I read all the time about the strategies and measures physicians and other health care professionals take to mitigate, reduce, or immunize themselves against burnout, moral distress, and empathic strain. We have been talking about this for decades, with an increase in “burnout” as a result. It seems time to shift the paradigm to allow for more productive discussions, acceptance, and strategies. Instead of talking about burnout, resilience, and self-care (I can see your eyerolls!), let’s talk about how we realistically manage this challenging and rewarding work.
Distress is a natural response to working in health care, for all the reasons people already know: witnessing suffering, high caseloads, a broken medical system, and making quick connections with patients and families to best meet and understand their needs. At its core, this is not transactional; it is relational work. For many of us in health care, this response can be exacerbated over years of clinical practice. Vacations only have a short half-life.
Yet, we continue to talk about ways we are personally responsible for our well-being (true enough) without acknowledging the acceptable, natural consequences of working with folks who are rightfully stressed and in challenging situations. If we 1) accept the fact that as providers, we will, of course, be emotionally impacted by this work we do, and 2) stop accepting that only the individual is responsible, we can open a window of opportunity to help ourselves, transform systems, and improve institutions; and therefore, our patients.
Changing the paradigm to include universal acceptance of the normal consequences of this human interaction invites, perhaps demands, that institutions and systems take as much, if not more, responsibility for this natural outcome. We can’t (and shouldn’t) immunize ourselves against burnout, as suggested in NEJM Catalyst (Insights Report, 2018): Assuming we can somehow avoid distress, this invalidates the work itself and paints individuals as robotic. We certainly know that approach to medicine is not valued by the public. Nor can we find much meaning in our work if we do not connect. I’m aware of the need to compartmentalize, wall off, in response to overwhelming stress. It can be an effective coping mechanism, but not for the long haul.
Keep going to yoga, painting, singing, walking in the woods, and practicing meditation. They help. If we don’t clearly acknowledge the human nature of working in health care, we will only continue to blame ourselves for what will naturally impact us all.
Let’s change the paradigm and add to the list of strategies:
1. Pushing back against an institution that doesn’t offer the social support necessary to do the work (i.e., provider debriefings, time off, not valorizing overtime). Shouldn’t this be their moral responsibility?
2. Pushing back against using “hero” language to describe the lengths to which providers go to help their patients – this only serves to undervalue the stressful nature of health care work. It also puts providers in a position to not be able to take time for themselves. (Last I heard, heroes don’t take time off).
3. Resist institutional resilience narratives. While bouncing back from difficulty requires resilience, it also requires realistic acknowledgment that the difficulty exists. A “resilient personality” does not obviate or erase the impact of the work we do, it does not immunize you from burnout, or ensure you will not experience moral distress.
4. Resilience should be replaced with the word sustainability to better describe the career-long efforts of any health care provider, including physicians, to remain in the work, find meaning, solace, and reward while accepting the nature of the work: It’s really hard, and it will always be hard (pandemic or no pandemic).
Efforts to support health care providers in doing this work for the long haul require honest acknowledgment from us, as individuals, our institutions, and systems that some things (i.e., distress) are endemic to the work, to the profession. We should work to find ways to sustain ourselves and each other, not pretend we are immune to the best and most challenging aspects of health care work.
Vickie Leff is a palliative social worker.