You’re not broken: a Commentary on Residue

Authors: Sean Griffiths, DO (Emergency Physician, USAF); Josh Lowe, MD (Emergency Physician, USAF); Rachel Bridwell, MD (Emergency Physician, USA) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

“Trauma team to the trauma room, trauma team to the trauma room.” This is a call every emergency medicine (EM) physician has experienced countless times. It is often met by an exasperated sigh as the critically ill patients are transported from scene, allowing you only a few moments to put on your game face and then shoot expressive looks at teammates to move quickly. You and your team spring into action; the patient is in extremis from multiple gunshot wounds to the head and chest.  Ultimately despite everyone’s best efforts and through no one’s fault, the patient dies. You conduct a short, perfunctory debrief with the team which, as usual, leads to pretty minimal effective feedback from anyone. This one patient is just another body to add to the long list of bodies in your career and finally you head back to the pod to pick up the next chart in the heaping pile of patients waiting to be seen.

You tell yourself the patient was always going to die no matter what you did and you mostly believe yourself. In that moment, you relive every order, procedure, disagreement with nursing staff or consultants, the debrief, and your documentation. Then the family arrives. You take an extra moment to reapply your game face, grab a swig of coffee, straighten out your scrubs, and take off your stupid Patagonia vest because you’re sweating. As you deliver the bad news, the family delivers their own death blow to you, wailing that their only other child died of leukemia this week and the funeral was today. Another far more painful sigh comes bubbling up, but you contain it because it doesn’t have the cathartic effect it had on your anxiety an hour before. You stumble through a few more sterile “I’m sorry’s” and several “We did everything we could’s” then hastily retreat to your desk. Your shift is now over and time to go home to your spouse and children.

You’re numb, you put on a different but equally important game face – the “parent face” and walk in with a smile. You fumble through the rest of the evening in a fog, drink a little too much after dinner, and tell your spouse work was “fine”. Then as you lay down in bed, for some reason that exists only within the rambling minds of EM physicians trying to fall asleep, you remember a movie quote from the 2001 cinematic classic Training Day – “When you kill someone on duty, they have to be your slave in the afterlife”. You didn’t kill anyone but that night you dream about an eerily similar young male patient with multiple gunshot wounds to the head and chest, his family, and the rest of your slaves.

Residue

Residue is the focus of an article by Preston Cline, Ed.D., a researcher, podcaster, medic, expeditionary team leader and cofounder of the Mission Critical Team Institute (MCTI). The paper focuses on changing the paradigm of how high-performance individuals deal with the intense experiences that are the foundation of the extraordinary lives they have chosen.

Residue is neither good nor bad, it is not traumatic or atraumatic; it is the residual emotions, thoughts, anxiety, successes, identity, and dreams that stick tightly to us from our experiences. It is the splattered blood on your shoes from the trauma bay, the moon dust of the Middle East still clinging to your backpack, the cup ring on your back porch after beers with your best friends, or the mud stubbornly caked on your wheel well from driving to a friend’s funeral two weeks ago. It is inconsequential in isolation, barely affecting you, but cumulatively over years of exposure, it gums up the works of your mind rendering you less effective in your mission, whatever that may be.

Residue shifts the approach to trauma and wellness from a pathological (deficit) based approach to a strength (asset) based approach with several fundamental truths:

• You are not broken. You are not a victim. You are not a survivor.
• You have chosen a hard path full of extreme experiences, both good and bad.
• These experiences leave residue that if dealt with appropriately, fuel greater achievement. If neglected, they can lead to worsened performance and feelings of failure, alienation, and resentment.

This strength-based approach avoids the problem-focused approach of other wellness techniques. Instead, residue management leads to self-directed, opportunity-focused, changes in behavior. Those who are struggling are often labeled, diagnosed, prescribed and treated in a manner which says, “something is wrong with you and here is how you fix it”. The inherent flaw in this approach is that there is no fixing it. Tomorrow someone else on shift is going to come across a critically ill patient, get a patient complaint, or argue with a consultant. No matter what SSRI they’re prescribed, how much they talk to a therapist, or how understanding their family is – the residue on their life will continue to build, gumming the gears of progress. Each person needs a way internalize this residue, release yourself from its sticky attachment, and move forward through life.

From one EM physician to another

You may not think you need this. From one physician to another, you do. We all process these important experiences differently, but we still all NEED to process them. There’s an apt metaphor for dealing with stress that is attributed to COL (ret) David Hackworth, a highly decorated Korea and Vietnam veteran. It basically states that everyone has a cup they can fill with trauma. Some cups are thimbles, others are swimming pools, but they all have limits. If you manage your experiences appropriately while embracing the residue left by positive experiences, you can dump out some of your cup to make room for future stressors. But if you let your cup overflow, there’s no going back or reversing damage; you have burned out to an irrecoverable state. This is the end state we are always looking to avoid, the forever burnout. We will cover some particularly salient points specific to the EM physician in coping with residue.

 1. Suffering as a Privilege

Dr. Cline quotes a military EM physician ruminating on this quote from Portrait of a Lady, “You must have suffered first, have suffered greatly, have gained some miserable knowledge. In that way your eyes are opened to it”. You’re suffering with regards to the trials of medical school and residency, the personal relationships that have withered on the vine, and the countless numbers of dead and dying you have laid hands on is not a weight you drag around your ankles to and from shift. It is a badge of honor shared between you and your brothers and sisters in medicine. Dan Dworkis, MD, PhD and an EM physician at USC Medical Center stated in a MCTI podcast, “Don’t let suffering go to waste”. Your suffering lets you know you still care deeply. If examined through the appropriate lens, your suffering teaches you how and in what direction to grow. Examining your suffering through a strength-based approach reframes the narrative. It helps you examine tragedy or loss through the framework of improvement, not through the view of damage done to your psyche from which you need to convalesce or run. Look at your shortcomings as opportunities to learn and build upon, not as an exposé on why you’re a terrible doctor.

2. Improving your inner dialogue and self-awareness

Similar to before a big resuscitation arrives, we all have particular self-talk phrases to keep us calm and confident right before to perform our best. We use our square breathing and tell ourselves “you got this, kid” or whatever your phrase is to get you in the mindset of conquering the task at hand.  Our inner dialogue after these events is equally critical for processing our residue. Balancing the honest critique of performance with the protection of your self-esteem is a precarious tight rope to walk, especially while on shift when the next patient we see after these moments is the scariest. We will often look elsewhere to place external blame, thereby preserving our self-image. However, this can lead us down the road of self-pity and a finger pointing, deflective, narcissistic path. Practicing self-compassion or “allowing yourself some grace”, will allow you to evaluate your performance in a non-accusatory way that can lead to the notation of areas of improvement. Scott Weingart, MD discusses his thoughts on self-reflection, “Let the real negative voices speak to you because they may say something valuable that you wouldn’t hear otherwise… but don’t let them speak too long”. Protracted negative self-talk leads to pathologic imposter syndrome and decision-making paralysis from fear of repeated failure. This will mature into an inability to search internally for legitimate shortcomings and the hindrance of our professional growth. Failure is an inevitable part of medicine, how we debrief ourselves after failure to handle and internalize the lessons learned is a choice.

3. The third thing

Residue delves into many other tools to help digest and cope with our experiences but the final point we will cover is the development of your “third thing”. The first thing is your job, the second thing is your family, and the third thing is anything that brings you to new learning and self-improvement. This third thing is a way to disconnect from your professional world and bring fulfillment away from medicine. This concept of the third thing is non-negotiable for your mental longevity and residue processing capability. Our job in medicine will one day end and if your entire internal picture is “the doctor”, this end in clinical medicine will wreak havoc on your unidimensional self-image. It is a fallacy to think that dedicating time to woodworking, fitness, a small business startup, or a Dungeons and Dragons clan will take away from your professional development as a physician. The lessons learned in these other endeavors are directly applicable to your life in medicine and give you a source of joy completely independent of EM.

The world may be on fire, but you don’t have to be

Every day it seems that there’s a new article about the slow death of EM and the pandemic of EM burnout as the COVID pandemic persists. We cannot begin to imagine solutions on a macroscale, but we are tired of articles and papers painting us as defeated victims in our burning EDs. Finally, at least for us, we have found an approach that has the solutions buried within our conscious thoughts.  All we want to be able to do is help other physicians improve their lives. We have to believe that a workforce full of motivated and mentally healthy physicians can overcome any obstacle that we collectively face. Please read Residue and hopefully it will help you process the experiences you face daily in EM as it has for us.

Disclaimer:  The views expressed in this post are those of the authors and do not reflect the official views or policy of the United States Government, Defense Health Agency, United States Army, United States Navy, United States Air Force, SAUSHEC, or the Department of Defense or its Components.

References

https://missioncti.com/wp-content/uploads/2020/06/RESIDUE-V.4-PUBLIC-DISTRIBUTION-4.20.20-1.pdf

Cline P, Dworkis D. MCTI Teamcast. Season 2 Episode 5. The Emergency Mind. July 19, 2021. https://teamcast.missioncti.com/episode/s2-ep5-the-emergency-mind

Orman R, Weingart S. Stimulus with Rob Orman, MD. Episode 55. June 28, 2021. https://www.stimuluspodcast.com/post/53-the-five-fears-of-scott-weing