Resilience and Broken Systems

cw: death

I have a white bear rule - don't think about dead people before bed. I started this rule in residency, when I would finish a shift that often involved an unsuccessful resuscitation of someone in cardiac arrest from heart disease, gun shot wounds, opiate overdose, or one of the many other fatal disease processes plaguing our area. After middle shifts, I would drive home late to my sleeping spouse, eat dinner, watch mindless tv, and go to bed. While trying to fall asleep, I could easily jump from pondering my day to analyzing my role in that last resuscitation to remembering what it felt like to watch someone die, because that was often my job. 

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Thinking about dead people before bed is not great for wellness. I refer specifically to dead people - not death, not loved ones who have passed, but the physical and sensory experience of the hands on care of someone undergoing death despite resuscitation. I have innumerable physical memories of what that experience feels like, looks like, sounds like, smells like. Emergency personnel experience a great deal of secondary traumatic stress from caring for people in catastrophic life and death circumstances. It comes with the job. I'm grateful for wellness strategies like meditation, mindfulness, exercise, and family support to help me through that stress. I have elaborate rules about what media I will consume to avoid triggering topics that may spin me down a rabbit hole to seeing dead people at bedtime. Though somewhat counter intuitive, mystery novels that aren't too gory are my favorite. Grey's Anatomy is a hard no. Those strategies work for me and are essential to maintaining ongoing wellness.

But. As much as I love mindfulness and resilience strategies for stress management for the essential roles they play in my life, I am profoundly concerned about how these strategies are recommended as an antidote to burnout in medicine. 

The days I am most frustrated and disconnected from my work are not the days when someone is critically ill. I love advanced resuscitation. I am honored to be present with families in these challenging moments and do my best to be there for them. That is the heart and soul of Emergency Medicine. 

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I hate when stuff breaks. I hate when the phones don't work. I really hate when the phones don't work, my patient has a ruptured appendicitis, and surgery is nowhere to be found. I hate when the otoscope in room 8 is broken. Again. I hate when I can't find an intubating stylet. I hate when it takes me longer to document a case in the EMR than it takes to actually see the patient. I hate when I can't get rocuronium for rapid sequence intubation. I hate when the script printer breaks and I can't fix it. I hate when I'm arguing with a consultant about the best care for a patient when the real problem is that neither of us have the resources we need to do our jobs. I hate when there are no beds in the hospital and people board for over 24 hours in the ED. I hate when there aren't enough doctors and nurses working to take care of all the patients. I hate when I'm shifting my circadian rhythms to accommodate my work schedule and I still can't fall asleep. I hate when I feel like there's nothing that I can do to fix it. Those are the problems that contribute to burnout for me. They are struggles healers face across the country and around the world.

Where are all the clinician burnout strategies aimed at rectifying those deeply problematic systems? We hold providers accountable for their wellness, but what about institutions? How can organizations step up to take accountability for their staff's wellness? Clearly a bi-directional approach is necessary. Resilience and mindfulness are essential for coping with the daily stresses of working in medicine as we work to combat suffering. Organizations must also look inward to learn what systems are contributing directly to staff burnout, fix them, and develop systems to build resiliency at scale. 

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I was encouraged by this recent Ross 2017 article in Annals of EM on wellness that discussed both individual level interventions and systematic improvements related to meaningful service, administrative burden, and the hospital culture around tribalism, feedback, and debriefing. Table 2 is on point! 

The Institute for Healthcare Improvement created an extensive "Joy in Work" model for leaders. Their strategies rely on listening to staff about what matters to them, identifying impediments, and committing to systems improvement. This impressive resource guides leaders on how to make a difference by augmenting joy and improving quality care.

Healers need individual strategies to cope with the life and death challenges we regularly face at work.  Health systems need to scale up resilience so that the process of healing doesn't destroy the healers.

Onward.