The combination of the US election ‘season’ and the devastation from the pandemic has left the country exhausted and in a shambles. The emotional and political wreckage from recent times has worked its way into the national character of America. Physicians, nurses, and staff have been particularly traumatised and exhausted after a year of constant death and uncertainty while living behind masks, shields, and other PPE with no real relief in sight. Clinicians and hospital employees feel a rising rage as they watch a lack of national leadership, health systems crumble, colleagues die, and their careers being permanently affected by circumstances.
No clinician trains to be a pandemic doctor but they are nevertheless. Meanwhile, the newspapers are full of demonstrators and politicians who demand the freedom to infect their neighbours and families but will, of course, also demand the best of medical care when they are ill. Health professionals are being asked to save the lives of some people who seem determined to kill them.
COGNITIVE DISSONANCE
My colleague Will Miller, MD, refers to what we are experiencing as professional moral distress, which is a more profound concept than the overused term burnout. Moral distress reflects the conflict we feel between what we know we need to do and what institutions will permit us to do.
Interestingly, the literature on moral distress is primarily from nursing. Recovery from it will require radical institutional changes, more clinician autonomy, and will affect physicians for the rest of their careers.
The doctor–patient relationship is built on trust. We need to accept that the patient is telling us their truth and we believe that beneficence, working for those patients’ wellbeing, is one of the principles of public health ethics. But the cognitive dissonance of communities that appear grateful for the sacrifices of health professionals yet engage in behaviour that completely disregards the safety of those same health professionals will not be forgotten easily. This time in history will leave scars.
General trust in the US has been shattered by the numbing repetition of lies and conspiracy narratives. Any hope that neighbours will learn to collaborate for the common good is undermined by the malignantly narcissistic figure of Donald Trump who spreads hatred and paranoia everywhere. The invasion of the US Capitol Building by a Trump-encouraged unmasked mob is a symbol of how fractured the country is and how much that fracture feels permanent. The pandemic has amplified the literal and figurative distance between neighbours and among family members, between teachers and students, between doctors and patients, inflicting a kind of collective psychological trauma that can be summed up by asking an older person when they think they will feel safe going to a movie or going out to dinner or seeing their grandchildren again. The answer is, despite vaccines beginning to be rolled out, a sad look followed by ‘maybe never’.
GENERALISTS IN THE FRONT LINE
The federal government, which has resources and expertise, has undermined trust in science and avoided rational suggestions for prevention of the disease. States and health systems fight over supplies and will undoubtedly fight over vaccines. In normal times, 50% of people are vaccinated at their primary care physicians’ offices and 90% of family doctors provide immunisations as part of their practice. So as the coronavirus vaccines become available to the general public, generalists will be the front lines in the campaign. They know their patients and communities, and they are trusted. They are distributed along the lines of the general populations in rural and urban communities. They have experience negotiating with those hesitant for whatever reason to get vaccinated. So, unless the practising community is at the centre of vaccine distribution, the country will fall short of its goals. At the moment, there is little talk of how the primary care workforce is central to the first wave of COVID-19, never mind that this will most likely be an annual process.
The exit of Trump will be a final act of pique and governmental destruction that will salt the earth of the country in a way that may make any rehabilitation and reckoning seem impossible. He has unleashed campaigns against voting rights, health care, the environment, education, housing, relationships with other countries in the world, left cities and states with irreconcilable differences and created levels of intolerance not seen since The Civil War.
REINVENTION
So what will rise, afterward. One can hope, some civility and understanding, collaboration, and a search for the common good — at the local and state level if not at the federal government. It depends on how widely Trumpism has metastasised. Family medicine will have to be reinvented both from a structural and educational perspective. Things worked moderately well in the half-century before the deluge, but the combination of the political violence visited on the country, the concomitant destruction of trust, and the glaring inadequacies revealed by a merciless pandemic have pointed out the urgent need for massive reform.
President Joe Biden not only has to clean out the Augean stables full of the s**t left by Trump and his Brownshirts, but also has to reinvent a health system focused on stewarding resources rather than just pursuing greed. Cooperation, collaboration, and unified movement toward a national health system is the only way to not be crushed again when the next pandemic comes along.
As Benjamin Franklin has been quoted as saying at the signing of the Declaration of Independence in 1776: ‘We must all hang together, or, most assuredly, we shall all hang separately.’ This is the time for physicians and the public to take that to heart.
- © British Journal of General Practice 2021