Anxiety and healthcare worker burnout are deeply linked.

Psychiatrist and researcher Jud Brewer returns to review his recent study showing the benefits of a short-duration app-based intervention on reducing anxiety and burnout symptoms in a group of physicians. Check out his YouTube channel here.

– What’s up Z-Pac? It’s Dr. Z, welcome to the ZDoggMD Show. I have a returning guest who was the subject of severe bromancing on my part, for our first hour interview we did before and wanted to have him back. Dr. Jud Brewer is the Director of Research and Intervention Research and Innovation, okay! I just had a small stroke… At the Brown Mindfulness Center. He’s a psychiatrist, a researcher, and like one of the world’s experts in things like digital therapeutics around mindfulness, mindfulness in general and on and on and on and on, but more importantly, he’s a brother from another mother. We’re gonna talk about anxiety and burnout in healthcare workers and beyond because this is a new study that was released, a pilot study with Dr. Brewer that we’re gonna talk about today that has an impact directly on our experience guys. So welcome Jud back to the show. What did I get wrong in that?

– Nothing, brother from another mother I love that, that’s great.

– You know, and then there’s apparently the… ‘Cause you wanna be gender neutral, there’s the sister from another mister and the what– what’s a sort of intersectionality? I mean there’s a million ways we could skin this Jud, all of them end with us getting canceled on Twitter. So let’s just go direct to the discussion. So when I heard about Dr. Lorna Breen, who is this emergency physician who lost her life to suicide, I reached out to you and said, “Hey, do you wanna talk about “this a little bit more on the show?” And your response was, “Well, I think the root of this “is really an issue of anxiety “and moral injury and burnout. “And we just published on this, “I’d love to talk about my research.” So hit me with what’s going on in that space because I’ve talked about burnout quite a bit on the show and how it may be the end stage of chronic moral injury, but there’s a million causes for it and I wanna get this out of the way. First, we’re not excusing the causes, we’re not excusing the systematic issues in healthcare that have led to “burnout”. But we’re saying here’s something you might be able to do personally in the meantime to help yourself survive.

– Right, and I think that’s a good way to look at it. There are institutional factors and there are individual factors. And you’ve probably talked about the institutional factors, one institutional factor that I think affects most if not all of us, is this lack of autonomy. Where we’re a lot of clinical care moves more corporate or more large group as compared to small private practice or whatnot. And I think that’s one institutional factor that’s actually affecting… That’s bleeding into the individual factors. Who says, wow, boy, I wish I had less control?

– But I think this loss of autonomy is something I’ve actually talked about with… I did a show with an EHR vendor, Athenahealth and they had their in-house expert on looking at data analytics and they actually looked at this and did a study and what they found with regards to their own users and burnout was lack of autonomy, lack of feeling they had the tools, resources to actually do their job. And it’s that perception of control, which I think in your paper you even cited the Kaiser study that had originally reported that in the ’90s.

– Right, yeah, that’s been around. It’s been going on for a long time. So institutional factors aside ’cause that’s certainly not the lane, not my lane. Other folks can drive in that lane much better than I can. Let’s look at some of the individual factors and there’ve been some folks really writing about this beautifully like Steven Southwick at Yale. One of my friends has actually written about a lot of these things around where we’re disconnected and things like that. So I think those are important individual factors, but also those bleed into institutional factors as well. I’d like to dive into one aspect of burnout that I had not actually realized, which was there’s a lot of anecdote around anxiety being correlated with burnout, but in fact to our knowledge, we hadn’t actually found a study where people had linked the two directly in clinical trials. I know you’re shocked.

– That sounds crazy.

– I know.

– It sounds so obvious.

– Yeah, I know and maybe because it’s so obvious nobody actually bothered to do the studies or I’ve missed that study that was done at the beginning of time or whatever. But I was blown away by that so that was one of the first things. So let me back up and say a couple of the other things that we’ve been seeing is that physicians and clinicians, healthcare workers in particular, are shock, really busy. And so one thing that I’ve been looking at is how can we pragmatically help people with can we find out what these mechanisms are? Can we target those specific mechanisms? And how can we do this in a pragmatic way? That’s not just like, “Oh, that’s a great idea. “Nobody’s gonna do it.” But, “Okay, here’s the mechanism. “Here’s something pragmatic “let’s all be clinicians about this “and figure out something.”

– And I think this is so crucially important because when you pitch doctors or nurses or frontline healthcare professionals on, oh, here’s some solutions for your burnout, they require a four hours a week of sitting in a mindfulness class or going on retreat or practicing in a way that’s just oppressive in terms of their time. As it is they feel like they don’t have enough time and control and now you’re taking another thing and adding it. So what did you do that was different in this sense?

– Yeah, so we built on the background, so there’s some great researchers, Mick Krasner and Ron Epstein at University of Rochester who did I think the first groundbreaking study. This was a JAMA article from 2009, so over 10 years ago. Where they found that mindfulness training was a way to really help physicians with burnout. And so that was really intriguing to me. Okay we can get at this, these were primary care physicians in general, reduce burnout significantly. Okay, wow this is interesting and one of the big barriers was like you were talking about, they had to take these classes in person, multiple hours a week, et cetera, et cetera. So one of these barriers to entry is time commitment and so I studying anxiety in particular, I wanted to see if we’ve been developing digital therapeutics. I wanted to see if this Unwinding Anxiety app that we had could actually reach physicians. And I like to work with the hardest populations to work with first ’cause if you can work with them, you can work with anybody and I can speak from personal experience. I know I’m a pain in the ass, you know.

– Hey ditto, man. Doctors are the worst.

– Yeah totally. They’re like, “Oh, that’s not for me. “I don’t have time I’m busy saving lives.” This is why you don’t see doctors go to the bathroom on television cause they’re too busy saving lives.

– That’s right.

– Yeah and it’s true. It’s a known fact. So here we wanted to see could we just get physicians to use an app based mindfulness training just to see if, do a feasibility study, see if they’d use it, see if they’d engage with it, see if it would reduce anxiety. And then we threw in some burnout measures just to see what would happen. True story, so we did this study at the UMass Memorial Medical system, the CEO there Eric Dickson, really forward-thinking guy, took a single email from him, one email to recruit all of the subjects that we needed for this study.

– That’s crazy, so what did that email say? So he sent out an email and everybody got recruited?

– Yeah, basic… Well what it says, long story short is that there are so many anxious physicians out there that it takes a single email to recruit all that you need. I even had a guy come up to me and say, “You know I didn’t “qualify for your study.” And I said, “That’s a good thing! “You’re not anxious enough, right?” So we used a couple of screening questions just so folks had to be in clinical practice. So we didn’t want administrative types as part of this, no offense to them, but we wanted to really see if this could affect–

– Hold on, oh on offense to them, all right? We don’t need your type here, okay. Remember that scene in Star Wars where they wouldn’t serve the droids? Those droids are you? I’m just kidding but I’m not really. All right, back to you Jud.

– So we wanted folks who were practicing and we also wanted folks who were just struggling a little bit with anxiety because it makes a lot of sense if you’re gonna try out an anxiety app and you’re not anxious you’ll be like, “Yeah, whatever. “I’d rather be playing angry birds or whatever.”

– Talk about anxiety, man that big fat bird just screws me every time I wake up at night actually perseverating about this. But that’s another discussion between you and me as counselor and patient.

– Right, we’ll take that off the mic. So our aim was just to see if these folks would use this program. We measured baseline, we measured anxiety, we measured burnout, we tried to keep this very pragmatic, very low burden for the folks. And then we had folks just start using the app and then we measured them a month later and three months later to see how they did. So what we gave them was this Unwinding Anxiety app where they would just learn first learn about anxiety, about how anxiety habit loops form, that was something that was a big revelation to me. You know I didn’t learn in medical school or residency that anxiety could actually be perpetuated as a habit.

– Ah, so and this when I read the paper, this really struck me because I was thinking about how incredibly habitual worry is for me and the way you spelled it out, I thought it was beautiful because it was in terms of sort of operant conditioning and this and that. Where you have a trigger, which is this thought that sort of very negative valence thought or emotion. And then the behavior, which is and I never thought of a worry as a behavior because you don’t think of thinking as a behavior. But I was like, oh, worry as a behavior that’s the conditioned behavior. Now why is it desirable? Because it has a reward and the reward is you either feel like you’re a little bit in control or it distracts you a bit. So you would think, well then this is perfect. I have a bad emotion and the behavior is I worry about it and then I feel better right? So what’s the downside?

– Well, how well do we make out when we play the lottery? So you can think of this if we’re worrying all the time and we happen to come up with a solution, our brains, these crazy associative learning machines, you know, true, true and likely unrelated, right? We’re worrying, we come up with a solution and we think, oh because I worried I came up with the solution. So it’s basically mental casino or mental jackpot or slot machine playing basically.

– And let me ask a question so the downside of this is repeated trigger, behavior, reward is gonna lead to repetitive loop of behavior which creates from worry chronic anxiety. Did I understand that correctly or how does that work?

– Yeah, so one, worry doesn’t really fix things and partly why it doesn’t do that is because it makes our thinking brain go offline. When we’re stressed or when we’re worried we can’t actually think that well. So the other piece to that is worry doesn’t feel very good. I’ve never had a patient come to me and say, “Doc, man, I just don’t worry enough. “You know I need to get that juice of worry going, help me out. “Is there a drug for that?”

– I’ve got a few.

– So there people when they start to worry it’s kind of like they’re moving toward this black hole of anxiety, right? And the more they worry the more they get caught up in worry. Their brain starts to realize, wait a minute this isn’t actually that rewarding. That feeling of control isn’t that controlling ’cause I don’t actually have that much control. That distraction from the anxiety is not that distracting because the worry is feeling bad unto itself and once we realize that we go over the event horizon to this black hole of anxiety, worry which feeds back to the anxiety which feeds back on the worry and then we’re a goner.

– And that what we talked about in our last discussion is this event horizon where it’s a loop and then it becomes just this suffering. And so just a quick story relating to this actually I’m gonna save that story for when you talk about your interventions because I experienced what you described in your paper just the other night, waking up at three in the morning with a negative emotion or concern that then led to worry. But I was able to actually do something pretty remarkable for me which we’ll talk about maybe just don’t let me forget.

– Oh, after this commercial breaks.

– Exactly. You know what? I like to generate suspense so people stay through and watch the ads because you know cash money millionaires Jud, you know how it is? Pimping ain’t easy. Anyways, so back to back to this worry, anxiety loop.

– Yeah so this had been described back in the ’80s and promptly forgotten from what it seems ’cause you know this guy, TD Borkovec from Penn State had published a bunch on it, a little bit more in the ’90s and it kind of trickled out. So I didn’t learn about this in residency but I started, you know I stumbled upon this when I was really actually with some of my patients who were using with this eating program and you know same type of habit loops. When we’re stressed, we eat to feel better and they were saying that stress, that anxiety is leading me to eat. Can you make an anxiety program? That’s actually what got us interested in looking at anxiety. So when I was looking at the mechanisms I found this literature and I was like, “Holy smokes”. This is exactly what I thought, holy smokes.

– That’s it, people don’t realize that scientists that’s what’s going on in their brain. Gadzooks!

– Holy reinforcement learning Batman.

– Yup.

– Yeah so I realized wow so because this mechanism is set up in the same way that these other mechanisms that we’d been studying around smoking and eating, we could actually target it the same way we were targeting those through mindfulness training. And in fact, we weren’t the first to come up with that idea, mindfulness-based cognitive therapy for example has been shown to be really helpful for anxiety, mindfulness-based stress reduction as well. So there’s a growing literature with those in-person treatments and then this paper from Epstein and Krasner from 2009 also showing mindfulness training helpful for burnout. I brought all these things together and said, “Okay, let’s see if this anxiety app “can help physicians, right?” So we give them the app, the idea is it’s 10 minutes a day videos, animations in the moment exercises. So for example, train them to map out these worry habit loops, start to see how unrewarding they are so we can tap into this reward system so they can find what I think of as the bigger, better offer. We might’ve talked about that before but basically find something that’s more rewarding. So a clinical example here would be, we look at our lists for the day for a clinic and we’re already 20 minutes behind and we could be going into the next exam room thinking, oh no, I know this patient it’s gonna take me much more than the 7.4 minutes that I’m allotted it’s gonna put me even farther behind. Then we walk in that anxiety is contagious or that worry or that frustration is contagious and then our patients blah, blah, blah, it doesn’t help. So we could do that as a habit and then we end the day and we’re like, “Wow, why am I so totally, emotionally exhausted?” Well we’ve been burning the candle at both ends, both from worrying all the time and then also doing our job. So we could do that or we could step out of it and say, take a moment just notice that habit loop, take a couple of deep breaths, feel our feet. Do some very short mindfulness practice as we’re touching the door knob, as we’re about to go into the exam room. So there we could go in in a grounded way where we’re able to keep our thinking brain online, be able to communicate and empathize with our patients as compared to being protective of our emotions ’cause we’re fragile and probably do a better job of helping our patient with your diagnosis, treatment, all that stuff. So that’s the idea is let’s teach them some mindfulness training, let’s use an app to do this. Long story short so we use the GAD-7 as an outcome measure, clinically validated I certainly use it in my clinic, is just built into the EMR. Nice and short questionnaire, it’s validated, it’s been shown to correlate very nicely with the HAM-A and other types of measures. Folks who had pretty high anxiety at baseline, they were in the moderate to severe range. By the time they got to the three month followup, we had a 57% reduction in GAD-7 scores, 57%.

– Wow.

– So yeah,

– No, no, no I mean that makes sense in the sense that okay, the app is having some effect. We’re addressing root anxiety which you’re theorizing is connected to burnout even though it’s never been studied and you actually looked at it in the study using Maslach Burnout Inventory and that sort of thing. Now the only question I would have is these guys were in a way self-selected. They signed up for the thing, they were motivated and they had an intervention and there wasn’t a control group where there was no intervention. So any thoughts on that?

– Yeah so I’ll talk about that in one second, but I also forgot to mention this correlation between anxiety and burnout. So we looked at that at baseline and we only use two items from the Maslach Burnout Inventory. One looking at cynicism, one looking at emotional exhaustion West and others had published on these showing that these are nice subset items to look at. So we found a strong correlation, really highly significant between both of those measures and anxiety. At that followup we also got a 50% reduction in cynicism and we got a 20% reduction in emotional exhaustion. Which I think is important to highlight so that 50% reduction in cynicism so you can think of individual and institutional factors. So cynicism is more an individual factor we can get caught up in cynical habit loops. We look at our low esteem and we think about how the system doesn’t allow us time to see our patients. Then we start to get cynical that’s the mental behavior, just like worry is a mental behavior and then we or whatever that reward is that we rage against the machine or whatever which it just burns us out right? So that piece we saw really significant and correlated reduction in cynicism. Interestingly only a 20% reduction in emotional exhaustion even though it was statistically significant, it makes a lot of sense because we’re not changing institutional factors with an app. So here we might even be seeing some specificity here

– That actually makes sense because cynicism is something again, it’s a little more controllable in terms of paying attention. Emotional exhaustion is the sum result of all the insults and a lot of that is institutional. You know a quick side note on this, I get a lot of messages from fans and a lot of them are very, very, very upset frontline caregivers who will rage in the most cynical possible way in the message and it’s paragraphs of just rage. This will never get better, I’m never gonna be heard. My boss is an idiot, I’m totally disempowered the patients are suffering and you could see that a reframing or a paying attention to that might actually change that so that they feel more empowered. But it’s tough because there is a component of emotional exhaustion imbuing their behavior there. So I’m curious if you have thoughts on that?

– Yeah, yeah, absolutely and I think this is where mindfulness comes in. It can help us see, have people really explore what do I get from you raging against the machine? This isn’t to say that we shouldn’t advocate or do all, it’s actually really important to do these things, to do advocacy work but if we are running full speed against a wall and we just keep hitting our head against the wall, that’s a problem you know. So what mindfulness helps us do is to step back and see what am I getting from this cynicism? Is it actually helping me change this system? One, it’s really exhausting to spin that wheel of cynicism itself. To me, it’s just really, really emotionally draining hence some emotional exhaustion coming from that. Two, it doesn’t actually direct us in a good direction when we’re really raging that’s why they call it blind rage we’re not seeing clearly. We’re running, we’re banging our head against the wall. So we can step back from that and see that what we’re doing might not be helpful. We can actually redirect that energy so that we can do good advocacy work with our thinking brain back online and thinking. So here we can then say, okay, well what would be the most skillful thing to do right now in terms of helping to change the system? As compared to running into the CEO’s office and saying, “Yo, I demand change.” They’re gonna be reactive and defensive, anybody would be, right?. Somebody runs at you with something that seems like a sharp object, which could even just be “Hey pointing out flaws in the system.” Everybody’s gonna be defensive there. So here we can step back and say, well, what’s the most skillful way to actually help the whole system move forward? What’s the best way to direct my energy so that I can do good and effective advocacy work?

– That’s the central premise of this is like how can we actually get results that will not only change our own personal framing of this but also change systems and I’m glad you bring those together. So far we’ve established anxiety and burnout are definitely, at least in the study that you showed connected. Which is an intuition that most people have but needs to actually be measured. The second thing you saw is that these patients, these doctors who are the participants in the study had real outcomes that showed improvement at one and three months. And then the question that we needed to get back to was what about the self selection bias? And the lack of a control group and that sort of thing.

– Right and I think that’s a really important point. So I’m glad you bring that up, so this was our first pilot study we wanted to just to see if there was a signal there before we went on to do randomized control trials. So we got a NIH funding from NIMH to do a randomized controlled trial. We didn’t do this with physicians, but we did this with people with generalized anxiety disorder. ‘Cause we wanted to see if we could help a broader swath of the population. At baseline that group… So we haven’t published this one yet we’re just submitting it for publication but that group showed very similar levels of baseline GAD-7 score. So similar in the respect to what our physicians were showing, they showed many more comorbid disorders. So I think we had 84% of them had comorbid depression or something else or something else, which is actually very real world. I rarely see a patient come into my office with just clean anxiety disorder. There’s usually something else going on. And long story short, we got a 63% reduction in the active group. In the treatment as usual group, we got a 15% reduction and because there were two arms we could do a Number Needed to Treat analysis. And so for the typical antidepressant which is gold standard treatment 5.15. So you’ve got to treat just over five people to get a remission in one person. With the Unwinding Anxiety app 1.6.

– That’s the most ridiculous Number Needed to Treat I’ve ever heard in my life, 1.6. So you basically treat one and a half people and you get an effect with your app versus 5.6 with the drug. And the app what’s interesting about it is that it is only just 10 minutes a day. It’s at the point of anxiety so sometimes if you’re like you said before, you’re going in a room, it sends you reminders too, right? To kind of pay attention so it’s an intervention that’s low cognitive load, low time, but very high impact it sounds like?

– Yeah and the aim there is to develop any habit that’s what a lot of my research is around is how to have this formed? “How can we break bad ones and form good ones?” The idea is to form a habit you do something short moments many times throughout the day. So here we can give people short 30 seconds mindfulness practices throughout the day. We can do that intermittently so they get intermittent reinforcement with that and they can learn, oh, I can actually take a moment and just feel my feet. I can just take a moment and check in with my mind, check in with my spirit, check in with my body things like that that are very simple, concrete, pragmatic and take 30 seconds. So that’s one of the ideas is to help people develop the good habit of being aware. The nice thing about this is physician’s report that they you better shock when you’re less anxious you feel better, but they’re also reporting a greater connection with their patients because they can actually pay attention while they’re working with their patients as compared to being caught up in their own anxiety. That’s one of the benefits that I love to see as these instead of side effects, side benefits of a bleed over effect of somebody benefiting from a treatment.

– That’s lovely and what’s interesting is it got me thinking again now to bring it to my own tragic case. So you know we’ve done shows on how a lot of physicians, healthcare professionals they tend to be a little higher intelligence on average it depends, it depends but physicians in general are very competitive and if you probably IQ tested them all, they score a little higher and with that higher intelligence comes a lot of anxiety it seems. It seems to ride along with it so this is very common and because they’re intelligent they can rationalize their way out of any kind of intervention. So I’ve been very resistant, you know I’ve been anxious all my life and it manifests in me, particularly at night. So back to this 3:00 AM awakening thing, so I was having a recently and when we talked in our last show about meditative practice. Over the last seven years, I’ve gotten much more facile with meditative practice, mindfulness in particular. And I noticed that, so I woke up at three and I had the thought that today I have to do X, whatever it was show or whatever I had to do And I could feel then the typical conditioned response, which is let me worry about this and start to plan this out. And right then I had enough mindfulness juice that I was like, oh, look what’s happening. This is interesting thought, behavior which is this worry. Now I know how this story ends because I’ve watched it many times. The story ends with me worrying, me then feeling like I’ve gotten a sense of control and then a new thought coming up and worrying about that and me staying up in a worry loop, unable to sleep, getting up at 3:30 AM to having coffee and ruining my day ’cause no sleep, anxious and nothing solved. So what if I just watch that, look at that oh I really want to worry about this, but I’m just going to watch that feeling of worry and something just amazing happened, it just dissolved. Like, “Hey, that was dumb I don’t want to do that. “I know how this ends.” And the next thing I know I’m asleep which has never in the history of my worry loops ever happened. So this issue works. It really does work.

– So let me see how do the sports casters do this for a soccer game? Gooooooooaaaaaallllll!

– I almost jumped out of bed and said that Jud, but my wife would have not taken kindly to that. Yeah, that’s how it felt. I was so elated because when I fell asleep I didn’t have time to gloat because I was fell back asleep. But when I woke up, I remembered. I was like, “Oh, I have this thing to do today, man “that should have kept me up. “It did try to keep me up.” And I was able to recognize it and that came from it. That’s not magic that was practice. Then I think what you’re doing with the app is very promising even though that was a pilot trial. You have the bigger trial with other anxious folks. How do people get the app and try it out themselves though?

– They can just go to my website, which is Dr. Jud and they can find it there. I think there’s a direct website, so that they can go to as well and they can download it. There’s more information they can find the papers et cetera about that.

– Is it very expensive to use?

– I should know this, I think it’s around $30 a month and then it goes down from there but I’m not the one in-charge of that stuff.

– Got it, yeah I see the business guys are doing that yeah. I have to say this, $30 for the first month if that’s what it is? If you have the benefits that actually you can find, it’s like compared to just the cost of a copay on an SSRI or something like that, there’s no comparison right?

– Yeah if you look at it as a if you have a copay for a clinical visit and then for a medication, once a month for example, it’s probably about the same cost depending on somebody’s health plan.

– I actually pay for Sam Harris’s meditation app as well, I pay for Headspace, I use like series of different apps and I find it to be the best money I’ve ever spent and it’s trivial compared to the cost of not having that resource so it’s a huge thing. Man, now to just wrap this up and apply it to where we are in our COVID-19 situation just because people care about that more than anything. We talked last time about the worry loop and COVID is a great example of how someone a continent away on a news report can sneeze on your brain and infect you with worry. And so these same techniques can apply to worry about anxiety about the COVID situation, correct?

– Absolutely, absolutely and I actually put a short animation together based on the New York Times article that I wrote on COVID anxiety as somebody wants to kind of understand the mechanisms behind how that works and how it can actually bring mindfulness in. That’s on my YouTube channel.

– I love it. So what I’ll do is I’ll link to all your different channels and dude, I wanna thank you again I’m hoping you’ll come back again and we can talk about yet another aspect of this because each of these is like a three hour discussion, but we’re gonna try to distill it for the short attention spans and I learn a lot from you every time you come on, man. And I suspect that that bit of a worry abortion that I had in the middle of the night was due to our conversation last time. So you can send me the bill, I will default on it but I appreciate everything you’re doing Jud, and thanks again and I hope you’re staying safe out there.

– I am, yeah I’m all 100% telemedicine right now so all good.

– Nice, I love it. Alright, brother cool well Z-Pac do me a favor, please share this episode leave stories about your own ways of dealing with anxiety, your own approach to mindfulness if you do that practice and what it’s done for you because you may just through your comments inspire others to get the help that would definitely benefit them. Alright guys, I love y’all and we out. Jud Brewer, peace.