Six months down. Six to go. I am officially halfway through what people have told me will be one of the most challenging years of my life. I’ve rotated through Cardiology, Primary Care, Gastroenterology, General Medicine, Psychiatry, Palliative Medicine, the Medical Intensive Care Unit (MICU), and Rheumatology. Finally I have reached every resident’s favorite rotation – vacation.
Intern year has been hard work, but I’ve enjoyed it and am extremely pleased with the experience my Internal Medicine program has provided. Each rotation has taught me a tremendous amount and helped me grow as a physician, but the most profound impact occurred during my back-to-back rotation in Palliative Medicine and the MICU. Last August, Atul Gawande wrote an insightful essay titled “Letting Go” in The New Yorker. He vividly illustrates the different mindsets for treating patients in palliative medicine compared with doing so in the ICU. He discusses the lost art of dying and how palliative medicine can help us regain that art. I was fortunate to have witnessed this sharp contrast by working in palliative medicine immediately followed by working in the MICU for a month.
The sights and sounds while walking through the halls of our Palliative Medicine floor are unique. One moment, I might walk past the “Caring K-9” dog, and the next moment I might hear peaceful sounds from a talented violinist as I walk by a patient’s room. As Gawande mentioned, the goal in palliative medicine is comfort, and any measure that may enhance comfort is fair game. Contrast that experience to the ICU, where I might arrive to work at 5 a.m. and by 5:01 a.m. might be doing compressions in attempt to restart a stopped heart. No morning coffee to settle in, no dogs roaming the hall, no violinists. It is intense and unpredictable in the ICU. Generally the goal is the keep the patient alive at all costs.
Watching people die is never easy. I must confess, however, that after back-to-back rotations in Palliative Medicine and the Medical ICU it becomes a bit easier. Several years ago, one of my major concerns prior to deciding to pursue medicine was whether I could handle the amount of death one sees as a physician. Up until my palliative medicine and ICU experience, I had witnessed death in relatively small doses on various other rotations as both a resident and a medical student, but emotionally I wasn’t 100 percent comfortable with it yet. The memories of seeing a person die during a Code Blue or hearing about the passing of a patient I cared for would linger for days. All this changed after working in Palliative Medicine and the MICU.
Some patients who come to the Palliative Medicine floor have very limited time. At the end of each day, it was routine to sign out to the overnight covering team and state “this patient is very sick, I don’t think he will make through the night.” Witnessing death suddenly became almost a daily part of my life at work. It was there where I first had to pronounce a patient dead. When I went to the MICU, I experienced death equally as regularly. The circumstances of death were quite different. As a tertiary/quaternary care center, our MICU tends to have extremely sick patients. Overnight shifts typically involve running to multiple Code Blues to attempt to restar a failing heart. In the MICU, death was again part of my daily life. Discontinuing all orders and ordering “Do Not Resuscitate” for a patient whom the family decides to withdraw care on is an unforgettable feeling the first time. I remember it took me five minutes before I could actually click “Accept” in the Electronic Medical Record. I routinely look back in the medical record to see how previous patients I have cared for are doing. Previously, I used to see most of my patients recovering and doing well. However, now when I click on old patient charts, I often receive the pop-up message: “This patient has been deceased.” Needless to say, I’ve quickly become accustomed to dealing with death.
I still reflect on each patient who dies, and some cases are more difficult to cope with than others – a patient in his 20s blindsided by cancer affects me at night more than a patient in his 90s who peacefully passes away. Nevertheless, there is no question that I have gone through a desensitization process. This was inevitable. The more one is exposed to a stimuli, the more one becomes accustomed to it. On the other hand, I have become acutely aware of the accumulative effect each death has on me. Despite the desensitization, each experience with death elicits an emotional response, and after time the sum of these experiences can take a toll on an individual. One lecture during my palliative medicine rotation addressed this topic, calling it “Compassion Fatigue.” It is a concept that has been studied the past three decades and refers to the secondary, post-traumatic stress that a caregiver experiences from the continuous caring of others for an extended period of time. An estimated six to eight percent of doctors and nurses suffer from compassion fatigue. The constant demands of time, energy, and empathy can leave one exhausted and unable to care anymore. I personally conceptualize it as a combination of “burnout” (the cumulative emotional toll) and “desensitization” (each successive death has less of an effect than the previous one). It can lead to symptoms such as hopelessness, bottled up emotions, anxiety, self-doubt, apathy, isolation, and decreased focus. Many non-health care professionals who care for sick loved ones over an extended period of time may experience this as well. The term is also often used in other contexts, such as when describing how excessive media exposure and solicitations to give money can often lead to donor burnout and skepticism.
After less than two consecutive months of witnessing death on a daily basis, I became aware of changes that occurred in me. I could not help but wonder how working in environments such as Palliative Medicine, Oncology, or the ICU affected individuals who worked there daily for several consecutive years. At first glance, the attendings I worked with in the ICU did not seem to display any of the above mentioned symptoms. But then again, what do I know about their personal lives and how it has affected them? Further, across the nation, departments such as the ICU and the Emergency Department tend to have high turnover rates, which likely has something to do with the intensity of emotions that one experiences while working in such fields over an extended period of time.
Changing one’s environment or taking time off can help overcome compassion fatigue. I pondered this thought, and considered the benefits of having all healthcare organizations provide caregivers an extended period of time off periodically. I believe that having doctors, nurses, social workers, etc., spend a period away from being in the trenches would only make them better caregivers when they return, and in turn this could lead to improved quality of care and more compassionate providers.
I recently watched a TED video of Stefan Sagmeister, CEO of Sagmeister Inc, where he advocated for the “one-year sabbatical every seven years.” All employees at Sagmeister take one year off every seven years, including the CEO. During that year they spend time experimenting, working on little projects they never have time to complete, learning new skills, etc. He points to other extremely successful companies and individuals who follow similar approaches. He maintains that the time off allows time for reflection, new insights and creativity, as well as increased productivity and interest in the job when they return. Integrating this concept into medicine would only benefit the profession. Perhaps providers in departments where death is witnessed almost daily such as the ICU, Emergency Department, Oncology, and Palliative Medicine could be given three consecutive paid months off every three years (in addition to regular vacation). Almost every clinician I know has some other non-clinical interests, and these interests could be pursued, but no clinical medicine should be pursued. No emotional turmoil. No witnessing another person die at your side. Perhaps their free time could be used toward improving his or her organization in other ways, thus justifying payment. Other providers dealing with death less frequently could be given three consecutive months off every five years or so. I’m just throwing out ideas and am not drawing up a concrete plan here, so please don’t scrutinize the details. Of course, the economics of such a plan and addressing the loss of continuity of care (which is less of an issue in the acute care fields that need such a program the most) are two important issues among others that would need to be addressed.
The big picture here is that techniques to combat compassion fatigue in caregivers would lead to an improvement in both patient care and physician well-being. Such a concept is counterintuitive to the deeply ingrained “working more is better” culture in medicine. This culture can change if there is more awareness around the concept of compassion fatigue. The best organizations in any field understand their employees’ unique needs and address them. Many healthcare organizations address the obvious employee needs such as medical educational resources, but most fail to understand needs that are verbalized less such as burnout and desensitization processes that caregivers are prone to. Those healthcare organizations that recognize these subtle needs will be the winners in the upcoming decade.
Vipan Nikore, MD, is an Internal Medicine Resident Physician at the Cleveland Clinic. He received an MBA from the Yale School of Management, an MD degree from the University of Illinois-Chicago, and a BS in computer science and software engineering from the University of Western Ontario. He has led projects at UNICEF in India, the WHO in Geneva, IBM, Sun Microsystems, Citibank, UCLA, and the Ontario Ministry of Health. He is the President and Founder of the youth leadership non-profit Urban Future Leaders of the World (uFLOW). His posts are personal views and do not necessarily reflect the opinions or positions of the Cleveland Clinic.
Hi, I am a philosopher of boliogy and about a month ago I started to work at the new ELSI department (we are just four researchers in the deparment)of the National Institute of Genomic Medicine of Mexico (INMEGEN for its name in spanish). The question of this post is the kind of questions we have … Hi, I am a philosopher of boliogy and about a month ago I started to work at the new ELSI department (we are just four researchers in the deparment)of the National Institute of Genomic Medicine of Mexico (INMEGEN for its name in spanish).The question of this post is the kind of questions we have start wondering about lately, especially since the raison d’etre of INMEGEN was to deliver a more predictive, preventive and personalized (3p’s) medicine. As a matter of fact, these were the central concepts in all political speaches in order to justify such an expensive project. It seams that the whole formula for politicians was linking the 3p’s with a promise of biotechnological along with social and economic development for the Country, (a Big Science project)Definitely, in our emerging departament, these are the concepts (3 p’s) that we would like to analyze in the context of Mexican public health. P.D. I really enjoy this blog, thanks
Well written blog. I think you have brought up some really great points and it’s interesting because I found myself drawing lots of comparisons from what you said to other fields like police, fire, EMS, social work, etc. Many people in those areas could probably benefit from similar thinking to what you’ve described for the healthcare field.
That said, other industries like corporate, teaching, arts, etc also suffer from their own form of compassion fatigue. It’s probably more on the “fatigue” side of things. But that idea of “working more is better” permeates almost all fields these days.
Thanks for your insight!
Shrink, I would agree that the country does ignore the need for non-stigma psychiatric care and for therapies such as psychotherapy. I’m sure psychotherapy may be helpful for some experiencing compassion fatigue, but I think awareness around the phenomenon is the key first step.
Anon, even if someone works 3 hours a day and witnesses death everyday it will cause the changes I noted – independent of the number of hours worked and system they are working in. I’ll save my thoughts on the medical residency system and the changes that I think are necessary for a future post and will focus on the issue at hand. Though I will note that if you “find it ridiculous that so many high-achieving, clever people can’t figure out that the process of medical training isn’t a macho trial in the trenches”, then perhaps you should dig deeper for an answer – examining the history and culture of medicine, and having an understanding of the complexity of the medical system and challenges to become a doctor may help. Combine that with a lesson on theories of change and organizational management and it may lead you to an answer. Usually when things dont make sense there is a reason. Also, I’m not sure I understand how a sabbatical would be feasible only if our system is less dependent on nurses and doctors. I’d also like to note that our hospital has patient outreach and social workers available to every patient as an option, and particularly all our palliative medicine patients have a tremendous amount of time allocated to working with these important health professionals.
Allegory of an Old Man‚Äôs MD-Son
Vipan – I have known psychologist Dr. Gene Schmuckler CTS, of our consulting firm, the Institute of Medical Business Advisors Inc http://www.MedicalBusinessAdvisors.com, for more than a decade. We met while in business school. He was my professor of organizational behavior. Since then, we have become friends and colleagues and have lectured together at various seminars and engagements. He also writes for us on his specialty of behavioral finance, medical workplace violence and physician career re-engineering. Of course, his advice was vital to me as I made my own career transition from clinical medicine about eight years ago [www.HealthcareFinancials.com]
When speaking or publishing, Gene sometimes asks exasperated doctors to recall the story of an old man who spent the day watching his physician son treating HMO patients in the office. The doctor had been working at his usual feverish pace all morning, and although he was working hard, bitterly complained to his dad that he was not making as much money as he used to.
Finally, the old man interrupted him and said,
Dr. David Edward Marcinko MBA
Worth noting that the medical residency system is practically designed to create compassion fatigue.
I find it ridiculous that so many high-achieving, clever people can’t figure out that the process of medical training isn’t a macho trial in the trenches. It’s first and foremost about financial exploitation. They’re being financially exploited as their ability to care for patients and to learn maximally effective healthcare skills is being eroded. Ironically, these same physicians who defend their own victimization often don’t understand why patients do “stupid” and self-destructive things like stay with an abusive spouse, or smoke, or fail to control their weight.
A sabbatical would be good. But to do that we need a system that is less dependent on physicians and nurses for most direct care, and takes better advantage of people like social workers or patient outreach workers who can do things like get to know very ill families so that they can know what the patient wants and provide the best palliative care even as curative options are still being tried.
This country ignores the need for non stigma psychiatric care. It is also expensive and insurance carriers will pay for psychosomatic er visits and chest pain evals, but not for psychotherapy. You and your colleagues need psychotherapy to understand the ambiguities of your work and to deal with the harsh realities of HIT scrituny and control which have further alienated the doctor-patient relationship. On that note, I concur with Propensity.