EP. 132: BURNING OUT ON THE COVID-19 FRONT LINES

WITH DHAVAL DESAI

Oct 1

WITH DHAVAL DESAI, MD

A hospitalist and author opens up about what it was like to struggle through the COVID-19 pandemic — and find moments of humanity — not only as a frontline clinician and healthcare leader, but also as a father and husband.

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Episode Summary

During the first year of the COVID-19 pandemic, the phrase “Healthcare Heroes” echoed through hospital walls and city streets. For many people, this felt like an overdue acknowledgment of the difficult and important work that healthcare professionals carried out during the most devastating healthcare crisis the world had seen in a century. But this phrase can also be problematic, romanticizing the sacrifices of individual clinicians without addressing the systemic failures that put them at risk, overlooking the mental health struggles they experienced, and undermining healthcare environments that encourage reflection about respect and duty.

Our guest on this episode is Dhaval Desai, MD, a hospitalist at Emory Healthcare in Georgia and the author of the book Burning Out on the Covid Front Lines: A Doctor's Memoir of Fatherhood, Race, and Perseverance in the Pandemic (2023), in which he details his personal narrative as a healthcare leader and frontline physician fighting to hold his hospital together.

Over the course of our conversation, Dr. Desai shares why he decided to train in both internal medicine and pediatrics, how his experiences caring for his ailing father revealed the flaws of our healthcare systems, the nerve-wracking first few months of the COVID-19 pandemic, his own struggles as a leader, healer, father, and husband during a time of deep uncertainty, how we can all better connect with patients through even a few moments of shared humanity amid our busy days, and more.

Dhaval Desai is a dedicated father, husband, son, and doctor. In his work as a caregiver and a colleague, he places a priority on the well-being of both the patient and the healthcare provider. His commitment to fostering and advocating for humanity in medicine inspired him to write a personal narrative of his experience as a frontline physician during the COVID-19 pandemic, Burning Out on the Covid Front Lines: A Doctor’s Memoir of Fatherhood, Race and Perseverance in the Pandemic. Along with sharing the story of his own struggles as a leader and healer during a time of intense pressure and uncertainty for countless doctors, nurses, and hospital workers, Dr. Desai calls attention to ongoing issues plaguing the healthcare system, including health inequality, racial injustice, an emphasis on metrics over compassion in treatment, and the alarming rate of burnout and suicide among healthcare professionals.
In 2012, Dr. Desai joined the staff of Emory Saint Joseph’s Hospital, where he currently serves as the Director of Hospital Medicine. He also works as a Pediatric Hospitalist at Children’s Healthcare of Atlanta. In addition, he mentors other physicians and contributes to optimizing hospital operations as Assistant Professor of Medicine and Distinguished Physician at Emory’s School of Medicine.
In this episode, you will hear about:
• 2:36 - Dr. Desai’s path to medicine
• 5:05 - How a Med-Peds residency differs from other medical residency tracks
• 8:06 - How Dr. Desai’s personal experiences have shaped his approach to patient advocacy
• 11:53 - Dr. Desai’s personal and professional life leading up to the COVID-19 pandemic
• 18:46 - Dr. Desai’s opinion on why it is important for leaders to be able to express emotion
• 24:53 - How Dr. Desai used his leadership role to help his staff navigate the emotional turmoil of the pandemic experience
• 28:32 - Moments when Dr. Desai suffered heavily from burnout
• 34:47 - Stories of the isolating effects of COVID-19 in the ER
• 39:53 - Our society’s support of healthcare workers
• 46:19 - Advice for young clinicians on ensuring humanity stays central to their work
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] During the first year of the Covid-19 pandemic, the phrase 'healthcare heroes' echoed through hospital halls and city streets. For many people, this felt like an overdue acknowledgment of the difficult and important work that healthcare professionals carried out during the most devastating healthcare crisis the world had seen in a century. But this phrase can be problematic to romanticizing the sacrifices of individual clinicians without addressing the systemic failures that put them at risk. Overlooking the mental health struggles they experienced and undermining the creation of healthcare environments that encourage reflection about respect and duty. Our guest on this episode is Dr. Dhaval Desai, a hospitalist at Emory Healthcare in Georgia and the author of the book Burning Out on the Covid Front Lines: A Doctor's Memoir of Fatherhood, Race, and Perseverance in the Pandemic, in which he details his personal narrative as a healthcare leader and frontline physician fighting to hold his hospital together. Over the course of our conversation, Dr. Desai shares why he decided to train in both internal medicine and pediatrics, how his experiences caring for his ailing father showed him the flaws of our healthcare systems, the nerve wracking first few months of the Covid-19 pandemic, his own struggles as a leader, healer, father and husband during a time of deep uncertainty, how we can all better connect with patients, even just through a few moments of shared humanity amid our busy days and more. Doctor Desai, thanks for joining us and welcome to the show.
Dr. Dhaval Desai: [00:02:35] Thanks for having me.
Tyler Johnson: [00:02:36] So we usually like to start out by having our guests explain to us, how did you get into medicine? How did you end up becoming a doctor?
Dr. Dhaval Desai: [00:02:44] It's a good question. You know, I think it goes back to childhood. One of the classic dreams to be a doctor, to help people. I always dreamed of being a quote unquote brain surgeon. But that rapidly changed as I kind of evolved out through that, and I really always desired a profession where I could interact with people, help people. And I still was always fascinated by sciences and the medical sciences. So that's what ultimately led me to my path of becoming a physician. I did have some kind of curves and side stops in betweens intentionally, but I was a briefly a high school Spanish teacher after college and then went on to medical school and residency. But everything I do, it's kind of more of a people person that I like to interact and have these relationships, and that's one of the things that I think has been the most catalyst, so to speak, to help me get where I'm at.
Tyler Johnson: [00:03:37] And can you talk through just a little bit? So you've discussed what brought you into medical school, but then how did you decide what you wanted to do within medicine? And then, you know, a lot of what we're going to talk about today is your experience during the pandemic, specifically as outlined in in your book. But to kind of set the stage for that, take us through how you decided what you wanted to do in medicine and then also before the pandemic hit. What was your job? What was your role? Kind of what were you doing day to day?
Dr. Dhaval Desai: [00:04:04] When I was in medical school, my third and fourth year, I always had this yearning I want to be an emergency medicine physician. You get to see a little bit of everything, do things fast paced. And when I did that rotation, I rapidly realized for me personally, there was a lot left to be desired. And what I mean by that is diagnostics, workup outcomes, and more importantly, the relationship with the patient. Everything felt rushed not to think that other fields in medicine, we don't feel rushed, but it really was just not the full circle of a relationship, of an encounter with a patient that I wanted. And I realized that I had obviously always an interest in pediatrics. I loved adolescents also, but I also like the adult world. And the idea of med peds combined internal medicine and pediatric residency was on the table for residency, and that's what I pursued as a four year training program. And I'm now board certified in both. And there's no looking back any day. When I look back on those days.
Tyler Johnson: [00:05:05] And I think before you get to your sort of your day job, just because I'm pretty sure Henry, correct me if I'm wrong, but I think you're the first doctor we've had who did a med peds residency.
Henry Bair: [00:05:15] That is correct.
Tyler Johnson: [00:05:16] Can you talk a little bit about, like, what's the idea behind that? Because, like, I remember when I was in medical school, the, you know, I haven't done anything with pediatrics in a very long time. But when I was in medical school, the pediatricians used to always like to say, well, the problem is that internists tend to think of kids as if they're just small adults. And they're not just small adults. Kids are totally different, right? Talk a little bit about what is meant by PEDs, and why would someone do that as a specialty?
Dr. Dhaval Desai: [00:05:43] Sure, it's a four year training program, rigorous four years. There is a big focus in the inpatient world, but also on the outpatient world, the so-called magic of med peds. And this is kind of a basic way to look at it. It makes you a stronger pediatrician and a softer internist. So it kind of balances you out on both sides. The nice part about it is that age continuity. So there's plenty of med peds graduates that go out into primary care. I would like to think that med peds grads have a little bit different training as their internal medicine and pediatrics for the outpatient workup and pathology. Obviously there's no OB or, you know, general surgery rotations like family medicine may have, but it really trains you for a higher acuity, higher diagnostic workup, looking for higher pathology. And for those that want to do two things. One, work in an inpatient setting. I personally am biased, but I will say I don't think there's a better residency out there that prepares you for an inpatient setting than a med peds. And I say that because you spend so much time in the hospital on both sides, and it gives you a perspective of how to navigate patients families and also exist in a multidisciplinary team, the so-called village, that we needed to take care of patients. The other part of it is those that, you know, may not be a hospitalist like myself and do choose to go on to fellowship.
Dr. Dhaval Desai: [00:07:03] There are fellowship opportunities where you can go both categorical ways internal medicine or pediatric fellowships. And there's also combined fellowships. So med grads are doing some really cool things with, you know, congenital heart disease, cf these disease processes that exist on the whole age spectrum and that foundation you get. And then there are those that say, okay, I did four years of med peds, I took the boards, but now I just want to be a kid doctor or now I just want to be an adult doctor, or I'm going to spend more time in the adult, less time on the kids. And that's okay, too. Nobody that I've ever spoken with in the med peds world has ever said, I regret that extra year of training. So it's a really special residency program. Not all academic centers have med peds, but it's growing. Where I work at Emory, they are actually starting a med peds program in the next year, so that's super exciting to hear because a lot of the medical students want it and they want to stay locally, so that's exciting. So that's kind of a brief overview of what med peds is. And that's where my passion led to me. Right until the pandemic when everything changed.
Henry Bair: [00:08:06] You kind of briefly alluded to this, but you talked about how some of your personal experiences actually informed your interest in shaping the human experience in healthcare. Can you share with us what some of those larger personal experiences were?
Dr. Dhaval Desai: [00:08:19] Yeah, yeah, yeah, yeah. I mean, so navigating my parents through the healthcare system has been obviously very eye opening. My father sadly passed away six weeks ago at the hospital where I work at, and that was very challenging, not only navigating him as a family member, navigating him as a physician and going through all of that. And I'm a very strong patient advocate. And, you know, it sort of scared me to think that, my goodness, the patients that don't have a doctor son who works in the system in struggling like this, What's going on with them? My wife was in a position pre-pandemic where she had to have an emergency surgical procedure. I remember how scared I was as the bystander or the the husband, the sort of second victim, if you will. And it was eye opening that so much of what we do in our interactions with patients is transactional. 2 or 3 words you say can stick and make an impact in a very positive or negative way, and sometimes we just don't have that perspective. So those are the types of experiences that I have had and continue to have that open my eyes. And I'm hopeful that they make me a better doctor over time to coach myself and coach others to, you know, get through it because it's tough out there. It's very tough.
Tyler Johnson: [00:09:38] It's striking to me that you have had this very interesting training, in the sense that you have a number of sort of subspecialty niches that didn't even exist until relatively recently. Right. So like med peds is a relatively recent innovation. And in part as you mentioned, that's due to the fact that people who used to have what were considered to be pediatric conditions, things like cystic fibrosis or congenital heart disease or whatever, are taken so much better care of now that they often survive into adulthood. And I know that some of the med peds people that I worked with in medical school told me that it used to be the case that a pediatric cardiologist would have patients who were 30 years old because there was just nowhere for them to go when they got to be adults. Right. And by the same token, it's striking to me that even the term hospitalist. So there was a guy who was in my church congregation when I was growing up who was kind of the quintessential, sort of not quite a country doctor, but that was kind of the feeling. And he used to tell me these stories about he was a primary care internist.
Tyler Johnson: [00:10:38] He would spend all day as the primary care internist. And then when he would get done seeing his patients in clinic, he would just walk over to the hospital. And any of the people from his panel who were admitted he would just go by and see them. That was his rounds. And then he would get their chart and write out their orders. And then, like that was the extent of his doctorly interaction with the hospitalized patients. And he was their primary caretaker both when they were in the clinic and when they were in the hospital. Right. And it's just really interesting to me to recognize that because of Bob Wachter and others over the last 30 years, there was this recognition that inpatient medicine has become so complex that that just doesn't make sense anymore, both because the care is too acute and complicated, and also because just in the same way that kids are not just small adults, hospitalized patients are not just healthy outpatients that happen to be in the hospital, right? They have their own sort of set of problems and their own sort of set of issues.
Dr. Dhaval Desai: [00:11:34] Yep. And then the other side, the bottom line of how hospitals operate, we need all hands on deck and we need throughput. We need quality improvement. There's a lot of sort of administrative, medical, administrative challenges that come up that you really need dedicated inpatient physicians to help you lead and sort of troubleshoot. Yeah.
Tyler Johnson: [00:11:53] Okay. So now getting up closer to your book itself, can you and you do this a little bit at the very beginning of the book. But before we get to the heart of the matters that you discuss in the book, can you just kind of paint for us a picture of both professionally but also personally? What was going on in your life as 2019 turned to 2020?
Dr. Dhaval Desai: [00:12:14] Let me start personally. We were expecting our second child. We had a four year old. Our second child was due in February towards the end of February 2020, and that's when he was born. There was sort of kind of a feeling that there was this virus out there, but it wasn't going to be a big thing. And if it was, it'll be like a common cold coronavirus. I'm a half pediatrician. I've seen coronaviruses in the pediatric population. It's nothing more than a URI. We had our son, and I remember on hospital day number two, my wife was nursing him and we had the TV on in the background. It was Good Morning America, and they were showing the cruise ship that was docked off of Seattle that was housing their guests who had Covid and exposures, and they would not let them off the boat. And it just felt so far, it just felt okay. Well, this is the West Coast. They're on a boat. It's contained. I am in Atlanta. I work at a system that took care of Ebola patients. Surely this is going to be just fine and there's not going to be an issue. Little did I know, my sort of makeshift paternity leave I took for about ten days was the last time of normalcy there was going to be. And bells started whistling and bells started turning. And professionally, you know, the world was changing. Hospital life was changing. Rumors were starting about what if we get a coronavirus patient? We were going to ship them off to the university hospital and keep them in the serious communicable disease unit like an Ebola patient.
Dr. Dhaval Desai: [00:13:48] That was the initial plan. And again, it was not going to be a huge impact. But the day I got back to the hospital, I remember walking up to the floor and I shared this anecdote in my memoir. You know, I was there getting back to work, and I was like, oh, let's see the baby picture. Let's do this. Let's, you know, just one of those fun social days, whatever. And there was like, caution tape as an X on a door and says, do not enter before talking to the nurse. And I'm like, what's going on in there? That's like, is it a TB patient? Like, is there something we need to know? Is it a workplace violence issue? It's like no, no, no he's positive. And I went, okay, so it's here. And that's how it started. And after that day literally it's kind of a blur. But every day changed in the hospital even by the hour in terms of guidelines, PPE, what are we doing? How do we treat. And it was a completely different experience professionally that my world got turned upside down and personally trying to navigate a newborn, a second child and a four year old that's very boisterous. And my wife on maternity leave. And it's it was tough. It was a beginning of a very, very challenging year for me personally and professionally.
Tyler Johnson: [00:14:59] Yeah. One of the things that you sort of detail at multiple points in the book is that you were not just working as a doctor on the front lines, but were also responsible in a leadership position in your hospital. Right. And one of the things that you talk about is, I mean, you alluded to some of the things that were changing, you know. So I think it sort of famous example, right, is the kind of mutating guidelines about PPE over the first part of the pandemic. Right. That at first they were saying people didn't really need to wear masks, and then later on that they did. And then there was, you know, and then eventually we were donning and doffing all the stuff and whatever. But, you know, I remember at the very, very beginning, we often didn't even have at least rapid enough to be very helpful diagnostic tests. Right. I mean, we were going almost entirely based on sort of syndromic diagnoses and suspicion, and then even the professional guidelines that were coming out to the degree that there were any professional guidelines from professional associations were changing all the time. So one thing that I wonder is that as a person who was both on the ground treating patients, but who was also responsible for communicating with your own doctors, what was sort of your thought process about communicating with people that you were trying to lead when it felt like the guidelines about something so definitionally important were changing all the time?
Dr. Dhaval Desai: [00:16:18] I'm an advocate of transparency, and I'm also a believer that silence is deafening. So when we are not saying something about this crisis that everybody's talking about and everybody knows something is brewing, that deafening in the silence behind it is too much. You have to say something, no matter if you have the right answer or wrong answer, or you frankly don't know what's going to happen. Acknowledging that was my motto and it would be at least daily email updates of where we are at. A lot of Reply All's, keeping the group updated, text messages back and forth saying this is the latest managing expectations. My team saying, well, what's going to happen when we run out of masks? What's going to happen when we have too many Covid patients to take care of and we can't do it? What's going to happen when three of us are sick and there's only four doctors that we can have working that day and managing, and these were all real scenarios that came up and I did not have answers to everything, but I listened, I validated, and I also showed that I was concerned and I was equally as scared at times. The day I will say I was the most scared is when I heard from my, you know, the daily 3 p.m. leadership huddle that the system has leased a refrigerated morgue, anticipating excess mortalities that are morgue can handle in the coming weeks.
Dr. Dhaval Desai: [00:17:40] And I remember in this leadership meeting, I heard that and I was like, what? And I was looking around left and right, looking for somebody to give me eye contact in shock and put their jaw drop and says, this is crazy. And guess what? Not one person did that. Everybody had the stoic look on their face. And I don't know if everybody was in this transactional mode to saying, okay, checklist, checklist, checklist. We're doing the next thing pretending to be strong. But I was like, guys, this is ridiculous. Are we listening to what we are hearing? This is very serious. We need to express some emotion around this. So, you know, I'm a type of person that I think it's okay to be vulnerable. I think it's okay not to be robotic. I think there's a time where leaders have to be strong, obviously, and a force to lead and navigate their teams. But I think any vulnerability is a strength because it humanizes us a little. And I'm a big believer in that. I don't know if I did that as well. At the beginning of the pandemic, when everything was sort of brewing, I think I was in survival mode more than anything, like most of us. But as things progress through the months, I definitely kind of approached it more in a vulnerable state.
Henry Bair: [00:18:46] So I want to pick up on something you mentioned in passing, really, but I think it touches upon something that goes deeper into your perspective of leadership and human relationship. You said that in moments like these, we need to express emotion, which, you know, in the context of like a in one of those leadership meetings, you might think, well, you want it to be efficient. You do want to make sure that things get done. So to me, it is striking that that was what was going on in your mind. I'm wondering if you can expound upon that. What do you mean by we need to express an emotion in this? Like why? To whom?
Dr. Dhaval Desai: [00:19:19] I'm not saying we get around a campfire and cry together. That's not what I'm saying. But I'm really saying if you're hearing something that's shocking, like you're going to now have so much mortality and deaths in this hospital that we will place bodies in a truck, a refrigerated truck, that is not what we are trained to do. That is not what we are used to. And frankly, that doesn't feel very human to me. What we are doing, and if we are facing a crisis where that is going to happen, I think it's appropriate for all of us to pause and say, okay, how does this make us feel? And again, I'm not trying to be all Kumbaya, but it really is, because I will say the mental health challenges that we all experience are a lot of experience. Like myself, I think one of the things is, and I remember in medical school, even on rotation, saying, you know, you can't show emotion. Sometimes you can't get overly attached to your patients and you know, you got to be strong and you have to have a thick skin. And that's fair.
Dr. Dhaval Desai: [00:20:13] But that's not a long term sustainable model, right, for a personal model. And that's what I mean by that. The way I would have prefaced it, and maybe I don't remember how I told my group this, but look, this is scary. This is what's going on. We are expecting likely more mortality than we can handle. So we have a refrigerated morgue if we need it. It is alarming and we're going to take it day by day. This is the power of words and those empathetic words that come with communication that can be firm. I don't do well with pure transactional type statements like that, especially when it's something so critical. But I remember that scene, and it really was shocking that nobody around me reacted like that. And maybe I was maybe I was the sensitive one, and maybe I was the one at that point. Should have recognized, ooh, something's brewing there. We need to do something about it. But, um, I will challenge anybody back in that room if we go back and kind of watch that on video. Like, what were you really thinking at that time?
Tyler Johnson: [00:21:05] That brings to my mind two thoughts. One is that so I'm a medical oncologist. When I attend on the inpatient oncology service, we always have interns or first year trainees who are who are rotating on the service like myself. And this is a yeah, like like Henry. This is a sort of a terrible thing to admit, but it's true. You know, the inpatient oncology service, right, are some of the sickest patients in the hospital. Right. So these are patients who often are not I mean, some of them are just, you know, transiently sick on their way to getting better, you know, through chemo or whatever. But many of them have late stage cancer. They've been heavily treated with lots of medications and are in some, you know, some phase of dying. And so because of that, whereas on a normal internal medicine service, a death while you're on service is the exception to the rule. On the inpatient oncology service, a death on service is the rule. And sometimes it's many deaths, right? We could have 5 or 10 people who die during a two week stint on the inpatient service. And the reason that I bring that up is because I came to recognize over time when I had been in attending for probably, let's say, 4 or 5 years, we were, you know, rounding one morning. And as we were rounding someone, I don't remember if it was a nurse or a member of the team sort of came over to the team that was huddled there and said, doctors, I wanted to let you know that patient so-and-so, who who had to be clear, had been on sort of comfort care measures, had died.
Tyler Johnson: [00:22:35] And I sort of heard that. And said, okay, thanks so much. And then, you know, went on to whatever the potassium of the person that we were rounding on or whatever. Right. And it took about 60s. It was like there was this sort of like delayed flare in the back of my brain, where then all of a sudden I was like, whoa, whoa, whoa, whoa, wait a minute. Somebody died, like, and not just somebody, but this was somebody that the intern in particular? I mean, I don't remember the details, but it's entirely possible that that was the first time that that particular intern had ever had a patient that they cared for die while they were on service. And furthermore, for all I knew, I mean, to me it felt like, okay, this was a person with very advanced cancer who was already on comfort care measures. And the death was not surprising. But to the intern, that news may have been devastating. It may have been surprising. It may have. They may have felt guilt. They may have wondered if they had done something wrong on the admission that led them to eventually be on comfort care that led to them or whatever.
Tyler Johnson: [00:23:41] Right? But the point is just to say that I had been doing it for long enough by that time. I had been attending for long enough, and I had become accustomed enough to death that I failed to recognize that for other people on the team, that experience might be hitting in a totally different way. And I try to really make an effort now, even if I'm in a place where I might be able to take something like that in stride, to really kind of slow myself down and say, well, now wait a minute, I need to think about how this is hitting every member of the team. So that brings me to the second thing, that what you were talking about made me think of, which is that during the pandemic, obviously at least one element of what I just described did not obtain during the pandemic because nobody was used to it. Nobody had encountered this before. Nobody, you know, had that as part of their routine. But I still I know that I got to the point during the pandemic, like at the beginning of the pandemic, I remember it felt like every time we got, you know, some terrible piece of news, it was like having a wave crash over me. And it was devastating. But then eventually, at some point, I just felt exhausted and numb.
Tyler Johnson: [00:24:53] I felt like I had received so many blows that rather than sort of giving every individual blow the dignity of being hurt by it, it was easier to just kind of try to like, check out and be numb to it because it was just, you know, bad news after bad news after bad news after bad news. Yeah. And so I don't know how that may have affected people who were, you know, sitting there in that meeting or at other points of the pandemic. But I guess, by way of a question, again, as a leader, you know, you were talking near the beginning of the podcast. You were talking about how one of your challenges, just in a general sense, is to try to keep people motivated and plugged into the deeper meaning of doing, you know, of being in medicine in the first place and all those kinds of things. So all of that is hard enough on a regular Tuesday, right? But in the middle of the pandemic, when people were almost everybody was working extra shifts and extra hours and is so tired, and plus they're dealing with the existential despair of what if I get this virus or whatever else? How did you, as a leader, try to help people to navigate that critical burden of burnout and fatigue and sort of, you know, existential tiredness?
Dr. Dhaval Desai: [00:26:05] I would say I did a few things. One, I would acknowledge that how hard this is, I would not downplay it. I am not the leader that's coming from a top saying, we can do this. Let's just get through it next week, next week, next week. We got this move on, acknowledging how hard it is, connecting with my team and the frequent communication whether it's email, text or in person or zoom. By then we were all doing zoom a lot to talking about this is what's going on, this is what's happening in our lives. And then we would have these little wellness sessions that would host just so that. We have conversations about what's going on, sharing what are we doing to take care of ourselves, and everybody kind of share their thing. And then it was it was challenged back and they said, what are you doing to take care of yourself? And I flustered with words. I didn't have any one thing to say. And I said, well, I go to Costco and I like going up and down each aisle. And it relaxes me to look at things in Costco and no one bought it, although I do love Costco. But getting back to it, you know, I think it's I think it was the humanity in it was my strength, honestly, as a leader, connecting with everyone as an individual and acknowledging that, yes, I have the superior role of being the leader and navigating and advocating, but I let everybody know that I'm on their side. I'm navigating and advocating, and I let them challenge me back. But that was the appropriate thing to do. I was not superior to where I have all the answers. And there was a time when we were getting, if you all remember, people were donating PPE stashes of stuff they had, and two of our physicians had stuff donated.
Dr. Dhaval Desai: [00:27:26] And I said, oh, guys, you know, we really should share this with the hospital and the central supply and let them divvy it out. And they kind of looked at me like, no, this is ours. And we're hiding this in this office, and we're going to keep this. I'm sorry we're not sharing this. If there's if things get worse, we need to look out for ourselves. And I said, okay, you know what? You're right. This is our secret stash. And we're going to keep it here. So I don't mind being corrected on that. And that was appropriate. And, you know, I think, you know, for what it's worth, every leader can experience a disruptive subordinate. And I don't like to use the word subordinate. But during that time, we really didn't have much of that because I think there was open communication and, you know, listening and validation of each other and also staying in the weeds. That's another reason I did it. I was not the leader that was far removed, saying, well, you're going to have to don and doff and wear all of this when you see these patients, because that's what you have to do. I was right there with them learning how to do it too. So that's the way I did it. And that's the way I still stand of any leadership role right now. And if I pursue another one, I tell myself that I have to still be in the trenches working as a clinician, no matter what type of leader I become or grow into.
Henry Bair: [00:28:32] I'm curious because again, this this is in the title of your memoir. So can you tell us moments when you have encountered this resignation, this burnout that you've been trying to help other people navigate through? Like, when did it hit you the most and how did you get through it or process that.
Dr. Dhaval Desai: [00:28:49] Summer of 2020? I was coming home after a busy day at the hospital. Keep in mind, my wife is now caring for a four year old who's out of preschool because everything shut down, and a infant newborn infant who's 6 to 8 weeks old and I'm away a lot of the days at the hospital and when I'm home, my mind is completely distracted. And elsewhere, when I'm trying to hold my baby or do something. And my daughter, she was learning to ride her bike without training wheels, and that's all she wanted to do. And that was going to be daddy's thing, my thing. The teacher is great, and I personally thought four was a little young to teach her because I didn't learn until I was six, but a lot of her friends were doing it and I said, fine, we'll do it. There's something to do. And all she wanted to do when I got home on a summer afternoon was go outside and practice riding her your bike. And that's the last thing I wanted to do. All I wanted to do was come in, shower, change and just kind of ride a wave veg and have my own time get through the night. And I say that openly. Not to say I'm a bad father, but that's how I felt that night. But I still forced myself that afternoon and, you know, got her out there training wheels off and doing my thing with her and like, pedal, pedal, pedal. And she actually did a few pedals without training wheels.
Dr. Dhaval Desai: [00:29:52] And it should have been this immense joy. That is so cool. You did it. Yay! You know, that's the type of dad I am. But in that moment, I remember faking my way through it and I was like, okay, I am not feeling any joy right now. I am not feeling this. There was another day after, you know, a week or two after my wife went back to work. I think she had part time initially. I don't remember exactly, but anyways, I had days where, you know, we were zooming for meetings and all said, okay, well now childcare is an issue, so I'll zoom meetings at home and have the kids, and I'm looking at my adorable three month old baby at the time, and smiling and cooing and doing all the cute things babies do. And I remember saying to myself, why am I not more happy in these moments? What is going on here. And I ultimately had to, to your point, kind of resigned to that fact. And that evening, tell my wife like something's not right. I am not feeling the joy. I am not feeling happy. I really think I need to do something about this. And whether that's medication, whether that's therapy, whether that's a combination of two. I don't know what it is, but something's going to have to change because I am feeling it. I am in it now. And that's what led me on my journey. That was the start of it.
Henry Bair: [00:30:56] That's such an important point, because when we talk about burnout in professions, I mean, burnout is sort of a vogue term now in the workplace and even in healthcare, I think we talk about it. We kind of confine burnout to the workplace. But as your story illustrates, the insidious thing about burnout is how it affects various aspects of our lives.
Dr. Dhaval Desai: [00:31:16] And it was weird for me because when I was in the hospital, I was there, but I was thinking, well, what's going on at home? Let me FaceTime the kids, let's check on them. When I was home, like, oh God, what's going on at the hospital? What's going on here? How did that situation go? And it was this colliding of the worlds, and I couldn't separate. They were overlapping and I couldn't escape either of them. And I didn't want to escape either of them. But I also didn't know how to manage both of them. And I would argue there's some professional burnout there, but I would argue deeper that there were some mental health issues going on, probably for a long time between the coin as you flip it, anxiety, depression, anxiety, depression. Which one is it? Depends on the day I was going through it, and this was the cherry on the top in my body was trying to tell me by summer the adrenaline is down. You are now going to have to do something to help yourself. And that's what I you know, I made a point with my primary care physician who's connected to the hospital. He comes and has lunch in the cafeteria, you know, that sort of thing. And he's seen me around, you know, he walked into my appointment, and this is important. I'm telling the story. And I said, you know, he's like, how are you doing? I'm like, honestly, not great. He's like, okay, when are we going to do something about it? It's time.
Dr. Dhaval Desai: [00:32:20] And I said, how do you know? He's like, are you kidding? I see you walking around the hospital. I see your face. You're struggling. It's time we pharmacologically do something. The time is now. And I said, are you sure we have to do that? Am I really at that point where I need that? Yes, yes. And I said, okay. And that was the start of that. And it was, you know, even for me in that moment, knowing that I was struggling and knowing this was the right answer, I still kind of fought the idea. Like, really, I'm going to have to be on medication. Like, how did I get to this stage? What happened? But it was good. It was a good epiphany for me at that moment, and my wife was very supportive, and I thought it would be a she's a physician, too, and I thought it would be a bigger deal for her. And she's like, it's fine, you're going to do it. And we're going to keep moving on to the next step. You're going to try it. And that's been a journey in itself, right? Managing psychopharmacology and changing medications. And that whole journey I talk about in my book of medication side effects, you know, adding therapy to it. And it's not an overnight solution. Right. And taking medication did not mean all of a sudden I was happy again. No, that was not. Yes, I was sleeping a little better despite having an infant.
Dr. Dhaval Desai: [00:33:23] I was, you know, managing things a little better. My appetite was a little better and I could say, okay, this is doing something in the back of my mind. I knew, okay, well, I have an issue and now I'm doing something about it. In those first few months, when I was going through that sort of process, I did not share it openly with anybody at the hospital. Not for fear of retaliation or embarrassment. I just said, I just want to keep this to myself. And what kind of changed that is when I read about Doctor Lorna Breen, who passed away from suicide in the summer of 2020, in her New York Times article, came out about the story of what she went through. And I promise you, when I still read that article step by step, paragraph by paragraph, of what happened to her in a temporal relationship, I have a visceral response. I clench up. I just feel like this could have been any one of us. I was never suicidal, but the path that went she had to go through and how she kind of had this downward spiral. Oh my goodness. It could have been any any one of us. And her story to this day still kind of chokes me. And it's very unfortunate the way it happened. But I'm glad her family has found this foundation to help make things better for all of us. But that story in 2020 was really more validation that I need to take care of myself.
Tyler Johnson: [00:34:47] For listeners who are not familiar with that story, if you Google her name, you can find articles from that time. But I think that her that this was a physician who, um, as you mentioned, died by suicide relatively early within the first year, I think, of the pandemic. But I think that her story was felt like I mean, it was certainly a shock wave on the one hand, but on the other hand, I think it felt like a wake up call to many health care practitioners at the time who, as you say, may not have been experiencing exactly the same things that she was and may not have had the same degree of things going on. But I think that everybody felt this sort of shock of recognition like, yeah, that is just how hard this is and just how overwhelmed we are and just how sort of, you know, bleak things seem right now. Right? And, and I know that even in Northern California, which during the first year of the pandemic, you know, it felt like we were sort of in a defensive crouch for a year because we didn't actually have an overwhelming wave of patients until the second wave that hit around the time that the vaccines were being released at the beginning of 2021.
Dr. Dhaval Desai: [00:35:56] And that was our third wave.
Tyler Johnson: [00:35:58] Yeah, the number of patients was not particularly high. But what was still going on, even though we were not facing, you know, refrigerated morgue trucks or whatever, like a lot of the cities on the East Coast, there was still just this almost sort of existential despair that attended everything, because on the one hand, in the hospital, it was like working with zombies. Right? Like you, you were too tired to really talk to anybody. You couldn't really establish community because you couldn't so much as take your mask off to eat a sandwich in the team room, right. Like, and it's very difficult if you've ever worn an N95 mask, it's just hard to talk in an N95 because you can't really hear and you can't really understand, and everything's sort of muffled and garbled and whatever. So it was almost impossible to form community. You weren't supposed to touch anybody. You were still supposed to stay six feet away from people, even if you were sitting in the team room working on your notes or whatever. I mean, it was just sort of the death of community, even in the hospital. And then when you left the hospital, at least here in Northern California, for all intents and purposes, you were virtually on house arrest, right? Everything was closed.
Tyler Johnson: [00:37:02] And I think that world shorn of community and shorn of even in many ways friendship, except for the very, you know, except for your immediate family. And then on top of that, to be trying to provide care. And I know another thing that I had just never I mean, it sounds so obvious as to be ridiculous in retrospect, but it had never occurred to me what an enormous help and privilege it is to have patients be able to be supported by their loved ones in the hospital. Right. And for a long time, Stanford was on complete lockdown, where nobody was allowed in for any reason, even if their, like, spouse was dying, they still had to zoom. They couldn't come in physically into the hospital and that was hell. I mean, to see these patients, many of whom are like, you know, covered in all of these lines and wires and different kinds of, you know, whatever. And who then are isolated from all the world and can only communicate by zoom screen. It's just it's difficult to convey how, like you say, like the feeling in your bones of how difficult that was.
Dr. Dhaval Desai: [00:38:11] I remember holding an iPad as an intermediary with a husband and wife, or the husband was at end stage of complications related to Covid, and she was reciting a prayer to him. And there I am in my PPE, just holding an iPad. How did we get here? And I'm, you know, to your point about lockdown and how patients, everybody needs an advocate. I think we said that at the beginning, but I can tell you there were adverse outcomes that patients experienced for those who could not advocate for themselves because nurses couldn't be in there for long. We're not in there that long. Right? And they're alone. So very challenging, very challenging times. Um, very impersonal times. Uh, and, you know, and this is not a plug for my memoir, but just talking to you guys, I bring up all these stories and anecdotes of what happened in real ones. And an analogy I like to use also is that hospitals are micro societies, and everything going on outside of the hospital walls in this particular community is transferring back inside those walls. And I think a lot of people who don't work in healthcare may not fully realize that. And there's a lot of stressors. There's not only the pandemic but the murder of George Floyd. There was so much tension, especially living in the south of what was going on. And we're better now because we experienced all of that. But going through that, as you know, the twin pandemics, so to speak, of Covid and racism, oh my goodness, surreal. All that we were going through, all of us and more especially our the minorities that were feeling it. So a lot of things going on during that time and you know, it comes down fundamentally that how do we work as a team and how do we take care of each other? And when do we know when too much is just too much? Right. And we're at a saturation point.
Henry Bair: [00:39:53] We've been talking a lot about some of the most difficult moments during the pandemic. We also do want to shine some light on the more positive stories, and one of the things that I think has we'll all remember if we were in healthcare during the pandemic was the phrase healthcare heroes. And I actually know plenty of people who don't like that term. I know plenty of people in healthcare who feel like it's. It's just my job. You don't need to, you know, glorify me any more than any more than my job requires me to do. But nonetheless, I'm wondering, what is your perspective on that phrase? And were there, if any moments of genuine heroism that you would like to highlight from the pandemic?
Dr. Dhaval Desai: [00:40:37] I would like to say that, you know, when we were healthcare heroes and we had banners and posters and food deliveries, the first part of the pandemic, it felt good. I'm just going to say that I'm like, wow, the community is really rallying after us and this is so tough, but we are actually being recognized. And historically, you know, hospitals and healthcare workers and the hospitals don't get recognized unless something bad happens or sentinel events, right? And now we're getting all this positive accolades and praise instead of, you know, for me, it felt like, okay, instead of this isn't you're right. This is an expectation of what I should do. I signed up for this. Fine. But now I'm getting that recognition saying, look, I'm being thrown into this fire, and this is a whole community that's rallying around with us. The problem with that is it was not sustained and health care heroes to zero essentially. Right. So we were all health care heroes for 3 to 6 months. Vaccine came out. And then 2021, there was no talk of us being heroes. And we had vaccine hesitancy. We had Covid surges in unvaccinated patients. And this talk, the three of us talking is not about the Covid vaccine and advocacy for that. But I'm saying the conversations that we had to navigate relate to total disdain towards healthcare workers and the theories behind everything, and that the conversations we had to navigate and the things we had to do when we knew that there could be something that could prevent you from being hospitalized and people were not doing it, the community was not necessarily all in in rallying for us. It was it was a whole different perspective.
Dr. Dhaval Desai: [00:42:01] And, you know, I'm always an advocate, especially after going to the pandemic, that healthcare workers truly are heroes, right? We are, to your point, being an oncologist in the hospital, seeing the end stage of cancer and navigating these patients and families through to all of the other work that we do. This takes a human toll on it, especially if we do it right where we have that human connection, and doing it right and knowing that patients are appreciating and receiving the care that they need. And we're getting that feedback back saying we navigated, we did the right thing for them in that time. That's very gratifying. And people often say, you guys are heroes. Thank you so much. And I'm not looking to be called a hero, but I do know what we do in healthcare, and I think we need to acknowledge it because, you know, instead of the old school mentality and I'm sorry to call it old school, but of soldiering through and this is what I'm doing, and I'm an ICU nurse and this is what I signed up for, and I'm going to be doing this and that and work all these long hours and see death left and right and boom, that's me. And I think a minority of people are programed that they can really successfully do that. But I think the majority of us are actually more human beings. And there's this whole new generation of workers coming in because we're looking at this that are now saying in their age group, you know, that 20 to 20 2 to 30 years old saying, look, my parents worked so hard that they were never home.
Dr. Dhaval Desai: [00:43:16] They were giving their soul to their job, whether it's healthcare or else. We're in a place where we're challenged. We don't want to do that. We can't do that. We have to have a balance and we have to say as leaders in our field, yep, that's perfectly okay. Let's have balance. But let's also make sure we're still being human, but acknowledge that we're going to have balance with it. You know? So what I'm getting at is that the workforce is now changing. And I think to motivate the workforce, we have to maintain that there is a human connection here, and we are ultimately making a difference in someone's life, whether we're seen as a hero or just an amazing caregiver. We're making a difference. And I'll say that point's very important because so much of healthcare is so transactional, and it's the whole phrase is our patient. Are they an object or are they a human being? And I worry, I worry that too many people are treating patients more like objects than human beings. And I've seen that with my dad situation of being in and out of the hospital for five weeks before his death. You know, overall it was good. But were there opportunities? And were there times when like this was not good? Yeah, there were. And I'm saying that it's where I work and I could see that. So, um, I digressed a lot with the healthcare heroes question, but I think it's an important points on, um, kind of where we were, where we're going and, you know, the next phase of our healthcare workforce and how we need to handle it.
Tyler Johnson: [00:44:33] Yeah, I think it's a point that some people, especially Housestaff, I heard make during the pandemic was the term hero can be very slippery because on the one hand, calling someone a hero, recognizing someone's heroism can be a beautiful way of saying, you demonstrated moral courage. You did this thing that was extraordinary, that goes above and beyond anything that you were probably expecting to do when you came to medical school, right? But on the other hand, what some of them pointed out is that even though it can, on the one hand, be an appropriate, helpful, even beautiful way to recognize moral courage. On the other hand, it can kind of be a cudgel, right? It can kind of be like a tool of manipulation to say, well, what do you mean? You want to work less hours? Aren't you a hero? You're supposed to be a hero.
Dr. Dhaval Desai: [00:45:27] It sets an expectation that you're going to do anything and everything.
Tyler Johnson: [00:45:30] Correct, right? Of course. Interns work 80 to 90 hours a week. Your health care heroes, right? Like, it's. This is probably resonating in Henry's bones right now, but, like, there's this. Whether they use a hero at your institution or not. But the point is, you have to be really, really careful because it does. And and, you know, to be clear, especially the first 6 to 12 months of the pandemic and especially on the East Coast of the United States and other places that really got hit hard, then there are times where the only solution is heroism, right? Like, I mean, there just weren't enough people to not have all the people working, all those zillions of hours and doing all of those terrible things. But if you extend it beyond the absolute minimum necessary, then it goes from being helpful and beautiful. I think can go to being a tool of of manipulation and pressure.
Tyler Johnson: [00:46:19] So, you know, we've talked a lot about kind of big picture questions, both in terms of what was the pandemic like and in terms of sort of what your perch as a leader during the pandemic at your hospital, what that was like? I want to bring it back down and sort of close the loop to the something that we talked about right at the beginning of the podcast, and that you've alluded to a couple of times through our conversation, which is that you have made the point multiple times. For example, you said a few minutes ago that you worry that in healthcare we have arrived at a point where we are starting to treat people like objects, at least in some cases, rather than like people.
Tyler Johnson: [00:47:03] And I know that the way that Henry and I have, we very much agree with that sentiment in the way that we have described that is that we feel like oftentimes doctors become like very, very complex machinists who are taking care of very, very complex machines, but that it becomes almost a technocratic endeavor because it's just about fix the machine and get them out of the hospital or, you know, whatever. So I guess my question, though, is that's an interesting philosophical point. But if you have someone who, let's say they're in their third year of medical school going through their, you know, their core rotations, or I think even more to the point, somebody who's going through the rigors of their residency or their fellowship, where they're probably busier than they've ever been in their whole lives, they're probably more tired than they've ever been in their whole lives. And they're feeling like, dude, it's everything I can do just to get the boxes checked, just to get the notes written. Like, you know, humanity. I'll do that next decade. Right now I just have to get my stuff done and get home. Right. What would you tell them about? Like, what are practical ways that that person on the ground who is busy and tired and stretched too thin can actually find a way to reinfuse their practice with a measure of humanity.
Dr. Dhaval Desai: [00:48:18] I would argue that they're not as busy as they think. And I say that with all respect to time, and I say that to myself when I'm trying to rush through my day, because I got to pick up my kids, that the extra 60 to 90s you can spend with the patient. And you may be wondering, well, what am I going to talk to them about? The one thing I few things I coach my team on social history is so important. So where do you work? What do you do for a living? Oh you're retired. What did you used to do? What part of town do you live in? Oh, I saw you travel. I've been there, you know, like find something common or. Oh, you had my colleague Doctor Smith yesterday. Did you know I went to medical school with Doctor Smith? You know, have a little bit more conversation. And I'm not saying that that's going to make you feel like more of a human being, but I guarantee you two things will happen. The patient will appreciate that connection a little bit more. They're more likely to remember you. You're more likely to remember the patient at the end of that. And you're going to feel like I'm I'm doing something more. It's like when Atul Gawande, I saw him present at the press Ganey conference for Patient Experience in 2017, I think, or 18. And he has the questions are, are you a technician or are you a clinician? And just to your point, machinist or what are we and where's the overlap in the two? And I would argue it comes down to simple things to help build rapport in a relationship.
Dr. Dhaval Desai: [00:49:39] And I you know, I don't work with trainees like you do. So you may you guys may be doing this already in your curriculum, but really coaching on that. And I will say when I was in training, especially residency, those skills or whatever they call them now when they observe you, I got coached on that several times. And this is not to toot my horn, but sometimes I was put back in the center of doing it in front of others, thinking I'm like, oh gosh, are they really putting me in the spotlight? But it's because I was told later that I'm actually establishing relationship with them and finding commonalities. And you know, that warmness, so to speak. And it ultimately I shared this. I didn't make up this one. But compassion is the antidote to burnout. And that's what I learned at one of the conferences I've been to. So if we can deliver compassion and receive some degree of compassion, those thank yous, those little things we really need to take back and say, okay, I actually did something good today. So that would be my simple first approach of if you can tell your trainees to change 1 or 2 things, try that and see how they do, because I know these are where we live by, and I see us including myself, scrolling, doom scrolling as we're walking the halls and doing that, we have time to do these things. We can make a little bit more time to do that. So not a magical solution, but that's one of one of the takes you can have on it.
Henry Bair: [00:50:53] We're not as busy as we think, and doing those things takes less time than we think.
Dr. Dhaval Desai: [00:50:57] There we go. Thank you. Well said, well said.
Tyler Johnson: [00:51:00] Both true. Well on that practical and hopeful note, dhaval Desai, we really appreciate you taking the time to be on our program, and we will link to your book and your bio in the show notes. And thank you so much for being with us and have a great day.
Dr. Dhaval Desai: [00:51:15] Thank you for having me.
Henry Bair: [00:51:16] Thank you very much. Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show. Available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:51:39] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:51:53] I'm Henry Bair
Tyler Johnson: [00:51:54] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.