The Special Plate

I ache.

A full-body, ears-ringing, head-spinning ache.

I sit at a table surrounded by the chatter of children, but their words remain noise in the background. I look across the table past the eyes of my company as the scene of my morning plays over and over in my head.

Stunned nurses look downcast in the hall outside the room. Wails of grief meet me at the patient’s door. I enter and pull back the curtain to find my patient’s wife in the bed, clutching the chest of the body that had contained her husband just minutes ago. Evidence of a failed resuscitation mars the smooth lines of the body. A taped endotracheal tube jabs the air, an interosseous catheter juts from a tibial plateau, thrust upward by the bed’s head-down position.

I am struck mute.

Sixty minutes prior, the body in this bed belonged to a living 50-year-old father of 4, who told me he was looking forward to going home to recover. He told me that this last admission, for seizure control for his brain metastases, was his “wake-up call.” He was going to spend more time at home, work less, and spend quality time with the wife he loved so much. The same wife I spoke to 30 minutes ago. The wife to whom I gave great news—that her husband looked better than he had all week. That he missed her and loved her so much. The same wife who now was wailing uncontrollably in the bed, clutching a lifeless, gray-skinned chest. The wife for whom I now have no words to offer.

I feel weak.

My work follows me home, and I am powerless to switch off the images that haunt me. I am not in control. I feel guilty that I am not with my family, that my body has left the hospital but my brain has remained behind.

I deflate the balloon and remove the endotracheal tube and interosseous catheter. I level the bed and cover them both with warm blankets. I slump to the bench by the window, my shoulders rolled forward, eyes downcast.

My trance is suddenly broken by my 10-year-old daughter’s hand on my forearm. She reaches across me to remove the plain white china plate from my place setting, and she replaces it with a worn plastic blue one, with ornate patterns on its chipped edges.

“It’s Daddy’s turn with the Special Plate!” she reports to the others.

My fog dissipates, and my family comes into view. My oldest son begins our house ritual of telling nice stories about the person with the Special Plate.

I am no stronger. My pain is no less. But the path to my recovery is clearer. I know that I cannot walk away unscathed from the tragedy I just witnessed any more than I can undo what happened. I realize that finding joy in life’s small rituals will not deflect a similar catastrophe in my future, but it may allay accompanying feelings of regret of small pleasures missed, should that day ever come.

So I reconnect.

The nature of a physician’s work, namely restoring health, requires that physicians immerse themselves in what is sometimes the worst day of their patients’ lives. Caring for patients in the midst of tragedy can be akin to crash-landing a burning plane: Even surviving the landing can take a heavy emotional toll, yet we expect ourselves to jump back into the cockpit for the next ready flight on the runway. We physicians are notoriously poor at attending to our own self-care, which often is cited as a factor in our high rates of burnout.¹

Emotional exhaustion and burnout affect between a third and a half of all physicians around the world, an issue that is now finally getting the attention it deserves from researchers and policymakers alike. Factors that are positively associated with exhaustion and burnout include increasing work hours, loss of autonomy, additional nonclinical responsibilities, debt, and issues of work-life balance.² Others point out that the loss of “community” brought on by time pressures, physical isolation, and electronic medical records (EMRs) that make personal communication less necessary has left physicians more removed from the colleagues that can help them cope.³

Even without these added pressures, the task of caring for those enduring some of life’s biggest challenges makes exhaustion a very natural human response. Those on the front lines of care suffer the highest rates of burnout among specialties, while those with more control of hours and less exposure to patient care fare best.⁴

Interventions to address burnout have focused on techniques to promote physician resilience. Resilience has been defined as the “ability of an individual to respond to stress in a healthy, adaptive way such that personal goals are achieved at minimum psychological and physical cost.”³ Developing resilience means owning up to our limitations, setting boundaries, and allowing us to engage with our work rather than withdraw from it. Self-reflective analysis of critical incidents allows these to become “teachable moments,” and their deconstruction can simultaneously allow for stress relief and restoration. Developing resilience is believed to be key in retaining physician talent, stemming losses in productivity, preventing errors, and promoting professional identity formation in physicians.^2-5 Successful interventions should target both individuals (teaching mindfulness techniques and habits, reflective writing) as well as groups (developing communities for discussion, promoting physical health, and making resources available for crises), as many other high-reliability organizations outside of medicine have successfully implemented.³

For me, ignoring emotions is akin to ignoring EMR pop-up reminders—it just means I will see them again, possibly at an even more inopportune time. Talking it out with colleagues, telling the stories of my experiences to loved ones, and reflective writing have been invaluable outlets for me to recover, to grow, and to continue my path to become more present to my patients, my learners, my family, and myself. 

Anthony A. Donato, MD, MHPE, is the associate program director of internal medicine at the Reading Health System in West Reading, Pennsylvania, and a professor of medicine at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.

References:

1. Gundersen L. Physician burnout. Ann Intern Med. 2001;135(2):145-148.
2. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013;88(12):1358-1367.
3. Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013;88(3):301-303.
4. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166.
5. Wald HS, Anthony D, Hutchinson TA, Liben S, Smilovitch M, Donato AA. Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice. Acad Med. 2015;90(6):753-760.