Issue 4: Care
By Dr HT Goh.
First of all, please let me apologise to you for contributing to the tsunami of 'in these trying times' emails that have inundated my inbox, as I suspect it has yours. In my more uncompassionate moments I wish these companies could suffer my withering gaze as it casts over their final sentences, which inevitably have a sudden realisation that their very offerings, conveniently available as several subscription tiers (discounted!), may humbly assist you.
These times are indeed trying for almost all of us, so it is important that we all do what keeps us well. Usually this is a combination of approaches like regular exercise, a healthy diet, or mindfulness, which are effective and which are therefore repeatedly recommended. This article addresses something a little different.
Although I have tried to be careful that the content here is not written gratuitously, it may nonetheless remain distressing. Although everyone keeps recommending that doctors should be authentic and reflective, I think they are picturing me meditating calmly after a cup of camomile tea, not having a breakdown over buying oranges at my local supermarket while I ponder profound existential issues.
While I think that what follows will be valuable in its own way, if you do feel that you are content with what you have in your toolbox and more will not help, or even worse, that such reflection will actively destabilise you, then you have my blessing (if you need it!) to offline immediately, and ensure that you are taking care of yourself. Now is not the time to gaze into your navel if it will allow an abyss to gaze back into you.
Personally, as I become more senior, the more basic lessons I've learned are paradoxically more helpful. In making increasingly complex and high risk clinical decisions, I take lessons from Francis Peabody's inspirational lecture when he announced "the secret of the care of the patient is in caring for the patient" , or I try and follow exhortation that "it is much more important to know what sort of patient has a disease than what sort of disease a patient has", popularly ascribed to William Osler. The General Medical Council (the UK's medical registration body) agrees and directs its doctors to "make the care of your patient your first concern". We persistently chase this goal of medical deontology.
But as the coronavirus has become a pandemic, the world has changed. I recall the thorny dilemmas posed as bioethics thought experiments at medical school, such as having to choose between two male patients for the last ventilator bed, one a 32 year old man with poor physical condition due to a severe drug use disorder and the other 88 years old but otherwise healthy. Well, now these avatars, once safely confined to the pages of my lecture notes, have leapt from the pages of my lectures into real situations. How should I be patient-focused when I am denying life-saving treatment to my patient? Are Osler's recommendations compatible with the monolithic entity of COVID-19?
In affected parts of Italy, doctors had to adopt age cut offs for ventilator beds, and some emergency departments divided into two sections, one triage-focused, and the other for treatment, because having to both choose who could obtain treatment and then to treat them was too traumatising. For these colleagues who, like us, are dedicated to trying to save lives, this has been unspeakably distressing and I understand doctors have been extremely reluctant to talk about this, perhaps so as to not panic people, but also almost certainly because deciding who takes the last ventilator bed is essentially incompatible with our contemporary professional and moral identities. Such a strongly utilitarian standpoint conflicts with those deontological urges that we are encouraged to follow. More pointedly, for a doctor to say that they chose who would die seems so grossly perverse and stigmatising that it must carry an incredible burden of shame and guilt.
This raises the concept of 'moral injury', which is defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code. The original concept was developed in military psychiatry to describe the emotional stresses that occur when, for example, you or your commanding officer chose to fire, or chose not to fire, or could not fire, and this resulted in the death of an innocent civilian, resulting in similar feelings of shame and guilt. The concept has been recently brought to wider consciousness as a contributing factor to healthcare worker stress during the pandemic by psychiatrist Prof. Neil Greenberg from King's College London along with some helpful recommendations (footnoted). In short, the pandemic situation has meant that we can often not say “I provided the best treatment I could, and it did not work”. Rather, “what I could offer and do for you was not of my choosing, and yet I had to choose, so here I am, apologising to your family about your loss”.
Unsurprisingly, healthcare workers during a pandemic are at particular risk of being derailed by these particular feelings. Here in Australia, the healthcare budget has been a major part of both state and national elections, and has suffered from budget cutbacks long before COVID-19 appeared. In the USA, the cusp of elections in the era of Me Too and All Lives Matter has brought with it renewed interest in health equity and socialised healthcare, with the gaps made more visible by the pandemic. In the UK, progressive systemic de-funding of the NHS for years has been accused of 'radicalising' medical staff and has resulted in high levels of medical stress. The McKinley cross-sectional study from late 2018 reported that a third of UK doctors surveyed were suffering from burnout and secondary traumatic stress. That this has occurred in wealthy countries seems particularly unjust and morally injurious. How could I morally injure thee? Let me count the ways.
With so many issues, accreting over time into injury after moral injury and grating against our increasing focus as doctors on the systemic and social factors affecting healthcare, how are we not to feel passionate and angry? I’m sorry to say that I can’t offer any easy solutions, as we both sit here in the vegetable aisle weeping, me trying to console you over the spinach.
So in the spirit of helping you through these trying times, I present to you a one-time pass, a discount coupon if you will, to last for the entirety of this COVID-19 crisis, for you to do what you can to keep working and to keep taking care of yourself, never forgetting that despite all the utilitarianism you need in your current practice that Kant could still be proud of you, and that sometimes, in these trying times, the most compassion you can muster today may be for only one person, that one person may be you, and that you would still be doing your duty.
The Care of the Patient, Francis Weld Peabody 1927 JAMA 1984;252(6):813–8. From a Harvard Medical School lecture in 1925. [PubMed] From <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3147198/>
Junior doctors have been radicalised by Jeremy Hunt’s smears Rachel Clarke, The Guardian
"Resilience, burnout and coping mechanisms in UK doctors: a cross-sectional study." McKinley, Nicola, et al. BMJ open 10.1 (2020).
Dr Goh is a psychiatrist currently working in Tasmania.