The B Word

Free advice for anyone interviewing for a job in healthcare: at some point, you’ll get the requisite, “so do you have any questions for me?” to which you can reply, “could you please share with me how your hospital/school/department/section/program fights burnout?” If the answer is “yoga, meditation, and a really fun happy hour,” I would encourage you to interview more broadly.

I don’t like the term, burnout, because we all use it but don’t necessarily align on what the term actually means. Eric Keller coined this scenario as the Hazard of the Common: a commonly used term that has a different meaning for different users thus leading to misunderstandings and miscommunication. To me, burnout makes it sounds like you’re tired and you just can’t take it anymore- there is an implicit suggestion that being burned out is your fault because of your own weakness, or worse, your lack of resilience.

My own personal preference, if I could redefine the lexicon for everyone, would be to use “moral injury” instead of “burnout.” Moral injury is described as the psychological injury that occurs when a person either causes, witnesses, or fails to prevent acts or events that violate one’s own values or ethics. There is plenty of literature about moral injury in the military but it has been applied to healthcare workers who, for example, witnessed the first wave of COVID-19 in NYC. I think it can be applied more broadly to healthcare workers today (albeit not with the level of acuity and severity in those other scenarios). 

As the ultimate problem solvers in medicine, IRs can be victims of their own success. One egregious example I’ll use is clogged gastrostomy tubes. (Cue the groans) How much time, energy, effort, and expense do IRs waste on fixing what is a completely preventable problem that apparently no one else can fix? When it happens over and over again, it is not surprising that IRs start to feel disengaged or even dehumanized because the cumulative moral injury is sapping our collective strength. That’s just one tiny example; many more combine to create a “death by 1000 cuts” scenario. How many times does an IR need to stay late to fix another freakin' G tube and miss a family event before she reconsiders her career choice?

Imagine working in a hospital where there was actually real, authentic engagement from a dedicated and accountable quality improvement team with genuine nursing leadership buy-in, who all believe that clogged G tubes are bad for patient care and that protocols should be in place, taught, and enforced because it will save time, energy, effort, and expense, not to mention improve patient care.

Several years ago, my son Holden was gaming. I looked over his shoulder, pointed to a blue thing on his character’s status bar and asked, “what’s mana?” He said, “mana is what gives my character the power to do special things.” If moral injury diminishes your mana, then you're left powerless to do the “special things” like mentor, innovate, and collaborate. So how do we build up mana, or moral strength? 

Moral gain or moral healing can be achieved through the manifestation and practice of deeply held values, in an environment that appreciates and supports those values. In other words, organizations that are able to align around shared values (justice, compassion, equity, kindness, and G tube patency, for example) both provide moral gain and limit moral injury. 

I think yoga and meditation are excellent practices to promote general well-being. A healthy diet, plenty of sleep, hydration, and regular exercise are also important. But to paraphrase a related tweet from @LGSentinel, fighting burnout with yoga and meditation is like telling someone in an abusive relationship to adopt healthier lifestyle choices. The problem lies not the individual; the problem lies within the system and how the individual and system relate, or not.

Here is my fear: if healthcare systems don’t meaningfully respond to the deluge of people leaving healthcare because of moral injury, they will continue to spend enormous amounts of revenue to replace those who have left; as we all know, recruiting/replacing physicians is even more expensive than traveler RNs costs. In order to recapture that lost revenue, healthcare systems will be forced to cut expenses and limit or de-prioritize “non-essential” programs (like G tube care protocols or technology that increases physician efficiency), which will diminish patient care. It also creates a negative feedback downward spiral that’s really going to hurt all of us in the end. 

Here are my suggestions to hospital administrators to avoid the downward spiral in imaging (some may also apply to other specialties):

1.     Trust us.

2.     Radiology-specific IT professionals who are empowered, invested, and accountable.

3.     Common sense adoption and leveraging of technology to increase (not decrease) efficiency.

4.     Re-embrace and value the human touch that makes patient care experiences special; in other   words, #3 will only take you so far.

5.     Have leaders openly acknowledge that moral injury isn’t an individual problem but a system problem that needs to be solved with system-level solutions.

6.     A really fun happy hour wouldn’t hurt.

(credit to ZDoggMD for the cover image)