Wednesday
August 9, 2006
As a medical resident, Rick van Pelt’s nickname was “Ice.” Drop him into any situation, any patient crisis, and the anesthesiologist was unflappable. “It was a compliment in a twisted sort of way,” he says.
Then van Pelt found himself front and center in one of those scary unexplained events in medicine. He had delivered a nerve block in the course of a routine ankle surgery, following all of the correct procedures. Everything seemed to be going fine that day in 1999 until about a minute later when the 37-year-old patient developed seizures and, soon after, cardiac arrest. Emergency surgery and a heart-lung machine were required to restart the woman’s heart.
That sequence of events created a fissure in van Pelt’s protectived façade. He appeared unaffected in the operating room, but later realized that he was losing his love of medicine. He was more edgy about high-risk procedures. His inner turmoil eventually resulted in a candid meeting with the patient, Linda Kenney, and together they found a new sense of mission. By 2002, the two had launched a nonprofit organization called Medically Induced Trauma Support Services, or MITSS, to better support patients and hospital clinicians wrestling with the psychological fallout of unexpected medical events.
The suburban Boston group soon realized that it had tapped a yawning need. As one of only a few organizations focused on the emotional underpinnings of hospital work, the founders of MITSS field calls from clinicians all over the country and frequently become engrossed in deeply personal conversations at conferences where they speak. “Everybody has a story,” says van Pelt, who currently practices at Brigham and Women’s Hospital. “They come up with these horrific things—events that never have surfaced to anybody.”
From long nursing shifts to brutal residency schedules, medicine is built on a culture of cool confidence—always prepared for the next code or complex pregnancy to roll in.
Increasingly, though, hospital administrators recognize that clinicians’ needs, whether they involve a medical error or sadness following a rash of patient deaths, require more sophisticated support than a phone number for an employee assistance counselor.
Another Boston-based organization, the Kenneth B. Schwartz Center, has been training hospitals around the country to host emotional debriefing sessions—called Schwartz rounds—at their own facilities. More than 90 health care facilities are now hosting the sessions, designed to reconnect frazzled clinicians with the ramifications of the medical decisions they make every day.
Meanwhile, individual hospitals are launching their own initiatives. By fall, Children’s Memorial Hospital in Chicago will open two “tranquility rooms,” complete with massage chairs and aromatherapy, to provide nurses and other clinicians a brief respite. “For [clinicians] who are new to the field of pediatrics, just the idea of children having life-threatening illnesses is something that I think can be very stressful,” says Barbara Bowman, the hospital’s chief human resource officer.
At Brigham and Women’s, van Pelt introduced peer support teams in July. The concept, which is being piloted in the operating room first, is to match up similarly trained clinicians—such as a surgeon with a surgeon—after a medical crisis or adverse event occurs.
Without some ballast, hospital clinicians will frequently say they feel dangerously off-kilter, says Kenney of MITSS. “They feel vulnerable in the work they are doing on a daily basis. They feel like they have self-doubt now. They feel like they are not doing good work because they are emotionally distraught.”
Although extensive research has been conducted about the effects of fatigue and workload on clinician performance, far less data is available about the impact of emotional support initiatives or lack thereof, clinicians say.
A series of late 1980s studies conducted by a Midwestern insurance company did identify a significant correlation between on-the-job stressors and malpractice claims. Employees at hospitals with a high malpractice risk were more likely to cite greater work stress than employees at low-risk hospitals. The body of research, published in 1988 in the Journal of Applied Psychology, also tracked a decline in malpractice claims, compared with the control group, among 22 hospitals that implemented a stress management program.
Addressing job stressors, though, is complicated by clinicians’ reluctance to even admit weakness. A 2000 British Medical Journal study, which compared perceptions among pilots and hospital clinicians worldwide, found that 60 percent of doctors and nurses believed they could perform effectively in a medical crisis, despite being fatigued.
In comparison, only 26 percent of airplane pilots agreed. Moreover, half of pilots—53 percent—believed they could leave personal problems outside their work, while most medical respondents were decidedly more optimistic, with 82 percent of attending surgeons saying they could mentally separate work and home life.
Without addressing underlying clinician emotions, a dysfunctional—and risky—hospital culture can percolate, van Pelt says. “The business case is that when you have poor communication, low morale and the spread of this poor communication to patients and beyond, you essentially create an inefficient [health] system,” van Pelt says. “On top of that, if you are not taking care of the work environment from an emotional standpoint, when these [adverse] events happen, you don’t hear about them.”
To better quantify the relative benefits, the Schwartz Center hired an outside firm to collect data from long-term participants, as well as before-and-after snapshots of hospitals that have recently started holding rounds, says Marjorie Stanzler, the center’s director of programs. The first results won’t be available until year’s end at the earliest.
But clinicians have informally cited a number of benefits, including a better ability to communicate and work together in clinical teams, Stanzler says. Since the rounds usually involve a cross-section of clinical specialties, participants develop a renewed respect and understanding of the skills that, say, a social worker or physical therapist brings to the table. Clinicians develop ideas and strategies for the future.
More than anything else, they feel less isolated, Stanzler says. “They sometimes say, ‘Now I realize that other people are driving home at night thinking about the same kinds of things,’ ” she says.
Doctors and nurses aren’t the only hospital staffers who take the pressures of the day home with them. Debbie Mandel, who has taught stress management strategies to hospital clinicians, says even nonclinicians can feel emotionally buffeted. At one hospital, receptionists recounted the strain of processing an influx of patients each morning. “The patients are not just nervous—they’re scared,” says Mandel, author of Changing Habits: The Caregivers’ Total Workout. “They can be a little bit aggressive. And the receptionist has to deal with that.”
Administrators also are no longer as sequestered from front-line medical decisions, says Annie Holt, R.N., vice president of quality at HCA’s Mountain Division in Salt Lake City. Holt, who has worked for more than two decades as a senior hospital administrator, says today’s leaders are more likely to sit down with patients and their families if a medical error or complex ethical question arises.
Previously, she says, the administrator would have been briefed and very involved with the related action plan, but not necessarily part of the sometimes raw conversation itself. “Due to the attention we pay now, which is appropriate to patient safety and continually improving our services, senior management is involved. And I think that’s a good thing,” Holt says. “But it’s not necessarily what we’ve been prepared for professionally.”
Holt has been involved in several patient disclosures over the years, and after one particularly difficult episode decided to make an appointment with a counselor.
Health care attorney Kenneth Schwartz founded the nonprofit Boston center bearing his name, and housed at Massachusetts General Hospital, just days before his death from lung cancer. Its mission: to promote compassion in medical treatment. In a 1995 Boston Globe magazine article, Schwartz wrote movingly about his own cancer battle and the significance of small caring acts by clinicians along the way.
The Schwartz rounds, held in 23 states as of July, typically start with a recent patient case that has touched a chord. To protect privacy, patient names are not used during the rounds. During one set of rounds hosted in Children’s Hospital at Dartmouth, clinicians began with the story of a teenager battling a chronic illness, says Toni LaMonica, one of the organizers. The teen was acting out, pushing everyone’s buttons. Clinicians understood that the attitude masked “a sadness really expressed through anger,” LaMonica says, as the teen wrestled with end-of-life issues.
“But in the meantime, [the teenager] was pretty obnoxious—difficult to work with,” LaMonica says.
At Houston’s M.D. Anderson Cancer Center, one recent session started with the case of a patient who was pleading to participate in a clinical trial but didn’t meet criteria, says Marlene Lockey, a senior social work counselor and one of the facilitators for the rounds.
Discussing that patient’s plea, which had touched everyone, triggered a broader discussion regarding when doctors should intervene if a patient is bent on pursuing any last-ditch treatment. For example, Lockey says, “patients with children at home will submit themselves to awful suffering or medical tests just to gain another day.”
For doctors in particular, the emotional pressures have worsened as external pressures of medical care—regulations, litigation and insurance coverage limits—increasingly influence how they practice, says Gary Malone, M.D., medical director and chief of psychiatry at Baylor All Saints Medical Center in Fort Worth. “But the family still sees you as 100 percent in charge.”
Picking at emotional scabs does carry risks, says Malone, who has treated doctors and other clinicians. “If you care too much, you are swallowed up and lose your objectivity and you won’t survive in the profession,” he says. “If you don’t care enough, you won’t help anyone.”
And physicians are the worst at reaching out, Malone says. Medical training teaches physicians that “you can override nature,” he says. “You don’t have to eat. You don’t have to sleep. You are smarter than other people. … The doctors I treat, think they can outsmart depression, outsmart alcoholism, outsmart their schedule.”
Van Pelt agrees. Within clinician circles, reaching out to employee or mental health services is seen “as a sign of weakness.” For that reason, van Pelt’s peer support program trains clinicians to help each other. Before its official July launch, the teams already had been activated several times. And van Pelt has been contacted by other hospitals interested in setting up a similar approach.
“I think there is a general recognition that if you are not taking care of your clinicians with support, that patient safety is impacted,” van Pelt says. “And that any improvement process in the hospital is potentially compromised by that isolation.”
Charlotte Huff is a freelance writer in Fort Worth, Texas.