November 13, 2020

Dear Interested Readers,

 

An Introduction To A Remarkable Book

 

I have been waiting for this moment for a long time. Two things that I have anticipated have happened simultaneously. First, the election is sort of behind us. If nothing else, the outcome is beyond our individual reach. We have opinions, but now that we have cast our votes, unless we live in Georgia, we have no formal way, other than writing a check, to participate in what happens next. I had planned that when the election was over I would put less emphasis on politics and write more about healthcare policy, practice management, and the joys and challenges of practice. 

 

The second event that I have been waiting for is the publication of Eve Shapiro’s new book, Joy in Medicine? What 100 Healthcare Professionals Have to Say about Job Satisfaction, Dissatisfaction, Burnout, and Joy. After I read the pre-publication manuscript that Eve gave me back in late March, I was delighted that Eve had asked me to write the foreword to her new book. I wanted to tell you all about it back then, but agreed to wait until the book was published. 

 

As you will be reminded, if you read the foreword which follows below, the timing of the writing corresponded to the peak of the first wave of the COVID pandemic. By the time I had finished my task I was convinced that Eve’s book provided great insight into the sacrifices that so many essential providers of care were willing to make. It has been hard to avoid sharing the insights that I gained from reading the 100 interviews that are the meat of this remarkable study of “real life” healthcare professionals. You may recognize that I have planted a few of the thoughts expressed in the forward into letters that you might have read from me since last spring. 

 

As we are now moving into what is being called the third wave of the pandemic, which may be the greatest call yet on overworked and exhausted healthcare professionals, I believe Eve’s book is even more important than I perceived it to be last spring. Dr. Fauci’s forecast is for a difficult holiday season and winter. I know that the challenges facing our healthcare system will primarily fall on the shoulders of the people, and others like them, who have shared their stories with Eve with the hope that their testimony may in some small way improve our understanding of the broad variation in human experience associated with trying to care for the sick. 

 

I hope that after you read the foreword you will be enticed to read the whole book. I offer it to you not so much for the instruction it provides, and it does do that, but mostly for the inspiration it will provide you. In the foreword I suggest that it is good bedtime reading. Just read the story of one provider and end your day with something that will give you insight into the commitment and the personal sacrifice that has always been the foundation of the joy that is the true reward of practice. To get your own copy of the book, follow the link to either amazon.com or taylorfrancis.com. 

 

Foreword to Joy in Medicine? 

 

Eve Shapiro’s Joy in Medicine? What 100 Healthcare Professionals Have to Say about Job Satisfaction, Dissatisfaction, Burnout, and Joy is a remarkable book that is inspiring and thought-provoking as it examines the material and spiritual forces that bear on the lives of those who work in healthcare. It is a “must read” for all of us who care about healthcare and the well-being of those who provide it. It is meant for you if you work in any area of health care, and its message is of interest to anyone who receives care.

 

No matter what place you occupy in the evolving hierarchy of healthcare, this book is for you. If your job entails managing other healthcare professionals, your board or CEO should require you to read this book. If you are the CEO or a senior manager in a system of care, you should read a few pages to orient yourself each time you venture out to speak to the people who look to you for leadership. If you are struggling and can’t remember why you ever thought there was a role for you in healthcare, this book has the potential to be a balm for your soul. If you are not a healthcare professional, reading this book will give you an even greater appreciation for the challenges that are part of the world that can at times come between you, your care providers, and our system of care.

 

Eve tells us in the Preface, much like the Methods section of a paper in a peer-reviewed journal, how she conceived of and conducted this work. We see the long list of open-ended questions that opened the door to reflection, personal revelation, and sometimes to confession. It is clear from the presentation of her process that her intention was not to generate more statistically significant data to add to all the metrics that are easy to find on burnout and employee satisfaction/dissatisfaction, but rather to give us the many complex personal images that the data obscure by averaging out our identities and quantifying our feelings to fit into some graph that could be the basis for a policy or strategy.

 

As Eve’s interviews underscore, the healthcare professionals who provide patient care deserve our collective interest in their humanity. Without some insight into who they are and the forces with which they struggle every day, we cannot fully appreciate the obstacles to providing the care we all want for ourselves and our families—and that can so easily compromise that care. As many of Eve’s witnesses told her, providing care can become hard very early on in a career that began with high ideals and expectations of service.

 

We learn from their stories that organizations’ preoccupation with finance and volume have forced more and more professionals, who once took pride in their clinical autonomy, to adopt the status of employees. We must counter by asking ourselves how we can take better care of the caregivers. Any circumstance that compromises their performance threatens us all.

 

After reading the thoughtful commentary and analysis in the Preface, Introduction, and the focused introductions of each of the four sections, I suggest you savor the story, or portrait, of one professional a day as a reminder of what is important. Eve has carefully crafted the testimony offered in each interview.

 

Every portrait needs an appropriate frame; it needs to be hung on the wall where it can catch the light that will draw your eye to the intricacies of the story the painter is trying to tell. I do not usually spend much time with prefaces and introductions. The Preface and Introduction to this book, however, serve to frame the portraits, containing information vital to our understanding and appreciation of the concerns expressed in the profiles that follow. When I first read the Introduction I felt that in this era of concern about “burnout” and professional satisfaction, her introduction would make an excellent article for the “Perspectives” section of The New England Journal of Medicine.

 

I don’t think it’s disrespectful to say that I have come to think of Eve’s profiles of healthcare professionals in much the same way as I’ve thought of the great AIDS quilt, created to memorialize individual lives of those lost in the protracted AIDS epidemic. Each panel of the quilt represented one person’s unique story. Each of the 100 profiles in Joy in Medicine? tells one person’s unique story, a portrait painted with the words of its subject.

 

I was delighted to tell my own story to Eve. Of the remaining 99 profiles, I know three of the individuals she interviewed. I can attest to how closely the words I read on the page match the words I have heard them say. That fact alone is remarkable and is a testimony to the respect and care given to each story. I believe that everyone wants to tell his or her story. It is human to want to be “known.” We also are intensely curious about other people’s stories. The stories of other lives reveal the paradox that although we are unique, we share many thoughts, concerns, challenges, disappointments, and small victories with people we have never met. As I read Eve’s words, I found myself saying, “That’s what I think, too.” At other times I am reassured that the feelings of failure, fatigue, fear, and outrage that have made me ashamed of myself at painful times have also been experienced by many of the 99 professional siblings she introduces to me. 

 

I received the draft of this book to review on March 20, 2020, at about the time when the government in this country started to take the COVID-19 pandemic seriously. We were less than a week into the isolation of social distancing, but it was already clear that medical professionals were going to be stressed far beyond anything they had ever imagined. We had been given a preview of what might lie ahead for us by events in China, Iran, and Italy. By March 20, many were sensing that we had crossed the threshold from a world we had known well, but would never live in again, and were standing for just a little while on the uncomfortable threshold of what we would soon call the “new normal.”   

 

Dr. Li Wenliang died of the virus on February 7, a little more than a month after he had tried to warn the world with a post on the Internet on December 30, 2019: “A new coronavirus infection has been confirmed and its type is being identified. Inform all family and relatives to be on guard.”

 

By March 20 we had stories of medical personnel in Italy who had given their lives while providing care. Before I finished reading the manuscript and had begun to write this Foreword, we would read of the first death from the virus of an ER physician in America, Dr. Frank Gabrin, who died on March 31, 2020. Dr. Gabrin was an experienced ER physician who worked at East Orange General Hospital in New Jersey and Saint John’s Episcopal Hospital in Queens. It was reported that because of a shortage of personal protective equipment (PPE), he had used the same mask for 4 days. Ironically, he had published a book in 2013 entitled Back from Burnout: Seven Steps to Healing from Compassion Fatigue and Rediscovering (Y)our Heart of Care. Soon the nightly news would contain reports of the daily 7:00 p.m. salute to care givers coming from doorways and windows of sequestered New Yorkers. 

 

During the past 7 weeks of continuing concern and suffering from the COVID-19 pandemic, as the number of lives lost climbs past 60,000 toward who knows what depressing number, I have found great solace in reading the testimonies that fill the pages of Eve’s well written and superbly organized book. They are stories that demonstrate, without a doubt, that although we have had inadequate PPE, too few ventilators, and woefully inadequate testing, we have had an abundant supply of committed people like Dr. Gabrin and hundreds of thousands of other healthcare professionals and other essential public servants like first responders, bus drivers, and grocery store workers who have been prepared and willing to answer the call to serve their communities.

 

As I read Eve’s book, I realized that the interviews she presents are proof positive that we have been blessed with people who are committed to service. The people who told her their stories between 2018 and 2019 would be the same people who would rise in 2020 to close the gap between the lack of preparedness of our government and the challenges of an enemy that we had never seen before. 

 

While reading this book I found myself thinking about three other pieces of medical literature that drew similar feelings from deep down inside me. One is Francis Weld Peabody’s famous 1927 paper and lecture “The Care of the Patient.” Peabody wrote during a time of transition and tension between “the art” of individual care in the home and office and the increasingly science-based care offered in the hospital: 

 

“Hospitals, like other institutions founded with the highest human ideals, are apt to deteriorate into dehumanized machines, and even the physician who has the patient’s welfare most at heart finds that pressure of work forces him to give most of his attention to the critically sick and to those whose diseases are a menace to the public health…there then remains little time in which to cultivate more than a superficial personal contact with the patients. Moreover, the circumstances under which the physician sees the patient are not wholly favorable to the establishment of the intimate personal relationship that exists in private practice….”

 

Peabody concludes with the famous last pronouncement that I hear echoing in the stories Eve gives us: “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

 

In the 93 years since Peabody offered us his wisdom, we learn through Eve’s witnesses that the tensions he described between art and science, institutional concerns and those of individuals, financial preoccupations and the time needed to see the “whole patient,” and the competing concerns of the mind and the soul, are still with us.

 

Eve’s book also calls to mind what I learned from Robert Cole’s 1993 book, The Call of Service: A Witness to Idealism. As a physician psychoanalyst, Cole presented many of the human responses to the personal sacrifices of caring for people and working in difficult environments, trying to achieve noble objectives that are often ignored or rejected by the status quo. Cole divided his fourth chapter, which he calls “Hazards,” into five parts that match nicely with many of the themes that emerge from Eve’s witnesses: “Weariness and Resignation,” “Cynicism,” “Arrogance, Anger, and Bitterness,” “Despair,” and “Depression (“Burnout”).” In this chapter, Coles described the mood of a medical student he knew:

 

“He was edging toward a fuller discussion of weariness, the resignation he sometimes felt as he stood at the nursing station and looked down a long corridor at all those rooms full of people nearing the end of their time on earth. He had once thought about all those people being so grateful for even the smallest gestures, and hence he was rewarded and even stimulated because he had so many chances to make them more comfortable. They were glad to engage with him, talk to him with warmth and appreciation. Now, it seemed, he was noticing the cranky side of even those people who were usually cheerful.”

 

Finally, I realized that Eve’s book was propelling me back to what I learned about the bidirectional process of care that was driven home for me when my own analyst suggested that I read Michael Balint’s 1957 classic, The Doctor, His Patient and The Illness. I had sought help because early in my practice I was struggling. It occurred to me that although I was in a group practice, I felt alone and uncertain whether anyone was noticing my efforts, or, more importantly, was aware of the mistakes I was sure I was making. Going from the intense and interactive environment of the busy floors of a world-class academic medical center to the relative isolation of an office was disorienting. Have you heard the description of the usual group practice, “doctors doing their own thing while sharing a parking lot?”

 

I longed for the opportunity to talk with colleagues about the management of the patients I was seeing but was afraid of revealing my sense of inadequacy. Little did I know that many of my colleagues were struggling with the same concerns. Fortunately, my group practice did have a prototypical clinician support group, much like what has evolved since the 1980s as Balint Groups. In these groups, doctors and nurses met over sandwiches at noon on Thursdays to discuss our feelings associated with practice. Our feelings often were an expression of our frustration with management or the loss of professional autonomy. I was heard, but I was also a “hearer.” In the group we revealed who we were and wanted to be in much the same manner as Eve’s witnesses present themselves in this book. That process satisfied our need to tell our own stories, enabling us to make it through until things might begin to change. It did not occur to me in the moment of those group encounters that we were calling out concerns and forming relationships that in time would result in organizational transformation.

 

It was clear that, like our patients, we wanted to be known. We wanted to be heard, but we wanted to be heard by someone who cared enough to want to learn who we were. Improvement began with wanting to be heard and was sustained by learning that our problems, worries, and concerns were shared by others. I am certain that reading the testimonies in Eve’s book will allow many isolated and disillusioned caregivers to realize that their own story is unique, but the issues and feelings described are shared by many. I hope, in time, that shared awareness will foster efforts to further improve the things that frustrate us all and prevent us from always presenting our best selves to the people who come to us for help.

 

Eve’s book offers us a chance to be “hearers,” and as we read, we realize that the story we are reading is also our story. Eve’s book reproduces the feeling of that long-ago lunchtime “touchy-feely” group experience for me. That experience is now almost a half-century behind me, lying halfway in time between Francis Peabody and Eve’s book. As I read her book I was reminded of how the positive expectations that called us to serve others run into the mundane realities that on some days can defeat us—and that the best defense is to avoid isolation from our colleagues who are trying to weather the same storm.

 

I met Eve when she co-authored The Patient Centered Value System: Transforming Healthcare through Co-Design with Dr. Anthony DiGioia in 2017. I have known and respected the work of Dr. DiGioia for many years. I was honored and delighted when Dr. DiGioia asked me to write the preface for that book. During that process, Eve and I recognized a “kinship” and continued to correspond after the book was published. She became a faithful reader, and frequent commenter, on the subjects I discussed on my blog, “Strategy Healthcare,” where I have frequently written about professional satisfaction, the joys of practice, and burnout.

 

Along the way we discovered we were “related.” We both held the late Dr. Jack Russell in our hearts as the most remarkable teacher we had encountered during our college and graduate school days. I took all of the English literature courses Dr. Russell taught at the University of South Carolina back in the mid-60s. Eve took Dr. Russell’s courses at the University of Maryland some decades later. It has been great fun to compare our experiences and to realize that Dr. Russell’s life demonstrated that one of the defining qualities of human excellence is the life-long, consistent pursuit of high standards with integrity.

 

In early 2018 I was delighted when Eve told me she had been inspired by a visit to the annual meeting of the Institute for Healthcare Improvement (IHI), where the focus was joy in work, to explore professional satisfaction or joy in medicine in her next book. After the focus on “burnout” that has been such a concern in every organization with which I have had contact, the idea of talking about joy, as much as or more than burnout, seemed like a novel idea to me. I was eager to see what she produced.

 

As her work evolved, I was a little surprised to hear that the people to whom she spoke were not complaining about burnout, per se. They had no shortage of concerns. They talked about all the things that are mentioned as etiologic factors in the discussion of burnout: the distortions to practice created by the EMR, inadequate time with patients, poor organizational support, demands that negate work-life balance, fear in the workplace, oppressive managers, the widget counting of relative value units, and so forth. But those she interviewed also explained their coping mechanisms; the little moments of satisfaction that sustain them; the choices they’ve made; the relationships that keep them afloat; and how their careers have evolved in ways they may not have expected, but that have remained consistent with their core values.

 

Eve recognizes this surprise in her Introduction and raises the question of whether there was a “selection” problem in her interviews. I too was surprised when she told me what she was finding, but as I thought about it, I concluded from my own experience that burnout is not the opposite of joy in medicine, or, if you prefer “professional satisfaction.” I remembered my confusion during my time in practice when I discovered that our organization had low rates of physician satisfaction; but when physicians were asked if they were looking to leave, their answer was “No.” The rate of turnover in the practice, which was in the low single digits, confirmed that response.

 

Healthcare professionals can easily articulate what is wrong, and they can also persevere through great personal distress. Training in healthcare is a great process for selecting those who can set aside or delay their gratification for years and years. Eve’s interviews confirm that we do have many organizational issues that decrease joy in medicine, but they also reveal a level of commitment that remains the preferred focus of the majority of professionals. This fact is good to remember—that strength can form the foundation of a better “new normal.”

 

I consider Eve Shapiro to be a healthcare professional even though she has no MD, RN, or MPH after her name. She is a writer who focuses on healthcare and is driven to help present our challenges, and what we have learned, in a way that might contribute to the continuous improvement of care.

 

This jewel of a book—a source of insight, inspiration, and spiritual sustenance—is also a practical guide and reference for the values we should sustain as we move into this uncertain time. This book should motivate us to use all we have learned about the contributors to joy and satisfaction in the “old” world while engineering out the sources of dissatisfaction and burnout as we enter the new one. Healthcare needs all of our awareness and activism if we are to successfully meet the challenge of providing everyone the care that should be their entitlement. I hope this book will provide you some relief and insight as it demonstrates the human qualities upon which we will build a better future.

 

It Was Great While It Lasted

 

I am talking about the weather. I have not figured out the relationship between the election and the weather, but when we arrived back in New London just before sunset on Election Day there was fresh snow on the ground. Between last Wednesday and Tuesday of this week the sky was crystal clear and the temps rose into the high sixties or low seventies each day. What an unexpected gift! It was just the diversion that I needed from all the craziness associated with the president’s reluctance to accept reality, and the concerns about the soaring case numbers, hospitalizations, and deaths associated with the pandemic.

 

I was thankful for the gift, and got in long walks in weather that seemed appropriate for early June. It all ended on Wednesday morning. The clouds rolled in and there was an intermittent light rain although it was still warm. Since Wednesday it’s been clouds, occasional drizzles, and temps in the forties. I kicked myself for not capturing a photo of the splendor while it lasted. I did use some of the time to move about a half a cord of wood onto my deck, and stack another half cord near the deck to be handy for those days that I know are coming soon. 

 

On Wednesday I did my five mile walk up and over Burpee Hill which takes me by my old friend “Thunder.”  I was not well received because I forgot to bring him a carrot or an apple. He kept his distance since he could see that I had nothing for him that was worth his effort to come over and say hello, but even under a cloudy sky and at a distance, it was good to see him again. 

 

As we wait in deteriorating weather for Donald Trump to make his move, I would suggest getting in a good long walk as a great way to manage the stress of the uncertainty of what he might do next. We have discovered that he was telling the truth when he said before the election that he would not accept the results of the election if he lost. 

 

Be well! I am praying that we all survive the uncertain aftermath of the election. While you are absorbed with the election craziness, don’t forget that the pandemic is raging. When you are out and about, wear your mask and practice social distancing as best you can. Look for opportunities to be a good neighbor. Let me hear from you. I would love to know how you are managing the uncertainties of our times,

Gene