Burnout: a work-related constellation of signs/symptoms, often without prior psychiatric history. Marked by existential crisis, emotional exhaustion, and depersonalization. That’s academic. I described what it looks & feels like at @MassGeneralNews @acgme @TheIHI [THREAD]
Early in intern year, I was caring for Mr. V, an elderly HD patient. 1mo earlier, he was living independently & working at HR block. Now, he was admitted with delirium. I couldn't figure out why. I couldn't fix it. Weeks went by. He floundered on the service, sicker by the day.
After 14 inpatient days, we finally diagnosed Mr. V. Months before, PCP prescribed Morphine CR- normally cleared by the kidneys, but his didn't work. It made him sleepy enough that he missed HD once, the start of a downward spiral. Perhaps an error was made that day by his PCP...
But the real error was that morphine was still on the ACTIVE MED LIST, given 2x/day for 2 WEEKS. I was poisoning him. I fixed it & Mr. V was lucid... but it was too late. He had chest pain. I stepped out to get an EKG. When I returned to the room, I was alone. He was gone.
This hit me hard. Really hard. I had just started as an MD and I felt singularly responsible for a medical error that killed a man.

I worried it would happen again, that I was the problem. It was the beginning of an EXISTENTIAL CRISIS- starting with the imposter syndrome.
Took a long time to shake off "I'm not good enough for this work."

... but 5 services were involved including renal & palliative, pharmacists & RNs who deal w this every day- EVERYONE missed it. A systems error led to my 'reduced sense of accomplishment,' to existential crisis.
What about EMOTIONAL EXHAUSTION? As an intern, @paullongMD cared for a man w osteomyelitis 2/2 IVDU. MRI showed extensive bony destruction, unclear acuity. Needed recent scan from hospital nearby to compare images. No problem, right? Paul makes the calls, sends a request...
Gets report, no disk. Calls again, disk made, but not mailed. He sees pt daily, ashamed, asks for more time. Pt is itching to use. 5am one dark winter AM, Paul bikes to the other hospital, effortlessly gets the disk. We review images. Plan: surgery. Paul goes to patient's room...
…only to find an empty bed. Pt eloped, never seen again. Soul crushing for intern who "moves mountains" to get things done only to fail. Repeat all year and you get EMOTIONAL EXHAUSTION. You stop trying. You CAN'T try anymore. Broken systems lead to emotional exhaustion.
Depersonalization, now, that’s a strange word. Let me explore it with a story from the amazing & inspirational @RanaAwdish. Rana was 7mo pregnant when she presented to L&D at her hospital with excruciating abdominal pain. She is terrified and on the verge of hemorrhagic shock...
The OB resident is at her bedside to ultrasound baby. Rana is an intensivist & ultrasonogropher, so she makes the diagnosis first. “there’s no heartbeat.” The resident, staring at the ultrasound display, says, “can you show me where you see that?"
She had just realized that her child had died in her womb- while critically ill. The resident was entirely oblivious.

Soon after, she is a patient in her own ICU (!)

Resident visits, plans to apologize... but ends up in tears, complaining about how hard the night was on him!
I can imagine how he felt: ashamed. When I've felt that degree of shame, I withdraw. No one understands it, so I pull away. Relationships wither with patients, colleagues & family. Everything is replaced with cynicism-- that's DEPERSONALIZATION, a consequence of broken systems.
So that's burnout - existential crisis, emotional exhaustion, depersonalization.
Or, to put it more simply, "the light inside is broken but I still work," (for now) - - thanks @psirides for the photo.
When our systems fail us, they wound us, and that wound can fester. It isn't an accident, because "every system is perfectly designed to get the results it gets” - Paul Batalden & Arthur Jones
Burnout has an impact on everyone, not just the clinician. Patients have lower satisfaction & increased harm, especially increased nosocomial infections & medical errors (more errors w higher burnout scores) and higher mortality rates. #ptsafety nam.edu/clinicianwellb…
For more info check out the @theNAMedicine resources on wellness. More coming soon as I begin my research at the intersection of burnout and #ptsafety in the ICU! nam.edu/burnout-among-…

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More from @laxswamy

Jan 17
It's six AM. I'm still in bed and my eyes are barely open. I reach for my phone. I check my email. Last night's sign out just arrived. I scan last the names I don't recognize, looking for one in particular... 🧵
I admitted you just hours before, just a few days into your symptoms. You got sicker fast. I remember you insisted that intubation 'wasn't within your wishes' to every clinician before me. I wasn't so sure...
You were in your 50s, no major health issues. Didn't like doctors or the healthcare system. I recognized the fear. I walked into your room. I knew how this would go- nothing new. I introduced myself- "I'll be the senior ICU doctor taking care of you. Is it ok if I examine you?"
Read 19 tweets
Dec 3, 2021
Does every admitted patient need a code status discussion? @AvrahamCooperMD and I propose a more individualized & patient centered approach. The current 'checkbox' practice leads to superficial discussions & inaccurate code status determinations.
sciencedirect.com/science/articl…
Both @AvrahamCooperMD & I have thought about this quite a bit since we were interns. I still remember residents asking me after I presented an H&P for a low acuity admit, "did you remember to ask code status?" not because it was clinically relevant, but because it was a To Do ✅
It isn't uncommon for me to hear from floor patients admitted overnight, "am I going to die?" not because they are so sick but because they were so scared because of the sudden code status discussion the night before. We can cause a lot of fear and anxiety if we're not careful!
Read 8 tweets
Oct 18, 2021
I had the chance to speak about individual well-being strategies... I opened by saying it's like asking a patient coming in with gunshot wounds if they've had their colonoscopy yet. It is a hard subject to talk about... 🧵#CHEST2021
I started with what I think of as 🚩🚩🚩 when I hear about wellbeing. Especially during covid. Especially in the ICU. See this thread for more! #CHEST2021
For the next portion of the talk, I share content from an AMA module I helped write for medical students in toxic or stressful environments. I think a lot of it applies to all of us in 2021. #CHEST2021 edhub.ama-assn.org/med-student-le…
Read 15 tweets
Mar 2, 2021
Highlights from an ICU delirium talk I give to the residents, please share your thoughts & feedback! Image credit: deliriumcarenetwork.com/art.html artist depiction of delirium in the hospital
Delirium: An acute change in attention, awareness and cognition caused by a medical condition that cannot be better explained by a pre- existing neurocognitive disorder. Often reversible.

Drugs don’t work to treat it... but they can precipitate it.
Patients often have altered arousal- from reduced responsiveness at a near- coma level (hypoactive) to hypervigilance & severe agitation (hyperactive)

Hypoactive delirium is a/w worse outcomes, including ⬆️mortality, ⬆️length of stay, ⬆️falls and institutionalization, lower QOL.
Read 33 tweets
Feb 27, 2021
I love working in the ICU. So much of what we do is just trying to reduce the harm we inflict keeping people alive long enough to either get better or not. The harm is immense despite that ... 🧵

cw: icu trauma
ICU patients, more than most any other, lose autonomy. Most icu patients can't make decisions about anything- either you're sedated or too confused or otherwise incapacitated. Imagine having no say in whether a needle goes in your body.
I'm not even talking about the really invasive stuff. Imagine having literally no say about how your body is positioned, turned. No control over your bladder or bowels. No control even being awake or asleep.
Read 10 tweets
Jan 13, 2021
More hospital strain is unsurprisingly a/w worse outcomes. As mentioned, a lot goes into the occupancy of beds suitable for mechanical ventilation: the bed/room and equipment- one MV bed is not always like another (are you in a converted unit)? but especially...STAFFING!🧵
In ideal circumstances, a sick ICU patient on a ventilator has a dedicated ICU nurse focused only on their care and a multidisciplinary team- a doctor, respiratory therapist, pharmacist, all seeing more patients but not so many that they can't give attention as needed...
Ideally, the other ICU RNs will have a good pt ratio too. When a pt needs extra attention (quite often with COVID), the bedside nurse notices changes quickly, extra nurses are on hand to help, and the doctor/others are available for immediate assistance and evaluation.
Read 12 tweets

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