Year's End

The last day of the year brought with it patients in every manner of crisis. A patient called in tears, certain that she has brain cancer, her head feeling like it is splitting in two.

"I want one of those things where they put a hat or something on your head. Oh, what is it?"

"An EEG?" I ask, grasping at straws.

"Yes, that's it! I want that!" she yells, dissolving into more tears. "And I think I have throat cancer, too."

The next call revolves around---what else? Narcotics.

"Why does the doctor want to decrease my oxycodone? I only did heroin once and it was just to celebrate. I won't do it again."

Again and again the calls come in, like everyone just seems to need to put their crises in my lap before the year is over. Maybe it's just pay-back for planning to leave altogether. Several patients manage to suck me in today, and I feel emotionally triggered by the ferocity of their trauma, my mind working with my psyche to mitigate the damage.

The highlight of my day is delivering bottles of sparkling cider to some of my favorite patients, leaving behind a smidgen of New Year's (non-alcoholic) cheer. A few shared laughs and blessings bestowed upon me round out the day, keeping me from sinking beneath the onslaught of unquenchable need.

Home embraces my weary bones like a treasured balm. Thoughts of what has proven to be a quite difficult and trying year lead to wishes and desires for a kindler, gentler year in 2008. Personal loss, worsening illness, and the physical manifestations of stress and burnout have all come home to roost this year. Through it all, I have tried to maintain a healthy "witness self" who watches the wheels without going under---a frequently Sisyphean task.

In 2008, I will leave my full-time job of seven years, piecing together a new way of earning a living, manifesting improved health, shrugging off the ills of undue stress, and re-embracing creativity and spontaneity. No resolutions, no promises, no enjoinders. Just a healthy desire for change, for health, and for a new chance to do it better.

Happy New Year, many happy returns, and may all beings everywhere be free from suffering.

The Countdown

The countdown continues as I face only 14 more work days before my full-time employment ends. As I connect with patients and inform them that I am leaving the practice, the reality of the change sets in. I also realize that some of my patients' lives will indeed change radically as they negotiate new clinical relationships that may or may not serve them as well as their relationship with me has done.

In terms of what I have done for patients, frequently going the extra mile---both literally and figuratively---I wonder if my going that extra mile has truly served them well. Having done so, their expectations may be that subsequent clinicians will do what I have done for them, and in this assumption they may indeed be sorely mistaken. If that is the case, did my going that extra mile only foster dependence and disempower them from a more proactive approach to their own care?

Enabling behavior among clinicians does occur, and in my (current) line of work---care coordination for the disabled and vulnerable---we are all guilty. However, if enabling does go so far as to disempower, then what has truly been served, the patient's needs or the clinician's own guilt?

For myself, this is the end of an era. It is the end of being in long-term therapeutic relationship with patients. It is the end of being a fixture in patients' lives year after year, through births, deaths, tragedies, and the inescapable comedies of error. It is the end of that feeling of responsibility of carrying the details of the care of so many on my own shoulders. I have gained much from that responsibility, and it has certainly fed my own need to be so needed. But is being so needed really all that it's cracked up to be?

As for my patients, they will survive, and they will navigate the new world without my presence however they can. Some will latch onto a new provider, some will simply fade into the healthcare woodwork. Abandonment issues will surface for some, and the more functional of these individuals will work through those issues and come out on the other side. For a few, I will just be one more well-meaning and earnest clinician who danced in their life for a while before spinning out of orbit like so many others before me.

In one exchange with a patient to whom I was breaking the news of my imminent departure, my patient said something about the fact that we had "done so much good work together" as if it was now all lost. My response was to counter that statement by framing it in the light of forward movement, of her new ability to build upon that foundation and realize more of her innate potential for self-directed advocacy. She agreed, but maintained her assertion that it was a loss of large proportions.

That day of finally closing the door on my seven-year sojourn---January 18th---is close on the horizon. What happens between now and then is only one part of the story. After that, a new chapter begins, and I will write that chapter with great interest and care. Perhaps it is already written and I only need to find it within myself.....

Pity vs. Compassion

"When your fear touches someone's pain it becomes pity; when your love touches someone's pain, it becomes compassion."

---Stephen Levine


Facing a return to work today after a long weekend, this quote speaks to me. It speaks of one of the touchstones of being in a helping profession, and of a life-long journey centered around developing, nurturing, and propagating compassion.

In the face of professional burnout, one can easily turn away from compassion, lose sight of it, and move into less therapeutic and unhelpful territory. This is what one might call compassion fatigue. Pity is an ugly cousin of compassion, but burnout can lead into much uglier territory still, like resentment and anger. Leveled against clients and patients, these emotions whittle away at the therapeutic relationship, leaving nothing but the starkest of connection. These manifestations essentially poison the well of compassion, but hopefully not beyond repair.

For myself, I am extricating myself before the damage is done, to me or others. I am exiting stage left with my compassion fatigued, but still intact and heartfelt. While I may feel badly for those patients whose abandonment issues will be stirred up by my leaving, better for them to face their issues than to face my loss of compassion.

Transitions are never easy. As the year comes to a close, change is inevitable, and I ready myself for the shifting sands and the equally inevitable challenges that change will bring. I will also endeavor to help my patients to do the same.

Phone Conversation: An Exercise in Boundaries

The phone rings at my desk.

"So," a voice says through the receiver. "Can I get my oxycodone prescription today?"

"Your oxycodone prescription?" I respond. "Is this __________ calling?"

"Yes, it's me. I need my prescription now! You've kept me waiting!"

"Now wait a second. You spent the whole weekend snorting heroin and I sent you to the ER in an ambulance because you were wandering your building naked and hearing voices," I say. "You also had a machete on the kitchen counter. I thought you were in danger. And now you want your oxycodone just like that?"

"Yes. I'm in pain and I need it and now you won't give it to me. Jesus Christ!"

"Listen." I try to be patient. "You were out of control this weekend. Even your son said so."

"But I was celebrating! Can't I celebrate like anyone else?"

"Well," I say. "You could have taken a friend out to a nice restaurant to celebrate. Or maybe gone to a movie and bought yourself something nice at the mall. Instead, you chose to go out on the street, buy some heroin, and then spent most of the weekend psychotic. How can we trust you with a bottle of oxycodone?"

"C'mon! I need my meds! You can't refuse to give me my meds!"

"Well, this is the story. I have decided that I will give the bottle of meds to your visiting nurse. She will keep the meds in the lock box and give you four pills every morning for you to take throughout the day. Then the next morning you'll get four more. That's the deal. Either you accept what I'm offering or you get no narcotics at all. No arguments. No bargains. Period."

"No, no, no. You can't do that. I need my fucking meds now!"

I sigh. "Look, _________. This is it. Take it or leave it. I have your prescription in my hand and I'm about to go find the doctor to have her sign it. I can just as easily shred the prescription and we'll talk after Christmas."

"OK. But I'd better get my meds!"

"I'll have the doctor sign your script now, as long as she agrees to my plan. But if you use any more heroin, take any street drugs, or do anything like that again, I guarantee you she'll stop writing those prescriptions right away."

"OK, OK," she grumbles.

"Merry Christmas, my dear."

"Yeah, yeah. Bye." She hangs up.

I hang up my phone and my colleagues applaud. An exercise in boundaries? Sure. And patience. And compassion. And insanity. Was I really on a leave of absence just five days ago? It seems like an eternity.

Running for My Money

Today was one of those days where this line of work can give an earnest Nurse Care Manager a run for his money. (And I do certainly feel like I'm running for my money today.)

First, there's the patient with acute psychosis who apparently went on an inhaled heroin binge this weekend to celebrate finishing a very important multiple-month medical treatment. She told me that a friend had suggested going out to a fancy dinner instead of blowing her money on heroin. "It was actually a pretty good idea," she said with a laugh. After discussing the voices in her head and her non-compliance with taking her medications, she agreed to go by ambulance to the ER for an evaluation.

Another patient just seems to be having a hard time getting his life on track (a familiar complaint and observation here at "Train Wrecks 'r' Us". I feel deep compassion for his suffering, but sometimes it seems we just have to sit and let them work it out themselves.

The next patient complains about my long leave-of-absence, and says over the phone, "You mean, you've been back since yesterday and you haven't called me yet? I missed you so much!" How will I break the news to her that, in five weeks, I'll be permanently gone from her life?

Still another patient hears the news of my imminent departure and says, "Oh no! Another doctor leaving me behind? What next?" (She always refers to me as her doctor.)

These and other reactions are enough to make me feel guilty for leaving, but then I simply remind myself of the reasons why I'm leaving, the multiple stressors, the fast pace, the overwhelming feeling that I am running a race with no end in sight. I've been running like this for seven years, and working full-time for eleven.

We all run for our money in many ways, and any line of work will generally keep one running. This particular line has simply worn out the treads of my old Nurse Care Manager tires. I'm just due for a tune-up, some new treads, and a new place to run. In old-fashioned terminology, I'm "plum worn out" and have opened myself up to a new way to make my living in the world. The hardest part of that process is saying goodbye, and that is without a doubt par for the course.

Hello and Goodbye

I returned to work today following my six-week leave of absence, and while it was nice to say hello to friends, colleagues and patients once again, the reality is that I also have to begin saying goodbye as soon as I say hello. With my exit (stage left) planned for January 18th, time is of the essence to begin the disengagement process. It's an interesting exercise, and long-disused emotional muscles are being flexed as we speak. And when new muscles are flexed, we all know there's some growing pains.

It's easier than I thought to get started. I have to try to say goodbye to more than 80 patients, many of whom I have worked with for seven years, sharing numerous ups and downs and the challenges of poverty and chronic illness. Having begun, saying goodbye is not as difficult as I imagined. Then again, I have yet to speak with the patients with whom I have shared the most closeness and emotional intimacy. That is where the emotional rubber meets the road.

I was on the phone with one particular patient today. I told her I would be leaving the practice on January 18th. She seemed to take it in stride, said she loved me and would miss me, and agreed to get together next week for what would probably be our final visit. Another patient simply said, "Why are you leaving? Is it for more money?". Well, not exactly. Just more time at home.

One of my favorite patients, a vulnerable twenty-three year old young woman---a year younger than my son---was the most wrenching goodbye to date. When I broke the news to her over the phone today, I felt myself wince, and I could hear the strain in her voice. We agreed to meet at her home on Wednesday to check in. That therapeutic relationship will be one of the most difficult to terminate. That is the first small pain of this process.

So, five weeks of goodbyes, explanations, the transfer of crucial information, and the formulation of a new work life. An interesting way to end a year-----and to start anew.

It's the End of My Leave as I Know It (and I feel fine)

Well, dear Reader, tonight marks the end of my six-week medical leave of absence from my full-time job, with Monday morning's return to my Nurse Care Manager's desk in approximately 14 hours from the time of this writing. So, what did I accomplish on this leave of absence, you ask? For posterity and my own edification, allow me to enumerate:

Resignation: first and foremost, during this period of time for reflection and self-care I came to the earth-shattering conclusion that I can no longer sustain the pace of my position, and I submitted my letter of resignation. While I return to the fray tomorrow at 9am, I enter only briefly, knowing full well that, come January 18th, my tenure at that position will have come to a timely end. Saying goodbye to beloved and respected colleagues will be difficult, but most challenging will be terminating my relationships with dozens of patients, many with whom I have shared a great deal over seven years. Be that as it may, the decision feels right, and I'm sure I'll process some aspects of it here on Digital Doorway. It's like giving up a part of my identity, both as a person and as a nurse, and the letting go (and grieving) process has already begun.


Hospice: I have applied and been hired for a position as a per diem hospice nurse at a small residential hospice not far from my home. I hope to complete my orientation there quite soon, and begin to pick up shifts as they become available. A goal long postponed.


New opportunity: I have contracted to serve as a Nurse Consultant for Nurse LinkUp, an online nurse networking community for which I previously provided occasional articles. When the site is re-launched, I will be providing original content, recruiting members and advertisers, and using my experience as a nurse to influence the development of the site.

Self-care: acupuncture, a sleep study, psychotherapy, rest, exercise, rejuvenation, solitude, writing, reading----I have had almost as much of these as I wanted (though a few more naps would have been nice......)


Home-care: laundry, organization, an enema for the basement, cleaning, winterizing---good medicine for the nurse with OCD.


Business idea: the development of stress management and burnout prevention workshops for nurses and other healthcare professionals.


Technological upgrade: we did it---we switched to Mac from Windows, and I am reveling in the change! Eat your heart out, Bill Gates!

The importance of decreased stress: the most crucial accomplishment and realization of these six precious weeks has been the need for decreased stress in my life. How else could I have cultivated the needed distance to realize that my stress level was leading me on a path of chronic stress-related illness and dysphoria? Without such a radical decision (with thanks to my wife Mary for pushing me), there may not have been a renewed commitment to self-care, and a realization that working full-time, 9-5, was just not working for me anymore. Not working? Nay, it was not working, and I was not fully living. I was caught in the maelstrom of stress compounded by a workplace wherein there was relentless demand with too few mitigating factors. A release was needed, and six weeks was only a taste of what that release might look like.

Granted, a professional life which is a patchwork of per diem positions, consulting, and self-employment may seem to some to be a self-made purgatory (and perhaps I'll feel similarly in a year or so), but for now, such freedom of movement and broader parameters are just what the doctor....er, I mean the nurse....ordered. Prescription received, and the co-payment? Priceless!

Good-byes: and now the goodbyes begin, and this long-awaited and dreaded separation can get underway. I realize that there is much to grieve, much letting go to do, and sadness and doubt are inevitable. Still, in my heart of hearts, I know that it's for the best, and I consistently remind myself of the line by Michelle Shocked which I have mentioned here before: "The secret of a long life is knowing when it's time to go."

Death in the Afternoon

This afternoon, I worked my second orientation shift at a residential hospice where I have been hired as a per diem hospice nurse. Situated not far from where I live, working in such a small and homey environment with no more than six patients at a time is a far cry from my usual work as a Nurse Care Manager for the poorest of the poor in the inner city. (More on that upcoming career transition in subsequent posts.)

As a nursing student, hospice work was my stated career goal, and although I have not actually worked for a hospice organization per se, I have coordinated and taken part in hospice care for a number of my patients over the years. As a visiting nurse, terminal patients would often remain on our service, with family members or an automatic pump administering morphine around the clock. I was honored to pronounce a number of patients dead, signing provisional death certificates and facilitating post-mortem arrangements.

Now, with my new official position as a nurse in a free-standing hospice, the opportunity to provide focused and specialized care to the dying has become a reality, and I'm happy to assume this new role, at least on a per diem basis for the moment.

Over the course of the day, my preceptor (a 30-year practical nurse veteran) and I monitored and cared for five patients with the diligent assistance of an equally experienced home health aide and one volunteer. Two patients in particular received the lions' share of our attention based upon their deteriorating health, non-verbal and semi-comatose condition, and apparent closeness to death.

Around 2:30 we entered the room of the one patient who we deemed to be closest to his life's denouement, checking his pulses and respiratory status every few minutes. His peripheral pulses became weak and thready, eventually becoming undetectable altogether as his body shunted all available circulatory volume towards his brain and heart and lungs. It was at this time that we also became aware that his hands and feet---previously painfully contracted with neurologically-based deformities---were now relaxed, the skin mottled and gray. Feeling his weakening and slowing carotid pulses, we marked the slow decrease in the force of circulation to the brain as his respiratory rate decreased, with quick gasping breaths marked by long periods of apnea (cessation of breathing). By now his rapid decline was obvious.

At 2:58 pm, I placed my stethoscope on his chest, detected absolute lack of movement of air in the lungs and completely absent carotid pulse. It was then that we pronounced him dead, signed the death certificate, and began the long list of phone-calls and documentation which follows a death in a facility such as ours.

Orientation or not, this death appeared to welcome me with open arms into the fold of hospice care. My comfort level with the dying process and the many clinical and interpersonal processes involved, all confirmed for me that this is a place where I would like to be. Bringing all of my training, clinical skills, compassion, and desire to serve to bear, I can now see that hospice and the shepherding of the dying towards their ultimate goal---a noble and comfortable death---is truly a place which I would like to call home.

As this gentleman's soul enters what the Buddhists call the Bardo stage, I wish him well on his journey, and I thank him deeply for the honor of attending his death. May he be free of his suffering, may he be at peace, and may we all be so blessed to die with such grace and nobility.

Psychiatric Units: The Next Extreme Makeover?

Making a visit to a friend in a psychiatric ward reminds me of everything a psych unit should be and generally is not. Ostensibly places where individuals in need of respite and psychological support are sent for “healing”, all of the units which I have visited generally lack every amenity which I would consider necessary for the creation of a truly healing environment. From the institutional colors of the walls to the utter lack of homey touches denoting any notion of soul, most psychiatric units still seem to lack the humanistic qualities that readily foster recovery, wellness, and normalcy. Hospitals---whether they be psychiatric or otherwise---sorely lack the amenities and cutting edge philosophies which could actually create truly healing environments.

In the unit which I recently visited, there is the poorly named “Relaxation Room”. Here, I was not surprised to find institutional furniture (what else could there be?), one bright fluorescent light fixture in the ceiling, and a maddeningly lame collection of plastic bins desultorily littered with colored beads, dry white rice (for “tactile stimulation”), an empty bottle of bubbles, and other detritus perhaps thought to have therapeutic and “crafty” benefits. In said relaxation room, there was no source of music. In an effort to create a sense of relaxation, one entire wall was covered with an enormous piece of wallpaper showing a life-size beach scene in a useless attempt to give the individual “relaxing” in the room a sense of being at the seaside. Two deflated bean-bag chairs sat lazily collapsed against the wall. The room is anything but relaxing. It feels more like a glorified closet, a dubious afterthought of pretend holism.

What might there be in a true “Relaxation Room”? A fountain. A selection of ambient, classical, and other calming music. A video monitor on the wall from which the patient can choose various nature scenes to watch and meditate on. Full-spectrum lighting and/or therapeutic lighting. Inspirational books written by spiritual leaders and others who offer words of comfort, solace, and empowerment. Meditation cushions. Clean and soft carpeting for doing yoga or stretching.

On a psychiatric unit, where can patients spend time? In the tiny “Relaxation Room”? A non-descript and highly uncomfortable “dining room” with hard wooden chairs and tables? Where is the exercise room, complete with yoga mats, exercise balls, and other non-threatening materials without sharp edges or other risk factors. Where can a patient really work off some steam? Where does one go to run, or to roll on the floor and stretch? How can physical health and fitness be so utterly overlooked when restoration of health is so paramount?

As for food, why can’t it be served “family style” at a long table, where patients sit together and pass food back and forth from serving dishes, fostering community, interaction, and socialization? Why must everyone receive their individualized institutional tray and sit---isolated and disconnected---as they “nourish” themselves?

Where is the garden? Where are the full-spectrum lights which studies have shown can counteract the ravages of Seasonal Affective Disorder? Where are the inspiring books, DVDs, and magazines? Where are the “healing clowns”, visiting musicians, poets and artists? Where are the plants and the stuffed animals? Where, dammit, is the comfort?

The “kitchen”, open for “nourishment” and snacks, sports Salada tea, tepid water, coffee, and crackers. Where is the fresh fruit? What nutritional choices are there other than sugar, caffeine and white flour? Where are the foods that truly nourish the soul, appease the appetite, and provide some modicum of sensual stimulation and satisfaction?

The most notable evolution vis-a-vis providing radically different environments within a hospital setting is the birthing room. Expecting parents have demanded that birthing suites and maternity wards within hospitals be designed in a way which provides the comforts of home within a hospital setting. This vocal and relatively affluent group has brought about enormous and revolutionary change vis-a-vis the nature of the birthing environment. Families in labor now ensconce themselves in wood-paneled suites with king-size, four-poster beds, birthing tubs, and numerous amenities meant to provide the laboring mother and her spouse and family a comfortable and home-like environment in which to undergo the process of birth. This is revolutionary, yet this revolution has not moved beyond the walls of maternity centers, and perhaps the psychiatric units are the next frontier in need of an “extreme makeover”.

I am sure that somewhere in this country (but more likely in Europe), there exist psychiatric institutions wherein humanism and holism are paid more than just lip service. For now, the majority of psychiatric institutions in this country are most likely similarly sterile and devoid of simple yet effective changes which could lend themselves to providing a much more pleasant, healing, and effective therapeutic environment.

In the end, money talks. Birthing is big business, and hospitals compete for families and continually try to outdo one another with their “birthing packages”, offering home-like experiences for deserving and demanding (and affluent) families who want a special birthing experience within the safety of a hospital.

As for the psychiatric patients, who will advocate for their experience of improved therapeutic environments? Will the families of those who need in-patient psychiatric treatment band together and flex their economic muscle, demanding change and improvement? Or perhaps there is a Victorian-era austerity or Dickensian horror which we collectively feel is still appropriate for those experiencing “madness”. Do we still negatively label those struggling with mental illness or extreme states of mind? Do we judge those who have attempted suicide as undeserving of a beautiful, calming, and truly healing environment?

Recovery from attempted suicide, mania, major depression, affective disorders, thought disorders or personality disorders can be a life-long process. Some never fully recover and must utilize psychiatric units as if they were equipped with revolving doors. If many of our most vulnerable citizens need to visit such places, why do we hesitate to offer them the most healing and supportive environments that we can? This is not just a medical question. It is moral question. And if this question was part of a pass or fail test, we would long ago have failed quite miserably.

Therapeutic Relationships: How (and When) to Say Goodbye?

What do clinical boundaries really mean? Where does a therapeutic relationship end and a friendship begin? When we interact on deep and profound levels with clients/patients over long periods of time---sometimes for years---what does it mean to say goodbye? Is it possible to satisfactorily take one's leave of a long-term therapeutic relationship and feel OK saying "Have a nice life!" as the door slams on your way out

Having just emerged from a psychotherapy appointment wherein I was discussing just these issues, my mind and heart are simply brimming with thoughts and feelings about just such scenarios.

Leaving a job is (almost always) a process of letting go, of relinquishing the past in the interest of a newly forged potential future. When one leaves a workplace, there are the inevitable goodbyes to colleagues, "subordinates", "superiors", and others with whom one shared a relatively large portion of one's waking life. This is no small matter, and such a leave-taking is more often than not fraught with uncertainty, nostalgia, and a tinge of regret. It is an accepted and normal phenomenon that, when one gives notice and begins to prepare to leave a workplace, that workplace will suddenly seem more friendly, more amenable, and more comfortable. It's almost as if the Universe begins immediately to test one's resolve to leave just as one submits one's resignation. How maddening!

For myself, being on a leave of absence has allowed me more than sufficient time to process my decision to leave, and I have already begun the process of considering my patients and colleagues and what those goodbyes will entail. In a recent post, I began to delineate those challenges. As for colleagues, maintaining contact is simple. Phone calls, emails, dinner or lunch invitations, the occasional party or professional gathering---those relationships can be maintained like any acquaintance or friendship. Inevitably, time and lack of frequent proximity will preclude frequent contact, with many of those professional but collegial relationships falling by the wayside over time, some more quickly than others.

Now, when it comes to patients, that is another arena entirely, and a great deal of forethought must be given to a decision to offer to maintain contact following the end of a therapeutic relationship. Of my 80 patients, there are probably thirty with whom I feel a deep affinity and positive mutual regard, so much so that ending those relationships will be emotionally difficult. Amidst that group of thirty there are probably ten people to who I feel an even deeper connection, and saying permanently goodbye would be painful. Narrowing the field further still, there are most likely two or three people with whom I feel an intimate, almost familial bond, and these are the therapeutic relationships which I could foresee morphing into friendships, albeit friendships with strict parameters and severely limited scope.

Considering such an outcome, one must ask certain questions:

-Does the client want continued connection?

-Is the offer of a continuing friendship/connection in the patient's best interest?

-Are you pursuing this friendship out of guilt or true desire for such?

-How will the new boundaries of such a relationship be established?
-How would said individual contact you?
-Will expectations of frequency of contact be considered?
-Why not just say goodbye?

There are dozens of questions to consider, many of which perhaps you, esteemed Reader, could raise (and please do!). This is a conversation worth having!

Those of us in Human Services and the so-called "helping professions" constantly face the issues of boundaries, transference, counter-transference, and projection. When facing the end of a therapeutic alliance, all bets are off and the game becomes simultaneously murkier and much simpler. The path of least resistance? Say "goodbye, nice to know you, have a good life, and thanks for being you". The path of potential complication (but also of richness and authenticity)? "Let's stay in touch and see what our new relationship/friendship is capable of within certain parameters". In all likelihood, most connections made in this way will, like tangential friendships, fizzle out over time. People move, phone numbers change, lives develop through unanticipated twists and turns, address books are lost, and the frequency of contact gradually subsides. Still, the effort was made, and true authenticity was honored.

As Jerome Groopman, M.D. writes so eloquently in his outstanding book, The Anatomy of Hope (and please simply subsitute the word "nurse" for "doctor" as you read):

"There are some patients whom a doctor grows to love. It is a unique type of love, distinct from any other type of love the doctor has experienced before. It moves outside the bounds of the usual doctor-patient relationship; feelings and thoughts are no longer strictly professional and are shared among true friends."

If this area is simultaneously murky and simple, I am certainly still in the murk. And, as I do in many areas of life when I am faced with difficult choices, I remember that age-old adage that I have quoted here on Digital Doorway before: "Don't just do something, sit there." Thus I will sit with these feelings, with this sense of impending and inevitable change, and perhaps, if I am quiet enough, the answer will make itself known.

Nurses and Hell

Did you hear about the nurse who died and went straight to hell?

It took her two weeks to realize she wasn't at work.

Harm Reduction

Today in Ottawa, a rally will be held in support of Insite, the first supervised safe injection site in North America for individuals addicted to intravenous drugs. A blog specifically devoted to this issue is promoting the rally, requesting that Canadian citizens supportive of this successful harm reduction technique make their presence known in Ottawa today. 

As strange as it may seem to the uninitiated, providing a safe, clean and supervised environment for injecting drug users is in the interest of the safety and health of all citizens. According to the Insite website, rigorous scientific evaluation has shown that supervised injection leads to: reduced use of injectable drugs in public where children can be exposed to such behavior; reduced overdose fatalities; reduced transmission of blood-borne infections such as Hepatitis C and HIV; reduced injection-related infections; and improved public order. 

From my own experience participating in street outreach to IV drug users, teaching regarding clean injection technique, the availability of needle exchange programs, and medical oversight of IV drug use significantly impact public health and actually reduces the economic burden of drug use on the taxpayer by reducing ER visits, avoidable injuries, unnecessary hospitalizations, infection with blood-borne pathogens, and death rates from such behavior.

In terms of the philosophy of harm reduction, we meet the addict where he or she is, and we provide education to reduce the risks incurred through such behavior. We understand that the behavior is harmful, yet we also recognize that many individuals are not ready to address their addiction through treatment, thus we seek to mitigate the deleterious effects of their behavior. In so doing, we demonstrate to the addicted individual that we understand the difficulty of quitting and that we will support him or her in that process according to their readiness to pursue treatment. The trust created through such interactions has been documented to have a greater success rate in bringing addicts into treatment for addiction, as opposed to "tough love" interventions which preach or force a particular set of values upon the target population. 

Form more information regarding the philosophy and practice of harm reduction, The Harm Reduction Coalition's website is an excellent resource. If your community does not allow needle exchange or other harm reduction techniques, consider contacting organizations in your area that advocate for such interventions, and discuss the issue with local and state legislators. 

Addiction is, for better or worse, here to stay, and even the addicts amongst us deserve a chance to stay healthy, be supported, and seek treatment when they are ready to do so. 

Attachment, Anticipatory Grief, and Goodbyes

Faced with returning to my full-time job in mid-December following my six-week medical leave-of-absence, it has become painfully apparent to me that my days there are numbered. With the prospect of a job-share having fallen through, I face a slew of choices vis-a-vis my employment status, and the possibilities, while exciting in their potential, also open up tender emotional areas of attachment and anticipatory grief.

Having worked in my current position for seven years, a great deal of my identity as a nurse has revolved around serving low-income, inner-city populations whose vulnerability to disease and psychosocial dysfunction makes them ripe for our services. An endless well of need and dependence, my group of 80 patients have lived in my brain and heart for all of these years, and my emotional closeness with a number of them makes it most difficult to consider leaving my position for new horizons.

I have practiced nursing in a manner in which "therapeutic use of self" is a frequent technique of connection and teaching, using examples from my own life and struggles with chronic illness and depression as teaching tools and methods of expressing sincere empathy. Such disclosure, as well as my very personalized approach to nursing practice and therapeutic relationships in general, engenders an emotional intimacy that is slightly outside the norm for medical and nursing practice. For this reason, I have become quite invested in the lives and well-being of some of my patients, and I fully realize that this is a potential factor in the eventual development of burnout and compassion fatigue over time. I recently wrote a blog entry about vicarious traumatization, a phenomenon which is more than theory for me. It appears that my patients' trauma and traumatic histories have also begun to trigger my own personal trauma history, further exacerbating my feelings of burnout and compassion fatigue.

With time on my hands during this leave of absence, I have had opportunity to reflect on my relationships with a number of patients, and the notion of saying goodbye and terminating said relationships brings me great pain. As I conjure a mental image of this patient or that patient, I experience a wincing sensation wherein I think, "Oh, no! How will I say goodbye to him/her?" And the thought of each patient of whom I am fond evinces yet another uncomfortable sensation of loss.

This workplace where I have given my all for seven years is like no other I have experienced. United in our mission to serve the poorest, sickest, and most dysfunctional sub-populations, we are also united in a day-to-day feeling of being overwhelmed, of swimming against a steady current of unquenchable need, and of knowing that our collective and individual levels of stress are potentially hazardous. As much as we complain about our patients and their neediness, there must also be an aspect of attachment and addiction to such drama on our parts as well. There must be some secondary gain for us as we slog through the challenges of our days, striving to keep our heads above water in a current which changes directions---and depth---without notice or sympathy for our collective and individual plight. The undercurrent of family and camaraderie under duress keeps us afloat, even on the worst of days.

Within the adjacent inner-city community health center with which we partner to care for our patients---and where our patients receive their primary healthcare---there is a team of doctors with the majority of whom I have developed stellar working relationships. These doctors, all of them very committed to the care of the disenfranchised, poor, and chronically ill, have consistently treated me with a level of respect and professionalism unparalleled in my experience as a nurse. This sentiment is echoed by most of my nurse colleagues, and the learning and teaching which these working relationships engender is priceless. On a first-name basis since the beginning, my opinions and suggestions are taken seriously by these docs, and our discussions are never one-way---rather, there is an exchange of ideas focused on the ultimate goal of improved health and function for our mutual patients, although I frequently do feel that I am left with more responsibility than I can handle. Still, I see that my efforts are recognized and appreciated, and that my opinion is thoroughly and thoughtfully considered. If I am mistaken, it is always pointed out in a gentle and kind way with a goal of teaching and learning which is free from games of power and hierarchy, with few exceptions.

So why leave, you may ask? Why walk away from a situation in which satisfying professional relationships, clinical skill development, and challenging medical and psychosocial situations stimulate my mind, spirit and soul? It is because this level of engagement and deep involvement with extremely needy and often dysfunctional patients over a long period of time has whittled away at my core, slowly but surely damaging my ability to enjoy life outside of my work, causing such levels of stress that my personal quality of life has become diminished. Whether directly related to this job or simply a matter of synchronicity and coexistence , my own constellation of chronic illness, chronic pain, and long-term struggles with major depression are necessitating a change of lifestyle, a ratcheting down of the intensity I experience vis-a-vis my professional life. Perhaps I understand and empathize with my patients so well because of my own chronic illnesses, but because of those personal issues, that empathy, while helpful and useful therapeutically for my patients, is slowly but surely eroding my own ability for healing.

Drawing on my interest in Buddhism, I realize that these sensations and feelings, while sincere and quite real, are a manifestation of attachment. Various attachments arise in relation to possessions, people, relationships, circumstances, and even feelings and sensations. My reluctance to leave my workplace after seven years is, to a large extent, a reflection of a certain level of comfort I have developed, even though that comfort paradoxically coexists with burnout, overwork, and a growing sense of frustration with the intensity of the work and the programmatic dysfunctions of our organization. How to reconcile all of these factors and stay on the same path without incurring further personal damage?

I am at a turning point in my career. There are new avenues of nursing and my professional self which I long to explore, yet slogging away on the front lines of inner-city nursing practice---and the stressors therein---is most likely keeping me from pursuing those new avenues, my energy consistently sapped by the vicissitudes of the ol' 9 to 5.

So, I'll keep thinking, reflecting, meditating on it, and embrace these three more weeks of my leave of absence. Returning to work in mid-December, I fully expect at this point to return with my 30-day notice of resignation in hand. Sad, true, difficult, painful, challenging........necessary. And in the immortal words of Michelle Shocked, "the secret of a long life is knowing when it's time to go".

Back to the Drawing Board, Wherein the Heart and Mind Discuss the Future

Back to the subject of my (currently non-existent) work-life, although the job-share position was ostensibly approved by the powers that be, the nurse practitioner with whom I was planning to share said job has accepted another position. Thus, the job-share is now defunct, and a vast blank drawing board appears on my horizon. Yikes.

So, when faced with a blank drawing board, what does one do? At first, nothing. The blank space is kind of nice, isn't it? See how the light reflects? Notice how that blank space is one upon which any number of potential futures can be projected? Why don't we enjoy it for a while?

But then the Mind in all its glory jumps in, grabs some (thankfully erasable) markers, and goes to town.

"So," the Mind says. "We have Option 1: return to full-time job as planned, and decide to stick it out for another 6-12 months. See all of the gains and stress reduction from the leave of absence erased in a matter of weeks. Hmmm. Maybe not such a good choice." The Mind looks puzzled.

"Well, then," says the Mind. "Option 2 seems better: return to work for the required 30 days, close up shop, say our goodbyes, terminate with patients and colleagues, and skedaddle asap, no looking back. Not a bad scenario, if I do say so myself." Some skeptical interest is perceived.

"Or how about Option 3, perhaps?" asks the Mind hopefully. "Offer to work per diem for old employer after fulfilling 30-days of full-time work in order to fulfill leave-of-absence obligations. String together several other per diem positions---one of which is quite close to home, actually---and have a renewed sense of professional invigoration? Let "The Mrs." carry the health insurance benefits, and take this golden opportunity to cut loose from the 40-hour grind! Work when you want to---some weeks will be extra heavy, others can be quite light. What freedom! What a concept!" The mind smiles.

Then the Heart steps up to the plate, chiming in. "Oh, God! All of those patients with whom we have cultivated intimate working relationships for seven years! How would we say goodbye? How would we terminate? What would it do to them? To my colleagues? To the workplace? How can I handle so many goodbyes?" The Heart wrings its hands.

The Mind rests a reassuring hand on the Heart's virtual shoulder. "Look here, cousin. Don't get so worked up. People leave jobs all the time, even ones in which long-term therapeutic relationships have been nurtured." The mind smiles reassuringly as the Heart looks dubious.

"We all have to say goodbye and move on at some point," the Mind continues. "Patients know that clinicians come and go. It's part of the process. Perhaps your leave-taking will cause some of them to become more self-sufficient, more empowered. Just imagine the relief you would experience when you released yourself from the responsibility you feel for those eighty people and their well-being!"

The Mind and the Heart sit in silence for a while.

"Y'know," says the Heart. I need some time to consider these scenarios. It's just too much to process today."

"I understand," says the Mind. "Change is always hard. Take your time, enjoy the rest of your leave-of-absence, and know that this is all happening for good reasons. Remember that drawing board? We can leave it blank for a while."

"Thanks," says the Heart. "I can only take in so much change at one time. It was enough to accept a six-week leave-of-absence. Let's clean the basement, then we can make dinner and watch a movie."

"It's a deal," says the Mind. "We'll put the drawing board in the corner for now. Let's tackle that basement."

Of Heroes, Parity, and Economics

Last night's post only scratched the surface of the culturally accepted norm dictating that mental health is not on par with physical health when it comes to one's needs for rest and rejuvenation---especially where work is concerned.

Work is, for better or worse, part and parcel of our lives, a veritable necessity for putting food on the table and clothes on our backs. As we moved out of an agricultural society into an industrial---and eventually technological---society, it obviously became necessary for an astronomical number of individuals to become workers who performed duties under the auspices of companies and corporations which held our livelihoods in their hands. Granted, an agrarian society is no panacea---share-cropping and slavery are excellent examples of that scheme's miserable failings---yet the industrial age brought with it abuses and restrictions on individual freedom which, while not necessarily slavery in name, certainly have kept many segments of society in quite similar and dire economic straits.

So, when one has chosen to enter a field of work in which the vagaries of the economy and the edicts of one's employer shape one's destiny, there is a certain amount of freedom that is abdicated. That said, even the self-employed feel that they too must abdicate some freedoms in the face of restrictive tax codes and the high cost of health insurance and healthcare.

For myself, I have chosen to enter the "Medical Industrial Complex", to riff on a phrase originally popularized by Dwight D. Eisenhower in 1961. Within said Medical Industrial Complex, a hierarchy exists, similar to the hierarchies within other disciplines and professional societies. The members of such systems are rewarded for their work based upon algorithms which take into account such notions as experience, education, applicable skills, and other factors which make one a candidate for the assignment of various tasks and responsibilities.

As I stated in yesterday's post, certain segments of society are held in higher esteem than others, earning astronomically higher salaries and benefits than those of us who slog away in blue-collar, "pink-collar" and even many white-collar positions. Most of us would agree that celebrities---including many actors, some entertainers, as well as many professional athletes---receive remuneration for their efforts which far seems to outstrip the relative value and social import of their (cultural and economic) contributions to society. CEOs are another story, and the scale of their remuneration is also sorely out of balance (think Ken Lay, may his soul never rest).

I stated yesterday that the hypothetical baseball player who experiences occupational stress could be pretty certain that his salary---often in the millions, or at least hundreds of thousands---would not suffer in the face of a leave of absence for reasons related to stress.

In my post, I compared myself to that stressed-out baseball player. Let's imagine that I was a nurse who was experiencing incredible levels of stress and burnout by caring for the destitute, chronically ill, and elderly who live in that baseball player's hometown. Maybe several members of his extended family---saddled with substance abuse, mental illness, or other disabling medical conditions---were actually on my caseload. When I decide that I need to take a leave of absence due to stress related to my work, why is it that I---a person providing essential services related to the health, well-being and survival of members of that baseball player's family and community---must do so without pay and with risk of economic hardship, while the baseball player (who essentially swings a piece of wood at a leather ball and catches balls hit by others with the same piece of wood) rests on his laurels and fat bank account, taking a break from his on-the-job stress on Maui? What is wrong with this picture?

Teachers, nurses, police officers, EMTs, substance abuse counselors, social workers, senior center directors, outreach workers, AIDS workers, hospice counselors, homeless advocates, housekeepers, medical assistants, home health aides, daycare workers, laborers----we all experience on-the-job stress, yet it seems only the rich and famous can have respite without negative economic consequences. The families of people in the military live on food stamps in decrepit barracks for the enlisted, yet we say we "support the troops". Again, what is wrong with this picture?

Our measure of "heroes" is askew. Who truly are the heroes? Who should be celebrities? Where are the trading cards of famous nurses and home health aides? When will substance abuse outreach workers have their day? Something is wrong in a culture wherein those who care for the dying must themselves struggle to survive. This is an emergency of priorities, one for which parity and balance seem far beyond reach.

In essence, the true heroes go unsung, and the make-believe heroes take home the prize.

Injured Soul? You're On Your Own

Recently, an anonymous commenter on Digital Doorway responded to a post I wrote about nurses and stress. He or she wrote the following:

"One major reason why nurses are stressed is because hospitals are understaffed. Management has been able to get away with this understaffing because they don't have to pay for workload-related chronic stress injuries.

"This is discrimination against psychologically injured workers who succumb to excessive WORKLOAD by getting depression or other chronic stress diseases.

"The hard-working employee who sustains a mental injury due to overwork is left without compensation which means they usually then go through a downward spiral of bankruptcy, loss of home, loss of pension and all the further stress that goes along with poverty.

"No wonder we have a health care worker crisis!"

The commenter makes some salient points. Taking my circumstance into consideration, seven years of working with trauma survivors and giving my all to the care of vulnerable individuals has led me to make a decision to take six weeks of unpaid leave in order to collect myself and heal. Why, within this society, are individuals serving the poor, ill and traumatized left to their own devices when it comes to recovering from providing such a public service? Why must burned out teachers and nurses take unpaid leave and use up their personal savings at a time when their service has exacted a psycho-emotional toll on their health?

Now, to draw an apt comparison, if a professional baseball player experienced undue stress and psychological trauma from the vigors of the season's play, would he need to eschew his multi-million dollar salary in order to take a six-week leave to clear his head and regain balance? Would he be forced to use his savings to pay his bills and care for his family while he recuperates? Would some portion of his astronomical salary be withheld? That baseball player, handsomely compensated for his work (which, in my mind, bestows precious little benefit on humanity), will have little difficulty making ends meet while he rests and recuperates.

Furthermore, as an individual appreciated and respected far above the nurses, social workers, factory workers and teachers who are truly a part of the backbone of the society, the athlete in question will have no fear of income loss as a result of his temporary disability. In fact, a guest appearance on Oprah or a Newsweek expose on the psychological stresses of professional sports would most likely be in order. Our athlete suffers in ways which may actually enhance his career.

On the other hand, take a burned-out nurse like myself and consider my options. While I may have the Family Medical Leave Act to allow me up to 12 weeks unpaid time off, short-term disability insurance does not allow for disability for mental health or substance abuse. In fact, many long-term disability insurance policies also exclude a mental health benefit. Parity for those suffering from mental health-related injury are basically left out in the cold.

The conundrum is thus: if I injured my hand at work caring for a patient, workers' compensation would be a no-brainer. But if I injure my soul at work? I'm on my own.

Job-Share Ahoy!

Well, well, well. It looks like my workplace has conditionally approved a job-share for myself and a Nurse Practitioner colleague following the end of my medical leave of absence. Suddenly, the future looks a whole light brighter.

What does this new reality mean for the earnest nurse who is ever-so-steadily recovering and recuperating from acute burnout, vicarious traumatization, and compassion fatigue? The true meaning of this new reality is multifaceted. Initially, it means that I will no longer carry the emotional, psychological, and clinical weight of some 80 patients on my own shoulders. Instead of a caseload of 80 for which I am solely responsible, I will share a caseload of patients with a very competent Nurse Practitioner of whom I am exceedingly fond. I will be in the office three days per week, and she will be in the office the other two days. With our excellent rapport, open communication, and superb documentation, we will bear this load together, neither of us slogging through the dreaded five-day week. We will meet for lunch once a month to discuss cases, talk by phone, communicate by email, and otherwise work as a well-oiled clinical nurse-machine, free of the burnout born of the forty-hour week.

I acknowledge that I am lucky to be able to either 1) afford to pay a pro-rated increased rate for my health insurance as a part-time employee or, 2) take part in my wife's health plan under the auspices of her place of employment. With health insurance being one of the major factors for many workers staying in jobs which they dislike or cause them undue stress, I realize that I am privileged in having choices vis-a-vis my healthcare and insurance.

As far as generating income, I also realize how lucky I am that, as a registered nurse, the ability to earn money on a per diem basis is one which makes the nurse a hot commodity in the current job market. With two per diem positions already in my employment portfolio---one with a visiting nurse agency and the other at a urban community health center) this part-time nurse can choose to earn extra money one week and slouch around the house the next. What better burn-out prevention could there be?

Taking a leave of absence was a leap of faith which was initiated by my wife (with only a mild threat of divorce) and embraced whole-heartedly by me when I realized that there was no other way for me to regain my emotional balance. With chronic illnesses slowly overtaking my previous state of relative good health, we both acknowledged that something had to give (and I had already "given at the office", so to speak).

Now, as the layers of stress begin to unravel after two weeks' leave, I now face the next four weeks of leave with a desire for further healing and recuperation. With part-time employment and brighter prospects at work, perhaps my life is truly turning around.

Nurses and Stress: A Rant

Thanks to a comment on yesterday's post, I was recommended to read this article on stress and healthcare workers. Brief and to the point, the article elucidates that Canadian "nurses, doctors and lab technicians have the highest levels of stress related to their jobs" of all interviewees, with 45 percent reporting that there work was "quite" or "extremely" stressful.

The International Labor Organization has identified nursing as an industry with relatively high levels of stress and burnout. In identifying the sources of stress in nursing, they elucidate thus:

"The role of nursing is associated with multiple and conflicting demands imposed by nurse supervisors and managers, and by medical and administrative staff. Such a situation appears to lead to work overload and possibly to role conflict. One form of such conflict often mentioned in surveys of nurses relates to the conflict inherent in the instrumental and goal-oriented demands of "getting the patient better" and those related to providing emotional support and relieving patient stress. Role conflict of this kind may be most obvious when dealing with patients who are critically ill and dying. Indeed, one of the areas of nursing that has attracted particular attention has been critical or intensive care nursing. Health care is also a sector which suffers a high rate of violent behaviour (see our pages on violence at work).

"Many studies on stress in nursing have attempted to measure, or have speculated on, the effects of such stress on nurses’ health and well-being. There appears to be general agreement that the experience of work-related stress generally detracts from the quality of nurses’ working lives, increases minor psychiatric morbidity, and may contribute to some forms of physical illness, with particular reference to musculoskeletal problems, stress and depression."

Hmmmm, says the nurse on medical leave of absence.

In South Africa, stress has been identified as the major cause of a nursing shortage in the setting of HIV/AIDS care. The BBC reported earlier this year that stress was harming nurses' sex lives, causing nurses to smoke more, and that stress-related absences from work costs the British National Health Service more than 300 million pounds per year.

Many nurses complain about frozen wages, lack of clinical supervision, increasing nurse-patient ratios, and rapidly shrinking benefit packages. While loss of benefits and frozen wages are ubiquitous across the general workforce (unless you're a CEO, member of Congress, movie star, or professional athlete, of course), nurses face other stressors which are singular to their profession. Workers in other professions also naturally face challenges typical to their careers and workplaces, and each of us can truly only speak from our own work experience.

We simply have to face the facts. Americans (and workers in other countries, as well) work too hard, earn too little, have paltry time for vacation and leisure, and are expected to marry their jobs to a degree never before expected in the history of labor. Unions have slowly been dismantled and vilified over the last century (especially here in the US), and healthcare benefits have crumbled, leaving many of us paying higher premiums and copayments for office visits, procedures, and medications. With housing costs and fuel costs through the roof, our paychecks have less buying power than they used to, and those of us in the middle class and working class are left to pick up the crumbs left behind by the 1 percent controlling the wealth.

Are nurses stressed? Of course we are. We earn moderate incomes within a high-stress industry where workloads have exponentially increased and benefits faltered. Retirement seems less than certain, the economy continues its volatile course, and the healthcare industry asks more and more of us without offering any further compensation. Still, I never regret my career choice, and have even encouraged others to walk this path. Nurses are always needed, work is generally easy to find, and when the economy hits bottom, we will still be irreplaceable, since illness never takes a holiday.

So, what's an earnest nurse to do, you ask? Dedicated to my chosen career, I take a few weeks to reassess my options, care for my body and mind, soul and spirit, and plan to reenter the fray with---perhaps---a hopeful and newly-minted outlook and approach. I have been ravaged by the effects of stress and vicarious traumatization, and I now attempt to reconstitute myself during this brief hiatus. I consider myself both lucky and blessed, and pray for my nursing brethren who are unable to afford the luxury of such self-care. May we all be free from suffering.

Open Heart---An Appreciation

I have a predilection for reading books about medicine and nursing, and nothing pleases me more than discovering yet another satisfying or thought-provoking read, of which there have been many, and of which I fully expect hundreds more such experiences.

Apropos of such literary leanings, today's praise report involves Open Heart: A Patient's Story of Life-Saving Medicine and Life-Giving Friendship by Jay Neugeboren. The author is best known for his book Imagining Robert, the story of his brother's struggles with mental illness and the burdens born by the families of individuals thus afflicted.

Open Heart tells the story of Mr. Neugeboren's experience as a man of more than sixty years of age, who, in excellent and athletic physical condition, experiences symptoms which go misdiagnosed for months, eventually leading to emergent quintuple-bypass surgery which saves his life. In the process of telling his story, the author not only communicates wonder over the technological developments which contributed to his survival. Mr. Neugeboren delves deep into the psyche of lifelong friendship, its importance to quality of life, and the challenges faced by the patient who confronts an often splintered and impersonal healthcare bureaucracy. His insights into the world of medicine, doctor-patient relationships, as well as his relative position as a upper-middle-class author whose well-heeled and educated childhood friends---all of whom are doctors, by the way---contribute to his well-being through their advocacy, professional connections, and knowledge.

There are many ironies addressed in Open Heart, not the least of which is the notion that, even given his relative privilege and access to high quality healthcare, several of Mr. Neugeboren's medical providers completely missed his tell-tale signs and symptoms of ischemic heart disease, putting him at great risk of debilitating illness and eventual death by myocardial infarction or stroke. That said, the author also is very determined to clearly acknowledge the additional (and enormous) privilege of having well-educated doctors within his closest circle of friends, all of whom went out of their way to support him, advocate for him, and procure for him the finest surgeons, hospitals, and medical treatment possible within the American healthcare system.

Despite (or perhaps in response to) his own class privilege and elevated societal status as a successful author, Mr. Neugeboren spends a great deal of time discussing what is wrong with American healthcare, eventually coming to the conclusion that access to appropriate, high-quality, affordable, and timely healthcare is the crux of the challenge facing the United States today vis-a-vis the health of its citizens. While he does not offer specific policy solutions to resolve the current healthcare crisis, the author does indeed use citations of appropriate literature to drive home the conclusion that the American healthcare system is broken, the poor are often left out in the cold, and that too many Americans go without healthcare in a country which spends more per capita on healthcare than any other industrialized nation. Taking his findings further, Mr. Neugeboren extrapolates his conclusions further into a global picture, wherein AIDS and other controllable diseases continue to ravage less developed countries, mostly due to a lack of political and economic will on the part of the United States and its economic peers. To wit,

"Valuing freedom of choice over constraints, and individual freedom over government regulation in the specific ways Americans do, we seem a long way from knowing how and when, if ever, we will be able, if in inevitably imperfect ways, to set reasonable and effective national healthcare policies."

The doctor-patient relationship also plays a significant role in Open Heart, and Neugeboren describes how managed care, too much reliance on technology, and the economic pressures which drive the American healthcare system have only served to undermine the trust between patient and doctor. He continues,

"We might begin, if only begin, it occurs to me, by thinking in terms of what my friends and I have been talking about---providing those contexts in which greater access to care, continuity of care, long-term care, preventive measures, and public health measures are encouraged and endowed. If, too, we restore the doctor-patient relationship to a central position in medical care, and if we avail ourselves of the marvelous technologies that exist while at the same time remaining skeptical of those technologies that are more expensive than they are curative (and that cause us to neglect more urgent health-care needs), then, I say, we have a pretty good shot at making it happen."

Neugeboren outlines how American tobacco companies prey on the young and the poor---both here and abroad---to make their profits while undermining the health of the world. He elucidates how access to quality care is often blocked by a class-based system which favors the wealthy and shuttles the poor to understaffed, overburdened, and poorly funded public healthcare facilities. The author also expounds how, in our post-modern awe of expensive technological advances, we have lost sight of what is most important in healthcare---the face-t0-face meeting of doctor and patient. And if that doctor is constrained from spending more than ten minutes with each patient due to increasing malpractice insurance, sky-rocketing overhead, and endless student loan repayments, this is a recipe for misdiagnoses, under-diagnosis, shoddy care, and missed opportunities for preventive measures which can ward off the advent of chronic (and ultimately expensive) disease.

On a global scale, one of the author's closest friends, Jerry Friedland, a medical doctor committed to fighting AIDS in Africa, describes his frustration at the (as of 2002) inadequate response to AIDS in Africa by the industrialized world. Taking a potentially controversial stance, Mr. Friedland and Mr. Neugeboren describe how Americans are quick to respond to sudden catastrophes---like 9/11, where 3,000 people died, however tragically---with fervor and purpose, yet, in the face of a long-term catastrophe like AIDS, we lose our momentum, even in the face of more than 3 million deaths per year in sub-Saharan Africa alone. Of course, they hasten to add, 9/11 was a watershed moment for the world and deserved the attention which it garnered, yet the relative loss and destruction inherent in that singular event cannot compare numerically with the ravages of worldwide disease, antibiotic-resistant organisms, global poverty, famine, ongoing war, and genocide. According to Dr. Richard Horton, the editor of The Lancet, "the major issue in medicine is not one of maintaining the pace of discovery, but of making sure there is equitable access, throughout the world, to the discoveries we have already made."

Citing studies by the World Health Organization, Neugeboren implores the reader to comprehend that, between 1990 and 2020, "unipolar depression (also called clinical depression) is second behind ischemic heart disease, in rank order of the global burden of disease (a measure of health status that quantifies not merely the number of deaths but also the impact of premature death and disability on a population)." He also cites a study stating that, "of the ten leading causes of disability worldwide, five are psychiatric conditions (depression, alcoholism, bipolar disorder, schizophrenia, and obsessive-compulsive disorder)." Food for thought.

Immunization, preventive healthcare, sanitation and hygiene, screening technologies, life-saving medicines---these are all well-understood tools in our arsenal against disease, yet economic constraints, xenophobia, and lack of political will often prevent such simple technologies from reaching those most in need. Lobbyists for the tobacco, alcohol, and firearm industries fill the halls of our Capitol every day, squeezing out the small voices who call for parity, justice, and equal access to quality healthcare for all. It is a sad state of affairs, and authors like Jay Neugeboren are able to bring such disparities to bear with wit, wisdom, and personal reflection.

Open Heart not only explores the challenges of personal, national, and global healthcare in the 21st century. It is also an ode to friendship, to connection, to self-reflection, and to gratitude for life. From the micro to the macro, from the familiar to the foreign, we are urged to consider the whole, be it our best friend down the street or an AIDS orphan in Niger. There is no qualitative difference between your visit to your local doctor and that orphan's need for a 20-cent immunization against measles. But there is a quantitative difference, and that orphan, sadly, is much more likely to be denied what she needs to survive.

We have a choice, and Mr. Neugeboren has given us a gift to once again see that choice clearly. I, for one, accept that gift gratefully, and will continue to bear in mind the lack of such a qualitative difference between me and that orphan, and will use my voice to remind others of her equal right to life, liberty, health and the pursuit of happiness.

Leave of Absence and Its (Dis)Contents

Being on a leave of absence presents a series of challenges, most of which I would deem "problems of luxury", yet their problematic quality is still worthy of my attention. And it is these challenges which occupy my mind most vividly from day to day.

First and foremost, during this time of rejuvenation and mental/emotional recovery, I am faced with the question of whether or not to return to my full-time job. Being on a medical leave of absence, I am required by law to return to work for at least 30 calendar days following my leave, yet the future beyond those thirty days is wholly uncertain, professionally speaking. My job---and all of its vicissitudes and benefits---is doubtless waiting for me to return in just under a month, and my desire to embrace that 40-hour challenge once again is waning daily.

So, the questions remain. What would it mean to leave my workplace, my work family, the comfort of the familiar? How would it impact my career, my personal life, my clinical development, my future as a nurse? How much should I worry about my patients and how my leave-taking will effect them? How much of my patients' experience is my responsibility? Haven't I given them enough for seven long years?

If I do indeed decide to leave my position, it begs the question of how I will move forward, earn a living, and piece together a sane, healthy work life, unencumbered by the burnout with which I have lived for far too long. Luckily, Mary is poised to have benefits early in 2008, ostensibly freeing me from the oh-so-American shackles of sticking with a job solely for the health insurance.

This opening which I have created for myself is truly an opening---a portal of opportunity---through which I can walk, run, saunter, stumble, or fall. The mode of entry through said portal still remains to be seen, but the desired outcome is, in the final analysis, sanity.

Daylight Dawns

Daylight dawns on Sunday morning after spending the night in ICU tending to my mother-in-law. The paradoxes of a hospital stay abound. Throughout the day yesterday, she was encouraged to stay awake all day in order to reprogram her brain to get sleepy at night. So, we did our best to stimulate her during the day and keep her from sleeping too much.

And then arrives the night shift. Settled intermittently in a marginally comfortable lounge chair next to her bed, I observe throughout the night how ICU is anything but restful. Noisy carts are pushed up and down the halls at all hours----shouldn't they have silent rubber wheels? The patients' sleep is interrupted almost hourly: phlebotomy, respiratory therapy, blood pressure, medications, portable chest x-rays. Nurses and therapists come and go, some chatting loudly as they enter the room. A long night is made more exhausting by the irony of turning the clocks back one hour at 2am. A long night made longer.

As for me, I can make myself comfortable enough, but the constant interruptions, beeping monitors, nurses bustling in and out, noisy carts in the hallway---it's enough to drive one 'round the bend.

In one of our chats in the wee hours, my sweet mother-in-law and I joke about how much patience it takes to be a patient, and how little rest one gets in the hospital. I remark about how she was forced to stay awake during the day, only to be tortured throughout the night at the moment she had fallen asleep. She's not amused.

If I wasn't so tired, it would be funny. For now, the irony will have to do. One comes to the hospital for healing, but the nature of the hospital environment denies one the rest one so desires and needs. Oh, the irony of it all!

Postcard from Texas

We are presently here in Temple, Texas, checking in on Mary's mother who is in ICU following carotid artery bypass surgery. Tonight, I will do the midnight to 6am shift (most of which will be spent sleeping in the recliner behind the curtain by the window) so that she can have her needs met if she wakes in the middle of the night. (There's nothing more miserable than having a nasogastric tube down your throat and nobody around to feed you ice chips when you're parched.)

Overall, though, this "caregiving visit" is a relative breeze: time by the hotel pool, writing emails and blog posts on the hotel computer, chatting with my father-in-law and the nurses as we sit in the room passing the hours, or wandering this strange Texan town. Plus, it's 80 degrees and sunny all day.

Beginning a leave of absence from nursing and being in such a hospital/medical environment could very well set off my stress buttons, but my role here is so minimal---so "nurse lite", if you will---that it is a pleasure to be of service. My skills are helpful in identifying when, for instance, Mary's mom's oxygen saturation is getting low and she needs the cannula back on, or perhaps to listen to the doctor and translate some of the medicalese for her dad. Energy output and stress? Almost zero. Value? High.

Anyway, nurses serve a purpose in families, and my "nurseness" certainly does come in handy at times like these. As long as my boundaries are clear and self-care remains of primary concern, no harm done and all is well.

So, dear Reader, remember the end of Daylight Savings Time tonight, set those clocks back, gain that hour of precious beauty sleep, and enjoy your Sunday, wherever you fare.

From deep in the heart of Texas,

A Nurse at Rest

Taking Leave: Exit Stage Left

Today saw the beginning of my leave of absence. "Taking leave"---an interesting concept to digest. Add to the notion of leave-taking the additional concept of "absence". But will the heart grow fonder? Only time will tell.

Divesting myself of my work responsibilities (and my attachment to caring for my patients), I extricate myself from the melee and enter a period of intentional self-care. What will become of me as I venture into these less travelled waters? Will I veer off course? Will I become lost in a maze of doubt and guilt? Or will I rise to the occasion, embracing this sense of freedom, allowing the emergence of a new feeling of expansion and openness to self-renewal? I think my old friend time will also tell me this story as well.

Just yesterday, in a moment of absolute serendipity and Jungian synchronicity, I attended---along with my wife and several colleagues---"Behavioral Health Grand Rounds" at a local medical center, wherein a world-famous doctoral psychologist lectured on the concept of "Vicarious Traumatization".

Also known as "V.T.", Vicarious Traumatization is the concept that a professional caregiver/therapist comes into contact with a traumatized individual as well as that individual's trauma material, consequently becoming retraumatized him- or herself in the course of that therapeutic relationship. It is well-known that a vast majority of clinicians who choose to work with trauma survivors have experienced significant traumas in their own lives, thus creating a dynamic in which an empathic and sensitive professional is repeatedly exposed to clients' trauma, and in the professional's commitment to providing therapeutic care, harm is actually done to the caregiver in the course of that relationship. Also known as "secondary trauma", V.T. is indeed a direct cousin to PTSD (Post-Traumatic Stress Disorder).

For better or worse, I am no stranger to PTSD myself, having been diagnosed in 2001 following the murder of my best friend by police in an unfortunate (and wholly avoidable) tragic set of circumstances which I have previously mentioned here on Digital Doorway. With this personal history, it is extremely clear to me that a number of my patients---whose lives are chaotic and rife with the effects of trauma---have begun to trigger my own trauma history as I go about the business of my work as a nurse.

Working in an ambulatory setting and caring for patients over years of close relationship and involvement in my patients' lives, the boundaries between myself and my clients are, by definition, more fluid than those practiced by many other health professionals. While these less rigid boundaries do indeed lead to more intimate therapeutic alliances with patients and their families, the cumulative effect on my psyche has certainly begun to be noticeable vis-a-vis the deleterious effects of such closeness in regards to my mental, spiritual and physical health.

There are those of us who consciously choose to work with members of society who have long suffered from the effects of abuse, neglect, poverty, and societal disenfranchisement. When one decides to immerse one's self in such an environment of lack and struggle against long odds, one must expect to pay a price for such involvement, especially if one is what I will deem "an empath". Being an empath is, in my book, a laudable occupation of spirit, yet the toll one pays for such a gift is often paid for dearly with stress-related illness.

So, exit The Nurse Protagonist to Stage Left, the curtain drawing temporarily on the well-furnished set of vicarious trauma, burnout, and compassion fatigue. As said Nurse Protagonist goes about reclaiming his sense of self and new-found (but temporary?) occupational freedom, we will be keen to discover along with him what new pathways of self-care and renewal will be embarked upon.

Is it difficult for our Nurse Protagonist to relinquish his sense of commitment and responsibility? Mais oui, monsieur (sings the Greek Chorus at Stage Right).

Can he embrace the challenge of enhanced selfishness, taking full advantage of this golden opportunity for renewal? Perhaps (says the orchestra conductor from the pit below).

Will he emerge from this time of self-reflection a changed man, a healthier man? We certainly pray for his deliverance from the throes of personal trauma (shout those who love and care about him from the bleachers).

Lastly, will he return to his place of work in five weeks, only to begin the traumatization process anew? (His patients and colleagues, friends---and psychotherapist---all wait with baited breath in the lobby.)

Stay tuned as the weeks unfold, as our traumatized Nurse Protagonist makes his way along this long ignored path of self-care and renewal. Admission is free. And the outcome? Certain to entertain.

Vicarious Traumatization

After eleven years of providing direct nursing care---all in ambulatory settings, mind you---I wonder when it will be time to take a break and approach my work in the healthcare field from another vantage point. While I, like many nurses, thrive on the interpersonal relationships which nursing engenders, I also long for a rest from the emotional tugging which is part and parcel of my work.

But what is it about that "emotional tugging" that is so exhausting, you ask? The answer, to a large extent, is vicarious traumatization, wherein the act of bearing witness to the trauma of others can lead to internalization of trauma and psychic distress by the clinician. Several studies cited on the American Psychological Association website conclude that clinicians with their own personal trauma histories are more likely to experience deleterious effects when working closely with patients experiencing trauma.

Taking into consideration that the majority of my patients have suffered multiple traumas and live chaotic and difficult lives, I am consistently in a place of feeling unable to fully relieve the suffering of those around me. Confronted day after day by individuals whose suffering continues largely unabated, I surmise that my own level of suffering appears to have concurrently elevated, perhaps in response to those for whom my efforts seem to have little effect.

Many of my patients experience depression, anxiety, PTSD, and other forms of mental illness and psychic distress, not to mention chronic pain. Interestingly, my own depression, distress and physical pain symptoms have become significantly exacerbated in the last few years, leading me to more fully appreciate and understand my patients' suffering based on my own experience. Having been diagnosed myself with PTSD six years ago following a friend's murder, I appreciate the long-lasting effects of such experiences and the immeasurable difficulty of recovery.

The concept of vicarious traumatization is one which we all---clinicians and non-clinicians alike---might understand, but it is only now, as my own physical and psychic suffering has become augmented, that I more fully comprehend the insidiousness of its impact on the unwary clinician.

Luckily, this Thursday, I will attend a "Behavioral Health Grand Rounds" at a local hospital, where several experts on vicarious traumatization will present their research, their findings, and their recommendations to those of us interested to know more. As my leave of absence approaches at the end of this week, this particular presentation could not be more timely. I welcome this information, and also welcome the self-realization that it may engender.

What Lunch Hour?

As I begin to plan for a five-week unpaid leave from the rat race, I feel particularly sensitive to messages, both implicit and explicit, that communicate that overworking is a culturally accepted practice.

In the last few days, I have begun to notice an ad campaign by Dunkin' Donuts (I refuse to link to their website, just to spite them) that truly speaks to what drives me to take a break from work altogether. This ubiquitous American purveyor of non-organic, non-free-trade coffee and fatty, sugary treats is now propagating billboards which promote a lifestyle unfriendly to slowness and thoughtfulness. "Eat on the Run!" screams one billboard, while another colorfully suggests that I "Work Through Lunch!". What have we come to? How did I become another victim of American workforce culture?

A recent study in the UK cites data showing that fewer and fewer Brits stop working in order to eat the midday meal. An article on Monster.com urges workers to take lunch breaks, and article after article cites the shrinking lunch hour and lengthening workday. In my own office, the majority of us eat lunch at our desks as we finish notes, check emails, and answer calls. And when five o'clock rolls around, so many of us seem to simply keep working since there seems to be no end to the work we need to do. No wonder we're all exhausted. The Japanese even have a word for death from overwork: Karoshi. At least it's not a purely American phenomenon.

So, those billboards that cajole us to work through lunch and eat on the run? Why not boycott Dunkin' Donuts, instead?

Moments of Sadness, Moments of Warmth

Today I had a moment of sadness as I told a patient that I would be going on leave for five weeks. As I began to tell her my plans, her face fell and she said, "I'll miss you so much, but at least I'll see you in December." This woman and I have a close relationship bordering on what seems like a friendship, and the genuine warmth between us is a gift, as it is with a number of my patients. I also assumed that she could read between the lines, and that this leave of absence may be more than I was saying.

Why was I sad? Because this temporary goodbye is, by extension, practice for a larger, more permanent goodbye in the future. Whether I will take permanent leave of my job by the end of the year, or whether I tough it out for a few months in hopes of seeing some programmatic changes, this leave of absence which begins in ten days will be a taste of what it might feel like to really say goodbye.

There are patients who tell me they love me. There are patients, like the one mentioned above, with whom I have a great deal of warmth and positive mutual regard after more than five years of getting to know one another. Granted, the relationships are one way in most respects, but that does not decrease their true humanity and genuine quality.

Just this afternoon, I was visiting a patient who has not filled several of her prescriptions for more than a week---including her morphine---because she has absolutely no money left, not even enough for a $1 copayment. What could I say? How could I react? I dropped a twenty-dollar bill on the table as I left her mobile home. She took my hand and thanked me so graciously, her eyes sparkling with tears. How does one say goodbye to someone with whom one has been so connected?

Confusion, sadness and anticipation all coexist. Whether that coexistence is peacable remains to be seen.

Compassion Fatigue, Monday Style

Today was the first Monday since I made the decision that a leave of absence is in the cards and coming soon. That said, my morning behaved in a way which underscored my need for a break and the "compassion fatigue" that has settled into my bones.

My first patient of the day was a 10am home visit to someone who lives in the subsidized housing near the clinic. I strolled through the lovely autumn morning and rang the bell, riding the rickety elevator to the third floor. My patient hangs out at a local community center, drinks what I fear is far too many beers on the weekends, and has personal hygiene which leaves much to be desired. Just last month, I visited and checked through her medications, noting that most of the prescriptions were dated from June of this year and had not been refilled since. Just to be sure, I called her pharmacy, and lo and behold, she has not filled a prescription in five months. With asthma, hypertension, high cholesterol, and a host of other chronic conditions, some of these medications are crucial to her well-being and survival.

"So," I began, "I see you haven't been taking your medications."

"Oh yes," she responded. "I take them every day like you taught me."

I shake my head. "Now, how can that be?" I ask, "when all of these prescriptions were filled in June and you haven't been back to the pharmacy since?"

She was speechless, stammered an excuse, and looked away.

"Look," I said. "These medications are not for my health, they're for yours. Either take them or not, but don't tell me what you think I want to hear. Tell me the truth."

"I'll start taking them all tomorrow, I promise," she said, putting out her hand for me to shake.

"We can shake," I said, "but I don't believe you today. We've done this before. See you next month."

"I love you," she said as I left her apartment, one of the few English phrases she knows.

I returned to the office, feeling angry that my months of work with her had done so little to effect her consciousness vis-a-vis her health. I drank a cup of coffee and went out to the waiting room to assess a patient who came in to see me without an appointment.

"I'm so anxious and depressed," she said with tears in her eyes. "I have chest pain, neck pain, back pain, a rash on my face, and my eyes feel hot. Also, I'm constipated, I'm nauseous, and I'm losing weight because I have no appetite. And the veins in my hands feel hot." She grabbed my hand as if to demonstrate the feverish heat of her fingers, which actually felt cool to the touch. Her husband sat on the exam table watching our interaction gravely as she enumerated her myriad symptoms.

Leaving the exam room, I went back to the office briefly, sat down, and literally lay my head on the desk, despairing over the fact that I had nothing to say to this tearful woman amidst her calamity of medical symptoms. Gathering my wits, I returned to the exam room, offered some supportive counseling, secured her an afternoon appointment with her doctor, and sent her home to rest for a few hours.

Did someone say compassion fatigue? This Monday morning onslaught of unresolvable circumstances in the face of multiple chronic illnesses and exhausted apathy seemed to wear on my soul like a grindstone. It was a day when my ability to be annoyed or have my patience worn thin was as raw as I could imagine it to be. (How may days until that leave of absence?)

Patience worn thin
compassion meter maladjusted,
crispy nurse lurches
towards rest
for the weary caregiver's soul.

Time for a Break, Damn the Torpedos

Quite recently, I wrote that burnout had come to visit, and I was uncertain of what to do. That despair of not knowing has given away to the simple realization that something had to be done, and that has led me to make the decision to take a unpaid leave of absence in the interest of my mental, spiritual, emotional, and physical health. For a hard-working, dedicated, and relatively codependent nurse, the decision to do something so dedicated to pure self-care is nothing short of a miracle (and I think my wife would agree wholeheartedly). But a leave of absence is something whose time has come, even if the bank account may feel quite differently.

Nurses are reknown for working until they drop, giving their all for patient care, and going down with the proverbial ship, damn the torpedos. Well, I have realized that the multiple torpedos of chronic pain, depression, grief, and reactivated PTSD are enough to warrant some serious self-care, and I'm the only one who can make it happen (with a little prodding from "The Missus").

When unfathomable stress couples with an untenable workload, no accrued time off, and personal issues crying out for succor, a decision to abandon self-care at such a crucial time is tantamount to suicide. As I have felt myself slip into a coma of denial and stress-induced despair, there has been a simulataneous realization that if I do not intervene on my own behalf, more debilitating chronic illness---beyond my current health challenges---may force a permanent leave of absence in the future, complete with permanent disability and loss of function. Therefore, in the interest of self-preservation and my own well-being, something has got to give, and work seems like the best candidate to be jettisoned.

In terms of my own attachments and aforementioned codependence, concerns over the well-being of my patients and my colleagues abound. I worry over how my colleagues will cope in my absence. I experience anticipatory guilt over the burdens they will bear. I worry about my patients, their feelings of abandonment, as well as the fact that after a five-week break, I just may not be able to face the rigors of my challenging job anew. All that taken into consideration, there is no denying that I have no choice but to choose my own health over any mechanism of denial which I can fabricate. The time has come, and I have to take a stand for myself.

There is a huge leap of faith involved in taking a step towards healing. There is also an enormous well of self-preservation that begs me to act before it's too late. Luckily, I have the support and wherewithal to be able to relinquish a month's pay in pursuit of personal healing, and I am grateful for that luxury which many others could never achieve. I hope to use my time wisely, and make some decisions from a place of calm.

I intend to use this forum to process my experience, describe my struggles, and elucidate the path upon which I'm embarking. Please come along for the ride---I could use the company.