A plea for help from the front lines of the COVID-19 pandemic [PODCAST]

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“This plea for help is on behalf of every hospital worker who has been on the front lines of the COVID-19 pandemic — from the environmental services staff and medical assistants who are often not recognized, to the social workers and chaplains who are surrounded by distress, to the physicians and nurses who continue to stand and receive the sick — we need more time off in the coming year. Some hospital workers will need to continue to be paid; others will just need permission and people to back-fill their roles until they return. If you are a business leader who makes logistical, technological, charitable, and financial decisions every day: I am asking for your time, financial wherewithal, personal connections, commitment, and expertise in strategic planning in order to give every front line COVID-19 hospital worker more time off in the next year than they can and will be allotted by their health systems. Consider using your unique talents to radically change how our country’s health care system moves on from this crisis.

Please help us. Help my friends and my colleagues. Help us do the thing we diligently, faithfully, and without hesitation tried to do for over half a million Americans this year. Help us survive.”

Kristin Adams Forner is an anesthesiologist and palliative medicine physician who blogs at Mending the Fractured Story.

She shares her story and discusses her KevinMD article, “A plea for help from the front lines of the COVID-19 pandemic.”

This episode is sponsored by the Substance Use Disorder Treatment and Recovery Loan Repayment Program. Would you like to help communities recover from the opioid epidemic? If you said yes, and you are a behavioral health professional or paraprofessional, then I have great news for you. Receive up to $250,000 in student loan repayment in exchange for service in a community disproportionately affected by the opioid crisis. Learn more and apply to join STAR LRP, the Substance Use Disorder Treatment and Recovery Loan Repayment Program. Applications close on July 22.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Kristin Adams Forner. She is a palliative medicine physician, and she wrote the KevinMD article “A plea for help from the front lines of the COVID-19 pandemic.” Kristin, welcome to the show.

Kristin Adams Forner: Thank you so much for having me. It’s my privilege.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Kristin Adams Forner: So I am a board-certified anesthesiologist who then went on to do a fellowship in palliative care, and so I now practice palliative care exclusively at a small community hospital within a larger health system just outside of our nation’s capital.

Kevin Pho: Take us through a sample day of what you do on the palliative medicine service, and maybe give us a sample of some of the common cases you might see.

Kristin Adams Forner: I am also the program director for our team. So we round each morning on the full list of patients that we have, new consults and ones that we’re following. We kind of divvy up, as we discuss each case, who’s going to see whom. It’s an interdisciplinary team, so on my team, I have a social worker, a chaplain, a nurse practitioner, and another physician. And so a lot of what we’re discussing when we round is kind of symptom management for each of our patients, as well as complicated family dynamics, goals-of-care decisions that need to be made, conversations, family meetings that need to be scheduled, those sorts of logistical things, and then who’s going to attend those meetings, which disciplines.

And then following rounds, we all kind of divide and conquer, if you will, to go see those patients who need us that day, with the goal being that we can get them to a place that’s more comfortable if they are having symptoms, but then also to make sure that the care that we’re providing them is the care that they want and deserve, so figuring out together kind of what their wishes are for their care. Oftentimes that’s involving the patients and their family members, so multiple family meetings each day. And then we write our notes and do it all again the next day.

Kevin Pho: And what would you say are some of your biggest challenges on a palliative medicine service, and how do you overcome those challenges?

Kristin Adams Forner: Yeah, good question. You know, I think the hospital where I’m currently located has a culture of medical distrust, which can be a really large problem when you have a team going in to try and figure out if the patients or their family members want to place limitations on their care, and if so, kind of what that would look like. So it’s not uncommon that we are received with a lot of suspicion, just even shortly after we arrive. So sometimes our biggest challenge simply is just getting our foot in the door to be able to have those conversations. That’s a really large challenge.

Where we’re located, we are within two miles of two long-term, or three long-term, nursing facilities, one of which is a ventilator facility. So we see a lot of really sick, chronically sick patients who come back to the hospital kind of multiple times for whatever ails them. So the beauty of that is that we get to establish relationships with these patients and their families over time, but it also means that these folks are really sick and require really good care, and that’s what we’re hoping to help our hospital provide.

Kevin Pho: Now, you mentioned that there’s a little bit of a culture of medical distrust in your area. What are some of the things that you say or do to gain that family’s trust, especially when it comes to palliative care?

Kristin Adams Forner: Yeah, I think the first, the biggest thing is to make sure that the folks that we’re talking to understand that we’re not the same thing as hospice care, because there’s a pretty common misconception that we are the same thing in the community. And so when we show up, you know, it’s not uncommon for them to kind of put their hands up and say, “No, no, we’re not ready for you yet.” And so we have to kind of provide some education and do some explaining about how we are further upstream in care than hospice or end-of-life care is.

Many of our patients often would qualify for hospice care, but that’s only if the patients and family members are ready to start placing those kinds of limitations. So we spend a lot of time just educating folks on who we are and how we’re here to help. And many times, if patients are uncomfortable, or they’re anxious, or they’re constipated, we can start simply by helping to manage those symptoms. And then once we get them to a place where they’re more comfortable, patients and families see that there is some benefit to having us involved.

Kevin Pho: So let’s transition now into the KevinMD article that you wrote. It’s titled “A plea for help from the front lines of the COVID-19 pandemic.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Kristin Adams Forner: Being an anesthesiologist, there’s a relatively higher rate of suicide within that field of medicine than in some others. So I have known a few people within the medical community, during my schooling and training and even in my practice, that have committed suicide. And I had another colleague, he was a year ahead of me in medical school, commit suicide shortly before I wrote that article.

And part of why I wrote it is because I was concerned about the level of moral injury that we as medical providers who were on the front lines of this pandemic have suffered, and what that might mean for the suicide rate for clinicians going forward. And so I just really felt this need to put on paper what my hospital’s experience had been like, why I was concerned, and what I thought might help to stem that tide, you know, in case there actually is a tide, or was a tide, of physicians or other clinicians considering ending their lives because of what they’d experienced.

Kevin Pho: Now, from your perspective and your experience, what were some of the reasons leading to potential moral injury, burnout, and suicide, just from your view of the medical system?

Kristin Adams Forner: Yeah, I mean, I think for the pandemic especially, there were some things that were relatively new sources of moral injury: having to tell patients and family members over and over and over again that they weren’t going to be allowed to have visitors, that, you know, for family, they couldn’t visit, and then having those patients ultimately die alone. That was a huge source of injury for all of us involved.

I think, you know, given our hospital culture’s distrust, we were really hesitant to limit CPR, even though we knew that fundamentally, if patients are dying from a lack of oxygen because their lungs no longer work, no amount of CPR is actually going to fix that problem. So always, at the end of the day, those patients were going to die. And yet we still felt like, in order to prevent complicated grief for these family members, we were going to need to go through those steps. That was another huge source.

I think, you know, sometimes the protocols for COVID were constantly changing. There were medications that we thought might work that we then found out didn’t. So that’s another source: Are we causing injury by some of the things that we’re doing, simply because this virus remains unknown?

Kevin Pho: You brought up some of these reasons for moral injury and burnout. Tell me what happened next and what the response was.

Kristin Adams Forner: So I think, you know, in our hospital, we began a series of services. One week it would be a memorial service for those we had lost to COVID. The next week it would be a celebration service for those who had overcome the virus. And I think that was helpful to kind of bring our community together and help us understand that we are all suffering together, but it’s at least together and not alone. And I think we just continued to talk through these things. We brought them up. We shed light on what we were feeling in these issues, and having that sort of communal understanding, I think, was also helpful, ultimately.

Kevin Pho: Now, if you’re a clinician, certainly in the midst of COVID and even after COVID, I think burnout and moral injury are still going to be present. What are some of the symptoms and signs they should look out for in order to potentially seek more help?

Kristin Adams Forner: So I think physical and emotional exhaustion is a big one, and sometimes that plays out by finding yourself more cynical. I know certainly that has happened to me. Finding yourself isolating yourself more, because you’re thinking, “The world doesn’t really understand what I experienced. The world doesn’t know, and I can’t make them understand that.” So that sense of isolation, I think, can be another sort of symptom. But, you know, at the end of the day, it’s all the things like not sleeping well and not eating well and not caring for ourselves, and those are all other signs that we’re not doing well.

Kevin Pho: So let’s say we recognize some of these symptoms in us. What would you recommend be our next steps?

Kristin Adams Forner: Tell someone, somebody that you trust. Find someone who is going to be able to sit down and hear you and listen to you. That’s the first step, I think, making it so that it’s not just you suffering that alone, that it becomes known. And then that in and of itself is getting help. But then obviously professional help, I think, is going to be necessary as well, and sometimes that means simply going to your administration and saying, “I need time off. I need a break.”

Kevin Pho: So we’re speaking in the middle of June, and in a lot of places in the country, things are getting better than they were, of course, during the worst of the pandemic. So in your hospital and in your experience, how are things now compared to a few months ago?

Kristin Adams Forner: Yeah, I think on some level, you know, what we’re seeing is that people are going on vacation again. They’re leaving work, and they’re feeling that it’s OK to take some time off and go be with their families, who they’ve missed, many of whom are, you know, away in other states, so they can now go travel to see them. I think we’re starting to see that people are starting to exhale on some level, I think, a little bit.

But, you know, at least where our hospital is, we still have several cases, and these are folks who either kind of just got vaccinated, so perhaps their immune system hasn’t caught up yet, or they chose not to get vaccinated. And so those folks are still our patients. It’s not over, unfortunately. And I think that’s the other part that’s kind of hard: We constantly are reminded that this is still going on. Even though it’s much better, it’s still a reality.

Kevin Pho: We’re talking to Kristin Adams Forner. She is an anesthesiologist and palliative medicine physician, and she wrote the KevinMD article “A plea for help from the front lines of the COVID-19 pandemic.” Kristin, I’m an internal medicine primary care physician, and for those other primary care clinicians who may be listening to this, what are some things that we could do in primary care that can make your jobs as a palliative medicine physician easier?

Kristin Adams Forner: Well, if you are working in an inpatient setting, call your palliative care teams when you’ve got your own distress, or you’ve got patients and family members who you think can use our services. We are always wanting to help our patients and families, but also our distressed colleagues. And I think if you do have any question about what is palliative care, how is it different than hospice care, how is it not the same thing exactly as comfort-focused care, ask. We’d love to answer those questions. We love to provide education. The more that we help people better understand who we are and who we aren’t, the better medicine our patients and families get.

Kevin Pho: So let me ask that question. Can you contrast palliative medicine to hospice care?

Kristin Adams Forner: Absolutely. So like I said earlier, palliative medicine is considered upstream from hospice care. So with hospice care, two clinicians have to believe that a patient has six months or less to live. With palliative medicine, somebody just has to have a life-limiting illness. There doesn’t have to be a prognosis associated with it.

And a lot of our job is, like I said, symptom management, navigating complicated family dynamics, especially when these families have to be making medical decisions, trying to figure out together with our patients what is the best care we can offer them. And what does that look like? Who are they? Who were they when they arrived at the hospital, and what was life looking like for them then? And then how do we, you know, optimize the care that they get when they leave the hospital, whether that is hospice care, because that’s what ultimately they decide they want and they qualify, or if it’s ongoing full aggressive care, making sure that those goals are communicated to the next teams that are going to care for them when they leave the hospital?

And what are the additional resources they need when they leave as well? Could outpatient community palliative care be helpful to them? Or is it, you know, they really just need more physical therapy or home health? What exactly is it that they need, and how can we help them get those additional resources?

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Kristin Adams Forner: You know, this was interesting. In the beginning of this whole pandemic, there was a lot of hero-making of us as frontline providers, and I think I kind of internally fought against that a little bit, because at the end of the day, we aren’t heroes. We’re humans. We have jobs that allow for incredibly meaningful and rewarding and, you know, purpose-driven interactions with patients and family members, and I think that that in and of itself allows us to endure incredible amounts of hardship and grief and sacrifice. But that doesn’t make us heroes.

And so at the end of this, I think it’s OK. It should be OK for us to say that we feel broken. We feel broken by what happened to us this last year and a half, and we don’t have superpowers that are going to help us overcome this. We might need to ask for help, and that’s more than OK.

Kevin Pho: Kristin, thank you so much for sharing your time and insight, and thanks again for being on the show.

Kristin Adams Forner: Thank you, Kevin. I appreciate your time as well.

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