A Good-bye Letter

Dear Healthcare System,

This letter has been long in coming as it has taken me a great deal of time to organize my thoughts. The changes happened gradually, or at least my ability to notice them did, and it occurred like the proverbial “death by a thousand cuts”.

I went to pharmacy school to help people. I wanted to be useful. I learned a lot about the human body, how it works, what happens when it doesn’t work and how different chemicals, proteins and drugs change the functioning of those systems. I learned that the average American takes way too many medications. My goal upon graduation was to work with my patients and other health care providers to gradually wean patients off of the large number of prescription drugs.

I was naïve. When payments for pharmacists are tied to product sales (prescriptions) and not services, it turns out that no one wants to pay for the service and knowledge to separate patients from these drugs. Here I was, a new graduate, with a mountain of school loan debt and a desire to help reduce pill burden for my patients but no one interested in providing compensation for this service.

So, I pivoted to the hospital environment and eventually emergency medicine. In that arena, I knew that the medications that I was giving to my patients were short-lived, one-time doses intended to provide an immediate (or near-immediate) response. I discovered an unknown talent in myself. I was able to anticipate the medication needs of my patients even before the physician ordered them. This led to a decrease in the amount of time that it took for the patient to receive treatment. I loved the work at the bedside and being able to quickly see if my suggested drug treatment was helpful. In school, I was continuously accused of “thinking too much outside of the box” which really hurt me when there was supposedly only one correct answer on an exam. When this different way of thinking was applied to the emergency room setting, it was actually considered a good and helpful attribute. If I’m being completely honest, I got some weird high from the adrenaline rush provided by working in settings where the line between life and death was sometimes a very thin one. I was ecstatic and proud when we worked hard and saved a life. I was devastated and mournful when our efforts were not successful. Although, neither set of emotions were allowed to be shown as there were always more patients to be seen and required care.

The work was hard. There were times when my 8 hour shift turned into 12 hours or even 15 hours. There were many nights that I didn’t eat and was extremely grateful for even one pee-break. I would leave work physically, emotionally and mentally exhausted and sometimes required more than a day to fully reset. And yet, it was worth it. Even when the patient didn’t survive, I felt that at least I was a part of a team that bought the family time to arrive, say goodbye and gain a sense of closure. I left work knowing that at least one person in this world was better because I showed up to work versus if I had stayed home. It wasn’t perfect. No job is, but it was work that I found pride in doing and I became very good at that work.

Over time, things began to change. It wasn’t one set occurrence or event. It happened slowly. Maybe I was simply slow in noticing the changes, I’m not sure. Autonomy in the work, personal responsibility for your patient’s care and individualized treatments were being replaced with strict protocols and pressure to adhere to whatever new requirement was placed upon us by the insurance or government regulating entities.

Small cuts to my soul

• One example was the change in the exam room layout in an attempt to improve patient satisfaction scores. The surveys that patients were filling out after their discharge were being linked to reimbursement for our services (aka the money). While I believe being caring and sympathetic to a patient is important, the majority of people that visit the ER are not usually having their best day. To expect everyone that leaves the hospital to score their happiness at a level mirroring a trip to Disneyworld is ridiculous. I have even been encouraged in meetings to use the “Disney model” as a basis of interactions with my patients. That’s bullshit. If a patient is truly sick enough to require emergency care, I could be parading around in a Snow White costume whistling tunes that make birds follow me through the halls and the patient would still rather be anywhere else. I have been a patient myself and would prefer competent, professional and caring medical treatment over a magic show. It was hard to be understanding to this shift in thinking when we were being instructed to conserve paper, routine equipment was being replaced with inferior (and cheaper) quality when at the same time every room was being outfitted with brand new, fancy TV’s. I understand the use of a television for a distraction during the long wait of a hospital stay but did those TV’s really provide better MEDICAL care?
• Another example revolves around the design of the emergency department. At one time, the department was arranged with patients being assigned to beds according to their acuity (aka how likely it was that they could die in the next few hours). The more critical patients were assigned larger rooms near the storage areas of the necessary equipment and medications. The less critical patients were assigned smaller rooms that may require more walking to obtain the medications and equipment but their condition was less likely to make those items urgent. This sometimes led to a longer waiting room time for a patient with a less critical complaint. Evaluation of this situation by an outside source deemed this unacceptable. The process was changed to one where every empty bed was assigned a patient. This sounded good in theory, but turned out very bad in practice. The patients requiring significant intervention and procedures were now found in our smallest rooms while the equipment and medications used to care for them were stocked on the other side of the department. Every time that an employee left the room to obtain a needed item, it increased the chaos level of the situation. The individual missed important information, information had to be repeated, frustration of waiting increased and these factors were added to an already stressful situation. Some departments in the ER, like pharmacy and respiratory therapy only staff one person for the entire department. In times where there are multiple critical patients requiring care, having them in close proximity of each other allowed these individuals to bounce between rooms providing assistance. When the critical patients are scattered throughout the department, these support personnel are not physically able to assist, leading to poor care, frustration and anger for all of those struggling to save a dying patient. Some individuals attempted to buck the new system but were reprimanded when the computer tracking devices showed a patient in the waiting room when there was even one empty bed. They eventually gave up and succumbed to this poorly designed system. I hoped that this change would be recognized as the failure that it was, but unfortunately it remained. We almost had to intubate a patient in the hallway because a patient being treated for an STD wasn’t finished dressing in the room that we needed. This may not have been ideal but the important thing was that the computer system reported very limited time with empty beds!

There were many more examples of the “little cuts” but this post is long enough and I won’t bore you with more details.

I began to feel lost, saddened, angry and frustrated as I drove home after each shift. I knew that my patients deserved better but struggled to find a way to provide that within the confinements of the system’s requirements. I blamed myself for not finding a better way to adhere to both my moral obligation to the patient and the rules of the organization. I decided that I was tired and it was simply that I needed more time to recover between the shifts. I started a side business (this one!) to utilize my creative side and hopefully provide some income to allow me to decrease my hours. I thought I simply needed a break.

I gradually decreased my hours and discovered that I was a happier person. Those around me noticed it, too. I attributed this to the decreased hours at “work” and ignored the fact that I as actually working harder with the business, a growing homestead and homeschooling my kids. I ignored the dread in my stomach when I drove into the hospital and the feelings of helplessness and frustration on the drives home.

The policies became even more strict and with less wiggle-room. I was no longer thanked for providing the best antibiotic regimen for a complicated patient but chastised because it was not the one on the insurance’s preferred list. I knew what the insurance wanted but I was still adamant that my suggestion was better for the patient. That no longer mattered.

Turnover is high in the ER. The physical strain of moving patients, the emotional toll of losing patients or hearing their sad stories and the mental exhaustion of trying to know all the answers when the pressure is on, all add up. Despite the normal turnover that I had witnessed, this was different. The place was starting to feel like it had a revolving door. I no longer knew the individual skills and mannerisms of the coworkers next to me. They didn’t know if I was competent in this area of work or if I was another “warm body” sent to fill a position. We lost trust in each other. While trusting the skills of your coworkers may not be vital in some areas of work, in this environment it is essential. And yet, we lost it. The frustration was evident in those around me. More people left and were not being replaced. Some were giving in and others were giving up.

• It didn’t matter that a patient didn’t really need to be admitted if they fit the criteria for reimbursement.
• It didn’t matter if there was a better treatment option as long as the system-approved option didn’t kill the patient.
• It didn’t matter that computer flagged a patient for a specific treatment and that treatment could possibly harm them. The order had to be placed in the computer. When questioned, I was instructed to “tell the nurse not to give it” and “I’m tired of coming in on my days off to argue each case that didn’t have these sepsis fluids ordered”.

People were exhausted. They were frustrated and angry. We wanted to do better but could not find a way to do it within the tight restrictions of the system. We turned on each other and even turned against our patients.

Again, I blamed myself for not finding a way to provide the care that I wanted to provide and survive the current environment. There had to be an answer, but I couldn’t find it. This weighed heavy on my soul. I told myself it was because I was tired. I needed rest to think clearly and to do better by my patients. I wasn’t providing them the best care and needed to allow others to take my place more often so that I could be better when I was there. I wanted to decrease my hours a bit more but didn’t know how to do that and be financially responsible to my family. Covid showed me a way when the hospital census in 2020 could not sustain a full-time staff and my working hours were cut for me. I supplemented the income by building the business and starting a part-time teaching job. The teaching job was a new challenge and gave me the opportunity to look into the fresh-faced and excited eyes of a group of soon-to-be health care professionals. Their idealistic view of what healthcare should be made me feel petty and jaded for not being motivated to do the best for my patients despite whatever challenges were in front of me.

I returned to work at the hospital determined to be better. I started my shifts in a good mood, even if I had to force it a little. I found work-arounds for some of the strict policies that gave me the opportunity to be helpful. I ignored some of the things designed to only make a person look busy and focused my time on my patients. This helped, but only for a while. I couldn’t completely ignore my surroundings. I would go home angry and upset because despite offering help, I could not make up for the fact that we were short seven nurses during my shift. I ignored my productivity requirement activities to help move patients in the bed, assisted them to the bathroom, provided drinks, set up IV poles, prepped and ran for meds but we were still slammed. We needed more staff but that was a resource that we were hemorrhaging in what appeared to be a daily basis. Maybe I wasn’t the only one feeling the “tiny cuts” to my soul?

Each shift provided new and even more frustrating scenarios.

• I witnessed a patient suffering a heart attack in the hallway when a room was tied up for the required 15 minute post-vaccination observation period. I am not against someone’s wish to get a vaccine but is the emergency department really the best place for this medical service? My answer was no, but the policy of offering vaccinations to patients in the emergency room was VERY important according to the many flyers and emails being distributed throughout the department.
• I assisted a student in reviewing a patient's chart who "died of Covid". It turned out that he was diagnosed as a positive Covid infection over two weeks before his presentation to the hospital with shortness of breath. The diagnosis pushed him into the Covid-protocol pathway. Was this the reason that his massive pulmonary embolism diagnosis (blood clot in the lungs) was delayed? I can't say for sure because I wasn't there. He was placed on the institution's approved protocol for Covid infection but never received aggressive treatment for the pulmonary embolism that was large enough to cause strain on his heart. Was this because we had tunnel-vision toward the diagnosis of Covid and didn't fully see the seriosness of the pulmonary embolism? I don't know because I wasn't there. I try not to judge this one too harshly because it is much easier to review a chart than to be in the moment. In the end, the patient died. Did his Covid infection increase his chances for the pulmonary embolism? Probably. Did we do everything in our power to give him a fighting chance to survive? In my opinion, probably not.
• I encouraged the quick use of antibiotics for a patient presenting with shortness of breath after receiving chemotherapy for cancer. I was told that we had to wait until his Covid test came back before we could treat for pneumonia. He had already had at least one negative test that day prior to presenting to our facility (there may have been two negative tests as the notes were unclear) but we still had to wait as that test "may have been wrong". In my experience, it isn't uncommon for cancer patients to develop bacterial pneumonia when their immune systems are hampered by recent chemotherapy. The delay in treatment was maddening for me. I had the antibiotics ready and was poised like a sprinter to get them to the bedside. The test was negative. Great! I started to take the antibiotics to the patient's bedside but was told that we must wait for the chest X-ray to confirm. What?! I'm not one to give medications to patients unnecessarily but when a patient is in an immunocompromised state (like after chemo), the need for quick administration of antibiotics is essential. 
• I witnessed a patient being admitted to the ICU for hypertensive emergency when the recorded blood pressures were erroneously recorded. Was the error due to inexperienced new staff, understaffing or something else? It didn’t matter, the ICU staff had accepted the patient to their list and he was soon to be transferred. I hid the blood pressure lowering medication in the pocket of my lab coat (and later returned it to pharmacy) so that we wouldn’t lower his blood pressure too much prior to his transfer. Yet, it still felt wrong.

In some stories, this is the part where the hero steps up and finds a way to change the system and make the world a better place. I am not that hero. I cowered. I didn’t know how to fix the things that I was witnessing, so I gave up. I hid in the corner and pretended that it wasn’t happening. I avoided even looking at patients that I knew weren’t receiving the best care. Then, I drove home feeling like the true loser that I had become.

Some have diagnosed the condition that I was experiencing as burnout, healthcare related stress or even moral injury. I’m not sure that the term really makes a difference. I didn’t like myself nor was I proud of the work that I was doing. And yet, I continued to allow the lure of a paycheck to continue to bring me back. Sometimes my stubbornness can cause me to be a slow learner.

The situation continued to decline. I made a personal decision to utilize my right for a religious exemption to not take the Covid vaccine. I have had Covid and recovered which has provided me with natural immunity. I have done my research and do not feel the data supports the claim that the vaccine decreases the transfer of the virus. Based on this info and the responsibility that I have to God to take care of the human body that He has entrusted to me, I felt obligated to decline. For the record, I have declined other vaccines (not all) for similar reasons in the past.

My religious exemption was approved. I should have been happy but for some reason I felt let down and sad. Looking back, I should have paid more attention to those feelings.

The Covid vaccine exemption required more steps to be considered a compliant employee than other, past exemptions. I was notified that I needed to watch a video with instructions on how to test myself for Covid. I didn’t understand how the unvaccinated employees were being required to test when vaccinated employees were not, even amidst data showing increased numbers of breakthrough cases in the vaccinated population. Wasn’t this policy designed for safety purposes? If testing was deemed necessary for patient safety, why didn’t it apply to all employees in contact with the patients?

I ignored my questions and watched the video. At the end of the video was a “quiz”. The “quiz” must be completed in order to complete the online assignment. I put the word quiz in quotation marks because it didn’t ask questions about the process of testing or any other aspect of the instructional video. The “quiz” consisted of two lengthy statements requiring the answer of yes to show that I agreed to their conditions. Among many things the statements required that:

• I agreed to pick up a test kit.
• I agreed to weekly testing and in-person delivery of the sample.
• I agreed to be put on unpaid leave if I failed to deliver the weekly sample.
• I agreed that if I failed to comply to these rules, it was considered a voluntary resignation.

 I immediately contacted my boss with questions.

• The window for test kit pick-up was short. I had previous work and funeral conflicts with the available pick-up times so I requested that the kit be mailed. This request was denied.
  • I asked if I could arrange for someone else to pick up the kit and was told “probably” but that a kit would NOT be released until I completed the online “quiz”.
• My work position is unique. In my attempt to decrease my self-loathing and stress, I have worked with the employer to set up my hours in a random and inconsistent way. I cover vacations, days off, etc. There are times when I don’t step foot into the hospital for weeks and others where I work many days in a row.
  • I asked for clarification of the weekly testing because I wasn’t even near the building on a weekly basis. I volunteered an alternative option of arriving to work early and providing a sample prior to every shift. This request was declined.
• Any deviation from the stated policy would result in my being non-compliant and require performance counseling and be placed at risk for “voluntary resignation” as listed in the online “quiz”. This was a head scratcher. If the policy was set up as a safety measure for the patients and staff because they were operating under the assumption that an unvaccinated employee was more likely to spread the disease, then why were they requiring an unvaccinated employee to physically bring in a sample every week even if that employee was not scheduled to work in the building? Wouldn’t that “expose” more people? And why waste the expense and man hours if the employee wasn’t even in contact with other employees or patients?
• Absolutely no deviation from this protocol was to be made. My mind began spinning.
  • What if an employee was sick from an illness unrelated to Covid (ex: kidney stones), would they still be required to present a weekly sample? According to the policy the answer was, yes. The employee would be too ill to work but could be placed on probation.
  • What if the unvaccinated employee wanted to take a vacation? According to the policy, no exceptions were noted for this reason. How could an unvaccinated employee spread the Covid virus to patients or other employees when they weren’t even in the same town?

This, like many of the other policies, simply did not make sense to me but I didn’t have time to contemplate it because I had to make arrangements to pick up my testing kit. The only way that a kit would be released to my name was if I completed the online activity. So, I clicked the buttons that would be accepted by the computer program to show that I had successfully completed the “quiz”. I felt sick to my stomach as I was formally agreeing to things that went against my conscious. I did it to remain employed.

It didn’t matter that I went against my gut because I later discovered that my arrangements for someone else to pick up the kit was denied when they drove to the facility for me. Each unvaccinated employee was required to pick up a kit in person. Now, I go back to my question of safety. If this whole policy was put into place to protect patients and vaccinated employees from an unvaccinated employee, then why expose the patients and employees to a parade of unvaccinated individuals as they presented in-person to pick up their testing kit?

This policy was beginning to look more and more like a punishment for not adhering to their vaccine mandate than a safety measure. I had given up time with family and friends, missed soccer games and skipped holidays to devote to this hospital and the patients. I know that I received monetary compensation for this time but there are other jobs that provided a paycheck and didn’t require these sacrifices. I had made these sacrifices for more than a paycheck. Why was I being punished for utilizing their own policy of a religious exemption to prevent something being forced into my body against my will?

I realized that I was spending way too much time worrying about a policy for a job for which I only average 4-5 shifts a month. Why?! I was hurt, I felt betrayed, and I wanted answers that they didn’t feel compelled to provide. I had placed a part of my identity into being a healthcare worker and didn’t want to let it go. I enjoyed the ego-boost of being considered a "healthcare hero" too much to step away and become "only a housewife". I was prideful but what was I basing this pride upon? Was it possible to be prideful and ashamed at the same time? If so, I was. 

After a bit of time, I realized that it wasn’t worth it.

• Some may criticize me for not requiring a termination letter.
• Some may criticize me for simply not getting the required vaccination in the first place.
• Some may criticize me for not doing more to fight the system.

And some of those people may be right. There will be people that may never understand the reasoning behind my decision but I simply could not continue to spend my valuable time and energy on this issue. I was fighting to keep a job that provided so much self-hate that I barely recognized the person that I had become. I participated in treatment plans that were not best for the patient. I ignored things that bordered on the definition of medical malpractice simply because they fit hospital policy. I didn’t find the courage or ability to change these policies that went against my moral compass. I was becoming a person that I didn’t recognize nor respect.

I still don’t know how to make the necessary changes but I know that I cannot do it in this environment. Sun Tzu instructs us not to go into a battle unless you know you will win (paraphrased). I don’t see a way to win so I’m walking away and saying good-bye.

To those coworkers that are still fighting a failing system to provide good care to their patients, I wish you the best of luck. The patients need someone on their side to look out for their best interests.

To the patients suffering from a failed system, DON’T GET SICK. In all seriousness, do everything that you can to live a healthy lifestyle and avoid the system as much as possible. Look for health options that aren’t tied down to large institutions as they should have more autonomy and be more likely to individualize your care. Consider finding alternatives to traditional, authoritarian-style health insurance. By removing the third party, the healthcare provider will be able to work for you and not for what the insurance demands.

To my employer, I cannot place the entire blame of my disappointment on you. The healthcare system is broken. The continued focus on financial issues is important to keep a business running but at some point it should be recognized that healthcare is more personal. Please consider finding ways to return to individualistic forms of providing care for your patients rather than strictly looking at the numbers and surveys. If you need help in this area, consult the front-line workers as they have experience in seeing the individual differences in the patients that they serve.

Meanwhile, I am taking a break from healthcare. An injury can never heal without proper rest. I need time to recover from my moral injury and to find a new way to be helpful to my fellow humans. I hope that with time, I can rediscover my self-respect and be the person that I strived to be when I entered the healthcare field.

Sincerely,

A Recovering Healthcare Worker