Demoralization, Depression, and Burnout
When helping hurts
God, I hate the feeling of not being able to help a patient. Hate staring at a CT scan and knowing that there’s nothing left for the surgeon to do.
Hate it.
Earlier last month, on a clinical shift I had at a hospital in the Northeast, I pulled up the CT for a patient who’d been referred to me. We’ll call her Maria, even though that’s not her real name.
She’d come in with a persistent cough, which she’d had for months. It had gotten acutely worse over the last couple of days. The ER immediately admitted her to the ICU.
I work in global health. I’ve seen my fair share of big tumors.
The tumor on that scan was massive. I gasped involuntarily as it loaded. There was no way that thing could come out.
What made things worse was everything I couldn’t control. It turns out that Maria’s presentation was delayed because her insurance had denied her initial requests for imaging. When she came to the hospital, she was, appropriately, triaged behind people with much worse presentations.
She’d also just been told that her ICU admission was not likely to be covered—because who goes to the ICU for just a cough? If the bureaucracy couldn’t be resolved, this one decision would put her and her family out literal hundreds of thousands of dollars.
Maria’s family lived three states away, unable to provide the social support that research showed was crucial for coping with serious illness.
Her husband had passed a few years prior, leaving Maria to navigate complex medical decisions alone.
So, as I walked into that room, to introduce myself to her, and to tell her that she had a tumor the size of a papaya in her neck and chest, I felt a familiar dread come over me—a dread I used to feel on the daily when I worked full-time as a doctor.
It wasn’t just disease I was fighting against. It was the systemic barriers too, the insurance, the bureaucracy, the financial hardship—none of it was within my power to fix, and yet I felt responsible for the outcomes.
This dread used to beat me down, engulf me in a heavy blanket of powerlessness. My lone efforts were insufficient, my surgical expertise flaccid against the onslaught of forces that were completely out of my hands.
There’s a name for that feeling.
Demoralization
By now, you’re used to me writing about burnout. And that’s because burnout is so freaking prevalent that I could build an entire career around it.
(Ahem…)
We’re used to the symptoms of burnout: fatigue, irritability, depression.
But what if burnout is more than that? What if those words are just too glib?
What happened to me—and what’s happening every day in our hospitals, clinics, and ERs—is more than just fatigue and irritability. It’s also distinct from (but overlapping with) depression.
It’s called demoralization.
Source: Markus Spiske on Unsplash
To quote from a yet-unpublished manuscript by the Dr. Abigail Nathanson—who studies demoralization from the patient side:
Demoralization is a psychological state characterized by helplessness, hopelessness, and the inability to cope with significant life changes. It is often seen as a reaction to a stressful situation, causing feelings of overwhelm and lacking the perceived ability to cope with current circumstances... Difficulty in treatment may stem from limited assessment paradigms, and is related to the very real nature of the suffering and the lack of control one has over the outcomes.
(emphases mine)
What drives doctors, nurses, and other health professionals into burnout isn’t just that they’re overworked. It’s not that they’re fatigued or irritable. It’s not that they treat difficult diseases.
It’s that they’re demoralized. It’s that they have very real suffering and a lack of control over the outcomes.
Demoralization and Moral Injury
And yet.
We continue to expect healthcare professionals to show up, day in and day out, keeping their heads down, all for the benefit of their patients. As if we’re just some limitless, fungible resource that can be thrown at an unsolvable problem.
It should be self-evident, but it isn’t. Health care workers are not a superhuman race from whom can be demanded inordinate, incessant, and obedient acts of valor.
We are not an impersonal cadre who can be subjected to the moral injury that comes from witnessing human suffering — especially the suffering begotten by ethically reprehensible decisions — and emerge unchanged.
You can’t expect us to stay awake till 11:30 every night to catch up on our charting, to forgo time with our children and partners, to navigate the frustrations of constantly failing tech, to be the heroes and angels of a pandemic—all while building a system on our backs that only serves to make insurance companies richer.
And you cannot expect us to keep silent about it either, even if speaking out might get us fired.
There’s a quote from Fred Rogers that resurfaces in every crisis. “When I was a boy and I would see scary things in the news,” Mr. Rogers said, “my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’”
Mr. Rogers is right. You will always find us helping. We will always be there. We want to be there.
But unless the system changes, unless it stops driving us into demoralization and moral injury, there will be fewer and fewer of us.
We will break.
We are breaking.
Has the demoralization in healthcare sent you looking for an escape plan? A survival plan?
I was there too. I got out, and I want to help you do the same. Here’s how to work with me:
→ Check out my courses here. They range from 4 weeks to a year, and they take you from “what the heck do I do next” all the way to clarity and a step-by-step plan that honors both your calling and your right to thrive. Click here to apply!
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