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Imagine you are a Haitian pediatrician working in the slum. And imagine that you are responsible for examining 10 patients per hour (or one patient every six minutes) all day long. And also imagine that these patients range in age from one hour old to five years old. And imagine that during the course of your day—every day—you examined babies and children with meningitis, pneumonia, malnutrition, severe anemia, sepsis, osteomyelitis, scabies, and impetigo, and that you had no functional hospital to triage the sickest. Would you be “burned out?”
I have observed Haitian physicians examining one sick baby after another and have wondered how they were doing. These physicians usually appear cheery and upbeat, but I have often asked myself what were they were really thinking and feeling. Did they feel sorry for the sick baby and the tired mother in front of them? Did they feel angry that they often have no good medical options for the baby? Did they worry about the outcome of the baby? Did they think about trying to change “the system” in Haiti? Did they feel like they lacked resilience and considered quitting their profession? Did my Haitian colleagues think they could return the next day and examine patients yet again? Did Haitian physicians just hide their feelings better than the rest of us because they are used to bad outcomes?
Burnout amongst physicians is a popular topic today in the US and European medical literature. Burn out is defined as a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of US physicians report at least one of these symptoms.
And what about foreign physicians who come to Haiti to work? How do we handle this enormous responsibility?
About 25 years ago I was working in a hospital outside of Port-au-Prince. This hospital had many volunteer physicians come from overseas to provide care. During outpatient clinic, we sat at little tables situated in the shade near the wall of the hospital and examined children held in the arms of their mothers who were seated next to us.
One day in this clinic I witnessed a very well trained US physician decompensate right in front of me. While she was taking a history from a mother from the mountains who was holding her baby on her lap, the US physician suddenly started speaking English to the mother. I was seated close by and couldn’t help but observe this interaction. The US physician was fluent in Creole but when she abruptly changed to English, it caught my attention. The US physician asked the mother in English, “Do You always keep the baby so clean?” The baby was filthy and malnourished and the mother had no real choice in the matter. The mother stared down at the ground like a puppy who was being disciplined. The physician continued, “Can’t you answer any of my questions?” The Haitian mother did not understand the English, but I am sure she understood the tone of voice and the look on my colleague’s face.
My doctor-friend had obviously lost it. She normally did not demean the Haitian mothers with sarcasm or cynicism. In my eyes, she was a very good physician. She had been in Haiti for a long time and was obviously “burned out.” In fact, not long after this incident, she had to be stopped from seeing further patients until she “rested up”.
How do I handle examining many sick Haitian patients in the clinic? I feel guilt. I always ask myself if I am doing the best that I can under really bad circumstances. I feel a heaviness in my heart and wonder if I am considering ALL of the bad choices for a given patient and ask myself if I am picking the “least bad choice.” I discuss my sickest patients needing an urgent disposition with my Haitian physician colleagues because they may know the local politics better. And in this way, I spread my guilt around a little bit.
In the June 20, 2018 issue of the New England Journal of Medicine, Leo Eisenstein, who is a fourth-year medical student, wrote a brilliant article–“To Fight Burnout–Organize.”
“The clinician who coined the term “burnout” was not a primary care physician buried under paperwork, nor an emergency physician beset by an unwieldy electronic health record. He was Herbert Freudenberger, a psychologist working in a free clinic in 1974. Discussing risk factors for burnout, he wrote about personal characteristics (e.g., “that individual who has a need to give”) and about the monotony of a job once it becomes routine. He also pointed to workers in specific settings — “those of us who work in free clinics, therapeutic communities, hot lines, crisis intervention centers, women’s clinics, gay centers, runaway houses” — drawing a connection between burnout and the experience of caring for marginalized patients.
“In recent years, burnout has become a chief concern among physicians and other front-line care providers. But somewhere along the way, the concept was separated from its original free-clinic context. The link between marginalized patients and clinician burnout seems to have gotten lost.”
I think this is very interesting. Leo, the young author, proceeds to say that he has been warned about being burned out by too many hours at work, too many bureaucratic tasks that takes him away from patients, as well as “death by a thousand clicks”…in other words, spending too much time in front of the computer instead of with the patient.
However, Leo precociously opines that a source of burnout for physicians results from realizing that “the experience of caring for patients when you know that their socioeconomic and structural circumstances are actively causing harm in ways no medicines can touch.” He feels that clinicians feel powerless and worn down by the poverty and oppression that their patients face— “when they cannot offer more to the patient that addresses the real cause for their illness.”
Did the US physician who I saw burn down right in front of me many years ago feel extra-demoralized that day? Leo states that “…eventually a physician will encounter patients whose health problems derive from a wicked, multigenerational knot of poverty and marginalization, and even the most astute, excellent physician may well find herself outmatched.”
I have felt this way many times in Haiti. I have felt powerless to help my patients. The Haitian infrastructure is so weak it leaves the patient at risk and the caregiver alone. But this situation has spurred me to physically take the patient myself to another hospital in Haiti or to a hospital overseas where my patient’s chances for survival increase dramatically. But this is time intensive and money intensive and not at all practical or feasible for Haitian doctors who have one patient to see every six minutes all day every day.
So what does Leo suggest to do to prevent physician burnout? He suggests that physicians organize.
“Organizing is both strategic and therapeutic — strategic because our collective labor and voice are greater than the sum of their parts; therapeutic in the sense that the activist Grace Lee Boggs articulated: “Building community is to the collective as spiritual practice is to the individual.” When we recognize ourselves not as individual actors each isolated in an exam room, but as a collective joined in common cause, we start to feel less alone.”
Leo uses a parable that many caregivers can easily understand: “A group of friends comes upon a fast-moving river where they find people drowning. The friends jump in headlong to save as many people as they can. But the drowning people keep coming. As soon as the friends rescue one, another comes into view. Eventually, one friend starts heading upstream. Another, exhausted, yells after her: “Where are you going?” The first one says, “I’m going to find out what’s throwing all these people into the river.”
Leo is absolutely right. The friend who headed upstream was changed. She saw the unending flow of drowning people coming their way. She deduced that there must be some force, hidden around the bend, that was sending people to drown. She noticed herself and her friends getting exhausted, all on the brink of burnout from the urgent, unending work. So she mobilized her friends to go upstream, for the drowners’ sake and for their own. In other words, they organized.
So what does this mean for Haitian physicians? Should the physicians working in the slums and in the Haitian rural provinces organize to help their patients and secondarily help themselves by maximizing their individual agency?
Leo sites groups of organized physicians in the States who are successfully coordinating their actions helping drug addicts. They are much more successful as a group than as individuals and suffer less burnout.
But this level of organization is not going to be universal today in the United States and certainly not in Haiti. The social determinants of health lay around the big bend in the river. And it is the governments, policymakers, insurance companies, and Big Pharma who are waiting. And physicians know this. Many physicians may be burned out, but they are alive. And they realize that if they take on “the system” that is exterminating the poor, they may be exterminated, too.
I believe it comes down to justice. The justice system in a country needs to function without bias to level the playing field for the sick. The “Baby Doc” Duvaliers and the Donald Trumps all around the world need to be held accountable by their own justice systems. The concept of activist doctors organizing is good and necessary, but their actions need to be supported by a strong national justice system that respects people and upholds the law.
Until this happens, physicians will slink into clinic each morning as little kids and grandmothers playfully tug on our scrubs. And we will slink out at night the same way…feeling powerless.
Leo Eisenstein concludes: “This kind of burnout is the feeling you get when you’re trying to rescue the drowning people but they keep coming. And you’re torn between competing exigencies: the proximal needs of the people drowning, and the distal need for naming, fighting, and demanding accountability for the upstream forces that are causing harm.”