Medicine is no stranger to discomfort. Whether you are a writhing patient waking up from surgery, a practitioner who must don more gear to re-enter a COVID room, or a tired resident whose pager is endlessly buzzing, you are not always pleased about your situation. It is no mystery to the general public (since the COVID-19 pandemic began) that healthcare providers are under extreme pressure at work. Research has shown that the mental health of providers was quite poor (i.e., rates of burnout and depression were high) prior to the pandemic hitting the globe. Asking providers who are already burnt-out to take on the pandemic is essentially like asking a tired toddler who has skipped lunch and missed their nap to solve a puzzling new toy while remaining kind and patient. Providers are not like children, but they are often treated as if their needs do not matter. You would never expect your child to perform well under extremely strained conditions, for reasons related to care and love. Exposure to such enduring levels of stress, having to always do more with less (e.g., dwindling PPE), and being confronted with consistently changing information, is overwhelming. Over and above the stress that accompanies the structural changes COVID-19 has brought and its disruption to daily medical life, there exists a strong fear of the virus itself, and its potential to derail both the bodies and lives of healthcare workers. Prolonged exposure to such high levels of stress, exhaustion, and what is called moral distress (i.e., feeling prevented from doing what you believe to be right in a given situation) is simply not sustainable.
Before the pandemic, plenty of system-wide stressors conspired to make providers feel overextended, cynical, and disengaged, although these are not the only contributors to medical exhaustion. The individual commitment from providers to meet these challenges head-on can be extreme, sometimes to the point of forgoing their own basic human needs. I have a nursing colleague who once told me that “you eventually just lose the sensation of having to pee, and power through it”. She reflected on how she was “scrubbed in for a liver transplant for thirteen hours and forgot about everything else”. Dr. Rana Awdish, author of the book In Shock, echoes this sentiment. She refers to wondering if doctors were somehow different from everyone else, almost superhuman, as “a twelve-hour case meant twelve straight hours in which you did not move from the operating room table…you learned not to drink or eat, you learned not to feel hunger or indulge thirst.” Today, I am hard pressed to find a place to take my mask off in order to eat while on the ICU, but such an inconvenience is far from novel. I have watched countless providers over the years skip their breaks entirely, explain how there is no time to waste in a cafeteria line up, or survive off of food provided for the patients. The systematic organization of medicine, and its historical ways of doing things, rewards (or at least ignores) self-sacrificial habits. The pandemic has simply exacerbated a very well engrained problem, that is, the habit of forgoing self-care to help others.
The traditional culture of medicine erodes providers. Age-old practices that attempt to condition practitioners to become hardened to feeling or expressing emotion is compounded by the simple fact that medical life is inherently difficult. Traditionally, senior staff can make residency training no easy task. Dr. Philip Stahel writes in his book Blood, Sweat & Tears “there was a joke that made the rounds about how interns took the blame for anything…attending surgeons would ask the junior house staff ironically: ‘why did you assassinate JFK?’ then interns would reply something like, ‘I don’t know sir, I’m really sorry!’”. Senior nursing staff might choose to be equally tough; many social and emotional barriers can be created by veteran staff which prevent new staff from feeling genuinely welcomed. Dr. Michael Leiter (a top Canadian researcher in the field of burnout) has said that even minor forms of neglect, such as when someone fails to say “good morning” back to you at work, can pervade your thoughts and change your mood. Healthcare providers must also battle their own internal consciousness. There is a degree of guilt that is always felt (i.e., that you are letting the patient or your coworkers down) if you do not rise to the occasion and say “yes!”. There are always more patients to see and endless amounts of work to do, but providers need to learn to say “sorry, I just can’t do that”.
A surgeon once said to me, while we were discussing the pervasive issues of burnout, long hours, and terrible working conditions for surgical residents, that “that’s what it means to be a physician”. There was no sense of lightness in this statement, it was as if to say: suffering is what it takes, and no one will come to rescue you, you simply must survive or leave the profession. Well, many providers are leaving their professions. Nurses are flocking away from intensive care units and emergency rooms that are overrun with COVID patients. Even worse, Dr. Karine Dion, a doctor practicing in Quebec, took her own life due to the stress and lack of support in her career as an emergency physician. The first step towards finding a solution to the mental health crisis facing healthcare providers is to admit that the current culture of medicine is detrimental. Doctors and nurses are healers and they want to help, but they themselves are facing abuse and mistreatment in their role. Most importantly, I want to note that this crisis is not a foregone conclusion. Despite the great amount of need that exists from patient populations, I feel it is a critical time to finally ask: what is it that providers need, and how can we help them say “no” in good conscience?