Shear Forces | Humanities | JAMA | JAMA Network
[Skip to Navigation]
Sign In
Views 10,329
Citations 0
A Piece of My Mind
October 28, 2020

Shear Forces

Author Affiliations
  • 1Department of Internal Medicine, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
JAMA. 2020;324(19):1943-1944. doi:10.1001/jama.2020.21746

The walk from my house to the hospital and back had become a symbol of transition, from family life to work, from work back to family life. Knowing we would both have long and sometimes disruptive hours, my husband and I chose to live a short walk from the hospital where we work. The location is convenient, although at times emotionally challenging to have neither physical nor metaphorical space separating work and family. So I created a transition ritual out of crossing the main intersection on my walk. As I cross from east to west to go to work, I intentionally breathe in preparedness, hope, and energy for the patients and colleagues who await me at the hospital and I breathe out warmth, gratitude, and comfort that my children are safe and nurtured in my absence. As I cross from west to east back home, I reverse the process, breathing in love, fun, and (more) energy for my family and breathing out the satisfaction of hard work, shared grief, and comfort that patients and colleagues are provided for in my absence.

In March 2020, this ritual that had served me so well failed abruptly. Coronavirus disease 2019 (COVID-19) arrived like a sucker punch, rapidly and menacingly infiltrating every sphere of my life with fear and uncertainty. In the early weeks of the pandemic, there was so much fear at the hospital—fear that I would not have enough personal protective equipment (PPE), fear that even adequate PPE would not prevent transmission of the virus during high-risk encounters, fear that I did not know how to help my patients, fear that I would have to choose who to help and who to deny life-saving therapy. There was incalculable fear at home, too—fear that my husband or I might bring home severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and endanger our children or each other, fear that my children would suffer psychological consequences from isolation or remote education, fear that we might not have reliable access to food, basic supplies, or other necessities.

I began to see others finding ways to cope with the fear. Some immersed themselves in the battle against COVID-19. Colleagues quarantined themselves in their garages or hotel rooms, avoiding the possibility of infecting their families while focusing fully on caring for patients in a COVID unit. Coworkers traveled to hard-hit areas to provide desperately needed medical support. Others immersed themselves in protecting their families. Moms in my neighborhood posted accounts on social media detailing their plan to hunker down—prepping a month’s worth of nutritious dinners and banana breads, safeguarding their families by avoiding any outside contact. Some parents embraced their roles as remote-learning teachers and poured themselves full time into their children’s educations.

I found myself at once deeply envious of the ability to fully devote to work and deeply envious of the ability to fully devote to family. As a physician bound by a duty to heal when needed, I felt an immense obligation to avail myself completely to patients and the community to help combat the pandemic. At the same time, I felt an immense duty to drop everything and protect my family from unprecedented threats to their physical and mental well-being. But as a frontline physician married to another frontline physician with 2 small children, I could do neither fully. Every effort toward one of these goals felt like it directly contradicted the principles of the other. Prior to the pandemic, I had invested intense effort into curating the elusive “work-life balance” and considered myself successful in executing the goal of half-physician and half-mom. But here was a situation that demanded no less than 100% physician and 100% mom, and none of my time management skills or productivity hacks could solve the incongruence of that equation.

In the spring of 2020, when I walked home from work, I could no longer exhale with the comfort of knowing my patients and colleagues were going to be OK. When I walked to work from home, I could no longer exhale with the peace of knowing my family would be safe and nurtured. The transitional walk that had symbolized balance for me now felt physically painful. East to west, my chest tightened as I longed to run back to the hospital and make a few more adjustments to medical plans, communicate with a few more families, give my colleagues a few more breaks. West to east, my heart ached as I wanted nothing more than to hunker down with my boys, to be a constant presence for them during the chaos and remove any risk that they could contract SARS-CoV-2.

Like many physicians, I struggle to name my own emotional symptoms, finding it easier to think in terms of physical illness. As such, the physical manifestations of my psychological battle grew more intense and constant. A gnawing tightness in my chest developed like the sensation right before an anguished scream, except the scream didn’t come and the feeling didn’t resolve. I began to wonder if I was, in fact, physically ill. Initially, I worried that I had contracted SARS-CoV-2. Fortunately, I tested negative. I gave serious consideration to every item in the differential diagnosis of chest pain, but nothing fit. A trusted colleague delicately suggested that the etiology could be psychological, and although I admitted that this explanation had face value, it felt unsatisfying.

I mentally flipped through the differential for chest pain again—esophageal spasm, pulmonary embolism, aortic dissection…until I stumbled onto something that made sense. In aortic dissection, a tear develops in the inner layer of the great vessel and blood enters the vessel wall. This tear becomes a life-threatening emergency because of the velocity-dependent shear force that further separates the 2 layers. Long-discarded memories came flooding back, and I visualized shear forces depicted on planar diagrams from college physics classes. When applied to a surface, shear forces result in one part of the surface pushed in one direction while another part of the surface is pushed in the opposite direction. The competing forces can have devastating consequences. In aortic dissection, these forces further separate the muscular layers with increasing risk of rupture. Patients typically report a tearing, ripping, or shearing feeling in their chest. In my struggle to find balance amid the pandemic, I too felt intense, oppositional forces simultaneously applied to the competing priorities of work and family, and it seemed to be tearing me apart.

Like others before me, I found that analogizing my distress to a physical phenomenon helped me make sense of my own story.1 With time and having a narrative that resonated with me, I began to heal. The cornerstone of initial management for acute aortic dissection is administration of medication to rapidly reduce the shear forces applied to the vessel walls. In contrast, I was trying to fix the problem by applying greater force to both sides, contributing more time to the COVID-19 response at work and more time supporting my family.

As part of my pre-COVID focus on time management, I have been tracking my time in 15-minute intervals over the last 3 years. Between the months of March and May I averaged exactly 53.6 hours per week at work and 53.6 hours per week in direct childcare. Perfectly balanced in a mathematical sense, but it felt completely off-balance in every other way. Rather than intensify my efforts, I realized I needed to rapidly reduce the shear forces applied to my life. Much of that was accomplished by reducing my own expectations for myself. Other therapy included asking for help and realizing when saying no was the healthiest choice.

Now, things have settled down a bit, both in case volume and uncertainty, as we know more about the transmission properties of SARS-CoV-2, are more comfortable with PPE supplies, and have more options for childcare. But I still remind myself that overly intense forces pulling toward work and life can tear apart the walls of a balanced life, and that the best therapy is sometimes just slowing down.

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

Corresponding Author: Stephanie Parks Taylor, MD, MS, Department of Internal Medicine, Carolinas Medical Center, Atrium Health, 1000 Blythe Blvd, MEB Fifth Floor, Charlotte, NC 28203 (stephanie.p.taylor@atriumhealth.org).

Published Online: October 28, 2020. doi:10.1001/jama.2020.21746

Conflict of Interest Disclosures: Dr Taylor receives support from grants 5R01NR018434 from the National Institute of Nursing Research and 1R21LM013373 from the National Library of Medicine, outside the submitted work.

Additional Contributions: I thank Brice Taylor, MD, for allowing me to share our family’s story.

References
1.
Farrell  CM.  Systole and diastole, strength and openness.   JAMA. 2020;323(17):1726-1727. doi:10.1001/jama.2020.3095PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×