Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
“I had sent an email to some key people in my organization about managing patients’ expectations and how that needed to be addressed differently on an organizational level. The truth of the matter is that I am powerless to change the way the system handles a lot of things. The more personally relevant issue is managing my expectations, both how I relate to the needs/expectations of those in front of me and my own personal needs and expectations of myself in delivering that care. Since we truly only have control over ourselves, the key question becomes how do I manage my own expectations better as a way of managing my own inner resources, namely, time, energy, and mental/emotional output?”
Anne M. Miller is a psychiatrist.
She shares her story and discusses her KevinMD article, “Managing expectations in the face of COVID-19.”
Did you enjoy today’s episode?
Rate and review the show so more audiences can find The Podcast by KevinMD.
Subscribe on your favorite podcast app to get notified when a new episode comes out.
Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.
Also available in Category 1 CME bundles.
Powered by CMEfy – a seamless way for busy clinician learners to discover Internet Point-of-Care Learning opportunities that reward AMA PRA Category 1 Credit(s)™. Learn more at about.cmefy.com/cme-info
Do you know someone who might enjoy this episode? Share this episode with anyone who wants to hear health care stories filled with information, insight, and inspiration.
ADVERTISEMENT
Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.
Today on the show we have Anne Miller. She’s a psychiatrist, and she wrote the KevinMD article “Managing expectations in the face of COVID-19.” Anne, welcome to the show.
Anne M. Miller: Thank you. Thanks for having me.
Kevin Pho: So we’ll get into the article a little bit, but first off, can you share your story and journey to where you are?
Anne M. Miller: Sure. As you said, I am a board-certified adult psychiatrist for about 12, 25 years at this point. I also have a background in integrative medicine, so I guess that would make me an integrative medicine psychiatrist. I’ve got some acupuncture background, and I’m in some coaching certification and professional trainings. I’ve done everything from working in a hospital-based practice, to an outpatient clinic, to owning my own private practice for about 17 years. Part of that time I did it cash; part of that time I did not. And I guess you could say you learn a lot doing all those different things.
What has probably really launched me more in the direction of formally doing coaching has to do with the fact that I’d rather teach people skills than prescribe pills. What I struggle with, I think, is that we’ve got a paradigm within medicine where, even though we have all this information out there on the internet for people, that does not necessarily make somebody an engaged consumer. It makes them somebody who at times can be a bit demanding and think they know what’s going on because they read whatever blogs, and they come in and want a certain pill to solve a certain problem. And I see medicine as much more than that.
It’s interesting to me that the whole field of lifestyle medicine has come to the forefront as an entity unto itself, because as far as I’m concerned, that should be the basis of all medicine, period, right? Diet, lifestyle, those types of changes where you engage a person in those types of things. And when we know that about 80 percent of what’s hitting the door in any practice is generally stress and/or potentially implicated or improved by diet and lifestyle, it blows my mind that that’s not the foundation of the medicine that is in existence today in American culture. That having been said, you are constantly swimming upstream trying to get people to implement change, right?
So yeah, I decided that I need a different paradigm; I need a paradigm shift. And while pills are amazing, and our health care system is amazing, I think, for acute illness, it is not that useful for chronic illness, and I think most docs would agree on that. So for me, it’s about how you help people shift and change. It’s about how you help people with the skills around that, and coach them, and be a partner alongside them in that journey.
One thing I didn’t mention is that about seven years ago, a key person in my life, who raised me part of the time, died. When you’re standing at the bedside of someone who you didn’t expect to die, she was in amazing health, this was pre-COVID, so it had nothing to do with COVID, and you’re realizing, “Gee, I’m 33 years away from being where she’s at,” you start to get serious about, “OK, what else do I need to bring into my life, and why am I waiting? What am I waiting for to move some of that forward?” And she was really amazing in that she was a role model, doing things in her 70s. I think we had conversations where she also was like, “You know, I waited too long, and I should have this, and I should have that.” So all of that is what brings me to where I am here today.
Kevin Pho: So why is it difficult to practice holistic medicine, lifestyle medicine, integrative medicine within a traditional psychiatry practice? What are some of the obstacles that prevent you from doing that within a traditional practice?
Anne M. Miller: Good, really good question. So time is one, right? That’s a huge one. Reimbursement is another; that somewhat goes with time, and in other ways doesn’t. And what I felt like within the culture with patients is that I saw this switch from, “OK, I don’t want prescriptions, but give me all these other pills,” right? So we switched from one set of pills to another set of pills, and you’re still struggling to get these people to recognize, “Nope, it’s really about a complete mind shift. It’s about diet and lifestyle. It’s what you’re putting in your mouth.” And I think in the typical way of American culture, we want to keep doing what we’re doing and just add something as we go, right? The real behavioral shifts, I think, are really hard for people, and I think this is where a coach comes in.
And I’m not sure. When I was doing a more holistic-based practice, I realized how critical coaching was to help people make change. But really, the folks that come to you for holistic, integrative medicine are like, “OK,” and it’s like another set of pills. And the other thing that is problematic with some of that is that it then presupposes that people have a certain amount of disposable income so that they can then go and get those pills, right? Whether it’s turmeric, whether it’s a detox formula, whatever. When in reality, it’s the core basis around breathing, stress reduction, diet, and exercise. But we want to be on the go, go, go, and we run off our adrenals like crazy in this culture, and it doesn’t work, and it costs everything.
Kevin Pho: All right, let’s transition to the KevinMD article that you wrote. This was at the end of February. It’s titled “Managing expectations in the face of COVID-19.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided?
Anne M. Miller: Sure. I decided to write it coming home one day pretty fatigued and burned out. And so it was born out of a moment of pure exhaustion, married to the insight of, “I’m not the only one that is having this exhaustion.” Having talked with some colleagues, whatever, I’m not the only one that’s wrestling with demand being greater than what we can provide. That particular day, I was dealing with the fact that we didn’t have enough therapists to go around. And so if my role in this one organization is purely, again, to prescribe medications and not to do the piece around therapy, and if I don’t have access to somebody who is a therapist that can provide some of those skills, I’m then doing all these extra steps, running behind. And the pressure and the stress for me of going home that night and struggling with, “How much of a risk is this person? Did I miss anything? Should I have done something different?” is what brought this article into fruition.
So the summary of the article would be me wanting to eat my way through some cookies that night and then realizing, you know what, I think you need to be your own therapist to yourself about what’s going on that needs to be addressed. So what I came up with was about five different things that I basically told myself I needed to work with, and then I decided maybe this needed to be an article.
So number one has to do with the expectations: You’re going to be overwhelmed in the current climate that we’re in. I mean, the climate pre-COVID wasn’t that great, but in the climate we’re in now, where people are more stressed, and now that the physical aspect and the hospitalization piece around COVID is less, I think what we’re seeing within psych is more demand, because these people have been holed up in their houses, the stress and anxiety have gotten bad, they’ve had trouble maintaining their jobs, blah, blah, blah. So they’re overwhelmed, they’re not presenting themselves in the best way possible, and they create a bit of chaos in the office, for the most part, with the demands. I’m not saying that those aren’t legitimate, but it’s a bit problematic. So number one, come from the perspective, at least with where they are, with where we are now, with fewer people working and the like: Expect to be overwhelmed. OK.
Number two, expect that people and patients will probably be dissatisfied, no matter how good you’re bringing yourself to that job that day. We like to bring our absolute A-team to it, and we like to have the validation that you really helped somebody. You like to see that validation in the form of somebody’s stress level maybe coming down within the office, and them thanking you on the way out, and that’s not always reality, right? It might be later that they’re having a conversation with somebody and say, “Gee, that doc really helped me.” And then again, they may never even see it, because they’re in their own little world. But expecting that patients and people right now are going to be dissatisfied, for me, helps downshift my expectations so that I’m handling things from a different, more open space.
Number three was to validate your own helper inside. What that is, is patting yourself on the back, saying that you’re doing the best job you can be doing, that you are, and being less critical of maybe where you didn’t meet your A game, to the best of what your expectation is. By definition, physicians have these incredibly high, perfectionistic expectations, and I think we’re our own worst enemies in our head. We just are. That produces really good care, but it doesn’t produce really good self-care for yourself at home, right?
So again, validating your own helper, providing nurturance or nourishment for the nurturer, that being to yourself, right? Like being more compassionate to yourself in whatever form that takes for you. And if you’re having trouble being compassionate, turning something on. What I talk about in coaching, when I’m working with somebody, is, “What are the three to five things that are inspiring to you that can help you mood shift?” How do we mood shift without it being a drug? There’s an amazing concept, right? How do we mood shift without a drug? What are those, listed for yourself, that you might need to keep scribbled somewhere? Because in the moment, you may not remember to go to it. So again, nourishing yourself, having compassion for yourself, and figuring out what you’re passionate about outside of medicine is critical.
And number five wraps a bunch of that up as well: good self-care techniques, regular diet, exercise. There have been plenty of studies talking about people, all of us physicians, needing to get eight hours of sleep, and when you compromise that sleep, thinking you can get by on five or six, that really affects your overall mood. It affects your overall ability to process through stressful situations. And everybody hears “breathing exercises.” What I notice with regard to people and breathing exercises is that they’re busy taking a hyper breath in, and it really is the out breath that accesses the vagus nerve. So I talk about singing and humming, even if it’s off-key, because you’re doing an out breath in order to hold a tune, right?
So I feel like, for me, mood shifting occurs with just a line or two of music. It doesn’t have to be a whole song, and again, it doesn’t matter if you’re off-key. So that helps relax the diaphragm, access vagal tone, all of that. We’re all resilient people. Nobody’s saying that, you know, you aren’t doing it right. These are just tips to move you forward and make it easier, make life easier. And I think we’re all looking for life hacks to be able to figure out how to do it better and easier.
Kevin Pho: So for a clinician who’s listening to this podcast or reading your article, how can they get started? Of all the tips that you mentioned, what’s the first one they should do?
Anne M. Miller: If they don’t have some sort of exercise program in place, I think that’s really key, even if all it is is walking, even if all it is is parking your car further out, or taking the stairs. There are ways that you can build some things in; it doesn’t have to be this huge thing. Tiny habits, I like that phrase, like putting little tiny habits in. You may not have time for 30 minutes or an hour to go to a gym, but I think you should figure out how to de-stress with the exercise. Figure out, even when you’re in the bathroom, doing some breathing exercises.
What I have found in coaching is that physicians and teachers are the world’s worst at even getting to the bathroom, which is a sad commentary, and they will tell me, “But I can’t drink fluids because I can’t get to the bathroom.” Are you kidding? So yeah, that is really key. And by the way, your brain really needs to be flushed out, so that’s really important, along with all your detox organs.
And if you’re having trouble implementing things in your life, get a coach, get a guide, get somebody that is walking the walk with you and partnering. For me, a coach became somebody that could help me reach my goals faster. It was somebody that helped me get out of my own way. It helps with mindset shifts. It doesn’t mean that however the coach managed to change his or her life around medicine is what they’re going to put out there for you to do. It’s about you coming to coaching with what your goals are, and that person meeting you where you are. So I think that’s critical.
Kevin Pho: So after you implemented all these techniques for yourself, how long did it take before you really noticed the difference, and it helped you to better accept the situation you were in?
Anne M. Miller: I think if you’re doing more than one thing to help yourself, and by the way, I think community and talking to other colleagues. Don’t be in isolation. I didn’t mention that before, but talking to other people is really critical. I would say you can start to see a difference in a week or so. You can start to feel your body relax within 20 minutes. The dilemma will be, OK, and this is where a coach can be really helpful, that you can get that relaxation in 20 minutes, but then you’re stepping right back into a stressful situation. So how do you maintain it in that situation, right? So then that requires teasing that out a little bit better. But literally, from 20 minutes to a week or two, you can see differences.
Kevin Pho: We’re talking to Anne Miller. She’s a psychiatrist, and she wrote the KevinMD article “Managing expectations in the face of COVID-19.” As you reflect over the last few years of the pandemic, we’re entering the third year of the pandemic, and hopefully, fingers crossed, things are winding down. What’s something that’s changed you clinically in terms of your practice, and how have you changed over the last few years?
Anne M. Miller: How have I changed? Well, definitely, I am now a psychiatrist turned coach, and I feel like teaching skills is really what my love has been since the beginning, so that’s a big piece. I would say it’s been more critical for me to spend more time with myself to be able to stay in a compassionate state while you have all sorts of craziness unraveling around you. It’s no longer that you have one person a day or one person a week that’s kind of ungrounded and unraveling all over the place; it’s every other patient. And I’m assuming, I hear from my family doc people, that that’s not that uncommon for them either. The number of referrals to me tells me that there is an increase.
So I think coming from more of an inspired, compassionate place, and needing to put that self-care in place for myself, has been hugely instrumental in being able to be present in the midst of somebody melting down in front of you. It’s the thing they tell you on the airplanes: Put your own oxygen mask on first. And as a culture of physicians, we’ve been taught to be extremely disembodied. You don’t have time to go to the bathroom, you don’t have time to do this, you’ve got to get the charting done, you take the charting home, you shorten your sleep. That’s all disembodiment. That’s all ignoring your own personal signals to the detriment of yourself, under the guise of, “I’m being a really good physician. I’m really committed. I’m really dedicated.”
And I think my philosophy has had to change: My commitment and dedication have to have me in the equation in order to be really good at what I do, and in order to really come from a place of a compassionate heart for humanity, which right now, on so many levels and across so many countries, is suffering. So if we don’t start putting ourselves in the equation, you end up with burnout, you end up with moral injury, you end up feeling profoundly, profoundly alone. And so I think that’s key at this point.
Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?
Anne M. Miller: Number one is that the overall system is broken, and no one person is going to be able to fix it. Thus, we can only do what we can do and bring ourselves to it in the way that we provide some choice with, right? So we need to show up even though the system is pretty messy. Number two, make taking care of yourself your first priority, or you’re no good to anybody around you, and that includes, obviously, your family, but I would also say showing up at work as well. Number three, find a coach, a mentor, a partner, someone to walk the path with you as you’re making the changes you need to make.
I think it would be best if we all made the assumption that we have been radically affected and potentially shifted and changed forever in the pandemic. And aligned with that is the whole Great Resignation that has occurred. If we pretend that we haven’t been changed by that, then you set yourself up for burnout, and you set yourself up for not being at your best. So in whatever form you like to do it, there are plenty of coaches out there. I’m happy to work with people, and if you google coaching for physicians at this point, there are plenty of them. So I think that summarizes what I would think people need to know.
Kevin Pho: Anne, thank you so much for sharing your time and insight. Thanks again.
Anne M. Miller: Thank you. Thank you. I really appreciate it.
Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
