Why We Care

During the COVID-19 pandemic we’ve seen the meme of doctors and nurses holding signs that read, “I stayed at work for you. You stay home for us.” This refers to health care workers willingly putting themselves (and their families) at risk to perform their work under more hostile than usual circumstances. When asked why, many will say they are, “just doing their job,” or that this is, “what we signed up for.” But this is not truly the reason they continue to show up. No one is purely following a blind sense of duty, especially not highly educated professionals who pride themselves on autonomy. This situation requires a more complete understanding. 

The helping professions, ones defined by moving toward rather than away from crisis, present an existential problem for those who perform them. Quite literally, they have chosen to accept the risk of personal harm in order to help others. Under typical circumstances in health care, this risk is low. There are certain times, though, when this reality becomes clear, such as when faced with the threat of a potential fatal infectious disease. The threat is even more apparent for soldiers, police officers, and firefighters, whose risk of physical harm is more immediately threatening. 

A person faced with an existential problem has the option to either proceed, assuming the risk, or to change course. The actions, and their outcomes, hinge on this choice. When the problem involves another person in need, the choice could be thought of as between the “I” and the “other”. Of course, when choosing “I”, one may be thinking of their children, spouse, or future ability to help in other ways. When considering the “other”, one may project the realistic outcomes the other person faces, their likelihood of survival, let alone their quality of life thereafter. If afforded time to think, one can weigh these things. In the moment, however, this is often not possible. And, as illustrated time and again, via heroic efforts, we most often choose the “other”. Why is this so?

The 20th century philosophy of Existentialism helps us understand the problem another way. It is posited that our actions become our practical identities, they determine our existence. When faced with an existential problem, we are confronted with the possibility of our “nothingness”. Because our identity is defined by the actions we take, inaction is synonymous with embracing the death of “I”. Conversely, to act is to choose “freedom”, experiencing the transcendence of one’s being in the world; living for something greater than the self. When thought of in this way, the question one faces is not, “Who do I choose?”, but rather, “Who am I?”. Answering the latter will immediately resolve the former. 

Bringing this back to our health care workers, the risk of actual death to the self is of lesser importance than the death of the experience of their existence, in keeping with the identity they have chosen and the actions that support it. 

At the risk of oversimplifying an entire school of philosophy, I put forward that health care workers care not because of their sense of duty, but because doing so is the manifestation of the freedom of the self, fulfilling the deep need to identify as part of something greater than themselves. This is as authentic as humanity can be. 

To all those who care and protect us, putting yourselves in harm’s way, thank you. Your willingness to help is the greatest example of what it means to be human. 

Be well.

Lessons From The Front Line

I just completed a week of attending on the acute medicine wards in the COVID-19 era. Needless to say, nearly everything about the workflow and environment was different. We are fortunate to not be inundated with cases the way many jurisdictions are, but the impact is still tremendous. Below I detail a few things I learned from this experience.

Uncertainty is the greatest fear of all. 

Even in normal times, we have a desire to know how things will go. Students want to know what’s on the test. Partners want to know how their counterpart will respond when they share something emotional. Children want assurances about how much playtime they will be allotted. We feel that knowing will alleviate our anxieties, convincing ourselves that some other unknown won’t simply take its place. 

During COVID-19, uncertainty is top of mind. The word, itself, is everywhere in news headlines. Health care workers are feeling fearful because they don’t know the risk to their personal safety, the state of the supply chain for masks and gloves, if their families will be in jeopardy, if they are unknowingly spreading the virus to vulnerable patients. Despite this, they show up. But the stress of the fear of uncertainty is obvious, representing an additional toll on our critical service-providers. 

Crises reveal the true nature of our leaders.

Left to themselves, particularly when told to isolate, the fear of uncertainty will mount on almost anyone. It takes good leaders, who understand people, to communicate effectively and consistently in order to alleviate (at least in part) the suffering of their constituents. These leaders are required at all levels of the workplace, politics, community organizations, families. In politics, especially, we don’t have to look far to see examples of good or exceptionally poor leadership right now. It’s easy to complain about leaders, but crises teach us how badly they are needed, and how important their skillsets are. None more important than the abilities to maintain humility and strength of conviction, helping those who follow believe that there is some semblance of a direction and vision. 

Patients in hospital feel the impact of loneliness.

During the pandemic, policies have quickly shifted from a focus on the individual to a focus on protecting the many. From an infection control standpoint, this makes perfect sense. Individuals give up some of their usual freedoms, doing their part to benefit society. Any ensuing feeling of loneliness is, for the most part, up to each person to reconcile. It is their responsibility to be aware of and address their own experience. For hospitalized patients, however, there is an important difference. 

Patients in hospital are, by their nature, dependent on others for the protection of their health. This dependence for health easily extends to a perceived dependence for overall well-being. Protocols include keeping patients alone in rooms with the door closed, minimal contacts with staff each day, and no visitors. This, all in the name of reducing the risk of spreading the virus, results in near total isolation. We support what they need for the recovery of their physical body but deprive them of any sort of socialization required for overall well-being. 

The patients with whom I interacted in this situation were, simply put, sad. It is difficult to imagine that this does not adversely affect their recovery from illness, COVID-19 or otherwise. Patients entrust us with their health. The impact of this type of isolation needs to be examined and mitigating strategies planned as the pandemic evolves. 

There are a lot of lessons to be learned from this experience. The ones I’ve highlighted here or only what immediately came to mind. What gives me optimism is knowing that humans are able to adapt quickly, finding ways to protect the most vulnerable, and humanity in general. 

Be well.

How hospitals consistently fail vulnerable patients

An 85-year-old woman is being sent home from hospital today. She had pneumonia, spending five days on oxygen. It was complicated because she already had heart failure and diabetes. Her medications were adjusted. She needs a walker. She lives alone. Her son is a two-hour drive away. She’s scared.

A version of this story plays out in hospitals across Canada every day. Our hospitals are failing to provide what patients truly need when they leave; the tools to reclaim personal responsibility.

A hospital admission works on three assumptions:

  1. Patients come to hospital for a perceived health need that cannot be managed elsewhere;
  2. Triage protocols weed out those who do not require hospital care; and
  3. Patients, if capable, will reclaim personal responsibility when they leave.

When a patient satisfies the first two assumptions, requiring hospital admission, a temporary dependency is created. This results in a transfer of responsibility from the patient to the hospital, for their immediate and future health. The vehicle for this shift is trust. Hospitals willingly accept this, as they house talented professionals who’ve spent their working lives preparing for these situations.

After their hospital stay, a patient ideally returns home, resuming independence. Doing so requires satisfying the third assumption. However, transferring responsibility back is not so easy. In hospital, responsibility is spread across multiple actors, all adept at their craft. Upon discharge, responsibility is placed solely on the patient and, if fortunate, their informal caregivers. The vehicle for this transfer is not trust; it is empowerment.

This is where hospitals are failing. They are right to assume that patients reclaim personal responsibility, based on the principle of autonomy. They are wrong to expect this will be done willingly or easily. The result of inadequate empowerment is a patient being woefully unprepared to manage themselves at home. More importantly, it leads to preventable human suffering.

What prevents hospitals from empowering patients? An overwhelming focus on money. In our publicly insured system, governments carry the financial risk for hospital care. To control spending, governments legislate hospitals to balance their books, working within constrained budgets. So, hospitals cut costs. Common tactics include closing beds, cutting staff, and reducing length-of-stay. Patients are sent home as soon as possible. There aren’t enough staff with enough time to help patients understand their transition home.

Lack of control over the entire spectrum of care is another challenge for hospitals. Frail elderly patients often require home care, convalescent care, or nursing home care after a hospital stay. Hospitals are at the mercy of third-party agencies, who control these resources. Staff can never be sure what a patient will be offered. Instead, they hope that a patchwork of services will materialize following the patient’s departure.

There is opportunity on both sides of the responsibility gradient. Patients must accept that hospitals cannot solve all of their health problems, and, so long as they remain capable, the onus for ongoing health maintenance will fall back to them. Funders and health professionals can help with this messaging. It should also be understood that although one can freely choose not to take responsibility, such a decision does not obligate anyone else to accept it.

On the hospital side, a critical eye should be cast on the alignment between stated values and daily reality. The search would quickly uncover routine instances where patients are not the foremost concern. Leaders must confront what is found with integrity and the desire to do better.

In a nation that prides itself on publicly funded health care, it is understood that society protects the health of its citizens by carrying the financial risk. This allows individuals to act without concern of financial ruin from health crises. This costs governments tremendously, but it is a business they ought to be in. The final opportunity is at this level. Governments are uniquely positioned to redirect the focus from balance sheets back to patients. If done, hospitals could properly afford to empower patients, resulting in healthier citizens and a more productive society.