Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman

You're listening to The Nocturnists: Conversations. I'm Emily Silverman. In the last few years, mental health has become a big part of the public conversation But what happens when the doctors caring for others are struggling themselves? 

Today’s guest, Dr. Jessi Gold, is an Associate Professor of Psychiatry and the Chief Wellness Officer at the University of Tennessee. She specializes in mental healthcare for healthcare workers, and in addition to her work in outpatient psychiatry, has become a trusted voice in the media on issues like burnout and mental health in the clinician workforce. 

Her new book, How Do You Feel? One Doctor’s Search for Humanity in Medicine, takes a deep dive into these topics, weaving in Jessi’s personal story along alongside the stories of four composite patient characters, and broader insights into the emotional toll healthcare takes on clinicians.

In our conversation, we discuss the differences between burnout, moral injury, depression, and PTSD; How mental health stigma continues to affect healthcare workers, The fear that clinicians feel when filling out their licensing paperwork, not knowing if they’ll be penalized for seeking care for mental health, And the great work that’s been done to REFORM that licensing process. 

We also dive into Jessi’s exploration of telemedicine, and her new role in reshaping wellness in healthcare systems. But before we dive in, first take a listen to Jessi reading from How Do You Feel?

Jessi Gold  

When I see Luke on my screen, I off handedly ask, how are you? I regret it immediately. For one, it's an overused question and not typically meant to evoke actual vulnerability. Most of us, when someone asks us this, don't have the time or energy for giving a real answer. Society is generally okay with that, we've decided it's polite, even acceptable, to answer on autopilot, but it isn't to me. To help Luke as a psychiatrist, I need the real answer. Predictably, he responds, "I'm fine." Fine is often a joke among mental health practitioners, because it usually means the person, like me so many times, is anything but fine. We've even given it an acronym, 'feelings I'm not expressing.' Luke, then pauses briefly and asks, "How about you?" This is the other issue with the how are you question. It begs to be reciprocated, but that's far removed from the purpose of our session, and in this kind of situation, we psychiatrists aren't supposed to talk about ourselves. Still, I noticed something about the quality of Luke's voice, something I've noticed in a lot of my patients lately. I can tell he's genuinely curious about my well being, that he wants to know the truth. He won't be satisfied with the answer they teach us to give when we are in training, which is basically to ask why someone is asking about us in the first place, turning the question back on them. I feel myself desperately wanting to tell Luke the truth, while ensuring him I'm safe and coping so he knows I can take good care of him. Psychologically speaking, I suspect this is the core reason for his question. I'm living through a pandemic too, and he's worried about my ability to help him. How am I? I think, trying to come up with an appropriate answer. The truth is that I'm busy and tired, but I don't yet know what deeper emotions those feelings are masking. I don't tell him that, though, because I worry he wouldn't trust a psychiatrist who can't figure out her own feelings. All that comes out of my mouth is, "I'm hanging in." "I get that," he nods, and we have a moment when we look at each other through the screens with what feels like mutual respect for our different roles in healthcare at this moment in time and how hard it's been. Something tells me he feels satisfied with my response, even though it wasn't long or heavy, it was enough to move us forward. 

Emily Silverman  

I am here with Dr Jessi Gold. Jessi, thanks so much for coming in today.

Jessi Gold  

Thanks for having me.

Emily Silverman  

So Jessi, I love this book. Tell us. How did you come to be a caregiver of caregivers?

Jessi Gold  

I think I've always been genuinely interested in how we train people, how we end up like this, and just a very observant person. And so starting in college I would be like, "Why are the people who seem like they'd be the best doctors dropping out of pre med?" And that led me to getting a master's in anthropology and doing my master's thesis on pre med as a culture. So I've always been just really fascinated by that conversation. Clinically, it evolved over time, like when I was in residency, I did support groups for the med students, where we learned about group therapy. So it was really my first exposure to that population as a clinician, but really the pandemic for me thrust that into what I was doing. My first job out of residency, I was a psychiatrist on a college campus, and a lot of the people who are working there were furloughed during the pandemic, and because of my interest in this population, I said, "Well, can I pivot and take care of faculty and staff and their dependents?" And I grew my clinic that way. I'd always been taking care of pre meds and folks that wanted to do medicine, but I wasn't inherently just seeing that population, and I think the pandemic and need, and having this long standing interest in the research and administrative aspects of this led it to becoming my clinical focus as well

Emily Silverman  

Pre med as a culture. What did you find in that paper?

Jessi Gold  

There was not a lot of data on pre med when I was in college, and there still is not a lot of data on pre med. And so I did qualitative interviews with people who came into college and wanted to stay and go to medical school. And so I looked at the people who stayed and the people who dropped out, and what kind of things were reasons behind that. Probably not surprising to anybody listening, grades and classes were the most brought up things, but advising was also up there, so not feeling supported in their interests, the culture of the classroom was brought up in there. So not just the classes are difficult, but the people in them were hard and the curves were hard. I remember all that stuff, and didn't really feel surprised by a lot of the answers, but I did feel like a lot of the people who dropped out were still looking at doing health adjacent fields like public health or global health, and so we had made an error in scaring away these people who would be great clinicians, I'm sure. And I never really loved that. I wasn't as keen on knowing about mental health at that time, and I wish that I had asked about that, because I see so much about perfectionism in that group when I see them as patients, and I see so much anxiety and test taking anxiety and stuff like that. But it wasn't all I thought about like it is now, like the mental health aspect of stuff, so I didn't ask a lot about that, but there's still not a lot of data about pre meds at all. It's almost like people think we just go to med school and med school is the problem, and we were fine before, which I just never have really understood.

Emily Silverman  

The test taking piece came up for us, too. When we did a podcast series on the emotion of shame in medicine, we were not planning to do an entire episode about testing, but we got so many stories about that that we ended up making a whole episode about that.

Jessi Gold  

Yeah. I mean, we have so many spots where tests are critical to going to the next level, and they're all very hard and not often based on what we actually learn in school. And they are intentionally tricky, I think, too to weed people out. And I've never been a good test taker. I threw up in the ACTs. I've always been somebody who put too much pressure on myself in general, and was a perfectionist, but the testing, standardized tests in particular brought it out in me times 100. I could do school tests just fine, but the idea that one test, one try, whatever they decided to throw at me, could determine my next part of life always was really hard for me, continues to be really hard for me, to be honest, but I've learned more about how to deal with that for myself, but I understand very well and empathize a lot with how much pressure is on us for those tests. And I probably passed step one by like a question. I remember going, "Oh, you can get a one in front of the score, and that's still passing. That's an interesting thing that I didn't know." And I had already had a lot of putting it off and getting migraines. And by the time I actually took it, I didn't think I could have postponed it any longer, but I still barely passed. And so I think if I had wanted to be a neurosurgeon, we would be having a bigger conversation around shame for me and my scores. But luckily, I wanted to be a psychiatrist, and had a little bit of a buffer there, but it's a lot of pressure on one day, one test.

Emily Silverman  

I noticed that in your book, you are taking care of residents, but you're also taking care of people who are mid career, especially during the pandemic. And so this is kind of a high level question, but when you look at the healthcare workforce these days, what do you see? There's pre COVID, I feel like we kind of weren't okay. And then there was COVID, that was its own flavor of not okay. And now we're in this weird post COVID time. So I'm just wondering if you could give us your take on where the profession is right now.

Jessi Gold  

I like that you put it that way. I think so many people think that COVID came down from the fairy clouds and made us sad, and we were fine before that. And obviously I was interested in this subject. Before that, people were doing research and trying to change policies and things before that. And then the pandemic came with novel stressors, and there's no way that all of the pre existing bad was going to be better. It was going to be compounded and worse. And then I think there's this belief now on the other side from leaders, but also honestly us, we kind of hope that we're fine now. I think we want to believe that that was a moment in time and we're better. But from my perspective, I feel like I have to regularly advocate pointing that out, that this isn't something that's gone now, and we're fine because we weren't good before, and I think that's really frustrating. What was causing it at the height of the pandemic had a lot to do with resources and needing to be front line and not really being able to let anyone else come in, and lack of redundancy and the chance of us being sick and all this stuff, which is not necessarily what we're thinking about all the time now, but we still have a lot of inherent systems problems and staffing problems and cultural problems that didn't go away with the pandemic, and maybe honestly, got shown more in the pandemic. I think we have a problem with workforce sustainability. Without nurses, we have trouble having doctors. I've definitely have had patients tell me that the hardest part of the pandemic wasn't the patients that they were seeing in the ER, but the lack of nursing staff. Staffing is a really, really big problem in keeping people in these jobs. I don't think that's going to get better, and I hate to be sort of like a Debbie Downer of sorts to anybody listening. But I also see college students, and college students care a lot less about prestige, and we're a field that's always gonna have certain expectations that are gonna take a long time to change if they ever change. But inherently, college students really value work-life balance, and we're not a field that has that. So I think we're gonna have a hard time recruiting into the field and sustaining our workforce because we already were, and a lot of those things are just unappealing to the generation that's coming up and going like, "Well, I don't have to go to that much school and be in that much debt, and I can work less." Like, come on, right? So I think we're having trouble like that. I hear often from the younger folks that are in training now that seeing attendings stressed and burnt out and depressed makes it harder for them. We use this word in psychiatry holders of hope, which is this idea that you see your therapist as this, like person who's doing things right, or whatever that is, but as you look as a student at a resident, or a resident at an attending, I think we always have this like it gets better. If I could get through this, it gets better. But I do think that the pandemic kind of ripped that open where students look and they go, "Oh, it doesn't get better. It's just different." And I Think that's very hard.

Emily Silverman  

How do you think about the clinician psyche? There's been this conversation about the word burnout, and maybe we should be saying moral injury instead of burnout. And then there's also other labels, depression. For example, you just mentioned PTSD is a big one that came up in the pandemic. And so can you be burned out and not depressed? If you're depressed, can you also be burned out and like, how do you disentangle PTSD and depression and burnout, but then, oh, wait, it's the system. How do you organize all of this in your mind? 

Jessi Gold  

I wish it was super simple, and I could be like, this is exactly how you do it. But I think what you're seeing is that there's a lot of subjectivity to mental health and diagnoses, and sometimes they're not necessary. You'll hear a lot of psychiatrists who work in this field very much wanting to distinguish between burnout and depression, and I think that they're right to do that in some capacity. I see burnout as a stepping stone to depression. It's a stepping stone to a lot of things, and I think it's really important that it's not just seen as work was hard and burnt out. There's a lot going on when you're burnt out. It's a constellation of emotional exhaustion, reduced sense of personal accomplishment, and either depersonalization, which is what we do in medicine anyway, to disconnect but all the time, or cynicism, like being angry. So it has these pervasive effects, but burnout is inherently caused by the workplace. Whenever I say that, I like to remind people, if you're a stay at home mom, that's your workplace. If you're in school, that's your workplace. But burnout comes from the workplace, so if you took time off or you took a weekend off, you might feel better. If you're depressed, you don't. If you're depressed, it's pervasive in your life. It's biologic, probably too a weekend off or a vacation is not going to part the clouds and give you sunshine. So I think that that's a clear distinction. I think depression obviously is not just caused by systems that we work in, and so I think that's important too. Depression also has a lot more symptoms to it, like lack of interest in things, or suicidality that you don't always have to see with burnout. Again, burnout is a risk factor for suicidality too. But I think we can distinguish on a scale what's going on there. When you look at moral injury versus PTSD, that's another scale. So moral injury was created as a term in the military to have something to call, something that wasn't yet PTSD, and it was a little different. And I think the big difference between moral injury and burnout is they might both be from the system, but in moral injury, it's because whatever you're doing or not doing or witnessing is against your core values or morals. The system that's causing burnout could just be paperwork that isn't against your morals. To do paperwork, it's just tedious and you hate it. I see them as similar enough, but maybe the causes somewhat are different, and the scale is different. Burnout and moral injury are both not in a psychiatric diagnostic manual. Someone listening might make an argument that they should be. I think they have been kept separate because of some of these differences, like origin of where it's coming from, but does make it hard if you just have burnout, because I have to find a way to, like, code it a little bit differently, or something like that. A lot of psychiatric diagnoses inherently overlap in what it presents as and sometimes can be difficult to tease apart, but sometimes it's not necessary. It really just matters if like, you were going to do a different therapy intervention or the meds might be different, then it would be really important to tease out what's causing the most distress, because inherently, that's what I'm looking at. How is it impacting your day to day life, and how much is it doing that, and what's causing that, and how do I help that?

Emily Silverman  

Yeah, that makes a lot of sense. We do have to impose some kind of order or organization onto it in order to make sense of it. It it helps to break that down, because I do think sometimes these terms get confused with each other. And in your book, you bring forward the stories of these different characters. I think there's four different patients who we meet, and you say at the beginning of the book that these are composite characters. So they're characters that you've created based on your experience seeing a lot of healthcare workers as their psychiatrist. And these composite characters have a variety of issues going on with them. We have somebody with obsessive compulsive disorder, we have somebody experiencing panic and anxiety. We have someone experiencing just emotional numbness, which I think is a really common one that people have. Tell us about coming up with these four characters and how you molded them based on actual patients that you've seen.

Jessi Gold  

Composites are interesting, because when you write about patients, there's a lot of things that go into that either you could stick to one patient and get consent, but that's really complicated too, because you're seeing that patient, they're reading about it, and they know everything you're thinking, because I do a lot of stuff about what's going on in my head, not really about the patient, but how we're thinking about treatment, and what I'm thinking about my own life in the interim. But you can do it that way, where you just write about a person, but I didn't want anybody to feel like I was calling them out in any way. Didn't want to get in trouble legally, too, but really more for me, I don't want patients to go, "Oh, that's me. Why'd you write about me?" So I got consent from some people that I worried would do that anyway, but inherently, picked these stories that I felt could robustly tell the issues that we're dealing with. I picked different phases of training because I think the issues are different, but they're important, and they all lead into each other. So like, by the time you're older attending, the way that you're experiencing things is as a result of all of the other things. But I really started going, "Okay, I want to make sure that I address the different stages, and then I want to make sure that the things that I'm talking about are different but interesting and showing up in a good amount of people."

It was very important to me to have a pre med for a lot of the reasons we talked about already, but I just think that we don't talk about that as part of the stepping stone process in our training. And it is its own stressors that lead us a certain way. Even if there's not a lot of good data, it still very much impacts how we process failure or how we process stress, or how we process competition, and we bring that with us into med school, which has its own beliefs and culture and curriculum, and I think that's important to talk about. And then we bring that with us even further into residency, where you don't have a lot of say in your schedule, and that kind of role is important to talk about for sleep and hours and responsibility without control.

The last one is a nurse. It was really important to me to include a nurse, because I think often we get the mic and we don't pass it, and their stories very much impact us. I thought about doing some other roles in the hospital, but I was worried that it would be a little confusing with training and all this stuff, to be able to explain everything for a bunch of different fields, but nursing felt like I could adjacently explain it as quickly as I could, but it was really important to me to make sure to include a nurse, especially given the experience in the pandemic, but to make sure that their stories were centered too.

So it was like phases of training, clear issues in those different phases, making sure there was a pre med, making sure there was a nurse, and diagnostically, I didn't want to tell the same stories. I wanted to make sure that the stories were different but interesting and common enough that enough people would relate to it and see themselves in it, even if they didn't have the same thing. So like the obsessive compulsive disorder patient, maybe not a lot of people have that. Maybe they have the personality traits around it and can resonate, but maybe they have something that's not anxiety and depression, and so they resonate in that way. So there's a lot of conversation around how, like, it's almost fine to have either of those because they feel commonplace, but if you have something else, it's more complicated. And I've heard that a lot from patients with bipolar or patients who have ADHD, even to be honest, and not feeling as understood because of that. And so I wanted to make sure that those conversations come up, even if it's within this particular diagnosis that maybe not everybody has, that the key is the themes and the experience and the things that we're hitting as barriers in different parts of our career, or in nursing versus medicine that are worth talking about.

Emily Silverman  

Yeah, in medicine, you hear a lot about which diseases get attention and which don't. For example, breast cancer. There's all this awareness and marketing around breast cancer awareness, and then other diseases like colorectal cancer, for example, don't get as much attention. And I'm just thinking about in the mental health world like you do hear a lot about anxiety and depression. Less about OCD, less about ADHD. Less about bipolar. I recently had a patient with trichotillomania, which I think I said that right, is it? But things like that that don't get talked about as much. And do you feel like the stigma is more on those diseases and almost less on depression these days?

Jessi Gold  

I think we have stigma for all of it still, and I wish we didn't. I've talked to a few folks who've had either more severe depression or a bipolar spectrum illness that have felt like that part isn't okay. In medicine, somehow we all have depression where we can go to work every day, take a medicine eventually, and we'll be okay instead of having bad severity. I think in that context, suicidality is still pretty stigmatized because people don't know what to do with that in the context of healthcare. I think mania has its benefits in healthcare, but if you're very manic, it doesn't. And so I think there's a line there that becomes problematic. And I think some of that all goes back to, like our own stigma about mental health, but kind of society's stigma about mental health. But I think further, what does it mean to have certain diagnoses and see patients? And I know you can treat them, and you can go back if you're safe, and you feel like you're safe, but I think that not everybody knows that or feels that, and so the perception is just carrying that diagnosis makes you unsafe, whereas I don't feel like people think about that with depression and anxiety, I think they would say like, oh, that person's too depressed. That's problematic. Or if you were hospitalized and had suicidal thoughts, like, maybe that would be more problematic. But I think just sort of run of the mill symptomatic depression that you can go see a therapist and get some meds for, like I honestly have had, is much more common and talked about and accepted as something you can do and be in medicine. But I think it's more severity and different diagnoses that you don't get exposed to enough that you go, "can that person be a doctor and have that?" And obviously the answer is yes, but I think it's all familiarity, if you haven't seen it and you don't know much about it, and in med school, you didn't get a lot on it, or what you saw was people making fun of psych patients, or whatever it is, you absorbed that those were problematic. And so then you go, "Well, should somebody be able to see patients, given that?" And I think it can be a big deal. And I've had people who have more severe mental illness, who are in medicine, say that they've seen patients with their symptoms get talked really badly about in front of them in an ER setting or in a hospital setting, and it also just made them button up and never want to tell anybody, but at the same time, they're super angry because they're like, "That person's me. You see me on the other side. You haven't seen me like that, but this is hurting me to see. But I don't even know how to say that."

Emily Silverman  

Yeah, you mentioned in the book the stigma that healthcare workers carry when they have mental illness and also when they seek treatment for mental illness, the fact that many healthcare workers are afraid to seek care or don't seek care because they don't want, quote, unquote, a mark on their record, or other clinicians who go off the grid and pay a mental health worker in cash under a different name so that there's no record of them getting care, because they're worried that if somebody finds out, their medical license is going to be taken away, or their job is going to be taken away. Talk a bit about that, because I know that has been a area where people have been trying to reform that. So there's maybe some hope in that regard.

Jessi Gold  

There's definitely hope, but there's also a lot of lore. So I think that that's a really important thing for people to realize, is that a lot of folks, me included, realized particularly in the pandemic, that a tangible win was to make licensing no longer illegal. It has often been illegal because it's not supposed to ask questions that violate the Americans with Disabilities Act. So the questions are only supposed to be current impairment, like right now, today, with your mental or physical illness, are you impaired and could you hurt a patient? It's not tomorrow or five years ago, and that's been a long standing problem. The issue is that the Federation for State Medical Boards doesn't actually have control, so they can say stuff, and nobody listens. So they've put out tons of stuff saying, like, don't ask these questions. But each state gets to decide, and it's really state by state advocacy that has worked to change some of this stuff, in part, led by the Dr. Lorna Breen Heroes Foundation to be able to say, how do we get tool kits to these people? How do we teach them about this stuff? For the same reason I'm telling you about the differences and belief about different illnesses. Some people on medical boards think that all people with certain diagnoses or certain experiences are of danger to patients, even if they're not of danger to patients, and even if it's not their decision to make. And so it's a lot of educating the states and the people who work on these boards. But I think a lot has moved forward in progress around that to making sure that they're at least in accordance of the law. Not every state. You can go on the Dr. Lorna Breen Heroes website and see where they are. You can find tool kits and stuff like that. But what I will say is the speed at which it's moving to change is not matching what people talk about around it. And so I always have patients like, "I'm gonna lose my license for being here. Diagnosing is something else. Tell me that med is for something else. Don't write notes. What are you writing in the note? Tell me what's in it." Just terrified of it taking away their job. And a lot of reasons we have high suicide rates. It's not completely attributed to that, but I think I also see people really sick because of that. So we wait until we have to or we don't. Those are the way that mental illness presents in people who are afraid that admitting something is wrong or asking for help will lose their entire identity. And so we have to change that narrative around licensing and tell people that it has gotten better and they can get help. And honestly, if something did become a problem, if it's in violation of a law, it's in violation of a law, it's just really hard to tell people, like, "Don't worry. You can fight it in a court." That feels crummy, and it might take a really long time. And so I try to say, like, if you need help, please get help. These things have moved substantially in the right direction to making it better. If you would feel good to be doing something to create change or be responsible for change, it's a really good area to spend some time in and work in your state to change, because you'll go, "I changed that, and now maybe people will get care, and I saved a life." Whereas epic and insurance companies and like all these things, are these big institutions that change around is really complicated. Whereas this stuff, you can see it, and you can make a difference, and you could help save a life that way. So if you feel also just so spun out by the system, where you just feel like there's nothing to do to make it better, it is a place that you could make it better, actually.

Emily Silverman  

Yeah. So a bad example of a licensing questionnaire would be asking aggressively, "Have you ever needed to seek mental health treatment in the last 5-10 years or ever?"

Jessi Gold  

I'm in psychiatry residency, they tell us to get therapy as part of training. They don't force it, but they suggest it highly. And you read that, and you go, does therapy count? Does the therapy that they made me get in order to be here count? And I mean, lots of people read words as they choose to read them, and answer questions as they choose to answer them as a result, which has been kind of how we've always done this is processing it through your own mind and deciding if you're lying. But we shouldn't have to do that. But yeah, have you ever sought treatment for a mental health condition, or, like, vaguely, as a result of a mental health need? Have you had to take time off work in the last whatever years? Inherently, if you took time off work, you made a good decision. You chose yourself, you stepped away to step back in better and like penalizing you for that is really, really wrong, but I think that that's a big fear for folks. "Oh, look. It says if I took time off, or if I asked for a disability for these reasons, that now I'm punished because I stamped myself as somebody who needed to do this, but it's the healthy thing to do."

Emily Silverman  

And sometimes those questions will be asked in the same section that they ask about malpractice and being arrested, and it'll be like, "Did you commit a crime? Did you do all these bad things?" And then it'll be like, "Have you sought treatment for mental health?" So it's sort of clustered in this, like bad section of the questionnaire that makes you feel like you've somehow committed a crime by taking time off. So that context of where it's located in the questionnaire, I think, is also really telling.

Jessi Gold  

They will do physical health, and then crimes, and then substance use and mental health in there, instead of, like, some continuity from physical to mental or putting them together, which is honestly better. Like, have you sought help for a physical or mental health condition in the last couple days due to impairment or whatever you want to ask, but they put it together. There's a state that I filled it out in where the question before was about pedophilia. I don't understand this flow, but I don't like it, and it makes me really uncomfortable, and I'm about to take a picture of this and send it to them and get really mad about it. I think that that stuff can give you subliminal messages that are unhelpful.

Emily Silverman  

And it's not clear what happens if you tell the truth, either.

Jessi Gold  

No, and it's not even clear what they do with your answers. So for the most part, nothing, but you don't get to see that, and you don't actually know well, how many people, if they check this box, are called and have more conversation? What are they actually writing that gets them called? It's not probably just checking the box, but we don't have enough clear cut examples to go, "Well, I don't rise to that level, but it's also not there that we have to have that level." But I do think that would help people know, like, I mean, so many patients that don't even want to talk to a therapist because of this stuff, and there's never been a question, even in the old ones that were written, that I ever felt was about just seeing a therapist. I think meds can complicate stuff, as it always can, but I just think that examples would help, or knowing if you did something, what happened to the information. I think people also get worried that it somehow gets public, because a lot of our numbers and things like that are public around licensing, and I think people worry that that answer becomes public, which is also such a hard fear, when you're already concerned to get help based on what other people are gonna think, or your patients might think, to then think, and then I checked a box, and everybody knew, that just is so crummy. So I respect and empathize a lot with these fears. It makes me sad when I see people that are really quite sick before they get help, and most of my healthcare worker patients say I haven't hurt a patient yet, and I'm like, is that our bar? Because that is a really crummy bar, and you don't want to hurt a patient. That's when the licensing thing is a problem. We need to be able to look sooner, and if we're too afraid to look sooner, then it becomes more of a problem, and it's a self fulfilling prophecy, right?

Emily Silverman  

Well, presumably, the reasons that these questions exist in the first place is to protect the public. So if there's somebody out there who doesn't know that much about mental health or mental illness, who says, "No, I want my state to be interrogating physicians about their mental health, because I don't want a doctor who's going to hurt me." How would you respond to that person, like, how do you assure a person that if your doctor has XYZ medical condition or mental health condition that it doesn't disqualify them from taking really good care of you?

Jessi Gold  

If your doctor had cancer, would you say, "Please don't come back to work. You have cancer." No one would ever say that to them. Ever. It would feel horrible. We respect people going through struggles like that. It feels serious enough that we would never make a comment like that, and yet mental health doesn't rise to the level. I think it's really important for people to realize that if people are getting treatment, that is much better than not. So the other side of the coin is they're very sick and they're treating you and they didn't get help for it, and we have higher rates of errors. We have less patient satisfaction, and that's just around burnout, not even depression. So if you're thinking, "Do I want a doctor who's being treated?" Well, if they're being treated, they're probably healthy enough to be there taking care of you, and you don't have to worry that they might be struggling with something that's unmanaged. I think that when people make decisions to prioritize themselves, it's a really important decision, and one that I would value as a patient, because it means that they see this job as something very important to them, that they need to be able to be at their best to do. And I think it's really important that we see our people that are taking care of us as the humans that they are. You like them more when they're human with you. You like them more when they're more empathetic. You like them more when they sit with you. They won't do that if they're not taking care of themselves. The way that they interact with you is often one of the first things to go, so I would respect a person who got help over a person who didn't think that they could. I would be sad for the other person, because it's more of the product of the system than that person and why they don't get help. But I would be very happy to know that somebody taking care of me was taking care of themselves too.

Emily Silverman  

And there are ways that these struggles we all go through as people can be a strength. A patient might really connect with somebody who has gone through a rough time, and who knows what it's like to be on the other side of it.

Jessi Gold  

 I'm a big fan of relevant self disclosure, not just disclosing because you feel like it, or if I prescribe someone, wellbutrin, I'm not like high five. I take that too, right? But if it comes up, like in some way that feels good, like they're hesitant, and I can tell them a story, either about someone I know, which is really about me or about me that would make it feel safer and make them feel more understood, and seeing it in somebody that they see as a clinician or that they respect, I think can be of benefit. And so, I do think that it makes me better at my job. I feel like I understand more what people are struggling with. I mean, I also understand how hard it is to get help a lot more than I did before. Being a burnout expert who couldn't identify their own burnout means inherently to me that it's very hard to identify, because I can rattle off symptoms without even trying, and I know what it looks like in other people all the time, and I can't identify it in myself. And so for me, understanding some of that stuff around my own experience also just made me have a lot more empathy for how hard it is for people to identify and ask for help and really know that they're struggling in the context of a workplace. And also just made me have a lot more respect for people in their experiences and like what I can do to inform and help them, because it is really hard, and we don't probably talk about that enough.

Emily Silverman  

I want to pivot and talk about telemedicine, because one of the points in your book that I liked best was the pros and cons of delivering psychiatric care through a screen. So you talk about how people sometimes come to you doing sessions in the car or they're typing stuff into the chat that they don't want to say out loud because somebody's just the other room, or something like that. How do you feel like telemedicine has changed the landscape of providing mental health care, and how do you see that evolving moving forward?

Jessi Gold  

So it will always be a thing now. We have trouble taking care of everybody, and we don't have enough mental health practitioners, and we certainly don't have enough psychiatrists, and especially not child psychiatrists. So once we figured out that this was possible, it doesn't get back in the box, it is out of the box. This is what we're doing now. And so I will just put that caveat, which is like anything I'm saying to complain or say things are better in one way or another, was also within the context of me completely accepting that it increases access, especially for folks that don't have anybody near them, and that alone is a reason to do it. However, when we first started telehealth, I'd never seen a patient like that. I like maybe once at the VA, saw somebody getting care at a different VA who remotely came in for mental health care. But I had never done it myself, and I had no idea what it was like. And for me, I like people. I like being in the room with people. I like sitting with people. I like seeing their facial expressions. I like seeing their body and what they're doing when I'm talking. I don't get very much of that on a screen. You get a face and so you get a very limited mental status exam. What's going on when I'm talking, what are you doing? Are you shifting? Are you tapping your feet? And I have no idea. There's just not enough cues for me from a mental status exam part. I also have felt for a long time that I had a lot more connection with the folks I had met in person first and then saw remotely. I don't know exactly why, but I do think I have less connection and empathetic experience through a screen. If you look at the data, there's not enough to tell you that that's true. There's the little that suggests it might be but for the most part, people say, well, but it's easier. I see healthcare workers. They don't want to drive over and park and take the time, and they just want to do it quickly and get it over with. So I think it's better for the population that I see in order to get them seen at all, but I think I'm much better as a doctor in person. I think I'm more distracted at home, and I think there are more distractions for them at home. I had people smoke in a park. I'm like, "Are you in a park?" And they're like, "Yeah." And I'm like, "Do you have internet in the park?", and they're like, "Yeah." I'm like, "Are you smoking a cigarette?" And they're like, "Yeah." And I'm like, "Would you have done that in my office?" It just really messes with people's concept of what's okay. They do it while they're driving on the highway, then I'm worried that they're gonna crash their car. That's not great. It's not a safe place to have feelings and have a good conversation. It's distracted. The best part about what we do is we sit and listen, and you get time without all those distractions, and you don't get that if you're driving or you're smoking. And I do think some people with certain diagnoses, like social anxiety, for example, sometimes trauma, do prefer having the distance for safety, but I will say it also gets people out of their comfort zone, for social anxiety, for trauma, you can learn that there is a safe place. And so I do think that there are some diagnoses that tend towards preferring it too, but that the way it has always been is helpful for a reason. It's a place you go. It looks the same all the time. We're there. We start on time, we end on time. That's the way it is, and you have the safety to talk about what you want, because no one else is there. And you mentioned that the typing in the chat thing, like, most of the time, a lot of your stress comes from the people you're around a lot, like relationships or kids, and if you can't talk about them because they're literally in the same room, like, that's not a safe therapy session either. Even typing, you can't be fully honest. Like, what if they're looking over your shoulder? I just think the safety of this space, the empathy of the experience, and my ability to really see the full picture of what's going on is limited by a screen. But in the same respect, it's not going anywhere. I would say more people than you would expect do like to still come in, and I think it just forces them to go somewhere and be somewhere, but it will be a thing in psychiatry and therapy for years to come, if not permanently, unless something else comes up before it.

Emily Silverman  

I spoke with a doctor recently, not a psychiatrist, different type of doctor, but she was telling me that she had a telemedicine visit with a patient, and they were in the chair getting a pedicure, and she actually said, "Let's reschedule." I'm wondering, if you've ever had to do that, do you ever say, "Let's find a different time when you're not operating a vehicle or whatever?"

Jessi Gold  

It's really hard because for mental health, if you tell them to reschedule, it's gonna be a month or something like, I'm not gonna make a special deal with you just because you were giving me a visit from a car. So to me, it might depend on the severity of the person and how much it would be better if they just talked to me because they're there. One person called me while grocery shopping and was like, talking to their friend and the cashier. And I was like, "Dude, I can't like, there's too many people involved in this conversation." I'm like, "Are you buying bananas? Like, I just can't concentrate." And so that time, I was like, "I would really prefer that you'd be somewhere that is you alone, that we can talk, where you're not buying food and you don't have a friend with you. You're going to be mad at me for telling you this, because you still made your appointment. But this doesn't actually count as making your appointment to me, because this is doing your appointment in the middle of something else." It feels like you got in the way. If someone's getting a pedicure and you're talking to them, they didn't make time for you. They just added you on to their day like a second thought. They don't feel like that to me. They're not a second thought to me, like I'm trying to help them and I can't help them if they're doing 75 things at the same time so very rarely, because psych patients and rescheduling can also be a whole thing too. And really wanting to make sure that I'm taking care of people anyway, because they showed up, but I will make people pull over so if somebody's driving a car and I can tell they're driving a car, I will say it is not safe for you to be on video while you're driving a car. And I'm not gonna do this via audio only, so please pull over or reschedule. And I hate that I do that, but I actually am terrified they're gonna get into a car accident while they're trying to be on the video with me. There was just, like, a YouTube guy who did that. He was making a video and he got in a car wreck. It's just very easy to do that, and like, I don't want to be responsible for distracted driving. And so that's a big no for me, and that's become a no over time, as I realized how many people were doing that. But bathrooms and bathtubs, not as much if you're not, like, naked in the screen, because I think inherently, that's a place to be private. And so sometimes people just sit on their toilet. They're not actually using the toilet. It's a complicated issue, particularly in psych, but I have done it, and there are some things that I put my foot down about.

Emily Silverman  

Tell us about being a psychiatrist who is in therapy. You said that when you go through your training in psychiatry. You're highly encouraged to be in therapy yourself. You said in the book, there's a meta level to my therapy whereby I can sometimes figure out what my therapist might be thinking about me, why she chooses to say something, or what skill or technique she is using. So it makes me think of a filmmaker watching a film, and it's like, "Oh, I see what you did there", kind of a thing. So is that your experience at all when you're receiving therapy, or are you able to kind of disappear into the patient role?

Jessi Gold  

I would wonder if it's just a mental health problem, because we are the tool. If you were in a primary care office and you had a doctor, I feel like you would be thinking similar differentials, but you need to hear it from someone else. I think psychiatry or therapy has this different level where the skill is really the person, but we learn some things to be able to do it better by watching our tape and having supervisors and getting feedback. And as much as it's encouraged, I have been like, that person's not good because I know everything they're doing and I'm bored or I just am annoyed by what they're doing. Like, this is annoying. My current therapist doesn't do that very much. She's very good. There are times where she points stuff out or says things where I'm just like, "I wouldn't have even thought of that. Like, you're really good at this." And probably I say that too much in a flattering way in the book. But we know certain things, but it makes it complicated sometimes to know them, like I know that if I bring something up in the last five minutes, it's gonna be judged for being brought up in the last five minutes as this door knob thing that we didn't wanna say until the end so we didn't have to deal with it. But sometimes I'll be like talking to my therapist, and I realized I forgot to say something, and I probably should say something, and I won't, because I don't want to deal with that conversation. Or I bought my therapist a present. I wanted to get her a present. I made the decision to get her a present, but I also wrote, like, a two page note about how I didn't want to process getting her a present. I was like, "I know that you're going to say all this stuff about me having done this, but here's why I don't really want to talk about that anyway, because I just wanted to get you a present." Just let me get you right and so like, I think having an awareness of some of that can make me overthink, probably like my interactions in therapy, it definitely made me overthink some of the writing.

Emily Silverman  

One of the narrative threads in this book is you dealing with your own mental health. So you're taking care of all of these healthcare workers. Many of them are dealing with serious mental health issues and trauma in the setting of COVID. You're taking care of them over telemedicine. You're also writing a lot, you're teaching a lot. You're extremely busy, and over time, you start to feel really tired. And you say in the book, "I'm so tired I can feel it in my bones." And you find yourself sleeping a lot. You find yourself getting sleepy during therapy sessions and having to keep yourself awake, whether that's through a rocking movement in your chair or playing with stress putty under your desk. Or one of my favorite lines in the book was about drinking caffeinated tea. So you wrote, "You can probably measure my mental state by the number of different beverages I have on my desk by the end of the day. Today, it's five." So I was wondering if you could bring us into that time a bit, and what that was like for you to be dealing with so much of that exhaustion.

Jessi Gold  

I think all of us face this thing where we think we're fine until we're not fine. I'm an over-worker to cope, and so I think I can juggle and balance a million things, and that's what I'm supposed to do. And if somebody's really good at our job, they can do that without it affecting them. And I think I've always believed that, that I could add more and be fine because I'm good at this or something, which is just like bonkers, but it's how I thought. And in that moment, I overworked also, because I had a lot of guilt about being a frontline worker behind a screen and listening to all these stories about people at risk and all this stuff, and feeling like, "Am I an imposter doctor because I'm behind a screen, and having a lot of guilt about that and being like, 'Okay, well, what can I do?'" And what I could do is outreach and education and support their mental health and do as much of that as possible. And so I just kept doing it. I was like, "I'm gonna keep doing more." And almost trying to make up for that in some capacity, but also because I knew that's what I could give. And I didn't really notice anything along the way until I was really bad, I would sit after work and turn on a dumb show and wake up four hours later, that kind of sleep where you don't even know you're sleepy or that you went to sleep, and then you're like, "Oh gosh, that was just like half the night, and now my night is ruined because I am up." And that feeling, in so many ways, like felt like it had to be a physical thing for me, because it was so bad and so heavy and so hard.

Somebody's got to be able to give me a vitamin or like something to make this better, because it can't be my mental health making me feel like this, like it's not possible. And again, as a psychiatrist, to believe that is sad in so many ways, and the product of the culture I grew up in, plus the culture I was trained in, and it's deep down in there, even if you spend all day helping other people think differently. And I think that that is critically important for all of us. I think for me, I've learned that I blew past a lot of warning signs that I just didn't see as warning signs, because I was fine and I could do my job, and I wasn't hurting anybody, and I was doing a good job, and people needed me. And you're like, "Well, I can't take time off, or there's nothing wrong with me. People need me right now. "And so you can make a lot of excuses to ignore the little things until they become really big things. And I think so many of us do that. I know I'm guilty still of doing that sometimes. So I think for me, I've had to re evaluate paying more attention to myself earlier and why the title of the book is, "How Do You Feel?" Because inherently, I never had asked myself that I just spent so much time asking other people that, that I didn't know that I had any changes. I didn't know I had any problems until I didn't have a choice but ask myself that, because I was so tired and so worn down and so checking in with myself earlier is a big thing. Another big thing I've changed mindset wise, is I don't see it as a failure. So I think I used to believe inherently that good doctors could do 75 things and be fine and it wouldn't affect them, and that this couldn't possibly be as a result of the job, because I'm good at my job, right? And I think now I look at it like, how can you not burn out in what we do, and how can you not feel sad by what we do, and how can you not be exposed to trauma by what we do? And like, we need to view it like that, so we plan for it and take care of it and forgive ourselves if we need to do something about it, as opposed to going, like, "How did this happen? That's such a shock. Also, I shouldn't do this. I'm a failure." And like, you know, it's like we have this belief that it's impossible and it's not impossible, it's actually highly probable. And that mindset shift has been, I mean, honestly, life changing for me in so many ways, because I get it now.

Emily Silverman  

As we draw this to a close, I'd love to hear more about what is in store for you moving forward, because you do so much. Your latest gig, I believe, is Chief Wellness Officer for the University of Tennessee system. So would love to hear maybe a word about that and any other creative work that you have forthcoming.

Jessi Gold  

I really like my new job. I'm Chief Wellness Officer for the entire University of Tennessee system, which is all five campuses of the University of Tennessee. It includes the Health Science Center. So I still see nursing students, medical students, all that stuff, but it's a pretty cool system role, where my job is to figure out how to center wellness broadly, and not go on any one campus and tell them what to do, but support them in elevating it and supporting each other, and finding where the good programs are and supporting that. It's kind of a cool systems thing. As a person who's always seen the flaws in systems and butted my head about it, this is actually a place where I can change them or do it differently, and that feels very empowering. Those jobs do exist, and it takes a little while to get there, but I think inherently, you can get to a place where you do have more power to make the choices and help people. And that's been really nice for me. I still see patients. Writing wise, I think sometimes I go, am I good now? But I care a lot about college students too. So I think sometimes about how to do something similar, to have conversations there. But I'm really focused right now on the idea that this book was written to start conversations. You might like it, you might not like it, but inherently it was written to be different than a wellness lecture and be different than a paper, and allow you to feel seen and understood and make other people understand what's going on for you in a way that's different, and being able to bring the book places and talk about it with people has felt really honestly healing for me, but also like, "Oh, this is how this can get better." To me, I see a lot of hope in just the conversations around it, and I'm excited about that, and being able to be a conduit of that in some capacity for folks through creative work, kind of like what you do. I think stories inherently can change culture, and we just don't tell them enough. And I hope in telling mine and telling some of my patients, that it will make other people want to tell theirs, and it'll feel like a cool domino thing where we can actually change this place.

Emily Silverman  

Well, I think that's a good place to end. It's been really great to chat with you and hear some of the behind the scenes of how this book got written and all the great work that you're doing with young people. It's just so important during this time. So thank you so much, Jessi for coming on the show to talk about your book, How Do You Feel?

Jessi Gold  

Thanks for having me.