The stressed-out E.R. personnel of the New York-Presbyterian Allen Hospital
Got used to the company of the little sparrow flying over their place of penance
She was always the first one present when the doors of the ambulance opened
She was always the first one present when they took a patient to an exam table
She was always the first one present when they hooked the whirring machines
She was always the first one present when the drilled routine of care kicked in
But one day her heart could not resist so much suffering and stopped beating
Plunging into the depths of their sorrowful spirits, she gave them a final cheer.
On April 27, 2020, Dr. Lorna Breen, chair of Emergency Medicine at the Columbia-affiliated hospital, committed suicide in her parent’s home in Virginia. She had been diagnosed with a Coronavirus infection, but she fully recovered; she was given a leave of absence from work and she decided to spend it with her folks. In a communication with The New York Times her father said: “She tried to do her job, and it killed her…Make sure she’s praised as a hero, because she was. She’s a casualty just as much as anyone else who also died.” [i] Her father said that she had told him that many patients were already dead when they opened the doors of the ambulances. She never had a history of Mental Health issues, but she seemed detached to him.
Once a suicidal patient decides to act, a Buddhist peace of mind sets in.
Physicians have been trained to face most of the stressful situation of our careers with a stiff upper lip and the steely determination to carry on, nonetheless. If you are taught in Medical School and professional training about the values of fortitude and resiliency, you will be the last one to ask for any help. As a result medical personnel are hard hit by an unusual incidence of suicidal acts and attempts, which will surely worsen after the Coronavirus pandemic finally ends.
Unfortunately, there are personal and institutional barriers blocking the remedies.
In a 2008 Health Affairs article [ii], Donald M. Berwick, Thomas W. Nolan and John Whittington coined the term “triple aim” to define the simultaneous pursuit of three objectives—improving the experience of care, improving the health of populations and reducing per capita costs of health care—to fix the care system. In 2014, considering the increasing burn-out and dissatisfaction of physicians and nurses with medical practice, Drs. Bodenheimer and Sinsky argued that: “the Triple aim be expanded to a Quadruple Aim, adding that the goal of improving the work life of health care providers, including clinicians and staff.” [iii]
Professional burn-out is characterized by a most evident and ignored tragic triad:
- High emotional exhaustion
- High depersonalization
- Low sense of personal accomplishment
A – High emotional exhaustion
The increasing demands of payors, administrators and patients on the time and resources of the health care personnel produces a generalized dissatisfaction with the perceived quality of their delivered care services. The level of resilient frustration is so pervasively high in our system that physicians, nurses, technicians, receptionists, and other ancillary personnel are literally “counting the days” until finally the day of salvation arrives—their retirement date.
B – High depersonalization
The negative feelings and bad vibe will inevitably foster the emergence of cynicism and sarcasm in the ranks of providers, with the resultant degradation of their rapport with the patients and families. It is a self-sustaining vicious circle. Patients complain that they are being ignored and/or mistreated, which triggers more negativity and disdain for the staff. As a result, the latter keep their bad attitudes without the possibility of pausing for a moment and reflect calmly on the impasse.
C – Low sense of personal accomplishment
For the majority of us who have chosen the medical career, profit and social standing are secondary considerations. What we most value is the possibility of helping our fellow human beings and at the same time enjoy the unique standing conferred by possessing a voice of authority. With the landing of the abominable “bean counters” in both the public and the private payor system, our maneuvering room is being steadily curtailed. Our decreasing satisfaction not only fosters our early retirement but also all kinds of drug and alcohol abuse in our ranks plus the potential of one day, out of the blue, start mulling about the unthinkable.
Shanabelt et al. studied the incidence of burnout with work-life balance in the US physician and general workforces in 2011 and 2014 to compare the results and significant trends, using the Maslach Burnout Inventory; they invited more than 35,000 physicians to participate and 19% completed the survey. [iv] They said that: “54.4 % (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.50 % (n=3310) in 2011.Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty.” They found minimal differences in the general workforce between those years.
Early on during our training, a taciturn hitchhiker steps into our cockpit.
Douglas A. Mata et al. conducted a meta-analysis of 31 cross-sectional and 23 longitudinal studies of the incidence and prevalence of depression in resident physicians.They found : “the overall pooled prevalence was 28.8 % of participants, ranging from 20.9% to 43.2% depending on the instrument used, and increased with calendar year.” [v] One in four physicians-in training has depression.
To glean more information on this issue, Lisa S. Rotenstein et al. extracted data from 167 cross-sectional studies and 16 longitudinal studies from 43 countries. They found: “the overall pooled crude prevalence of depression or depressive symptoms was 27.2%…Depressive symptom prevalence remained relatively constant over the period studied…In the 9 longitudinal studies that assessed depressive symptoms before and during medical school (n=2432), the median absolute increase in symptoms was 13.5 %.” [vi] They also found that only 15.7% sought medical treatment for their symptoms. There is a tall price to pay.
Amy M. Fahrenkopf et al. studied the incidence of medical errors among resident physicians of three urban children’s hospitals by evaluating the depression with the Harvard National Depression Screening day scale, the burnout using the Maslach Burnout Inventory, and the rate of medication errors per resident per month. They found: “24 (20%) of the participant residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed. Burn-out residents and not-burnt out residents made similar rates of error per resident month.” [i]
There are several factors that block physicians, and other medical personnel, to seek the needed counselling. The crazy work schedule of physicians and residents, the confidentiality issues that might affect the licensing status of practitioners, the personal issue of loneliness and divorce, all contribute to it.
We have dawdled about writing a book on Physician/Nurse burn-out
Lorna’s valiant sacrifice shook our torpor and took us immediately to task
(This article is based on our upcoming new book Emotional Frustration- the hushed plague)
Stay distant. Stay safe. Stay beautiful.
What do you think? Please tell us.
Don’t leave me alone.
[i] Amy M. Fahrenkopf, Theodore C. Sectish, Laura K. Barger, Rates of medication errors among depressed and burn out residents: prospective cohort study. British Medical Journal. 2008 March 1: 336 (7642) ; 488-491. Doi: 10.1136/bmj. 39469.763218 BE. https://ncbi.nlm.nih.gov/pmc/articles/PMC2258399
[i] Top E.R. Doctor Who Treated Virus Patients Dies by Suicide, The New York Times, April 27, 2020. https://nytimes.com/2020/04/27/nyregion/new-york-doctor-suicide-coronavirus/
[ii] Donald M. Berwick, Thomas W. Nolan and John Whittington, The Triple Aim: Care, Health and Cost, Health Affairs, May/June 2008. https://doi.org/10.1377/hltaff.27.3.759
[iii] Bodenheimer T., Sinsky C., From triple to quadruple aim: care of the patient requires care of the provider, Annals of Family Medicine, 2014, November-December; 12(6)573-6. Doi:10.1370/afm.1713. https://ncbi.nlm.nih.gov/pubmed/25384822
[iv] West CP, Dyrbye LN, Shanafelt TD, Physician burnout: contributors, consequences and solutions, Journal of Internal Medicine 2018 June 283 (6) 516-529 doi 10.1111/joim. 12752. Epub 2018 March 24. https://ncbi.nlm.nih.gov/pubmed/29505159/
[v] Douglas A. Mata, Amarco A. Ramos, Narinder Bansal, Prevalence of depression and Depressive Symptoms among resident physicians. A Systematic review and Meta-analysis, Journal of the American Medical Association, 2015, December 8: 314(22) 2373-2383. Doi: 10.1001/jama 2015.15845. https://ncbi.nlm.nih.gov/pmc/sticles/PMC4866499
[vi] Lisa S. Rotenstein, Marco A. Ramos, Matthew Torre, Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation among Medical Students, Journal of the American Medical Association. 2016 Dec.6:316 (21); 2214-2236. Doi: 10.1001/jama 2016.17324. https://ncbi.nlm.nih.gov/pubmed/27923088