Doctors and nurses who work in PICUs often deal with emotionally difficult events. These events take a toll. They can cause long-term psychological problems that, if not addressed, can impair the ability of doctors and nurses to care for patients in a competent and compassionate manner. Furthermore, effective treatment is available. But there is a paradox. To get treatment, one must acknowledge the problem. Acknowledgment of the problem may not be encouraged, or may be discouraged and stigmatized, in the intensive care culture. This article describes a case in which a physician has classic signs of overwhelming grief and burnout, and it discusses the appropriate response.
Doctors and nurses who work in PICUs often deal with stressed parents, critically ill children, death and dying, and other emotionally difficult events. These events can take a toll on the health care professionals. In some cases, the emotional toll of constant exposure to such stressors can cause psychological problems. If those problems are not recognized and addressed, they can impair the ability of doctors and nurses to provide clinical care in a competent and compassionate manner.
It is not always easy to recognize or acknowledge when we or one of our colleagues needs help. To get help, one must acknowledge that a problem exists. Such acknowledgment of the problem may be discouraged and stigmatized in the intensive care culture. This article describes a case in which a physician has classic signs of overwhelming grief and burnout. We then asked experienced clinicians in critical care and psychiatry to discuss the appropriate response.
Daria has been an attending physician in a PICU for the past 6 years. Her PICU admits children across a wide range of specialties, including cardiac surgery and oncology.
In recent months, Daria has been struggling with emotions of despair and sorrow. Her practice style is to make close personal connections to her patients and their families. As a result, she has grown close to many families whose children have died. She always telephones parents in the days after such deaths, and she sees them for bereavement meetings 8 weeks later.
After a number of especially traumatic deaths, Daria is troubled by poor sleep. She dreams about children who have died. When awake, she sometimes thinks obsessively about events surrounding these deaths. She worries that she may have missed something when a child was deteriorating. She rethinks the steps she might have taken in their clinical management. Her colleagues in the PICU brush off her concerns, assure her that she is a good doctor, and tell her that everything will be fine. Daria feels that she cannot articulate her thoughts. She worries about whether she will be able to keep working in the PICU.
One morning, when resuscitating a cyanotic infant admitted acutely through the emergency department, Daria experiences an episode of panic, desperation, and grief. She becomes convinced that intervention will be futile and that the infant will progress to cardiac arrest. She cannot bear the thought of witnessing the death of another child and the distress of another parent. She calls for additional help, and when it arrives she leaves the room.
Daria goes to her office. Alone there, she begins to cry. She feels that she is drowning in the sadness of her career and that, even though she has worked very hard to succeed, she may have to give it up. One of her intensive care colleagues, Marcia, hears her crying. Marcia tries to comfort her. Daria opens up to Marcia about what she has been going through. What should Marcia recommend that Daria do now?
Suzanne Crowe, MD, Comments
This physician is struggling to deal with the chronic grief and loss that are an unavoidable part of her clinical practice. She is not doing well. Her emotional well-being is suffering as a result. This struggle may be due in part to her inability to recognize the emotional toll grief and loss are taking on her. This phenomenon has been described as “disenfranchised grief.”1
Health care staff caring for children and adults who are dying may experience grief but lack societal approval to articulate the loss and express the emotions that follow. Compassionate doctors and nurses form strong emotional connections with children and their families in the PICU. These connections are severed on the death of the child. The loss may be compounded by moral distress about decisions by parents or colleagues during the child’s admission. Bearing witness to pain and grief over and over again may lead to secondary or vicarious traumatization.2
In Daria’s case, there is a clear need for urgent intervention because it has reached a point where the clinical care of a child may be compromised and a kind and capable doctor may be lost from the specialty. The first duty of justice and care is to the patients in the PICU. Daria feels the need to continue caring for patients, but, ironically, she is unable to do so unless she acknowledges her own needs. Facilitating Daria’s temporary move out of the clinical environment will respect the safety needs of the patient and allow her space and time to address her bereavement needs. A step back from direct patient care respects the right of the patients and their families to have safe and competent care, and it respects Daria’s needs as a human and health care professional.
There are conflicting published studies examining the area of engagement with patient needs and the development of emotional burnout.3
Daria may benefit from “supervision,” a term used in social work, psychotherapy, and psychology to describe emotional and psychological mentoring.4 Supervision creates protected space for the professional to meet with a colleague on a regular basis to confidentially discuss the emotional effects of caring for patients and clients. Negative cognitive patterns such as “Only I can help” or “It’s all my fault” can be explored, with the aim of gaining insight into the physician’s reactions and needs.
Immediate and ongoing support should be combined with a medium-term strategy to support all staff in the PICU. This support may include a regular forum to discuss challenging cases, possibly facilitated by moderators from outside PICU. The role of a layperson in attendance to provide family perspective may contribute in some cases. PICU physicians should be strongly encouraged to take all rostered time off. That necessary rest will make them more effective clinicians, teachers, and researchers. Supervisors should encourage doctors to keep portfolios of practice development.
Mental health in medicine must come in from the cold and form part of a doctor’s continuing medical education.
Shayla Sullivant, MD, Comments
Daria is in a very difficult situation both personally and professionally. She appears to be suffering from more than everyday stress or compassion fatigue. Secondary traumatic stress has been defined as the destructive emotional distress resulting from an encounter with a traumatized and suffering patient or client who has suffered primary or direct trauma.5 This distress must be addressed right away or she could end up harming herself or a patient. Daria was lucky to be able to step out of the last resuscitation, but this option may not always be available.
As the Adverse Childhood Experiences Study is changing the way we understand toxic stress in childhood, new studies help us understand the stress that we, as physicians, experience in our work with patients in crisis.
The symptoms Daria is experiencing are similar to those of posttraumatic stress disorder: She is having nightmares and she is anxious, second-guessing herself and the care she has provided. She does not appear to have a support system in place that allows her to process her grief and maintain some perspective on her work.
Marcia’s responsibility is clear. To help her colleague and to protect future patients, Marcia has a duty to assist Daria in getting help. She should help Daria contact the employee wellness program (or similar option).
But doing so may not be easy. Daria might resist, and with good reason. Current medical licensing boards routinely ask doctors at the time of renewal about their mental health diagnoses. A recent study evaluating female physicians found that one-third had been diagnosed with a mental health condition since medical school, but only 6% of those had ever reported this condition to their state licensing board.6 It is an impressive dilemma for our age. We know that physicians encounter high levels of stress that predispose them to anxiety and depression, and yet there is no incentive to ask for help until very late in the game.
The consequences can be tragic. Female physicians die by suicide at 3 times the rate of nonphysician women.7 Fortunately, interventions work. A good treatment program can help Daria and save her career. It is ironic that 1 reason she may not seek help is fear that doing so may hurt her career. Many doctors go into treatment only if they are forced to do so, partly because the risk of getting care is seen to outweigh the risk of soldiering on. This situation needs to change if we really are committed to having healthy physicians.
Marcia will be more successful in getting help for Daria if their division leader and institution support staff who seek care. This support is critical because the number of patients we see is tallied and compared with those of our peers. There are no relative value units for taking good care of yourself.
This case reminded me of a trauma in my own life. I was completing my consultation liaison rotation when my brother Chris died suddenly at age 29. It happened overnight and was truly a shock. He had flu symptoms for 2 days and finally went to the emergency department. They initially thought he was having a myocardial infarction. But because his pain had subsided, and it was Sunday of Memorial Day weekend, they did not call a cardiologist. I was furious and demanded a cardiologist, who diagnosed an aortic dissection. He died in surgery that night. It felt like a horrible dream.
In the middle of it all, I realized that I needed to call work and return the consult pager and that I was scheduled to be in the psychiatric emergency department the next week. I was almost 8 months pregnant. I had already been worried about the unpredictable nature of agitated patients I might encounter. I remember a surge of emotion: responsibility to my colleagues, fear of not making good decisions in the emergency department, fear of becoming depressed, concern about my unborn child.
I was lucky that our program had a counseling center, where I saw a psychologist, and he helped talk me through it. I spoke to my assistant program director. I was lucky again. She encouraged me to take bereavement and sick leave. I also had tremendous support from my husband, family, and friends. Those 3 weeks are a blur; I think I planted some flowers in the yard and spent time with my family, but honestly I hardly remember them.
I will never know whether that break made the difference, but I imagine it did. I did not become depressed during that time. I certainly was grieving the loss of my brother, but I also loved becoming a mother and starting fellowship that fall.
It never really hit me until reading about Daria just how unusual my situation was at that critical time in my life. Several factors allowed me to discern what the next best step was for me and, in the long run, for my patients. I was able to see a psychologist to figure out how and when to return to work. He did not tell me what to do but instead asked good questions and helped me figure it out. The program supported me by allowing me time off.
We have a responsibility, as individual doctors, to recuse ourselves when we are not able to provide the care our patients need. We also need to be realistic as a profession about how important it is to help colleagues take care of themselves. We need to eliminate barriers to self-care so that doctors do not feel penalized for taking care of themselves and therefore can take better care of their patients.
Laura Miller-Smith, MD, Comments
Daria is suffering from burnout syndrome (BOS). BOS is generally diagnosed via the Maslach Burnout Inventory. It consists of emotional exhaustion, depersonalization, and a reduced sense of accomplishment.8 Daria seems to have all 3.
Burnout is common in PICUs. Garcia et al9 reported that approximately 70% of PICU physicians have symptoms of BOS. Nurses are also at high risk, with reports of 25% to 33% of nurses having severe BOS and 86% reporting some symptoms.10 The Critical Care Society Collaboration recently published a call to action for individual care providers and hospital administrators to recognize the pervasive presence of BOS in the field of critical care medicine. This call to action suggests that we must shift our understanding of the causes and the consequences of BOS, with focus on both the individual and the health care system.
The consequences of BOS are far reaching. BOS has been correlated with an increase in reported medical errors and with decreased patient satisfaction.11,12 Recent studies show an association between BOS and health care–acquired conditions.13 BOS is linked to higher levels of staffing turnover, limiting resources, contributing to stress, and perpetuating the development of burnout symptoms. Because of our professional obligation to prevent harm and maximize benefit to our patients, we are ethically obligated to address this growing concern.
As Daria’s colleague, and as an intensivist advocating for the best care of patients in the PICU, Marcia should counsel Daria to speak with her section chief about taking some personal time. Daria should be encouraged to seek resources to help treat symptoms and build resilience. In addition, Marcia should engage her colleagues and division leaders to address system factors that could be contributing to BOS among their health care team. Although Daria’s current situation may be limited to her, literature suggests that she may be the “canary in a coal mine” for her work environment.
There are concrete steps that care providers can take to preserve their emotional and psychological health. They must protect time for their own well-being. Resilience, the ability to recover from acute, stressful situations, can be taught and strengthened. Resilient people have, or learn, the ability to set personal boundaries, accept uncertainty, and embrace self-reflection. Resilient people cultivate strong personal relationships and activities and interests outside of work.14
There are indications in the vignette that the culture at in Daria’s PICU may have contributed to her BOS. Daria has been through multiple “traumatic deaths” without evidence of debriefing opportunities. She has reached out to colleagues who “brush off her concerns,” not recognizing the significance of her complaints. One can surmise from the text that Daria fears consequences should she express concerns, in that she will be pressured to take time away. Although time off could be a necessary response, the negativity surrounding this possibility indicates that self-care is not normalized or accepted in her working environment. A culture that does not recognize the symptoms of BOS will contribute to its persistence. Just as frequent episodes of moral distress may leave a moral residue across an environment, BOS that spreads among providers can contribute to a pervasive negativity in a unit that may be hard to clear.
This case illustrates the need for both Daria and her institution to take burnout seriously. Daria needs to learn how to set appropriate personal boundaries and realistic work expectations. She has voluntarily taken on roles with bereavement that have been emotionally draining and have limited her ability to control work hours and take time away. Physicians tend to take on work outside their normal scope of duty. Doing so can have significant consequences and ultimately prevent us from fulfilling our fiduciary duty to our patients, just as Daria was unable to care for the patient in the vignette. A therapist, or even successful colleagues, may be beneficial to Daria as she works to set these boundaries and recognize burnout in herself.
What can an institution do? Some institutions proactively manage BOS. The Mayo Clinic, for example, has included mitigation of BOS in their safety culture. They use teams of front-line physicians, department chairs, and administrators to identify drivers of BOS.15 Physicians are actively engaged in developing strategies to address those drivers. Although there is no single solution to best manage BOS in all situations, an important concept is engagement.
As Maslach stated, the opposite of burnout is engagement. Engaging the health care team in identifying sources of stress, debriefing after stressful events, using training sessions on resiliency, altering work schedules when necessary, and increasing ethics discussions on difficult topics might all help prevent or mitigate BOS.
Daria is a good doctor who is in trouble. With help from a collaborative and supportive culture, she can develop the personal skills she needs to build success and longevity in the career she values.
John D. Lantos, MD, Comments
Flight attendants always say, “Put on your own mask first, before trying to help others.” On the airplane, the reason for this seems obvious. If you pass out, you are not going to be able to help your loved ones. Thus, it is not a sign of selfishness or weakness to recognize and take care of your own needs so you can then take care of the needs of others.
That simple wisdom has been lacking in medical education and medical practice. Doctors may see themselves, and be seen by others, as people who can rise above the serious emotional toll that our work entails. The consequences can be tragic.
Caring communities must support caring professionals. The first step, as always, is to acknowledge the potential for problems. The next step is to put systems into place to allow those problems to be recognized and addressed. We will not be able to care for our patients well unless we first take good care of ourselves.
All authors contributed to the design of this article, the drafting of the manuscript, and the review of the manuscript, and all authors approved the final manuscript as submitted.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.