There is an old English fable that describes a period of drought. In the midst of famine a mysterious lady arrives leading a giant cow. She instructs the villagers that the cow will fill any single pail, no matter the size, with milk, on a daily basis. The cow was able to provide a seemingly limitless supply of milk until one day when someone brought an unfillable bucket full of holes and sat down to milk the cow. The milk gushed into the bucket but ran away through the holes. As the last milk was drained the cow’s hide had become dull, clinging to the curves of her famished ribs. In great distress the maddened Dun Cow ran far away over the hills and was never seen again.1
THE LIMITS OF COMPASSION
In times of need health professionals have always given their time freely. Doctors donate significant time to the health system through pro bono work, usually in the form of administrative tasks undertaken after hours or as extra clinical time for our vulnerable patients. Our hospitals run on unpaid junior labour. When we examine any crowded A&E department, any mental health service, or any busy ward, there will be health professionals donating their time so that patients don’t suffer the consequences of overwhelmed, underfunded hospitals. Around the country, doctors consistently volunteer their time in medical education, research, policy, and planning. Expectations are high: intrinsically and extrinsically. We do not wish to let our patients or our colleagues down, so we use less sick leave than we should. Consciously or unconsciously, health leaders use this professional guilt to staff their services and manage their budgets.
During crisis these extra services are freely given. We recognise the importance of contributing to our communities, and most of us are financially stable enough to weather the compassionate donation of time and resources we need to give at the moment, one bucket at a time. However, compassion is a finite resource. One of the greatest strengths (and weaknesses) of our profession is that most of us will fill in the gaps in the health system any way we can. Most of us see our job as a vocation; we donate time because we actually care.
Unfortunately, the one thing we know in our profession is that bleeding hearts eventually cease to beat. Doctors are burning out. This causes one of two outcomes; they become cold and sometimes unintentionally cruel foot soldiers in a dysfunctional system,2 or they become unwell themselves.3 We now have junior staff dying from suicide at unacceptably high levels, and bullying and harassment is rife. Substance abuse, depression, and anxiety are also common.4 Others will lose their health, their marriages, and solid relationships with their children. We all know kind health systems get better outcomes.5 Burned out staff who are experiencing their own suicidal thoughts have little capacity for kindness.
At the moment, many of us are acquiring a self-care debt. We do so willingly, but eventually this debt will need to be paid with appropriate strategies (time off) or unfortunate consequences (our own illnesses). Life is unlikely to return to normal soon, if ever. We will have a backlog of late diagnoses, emerging mental illness and, of course, trauma. All are complex and poorly funded. The demand for compassionate donation of time will continue.
However, the main issue is moral distress. Moral distress is a predictable response to situations where we feel we have an ethical responsibility to do something about a problem but we cannot act in a way that preserves our integrity. As the pandemic continues there are things we know will continue to be critical for the wellbeing of our patients; safe housing, a secure income, and, particularly for our critically unwell mental health patients, access to tertiary care when needed. We pour our resources into patients needing this care but we are often unable to acquire appropriate services and our care is an insufficient substitute.
Like the Dun Cow, when we feel our energy run through a sieve with little outcome we find we have less to give to the community and we become burned out.
As our healthcare context continues to change it will be essential that we involve GPs in mapping health service gaps. We are the providers who fill these gaps in multiple intersecting health systems but our resources are not bottomless. We cannot provide 24-hour care for our suicidal patients or a safe home for victims of domestic violence. The bridge that we often offer is compassionate care, but that is rarely enough to keep our patients safe. This is deeply distressing.
If general practice becomes unsustainable we will lose the most effective and efficient health service we have, and it will not be easily replaced. Particularly in times of disaster we need the capacity to have a flexible, innovative, adaptable workforce that meets the needs of the majority of people wherever they live. In order to do so we cannot continue to rely on goodwill alone to consistently fill service gaps in the community. It’s time we involved GPs in the critical analysis of the holes in the system, before our capacity for volunteer labour drains away.
