"The truth is of course is that there is no journey. We are arriving and departing all at the same time." David Bowie
Just over a year ago I transitioned from my clinical and teaching practice at a family medicine residency to healthcare consulting. This was no easy farewell. I would be leaving a residency program where I served as psychologist/clinician, educator, mentor and colleague for 19 years. I was leaving a place where I felt deeply imbedded in an integrated and beloved vulnerable safety net healthcare community in East Los Angeles. The night before I was to announce my resignation, I made a pact with myself that I would do my best to be mindfully present for each and every farewell encounter over the weeks ahead. My connections with others are important to me, and I felt a strong need to honor each relationship as well as I could in the face of this impending departure. I bolstered myself for the emotional intensity to come and made a plan for how I would take care of myself.
My bolstering and planning were imperfect at best.
Over the course of the month, a patient would arrive for counseling, enter into the content of their exploration, and I would do my best to listen and assist. About twenty minutes into the session, I would find a way to say something like, “I have something important to talk to you about our work together…” At this point I would let them know of my tenure at the clinic drawing to a close.
As clinician colleagues, you already can imagine the variety of reactions I received. These ranged from tearful sadness, bitterness, and helplessness to tearful appreciation and celebration of our work together. Blame, abandonment and unfairness surfaced often in our conversations as well. I struggled with having shifted from a source of support to a source of consternation and loss.
The most painful aspect of these conversations was the unfinished work, the ongoing losses and health and trauma challenges, the poverty and immigration and deportation threats that impacted mind, body and spirit. Some of these patients were relatively new to counseling, others had taken advantage of counseling off and on as needed over many years, returning to the safety and intimacy of my office as needed.
This pattern of delivering news of my departure repeated itself hour after hour, day after day, for the entire month. The clinical meetings were punctuated by colleagues and residents stopping by my office to also say farewell. It was hard to catch my breath. I did my best to stay present, but the pull to turn away, to close off and to escape the overwhelming emotions was deep and powerful. This is not an unfamiliar response of medical caregivers in the face of strong emotionally laden patient encounters.
On the other hand, my announcement also invited a rich and unexpected opportunity (from patients and colleagues alike) for conversation about our relationship, our mutual impact, and reflection on life and change and the power of empathic human connection. The immediacy and honesty of these conversations filled me with joy, appreciation and humility. I celebrated the many gifts of profound human connection I had enjoyed in the context of that remarkable community. In these moments, my breath returned deep and full.
When the month of farewells drew to a close, I was depleted and spent. It would take several weeks to find my way back to myself. A year later, I now wonder how I might have managed the emotional intensity differently and more effectively. My self-care model of recuperating wellbeing at the end of each day or two through movement, nature, family, and play now appears less than adequate. I presume I would have fared better if my self-care strategy was woven into the fabric of my encounters throughout the day.
While the stressful situation I describe was unique to my career transition, the larger issue of workforce vitality in health care is pressing and relevant. Health care delivery is an honorable profession marked by concern, altruism and sacrifice. Yet worrying about and intervening with others can be uniquely depleting when practiced in the context of complex patients, uncertainty of decision making, onerous record keeping, and demanding time and productivity pressures. With the arrival of the Affordable Care Act, and in the shadow of health disparities, practitioners and health care systems are working furiously to meet the many pent-up medical needs of patients along with the onerous reporting/documentation requirements of practice. Systematic attention to practitioner sustenance is an essential but missing link in the ongoing effectiveness of the U.S. health care system. This is especially true for practitioners working with underserved and minority communities, and where social determinants weigh heavily on patient health.
Our health system can ill afford practitioners who have lost their calling to care for others. Burnout and cynicism are risk factors for poor quality care, medical errors, and low morale. Moreover, practitioners under pressure are at increased risk for a whole host of medical and mental health conditions. Colleagues who leave their job due to burnout leave a wake of consequences ranging from lost continuity of patient care, to the costs of hiring and training. A colleague who resigns due to stress (or in worst case scenario takes his or her own life) impacts the emotions, morale and workload of remaining colleagues.
What is a practitioner to do? What are key elements of a practitioner wellbeing initiative or policy? What are the costs and losses experienced in organizations that remain insufficiently attentive to the vitality of their practitioners? What is the wellbeing imperative for healthcare organizations? I propose enhanced attention to mindful practice, meaningful practice, collaborative practice, and sustaining practice.
Mindful practice grows out of a tradition that speaks to fully immersing oneself in the moment at hand. It is built on a foundation of observation of self and other. It is bolstered by an awareness that stress lives in the transitions in life. This includes big transitions as in a marriage, a new job or a death. It also includes the small transitions from patient to patient, from home to work and back again, and from work in the clinic to rounds in the hospital. Pathways to mindful practice can include focusing on the task or conversation at hand, minimizing internal thought distractions as possible. Attention to breath can be a very powerful pathway to mindful presence.
Meaningful practice can grow only from the rich soil of reflection. One must enter into a conversation with oneself and others about priorities, values, and calling, and the ways that these are vulnerable to erosion and change in the face of external demands that outpace internal resources. Shared celebration of the successes and positive impact of one’s work on others is essential rocket fuel. An enlightened healthcare organization is one that creates and welcomes opportunities for reflection on the meaning of one’s work, encouraging sharing of practical examples of positive impacts on others. Humanities can provide a powerful on-ramp for just this type of reflection. Consider the words by Rumi from the 13th Century:
Don’t turn your head.
Keep looking at the bandaged place.
the Light enters you.
Collaborative practice facilitates an interpersonal approach to patient care. This encompasses shared decision making models and optimally functioning health care teams. Success in each of these arenas requires investment in learning innovative ways of communicating and of navigating conflict while enhancing nurturing. Collaborative practice is built on a strong foundation of listening, caring and expressed empathy. In the hectic pace of healthcare delivery, is there a place for appreciation and gratitude for patients, colleagues and for oneself?
Sustaining practice draws upon finding joy in one’s work and in one’s life. It grows from the rich soil of social support and humility. For me, mindful movement, immersion in nature and the richness of sharing time with family, friends and beloved colleagues are powerful sources of sustenance. Enlightened leaders in healthcare are willing to take on the impressive task of considering the costs (financial and otherwise) and benefits of practitioner vitality initiatives that support a humane life balance.
So if life is in fact a series of constant and simultaneous arrivals and departures, it makes sense to do what one can to be there for all of them. It makes sense to show up and to pay attention. It lends an argument for enduring the painful farewells and for celebrating the precious reunions. And it makes sense to share this wisdom with others who are arriving and departing all around us all of the time.
Jeffrey M. Ring, Ph.D. is Principal at Health Management Associates where he works with health care organizations and medical education programs to provide innovative whole-person integrated behavioral health care to vulnerable and safety net populations. As a certified leadership coach, Dr. Ring works with leaders and teams to strengthen effectiveness and efficiency. Most recently, he is involved in projects aimed at improving practitioner and team wellbeing. He is Clinical Professor of Family Medicine at the Keck School of Medicine at the University of Southern California, and is the first author of Curriculum for Culturally Responsive Health Care: The Step-by-Step Guide for Cultural Competency Training (Radcliffe Oxford, 2008).