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The Compassion Conundrum: Navigating Stress and Burnout as a Healthcare Worker

My mission in life is not merely to survive, but to thrive; and to do so with

some passion,

some compassion,

some humour,

and some style.

(Maya Angelou)

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.

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What would happen if we lived compassion in 2018?

On January 1st 2017, I wrote:

This morning, Eva was discussing about aiming to ‘make friends with discomfort’ in 2017. For her, the discomforts are many and multifaceted and are not limited to the discrete physical symptoms associated with treatment for breast cancer. The complex psychological effects of living with this illness and its treatment continue to surprise us, as well as the inevitable emotional instability associated with tiredness and stress and anxiety…[we] discussed further this making friends with discomfort and amended it to making friends with vulnerability and discomfort. The last weeks’ journey has been one of vulnerability in different ways. The sensation of being vulnerable to a life-threatening disease process; the vulnerability towards treatment; the vulnerability of our family to this massive emotional and practical upheaval; the emotional and psychological vulnerability we have all felt as individuals…

The last couple of years we have discussed personal intentions for the year ahead. For example, a couple of years ago my wife suggested ‘making friends with uncertainty’. Of course, by the end of each calendar year we had not risen to such fabulous heights of enlightenment that we had perfected dealing with these complex feelings and experiences. However, like goal-setting, identifying an area for personal growth is the minimal start needed in the process of change. Rather than choosing an arbitrary or completely abstract concept (perhaps making friends with vulnerability is a completely unrelateable issue for you…I would argue it’s not, but that’s another story…) choose something which you see would make demonstrable, tangible difference in your life right now if you learned that lesson. For us, these were concrete, workable concepts that we felt we could pursue in the year ahead.

Last night (New Year’s Eve, in bed by 9.15pm, thank you very much), after writing my first blog post yesterday, I was assailed by the predictable onslaught of doubts and negative self-talk: ‘what the hell are you on about? What is ‘curiosity, disrupted’? What is the deal with that shitting comma? Yes, I know it’s a fabulous grammatical tool which will bamboozle your readers with its utterly disruptive ambiguity, but really? And how pretentious is blogging anyway? Like there aren’t enough blogs in the world. And just because you had a few compliments on last year’s blog (where you obviously hijacked your wife’s experience of cancer to express your own existential angst, you bastard) you now feel like 2018 is begging for another edition of your own naval-gazing self-absorption? What about the Rohingya? Do you think they give a shit about your blog? Go to Mosul if you think you are such a gift to the world.’

Although my own internal, unfiltered, uninvited monologue sounds perhaps rather extreme when written down verbatim, I imagine it’s not too different from that which runs through the minds of us all when we choose to present our wares to the world. For many this can be sharing your creativity, whether that be in artistic form or a presentation to the board suggesting an innovative solution to a complex problem. We are called in our base human-ness to share ourselves. Some choose to do it for artistic expression’s sake; others do it to put food on the table.

Once I’d retired to bed positively bursting with optimism about my latest blog, sans phone (intention number two), I turned to the pile of books on my bedside table: The Compassionate Mind by Paul Gilbert, Tribe of Mentors by Tim Ferriss, Finding My Virginity by Richard Branson, Rising Strong by Brene Brown, The Art of Happiness by the Dalai Lama and Howard C Cutler, The Mindful Path to Self-Compassion by Christopher Germer, and Bringing Yoga to Life by Donna Farhi. (No, you’re not mistaken; it’s like the self-help section of a major bookshop vomited up Bali in the middle of Silicon Valley.) All are in various states of readedness.

I picked up the first one, Paul Gilbert’s brilliant analysis of the old mind/brain v the new mind/brain, and how the biological and social evolution of the human prefrontal cortex has caused all sorts of irritating habits along with its ability to meta-analyse our internal states. He describes three types of affect (emotion) regulation systems in the human brain which he describes as:

  1. The driven, excited, vitality system: this is incentive/resource-focused, and is characterised by wanting, pursuing, achieving, and consuming. It has an activating effect on us.
  2. The content, safe, connected system: this is non-wanting/affiliative-focused, and is characterised by safeness and kindness. It has a soothing effect on us.
  3. The anger, anxiety, disgust system: this is threat-focused, and is characterised by protection and safety-seeking. It can have both activating and inhibitory effects on us.

These systems can also be conceptualised as relatively discrete but closely interlinked neurobiological and hormonal systems.  It’s not difficult to look at ourselves in our day-to-day lives and see how and when these affective systems are driving us. (Affect is a fancy word for emotions in this context.) Emotional intelligence is the concept that by being aware of what is happening at an affect level, we can better gauge what is transpiring both in our own internal state as well as that of others. Again, it is not difficult to figure out why this is important in business, organisational reform, the doctor-patient relationship, politics, romantic and parent-child relationships, etc etc. But how often do we do it?

He later writes,

…We require both a sophisticated and an agreed form of welfare-focused social organization to contain our potential tribalism and abusive power hierarchies, and we must also recognize that, if we don’t understand and train our minds very carefully and learn to be wary of  allowing ‘new brain/mind’ competencies to be directed by ‘old brain/mind’ passions, we’re going to be in trouble…We are a species that has evolved to thrive on kindness and compassion.

That last sentence struck me. We have evolved to thrive on kindness and compassion.

It makes sense on first pass; we know that we ‘feel’ better when others are kind and compassionate towards us…but we rationalise it along the lines of, ‘I don’t live in a world where I can expect to feel pleasurable feelings all time.’ Which is true.

So what does compassion actually mean? Is it a weak sense of gushing over pictures of malnourished orphans on the other side of the world? Is it something only nurses feel? Is it intrinsically related to the maternal and the feminine – that whole stereotyped characteristic which is not championed and modeled by the (generally) male leaders we follow? (A whole other issue and problem which I would love to write about at some point.)

Compassion is derived from the Latin com- ‘togther’, and pati– ‘to suffer’.

To suffer with. To suffer together.

As a doctor, I am galled by the focus on ‘personal resilience’ which is extolled as the answer to the ‘tribalism and abusive power hierarchies’ that haunt my archaic and ponderous profession. A medical school colleague of mine was found dead late at night in the operating theatre changing rooms back in Scotland in August. In Australia, stories abound over the past few years of doctors who have suicided in the pursuit of what was traditionally considered an altruistic and compassionate vocation.

So what would happen if we lived compassion? I have clues and ideals and visions of what could happen, and I will strive in my relationships and professions and society to be a ‘compassion disruptor’. To be explicit: it is not about simply being nice to people or ourselves. Compassion is about stepping out of our comfort zone and proactively engaging with our own, and others’, suffering.

Here are some examples of questions about how compassion could disrupt:

  • In a meeting, a manager publicly humilates a colleague for a genuine mistake they have made. How would you engaging in their suffering affect them? Do you fall on the side of, ‘they made a mistake so they deserve this’, or ‘we all make mistakes and it is not helping the situation by humiliating the perpetrator of it.’ Mike Maples Jr., a partner at Floodgate, a venture capital firm that specialises in startups, says, ‘I find it is better to be focused on honoring the discovery of the truth rather than determining who is to blame.’ Would being compassionate, focusing on the ‘discovery of the truth’ (e.g. a root-cause analysis to identify the chain of events leading to the mistake) rather than lambasting an individual be more helpful?
  • When facing a client, and presenting a solution to the problem they have presented you with, you end up receiving all the credit and praise. You know, however, that a junior associate was the one who came up with the paradigm. The client knows your CEO personally and is likely to mention you favourably. How would compassion towards your junior colleague affect this situation? You know that they stayed late finishing the proposal; how would you empathising with them ‘in their suffering’ change your response? The moral or ethical answer is not difficult to deduce; but would you choose to believe that being seen as charitable and humble is something you would rather be valued for rather than being perceived as cut-throat and win-at-all-costs?
  • As a doctor in a busy emergency department, you are faced with an emotionally dysregulated young person who has self-harmed. They have presented to your ED multiple times, and have a history of cannabis and alcohol misuse. You have treated other family members of this person, who have a selection of forensic charges and substance abuse issues between them. How could the situation be defused by you responding with compassion? How have people usually responded to this young person – both professionals and other family members throughout his/her life? Is acting compassionately likely to smooth the transition of this patient through the ED to the appropriate inpatient setting, or as appropriate to be discharged with follow-up? How does your previous experience with this patient, and other similar clinical scenarios, affect your decision to ‘suffer with’ or to reduce your emotional engagement with this patient?

In 2018, I wonder how we can change our relationships if we acted compassionately? How could we treat ourselves differently (more effectively) if we responded with an awareness of our old mind/brain – that reactive, defensive, safety-seeking part that avoids danger, and which is hijacked by the new mind/brain which chastises us for being in the situation of experiencing those feelings?

If we can change in our intimate relationships?

If we can change in our family relationships?

If we can change in our professional relationships?

If we can change in our societal relationships?

If we can change in our relationship with and to the Other, seeing our selves reflected there?

It could be great.

(But honestly, that f***ing comma.)

 

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