What Can Physicians Do?

Preparing for the unimaginable.

Posted Mar 21, 2020

Physicians are an interesting mix of rugged individualists and dogged rule-followers. Our training teaches us to think independently, to be critically analytical, to be endlessly curious, and to refuse easy assumptions. But we are also taught to adhere tightly to policies, regulations, legislation, standards of care, and cultural norms to avoid painful consequences. In recent years, avoidance of negative consequences has overshadowed rugged individualism as more physicians have transitioned out of private practice into employed positions.

That transition has created a cohort of physicians with less latitude to make decisions on their own. They are more accustomed to following guidance from corporate leadership and to being chastised for thinking outside of corporate boundaries. They are also finding themselves more often in double binds—knowing the care their patients need but being unable to provide it—and at risk of moral injury.

What happens in this environment when a situation arises that no one has ever seen before? How do we prepare for the unknowable, and perhaps even the unimaginable? How do we protect ourselves, our coworkers, our families, and our patients (not necessarily in that order)? How do we respond when what we believe is right does not align with what our employer expects, or what the reality of a given moment allows? 

A distressing dilemma facing U.S. clinicians already, just weeks into the pandemic here, is the scarcity of personal protective equipment (PPE) [i][ii]. Lack of PPE puts clinicians in the impossible quandary of not only putting themselves at high risk, but also potentially acting as a vector for viral spread, and risking all those with whom they come in contact later.

Do you tend to the patients in need right now, at risk to yourself and others, or do you delay care for those in need now, so you do not weaken the healthcare workforce or contribute to the contagion? This was a reality during the Ebola epidemic, as well. Those who rushed in often contracted the illness and many died. Those who took the time to properly don and doff PPE survived, continued caring for patients, and returned to their families when the epidemic passed.

Some suggestions for how to prepare yourself for exquisitely difficult decisions that may be ahead:

  1. Think. In quiet moments before the tidal wave hits, think through scenarios. Look for literature [iii][iv] that might guide you, adapted to your institution and specialty. Seek spiritual guidance, if you feel it would be helpful. Be sure you are clear with yourself about how you would respond if you did not have PPE.
  2. Talk. Find out if your institution has put policies or procedures in place to manage difficult decisions. Establishing constructs such as crisis teams or ethics panels to shelter clinicians from the individual burden of making wrenching decisions about severely constrained resources is critical. Talk through contingency plans with your family, for minimizing risks to them.
  3. Act. The landscape of a pathogenic wildfire such as SARS-CoV-2 may shift by the hour. The operational tempo in clinical spaces may far outstrip the op tempo possible for even the most efficient large organizations. Therefore, waiting for guidance may lead to frustration, feeling misunderstood, and being perpetually behind in preparedness or response. It may magnify already existing moral distress or injury. Leadership is not a title; it is a mindset. Adopt it and implement it. Make changes where necessary and ask forgiveness much more often than you ask permission.
  4. Support. Ask for help when you need it, and offer it in abundance when you can. This is going to be a very long, difficult campaign. If you need sleep, help with a decision, or a minute of quiet to get centered again, ask for it, and offer it in return. This is not a time to be a rugged individualist, but a time to be a flexible, adaptive collaborator.

There are no easy answers to a situation that is like nothing the vast majority of us have ever seen. We may expect herculean efforts and perfection from ourselves, but to get through this, we will need an abundance of forgiveness, solidarity, and courage.

References

[i] https://www.forbes.com/sites/billfrist/2020/03/20/a-call-for-national-leadership-to-stop-the-protective-equipment-shortage/#63c98dff2d9

[ii] http://www.cidrap.umn.edu/news-perspective/2020/03/who-warns-covid-19-related-protective-equipment-shortage

[iii] https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf

[iv] https://journal.chestnet.org/article/S0012-3692(15)51996-X/fulltext