After reading the title of this article, you may think that I am one of those hospital higher-ups trying to peddle “social hour” as a miraculous cure for burnout rather than an ineffective band-aid on a broken system.
I can assure you, I am not. I am one of the residents on the front lines.
I recently worked a 26-hour shift during which I only found time to pee twice and subsisted on hospital crackers and liquid meal replacements. The rest of my shift was spent at the computer, working on admissions and discharges, coordinating with multiple different attendings and interns, and trying not to pass out. At the end of that very long day, all I felt was a sense of shame and inadequacy for not being the kind of doctor I want to be. Despite giving everything my body and mind had to give to the hospital, I knew that I was selling my patients short, spending only minutes with each of them. I had no time to go to the bathroom or microwave a meal, let alone teach my interns. I felt empty, and at the same time, like I somehow should have been able to give more. This is not what I had signed up for.
After such shifts, I embody the “moral injury” popularized by Dr. Zubin Damania, MD, famously known as ZDoggMD, who likened the discord between the values that called us to medicine and the actualities of our daily work to a soldier’s moral dilemma on the battlefield. There is a recent push for the term “moral injury” to replace “burnout” and to shift the focus to the systemic structure perpetuating the discord rather than the individual’s human reactions to a broken system.
Such a perspective shift was similarly necessary at the start of the modern patient safety movement. After the notion caught on that “to err is human,” blame for medical errors has been shifting from the individual to the system. The new approach examines how to create error-proof systems rather than expecting humans to be error-proof machines.
Now, the National Academy of Medicine is proposing a new movement, “To care is human.” Blame for burnout must also shift from the individual to the system.
I am uplifted that articles about burnout and videos about moral injury are flooding my Facebook newsfeed. It is a beacon of hope that the National Academy of Medicine envisions a movement of the same scale as patient safety, and that this year’s annual Accreditation Council for Graduate Medical Education (ACGME) national meeting was titled Redefining Meaning in Medicine. However, as we continue to spread the word and advocate for change, we are still at risk of perpetuating the cycle of learned helplessness that has spiraled us deeper into this disaster in the first place.
The anger among residents behind physician mistreatment is palpable, as it should be. Physicians are dying at staggering rates. The current system is not working, and we, the residents, are calling for a complete overhaul. Wrapped into the outrage are several small-scale efforts, such as wellness committees, retreats, humanism rounds and mindfulness, which are viewed with disdain as half-hearted band-aids, attempts to appease us without a true commitment to improvement. These efforts are often plainly rejected as evidence that the higher-ups simply do not get it, or that they simply do not care. As Jennifer Bernstein argues in her aptly titled series Resident Wellness is a Lie: “Wellness is not a yoga class, or a coffee cart or a meditation practice. To be well is not such low-hanging fruit.”
I agree with most of the arguments in the Resident Wellness is a Lie series, as well as many of the other articles chronicling the built-in deficits in our current system. But when we rebuke all organizational attempts at promoting “wellness” as impediments to “real change,” we risk alienating our potential allies and throwing the baby out with the bath water. And in this fight, we need all the allies and ideas we can get. The way forward is not with an either/or mentality. We do not need to choose between small scale efforts or system overhaul; small scale efforts can fuel our system overhaul.
I view these band-aids as evidence that administrations are at least interested in finding solutions, and their inevitable failures as evidence that administrations do not know what we actually need on the front lines. The higher-ups have no reason to put any energy or effort, however little it may seem, into interventions that they know will fail, while they have quite a lot of reasons to support successful endeavors. The cost of burnout in productivity and turnover is astronomical, so whether the motivation is moral or economical, there is clear incentive to find solutions to this problem.
The issue then does not arise from a lack of desire to support us, but either from not knowing how or from not having the resources to make the large-scale changes we seek. When we blame the organization itself for holding out on us, it’s like when patients come to urgent care seeking a magic pill to eliminate their chronic pain. We tell them that if we had a magic pill, we would give it. I also believe that if our CEOs had the magic pill, they would give it.
All of this anger and rejection of the system may seem benign, but when we view ourselves as outside of the organization, we also take away our own power. Then, when we inevitably hit up against the walls of bureaucracy and change does not occur fast enough, we may be tempted to say that we are ineffectual and throw up our hands in despair. As Parker Palmer writes about the education reform movement, “We sometimes get a perverse comfort from insisting that organizations offer the only path toward change. Then, when the path is blocked, as it often is, we can rest in resentment and blame it all on external forces rather than take responsibility ourselves.”
When our government does not fund more residency spots, or our country remains far away from a universal health care system, we need short-term wins to keep us going, or we risk perpetuating our learned helplessness. While we continue to expose the extent of the problem and call for a complete overhaul, we need to take tangible, smaller changes into our own hands. We need effective band-aids to help tamponade the bleed until we can fix the deeper wounds. We are dying. We can’t afford to wait until there is a complete system overhaul to try to find pieces of meaning in our careers, and our patients can’t afford to wait either. But we also can’t afford to be complacent.
How do we do this? We need to work together with administrators to come up with interventions that have an effect, even if we all know they will not be a cure. In a similar way to the patient safety movement, just because the blame is shifting from the individual to the system does not mean that the solutions shift from individual to system. It is up to the front lines to perform root cause analyses on our daily moral injury and clearly state what we need. It is our administration’s responsibility to listen. These short-term wins can make our work environment a little bit better, help us feel a little bit more empowered, and fuel us towards our greater mission of overhauling the system’s deeper issues.
Full disclosure, I have started my own wellness intervention as part of the Back to Bedside Initiative through the ACGME. At the recent ACGME meeting, there was a poster presentation session featuring all thirty Back to Bedside projects from different residency programs. It was incredible to see what we have created while working as full-time residents. Most of these projects were small-scale enough to be taken to any institution, and they all centered around a few common themes aimed at promoting meaning in medicine.
My next post will delve into a discussion of these themes, in hopes that others may feel inspired to try out some of these effective band-aids while we work on healing our deeper wounds.