I was on my honeymoon in Colombia when I first became aware of the true extent of my post-traumatic stress disorder. My husband and I were walking across a smooth, granite platform to take a closer look at a fountain in downtown Cartagena. As we neared the structure, mist from the fountain’s jets dampened the ground at my feet.
I froze, paralyzed with fear by a flashback — my first — triggered by something as ordinary as wet pavement on a warm day.
Two years earlier, I was working in civic engagement efforts in Baghdad. One morning, as I walked across a smooth, granite platform toward my apartment, gunfire erupted. I tried to run, but my flip-flops bested me on the pavement, still damp from an early mopping. I slipped and fell backward, hitting my head hard enough to knock me out. When I opened my eyes minutes later, the platform was covered with my blood.
That happened 15 years ago this week, those Ides of March when American forces invaded Iraq.
Back home in the U.S., it was clear to those around me that I had PTSD. It wasn’t until six months after my honeymoon, however, that I had the courage to acknowledge that I needed help. It’s not easy seeing your own weaknesses, much less conceding them. But when my habitual glass of wine with dinner became a bottle, and fireworks left me sore and sleepless for days, it was hard to fight the signs.
Celexa for guilt. Ambien for sleep. Therapy for months. My psychologist and primary care physician spoke regularly to coordinate my care. Most importantly, family and friends became members of my care team. Isolation is a trauma victim’s ill-advised drug of choice, one my loved ones and clinicians wouldn’t let me take.
Trauma in health care
Some people who contract a disease become experts in it. I’m one of them. We obsess over the research. We learn the signs and symptoms, and develop a private language with our fellow patients. We learn each other’s triggers and tactics, like an army of code talkers who just … know.
Which is why today, as a health care advocate who has struggled with PTSD, it’s clear to me that many of our country’s health care providers are struggling with trauma, as well. And we’re doing little to support them.
A few weeks ago, I was talking with a physician who served our country in Iraq. We chatted nostalgically about the taste of sand and shawarma before he said something that gave me pause: “You know, I’d go back to the field any day. Beats practicing in my clinic.”
“Why’s that?” I asked.
“I didn’t become a doc to put up with billing codes and power struggles. I thought that PTSD would hit when I came home from Fallujah. It’s so much worse when I come home from the office. Truth is, I’ve lost my sense of purpose.”
That struck a chord.
Clinicians are experiencing epidemic rates of what we casually call “burnout,” with such symptoms as fatigue, irritability, and stress — like we’re talking about the trials of new parenting.
But there’s something beyond burnout happening in health care today. More than half of primary care physicians are at the end of their ropes. Nearly 1 in 3 resident physicians have symptoms of depression. One in 10 medical students have thoughts of suicide. They’re not stressed out or, as my family was fond of saying about me, “adjusting.” They’re experiencing trauma — that loss of meaning cited by the army medic.
‘Tiny betrayals of purpose’
Clinician burnout is frequently chalked up to the eight-minute visits with patients, the six hours spent each day entering data into electronic health records, and the demands of a profession where life-and-death decisions must routinely be made. But this short list of factors doesn’t get to the real wounds of practicing medicine .
In an article in the Atlantic, Dr. Richard Gunderman offers a more nuanced breakdown of causation. He notes that “burnout at its deepest level is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice. [Physicians] find themselves expressing amazement and disgust at how far they’ve veered from their primary purpose.”
Gunderman isn’t the first to explore the cumulative impact of these “tiny betrayals of purpose.” In his book “Achilles in Vietnam,” Dr. Jonathan Shay, a psychiatrist who studied Vietnam veterans, made the case that actions that contradict an individual’s core purpose — either compulsory or voluntary — can result in a kind of “undoing of character.” For clinicians, much like combat veterans, these violations of character can build up, with damaging consequences.
It’s not just the eight-minute visit: It’s that an eight-minute visit means physicians can’t provide whole-person care to patients whose diagnoses aren’t easily logged into a computer. It’s not just the six hours of daily data entry: It’s that it takes clinicians’ eyes off their patients, missing the very connection with humanity that drove them into this work. And it’s not just the problematic quality metrics that physicians are subjected to: It’s that those metrics have crowded out deeper connections with patients to help them manage triggers and navigate treatment.
During grand rounds at Duke University School of Medicine, Dr. Andrew Morris-Singer, a leading voice on physician burnout and an advocate for primary care reform, remarked that the state of the system is resulting in a generation of clinicians practicing medicine “in a manner inconsistent with their values.” The results of this inconsistency can be fatal. More than 400 providers take their lives each year — an industry suicide rate second only to the armed forces. If that doesn’t compel us to act, then the impact of burnout on patients should ignite a national conversation. Clinicians with mental health challenges make more mistakes, take more sick days, are less engaged in their work, and are less empathetic.
It’s time to call burnout what it really is: trauma. As I and so many others who have experienced trauma have come to realize, its sufferers don’t always see the signs. Health care providers are no different. Others need to help them see what they are experiencing. That job needn’t fall solely to their family members or colleagues. Patients — you and me — need to step up and call it out, to demand action by health care organizations to address it, and to offer a community of care that serves as a powerful antidote to isolation and retreat.
If we don’t, if we continue to disregard the epidemic of trauma among our physicians, lives — of patients and providers — will be unnecessarily lost.
During a panel at last year’s Aspen Ideas Festival, Morris-Singer offered a simple challenge: “The next time you wrap up a visit with a health care provider, ask him or her, ‘How are you doing?'”
I echo that. Let’s start a conversation with our health care providers and listen, really listen, to their needs. As William Osler, father of modern medicine, famously remarked, “Listen to your patients. They are telling you their diagnosis.” Clinicians, too, are telling us their diagnosis. It’s time we responded.
Elizabeth Métraux is the director of marketing and communications at Primary Care Progress, a national nonprofit organization that aims to build stronger primary care teams.
I have several comments regarding this article and the implications made by it. First, I get a quasi-nauseous feeling when people start talking about poor, overworked doctors – overworked mostly by having to code the transactions they make – who are suffering from depression and anxiety, which has now morphed into PTSD. And now the article about these “wounded” docs is being written by someone who has PTSD from slipping on a slick tile floor during a brief firefight. Try watching your best friend’s face get eviscerated from an IED blast.
But that isn’t my main problem with this article. The main thing is that, according to the author, we have PTSD-depressed docs running around treating people with real illnesses and then going home feeling sorry for themselves because they had to spend time on paperwork. Do you have any clue as to how many people in this country die – as in DEAD – from Preventable Medical Error! Over 400,000 every year. And when you count Serious Harm into those statistics the numbers jump into the millions. And now you tell me that some poor guy whose finger hurts from writing codes on a billing statement thinks he had PTSD?? No wonder we have so many people dying over here. We have thousands of Physicians feeling mistreated because they are asked to perform a bureaucratic function. I’ll tell them the same thing I’ve said to other physicians to there face. If you are so put off (‘nee Traumatized) by your job, go be a Hedge Fund Manager. At least we would all know what kind of person we are dealign with then.
obviously ^^ written by a non-provider who has absolutely no clue regarding provider job demand and the personal toll this extracts over time from the burden of giving “care”. absolutely. no. clue.
Cited the article — and THIS comment — on my KHIT.org blog.
Relational Leadership™” post.
I wish this is talked about in the C- Suites of health care organization and in medical schools.
Since Medicare sets a lot of the standards and metrics that other insurers pick up which of our organizations is/are going to stand up for this herd of dysfunctional traumatized and actually make things change or get disruptive enough to force a change?
Thank you for this insightful article – we as a society only look for the physicians to fix our problems and neglect to care for the health of the physicians, because we automatically assume that they take care of themselves. Less burnt out physicians = higher quality of healthcare
How do we increase the volume on this discussion. I am CEO of a community health center with some amazing docs who are ready to toss in the towel for the exact reasons highlighted in this article. I want to be part of a solution!
Thank you for asking. I have already described the EHR obstruction of physicians (and other staff) doing their jobs. So far, much of my own talking with administrators has been met with helpless shrugs and “We’re sorry, but…”
Last year, I was scheduled to evaluate involuntary committed psychotic patients in a hospital “office” where the patient would sit and block the only exit. The doctor would be seated behind a desk/ computer wedged in the distant corner. This room was off a locked corridor that was not even within earshot of the nurses station. Five administrators and myself: I was told, “Sorry, this is all we have today. What about this isn’t safe?” But the best was the guilt card laid out by a woman who never entered the unit. “What about the patients? ” she asked, her forehead wrinkling to concern. “I’m sure you must really care….don’t you? ”
Another hospital and another state, I was educated about the law. As a doctor, I was required to obtain signatures from geropsych patients from a menu of “code” choices: none, iv fluid support, or CPR. No choice for full resuscitation. Patients admitted because they were suicidal, homicidal asked about how much effort staff should take to revive them?
Would you put your family member in these hospitals, both prominent in their communities?.
Physicians burn-out working in what can be a crass culture with a pretense of humanity. You’re are a great Doc as long as you keep your numbers up, no matter the problems, and your mouth shut.
As long as most administrators focus on what’s expected from them and doctors and unwilling to go to bat for what’s harmful to their staff and patients, there will be no change. Many would disagree, but technology without sufficient staff who are rested enough to care will really do “More harm than good.”
Again, thank you for asking.
Peggy Finston MD
http://www.Acu-Psychiatry.com
Any advice to someone considering medicine as a second career? Can one still find a sense of purpose and meaning caring for patients in the era of EHRs, algorithms and checklists?
Well said. I hope that this article (along with those referenced in it) will create a loud enough voice to garner positive action by physicians and payors and administrators. Our physicians must become healthier. Healthy physicians are foundational to the health of our nation. This patient is counting on it.
“The next time you wrap up a visit with a health care provider, ask him or her, ‘How are you doing?’”
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I routinely do that with my doctors. The reaction I get of pleased surprise validates your point.
If I have an established relationship, I too ask them that, usually up front. Both doctors and patients are struggling to do our best in a dysfunctional system, we need solidarity (as Victor Montori discusses in his excellent book).
Thank you for the most insightful article I’ve read that tackles the toxic “side effects” of healthcare “progress.” Most innovations have disempowered physicians to use their clinical thinking. Instead, we have morphed into data entry “experts.”
Take EHR ‘s. Aside from distracting physicians from patient encounters, the software dictates what minutes remain of the “clinical interview.” There is minimal time for conversation that might reveal the context of the patient’s concerns. Physicians are forced to ask exhaustive lists of check boxes, some of which are usually irrelevant to that one patient. They have little to no discretion about guiding the interview to what’s relevant or even recording what he learns. There is literally no place for that on some software. If such a text box exists, the volume of unrelated data obscures what might be helpful to the next covering physician.
In fact, most every step of diagnosing, treating, and discharging a patient involves the physician surrendering his expertise to a computer record that presents “yes and no’s” data without nuance or direction. Any shift in treatment from implicit or explicit protocols is fraught with more paperwork and little freedom to follow physician judgement.
In the end, the computer “wins” and administrators are satisfied. The medical record has “evolved” into a billing form. The doctor and patient are left out of that loop.
Peggy Finston MD
http://www.Acu-Psychiatry.com