Patricia Watson, a psychiatry professor with the National Center for PTSD, describes what it’s like for healthcare professionals to maintain well-being during a chaotic crisis such as the current pandemic. “It’s like a dance where you’re having to take a step forward and take a step back; and sometimes the dance has to be very quick… to support each other and take care of yourself, sometimes in seconds. And at other times you’ll have more time and more ability to do some of the things we know are helpful to people.”
Watson’s message: this disaster is ever-changing; well-being varies greatly from person to person; there’s no point in being prescriptive about what to do; everyone needs to adapt, experiment, and be creative.
Phyllis Napfel, a senior clinical nurse who has worked in the shock trauma operating room at the University of Maryland Medical Center for almost three decades, told me how she continues to adapt in a chaotic world. In 2018, as a result of cumulative stress on the job as a trauma nurse, Napfel experienced trauma herself. “I had no wall between my patients and me.” At first, she remained stoic. The culture of her shock trauma unit is, as she describes it, not to show vulnerability. But as her anxiety and depression began to manifest in crying outbursts and flashbacks, she sought help. Her experience offers valuable lessons for coping with stress and burnout. Now in treatment and much more self-aware, Napfel is “putting herself out there.” To confront stigmas attached to self-care, she is giving in-service workshops on stress and resilience and finding them to be cathartic.
When Napfel gets “nudges” to do something for someone else, she acts on them. She checks in with people and asks questions, she writes cards and notes, and she sends gifts. These uplifts, these small acts demonstrating a caring connection, brighten her mood. She’s become a mentor in the unit and the kind of colleague people gravitate toward because she listens to them. Napfel dances with the bear by “helping the world.”
So, when can you stop dancing with COVID-19?
As in the old joke about the bear, you can stop dancing when COVID-19 stops dancing with you.
The bear is untamed and nasty and showing no signs of exhaustion. And yet, as in the case of Nurse Napfel, it’s possible to keep your balance and achieve states of what she experiences as “compassion satisfaction.”
I’ve come to understand something glaringly obvious that is worth repeating. There are in fact two crises hitting healthcare at the same time. The second crisis, since January, has fed on the first. COVID-19 exploded on the scene because our healthcare system was already stretched, and our political system proved incapable of facing a pandemic. Lack of medical supply and preparedness, and lack of decisive action even when warnings were being shouted from the rooftops by epidemiologists, seem to have been responsible for thousands of unnecessary deaths.
Before COVID-19, healthcare leaders were being challenged on multiple fronts. Threats came from competition and mergers, declining reimbursements, shortages in nurses and specialty staff—and a distressed workforce. Electronic health record-keeping, seen by providers as a process of automated billing rather than a means for improving care, was adding strain without realizing compensatory value. Productivity was on the rise, but so were rates of depression, occurrences of work-home conflict, and incidents of suicide.
Many have used the word burnout to capture the effects of this noxious gallimaufry on healthcare providers. Others prefer to call it moral injury, the suffering experienced by caregivers when they feel stymied by the system, unable to live up to their ideals and to care for patients as they feel they should. My intention in this paper is to identify the contextual culprit, never to shame its victims. Good people are working in bad systems.
Burnout/moral injury can manifest as three kinds of loss: loss of mental and emotional energy, a sense of depersonalization and loss of empathy, and cynicism and loss of meaning—normal reactions to working in an unsupportive and sometimes toxic workplace. It’s not the physician, it’s the setting!
Dr. Michael Goldberg, Scholar in Residence at The Schwartz Center for Compassionate Healthcare, argues that burnout cannot be treated by increasing resilience alone. The four interventions for curbing burnout that have empirical support—small group sessions, stress management, mindfulness, and communication skills—all healthy practices, cannot cure burnout. According to Goldberg, without significant structural change in healthcare, programs that focus on individuals are just producing stronger canaries to be sent into coal mines.
Even if burnout and moral injury have shape-shifted under the pandemic regime—as so many healthcare workers have resolved their feelings of ambivalence and rediscovered their purpose and calling—it remains true that healthcare institutions can always take better care of their caregivers.
And now, enter COVID-19, the bear.
The bear adds new threats in an already dysfunctional environment. There is fear of getting sick and dying or bringing the disease home. There is worry about being deployed where you lack skills or being made to suffer financial loss. There is dread of the unknown.
Carisa Parrish, a psychologist and associate professor who directs training within Division of Child and Adolescent Psychiatry at the Johns Hopkins School of Medicine, relies on evidence-based care, includes parents in her programs, and asseverates the value of mindfulness. Parrish wants to help providers rediscover “the joy in medicine.” Yet she acknowledges they, and she, are experiencing strain from every direction. Social distancing and sequestering prevent low intensity ways of coping with stress; childcare, for many workers, requires “strategic child management” such as relying on multiple babysitters; constantly changing in and out of PPE is exhausting; the constant flux of learning new roles and rules invites cognitive strain, confusion, and resentment. There is anxiety in getting used to a new protocol, and then potentially fresh anxiety in doing away with it. And always, always, there is the existential question, are we safe?
Mike Piet, an EMT and paramedic student who recently volunteered in a Queens, NY, hospital, described in stark terms the reality he witnessed each day: Healthcare workers whose very identity is centered on helping others, whose jobs have devolved to keeping bodies in homeostasis, are laboring in a seemingly endless present. For COVID-19, there is no treatment, no therapy, no cure. These are battle conditions.
The death toll from COVID-19 in the U.S. is rising at an alarming rate. Many healthcare workers have died from the disease. Front-line physicians, nurses, and supporting staff are vulnerable to becoming second victims—casualties of stress and trauma. The healthcare community continues to explore every possibility for consequential, humane action—emphasizing caring for self while caring for others.
This article is the first in a series that tells the story of how physicians can develop coping skills to manage extreme burnout