The story continues from link (Part 2).
I must take a deep breath. I must ask for help.
The Self-Knowledge Path
I could go away and work in another hospital. We have many good hospitals in Brazil. Some even employ emergency physicians who are local graduates. I really could. In truth, there would be no shame if I left the hospital. But I decided to give it one more try.
I just want to make clear that there is no single route back from burnout. It is a multifactorial treatment. You need emotional power. Some you may already have, or you can develop with a mental health specialist’s help. Some you will gather alone, or family and friends will help you to recover if you are lucky enough. Read, talk, discuss, and share with your community. You will never be alone because it is the system that is inflicting moral injury and burning you, and everybody, out.
Each person needs different means and tools to recover. We have to acknowledge that not everybody can afford all of them. Not everybody can pay for a therapist or even leave their work. I was one of the lucky ones. I could.
I promised myself and others that I would get better, and I wouldn’t give up. I felt obliged to improve the system that had harmed me. The system that made me afraid; afraid that I would fail.
It was not easy! It wasn’t “just not thinking about it.” It wasn’t “just a phase.” It wasn’t “just yoga.” It wasn’t “just wanting.” It was more than all the above. It took a long journey of self-knowledge: Who was I? What did I want? How could I achieve that?
Gradually, intertwined with relapses, the healing process began. I returned to therapy. Thanks to all support from my amazing friends, -virtual friends, present friends, distant friends- mentors, mentees, students, residents, followers, I was overwhelmed with affection and understanding. There were messages of encouragement everywhere I looked and listened. I did not plan this. It happened organically from across our community, and sometimes unintentionally, as I reached out to others, who always found time to help me.
Kindness can save a life! If you feel so, just go around saying how important people are in your life. I assure you that the kindness and positive comments of these people saved me.
I improved gradually in small steps. With empathy and determination, I took one step after another. Each step led me to find new perspectives. With each small victory, I felt a small but important celebration in my heart.
Yet, I wanted to make sense of it all. How to endure the moral injury? How to continue working here? I desperately needed to make sense of my job.
Why Me?
In addition to therapy, I went on leave. I flew away and spent time in Mozambique, an LMIC, with many more difficulties, compared to Brazil. They were just beginning to develop the first emergency medicine residency program, and they had a lot more work to do. They were seemingly starting from scratch, and they had fewer resources than we had in Brazil. I found their enthusiasm and resourcefulness more inspiring than I thought possible.
It wasn’t because I could see how lucky we are in Brazil, but they did their best even though they were aware of their problems. I knew that there was no way that I could give up after seeing them.
I returned to Brazil, where people were eager to work with me. I felt they had missed me. They showed me that I made a difference.
I was fortunate to see my work environment improved. The administration had started to ‘get it,’ and now they cared about what we do. They realized that efficient systems saved money, so they were helping us achieve better care for our patients. Our department was renovated. They hired more people, and we got better medications. It all helped. It felt as though they were listening.
So recovering from burnout not only helped me to accept that problems are a part of the system but also made me realize people make the system. Therefore we can change it to accommodate our needs. Not the contrary. We need to END moral injury by addressing it and demanding solutions! We don’t need to be resilient to it!
In the beginning, I understood that I needed to be present in all my tasks, but that’s a challenge in the hectic world of emergency medicine. In truth, we are not as good at multitasking as we let ourselves think. However, we get better at prioritizing and scheduling tasks as we develop as clinicians. More importantly, we learn to give each task the proper time and attention it deserves.
As time passed, my most challenging feelings diminished. I redefined my responsibilities and my choices, redefined my motivation, my ambition, my purpose. I adjusted my expectations. I found a new power.
Then, gradually, the love for Emergency Medicine and the energy to become the doctor I aspire came back. However, I still had to face my demons and deal with the most painful side of emergency medicine: Delivering bad news.
“Most of the time, the fact that you care is enough” is one of the most effective pieces of advice that I ever received. It helped me relieve the intense pain that I didn’t even know it was there. I still remind others and myself of it regularly.
For example, I dealt with the tragic case of pediatric cardiac arrest, brought in by another medical team. We did CPR over an hour, as this was a very delicate situation with a child. At the debriefing, I was careful with both teams from the other hospital and our own. Although I was worried about having the conversation I did, I was shocked and stunned to hear the reply. The doctor shrugged and said:
– Yeah, right. Can I go now?
He was in a rush. He didn’t even want to hear the debriefing. He didn’t appear to care! The disdain broke my spirit, and the whole team felt the same anger. It made everything harder to cope.
I took a deep breath, thanked the team for all the effort, asked them to prepare the body, and went to the waiting room to talk once again with the father. I had been there a lot of times, talking through everything as we were trying to resuscitate, so he already knew me, and immediately recognized my expression of bad news. I sat next to him and told him everything we did. I was trying to remedy the anguish while allowing time for understanding.
– There was nothing more we could do. I’m so sorry, but he died.
The father stared at the floor for a while.
– My wife is eight months pregnant. What should I do now?
He was in despair. Next came tears. I waited. Present. Then, he looked at me with honest:
– Thank you, doctor, for everything you did.
I will never forget them.
“Most of the time, the fact that you care is enough.”
I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.
Now, when I have to deliver bad news, I try my best to be there and look in the eyes. I patiently wait to make sure until there is no doubt. I don’t try to hide my feelings, and I finally feel I’m always telling the truth:
– We are doing everything we can.
I ensure that they know we care. I make a difference there. My pain eases as theirs alleviates even a little.
“Most of the time, the fact that you care is enough.”
I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.
Finding My Ikigai
Ikigai is a Japanese concept that means “a reason for being.” In English, the word roughly means “thing that you live for” or “the reason for which you wake up in the morning.” Each individual’s ikigai is personal and specific to their lives, values , and beliefs. It reflects the inner self and faithfully expresses that, while simultaneously creating a mental state in which the individual feels at ease.
The thing I like most about ikigai is that it is for everyone. You have to understand yourself to achieve this deeply. Seeking self-knowledge can be the most challenging part.
– Am I doing something that I love?
– Am I doing something that the world needs?
– Am I doing something that I am good at?
– Am I doing something that I can be paid for?
YES!
So, where am I now?
Well, I still love heart attacks! I love the look of amazement of the interns when we save a life. I love the self-satisfaction of the residents when they can do something correctly for the first time. I love how happy the team gets when we can do perfect resuscitation. I love the peculiarities of each patient, their life, culture, and beliefs. I love to learn something new every day. And that’s why Emergency Medicine!
I love heart attacks! But when we can't save, when the system fails, when the patient dies but I feel that I softened the pain, even a little bit, by showing that we care, I know I can endure.
Thanks for the text. Speaked to my soul.