I have heard from more than one retired anesthesiologist about becoming aware of the weight of the pager after it is relinquished. I imagine other physicians engaged in critical care, trauma (physical and emotional), other emergency, and obstetrical care might have heard similar descriptions. Have I left anyone out? We do a pretty good job of negotiating chronic professional anxiety at a subacute level. In fact, we are so accustomed to coping with stress we are almost unaware of its presence, it is the air we breathe. I am reminded of this when there is time for longer conversations with my colleagues and we meander through many perspectives on being a physician. In conjunction we are also parent, spouse, friend, leader, team member, negotiator, educator, mediator, we sit on committees, attend to continuing education, administrate. We are a busy, productive group. For the first time this year I am hearing stories of overwhelm: households in shambles because there is simply no way to manage it all, clinicians at the brink of exhaustion with nowhere to turn, chronic frustration, anxiety. And these are all clinicians apparently holding it together on the surface, we look good even as we are imploding.
We provide comfort, reassurance, safety, and a vast underlying knowledge supporting ongoing decision making. Sometimes exchanges are serious, considering all of the possible outcomes in caring for a really sick patient. And sometimes even healthy patients hold gut wrenching surprises. In the last year the potential of covid accompanied our every interaction: the possibility of becoming ill, dying, bringing illness home to family, wondering about the possibility of infection in every single patient, negotiating the embroiled politics, and caring for the sick in futile circumstances. Expectations for communication and connection in personal protective equipment had to evolve overnight. I don’t know about you but if I never have to put an N95 on my face before what would normally be a meaningful conversation, I’ll be happy.
We are more aware now, however, of the burden of our work. This last year was a daily almost overwhelming challenge. And the telling is in our stories and the sheer volume of burnout among clinicians. Anesthesiology published a study outlining the numbers, contributing factors, treatment of, and a conceptualization demonstrated in an old but still relevant assessment of burnout (Anoushka, et.al., 2021). The numbers and potential sequelae are sobering. Before the pandemic concepts of burnout, recognition and treatment were just becoming an acceptable topic of conversation. Now the topic is unavoidable. Physicians and all of our team members are treading water mid ocean with no rescue in sight. I don’t know about you, or how training may have changed in the last twenty years but we didn’t learn how to take care of ourselves then. We learned in training to be proud of setting our own needs aside in order to best focus on the patients in our care. Now, we are drowning in anxiety, depression, drinking, cynicism, dissociation, depersonalization and in so doing we are learning the grave consequences of a major misstep in our training. The oxygen mask goes to the caretaker first, so that good care can continue.
The pager is a great weight. It holds the ever present emergency around the corner that we are asked to act on effectively, involving rapid, consequential decisions. Even on consecutive, so called easy days, it holds critical possibility. A patient could die in our hands today, be gravely injured, even in the easiest of cases the possibility is always present. But because the brain isn’t equipped to hold this in overt awareness on a long-term basis, the reality resides more in the depths of our subconscious. It is time now to change this.
It’s time to reconsider our relationship to the practice of medicine and the systemic problems we face. It’s time to consider our well-being, reflect on our purpose, and what might best contribute to our longevity as clinicians. We worked hard to get where we are, and, my guess, most of us love our work. We are needed by so many and if we are to continue providing outstanding care, we must take seriously the examination of our needs. As a byproduct this also role models self-care and self-respect to the patients we care for. There is a link below to the Maslach burnout scale if you are curious about where you might fall. While the good news is there are answers, none are easy. But we can begin to engage some important cultural shifts with simple action. Support each other, look out for each other, check in with each other. Try looking a bit below the surface, not all smiles are cheerful. Become comfortable suggesting, or hearing, that maybe a professional ear is what’s wanted. I have grown comfortable listening to the surface and the depths, and I am constantly amazed at our resilience and capacity to care. I have grown comfortable making the protection of our resilience a top priority. Perhaps once we have turned our focus inwards we can begin to address the herculean task of the wider cultural shifts necessary. Thank you for listening.
Anoushka M. Afonso, Joshua B. Cadwell, Steven J. Staffa, David Zurakowski, Amy E. Vinson; Burnout Rate and Risk Factors among Anesthesiologists in the United States. Anesthesiology2021; 134:683–696 doi: https://doi.org/10.1097/ALN.0000000000003722