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A Piece of My Mind
October 6, 2020

Calming the Storm

Author Affiliations
  • 1Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
JAMA. 2020;324(13):1290-1291. doi:10.1001/jama.2020.18800

The barrage of sharp pains throughout my abdomen, the daily headaches, the weight loss, all had me convinced that I was dying. I would lay awake for hours each night wondering what terrible disease I had and what, if any, treatments would be available to me. Even as negative test result after negative test result kept rolling in, none of it provided me the reassurance that it seemed to provide the doctors. I knew what I was experiencing was real. How could the cause of symptoms so painful and life altering be so hard for others to identify?

The path to a career in medicine is long and arduous. Early in the journey, I learned of the immense physical and emotional toll this profession can have on a person. The countless hours of studying, the examinations lurking around every corner, the constant comparing of myself with peers, and the uncertainty of where my training would lead me, all contributed to overwhelming anxiety.

After burning through numerous primary care doctors, whom I quickly labeled as uncaring idiots, I arrived at the office of the person who would help me get my life back on track; the person who would help me calm the incessant storm in my mind. She wasn’t a psychiatrist or any type of subspecialist. She was an overworked and underpaid primary care physician who was willing to listen and had the patience to try to understand me as a person. She helped me realize how powerful the mind can be and how stress can manifest as physical symptoms. Over time, she helped me identify the triggers of my symptoms early and develop ways to keep the anxiety from spiraling out of control. I am forever grateful for her patience and compassion.

I took this difficult time in my life as an opportunity to focus on my own well-being. I dedicated myself to maintaining a lifestyle that promotes both emotional and physical health. A healthful diet, regular exercise, and relaxation helped get me past that dark period and has since helped me overcome countless stressful events that life has brought. Of course, there are still moments when I feel the daily pressures bearing down on me but through the habits and skills that I have developed, these moments are fleeting, and I now take them as opportunities to refocus on my own well-being.

As a cardiology fellow, I regularly see patients who are convinced that they have a serious heart issue despite negative test results. One woman in particular comes to mind. The chest pain she experienced caused her to go to the emergency department multiple times and her ischemic workup always showed negative results. She had been seen by multiple specialists, including a cardiologist. Her workup had been extensive and unrevealing before she saw me for a second opinion. I tried to channel the patience and understanding that my primary care physician had with me when I was going through such a rough time. Unfortunately, I don’t think I was able to make such a connection. Hopefully, I will get another chance.

Heart disease is so prevalent and deadly that even the possibility of having a heart condition can create an enormous amount of anxiety in people. While reading ambulatory heart monitors, I always find myself thinking about how many of the patients who had worn the monitors had been prescribed them due to symptoms caused by underlying stress and anxiety. Often when I see that a monitor has dozens, or even hundreds, of events recorded by the patient for symptoms, the associated rhythm strips end up being completely normal. I suppose the fear of cardiac issues is so overwhelming because of the potential to strike so suddenly. The specter of sudden death can create anxiety in anyone and can lead a person to attribute even the slightest and most brief palpitation to being a symptom of life-threatening illness.

The ongoing coronavirus disease 2019 (COVID-19) pandemic similarly creates a tremendous amount of stress and anxiety among people. The speed with which this infection has swept over the world, leaving devastation and despair in its wake, forces us all to worry about what the future may bring. The uncertainty around transmission, symptoms, testing accuracy, treatments, and risk of lasting complications and death all add to this growing distress. This pandemic is creating a perfect storm of stress, fear, and confusion that can push anyone to their breaking point. This unrest manifests in different ways in different people, and the potential for people to develop physical manifestations from this stress is very real. It seems like every day we are hearing about new symptoms associated with COVID-19 and the potential sequelae of even mildly symptomatic infection. The possible cardiac manifestations are particularly worrisome and combine the fear of COVID-19 with the already substantial fear of heart disease. Acute myocardial infarction, arrhythmia, myocarditis, and cardiomyopathy have all been described as complications.

It certainly won’t only be cardiologists who will field more inquiries regarding the potential symptoms of COVID-19. Physicians from nearly every specialty will likely be seeing more patients presenting with vague symptoms that they are attributing to this disease, adding to the enormous workload that already exists. As physicians, we too are stressed by this pandemic—by the fear of being infected by a contagious and potentially deadly virus, by the fear of infecting our loved ones, and by the constant reminder of our own mortality. We are not immune to these dangers just because we are doctors. Physicians also now find themselves grappling with the added stress of seeing more patients, having normal work flows completely disrupted, and having to answer questions about an infection that is incompletely understood.

Our patients, our families, and the public in general are all looking to medical professionals now more than ever to provide answers to their questions. Many physicians are having to go beyond their normal scope of practice in order to empower patients to take the measures necessary to slow the spread of COVID-19 and to be available for them to share their fears during these difficult times.

Hopefully, as we continue to learn more about COVID-19, the many uncertainties that currently exist will begin to subside. In the meantime, we need to be vigilant in trying to understand these patients’ concerns. We need to be curious about our patients as people, not simply as patients and should take the time to understand their lives and their apprehensions. Faith Fitzgerald, MD,1 once wrote how curiosity “converts strangers…into people we can empathize with.” Harnessing this curiosity will not only help us to develop more therapeutic relationships, it may even provide some comfort by learning how those outside of the medical profession are coping with this pandemic.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Jesse John Goitia Jr, MD, Department of Cardiology, Kaiser Permanente, Los Angeles Medical Center, 1526 N Edgemont St, Second Floor, Los Angeles, CA 90027 (jesse.x.goitia@kp.org).

Conflict of Interest Disclosures: None reported.

References
1.
Fitzgerald  FT.  Curiosity.   Ann Intern Med. 1999;130(1):70-72. doi:10.7326/0003-4819-130-1-199901050-00015PubMedGoogle ScholarCrossref
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    1 Comment for this article
    EXPAND ALL
    Don't Listen to the News
    Eugene Breen, MB, MRCPI, MRCPsych | Mater Misericordiae University Hospital Dublin Ireland
    Dear Editor,

    I found myself getting not a little spooked whilst reading Dr Goitia's article, the reason being that we all know there is a war - but please stop talking about it! I spent much time last week telling anxious patients to "stop listening to the radio" because they were becoming uncontrollably anxious. One young person lost several kgs in weight and started sleepwalking. Another is afraid to touch anything in case she "gets it" and she stood with double masks at the far side of the office as I interviewed her friend. My colleague's 8 year old
    child has skin peeling from her little hands because the teacher makes them use disinfectant many times a day. We all could go on.

    The media are driving people crazy! All the chat shows, the news shows, the advertisements are about "it". My stock question in psychiatric interviews now is "And does Covid bother you much?"... Sorry I mentioned "it."

    Dr Goitia is of course correct in saying that somatic symptoms are often anxiety-related and it is great to hear how he got such a human physician to connect with him and walk him through that distressing illness. We need to tell people to stop immersing themselves in media coverage of this virus and advise them to embrace The Big Five - a good night's sleep; a healthy diet; exercise; social contact family and friends; and useful or suitable work/occupation.
    CONFLICT OF INTEREST: None Reported
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