politics and practice based on mindfulness

Saturday, December 13, 2008

self care: why doctors and nurses don't always follow their own advice

In November 2004 I heard my teacher TKV Desikachar tell a room of yoga therapists that we couldn't help our students unless we either had been healed or were engaged in a process of healing ourselves.   

Since then in my clinical practice, I often hear doctors and nurses confess to me that they've spent years avoiding wellness practitioners, exercise classes, and even regular annual check-ups because they're too ashamed to admit to another professional how they plopped off the wagon years ago.  

What's so wierd is that the health problem they're running from can be so ordinary -- depression, obesity, bad sleep habits.  But the shame is still there.  They're attached to the idea that they're smart, well-informed people when it comes to exercise/nutrition and its effects.  And they're ashamed they've failed.  

One of my students -- an elfin, sweet-voiced woman who's also a highly respected clinician in the hospital -- tried to answer my question about her last annual physical.  Her eyes darted nervously around the room "It's been, uh, years?" then she laughed it off.  And, OK, I  did too.

Despite our snarky giggles over her negligence (clinician bunker humor), the situation is just too widespread for us to chortle.  Lack of physician and clinician self-care results in procrastination on important baseline tests at best.  At worst, it can utterly sabotage personal health.  

Putting off self-care can compromise the health of their patients,  too.  In the limited time that clinicians have with patients they need to talk -- with sincerity and credibility -- about the inevitable outcomes of lifestyle choices.  Not every disease is preventable, but the ones that are (typically chronic conditions) lead to a cascade effect, eroding overall health.

One of the few organizations trying to make a direct effort to address wellness needs among clinicians is a certifying organization called Planetree which tries to change hospital cultures one at a time.  Martha Jefferson Hospital is planning to gain the Planetree certification through a gradual process that began in '08.  To complete certification, they'll have to offer employees wellness and health services as well as measuring improvements in employee health. The bottom line imbedded in the Planetree model, is that physicians can't support wellness in patients if they smoke, live off their nerves, are sleep-deprived, short-tempered, or grossly overweight. You can learn more (http://www.planetree.org)
It seems crazy that hospitals need this kind of external advice to manage employee health, no?  But they do, and it's great when they ask for help. The roots of the problem begin outside the hospital, in medical training and insurance models. 

Then there's the nasty reality of ME, medication error, affecting over one million patients every year.  The problem begins during doctor training.  You remember ER -- and feeling grateful you weren't on that gurney.

An alarm was sounded abut physician fatigue and ME in a 2004 study in the New England Journal of Medicine.  In 2006 the National Academies reported that over 1.5 million patients are sickened or injured by ME every year.  These findings were underscored by a recent congressional report on the impact of resident fatigue on widespread ME and patient deaths.  
The need for computerized records, failure to upgrade to e-prescribing, faulty protocols, and product liability are also cited as causes of ME. See the 2006 National Academies study of ME http://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.html

In our "bowling alone" society we forget how much we need personal, live, real-time support to make significant changes.  It can be hard for anyone responsible for the welfare of others to admit that they need exactly what they try to give: a lot of one-on-one care.

Beyond re-examining assumptions about sleep requirements at the resident training stage, everyone who is interested in reforming healthcare eventually needs to look at the docs and nurses.  That is, to figure out how and why this pattern of clinician burn-out is sustained over time -- to the detriment of their health and happiness, and that of their patients.