I sat knee-to-knee with a nurse practitioner at a school-based clinic in rural Ohio. Choking back tears, she described a patient she just couldn’t seem to get out of her head: a middle school girl, accompanied by her mother and a social worker. Just days prior, the girl was dropped off at her father’s home for the weekend. Before the promised Friday night football game, she discovered his body on the floor of the bathroom. Within the hour, paramedics were laying a sheet over his corpse. Another victim of an opioid overdose in a region of the country that has been devastated by the epidemic.
That was only part of the story.
As I spoke with the NP, she described the girl coming into her exam room, listless and distant. Mom was shouting with the social worker and insisting that it was a “good thing” he was “finally” out of the picture. Her daughter would get over it.
While the adults in the room fought, the NP noticed the girl furiously scratching the back of her head. She lifted her hair to examine her scalp.
Lice. Hundreds of nits covered the girl’s head, with spots rubbed raw and scabbed over. She must have had them for weeks, maybe longer. The girl looked down at her feet in shame. Then her mother, picking up on the encounter, eyed her daughter with disgust. “She’s filthy, isn’t she?” she spewed.
“And just like that,” the NP said, “the mother left. She just left. She couldn’t even stand to look at her own daughter.”
The NP was crying now.
“How do process that?” I asked.
Through sobs, she said she doesn’t — that it just stays with her. For herself and colleagues like her — soldiers in the trenches of our nation’s healthcare system — “It hardens us all. It’s the poverty and the brokenness and the addiction and the inequity and the hate. But what can we do? The public won’t act, so we have to.”
Her story is no different than hundreds I’ve listened to over the course of the year — along the southern border, in community health centers, in prisons, on Native American reservations, in the hallways and exam rooms of some of the most esteemed academic medical centers in our country.
Primary Care Progress, a national nonprofit working to strengthen primary care teams and clinicians — supported this effort as an exploration of challenges faced by today’s primary care workforce — principly among those hardships, the prevalence of burnout. We expected to hear what we all hear when clinicians bemoan the system: the rise of the electronic medical record, cumbersome administrative burdens, the frenetic pace and long hours. To be sure, those headaches certainly came up.
What we didn’t expect to discover, however, was our own central role — as patients and the public — in so much of their professional trauma.
Clinicians as Canaries in the Coal Mine
It’s easy for those of us on the outside of the burnout epidemic to wonder how a profession so skilled at healing lacks the knowhow to heal themselves. Indeed, who among us doesn’t feel overworked and undervalued?
But there’s something deeply disturbing about this growing crisis in medicine, because what we’re witnessing isn’t so much a failure to thrive in America’s clinics; it’s a failure to act in America’s communities.
Take, for example, the events of mid-November. In a hospital waiting room, a trauma surgeon in Thousand Oaks, California changed her bloodied scrubs. She stood in front of a bathroom mirror to rehearse the name of a victim so she didn’t accidentally say the name of the one an hour ago. Then, donning her starched white coat and well-trained detachment, she met with the family to notify them that their 22-year-old son was dead. Her team had done all they could. She was sorry. Later that day, she mourned their deaths. Alone.
Days later, a row between the National Rifle Association and healthcare professionals ensued over remarks by the NRA following the mass shooting that doctors should “stay in their lanes” when it comes to gun violence. Providers hit back with a powerful, viral social media campaign to draw attention to their critical role in treating victims of gun violence.
While the NRA and clinicians nationwide debated the issue, there was an important point missing from the dialogue: the NRA was right. Gun violence shouldn’t be in physicians’ lanes; it should be in our lane to prevent it.
The truth is that there are countless areas in which we’ve abdicated responsibility. Hundreds of Freddie Greys across the country had a doctor. Thousands of children in detention facilities on America’s southern border have nurses. Millions of incarcerated men and women in our country’s overcrowded prisons have providers. Community health workers offer care in homeless encampments and outpatient drug treatment facilities nationwide.
At a recent visit to a community health center in suburban Seattle, I asked a group of doctors sitting around a conference room to share the best part of their week. One clinician noted that after days of negotiating with a local electric company, she was able to get her patient’s electricity turned back on. “It was important,” she said, “because she’s on medication that requires refrigeration.” Another glowed when talking about the clinic’s new food pantry that was now open to serve its food insecure patients.
All that’s laudable — and an absolute travesty. A sobering testament to America’s contentment to neglect social and structural determinants of health.
For those of us who aren’t in clinics or emergency rooms every day, we can look away when we see injustice. Healthcare professionals don’t have that “luxury.” While they’re checking their clothes to make sure there’s no visible blood before they break the news to a family, the rest of us listen to white men tell us it’s too soon to address gun reform in the wake of another mass shooting. While an oncologist tries to figure out how to treat a mother’s cancer when she can’t afford her medications, policymakers explain why it would be imprudent to tackle healthcare coverage or rising prescription costs.
Our healthcare providers don’t get to turn a blind eye to symptoms of America’s divisions and inactions. They also don’t get to decide who deserves treatment. The victim or the shooter. The immigrant or native born. The nationalist or the progressive. For clinicians, they’re all “patients.”
But healthcare professionals do suffer the consequences.
William Osler famously remarked, “Listen to your patients; they’re telling you their diagnosis.” We, too, need to listen to our clinicians. Story by story, they’re telling us that our nation is in crisis. That too many people are dying too unnecessarily from too many treatable conditions by too many factors that we can control.
Sure, no one likes the electronic medical record. But that’s not at the heart of burnout. It’s our inaction that’s driving our collective burnout — not just in healthcare, but in all care. Again and again, providers across the country are put in a position of saying, “We did all we could.” They may have done all they could, but the rest of us haven’t.
Why should the public care about the well-being of a well-heeled workforce? Because when the problem is on us, then so, too, is the solution.
So stop asking providers if they’re burned out; of course they are. Instead, start asking: Did we do all we could to heal our nation? Maybe then we can be a part of healing the healers.