COVID and the Texas freeze: death by a thousand cuts

In February, Texas lost power and water.  A winter storm disrupted a power grid ill-prepared for freezing temperatures, shutting off power to homes, businesses, and water treatment facilities. Water pipes burst, water pressure dropped, and the water became unsafe for drinking or cleaning.  My house was without power, internet, or wireless data for (only) 36 hours and water for two days after that.  I consider us fortunate.

The local hospitals worked on special low-water safety protocols and clinics were closed.  Some providers were stuck because of unsafe driving conditions while communication systems were down.  When I was able to get back onto emails, colleagues in my section had an email string for who has what at home in case someone is in need of a shower, food, or heat.  Also in my email string was a request for a biosketch for a grant renewal, a reminder to do my monthly physician time study, a notice that my DEA license was coming up for renewal, and a note from a student who needs my handwritten signature on a form for her dissertation.  She would be able to stop by my house to get it because she needed to stop at a stationers nearby to pick up 20# paper for said dissertation.

It’s as if two worlds run in parallel.  One that adjusts to repeated catastrophes: numerous changes to work and family life because of COVID, weather disasters, personal and family health crises, even basic safety issues.  And the second world that nods to the mess that everyone seems to be facing and yet continues to hold fast to its previous set ways.

My colleagues valiantly rose to the challenge of patient care with limited water and electricity this week.  They compartmentalized and prioritized.  And this week, we’ll all clean-up.  And take care of the less important, less urgent requests on our time and energy.  But how much more do we have to give?

Before SARS-CoV2 was mutating in its animal host, our health care system was ill before it came to the U.S. and impacted our health care system, our social interactions, and our economy.  Burnout of doctors, nurses, pharmacists, and others working in the health care system was clearly identified as a worsening crisis with the potential to endanger patients and the future structure of the health care system if left unchecked.  We are a year into the pandemic and, while there is some hope of improvement, we have a long and uncertain way to go.

Causes of burnout fall largely into 2 interrelated camps:  personal resiliency and system flaws.  As a card-carrying member of the “Burned Out Health Care Providers Club,” I can say without a doubt that personal resiliency matters. We all need to practice caring for ourselves and our mindsets. Institutions and society as a whole have an opportunity to help every one of us increase our personal ability to cope, to be strong, and to come out of the other side of crises intact.

As provider burnout became more evident over the past decade, health care systems invested heavily in the concept of building personal resiliency. Unfortunately, an underlying message (real or perceived) to a hurting, exhausted group of overachievers was anger and shame – burnout was a personal failing, and we needed to add something else to our lives to do our callings. Part of this negative response stems from a failure to adequately attend to the flawed systems themselves. Now, more than ever, we must examine these flaws openly and transparently and rectify them.

I am reminded of the death by 1,000 cuts torture method.  Getting a handwritten signature as an administrative barrier to completing a multi-year graduate program is an example of a cut. In and of itself, it is almost trivial. Yet it was hours of time for the student and mentors. Our days in health care are littered with tiny cuts. Each office, agency, policy, and third-party payer makes their own requirement of providers, from pre-approvals for patient care, to how we request a fix for a computer glitch. To the designers of each of these separate processes, their ask does not seem that much work. Yet they add up.

Early in the COVID pandemic, we made rapid systemwide adjustments. Years of telehealth red tape was cut in weeks.  Deadlines were extended for quality reporting. Continuing medical education requirements were adjusted.  This response shows what we can do when we face a crisis – we can put systems and ingrained processes into a broader context and ask ourselves, “does this (fill in the blank) really matter?”  As we enter the new normal – which is really the old normal plus COVID minus resources – I encourage a continued and aggressive examination at all levels of what we are really asking of our health care providers.

Heidi Russell is a pediatric hematology-oncology physician.

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