COVID’s challenge: moral injury

By Caitlin Kelly

I hadn’t heard that phrase until September 2019, when I sat down to interview an American physician, Dr. Emily Queenan , describing why she stopped working in her native country and moved to work in Ontario. It wouldn’t have been the easiest choice, choosing small-town Ontario with mixed-race children and having her husband leave a corporate job.

But it was absolutely the right choice for her.

From my 2020 story for The American Prospect:

 

Dr. Emily Queenan, who is American, also voted with her feet; after studying biology at Williams College, working for Americorps in Peekskill, New York, in community health, and attending medical school at the University of Pennsylvania, she did her residency in Rochester, New York. She opened a family medicine practice there in June 2009, closing it in May 2014—and moving to Canada.

After being recruited by an agency of the MOH, Queenan visited four cities selected from a list of rural communities needing a doctor, She chose Penetanguishene, a middle-class town of 8,962 in northern Ontario on Georgian Bay, a beautiful area that welcomes many summer-home visitors.

“It was a wrought decision to close my practice,” Queenan says, sitting in the 1920s-era red-brick house in small-town Ontario whose main floor is now her office. “I envisioned having my [U.S.] practice for decades. But I was really burned out by the burden of being someone’s family doctor and the moral injury of denying care versus the lack of payment versus dealing with your own medical bills. This is not asked of other professions.”

Still in New York, Queenan attended a local meeting of Physicians for a National Health Plan, an American advocacy group founded in 1985 by Dr. Steffie Woolhandler and Dr. David Himmelstein, “trying to decide what was next. I was on the cusp of turning 40 and saw a career of fighting stupid fights. Doctors across the country were going through exactly what I was going through. I am not unique.”

 

 

Maybe you are, or know, a physician or nurse or other healthcare worker; my first husband is a physician I met when he was finishing med school at McGill so I watched him through his residency and early practice — which brought him to some unpleasant realities.

Most healthcare workers choose their profession because it expresses their values — to help and to heal, whenever and wherever possible.

Covid has torn their world to shreds, as evidenced by the recent suicide of Dr. Lorna Breen, an ER physician who had worked in a New York City hospital under such terrible circumstances that her sister said she called it Armageddon.

Her father is also a physician, so she would have grown up with this moral code.

From The New York Times:

 

“She tried to do her job, and it killed her,” he said.

The elder Dr. Breen said his daughter had contracted the coronavirus but had gone back to work after recuperating for about a week and a half. The hospital sent her home again, before her family intervened to bring her to Charlottesville, he said.

Dr. Breen, 49, did not have a history of mental illness, her father said. But he said that when he last spoke with her, she seemed detached, and he could tell something was wrong. She had described to him an onslaught of patients who were dying before they could even be taken out of ambulances.

“She was truly in the trenches of the front line,” he said.

He added: “Make sure she’s praised as a hero, because she was. She’s a casualty just as much as anyone else who has died.”

 

When patients die in the ambulance, on stretchers, in waiting room chairs, or after appearing to be recovering, your skills, strength, speed and teamwork still aren’t enough.

 

You just can’t help.

You can’t comfort.

You can’t save.

 

You feel angry and helpless and overwhelmed — for doing everything you know and it’s not enough.

Let alone re-using PPE.

Here’s a definition from a PTSD website run by the VA:

In traumatic or unusually stressful circumstances, people may perpetrate, fail to prevent, or witness events that contradict deeply held moral beliefs and expectations (1). Moral injury is the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to such events (2). A moral injury can occur when someone is put in a situation where they behave in a way or witness behaviors that go against their values and moral beliefs.

Guilt, shame, and betrayal are hallmark reactions of moral injury (e.g., 3). Guilt involves feeling distress and remorse regarding the morally injurious event (e.g., “I did something bad.”). Shame is when the belief about the event generalizes to the whole self (e.g., “I am bad because of what I did.”) (4). Betrayal can occur when someone observes trusted peers or leaders act against values and can lead to anger and a reduced sense of confidence and trust (5).

 

Exposing oneself to millions

By Caitlin Kelly

Thanks to a reader here, I decided to pitch one of my earlier blog posts as a larger, reported story about medical touch — and my own experience of it — to The New York Times, and it ran today, prompting many enthusiastic and grateful tweets.

Here’s the link, and an excerpt:

It started, as it does for thousands of women every year, with a routine mammogram, and its routine process of having my breasts — like a lump of dough — manipulated by another woman’s hands and placed, albeit gently, into tight compression. It’s never comfortable, but you get used to it because you have to.

Unlike previous years, though, my next step was a biopsy, for which I lay face down, my left breast dangling through a hole in the table. Several hands reached for what’s normally a private and hidden body part and moved it with practiced ease, compressing it again into position for the radiologist’s needles, first a local anesthetic and then the probes needed to withdraw tissue for sampling.

I was fearful of the procedure and of its result and, to my embarrassment, wept quietly during the hour. A nurse gently patted my right shoulder and the male radiologist, seated to my left and working below me, stroked my left wrist to comfort me. I was deeply grateful for their compassion, even as they performed what were for them routine procedures.

 

It is decidedly weird to out one’s health status — let alone discuss your breast! — in a global publication like the Times — but it also offered me, as a journalist and a current patient undergoing treatment,  a tremendous platform to share a message I think really important.

 

I hope you’ll share it widely!

 

 

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Every patient needs to be touched kindly and gently

You Can’t Quantify Kindness: Our Statistical Obsession

Chicago graph clim
Like this....but with feelings! Image via Wikipedia

Great piece in The New York Times by Alina Tugend about our growing — and misguided — obsession with measuring everything in our lives:

Numbers and rankings are everywhere. And I’m not just talking about Twitter followers and Facebook friends. In the journalism world, there’s how many people “like” an article or blog. How many retweeted or e-mailed it? I’ll know, for example, if this column made the “most e-mailed” of the business section. Or of the entire paper. And however briefly, it will matter to me.

Offline, too, we are turning more and more to numbers and rankings. We use standardized test scores to evaluate teachers and students. The polling companies have already begun to tell us who’s up and who’s down in the 2012 presidential election. Companies have credit ratings. We have credit scores.

And although most people acknowledge that there are a million different ways to judge colleges and universities, the annual rankings by U.S. News & World Report of institutions of higher education have gained almost biblical importance.

As the author of a newly released book about working retail I haven’t once (honest!) checked my amazon ranking number.

Seriously, what good can it possibly do?

Will my hips suddenly shrink or my bank balance double? I wish!

My thesis about why retail associates are so horribly paid is linked to this data obsession: you can’t measure kindness!

Think about the very best salesperson you ever met — (or hotel employee or waiter or nurse or teacher).

The EQ — or emotional intelligence — the skills that really left the strongest impression on you, are probably not their technical mastery of that new Mac or their grasp of the essentials of calculus, but how they helped you: with patience, humor, calm, grace.

All of these are essential qualities we simply cannot put on a graph.

And that which we cannot measure, we do not value.

I was in the hospital in March 2007 for three terrifying days, on a IV with pneumonia, from overwork and exhaustion. (Don’t ever get pneumonia — it makes you cough so hard, for hours at a time, you can break a rib.)

I finally begged the nurse to swaddle me tight in a cotton sheet, like an infant, to ease my aching muscles. She never raised an eyebrow at my weird request, but did it at once, with a compassion that I will never forget.

That healing quality of care, invisible, unmeasured and therefore too often undervalued, is not inscribed anywhere in my medical records.

It should be.