best practice, social neuroscience therapy
Emergency medicine should be a verdant garden of meaning, value, and respect, so why do burnout and thoughts of quitting medicine plague this garden? Why does the ED feel like a wasteland for many physicians today?
It is the perfect storm for burnout when another employed “provider” is put in short-staffed, relatively unexperienced assembly line for a corporation focusing on documentation, protocols, metrics, and billing for “customers” who are increasingly unhappy with your speed, prices, service, and outcomes—with a growing population of repeat “unfixable” patients who use up enormous amounts of human, technical, temporal, and emotional resources and energy—while company executives are monetized with absurd salaries and your own paycheck is shrinking.
“Nice” patients are turning to minor emergency clinics that are literally everywhere and serviced predominantly by nonphysician providers (NPPs), many of whom you trained. This tips the scale even further toward emergency physicians spinning plates in a strange circus of patients with extraordinary psychosocial stresses and chronic end-stage diseases.
When other types of patients come in, we do outrageous amounts of overpriced testing to reassure them of all the diseases they don’t have. We tell ourselves the lie that we do this to make the patient and family happy to prevent being sued or not to be written up by someone in the hospital for not following protocol. Then, as we make our pitch at the end of their multi-hour visit, the patient says something like, “Then why do I feel so short of breath? Why does it feel like my heart is pounding so hard? Why does my stomach hurt so bad? Why am I so tired? I know there is something wrong!”
There is something wrong. May I suggest beginning with a little truth-telling?
- Most patients may not need to see an emergency physician (which is why they are OK seeing the NPP at the clinic or whoever on telemedicine or even the chiropractor-acupuncturist-supplement distributor at the strip mall). Most come to us for reassurance; they are the worried well. We try to reassure them with a conveyer belt of labs and radiographic images. To no one’s surprise, this barely works and comes at an extreme cost to individuals and society and doesn’t work at all with the difficult, frequent patient.
- A majority of patients with significant pathology who come to us are often unfixable—at the end of life, stuck in a chronic progressive disabling disease, or shackled in a behavior pattern that perpetuates ED visits. The story underneath most COPD, uncontrolled diabetes, alcoholism, overdose, STIs, abuse, chest pain, wound problems, and even many “accidents” are smoking, too much alcohol, too many drugs, unhealthy relationships, poverty, obesity, and homelessness. An unhealthy body is often the result not of a bad brain or bad genes, but simply a difficult, often unfair, and unhappy life.
- The number of patients who do need to be in the ED, whose lives we “save” to return them to a life of purpose—and they are grateful—is so small that it is hardly sustainable. Add more CMS requirements and outcomes-based pay structures, and the dose-response curve for job satisfaction tanks.
Social Neuroscience Therapy
This perspective is scientifically validated by studies proving that social determinants are foundational to disease. The vectors of many social determinants are depression and anxiety. These are often the accumulated adaptations to fear and sadness from life’s adversity and a loss of connections more than the fabled “chemical imbalance in the brain.” (Johann Hari. Lost Connections. New York: Bloomsbury; 2018.) We in emergency medicine in particular do not want to “manage” these patients with benzodiazepines and SSRIs because of the need for ongoing monitoring, not to mention that any benefit is lukewarm at best.
Consider the following paradigm shift of offering emergent social neuroscience therapy instead of adding a troponin, D-dimer, and a CT scan again. What can you offer that has been scientifically validated, is cheap and fast, and that might occasionally work? I have made the following sheet that I call Nine Daily Points.
- Go out in nature for 30 minutes.
- Wonder. Watch a child or spend time with a pet for five minutes.
- Listen to a song that makes you dance, feel inspired, or cry for five minutes.
- Practice a spiritual ritual such as prayer or meditation, individually for 10 minutes or communally once a week.
- Find humor and laughter and share them; it takes one minute.
- Exercise at home, in your neighborhood or gym, or do activity at work for 30 minutes.
- Eat or have coffee with a friend or family member for 10 to 30 minutes; ask questions.
- Think of a future event that makes you happy—a trip, event, hobby—for one minute.
- Engage in acts of kindness and encouragement or give compliments five times a day.
Mark off each point every day for a week and then reassess. Chances are there will be some light in that darkness.
This emergent social neuroscience therapy is not just for patients; it is also for us. Working through these every day and finding natural ways to experience a natural aliquot of dopamine happiness instead of an artificial bolus of dopamine from smoking, drinking, drugs, sex, overeating, and risk-taking behavior is a proven lifetime therapy.
If you don’t completely buy the premise that emergency medicine is predominantly crisis management of social determinants, you may still find that going through these with a patient takes a fraction of the time it would take your unnecessary D-dimer to come back. I know some may find it uncomfortably hokey. Agreed. But consider trying it just once. Your worried well patients and even your unfixable patients may say, “Wow, a doctor never sat down to talk like this. I really like you.” If that happens, your shift suddenly produced meaning, value, and respect—for both of you.
Dr. Mosleyis an emergency physician in Wichita, KS.
