When the fall meets winter, before the snow is thick enough to obscure the road, the black tarmac can beguile you into driving on it. For those of us who have watched as winter makes it’s entrance, we know that the most dangerous driving is on those clear roads, topped with black ice, that can send your car careening off course.
Research shows us that one out of every two doctors are burnt-out and that doctors have the highest rate of suicide of any profession. Beware of suggestions that the problem will go away when doctors develop more resilience, take personal time or do yoga: these are just putting a coating of black ice on the problem- it looks safe but can send us careening dangerously off course.
To show you the road on which one doctor travels, let me introduce you to Dr. Johns, a Canadian family physician. Before we look at the road he is now traveling, let’s take a peek at the road he took to get to where he is. In his late teens and twenties, he worked hard, often around a hundred hours per week, with his nose in a book and caring for patients. Car accidents, severed arms, the agony of multiple illnesses coupled with old age, cancer in children – all the most devastating human conditions, sent him to study more, work harder, learn what he needed to to care for these patients. Many say medicine is a calling but it is built on a foundation of tenacity to help patients, coupled with the grit and determination to do so. Dr. Johns accumulated debt while others were earning, spent his nights by bedsides of the ailing while others were out having a drink with friends and eventually became a doctor. Resilience? He had that in spades.
Let’s zoom forward to the road Dr. Johns walks on today. Fifteen years after his training, he now has well over a thousand patients in his care.
“I carry these patients with me. The ones that are suffering, worry me. We are the ultimate patient advocate. We are responsible for their care, their well-being and ultimately their lives. Their care is my responsibility.”
Is he burnt out?
“I see it as a cumulative moral injury that I carry.”
Moral injury? Let’s break that down by looking at some of his patients, like the ones with knee or back injuries. The first problem is getting the tests needed for diagnosis - sometimes with wait times of one to two years. When the tests are finished and surgery is needed, add another year or two of waiting, at least. During that time, Dr. Johns explains, his patients are less mobile, maybe unable to work or adequately care for their children or aging parents. They are plagued with chronic pain, with each step eventually bringing agony. Dr. Johns works longer hours seeing these patients and calling hospitals and surgeons to try to get them better care.
“I work harder than ever before but I have so much more guilt about the patients I can’t help. It is enforced mediocracy.”
So what can Dr. Johns do? He worries about treating the pain with painkillers and risking drug dependence. He worries about their financial precariousness and their loss of independence and dignity. He worries about the patients who have multiple illnesses and are increasingly isolated form their community by their lack of mobility. He worries about the development, often inevitable, of depression secondary to chronic pain and the loss of the ability to work and care for those who need them, because mental healthcare is simply another wait of years.
Many of these factors Dr. Johns cannot change, because “the decisions about the availability of diagnostic tests, access to surgery or mental health services are decided by administrators who manage the system but are not accountable: they never sit with the patient and hear their stories. They never feel responsible for their care.”
In Canada, these administrators decide what services are available and in the United States, they decide access in different ways. But all administrators forge the care patients receive, without having any responsibility for each patient impacted.
So, moral injury? Dr. Johns argues that the care that he trained so diligently to provide is not the care his patients get and he is powerless to change that. It is, for him, a deep moral injury. This is the evisceration of doctors.
Dr. Phillips, who works as a hospitalist, points out another serious gutting of doctors: doctors in hospitals are discouraged from bringing to the attention of the media the lack of beds, equipment and access to operating room times. Many are threatened with loss of privileges or loss of their jobs if they speak to reporters directly. So, how do you fix a problem that is out of your control when you cannot speak about it?
Recently, the NRA told doctors to stay out of the gun control debate, by asking them to stay in their lane. Responses from doctors on twitter told stories of gun violence with the sassy hashtag #ThisIsOurLane. However, despite speaking out, patients with gunshot wounds are still flooding into hospitals because doctors have no control over policy, but are responsible for saving the lives impacted by policy.
This is just a small glimpse into the road that doctors travel. If we let administrators and policy makers have control over patients’ lives but never have even one patient under their care, if we muzzle doctors from speaking out or ignore them when they do speak for patients, then we have the conditions for burnout. If you coat that road with thin ice of words like ‘resilience’ and suggestions like ‘lunchtime yoga’, there is a good chance that you are creating black ice that will drive any change dangerously off course. Worse, much worse, it is patients who drive that road with their doctors and often careen off into the ditch of increased disability, pain and suffering.
Doctors suffer in a system they cannot change for the better — they burnout and they die — because when they are crushed by the moral injury caused by the weight of the thousands of patients who they cannot help.