Healthcare Musings For May 5, 2023

May 5, 2023

 

Dear Interested Readers,

 

Medicine and the Struggle For the Soul of America

 

One of the members of my Monday morning book group is a woman who is a retired minister and hospital chaplain whose oldest daughter is a physician’s assistant in rural Maine. I first met my friend’s daughter during the summer several years ago when she was working in a clerical role at the Dartmouth Medical Center. At that time she was eagerly anticipating becoming a PA student at Northeastern University in Boston in the fall. 

 

I was impressed by her warm personality and obvious intelligence and tried to be supportive of her plans of becoming a medical professional by giving her a stack of my favorite healthcare books. At the time I was very excited about the opportunity we had to really improve the quality of care. It was the early days of the ACA and there was good reason to believe that we were finally prepared to deal with just how dysfunctional and deficient healthcare was in America. It was pre-MAGA, Obama was president, and I think that I was trying to recruit her to “the cause.” I can’t remember all the books I pushed on her, but I probably gave her John Tousaint’s 2010 book, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry. I am sure that I gave her Charles Kenny’s excellent 2008 overview of the quality movement in healthcare, The Best Practice: How The New Quality Movement Is Transforming Medicine. 

 

 She was very enthusiastic about her future, and over the intervening years, I have gotten reports on her progress from her mother who is very proud of her commitment to helping others. Her PA daughter is the oldest of three young adults. My friend has two other children, a son and another daughter, who are active in nonprofit efforts to improve the social determinants of health working on efforts to improve housing. For my friend and her adult children, caring for others is a strong family trait.

 

Our little group is reading a small book which is a collection of four essays published in 1999 by the theologian Barbara Brown Taylor entitled The Luminous Web: Essays on Science and Religion. As we were beginning the conversation last Monday, someone made a comment about my recent use of AI to discuss burnout and the difficulties of practice in small towns and rural environments. In the conversation that followed, I was saddened to learn that my friend feels that her daughter who is now an experienced PA practicing in Maine for a few years was approaching “compassion fatigue.” At the time my friend used the term, I assumed it was synonymous with “burnout,” and I think that she was using it as such, but some reading has led me to understand that although compassion fatigue and burnout may coexist and share many characteristics at a practical level they are related but not exactly the same concern. In a relatively recent review of the two conditions, we read:

 

Compassion fatigue is a form of burnout unique to professionals whose work involves caretaking or providing emotional support to others. Before COVID-19, compassion fatigue was a term mostly applied to physicians, health care workers, behavioral health professionals, counselors, and social workers…

…[Healthcare professionals] have traditionally operated from “compassion satisfaction,” or positive feelings derived from helping others. Compassion satisfaction includes positive relationships with colleagues and a conviction that one’s work makes a meaningful contribution. Compassion satisfaction is maintained by feeling empowered as helpers. 

Compassion fatigue happens when a professional becomes depleted from repeated exposure to another person’s chronic adversity or traumatic stress. [Healthcare professionals] are naturally compassionate and empathetic… 

…without mental health resources at their disposal [they] are particularly susceptible to compassion fatigue. In addition, compassion fatigue impacts…team members who are naturally empathetic, have not developed adequate coping mechanisms, and/or whose organization lacks work-life balance. These factors can lead to exhaustion, weariness and often cause affected professionals to shut down. 

…it’s important to recognize that shutting down due to compassion fatigue is a means of self-preservation. It’s a way of turning “off” a system that has been running on overdrive and has hit its limit. But, unfortunately, shutting off compassion goes entirely against the deeply embedded values of most [healthcare professionals], leading to a sense of self-devaluation and guilt that only intensifies the experience of compassion fatigue.

The most common signs of compassion fatigue are: 

• Insomnia and other sleeping problems

• Intrusive and/or negative thoughts

• Hypervigilance

• Anxiety

• Isolation and disconnection

• Substance abuse

• Changes in appetite

• Irritability and depression

• Increased cynicism, negativity, and apathy

Burnout is similar to compassion fatigue in that it shows many of the same symptoms. In addition to irritability and depression, anxiety, cynicism, apathy, insomnia, and substance abuse, burnout can lead to many physical problems like a weakened immune system, heart disease, high blood pressure, and type 2 diabetes. In addition, burnout reflects work-related hopelessness and feelings of inefficacy. 

Compared to compassion fatigue, burnout does not necessarily stem from extending oneself beyond their capacity to help others or the overwhelming emotions that result from taking on others’ adversities. 

 

I don’t know if my friend’s daughter is suffering from burnout or as she called it “compassion fatigue.” There are a lot of similarities, and I am not sure that it is easy or even beneficial to tease them apart. My friend’s daughter does describe to her mother the personal impact of workforce shortages, very crowded schedules, insufficient time and resources to practice optimally, and a sense that her professional life is never going to get any better. As a result, it seems that she feels physically and emotionally exhausted and is being robbed of the opportunity to enjoy the professional satisfaction that she had hoped would be hers as a caregiver. 

 

A phrase that often comes to my mind when I think of the current practice challenges is “The harder I/we try the behinder I/we get.” A quick review of the literature confirms that my friend’s daughter is not alone, but you don’t have to go to the medical literature to know that delivering care is becoming an emotional challenge and disappointment for those who work in healthcare and that the damage to caregivers negatively impacts patients. I have had many conversations with friends and family that suggest that a sense that things are getting worse is not limited to those who deliver care. Patients express their anxieties about access, time with a concerned provider, out-of-pocket costs, and errors in care associated with the stress on providers. The changes they perceive in their access to care and their time with their providers are the flipside of what my friend’s daughter, the PA, is feeling and the result of a focus on finance and the growing workforce shortages across the country which are particularly problematic in rural America.  

 

Healthcare is no longer the center stage issue that it was back in 2008-2013 when I had leadership responsibilities and when my friend’s daughter was eagerly anticipating a satisfying career providing care in an environment where she was needed and would be appreciated and given the support she deserved. What are the root causes of the changes over the last decade? I can’t believe that the answer is that the country can’t afford better care. Objective, reliable data demonstrate that similarly wealthy and even less wealthy countries are doing a better job. These countries also faced the same challenges from the pandemic. They also have had their economies challenged by international military conflicts, the effects of global warming, supply chain failures, and rampant inflation that has shaken international finance and caused instability in banking. Yet, they continue to provide care to all their citizens and their citizens don’t usually worry about their neighbor’s love for guns or the safety of going to school, the grocery store, a church, a doctor’s office, a synagogue, a parade, a dance party, sitting in a university library, or asking their neighbor to be quieter.

 

I can’t speak to the feelings in other countries, but I do feel that our concerns for one another have been diminished as we have become more concerned and less certain about our personal safety and health in a deeply divided nation that once embraced pluralism and was moving toward equal opportunity and now teeters on the brink of authoritarianism. Paradoxically, we are divided in so many different ways that it is difficult to conceptualize how to effectively put all the pieces back together. Intersectionality may describe the experience of many but it doesn’t provide definite solutions or even effective coalitions for change.

 

It is interesting that the times when we come closest to unity are brief periods when we feel collectively challenged as we did in the immediate aftermath of 9/11 or in the early days of the pandemic. Between those brief moments, there is no unifying cause and no collective strategy that we can all decide to follow to get back on track toward the continuous improvement and resolution of the problems that would fulfill the dream of living in a nation where there was equity in healthcare, education, housing, and all the social determinants of health. Thomas Jefferson eloquently described our right to “the pursuit of happiness.” Dr. King gloriously envisioned a future of equality in his “I Have a Dream” speech sixty years ago. Despite good intentions, in terms of healthcare, we are still a long way from the dream Dr. King shared in 1963 and the universal inalienable rights that Jefferson described more than two centuries ago. 

 

Rather than being where Jefferson and King thought we could be, we have had to add “diseases of despair” to the healthcare vocabulary. Heart disease, cancer, genetic disorders, and infectious disease have been joined on the list of public health concerns by gun-related deaths, and drug overdoses, Our collective mental and emotional health is surprisingly jeopardized in the midst of what should be enough wealth to give everyone a path to good healthcare and a future with the positive expectations that Jefferson and Dr. King both believed could be achieved through a unity of purpose. 

 

Last weekend, before my friend told me about her concerns for her daughter I was inspired by reading a column that  David Brooks had written entitled, “Joe Biden and the Struggle for America’s Soul.” Brooks recognizes that soul is not a word that we frequently use these days in an increasingly secular environment. In her 2021 book God, Human, Animal, Machine: Technology, Metaphor, and the Search for Meaning former evangelical turned atheist, Meghan O’Gieblyn, puts “soul” in its more common current context. She writes:

 

It is meaningless to speak of the soul in the twenty-first century (it is treacherous even to speak of the self). It has become a dead metaphor, one of those words that survive in language long after a culture has lost faith in the concept, like an empty carapace that remains intact years after its animating organism has died. The soul is something you can sell, if you are willing to demean yourself in some way for profit or fame, or bare by disclosing an intimate facet of your life. It can be crushed by tedious jobs, depressing landscapes, and awful music. All of this is voiced unthinkingly by people who believe, if pressed, that human life is animated by nothing more mystical or supernatural than the firing of neurons—though I wonder sometimes why we have not yet discovered a more apt replacement, whether the word’s persistence betrays a deeper reluctance. I believed in the soul longer, and more literally, than most people do in our day and age.

O’Gieblyn, Meghan. God, Human, Animal, Machine (p. 6). Knopf Doubleday Publishing Group. Kindle Edition.

[I added the bolding for emphasis.]

 

Brooks does explain how “soul” is being transitioned from the religious to the secular world by Joe Biden and what the transition should mean for us all. 

 

Joe Biden built his 2020 presidential campaign around the idea that “we’re in a battle for the soul of America.” I thought it was a marvelous slogan because it captured the idea that we’re in the middle of a moral struggle over who we are as a nation. In the video he released this week launching his re-election bid, he doubled down on that idea: We’re still, he said, “in a battle for the soul of America.”

I want to dwell on the little word “soul” in that sentence because I think it illuminates what the 2024 presidential election is all about.

What is a soul? Well, religious people have one answer to that question. But Biden is not using the word in a religious sense, but in a secular one. He is saying that people and nations have a moral essence, a soul.

Whether you believe in God or don’t believe in God is not my department. But I do ask you to believe that every person you meet has this moral essence, this quality of soul.

 

The hook is the idea that every person has a “moral essence” and Brooks will go on to argue that if you accept that idea you have defined your political position. He continues:

 

Because humans have souls, each one is of infinite value and dignity. Because humans have souls, each one is equal to all the others. We are not equal in physical strength or I.Q. or net worth, but we are radically equal at the level of who we essentially are.

The soul is the name we can give to that part of our consciousness where moral life takes place. The soul is the place our moral sentiments flow from, the emotions that make us feel admiration at the sight of generosity and disgust at the sight of cruelty.

 

Brooks goes on to give everyone the benefit of the doubt based on the fact that they have a “soul.”

 

Most people yearn to lead good lives. When they act with a spirit of cooperation, their souls sing and they are happy. On the other hand, when they feel their lives have no moral purpose, they experience a sickness of the soul — a sense of lostness, pain and self-contempt.

 

Brooks would like to revive our use of “soul” or at least give it some political meaning. He salutes the fact that President Biden is using “soul” in the political realm. I like Brooks’ idea of reclaiming or redefining the “soul”  because it has always felt to me that what drives the desire to provide medical care arises from what we could call our “soul” or something close to that ancient concept.

 

It may well be that when circumstances make practice difficult for medical professionals like my friend in South Carolina, from last week’s letter, or for the PA in Maine, either burnout or compassion fatigue is the inevitable result. Across the country, but especially in rural environments and in our poorer city neighborhoods, circumstances in the organization and finance of care become a barrier to fulfilling this moral sensibility. The current dysfunction of care delivery has compromised the moral purpose that was so important in the choice of so many of us to become caregivers, and we feel the loss and it disturbs us because we have souls and it feels wrong.

 

Getting back to Brooks’ analysis and the importance of “soul” in politics might provide even more enlightenment as we try to understand our current dissatisfactions with healthcare in America.

 

Political campaigns are not usually contests over the status of the soul. But Donald Trump, and Trumpism generally, is the embodiment of an ethos that covers up the soul. Or to be more precise, each is an ethos that deadens the soul under the reign of the ego.

Trump, and Trumpism generally, represents a kind of nihilism that you might call amoral realism. This ethos is built around the idea that we live in a dog-eat-dog world. The strong do what they can and the weak suffer what they must. Might makes right. I’m justified in grabbing all that I can because if I don’t, the other guy will. People are selfish; deal with it.

 

Those words took my breath away. I am sure that at least 45% of the country, those who believe in Trump, those who would never vote for a Democrat for cultural reasons and their addiction to Fox News, and those who are afraid to resist him for fear of the backlash from the Trump base in their community, would push back on that analysis. My guess is that they would contend that they do care, its just that they are trapped in circumstances beyond their control and that it is morally right for their highest priority to be the well-being of their families and to do that they must favor a few distasteful policies and support those who will protect them and their critical interests. Those who are outside their circle of concern can fend for themselves, and they will just use their resources to buy concierge care.

 

But, Brooks hammers on with his condemnations:

 

This ethos — which is central to not only Trump’s approach to life, but also Vladimir Putin’s and Xi Jinping’s — gives people a permission slip to be selfish. In an amoral world, cruelty, dishonesty, vainglory and arrogance are valorized as survival skills.

People who live according to the code of amoral realism tear through codes and customs that have built over the centuries to nurture goodness and foster cooperation…In the mind of an amoral realist, life is not a moral drama; it’s a competition for power and gain, red in tooth and claw. Other people are not possessors of souls, of infinite dignity and worth; they are objects to be utilized.

…One of the hardest, soul-wearying parts of living through the Trump presidency was that we had to endure a steady downpour of lies, transgressions and demoralizing behavior. We were all corroded by it. That era was a reminder that the soul of a person and the soul of a nation are always in flux, every day moving a bit in the direction of elevation or a bit in the direction of degradation.

 

Brooks is a card-caring conservative. Biden sells himself as a champion of democracy, but I think that Brooks would say that they share a vision of what we owe one another, and I would say that the values that most of us brought to our professional lives were planted in the same soil of acceptance that everyone is deserving of the best care we can provide. It has just been so hard to live in that vision when the externalities that we must deal with are often attacked by amoral realism which seems to be in an unholy alliance with “Christain Nationalism” complicated by an odor of White Supremacy. 

 

Brooks’ conclusion was straightforward:

 

The contest between Biden and Trumpism is less Democrat versus Republican or liberal versus conservative than it is between an essentially moral vision and an essentially amoral one, a contest between decency and its opposite.

 

I am left wondering whether there can ever be meaningful progress toward the eradication of poverty, equality in the social determinants of health, or a reversal in the decline of the experience of delivering care that has caused, take your pick or take both, widespread professional burnout or compassion fatigue. 

 

There was a time when I was concerned about my own ability to withstand the forces that cause burnout or compassion fatigue. Now, based on my concerns for myself, my family, my friends, my community, and everyone, even those who are drawn to “amoral realism,” my concerns are more encompassing. Now I worry for all of us and pray for the strength of our collective secular souls.  

 

His Face Fell–Twenty Years Ago

 

It was May 3, 2003, that New Hampshire woke up to discover that sometime after midnight there was no more saving the face of the Old Man of the Mountain. For many years there had been attempts to keep the Old Man of the Mountain together with cables, but those efforts ultimately failed twenty years ago. In a strange way, it was like a death in the family. This week I have been reliving the sad event on a nightly basis because every evening there is a different angle about the tragedy presented on the evening “news magazine” of WMUR, the only television station in New Hampshire. Click on the WMUR link and watch the whole story in 6 minutes. It was an amazing scene!

 

 

I was a fan of the old man long before his face fell off its perch on Cannon Mountian. I can’t remember when I first visited his mountain home, but I had heard a rendition of Hawthorne’s “The Great Stone Face” many times in my childhood. It was one of my father’s favorite stories. He used it in more than one sermon. You may remember that I used “The Great Stone Face” in these letters in a piece three years ago entitled “Does What We Consider Shape Our Approach To Patient Care?”

 

You probably remember that Hawthorne’s story is a tale with a moral. My dad used it to reinforce the idea that what we admire and essentially worship has an impact on who we are. The scripture that goes with that idea comes from St. Paul in his letter to the Philippians. In the eighth verse of chapter four, he writes:

 

Finally, brethren, whatsoever things are true, whatsoever things are honest, whatsoever things are just, whatsoever things are pure, whatsoever things are lovely, whatsoever things are of good report; if there be any virtue, and if there be any praise, think on these things.

Philippians 4:8 King James Version (KJV)

 

It feels like there must be a way, but I am a little at a loss as to how to factor healthcare into the fate of the Old Man of the Mountain and into the moral that Hawthorne and my father were pushing, but I am glad to report that the Old Man may be gone but he is not forgotten. Maybe it is enough to remember his passing and the message that even in healthcare what we think about has an impact on outcomes.

 

The old man is gone but his image lives on our license plates and state highway signs. People go to his “grave” to mourn his loss, and there is even technology that allows you to look at the mountain and see what it looked like before the old man fell on that faithful night. Old men do fall. I know that as a fact of personal experience. I also know that what is constantly on our minds shapes our collective future which is part of what David Brooks was trying to tell us in his article that was central to this letter.

 

For me, it is much easier to think positive thoughts when I am out for a walk. I have been walking in a new place recently. A new friend has been advised by her doctor to take it easy which means that her two black labs needed to be walked. I walk every day; so I figured why not walk her dogs? A big payoff has been the exposure to two neat dogs and some interesting scenery on her property. The header today is a pond that my friend created from a glacial kettle hole. I can hardly wait until this garden in the woods blooms. 

 

The Old Man of the Mountain is gone, but his lesson remains true. I recommend reading Hawthorne’s tale if you have never read it. There is also a terrific Audible version that I enjoyed on one of my walks this week. It does make a great case for the truth that we think about, and what we look at, does make a difference. Ultimately, what we “worship” shapes us.

 

I believe that it is also true that what attracts our national attention also impacts what we do collectively. I have got to believe that burnout and compassion fatigue don’t have to be terminal conditions if together we focus on and work toward the image of better health for everyone. We could apply the admonition to “Think on these things”  to a vision of a world where we recognize that everyone has a soul which means that all of us are of “ infinite value and dignity” and therefore should be treated with great care and equity and then see what happens to the health of our nation.

Be well,

Gene