The canary in the mine: burnout and resilience in times of pandemics


Last week we had an interesting discussion at 34 Conference on bioethics co-organized between the Faculty of Medicine of the University of Lleida and the Borja Institute of Bioethics of Ramon Llull University.

In my presentation on Bioethics and pandemic spoke of the need to cultivate and promote resilience during the pandemic, meanwhile @oyuguero commented a tweet from Dr. @GavinPrestonMD, which literally said: “Medicine is the only profession where when the canary dies in the coal mine, the leaders simply say: why can’t we find more resistant canaries?

¿Resiliencia vs burnout?

Resilience to survive insufficient or inadequate structural conditions?

Or a little further on, did the vocation serve to perpetuate otherwise unacceptable working conditions?

And this is the case, Would building resilience mean perpetuating inadequate working and professional conditions?

If something has amply proved the The Covid-19 pandemic is its ability to amplify and highlight pre-existing conflicts or problems, taking them to unsuspected limits. We could say that one of the crises it has amplified is that of the health professions.

Three axes to analyze the Covid-19 pandemic

The pandemic hit us with all its hardness in March, it put all of us, health professionals, the whole of society into orbit and we have not touched solid ground since then. I think in order to to properly analyze the pandemic, we must focus on three axes:

– In the first place from where the pandemic affects us, that is, what was the previous situation

– Second, what elements can help you survive while we orbit, with an irregular trajectory and a situation with very high uncertainty

– And third, where we want to be when we return touch the ground. The pandemic will not get us where we started, but it is essential to know where we want to go.

Before the pandemic, we cannot forget that the health sector was already in crisis. Burnout figure from burned professionalsHe was very tall. Depending on the field or specialty, the burnout figures varied (before Covid-19) between 20 and 80% and, in the best of scenarios, 1 in 5 health care workers was burned.

Burnout had been defined as a hidden health crisis, and was recognized because it has a high cost, not only on a personal level in professionals, with a higher health risk, both physically and mentally (if we still think they can be differentiated), but also at the level of quality of patient care.

The concept of burnout is relatively new, described in the 1960s by Freudenberger and subsequently conceptualized by Christina Maslach which develops the well-known questionnaire Maslach Burnout Inventory (MBI). The axes of the syndrome are three:

– Emotional fatigue or mental exhaustion

– Depersonalization

– Decreased performance with perception of work inefficiency

At the end of 2019, Danille Ofri, in Academic Medicine I was talking about ‘The deal‘, the covenant or alliance, in relation to commitment of doctors to their patients, but he also referred to the profession’s commitment to its professionals: “Resilience? The doctors I see are some of the toughest people out there. May they get through this heartbreaking system, they mostly manage to take care of their patients and not go out in droves, that’s resilience! … the despair I see among our colleagues today is more than exhaustionIt is a betrayal of the trust we have placed in our own profession ”.

Burnout should be seen as a health system problem

Such high figures for this disorder should have already warned us that burnout was a deeper and wider problem than individual difficulties in adapting to professional needs; in fact, it should be considered more of a system problem than a personal problem.

And surely this conflict is somehow related to the health professions had not completed their transition to the 21st century and we have dragged a gap (rather abyss) in between implicit social contract (what society and health systems expect from health professions) e explicit social contract (working and contractual conditions for the fulfillment of the implicit contract).

Mayor, in an editorial in BMJ, has marked us the way forward to know where to go. He commented that burnout was “a system level problem that requires a system level response”, Noting the toxic aspects of the medical profession that cause and maintain exhaustion, promoting the clinical leadership and a supportive organizational culture, considering the well-being of professionals as a central part of patient-centered care, as it clearly affects patient care and recognition of the well-being of professionals as a quality indicator for all health systems.

In the face of the Covid-19 pandemic, we need to be resilient, not just healthcare professionals

But in the middle comes the pandemic, which accentuates pre-existing conflicts and creates new ones … and we will have to survive. This is where for me it is it is important to introduce the concept of resilience. Burnout may be, as Lemaire commented, a response to totally inadequate professional conditions that need to be rethought, but resilience will be necessary and essential to survive. not only in the toilets but in the general population.

Rosenberg, pediatric oncologist, in his article ‘Cultivating deliberate resilience during the 2019 Coronavirus pandemic‘analyzes what she has learned about resilience in her professional field, how some families after going through a process of serious illness or the death of their children are devastated and others undergo a transformation.

Resilience is the process of adaptation to adversity, trauma, tragedy, threats or major sources of stress, this process will allow it to be overcome and adequately integrated. It reminds us of that resilience it is not a personality trait or a personal quality, but an active process, complicated, contextual and promotable, that it requires deliberate effort and as such, deliberate actions and the activation of resilient strategies.

Rosenberg identifies himself three types of resilient resources:

– Individuales, which individual characteristics and personal abilities would be, which would be important to identify and activate

Community, which would include all social supports, both formal and informal, fostering a sense of connection

Existential, which would give the meaning and purpose

I recommend a peaceful reading of the article.

Victor Frankl, the so-called psychiatrist of the sense, after his experience in the extermination camp of Auschwitz and after losing everything, including his family, he commented “you have to survive before you live again“.

Resilience vs fighting the conditions that generate burnout? Both are not a dichotomy. Both will be essential and necessary to be able to cope with the exceptional situations and times that we have to live. But mainly thinking and guiding where we want to go, as a healthcare profession, and how we want to position ourselves when we touch the earth again. Since this movement will not happen spontaneously, it requires a clear path and leadership to reach.

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