Making time for griefwork

All kinds of cross-connections become evident as you work with people to try to improve the quality and safety of patient care, as we seek to eliminate preventable harm.  But I never expected a psychiatrist's book about combat trauma to offer an insight.  The book (recommended by Budd Shenkin), is Jonathan Shay's Achilles in Vietnam, Combat Trauma and the Undoing of Character.  And a powerful book it is, a must-read to understand the devastating long-term impact on personality that can result from wartime situations.

The first section of the book deals with the impact on troops when their commander betrays the trust of his troops.  The context:

The mortal dependence of the modern soldier on the military organization for everything he needs to survive is as great as that of a small child on his or her parents.  No single English word takes in the whole sweep of a culture's definition of right and wrong; we use terms such as moral order, convention, normative expectations, ethics, and commonly understood social values.  The ancient Greek word that Homer used, themis, encompasses all these meanings.

When a leader destroys the legitimacy of the army's moral order by betraying "what's right," he inflicts manifold injuries on his men.

I don't mean to minimize in any way Shay's application of this concept to the battlefield, but as I read it, I saw an analogy to health care.  Let's see if you appreciate and agree with my extension of the concept.

At our Telluride Patient Safety Camp, it is not uncommon to see evidence of trauma in the faces and stories of our residents and medical students.  A common theme is that they had witnessed a senior physician engaging in a practice that harmed a patient, followed by (at best) a lack of disclosure and (at worst) a lack of acknowledgment that such harm had actually occurred.  The young doctor's shock is exacerbated by the feeling of guilt that he or she had not intervened in the procedure to stop the harm from taking place.  Whether or not the resident had been required to participate directly in the actions being taken or was simply observing was not necessarily germane to the reaction.

What has happened? An idealist young doctor, who only recently had solemnly taken the Hippocratic Oath to "do not harm" at the behest of senior educators, was witnessing a betrayal of "what's right."  This observation is a searing experience. Combined with a feeling of powerlessness to intervene, to use Shay's words, the event "taints the lives of those who survive it."

Each resident or student who has the experience reacts and behaves in a different way afterwards, employing his or her own coping mechanism.  The damage often remains in the form of guilt.  For the vast majority, I suggest, the trauma teaches them a very, very bad lesson:  "Hide your mistakes.  Rationalize them away.  In any event, never acknowledge or disclose to the patients and family members."

The whole effect is compounded by another aspect of such events, the silence that surrounds them. Shay explains:

There is a growing consensus among people that treat PTSD that any trauma, be it loss of family in a natural disaster, rape, exposure to the dead and mutilated in an industrial catastrophe, or combat itself, will have longer-lasting and more serious consequences if there has been no opportunity to talk about the traumatic event and those involved in it, or to experience the presence of socially connected others who will not let one go through it alone.

Griefwork encompasses the whole range of formal and informal social exchanges that soldiers at Troy and Vietnam practiced after a death.

We have seen evidence of the power of such griefwork at Telluride.  Those of us who were present on one session's first day, June 11, 2013, will never forget Michelle Espinoza's story, when she related witnessing a serious medical error in the treatment of an obstetric patient, with the resulting death of the baby. To make it worse for Michelle, she realized the error was occurring as it took place but felt that she, as a trainee, could not intervene.  That trauma, in the form of guilt, had lived with her for months.

As she told the story to the residents and faculty, the group's engagement and empathy were highly evident, from the shared tears to the incredibly supportive comments from all in the room.  Equally evident was gratitude on the part of other young doctors that Michelle had shared her story.  She was not alone in her experience:  Similar stories from other trainees began to flow.

What was the effect of this?  A reaffirmation for Michelle and the others that they could go on and pursue their dreams, consistent with their Hippocratic Oath.  Here are her words:

Today’s experience was life changing. Today it was reaffirmed to me why I had decided to make medicine my vocation. You see for me, Medicine is not just a career, it is a God-anointed life calling. To be here in Telluride is truly a blessing, and to be surrounded by such knowledge, talent, wisdom and passion is AMAZING.

Today I learned that I am not alone in thinking our hospitals are one of the most dangerous places for patients. That my internal conflict regarding my concerns for residency training is not isolated to my hospital, and that there are people who not only believe this is wrong, but have dedicated their lives to making a change. It’s divinely inspiring and I can’t wait to see what the rest of the week brings.

Let's consider the generalizable lesson.  Our society selects the most well-intentioned young people to be physicians, and we invest years of effort and huge financial resources in their training.  We then expose them to betrayal and trauma when their leaders and mentors fail to acknowledge the harm that is being meted out to patients and families. We follow this betrayal with silence, rather than empathy and support.  We leave no time for griefwork.

As Linda Pololi notes, this destructive behavior not only occurs in clinical settings.  It is endemic to the environment of medical schools themselves:

Our data show that the way medical schools are structured and the norms of behavior among faculty can create huge barriers to effective relationship formation . . . a medical school environment that could at times negatively impact patients and our system of health care as a whole.

There is a parallel between disconnection and emotional detachment among medical school faculty and ineffective communication between doctor and patient.

Research shows that physicians remember for decades mistakes they have made, feeling guilty and humiliated and isolated in their shame. Only by creating transparency, so they can discuss mistakes openly, can these destructive feelings be relieved. Equally important, open discussion enables the physician and others to learn from these mistakes and prevent them from recurring.

A similar call for griefwork was offered by a young doctor, Pranay Sinha, in a recent op-ed:

We need to be able to voice these doubts and fears. We need to be able to talk about the sadness of that first death certificate we signed, the mortification at the first incorrect prescription we ordered. . . . . A medical culture that encourages us to share these vulnerabilities could help us realize that we are not alone and find comfort and increased connection with our peers.

Often overlooked in discussions of the Hippocratic Oath is its imperative to teach.  In that regard, let's consider that Shay's work reinforces an observation I made a few years ago:

Clinical and administrative leaders in hospitals must strive to undo the culture that is embedded in these centers of learning and help those who have devoted their lives to alleviating human suffering to start, first, to alleviate their own suffering and sense of loneliness and isolation.