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"Humanness that connects all of us"

(Interview done June 18, 2020)

I’m Rachel Davis Martin and I’m an assistant professor for the medical school. I do research for the Emergency Medicine Department four days a week on suicide prevention efforts and substance abuse treatments. One day a week I work at Hahnemann for clinical work in which I provide integrative behavioral health care. I do behavioral therapy, provide warm handoffs, and dual visits with the residents.

What was your experience like in this pandemic?

Because I wear two hats in my job the effects of the pandemic have been different across the two. In the emergency department it became apparent that everybody had to do remote work; we couldn't enroll patients into our studies anymore so the patient base and contact we had with them changed significantly. We were now sitting behind a desk behind a computer-- all day, every day.

My responsibility as a supervisor in these research studies was to make sure everybody had work to do. A bulk of my time was setting aside my own needs to make sure my staff was taking care of-- they weren’t sure if they would have funding through the pandemic. I think it was a kind of a shift there-- to make sure everyone had a job and could keep their job, while keeping something that typically isn’t in the forefront of my mind-- that at any minute the funding from this grant may not support the work we are doing because we are not enrolling patients.

But we managed to keep all of our staff fully funded the entire three months we were working remotely. And we are going to start enrolling patients again next week!

That’s wonderful to hear!

So there's this weird sense that normalcy is going to slowly return, but we have no idea what that's going to look like. The other hat I wear is the clinical care that I do. That's something that I think has been a real bright spot in this pandemic. So typically on a given shift of mine, I'll have one or two no-shows. New patients are twice as likely to no-show an appointment— about 50-60% show rate for initial appointment with somebody. But because we made an abrupt shift to telehealth where we use phone calls and video communication with patients, we were actually able to significantly improve our show rates. So I think a huge barrier to access to mental health care, to behavioral health care, has been kind of reduced to almost nothing because of something so tragic as the pandemic. And now I think in the last three months of doing tele-health, I've had maybe three patients not attend their appointment, meaning they didn't answer when I called. It's been interesting. I've been trying to— I've been grappling with this idea that good can come from tragedy and you have to make that true or else it can be just sort of devastating.

And so in working with all of the patients during the telehealth, so much of what we work on is kind of normalizing this human experience: that abrupt change is hard. Even for people who typically are kind of okay with change or a little bit more like go-with-the-flow and flexible, everybody over the course of the last three months has found their threshold for where it just stops being comfortable and it just stops being okay.

This pandemic, I think, has really highlighted for me the kind of base humanness that connects all of us— which is wanting security about routine and normalcy in our days and a sense to feel connected to people.

People, like extroverts especially, have really struggled with the lack of connection. But even the introverts that I work with, after two months, after the three months are "I'm ready to see people again." And so I think that kind of that connectivity to other people and wanting for normalcy is very apparent in almost every conversation I have at some point with people-- providers and patients throughout this pandemic.

You mention there might be some good coming from telehealth and I assume it may be because of the increase access— patients may be getting more of the care they want in a certain way. Did you notice that patients like telehealth?

It's funny because patients that have social anxiety really like it. I've found people that with anxiety have a tendency to be more excited about this idea that they can stay in the comfort of their own home. One of my patients has extreme anxiety around driving, even riding in a car. And so every appointment that we've been working on focused on driving and how to get to your appointments and ways to cope with anxiety. And now that that part of the conversation has shifted. I think that there are some added benefits to tele for those patients.

On the flip side, it's kind of been harder to do family work and couples therapy. I'm currently working with a couple and our very first appointment was over the phone. We shifted to video so it makes a little bit easier to kind of see. It's difficult when you need to manage multiple people if you're just on the phone because you're having to find the balance trying not to interrupt each other and knowing how someone's gonna handle the information. With kids, when you're trying to assess ADHD, it can be difficult.

So there's both sides. There's good and there's bad that comes with it. There's enhanced access, but then difficulty with being able to see all the things that you need to see in a specific appointment. I think that the solution in the future is a remedy of having a blend of both so that you keep and maintain high access but then enable an environment necessary to do the best practice, best care for the patients.

You mentioned that the pandemic has made things worse for people like extroverts because they can't see people. Have you noticed unique things about this pandemic that has worsened other or certain mental health problems?

I know that patients with health anxiety have taken it particularly hard because things that they hadn't previously considered as a possibility opens the door to all of these invisible things that are scary than the visible things that they were already worried about. So that's an interesting one.

I think something that's unique about the pandemic that we wouldn't have in everyday life is the kind of cycles that people are going through and how long one can accept something. It manifests in this way: a lot of people who thought this is a sprint weren't prepared for the marathon that was to come. And so really educating people on this idea that it's okay— that the strategy that got us in for the first two weeks is failing and that you need a new strategy to get you to the next two weeks; and that likely in another two weeks it will fail as well and you have to kind of keep switching.

When you run a marathon, the first six miles are significantly different than the last six miles. And even around mile 14 to 15, your body goes into this different point where it comes into where it's burning fat versus muscle and the tricks that your brain puts on you as you do that. When you have a pandemic like this, where everyone's forced to kind of be in the same situation, you can really help people understand that it's okay to fail and you're expected to fail repeatedly at things that you typically can do well. Yoga is great, I love to do yoga, but at some point, you know it's not effective anymore. Mindfulness is fantastic, and I do it regularly but there are just days that mindfulness just isn't happening. You know, it's like stuff like that. The pandemic is kind of unique in showing how people experience coping.

If I could transition a little bit, you mentioned this earlier—I guess I didn't really know much about your research and how you coordinate all of that. You mentioned getting grants for your learners and protecting them, can you tell me more about that?

Yeah, so I currently work as a co-investigator on two large projects. One of them is a clinical decision rule for suicide prevention. So trying to identify what are sort of the best questions to ask patients to identify risk of suicide, that will then create a tool to inform providers for how they should handle talking to patients about suicidality and what sorts of best practices should be placed in the hospital: which patients should be on one to one observation versus one to four observation, which patients are actually more likely to hurt themselves while they're in the, in the hospital versus when they're discharged those sorts of things. So it's an assessment based study and that's why it was deemed like not relevant enough to kind of keep doing it throughout the pandemic. So suicidality is a huge issue— it's the 10th leading cause of death in the United States and it's the eighth cause of preventable deaths.

We can prevent suicide with various efforts. I think one of the domains that how COVID and the pandemic really going to impact this area is that there is this expectation that there will be increases in suicide in the future to come. In our study right now for the clinical decision rule that we're working on, I am our safety officer. So I have to review adverse events that come up-- for that study, adverse events include: suicide attempts, visits to the hospital, both ED and inpatient for a psychiatric reason. Prior to the pandemic, it was a blend: some was just visits for a psych reason, some, some were a blend of suicide attempts and psych issues. The last eight adverse events I've received in the last six weeks are all just suicide attempts. Even just within the study population there has been an increase in suicide attempts. And so I think that our work and suicide prevention efforts are going to become more relevant than ever— partly because of the pandemic.

And then the other work that I do is on substance use treatment access and modalities. So the other project that I have going on right now is working with a mobile app that helps patients engage in treatment for Suboxone, for their opiate use disorder. It's an app that's in the development days that gives people the opportunity for people to earn prizes to engage in treatment: that includes taking their medication, staying off of illicit drugs, showing up to their appointments, those sorts of things.

So that project is in its early days as it is enrolling. What we do know is that the pandemic significantly impacted how many patients were coming to the ED. So we've seen this huge decrease in how many people are coming in. And so it has us wondering, what is happening to these people with opiate use disorder? Are they just not using as much, are they not overdosing as much, or are they overdosing and not coming to the ER anymore? And if that's the case of how many more people have died, because they didn't go to the hospital out of fear that they were going to get COVID in the hospital. So that, in both of my domains of research, I think COVID likely has a significant impact and will continue to have a significant impact.

I have written a grant that I submitted that's looking at using wearable biosensors, like wrist watches and those sorts of things to help monitor alcohol detox, because I hope to create a mobile platform that's linked to wearable devices that can be used to outpatient detoxify patients. So that like in family medicine, the provider who wants their patient to go through treatment and no longer has to stay anywhere to go through detox and then do a step down program but can do that pretty easily with this sort of technology aiding them. I'm actually doing a grant now is October on that topic.

That's really cool. Yeah, I had a patient who needed to see a vascular surgeon urgently but she wouldn't go to the ED-- she just wouldn't go and I was concerned. When she finally went she ended up with an amputation— I felt so bad for her.

They’ve been talking about how the impact of the chronic health conditions being negatively affected--and in the months to come is really going to become apparent. We used to have beds in the hallways of the ED and so at University campus, any given day the bed capacity was 120--— everybody was full. Ideally it's more like closer to sort of 96 if they're not having to double up hallways. And at our sort of lowest volume point during our pandemic surge, there were days in the ED that there were only 25 to 30 patients.

I’ve seen that when I do my hospitalist work. I would look at the ED census and at times it was like nothing.

Now we're at 80% capacity and we're like 60 people-- which is still half of what we used to do, which is crazy, but I'm sure burnout for physicians is probably better with that demand— not having to manage an absurd number of patients at a time. But then there's another side, there's this idea of having to wear all of that PPE for extended periods of time and just the emotional and psychological pressures of being in that environment. I would imagine you're not always scared that you're going to get sick, but you're acutely aware that at any point in time you could come into contact with somebody and you hope that your PPE is still working.

Did you notice more of that?— fear or stress in the providers, nurses, and other workers?

From a couple of group meetings, I got the sense that there's just more gallows humor, just kind of more sarcasm around some of the stuff that let me know there were increases in their current coping mechanisms around what they see. I think one of the things that has helped keep people from feeling as scared is that since the very first week of the pandemic, when we started to put in place all the safety precautions we had, we've had zero staff, both nurses and physicians, get COVID. There was in the very beginning, I think it was one resident and one nurse trainee who were exposed. And I think one of them ended up not even coming positive, but they were under observation for those two weeks.

There's a trust in our department to take care of us. Our chair is absurdly responsive. He is really kind and really caring and he's on the frontline all the time and he advocates for the needs of his staff in a really good way. I think that that has kind of helped with some of the fear. They've done a really good job of just hiring new people to make sure that there was enough staff coverage and that people weren't feeling burnt out or felt that they just like didn't have the access or resources that they needed.

It makes me feel kind of proud. Like yesterday I saw a map that was showing state cases across the country. Umass is the best. Massachusetts compared to the whole country has had the largest decrease in the last two weeks. And like, I can't help, but think that like everywhere I've gone in the past few weeks with community here and coming to university campus kind of just demonstrates like why there's just so many safety precautions and everybody seems to be doing the right thing. I didn't see a single person without a mask on around the med school at all. It's very reassuring.

Any sources of joy to keep yourself well?

I do this happiness project journal. There's a book called the happiest project and kind of talks about like habits that make people happy and the things that they do. And out of that project, this person that created a journal where it's a five year journal and they give you like three short little lines to write on each day. You essentially jot down one or two thoughts for the day. And I started doing this back in January. I have several friends who do it and my wife's done it for a couple of years so I started doing it. And I'm really interested in the next few years to see as these dates come up, what were some of the thoughts. I have this very, very real time snapshot of the emotions that happened, the things that happened— when you only get one or two lines, you really pick the thing that stands out to you about that day. And so I would be really interested to see in a few years time, like looking back at a date like March 15th: "This isn't that much of a big deal. People don't need to worry this much." And like March 17th: "We're told we can't go back in the office. Never again." April 3rd, "Losing my mind. Kids are no longer in daycare, we're homeschooling." It'll be really interesting. I haven't gone back to look at any of it yet because I want to wait and just sort of see how things play out.

Photos: H. Del Rosario

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