critically ill children infected with Covid-19.” They recommended parents to seek proper professional help if their children had any of the following symptoms:

  1. Becomes pale, mottled and feels abnormally cold to the touch
  2. Has pauses in their breathing (apneas), has an irregular breathing pattern or starts grunting
  3. Severe difficulty in breathing, becoming agitated or unresponsive
  4. Is going blue round the lips
  5. Has a fit/seizure
  6. Becomes extremely distressed (crying inconsolably despite distraction), confused, very lethargic (difficult to wake) or unresponsive
  7. Develops a rash that does not disappear with pressure (the Glass test)
  8. Has testicular pain, especially in teenage boys

On May 4, 20220, the New York City Department of Health issued its Health Alert #13 stating that 15 children in New York City hospitals have been identified with a multi-system inflammatory syndrome that resembles Kawasaki disease and/or toxic shock syndrome. The NYC experts said that: “clinical features vary, depending on the affected organ system, but have been noted to include features of Kawasaki disease or features of shock; however, the full spectrum of disease is not yet known. Persistent fever and elevated inflammatory markers (CRP, troponin, etc.) have been seen among affected patients. Patients with this syndrome who have been admitted to pediatric intensive care units (PICUs) have required cardiac and/or respiratory support. Only severe cases may have been recognized at this time.”

On May 9, 2020, Governor Andrew M. Cuomo of New York informed in his daily update that three children had died of this multi-inflammatory syndrome in the New York area hospitals. Moreover, they had already identified up to 75 children with the syndrome. They were initially admitted without any respiratory symptoms but they all tested positive either for the virus or its antibodies. He warned that it is a developing serious situation.

Sadly, the emergence of this Kawasaki-like syndrome might just be the tip of the iceberg.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

 

Emotional toss-up during Social Isolation

“Doctor…I never had so many fab orgasms—not going back to same old.”

Wanda X. is a lovely middle-aged entrepreneur that had the misfortune of being surprised by the “staying at home” order in a business trip to a distant state. Fortunately, she had an old friend from college that gladly welcomed her to bunk. Unlike her, she has been single and childless, which gave her a lot of sexual leeway.

One of the little perks of her friend’s lifestyle is to unabashedly recur to the use of a dildo whenever she had the irrepressible urge for satisfaction of her sexual needs. Reluctant at first to try it, Wanda X. eventually relented, after a month of seclusion. Slowly she learnt how to practice with a sexual toy in a responsible, adult way. When she would be able to return to her home, she will sit down to chat with her partner. She will tell him that she finally had it enough of her culturally-assigned role of a passive giver of love and that she demands the urgent addition of a more fun dual role of receiver too. Holy mackerel!

The emotional toss-up of the Social Isolation will shake up many conventional couples.

One of the most disregarded aspects of the mandatory Social Isolation that we have been enduring for more than one month already is its serious emotional toll on us. Like the young women and men that went into isolation in a Florentine villa in the Decameron, those coming out of this seclusion will not be the same ones that went in. At the civic level, there will be multiple changes in our societies, especially for labor opportunities.

The economic analysts are predicting that, besides the contraction of consumer spending due to loss of jobs, there will be a two-speed labor market. On one hand there will be persons that can work at a distance and with little physical contact. But on the other hand, there will be those that will be dangerously exposed to contagion. This will bring a generalized angry mood in the street like we have never witnessed before. No longer will we be able to count on the help of a smiling barista at our Starbucks; she might be too worried about being infected while mulling about her son’s day care. After her shift is over, she might be too stressed out to even consider going out with her girlfriends.

I‘m a single Mom working long shifts with hardly any toilet breaks for the barely minimum to pull my kids and I a few inches away from the always menacing edge of the poverty pit.

And you expect me to smile? About what? Com’ on. Grab your latte and move on, Buster.

Next customer in line!

The same anxiety and depression that pervades the working environment will be translated in a creeping loss of libido and eroticism in many blue collars’ bedrooms. Those lucky enough to have a privileged spot in the New World order will be less amenable to servile attitudes in loving, especially because many will be women.

The ladies will demand equal rights with their partners, which is a positive outcome. The manly partners that are out of a job will have to stay home to take care of the kids. And if they want to keep their women happy, they would have to learn how to cook nice meals. And be more attentive to their “little details”, including listening to them and bringing them flowers regularly (a bouquet once per month will not break the family budget)

Only with the combined effort of all the genres, will we be able to cross this junction.

Stay distant. Stay safe. Stay beautiful.

(This article is based on our upcoming new book “Emotional Frustration – the hushed plague.”)

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse burnout – Part V Suicide

The  stressed-out E.R. personnel of the New York-Presbyterian Allen Hospital

Got used to the company of the little sparrow flying over their place of penance

She was always the first one present when the doors of the ambulance opened

She was always the first one present when they took a patient to an exam table    

She was always the first one present when they hooked the whirring machines

She was always the first one present when the drilled routine of care kicked in

 But one day her heart could not resist so much suffering and stopped beating

 Plunging into the depths of their sorrowful spirits, she gave them a final cheer.

On April 27, 2020, Dr. Lorna Breen, chair of Emergency Medicine at the Columbia-affiliated hospital, committed suicide in her parent’s home in Virginia. She had been diagnosed with a Coronavirus infection, but she fully recovered; she was given a leave of absence from work and she decided to spend it with her folks. In a communication with The New York Times her father said: “She tried to do her job, and it killed her…Make sure she’s praised as a hero, because she was. She’s a casualty just as much as anyone else who also died.” [i] Her father said that she had told him that many patients were already dead when they opened the doors of the ambulances. She never had a history of Mental Health issues, but she seemed detached to him.

 Once a suicidal patient decides to act, a Buddhist peace of mind sets in.             

Physicians have been trained to face most of the stressful situation of our careers with a stiff upper lip and the steely determination to carry on, nonetheless. If you are taught in Medical School and  professional training about the values of fortitude and resiliency, you will be the last one to ask for any help. As a result medical personnel are hard hit by an unusual incidence of suicidal acts and attempts, which will surely worsen after the Coronavirus pandemic finally ends.

Unfortunately, there are personal and institutional barriers  blocking the remedies.

In a 2008 Health Affairs article [ii], Donald M. Berwick, Thomas W. Nolan and John Whittington coined the term “triple aim” to define the simultaneous pursuit of three objectives—improving the experience of care, improving the health of populations and  reducing per capita costs of health care—to fix the care system. In 2014, considering the increasing burn-out and dissatisfaction of physicians and nurses with medical practice, Drs. Bodenheimer and Sinsky argued that: “the Triple aim be expanded to a Quadruple Aim, adding that the goal of improving the work life of health care providers, including clinicians and staff.” [iii]

Professional burn-out is characterized by a most evident and ignored tragic triad:

  1. High emotional exhaustion
  2. High depersonalization
  3. Low sense of personal accomplishment

A – High emotional exhaustion

The increasing demands of payors, administrators and patients on the time and resources of the health care personnel produces a generalized dissatisfaction with the perceived quality of their delivered care services. The level of resilient frustration is so pervasively high in our system that physicians, nurses, technicians, receptionists, and other ancillary personnel are literally “counting the days” until finally the day of salvation arrives—their retirement date.

B – High depersonalization

The negative feelings and bad vibe will inevitably foster the emergence of cynicism and sarcasm in the ranks of providers, with the resultant degradation of their rapport with the patients and families. It is a self-sustaining vicious circle. Patients complain that they are being ignored and/or mistreated, which triggers more negativity and disdain for the staff. As a result, the latter keep their bad attitudes without the possibility of pausing for a moment and reflect calmly on the impasse.

C – Low sense of personal accomplishment

For the majority of us who have chosen the medical career, profit and social standing are secondary considerations. What we most value is the possibility of helping our fellow human beings and at  the same time enjoy the unique standing conferred by possessing a voice of authority. With the landing of the abominable “bean counters”  in both the public and the private payor system, our maneuvering room is being steadily curtailed. Our decreasing satisfaction not only fosters our  early retirement but also all kinds of drug and alcohol abuse in our ranks plus the potential of one day, out of the blue, start mulling about the unthinkable.

Shanabelt et al. studied the incidence of burnout with work-life balance in the US physician and general workforces in 2011 and 2014 to compare the results and significant trends, using the Maslach Burnout Inventory; they invited more than 35,000 physicians to participate and 19% completed the survey. [iv] They said that:  “54.4 % (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.50 % (n=3310) in 2011.Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty.” They found minimal differences in the general workforce between those years.

Early on during our training, a taciturn hitchhiker steps into our cockpit.      

Douglas A. Mata et al. conducted a meta-analysis of 31 cross-sectional  and 23 longitudinal studies of the incidence and prevalence of depression in resident physicians.They found : “the overall pooled prevalence was 28.8 % of participants, ranging from 20.9% to 43.2% depending on the instrument used, and increased with calendar year.” [v] One in four physicians-in training has depression.

To glean more information on this issue, Lisa S. Rotenstein et al. extracted data from 167 cross-sectional studies and 16 longitudinal studies from 43 countries. They found: “the overall pooled crude prevalence of depression or depressive symptoms was 27.2%…Depressive symptom prevalence remained relatively constant over the period studied…In the 9 longitudinal studies that assessed depressive symptoms before and during medical school (n=2432), the median absolute increase in symptoms was 13.5 %.” [vi] They also found that only 15.7% sought medical treatment for their symptoms. There is a tall price to pay.

Amy M. Fahrenkopf et al. studied the incidence of medical errors among resident physicians of three urban children’s hospitals by evaluating the depression with the Harvard National Depression Screening day scale, the burnout using the Maslach Burnout Inventory, and the rate of medication errors per resident per month. They found: “24 (20%) of the participant residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed. Burn-out residents and not-burnt out residents made similar rates of error per resident month.” [i]

There are several factors that block physicians, and other medical personnel, to seek the needed counselling. The crazy work schedule of physicians and residents, the confidentiality issues that might affect the licensing status of practitioners, the personal issue of loneliness and divorce, all contribute to it.  

We have dawdled about writing a book on Physician/Nurse burn-out                 

Lorna’s valiant sacrifice shook our torpor and took us immediately to task

(This article is based on our upcoming new book Emotional Frustration- the hushed plague)

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

References

[i] Amy M. Fahrenkopf, Theodore C. Sectish, Laura K. Barger, Rates of medication errors among depressed and burn out residents: prospective cohort study. British Medical Journal. 2008 March 1: 336 (7642) ; 488-491. Doi: 10.1136/bmj. 39469.763218 BE. https://ncbi.nlm.nih.gov/pmc/articles/PMC2258399

[i]  Top E.R. Doctor Who Treated Virus Patients Dies by Suicide, The New York Times, April 27, 2020. https://nytimes.com/2020/04/27/nyregion/new-york-doctor-suicide-coronavirus/

[ii] Donald M. Berwick, Thomas W. Nolan and John Whittington, The Triple Aim: Care, Health and Cost, Health Affairs, May/June 2008. https://doi.org/10.1377/hltaff.27.3.759

[iii] Bodenheimer T., Sinsky C., From triple to quadruple aim: care of the patient requires care of the provider, Annals of Family Medicine, 2014, November-December; 12(6)573-6. Doi:10.1370/afm.1713. https://ncbi.nlm.nih.gov/pubmed/25384822

[iv] West CP, Dyrbye LN, Shanafelt TD, Physician burnout: contributors, consequences and solutions, Journal of Internal Medicine 2018 June 283 (6) 516-529 doi 10.1111/joim. 12752. Epub 2018 March 24. https://ncbi.nlm.nih.gov/pubmed/29505159/

[v] Douglas A. Mata, Amarco A. Ramos, Narinder Bansal, Prevalence of depression and Depressive Symptoms among resident physicians. A Systematic review and Meta-analysis, Journal of the American Medical Association, 2015, December 8: 314(22) 2373-2383. Doi: 10.1001/jama 2015.15845. https://ncbi.nlm.nih.gov/pmc/sticles/PMC4866499

[vi] Lisa S. Rotenstein, Marco A. Ramos, Matthew Torre, Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation among Medical Students, Journal of the American Medical Association. 2016 Dec.6:316 (21); 2214-2236. Doi: 10.1001/jama 2016.17324. https://ncbi.nlm.nih.gov/pubmed/27923088

Do not listen to (some of) the French

As millions of other citizens and residents of the United States of America that have complied with the largely state-mandated “staying-at-home” guidelines, we have been glued to the television screens when the official daily news conference from the White House appears between 5 and 6 PM Eastern Standard Time. It usually involves the top administration officials and renowned public health and emergency officials that are dealing with the Coronavirus pandemic and the remedial measures.

One of the most mentioned and debated  issues is whether to use chloroquine, an anti-malarial drug, to treat the acute symptoms of the grave infection, which is based on some incidental reports from French physicians that treated patients with Coronavirus. Event though they do clarify that much more comprehensive clinical research studies, which are underway, are needed to give a seal of approval to this drug, the legend of its usefulness persists; it has been used “off-label” by some physicians with mixed results. However, it has produced serious cardiac arrhythmias in others.

In a recent correspondence to The Lancet, Dr. Joan Paul Moattti, a professor of the University of Aix-Marseille, questioned the responses of the French administration. He said : “Faced with criticisms, French authorities claim that their policy towards the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been evidence-based—they appointed an advisory board of 11 scientists to help manage the crisis. However, in situations where decision makers face radical uncertainty, sticking to conventional approaches might jeopardize the science-policy interface.”

First of all, he criticized the lack of massive testing of the first responders and possible cases in the beginning of the pandemic in March, unlike the authorities of South Korea that tackled the pandemic following the guidelines of the WHO:

  1. Massive tracing
  2. Contact tracing
  3. Social distancing

France did not implement a national lockdown until March 17, many days after the pandemic had been identified. Moreover, he claimed that the country was not prepared to carry out the critically needed massive testing as it only had 45 public health laboratories that could process the samples for a definitive diagnosis of cases. Rather than designing a rational plan to scale up the testing, the authorities argued that massive testing was not needed once the infection became generalized; they only changed course on March 28, after  a national uproar about their carelessness.

The widespread diffusion of the very preliminary—and inconclusive—results of treatment with Chloroquine fueled big speculation in the world media and an acrid controversy in the biomedical community; he claimed that there are alternative methods to evaluate the safety of some drugs without the need to wait months for the definitive opinion of the clinical researchers that conduct rials of the same. This dereliction of duty in a context of urgency: “has reduced the ability of authorities to mitigate the effects of irrational online rumors and regulate prescription practices of health professionals.”

The author has high hopes in a much smarter commission of 12 experts designated by the French authorities on March 28—they seemed to have done a radical public about-face that very day. It is chaired by Dr. Françoise Barré-Sinoussi, a renowned virologist and Nobel Laureate of Medicine in 2008.who, as a highly educated woman, might be endowed with a bigger dose of common sense in the public forum. He said: “the second commission seems an implicit recognition of the intrinsic difficulties of directly using science in political management of a health crisis.”

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

Are Singles better prepared for Social Isolation?

The quasi-centennial woman had been living in the same humble shack with a loyal dog and a dozen chickens in a small clearing of one of the most forbidding sub-tropical forests of South America—El Impenetrable, a large expanse bordering the Bermejo River in the northwestern part of Chaco province and the southwestern part of Formosa provinces of Argentina. One of her many grandchildren, and sometimes even a great grandchild, would come to check on her and bring supplies almost daily but they all preferred to live in a nearby small urban settlement.

She claimed that her social isolation in such natural habitat suited her just fine. She woke up early every day to do her homely errands with enthusiasm, preparing her own meals based on a largely vegetarian diet with some poultry or freshwater fish. She continued to smoke moderately, and she sometimes drank a little alcohol too. When the reporter asked her what the secret of her unusual longevity was, she said:

“Because I don’t have a man that heats up my head every day.”

The forced social distancing and isolation brought by the Coronavirus pandemic has forcibly obliged millions of people to stop working in public/ private institutions or attending educational institutions with a resulting estrangement from other persons. Individuals with stable sex partnerships have been traditionally considered as more apt to withstand the Mental Health consequences of this kind of social situation. However, the previous existence of millions of men and women who had expressly chosen a single lifestyle in modern societies has gravely questioned that assumption.

In an article of the Health section of The Washington Post, Joan DelFattore reviewed the responses from several singles contacted by e-mail or found in the social media. “This is the moment I’ve been training for all my life!’ an unnamed introvert asserts in a Facebook post…Edie Jarolim, a freelance writer and editor in Arizona, can relate to that sentiment—that adults who have chosen to live alone may be better adapted than many to the stay-at-home restrictions in place in large parts of the USA.” Most of the respondents were nonetheless concerned that they could be discriminated against if rationing of the scarce health care resources—lifesaving ventilators for example—were eventually instituted in a dramatic junction of this terrible pandemic.

A longstanding complaint of the singlehood-by-choice surfaced again: the lack of respect for their lifestyle choice from the mainstream citizenry. Many persons confound the fact of “being alone” with the sentiment of “being lonely.” Especially because they disregard that many of these singles do have a strong social support. Moreover, the lack of sentimental strings prods them to seek a varied company.

Since Biblical times, humans have been strongly encouraged to socialize and live in partnership with the opposite sex for healthier social outcomes. There has been a large pool of scientific literature to buttress the need for a stable sexual partner to avoid anxiety/depression, insomnia, obesity, cardiovascular disturbances, etc. But how about those individuals that expressly chose the singlehood to be more creative?

Julie C. Bowker, Miriam T. Stotsky and Rebecca G. Ekin published a seminal paper in 2017 where they examined the links between the withdrawal subtypes and some psycho-behavioral variables, finding challenging results for the avoidance models of withdrawal; they found that unsociability is associated positively with creativity. Julie Bowker said: “they are not antisocial…they don’t initiate interaction, but also don’t appear to turn down invitations from peers. Therefore they may get just enough peer interaction so that when they are alone, they are able to enjoy that solitude.” In order to study these unsociable-by-choice from the truly shy individuals or those who exhibit abnormal anti-social attitudes, they recruited 295 college students and subjected them to a battery of psychological testing. They found that those who were in fact shy or antisocial scored lower than average on the creativity indicators; the participants who were “unsociable” scored higher on those same indicators.

These authors proposed that unsociable persons “may be able to spend their time in solitude constructively, unlike shy and avoidant individuals who may be too distracted and/or preoccupied by their negative cognitions and distress.”

A question that has lingered in our mind for many years might merit to come into the open on this occasion. Like most human beings, we have commiserated with the miserable and lonely life that Vincent Van Gogh endured until the very last instant of his tortured life. However, would he have been able to produce so many beautiful tableaux of so many simple situations if he had been a most happily married man?

Stay distant. Stay safe. Stay beautiful.

(This article is based on our upcoming new book Emotional Frustration – the hushed palgue)

What do you think? Please tell us.

Don’t leave me alone.