Keeping Professionals Professional During the Pandemic
Hoping to help limit the damage, we began compiling information about what we came to call COVID-19 Stress Disorder (CSD). We wanted to tell physicians and others how chronic exhaustion and emotional turmoil undermine both clinical performance and ethical practice — and suggest ways clinicians can care for themselves and recharge their batteries during the pandemic.
Then on Sunday, April 26, just six weeks after the World Health Organization declared a pandemic, Lorna M. Breen, MD, committed suicide. Dr. Breen was a top ER physician and medical director of the emergency department at New York-Presbyterian Allen Hospital. She knew how to handle crisis situations. Covid was more than she could handle.
Suddenly it seemed everyone was discussing the toll COVID-19 was taking on doctors and nurses. Healthcare professionals published articles about the damage caused by too much work, too little support, and too few clinical options. Experts explained what institutions could do to protect clinicians’ mental health and suggested ways individual practitioners could protect themselves.
Now that this information is readily available, we want to contribute to the growing discussion by focusing on the area we know best, professionalism.
Caring for yourself so you can care for others
According to PBI’s first law of professional boundaries, “Everyone has a violation potential (VP) and it is constantly changing.” Given the unprecedented strain caused by the pandemic, VPs are likely to be changing in just one direction for some time to come.
Those now on the frontlines are threatened by a dangerous confluence of external Risk Factors (potential contamination, huge caseloads, disrupted routines, anxious patients, lack of data and/or lack of clarity about state regulations) and internal Vulnerabilities (difficulty saying no, need to please, fear of failure, workaholic tendencies).
Self-care can ease the stress generated by vulnerabilities and risk factors. Opportunities for downtime and recreation are hard to come by during a pandemic, but there are ways to carve out moments for yourself and gain some perspective. And as tough as it is to connect with loved ones right now, when concerns about infecting others are so high, avoiding isolation has never been more important. (For more self-help ideas, see below.)
Stop fending off feedback
As important as self-care is — and it is crucial — we want to call your attention to the two other factors in the PBI Violation Potential Formula — Resistance and Accountability. Taking action now to reduce the first and enhance the second can significantly reduce your VP.
Resistance is an unwillingness to accept your own vulnerabilities and consider the risks you are running. If you were skating on thin ice — and of course you are, metaphorically — a friend who saw you ignoring red warning flags would try to alert you to the danger. If you refused to heed the warning, insisting that you were not being careless, your resistance could lead to disaster.
Healthcare professionals are constitutionally and professionally prone to resistance. Many are so committed to perfection, they refuse to accept that they are making a mistake or setting themselves up for one. Taught to be ‘tough’ and immersed in a culture that disdains ‘weakness,’ they insist that they can handle whatever is thrown at them, no matter what red flags are flapping around them. The result is often disastrous. Turning your back on a problem does not make the problem disappear. It just prevents you from dealing with it.
It’s not easy to overcome such resistance. Many of those who show up at PBI remedial courses refuse to accept their need for help until board discipline forces them to face facts. Looking back at what went wrong, they are often amazed at all the red flags they missed. And mortified to have behaved in ways they never thought they would.
The first step in overcoming resistance is to cultivate humility. Accept the fact that despite all your training and experience, you are still a fallible human being. When someone criticizes something you’ve done, pause before dismissing their feedback and ask yourself if they might be right. If you disagree with the specifics, consider larger issues that might be involved. Someone who suggests you were unnecessarily rude to a patient might be mistaken about the particular interaction. But their comment may reflect a more general perception that you are intimidating or brusque with patients.
A few other ideas for overcoming resistance:
- Separate feedback from the person giving it. Even someone you dislike or disrespect can make a valid point.
- Keep your eyes on the prize: Ask yourself if the criticism might help you accomplish what is most important to you.
- Notice signs of reflexive resistance. If a comment makes you angry or causes you to attack the commentator, they have probably hit upon an uncomfortable truth.
- Finally, get help from someone you trust. Before you reject feedback, take a minute to check in with your friend to see if there may be some truth to the comment. This approach works best if you agree ahead of time that you are both eager to improve and avoid mistakes, and will therefore be honest with each other.
- Buddy systems like this have proved their value. In the U.S. Air Force the trusted friend is called “wingmen.” In the Army there are “battle buddies.” The Navy has “shipmates.” PeerRxMed (https://www.peerrxmed.com/), is “a free, peer-to-peer program for physicians and others working in health care designed to provide support, connection, encouragement, resources, and skill-building.”
Harness the power of accountability
Peer groups can also serve another valuable function. In addition to helping members overcome their reluctance to face trouble spots, friends can hold each other accountable in a variety of ways. If one person forgets a pledge to take regular breaks, the group can help them stay on track. If someone mentions flirting with a colleague or forgetting to note something in a patient’s record, the others can make sure they think twice about what they are doing.
Research has confirmed the power of accountability. People who know they will have to explain themselves to others are far more likely to pause and consider the consequences of what they are about to do. If you and your friends agree to tell each other about what you’ve done, even if it’s simply over lunch, each of you will think more carefully before acting.
In normal times, federal agencies, state medical boards/Canadian colleges, and employers provide a serious level of accountability. Unfortunately, such official accountability is yet another victim of COVID-19. Overwhelmed by the sheer magnitude of the pandemic, hospitals and regulators are relaxing standards and allowing things they would otherwise never sanction. Residents are being ‘redeployed’ to provide care they have not been trained for and retired or inactive healthcare professionals are being recruited to care for patients. The Centers for Medicare and Medicaid Services (CMS) has released a 40-page emergency declaration listing blanket waivers for everything from out of state licensures to supervision of nurses.
Most if not all of these changes to accountability will end once the COVID-19 crisis is under control. In the meantime, it is important that healthcare professionals take steps to enhance their own accountability, for their own sake and for the long-term health of the profession.
- For more information about PBI’s Violation Potential Formula, “red flags,” and other issues just discussed, check out The Physician’s Guide to Professional Boundaries: What you don’t know can end your career,by Stephen Schenthal, MD, MSW
- PBI’s Maintenance and Accountability Seminars (MAS) provide ongoing support during times of transition and stress. For more information about these small-group, virtual sessions, see our recent blog post, “How PBI’s “Maintenance and Accountability Seminar” Course Supports Long-Term Success.”