My mission in life is not merely to survive, but to thrive; and to do so with
and some style.
He is the best physician who is the most ingenious inspirer of hope.
(Samuel Taylor Coleridge)
To become comfortable with uncertainty is one of the primary goals in the training of a physician.
(Sherwin B Nuland)
In the discussion around physician burnout, a common ‘either/or’ dichotomy has abounded: physicians need to become more resilient, or systems need to change. However, both seem untenable as the sole solutions to this issue. How can physicians become resilient enough to cope with struggling, ever-more stretched systems, where, as the patient becomes a market-oriented consumer, demands are only going to increase? And how can these self-maintaining monsters of systems, change? If a healthcare system was composed entirely of doctors (and there may be some doctors who think this is the case), maybe there would be some hope of the system itself changing to suit them better. But we’re a small cog within this system which, despite being called ‘healthcare’, is focused on pathology, and is affected by political and socioeconomic powers far beyond the cubicle curtains. Healthcare is a self-perpetuating, self-maintaining beast. All the components and individuals and sub-systems act in an interminable rhythm, and it is only disrupted by events of cataclysmic proportions – either good or bad (think WWII and the evolution of the NHS in the UK in 1948. And think of the state of the NHS today.)
In Braving the Wilderness, Brené Brown writes,
Benito Mussolini relied heavily on the line “O con noi o contro di noi” (“You’re either with us or against us.”) The problem is that the emotional plea is often not based in facts, and preys on our fears of not belonging or being seen as wrong or part of the problem. We need to question how the sides are defined. Are these really the only two options? Is this the accurate blaming for this debate or is this bullshit?…The ability to think past either/or solutions is the foundation of critical thinking, but still, it requires courage. Getting curious and asking questions happens outside our blinkers of certainty.
In looking for solutions to this growing problem, we – the doctors, staff, system – need to look beyond either/or scenarios. If I could pick one word to sum up the current practice of medicine, it would be uncertainty. Paradoxically, however, everything about our jobs, and the system, is to deliver certainty to all the stakeholders. Patients want to know, ‘This is your diagnosis. This is the treatment. This is the prognosis.’ But how often does that happen? Even the common cold we need to hedge with warnings: ‘It’s most likely viral, but should your headache worsen, or if it has not resolved in seven days, or you start developing a non-blanching rash, come back and see us…yeah, if the headache gets pretty bad, I mean….well, if it gets so bad, you should probably see someone sooner…if it’s eight days then check in with your GP and maybe get some bloods done…you’ll know if it’s non-blanching…yes, you can get a rash with some types of cancer…’. Etc etc.
Patients come, and rightly so, expect serious conditions to be excluded, and a reassuring narrative to be given which provides a schema in which to understand their symptoms. A break of the lower leg during a footy match in a 22 year-old man needs little explanation; an episode of psychosis in a 50 year-old stay-at-home mother with a vague history of depression, or liver failure in a 27 year-old with a possible family history of an autoimmune condition requires a lot of postulating and hypothesising. It often ends with a summation of, ‘The human body is very fickle. We don’t know a lot about how it works, or why things go wrong. I don’t know why it’s happened to you at this point in time. I don’t know if it’s been precipitated by something you or anyone else has done, and most likely we never will know.’ Or more often, we err on the side of compassion: ‘No, there’s nothing you have done to make this happen.’ In our compassion for our patients, we realise that on top of a life-changing diagnosis, they don’t also need to consider whether there is any personal responsibility for what has happened. It would make us sad to send them away from our clinic, seeing the fear in their eyes, now compounded by potential guilt and regret. In our treatment of patients from every spectrum of society, we disengage any sort of judgement about personal responsibility or lifestyle choice or consequences; this is not our place, we tell ourselves, society tells us, and the system tells us. Just be compassionate, and treat what’s in front of you. And we do (and just internalise the judgement and then spread it around on more acceptable targets – ourselves, management, a colleague who made a mistake.)
What do health services want? They want certainty. They want preventative medicine, then quick, accurate diagnoses if anything does go amiss, with as small a chance of re-presentation as possible, and to find definitive outcomes if they do. Which includes, but is not limited to, treatment, housing, addiction cessation, rehabilitation, unicorn horn DNA.
Primary care wants clear descriptions of what has transpired during a hospital admission, what the patient’s progress was, and what changes have been made in her or his medical management. They want guidance about when to seek re-review or re-admission. They want a sense that the big brother hospital understood that their patient, who comes in weekly with his disabled wife, is depressed, and poorly mobile, and often incontinent, and drinking a lot, and possibly struggling to care as he should for his wife. Do they get a sense that this has happened? Sometimes they will. But not always.
Tertiary services want primary care to provide a catch-all net for all things that have not been able to be attended to in a three-week hospital admission. Despite the physios and OTs and social workers and psychologist and dietitian and (if you’re lucky) specialist nurse who saw them then, it would be great if the GP could encapsulate all that in their next 9 minute post-discharge appointment with the patient. The GP must pick up patients, make sense of multiple investigations and opinions from varying teams, many times who will say, ‘Dx: ???. Re-admit if it happens again,’ and keep them out of hospital as long as possible. (By re-admit, they mean send to ED, where they will be triaged by a highly-skilled, stressed, harried ED physician who is managing ramping ambulances at one end and a bed-blocked hospital at the other end of her department.)
Governments want certainty. They determine how much money they will exact from tax payers, will allot it to a health service, and then need guarantees that no matter what happens, the health provider will provide whatever service is needed. Healthcare executives – who may be doctors or nurses who have been working in this spiralling system for decades – hold purse strings tightly, whilst clamouring clinical departments say, ‘We can’t meet these increasing needs with the same resources we once had.’ The executive, in an act of both self- and service-preservation, sends service-wide emails, decreeing a reduction in this test or that, or a limit on this locum or that nurse pool, and sits in an office, awaiting with bated breath a new financial year with hope that nothing dreadful happens in the interim, and hoping for a magical sum of money that will gift – yes – certainty – for the year ahead. They feel guilt for their colleagues holding the front line; fear of state departments demanding ‘show cause’ for every dollar over or adverse event which should have been prevented; and an internal smouldering of waning energy and stamina.
The junior doctor falls from final year of medical school into their intern year, and certainty becomes an alien concept. Suddenly they have money, no time, reduced energy, waves of anxiety and stress. He or she has moments (hours?) of feeling like not knowing anything and yet feeling like they should know so much, the incongruence of books and supervised placements compared with a lonely night shift handling a moribund patient, a ragged contrast. Registrars, hardened after a few years at the coal face, dig their heels in, do their shifts, study for exams, and possibly squeeze in being a parent or a partner or a carer. The other facets of life which make us human need to wait. Just a year or two. Or three. Or four if the re-sits don’t go as planned. Oh, and the patients receive that registrar’s care and attention, day after day. After day.
And the consultant, the leader of the team. A team which consists of nurses and OTs and social workers and nurse practitioners and medical students and physiotherapists and electrophysiologists and dietitians. Yes, you, gastroenterologist, you are now a leader. Remember that one lecture you received on clinical governance? Yes, that’s you now. You’re paid $300,000 a year, so just do it. And make sure all your patients get better quickly, and completely. And make sure your registrars are supported. And make sure that they are looking after the interns and residents. And remember medical student teaching. And the departmental roster. And accreditation. (Squeeze in the UGIE on the oesophageal variceal bleed at 2am, and work until 7pm the same day, thanks.) And CPD. These must all be done, for sure. For certain. Otherwise, you are unsafe, patients are at risk (i.e. there’s always the risk of people dying due to your actions or lack thereof), and on top of that, your department/hospital/health service will get less money next time round to combat the same problems. Yes, your child’s sick, that’s marvellous. So are your patients. And your registrar. And a quarter of the nursing staff. Pretty rough your marriage has broken up; take Monday and Tuesday off and we’ll see you back on Wednesday (can you cover the following weekend to make up for that? Your colleagues covered you on Monday and Tuesday, so, you know….?)
And the intern can’t eat due to nausea and anxiety. And the registrar can’t sleep due to being messed up coming off night shifts and looking after children, and then studying for exams. And the consultant can’t bear to stand there in front of the team and say that he doesn’t know what to do with Mrs Smith in bed 8 on her fifth admission this year – again. So he sends her back to the nursing home to the GP. And the director of medical services says that she needs you to show-cause for the two locums this month, whilst shrinking inside because she knows that they covered your colleague off sick with stress and you and your other colleagues shrank in shame and exhaustion when it was put to you to cover for him. And she calls the Department with a sweaty hand on the phone, and a shaky voice and assures them that this is short-term and temporary and they are working on ensuring that there is always space in the system to account for this.
And they all – the nurse, the administrator, the intern through to consultant – keep coming in day after day, because the patients keep coming. The intern turns up because he is aware that the resident is covering two wards by herself, and needs help. And the registrar refuses to take her study leave because her consultant is covering for his colleague. And the consultant can’t have another day off, despite his wife going through chemo, because there is a ward of 30 patients waiting, and his registrar and intern cannot be expected to make all these decisions again and again.
So why do they keep doing it? Partly this compassion conundrum, and partly either/or thinking – only the system must change, or it’s just me. Okay, we were all uptight, type A, hard-working, diligent folk who wanted a secure job which ‘helped people,’ and we invested our time and money and energy and relationships into getting where we are now. But the compassion, which we don’t show to ourselves, or extend to colleagues, or would ever show to managers, and which can also be the source of the compassion burnout towards our patients, runs deep, compounded by empathy and altruism and high expectations. We like our patients…but recently, we’ve not liked them quite as much. We got pissed off that they presented with chest pain again, with their poorly controlled BSLs, and an inability to stop smoking. But we followed the protocol, to look after them. And we did get annoyed when the man with decompensated liver failure re-presented, drunk, for an ascitic drain at 3am on a Wednesday. And don’t get me started on the lady with borderline personality disorder who has pulled out chunks of her hair and actually severed her flexor tendons this time, all because of her stepdad who took her innocence as a little girl, which she reminds us and the rest of the ED of time and time again. So we lament society and education and family, and feel like we’re sticking our collective pinky in the growing crack in the dam. But this compassion glues us there.
We stand back and regard the messy humanity that we see before us, and feel discomfort. Discomfort at their distress. Discomfort at our share in this messy humanity. Discomfort at our own messy humanity. We do chest compressions and we hear agonal breathing. We see a lifeless newborn delivered and hear a father’s sobs. We listen to the screams of the woman in resus as the police ask her about the oncoming lorry which has taken her family. We see the 70 year-old without family, with severe rheumatoid arthritis who has fallen, and has lain in her own faeces for three days, and now has an acute kidney injury and rhabdomyolysis.
So we do it, again and again. There are very, very few either/ors in our jobs, but our thinking towards ourselves and our colleagues is either/or. We navigate like a jittery compass, receiving input from multiple stimuli to help us in our decision-making processes. We do another ward round, and learn another software update for the new system which will integrate every man and his dog (sometimes), and we hit the books, and we try to be pleasant to colleagues, and we supress the nagging feelings of failure when we repeatedly cannot do our best. And we blame the management and the system and the state and our boss and our juniors – because, yes, we’re that hierarchical, that a 36 year-old with 8 years experience as a doctor is a ‘junior’ – and the lazy colleague. Only when someone pulls us up for blaming a patient do we shrivel away in shame. For there is compassion there, always, deeply buried though it may be. Buffeted and battered at times, only brought out in its fullness in a rare moment of human connection with a patient, where things are tidy, when they see us, when we see them (if we’re not too hardened).
Burnout is prevalent. Chronic stress is dangerous. Doctors are developing destructive coping mechanisms, which can exacerbate mental illness and can result in suicide. How do we stop it? By dredging up compassion again and again, for ourselves, for our colleagues, for our leaders, for our patients. All of them, including us, (yes, even our patients) do things that exacerbate the load on the system. Some colleagues communicate in bullying and unhelpful and blaming ways – because they too are broken in some manner.
I’m committed to helping doctors (and nurses – for the issues overlap more often than not) to find our compassion again, in the midst of the uncertainy. Without compassion for ourselves and one another, patients will not get the treatment they deserve. The history of our profession has done little to help develop a culture of compassion. The drive for certainty and answers and excellence has been placed above the simple acts of kindness and human connection which make us…human. In this age of ever-increasing uncertainty, and multiple options and treatment pathways and causes and biopsychosocial factors, bumped by genetics, affected and effected by epigenetics, adjusted by climate change, and shaken by political tremors 15,000 km away, the only certainty we do have is that we each possess ongoing remnants of compassion. The most expert diagnostician; the most heroic military trauma surgeon; the most cerebral cytopathologist; the most enthusiastic epidemiologist – all are united in their humanness through their compassion. As a psychiatrist in training, I could provide lots of great explanations for why individuals struggle to access feelings of compassion, but this is not the point: except for the antisocial personality disorders amongst us, or those at the extreme end of some neurodevelopmental disorders, our compassion is present.
We can’t change the system quickly. We can’t change our patients. And we can’t even change ourselves all that easily. But we can use what we have. Let’s leave either/or thinking. Let’s work collaboratively with colleagues to instill compassion. Let’s inspire hope, like Coleridge said. Let’s remember Maya Angelou, the natural phenomenon of wisdom and literature and philosophy and poetry, who was mute for years as a little girl after suffering trauma and subsequently believing that her words could kill, that life is to be lived with some passion, some compassion, some humour, and some style.