Changing the culture of medicine needs many actions but one that each individual can control is the need for self-care
Reproduced from The Guardian, June 1 2017
It’s still dark outside and I am wide awake, unintentionally. A vice-like grip encircles my abdomen, travelling up to my chest. The heaviness is a reminder of a new morning and with it, a host of new responsibilities. Yesterday was a difficult day, but no different to the week or the month before. Come to think of it, most of the past 20 years have been crammed with difficult deliberations, near-misses, moral dilemmas, organisational decrees, formal complaints, frustrated colleagues, upset trainees, demanding people and needy patients. It’s only the permutation that changes.
But these days my head swirls with fatigue and resentment mingling contradictorily with satisfaction and meaning. There is a lot in daily practice that call for debriefing but there is rarely the time for it or the company of doctors who aren’t engaged in more “consequential” things. Crowded thoughts must be repressed or hustled out to make room for another day.
A brisk run curtails my ability to ruminate but the thoughts return to lap hungrily at me the minute I stop. What to do about my refugee patient? In his dying days from his wheelchair-confined space he folds his hands and begs me to reunite him with his wife and “if I have to choose between my children, this son”. Can a compassionate visa process outpace a failing liver? Not for a refugee – but I promise to try. The usual means are quickly exhausted but his plight bothers me so I write to the minister. Creating an email with equal measures of pleading and professionalism is emotionally exhausting. When there is no response, I console myself that I did my best and must move on.
In hospice, a dear patient is unconscious after a rapid illness that left no time for treatment. I introduce myself to the stunned husband and sit at her side. The last time I held her hand it had felt warm. I know that I am supposed to intellectualise this moment and blame the disease, not the doctor. But directly in my line of vision is a card that asks, “Mummy, when will you come home?” Tell my intellectual story to the little girl.
But even before I have had time to absorb these misfortunes, a nurse calls. She is feeling bullied but senses the power differential too great for her voice to matter so she resigns herself to remaining silent at work but tearful among friends. My voice stays steady but inside, I am fragmenting, dismayed at the ugly underbelly of medicine that is taking its time to shrink.
I love being a doctor. It’s what I always wanted to do, this work so rich in content and even richer in meaning. There is gratitude, comfort and undeniable privilege. Still, on many days I feel emotionally barren, fearing that the day has just begun and I have nothing left to give. I am not alone: my stories compete with those of the harried intensive care doctor, the rushed GP, the sleepless surgeon, the overwhelmed emergency physician, and practically every nurse I know. But it does get me wondering how long it is possible to keep absorbing the setbacks and vicissitudes of our patients’ lives and pretend that none of it affects us. Is the magnitude of a life’s work enough to outweigh the depersonalisation of the self?
“Can’t you slow down?” my sweet friend asks. “Take time off or something?”
And park my worries where? Hand my patients to whom? Say what to the management? Importantly, nothing would change on one’s return except a larger pile of work. No doctor has the capacity to take on the additional work of a stressed colleague with sympathy and understanding and without judgement at what is widely perceived to be a personal susceptibility even though the evidence screams otherwise.
The worse the burnout, the greater the risk of medical error.
Depression and suicide are dire and thankfully uncommon occurrences but stress and burnout, hazily defined, are ubiquitous and can be the precursors to deeper trouble. They aren’t confined to junior workers as the recent suicide of a senior Australian gastroenterologist shows. In a heartbreaking letter, his wife observed that despite feeling flat “he continued to see patients, do lists, go to work, get home late.” Alas, this rings all too true for many.
It is widely known (and resolutely unacknowledged) that doctors somehow become convinced that in a life of privilege and meaning there can be no dark and overwhelming side. That it is forbidden to endure forlorn or wobbly moments when you are doing good, helping people, caring for them on your drive home, worrying about them in your sleep. But of course, there is – and it directly impacts patient care. The worse the burnout, the greater the risk of medical error.
You might ask what’s so special about healthcare providers. Many careers are stressful, and burnout is not confined to medicine, but this is the kind of thinking that has led us into an epidemic of silent suffering. For far too long it’s been a sin to even suggest that bearing witness to human suffering on a daily basis is uniquely onerous. The responsibility for people’s lives is real and exacting. Combined with the rising incidence of complaints, verbal abuse and physical harm it can be soul-destroying. And yet, you can love your work, think it the best job in the world, and feel amateurish for wanting a break.
Changing the culture of medicine needs many actions but I think one that each individual can control is the need for self-care. The notion that we, whose job it is to provide compassion, may actually be in need of it feels misplaced when every patient appears needier. But doctors and nurses must realise that self-care and altruism can co-exist. Protecting our own emotional health is compatible with advocacy for others. Without compassion for the self, we will have nothing left to give.
It puzzles me that exceedingly high-achieving doctors think they are the problem when the truth is that the majority of us are careworn and strained. How have we managed to lock each other out? No clinician should pretend that juggling patients, family and personal relationships is easy – imagine how therapeutic a workplace could be if we allowed ourselves to relent somewhat and shared with each other why it’s hard. Knowing that we are hurting together fosters ways of healing together.
Good medicine relies on having space to reflect, absorb, falter and recover. In this, the counsel and support of our peers is crucial but so is tuning into the inner voice that says it’s time to seek help. In a lifetime of kindness to our patients, it is OK to be kind to ourselves.
In Australia, the crisis support service Lifeline is on 13 11 14. In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255