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Canaries in Society’s Coal Mine: The Untold Story of Physician Trauma
While physician burnout is a hot topic in healthcare, another issue that is rarely discussed but of real concern with medical providers is trauma. Usually reserved for discussion of patients in the ER or as a talking point after traumatic events the trauma we’re referring to today is that which some providers face when dealing with the realities of day-to-day practice.
This type of trauma goes well beyond the long days of caring for a multitude of patients and beyond the ever-expanding administrative requirements necessary to fight for reimbursements from insurance companies.
Today’s guest blogger, Elizabeth Metraux, suggests this trauma goes much deeper than that.
Elizabeth is the founder of Women Writers in Medicine, a start-up dedicated to amplifying the voices, experiences, and research of women in healthcare. Elizabeth’s work has appeared in The New England Journal of Medicine, Health Affairs, STAT, Medium, and more. She regularly speaks across the country – from the stages of the Aspen Ideas Festival to the lecture halls of Harvard.
Our Conversation with Elizabeth
AMP: Elizabeth, you are the first guest blogger we have had with experience working in Iraq. How did you end up in Iraq and how did that experience shape the work you are doing now?
ELIZABETH: I was young and reckless, actually. I’d spent the previous years traveling internationally for work on political campaigns. As the Iraq War loomed, I moved to the Middle East to freelance in communications for NGOs and political groups. It wasn’t long before I was leading State Department-funded initiatives to foster civil society throughout the region.
Among the many lessons gleaned, my experiences instilled in me a profound appreciation for Maslow’s Hierarchy of Needs. While I thought I was effectively evangelizing the merits of democracy, populations I served were struggling to meet basic needs. They were hungry, homeless, and actively nursing the wounds of conflict. I learned that health comes first — it always and must come first. And because health is so elemental, if you want to understand the state of a society, you first examine the health of their people. To improve lives and livelihoods, you first meet health needs. And if you want to get a finger on the pulse of what’s really going on below the surface, talk to healthcare professionals first. Our healers play a critical role as canaries in society’s coal mine.
AMP: In an article, you wrote for STAT, you said, “It’s clear to me that many of our country’s health care providers are struggling with trauma… And we’re doing little to support them.” Can you expand on the trauma you are seeing and its root cause?
ELIZABETH: When I talk about the trauma of the workforce, I’m talking about something far deeper than long days and EHRs. Indeed, I have little sympathy for burnout; many of us are overworked or feel undervalued. I believe what we’re witnessing in American medicine isn’t just professional overwhelm; it’s the pain of disconnection — to others and to our sense of purpose — and the guilt of neglect. Because we’ve allowed healthcare to evolve into big business, and we’ve allowed the social determinants of health to devolve into issues too politically incendiary to address, we’ve pushed clinicians from the work of prevention and healing into the work of transactional treatment and billing.
I was recently talking with an emergency physician in Chicago who had lost a patient the previous night on the South Side. A young black man gunned down in a racially motivated attack. He was the second child in the family lost to gun violence. Hers was a story we’ve heard countless times.
But here’s the thing. When I listen to those narratives, as a patient, I get to hear them in third person; physicians don’t have that luxury. I can turn off the news; she’s watching it unfold in front of her. She has to tell a mom her son is dead and she did all she could to save his life. I don’t even have to try to prevent his death.
And the list of preventable drivers of poor health and mortality is long – homelessness, food insecurity, poverty, violence, racism, and so on. We’d be obtuse to think that being exposed to, responsible for, and alone in dealing with these fixable problems on a daily basis doesn’t have a lasting impact, especially when clinicians are operating in a system that doesn’t always provide the support and resources to address these root causes that drive up costs, compel overutilization, and leave providers with few available options for meaningful care.
AMP: Knowing the root cause, what can support staff do to help physicians? As well, what, if anything can patients do to help the physicians that serve us?
ELIZABETH: The path forward requires patients and providers to come together to demand action. We cannot keep forcing clinicians to quite literally put band-aids on problems that broken policies have created. If it’s our social determinants of health that are at the root of poor health, unsustainable healthcare costs, and a healthcare workforce struggling to keep their heads above water, then we have to address it at a policy level.
And this isn’t unprecedented work. Among comparable countries, the U.S. is an outlier in healthcare spending at a staggering 18% of GDP. We also have the worst health outcomes and the highest rates of burnout. A country like Norway spends closer to 10% of GDP and boasts some of the world’s best outcomes and lowest burnout scores. But when healthcare spending is combined with other social services, developed nations similarly hover around 30% of GDP. So, objections to increasing social spending as a means to decreasing healthcare costs and lowering burnout are unfounded. We have the resources; it’s a question of allocation and will.
I’m heartened to see more and more health systems beginning to act. Groups like Kaiser Permanente and New York Health + Hospitals are “prescribing” housing and establishing farmers’ markets and cooking classes in the food deserts of underserved neighborhoods. It’s a first step, but more collective action — among patients, providers, payers, and policymakers — is needed.
AMP: What proactive steps can our medical schools take to tackle this issue for future physicians?
ELIZABETH: Two things: push more students into primary care and public health. And two, teach — concretely, unapologetically, and specifically — the skills of advocacy.
That primary care is the dog to kick in medicine is no secret. I see so many young people in med school with that same zeal for the trenches that I had when I was a 20-something in kevlar. And yet, for their intrinsic motivation and spirit to serve the underserved, we do everything we can to veer them away from that path. We make student loans unmanageable. We make primary care unsexy. We advertise surgical specialties on prime-time television. And — until the 2012 landmark study in the Archives of Internal Medicine — we’ve let burnout go unchecked. That needs to change.
And secondly, advocacy should be a central tenet in American medical education.
In his powerful essay in the New England Journal of Medicine Catalyst, Leo Eisenstein wrote, “As medical students, we are educated about the social determinants of health and increasingly warned about burnout, yet little is made of how the former may contribute to the latter — for example, how clinicians may feel worn down by the poverty and oppression their patients face; may feel powerless when they cannot offer more than, say, a form letter to a landlord explaining that turning off a patient’s heat would be deleterious to her health… If medical schools and residency programs are serious about burnout, they have to teach us about collective action — teach us to ask, ‘What can we do?’” So if our collective inaction is driving up burnout, then we need to learn how to leverage collective action to fix it.
AMP: Can you expand on what you refer to in the article at “tiny betrayals of purpose?”
ELIZABETH: The real heart of that quote — a line from Richard Gunderson in a piece in The Atlantic—is what he says next: “Tiny betrayals of purpose, each one so minute that it hardly attracts notice.”
It’s been said that if you set sail for England from the port of Boston and your navigation is just one degree off, you’ll wind up in South Africa. There may be some hyperbole in that, but it’s an apt comparison to what Gunderson was describing. More often than not, our compromise on values is subtle. Our providers yield to a few more clicks of a mouse. Patients tolerate just one less minute in the exam room. A nip here. A tuck there. In time, however, we’re relegated to a name on the “in network” list or some number in an EHR. And that’s never what clinicians signed up for, nor is it in the best interest of patients.
Gunderson went on to say that these tiny betrayals of purpose catch up to us. Doctors “eventually find themselves expressing amazement and disgust at how far they have veered from their primary purpose.”
AMP: Is there anything that can be done to reverse these or is it just knowing how to navigate them in a healthy way.
ELIZABETH: I don’t accept that learning how to navigate a system is a solution to the failure of a system. None of us should accept that burnout or trauma or depression are simply occupational hazards of working in healthcare.
AMP: For any physician reading this who may be experiencing the trauma you talk about or someone who knows a physician experiencing this, what resources would you recommend?
ELIZABETH: I want to be careful not to categorize all forms of distress as burnout or PTSD or trauma. There’s a spectrum, and we need to do a better job of acknowledging that there are important, non-interchangeable interventions that vary depending on your unique circumstances. Relatedly, we also need to stop pretending that a prescription for mindfulness is a catch-all cure for everything from professional dissatisfaction to clinical depression.
But if you are experiencing the weight of what I described in my article, then I’d encourage you to reach out — to a colleague, a friend, a family member, a pastor, a clinician. I shared then and believe now that, “Isolation is a trauma victim’s ill-advised drug of choice.” So many of us have been in that dark place of overwhelm, guilt, loneliness, and exhaustion. We don’t get ourselves out of those places alone, but we do make progress with others — we also make change. And we need change now more than ever.
I may be a writer, thinker, PR nerd, and Grey’s Anatomy devotee, but first, I’m a mom.
So when I’m not on the road capturing and telling your stories, I’m listening to the stories of my daughter – a fearless, compassionate, brilliant spirit who lives in her own world of limitless possibilities.
And shouldn’t all women have the joy – the right – to be so unrestrained with our ambition and ideas?
That’s why I founded Women Writers in Medicine. With 15 years of experience around the globe helping individuals and organizations disseminate their ideas, I’ve seen firsthand how game-changing it can be to get our stories out there. From running State Department initiatives with young journalists in the Middle East and former Soviet Union, to leading communications for the National Institutes of Health’s workforce diversity efforts, I have enough hard-won wisdom and wild optimism to know that your message can inspire conversation, connection, and real change, too.
Elizabeth’s work has appeared in The New England Journal of Medicine, Health Affairs, STAT, Medium, and more. She regularly speaks across the country – from the stages of the Aspen Ideas Festival to the lecture halls of Harvard. She also hosts Women Writers in Medicine’s podcast “Stories, Scrubs, and Spirits: Tales from the Trenches of Care.”