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In the 1970s, an American psychologist, Herbert Freudenberger, was working extra time in a thriving private practice on the Upper East Side in New York and at a drug treatment clinic in Bowery. After months of increasing stress and exhaustion, he woke up one morning unable to move from his bed.
Freudenberger examined his symptoms, none of which correspond perfectly to a pre-existing psychological disorder. The sensation reminded him of the cigarettes that his young addicted patients were holding in their therapy sessions, the fire coming dangerously close to their trembling fingers.
Freudenberger himself was diagnosed with the first case of burnout named – a state of exhaustion caused by the excessive demands of the workplace.
In his initial article, Freudenberger described a condition that manifested as physical symptoms such as fatigue, headaches, or shortness of breath, and emotional symptoms such as frustration, anger, paranoia, depression, and indifference. The most likely people, he explained, are those whose work requires emotional work and empathy, putting "help professions" (doctors, nurses, social workers, teachers, etc.) most at risk.
Nearly half a century later, Freudenberger's idea sparked a global debate. On May 28, the World Health Organization included burnout in the latest revision of its global manual on diseases, describing it as a syndrome resulting from "chronic stress at work that has not been successfully managed. "
The high cost for hospitals
No profession is immune to burnout, but modern health care seems almost designed to invite it.
Despite the lack of sleep, a lot of pressure, increasing regulation and personal stress, health care workers need to stay present, alert and compassionate to frightened people in emergency situations.
The balance sheet is dizzying. In the United States, doctors kill themselves twice as fast as the general population. More than half of American doctors say they are physically or emotionally exhausted and find their work less meaningful than in the past. According to a recent study, burnout costs $ 4.6 billion a year to the American medical system.
Factor in medical errors caused by exhausted and disengaged doctors, and the cost can be even higher. A 2018 study by the Stanford University School of Medicine found that exhaustion caused by burnout resulted in more medical errors than dangerous hospital conditions or faulty procedures .
But in a context where it is difficult to find cost-effective solutions to crises, a Boston-based nonprofit organization has identified a treatment for non-invasive, low-cost burnout with few noticeable side effects: bringing together caregivers to talk about themselves.
The Schwartz Center for Compassionate Healthcare launched its Schwartz Center Rounds program in 2002. Today, more than 600 hospitals worldwide participate in moderate group discussions aimed at preventing the burnout of hospital workers and reducing the risk of burns. strengthen their compassion for patients and for themselves.
All those who interact with patients can visit the clinic's hospital: surgeons, nurses, occupational therapists, janitors, who make sure that the floors are clean but not too slippery. The meetings take place in small local hospitals and in giant regional hospitals, from San Diego to Dublin via Christchurch, New Zealand.
Wherever they are, the structure is the same. Organizers choose a topic: dealing with the patient's family, for example, or diving into a particularly heartbreaking recent case. A group of pre-selected volunteers share their point of view to initiate the conversation. Then he opens to the discussion.
Moderators are slowly moving away from efforts to diagnose or solve problems – which is no small feat in a room where people diagnose and resolve all day, every day. Normal hospital hierarchies do not apply. The only thing participants are allowed to do during the rounds is to talk about their feelings. No judgment. No fixation. Just talking.
Meetings are usually held at lunch time, but no one comes for food. Lunch at Schwartz Rounds typically involves the type of bland sandwiches and vending machine-type chips available at workplaces where people tend to eat quickly and upright if they eat them.
The goal of Schwartz Rounds is to encourage health care workers to do what most of them never do at work: take the time to put yourself first. Do not think of what should have been done for a patient in the past or could be in the future, but the feeling that a demanding and sometimes painful job made him feel.
The hope is that by sharing their own experiences and hearing others do the same, caregivers will leave with more compassion for themselves and then more energy and space for show compassion and empathy to patients.
"In a context of high volume, the high-pressure atmosphere tends to stifle the compassion and humanity inherent in the caregiver," said Kenneth B. Schwartz, founder of the Schwartz Center for Compassionate Health Care, in which tours are the key program. "But the quickest break in the hectic pace can bring out the best in a caregiver and do a lot for a terrified patient."
Schwartz Rounds are this break. The change that they bring to the hospitals provides avenues to combat burnout elsewhere.
"You can not pick on yourself": visits to primary school
The Intermountain Primary Children's Medical Center, better known as Primary Children, is one of the largest pediatric hospitals in the United States. It serves one million children in a coverage area of 400,000 square miles. It is a Level I trauma center. Extremely ill or injured children are airlifted to the mountainside campus in Salt Lake City, Utah, up to Alaska.
To work in Primary is to be faced daily with the most unjust and arbitrary life. The facilities are dazzlingly clean, with touches that attempt to alleviate the austerity of a hospital. There are murals and brightly colored play areas, art and music therapy, as well as games for inpatients. But it's still a workplace where about 200 children die each year, even when everyone is working hard. This is not a job that is easily left at the end of a shift.
The Schwartz rounds started at the hospital in 2014. They take place 10 times a year and attract at least 85 people each time, usually more.
In one rounds session, Quartz At Work was asked to observe in 2018 about 100 people who gathered to talk about "non-compliance" or when a patient or family is unable or unwilling to follow. the treatment protocol of his doctor.
There are many reasons why families of patients do not follow the doctor's instructions: lack of understanding, lack of resources, mistrust, negligence. For a health care team that has worked hard to care for a child, it can be heartbreaking and annoying to see the young patient's condition deteriorate on subsequent visits. It's not hard to see how a caregiver might become a little colder or a little shorter at each visit, distancing themselves from the dreadful conversation they attend, the one where they have to tell a child and to his parents as their illness progressed past the point of help.
"The parents look at us like" you always repaired them. "And a day will come when you will not be able to fix them," said a caregiver during the rounds, to understand the nods. "You can not reverse the irreversible. When they die, part of us breaks off too. "
In Schwartz Rounds, there is no question of how a hospital employee "should" behave. People talk about the uncomfortable emotions they can not express to patients: pain, confusion, rage.
It is not meant to be about solutions either – no "study on increasing medication compliance after discharge", but people share their own coping strategies and their own ways of accepting the reasons for which they make the choices they make. In medical language, patients who resist or do not follow the protocol are often referred to as "difficult". But what does it mean to be an "easy" parent of a seriously ill child or an "easy" young person who knows that they have won? do not see adulthood?
A social worker talked about a conversation with a teenager with a serious and complicated disorder about the teenager's refusal to continue treatment. The young person desperately needed someone to hear and recognize her choice. In this case, the caregiver decided, helping meant listening to this patient say what he had to say, rather than forcing him to take a path he did not want to take.
No conversation in this room can change the fact that some families will not do what is necessary to keep their child well. But that can displace doctors, nurses and other people who have slipped too much in one direction between over-involvement and disengagement in a healthier environment. He can readjust their grip on each case, each patient, so that he can focus when needed and let him go when needed.
"You can not go after yourself," says a gray-haired doctor before the group broke up. "You should not assume the burden of every patient, nor the path of burnout."
The human, healing touch
Boston-based health lawyer Kenneth B. Schwartz was diagnosed with stage IV lung cancer in 1994 at the age of 40.
As a lawyer, Schwartz knew the procedures and protocols that hospitals supported to keep people alive. As a patient within this system, he was struck by the magnitude of the non-billable and uncoded acts of kindness offered by caregivers on their best days: a pressure on his shoulder before the surgery, results quickly to save, a note of encouragement after a new difficult.
"For as skilled and competent as my caregivers, what matters most is that they have sympathized with me in a way that gives me hope and makes me feel like a human being, not just a disease, "wrote Schwartz in a 1995 Boston Globe Magazine article became a kind of manifesto for the program. "In a way, these calm acts of humanity have felt more healing than high-dose radiation and chemotherapy that are hopeful of a cure." He died in 1995, a few days after the founding of Schwartz Center, a health care center in Boston.
Schwartz was a person of great power, humiliated by the realities of the disease, an experience that gave him an additional perspective and increased empathy for health system actors. This upgrade is integrated with tower design. "It is valuable for a young doctor to see a former doctor say," It really upset me, "said a British participant in a study.
The rounds humanize those who have been placed on pedestals and those whose experiences have been neglected or ignored. During a visit to the hospital, a member of the translation team asked for a complaint: if she was asked to tell a family that her child had died, thank you for providing this information before entering the hospital. piece. A doctor in the room stood up to say that he had never thought of doing that before and that he would never put a translator back in this situation.
It's "hands-on": Sleeves at Kaiser San Diego
The Kaiser Permanente Medical Center in San Diego, an outpost of the national health care consortium in Southern California, treats thousands of patients each year. Last spring's Schwartz Center meetings focused on a pervasive, but rarely acknowledged, problem of patient discrimination against hospital staff.
The first of the three panelists to speak was a nurse. Speaking carefully, he recounted that he had entered a room equipped with curtains to take care of a patient, but that he was blocked by a member of his family who assumed – precisely in this case – that the nurse was homosexual.
"Go on," shouted the man. "You are dirty. You are disgusting. He pushed the nurse out of the curtain booth. The patient had a critical emergency. Her family chose to delay her treatment for an additional hour – and risk her life – so she could locate a new nurse.
"My compassion should not change because others see me, but it requires practice," said the nurse, her voice wavering slightly from emotion.
The stories started to flow. The grotesque racist patient who threw bed pans on any color healer who entered his room. The man saved from death by the experienced and diverse staff of the hospital, who insisted on having a white doctor only once he was fit enough to speak.
Another doctor said that after being treated by a patient, she discovered that only people outside the medical profession were really friendly. Her fellow doctors rationalized so many similar experiences that they could not understand what she had experienced. Later, another woman stood up and shared, with a note of surprise in her voice, a sexually abusive thing that a patient had made her. She had never told anyone, she said. There has never been a moment when she felt able to do it.
In a speech made in 2018 at UCLA Medical School, Atul Gawande, doctor, writer and health sector leader, said that people generally opt for medicine because they believe everyone has the same right to receive care. In practice, it is difficult. Rogues fall ill, as abusers, rude and generally decent people, except when they are afraid and they hurt.
"To consider people as having a life of equal value means recognizing everyone as having a common core of humanity," Gawande said. It is not possible to be open to the fullness of another person's experience if you are never given the space to deal with the confusing, painful and frightening parts of your life.
"Hello, I am also a person"
Despite all the time and money spent trying to find a way to prevent physician burnout, addiction and suicide, there seems to be a transformative power of simply saying "C" happened, and it was nil "in a room people who understand.
Research on cycle efficiency is limited but encouraging. An independent evaluation commissioned by the Schwartz Center in 2008 found that 84% of US Round participants reported feeling more compassion for patients and their families as a result of the program, and 90% better communicate with their colleagues.
A study conducted in 2012 on series of pilot tests introduced in two hospitals of the United Kingdom's National Health Service revealed similar support from staff.
"I really enjoyed the language. You hear used words that you do not normally hear, such as anger, guilt, shame, and frustration. They are obviously present, but there is no outlet for them, "said one participant. As another said, "I was a skeptic and now I am a convert."
Doctors, nurses and caregivers play a special role. In the literal questions of life and death, they are considered as the guardians of health, of the freedom of the hospital, of pain. It's a huge responsibility that goes with a great reward on the best days and challenges, and almost every day.
"The old school had the habit of dealing with this:" We are the best, we are tough, we do not sleep, it's not great, "said a Kaiser doctor. I think it's different.The new generation says, "Hello, I'm also a person."
But it is not only healing practitioners who see their empathy tested regularly at work. These are the police, the teachers, the parents – almost everyone who is asked to give their time, attention and understanding to others, again and again, so tiring or so long of the day has been.
Schwartz Rounds is important, not only because most people will have an interaction in a hospital as a patient, to be loved or caregiver, but also because compassion is necessary to our fundamental functioning as being human. It is also a resource that can be both exhausted and renewed. To do this, we must give people the necessary space to support themselves.
It is not impossible to imagine Schwartz Rounds programs operating in a variety of professional settings. All it takes is a room, a confidentiality agreement and a willingness to share and listen.
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