BY: MARILYN "MIMI" PATTISON, MD
Dr. Pattison is medical director, Franciscan Hospice and Palliative Medicine Services, Tacoma, WA.
Editor's note: Marilyn "Mimi" Pattison, MD, attended CHA's eighth annual Physician Leader Forum on Amelia Island, FL, in November 2005. The forum's keynote address was delivered by Robert Wicks, PsyD, chair of the Pastoral Care Department, Loyola College, Baltimore, and the author of many books on spirituality and healing. After reflecting on Wicks's talk, Dr. Pattison wrote the following article.
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Summary
Although they are healers, physicians are not themselves immune from "secondary stress." In fact, they may be more susceptible to it because they tend not to acknowledge the fact that it exists.
In this article, the author, a hospice physician who is a former nurse, explains her personal strategy for combating secondary stress: increased emphasis on maintaining a healthy personal spirituality. Her approach includes morning reflection during her morning fitness activities, making time for family and leisure activities, and, most importantly, incorporating spirituality into her daily work.
Bringing her spiritual self to the office and invoking spirituality at the "right" time — not just at set, convenient times — has helped her deal with today's challenges: time pressures, the threat of litigation, reimbursement issues, and misaligned incentives.
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"To stand in the darkness" is a metaphor I recently heard employed in a presentation by Robert Wicks, PsyD. It is a metaphor that certainly describes how most physicians nowadays see themselves. The "darkness" around us is real and ever-present — time pressures, the threat of litigation, reimbursement issues, misaligned incentives — the list sometimes seems endless. But Wicks's talk helped me see this "darkness" from a new perspective. I now recognize that all caregivers are at risk of "standing in the darkness" and that all can benefit from self-care. I'd like to share this perspective in this article, hoping that readers find it as encouraging as I do.
Secondary Stress
I am a hospice and palliative medicine physician (and a former — one might say "recovered" — nephrologist). As such, I see deep sadness, all stages of grief, and loss every day. The hospice field is unique in that it encourages self-care for the caregiver. Even so, physicians tend to assume they won't need it. They tell themselves that secondary stress — stress suffered by people who interact with trauma survivors — "cannot happen to me." "After all," they think, "I am a doctor and above all that."
At times, I used to think that way too. However, now that I've had an opportunity to hear Wicks speak about secondary stress, my perspective has changed. We physicians all "stand in darkness." In our work, virtually all of us suffer secondary stress, to varying degrees. It is tragic that the medical profession acknowledges only severe cases of secondary stress, cases that require medical help. What about prevention and early intervention? Don't we preach those every day for our patients? Why don't we seek prevention and early intervention for ourselves?
Wicks argues that secondary stress has three components:
- Chronic secondary stress, sometimes called "burnout" or "compassion fatigue"
- Acute secondary stress, sometimes referred to as "vicarious post-traumatic stress disorder (PTSD)"
- The unique unhealthy aspects of the medical health care culture today
We physicians all readily identify with these components, realizing that we have no choice but to face the systemic stresses in medicine. Our challenge is to find the inner resources that we need to face them.
"Put Jesus in Your Pocket"
Of course, each person has his or her way of dealing with secondary stress. In my own case, an upbringing in a strong Catholic faith has provided me with a foundation for "standing in the darkness." The Sisters of Charity of Leavenworth helped mold that foundation during my training as a nurse (before going on to medical school). And the privilege of having worked in Catholic health care for the past 15 years has reinforced that belief system.
What is that belief system? It involves belief in a greater being, for one thing. It also involves finding meaning and purpose in my work, work that follows in the healing footsteps of Jesus. It is a system that appreciates the life cycle, spiritual presence, and basic Christian beliefs. My belief system also emphasizes the importance of commitment. A favorite saying that has guided me is: "Until I am committed, there is a hesitance, a chance to draw back. But the moment I definitely commit myself, then God moves also, and a whole stream of events erupts. All manner of unforeseen incidents, meetings, persons, and material assistance which I could never have dreamed would come my way, begin to flow toward me."
My commitment to medicine helps me maintain a calm attitude in stressful situations. My colleagues are often intrigued by the cheerfulness with which I approach hospice care; so are patients and their families. "How do you do this work?" they ask me. "I love my work," I tell them. "I've grown into it." "Thank God for you," they say. What I say to myself is: Thank God I have found this work.
To have spiritual sense and meaning for the work I do every day allows me to "stand in the darkness" and yet remain whole — challenged and stressed at times, but still able to experience peace and joy.
I am often called upon to "deal with" family members who are overwhelmed with grief and disbelief. Staff members call to say, "We need you to come work your magic with this family — to "turn this around"; to "stop this prolonged dying process" — or some other such seemingly impossible request. But I am not a magician. I am a faith-based physician privileged to practice in Catholic health care.
Taking this approach to caregiving certainly doesn't occur automatically or without God's grace. Years ago, on a day when I was feeling overwhelmed about an upcoming family conference, I was given a great piece of advice. "Put Jesus in your pocket," I was told. "If you show up, he will do the work." Talk about magic! Those words have been magic for me. I often say a brief prayer for inspiration as I enter a difficult situation. Doing so helps me feel more grounded and open to higher influences. When that happens, giving difficult news comes easier.
The Story of R. T.
Does all this help one deal with secondary stress and be able to "stand in the darkness?" Unquestionably. Positive results from interventions also help. Let me share a recent story with you. R. T., as I will call him, was a 78-year-old gentleman with advanced chronic heart failure. He had recently undergone heart surgery that had not improved his status. Because he was at high risk for dying soon, I was asked to see him and offer him hospice care.
R. T.'s family surrounded his bed as he explained to me that the surgery really had not helped and he was not doing well. I spoke gently with him about the fact that we thought he would die soon and that I was here to help him and his family. I said that we had a different type of care — comfort-focused care for him and care and understanding for his family. His color turned more ashen. He was diaphoretic and short of breath as he grabbed his wife's hand and declared, "I feel so much better now. I know where I stand. We need to talk."
Tears filled the eyes of most of those present as we watched R. T. move into different space, the spiritual world of dying. There was so much light in that darkness — one did not have to look very far for it.
R. T. died within 36 hours of our conversation. His symptoms were well- controlled, and he died peacefully, with family members at his bedside. The medical student accompanying me that day had a profound experience to share later with classmates — an experience that, I trust, will mold his professional career. I look forward to seeing R. T. again, someday, somewhere. Thinking about him reminds me that when we caregivers take care of ourselves "in the darkness," we help not only ourselves but also our patients and their loved ones.
The "Right Time" for Spirituality
Wicks says that spirituality should be invoked at the right time — not at the end of the day, but at the right time. For me, the right time is often before a difficult intervention, and at the beginning and end of a family conference. Prayer, usually led by a chaplain, opens and closes difficult times with grace. Such interventions and prayers can't always be scheduled, however. One must make a conscious effort to recognize the time appropriate for them — they do not "just come naturally."
For me, the concept of a "right time" for spirituality also applies to how we handle caregiving challenges. To my colleagues I say, "Believe what Wicks says. Read his works or, better yet, take the opportunity to hear him speak. We are all affected by secondary stress. How are you handling yours?"
I feel comfortable with the ways I have found to handle secondary stress. My approach includes morning reflection during otherwise boring physical exercise; self-care, including time for family and fun; but, most important, incorporating spirituallity into my daily work. My Catholic health care system allows me to do that. I would like to see other systems give their physicians opportunity and encouragement to do it, too.
We physicians must remember our roots in the history of our caring profession. We must work within our faith beliefs and practice them daily. And we must allow spirituality to be OK in medicine, not just in private or at worship services. It is OK — some say it is even "magic."
Copyright © 2006 by the Catholic Health Association of the United States
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