Do no harm, even though your patient might.
Although Dickens characterized Dr. Alexandre Manette’s plight as “the best of times and the worst of times,” to many of us today, healthcare may seem to be in the worst of times. And perhaps, the title of the source of those words, his classic “A Tale of Two Cities,” also has an unfortunate relevance as it has been noted that we are currently of two minds in our culture.1 That the conflict is over a public health issue, which should only be a call for unification, is all the more puzzling and distressing.
A rather sobering litany of the extreme challenges facing contemporary healthcare and its providers was recently outlined. These include: increasing price competition, narrowing of insurance networks, increased EHR expenditures and clerical burden, burgeoning mergers and consolidations, threats to organizational survival, a technological arms race and threats to cybersecurity and the national shortage of nurses and workers generally.2 Thus, also very concerning, though perhaps not surprising, is the prediction that physician burn-out will not abate, but increase in the next two to three years.3
In addition to this described morass of contemporary health care landscape issues is the COVID-19 pandemic, its resurgence, and its unrelenting pressures which have been described this way: “The coronavirus crisis was more novel than we thought, more taxing than we expected – and its consequences will last longer than we anticipated.” 4
Provider fatigue, anxiety and threat aside, the pandemic revealed a societal schism that has impacted Medicine in a, heretofore, inconceivable manner. The frustration, and now, resentment and anger, at treating the unvaccinated is understandable and, while emotional, is even rational.5,6 But, as providers we have historically been charged with and attempted to non-judgmentally care for even those who failed to take the responsibility they might have for their condition. Perhaps done with a condescending headshake, stern advice or back room comment, care was nonetheless provided for the smoker, substance abuser and helmetless motorcycle rider.
A contemporary constellation of factors, including the incredible lethality of COVID, has brought this further fundamental emotional challenge to health care providers. COVID’s first wave brought (far too) many instances of specific moral distress. Now what is perceived as the irresponsibility of the unvaccinated as a threat to others and taxing to provider energy, compassion and commitment, further creates a mélange of resentment and distress, perhaps even fueled by conscious or unconscious biases. Providers are understandably emotionally conflicted between struggling to control emotions to provide objective care and the moral distress of often doing so without compassionate engagement. The changing ratio of joy to stress in medicine is reaching an unacceptable and professionally lethal imbalance.
We would not to presume to fully understand the cognitions and emotions of those who deny and refuse to safeguard themselves and others. But, we can return to reiterating, reconsidering and refreshing some core tenets of medical care that may bolster waning resilience in ourselves and our colleagues.
First, we must never forget the origins and commitment to the superordinate goal of caring; caring for those in need regardless of circumstances. Whether in diagnosis, class, or ability to pay, Medicine’s beneficence was displayed when needed. Perhaps nowhere is there a better example than military physicians rendering aid to enemy civilians and even combatants.
This has been part of Medicine’s singular character. Voltaire said:
Men who are occupied in the restoration of health to other men, by the joint exertion of skill and humanity, are above all the great of the earth. They even partake of divinity, since to preserve and renew is almost as noble as to create.7
And that nobility is embodied in the ability to rise above circumstance when need is clear and called upon.
Despite the distraction, negativity and even disrespect, there must be a recognition and experiencing of the good that is still being done, the successes that are still occurring and the gratitude that most patients feel. Even more so, providers need to help each colleague, member of the professional family, retain this recognition, perspective and joy.
Certainly organizational systems should do all that is possible to manage patient flow, maintain supplies and provide visible, congruent and supportive leadership. Deliberate self-care is also needed, whether that is alternate engagement or making use of supportive resources. Realistic integration, commitment to professional principles and personal engagement mute resentment and promote resilience in these worst of times until the best of times can be regained.
Michael J. Asken, Ph.D. is the Director, Provider Well-being, and Vice-Chair, Physician THRIVE Wellness Committee, UPMC Central PA Region.
Lindsay Papachristou, M.D., FACEP, is an emergency medicine physician and Chair of both Physician THRIVE and the Physician Wellness Committee, Emergency Department, UPMC Central PA Region.
1. Boxell L, Conway J, Druckman J, Gentzkow M. The pandemic actually helped bring Americans together- briefly. The Washington Post. 2021; https://www.washingtonpost.com/politics/2021/08/24/pandemic-actually-helped-bring-americans-together-briefly/
2. Shanafelt T, Noseworthy J. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and prevent burnout. Mayo Clinic Proceedings. 2017; 92(1): 129-146.
3. Weiner K. Clinician Burnout Is Only Getting Worse. Here’s How to Tackle the Problem. NEJM Catalyst Innovations in Care Delivery. 2021;2(2): 02 10.1056/CAT.20.0689
4. Taddei F. A view from Italy: An economist and faculty member at SAIS Europe peers into the past, present and future of our Covid-19 world. Johns Hopkins Magazine. 2020. 72 (2), 43-45.
5. Gordon D. No jab. No service. Doctors flip the script on Covid-19 vaccine mandates. Forbes. 2021: October 1: https://www.forbes.com/sites/debgordon/2021/10/01/no-jab-no-service-doctors-flip-the-script-on-covid-19-vaccine-mandates/?sh=23dfa840109f
6. Morocco M. Doctors like me have a lot of anger at this new Covid surge. Los Angeles Times. 2021; August 12: https://www.latimes.com/opinion/story/2021-08-12/doctor-anger-vaccinations-covid-surge.