By Mary Meyer, MD, MPH

"As a follow up to our conversation, work on not being abrasive and emotionally tied to your point of view. Work on trying not to make assumptions. Is there anything we can do to help you work on your leadership skills?"

In spring 2023, I found myself staring -- seething -- at my boss's email. At the time, I was nearly at rock bottom. And I wasn't alone. By any measure, it had been a challenging 3 years for the American healthcare workforce. Burnout had skyrocketed. A quarter of American healthcare workers were experiencing anxiety and depression, and one in five was eyeing the nuclear option -- leaving healthcare altogether. My own emergency department had experienced so much attrition I gave up counting the physicians who had come and gone (to this day, when I don't see a physician for a few weeks, I assume he or she has quit). Healthcare at large was nearly at rock bottom.

None of this started during the pandemic, of course. With the benefit of hindsight, it is now clear that the healthcare industry was overdue for a reckoning by 2020. Psychological stress, secondary trauma, workplace violence, dysregulated circadian rhythms, physically demanding work, and unrealistic expectations of perfection -- long shouldered by healthcare workers and thought to be part of the job -- had done their damage.

Surveys in 2022 found a whopping 40% prevalence of emotional exhaustion (code for burnout) among American healthcare workers, but 32% were already reporting emotional exhaustion in 2019. When researchers retrospectively examined healthcare workers' responses in a national survey administered between 2017 and 2019, they found the prevalence of insufficient sleep and depression were 41% and 19% respectively, both significantly higher than non-healthcare workers in the same survey. Data from the pre-pandemic period consistently point to elevated levels of moral injury and attrition across the spectrum of healthcare, reflecting the high cost of being a caregiver.

The seeds of clinician burnout and attrition were planted decades ago: the pandemic simply turned them into a bumper crop. Such is the nature of disasters in general and pandemics in particular.

The Aftermath of Disaster

But great public health crises have generally been followed by upheaval. Disasters act as amplifiers and accelerators, exposing the long-festering cracks and weaknesses of society's infrastructure and then toppling anything that can't withstand the pressure. They destroy traditions and livelihoods alike; they make the impossible possible and the unthinkable reality. Cultural norms are suddenly upended. Whole communities become poverty traps, where the initial damage and subsequent migration exceed the ability to rebuild.

All of this makes intuitive sense -- the concept that disasters trigger upheaval. What is less intuitive is that disasters, by virtue of the havoc they wreak and the assumptions they crumble, often facilitate growth. In the vacuum that follows a disaster or a pandemic, there is opportunity and a path for previously marginalized ideas to flourish.

In the late 1990s, a pair of psychologists from the University of North Carolina at Charlotte coined the phrase "post-traumatic growth" to describe the concept that adversity can result in profound growth. Traumatic events, like disasters, cause most people to experience varying degrees of anxiety, disbelief, intrusive memories, and a yearning to return to the way things were. But ultimately, the extraordinary nature of these experiences and the window into a different perspective they create can serve as a catalyst for growth. This growth can happen at the individual and organizational level, and it goes beyond resilience (the ability to cope in the face of adversity). It involves adaptation -- a cognitive rebuilding that accounts for the new reality and the lessons learned from the collapse of the old reality.

A Changing Field

Today, in the post-pandemic period, ask any clinician how it feels to be in healthcare, and you will likely get the same answer: it's exhausting. The pace of change is dizzying. There are not enough clinicians for a nation of rapidly aging patients with a portfolio of chronic diseases. Many of us are still processing trauma from the pandemic even as we adapt to our new normal.

Yet, it is this very messiness that offers reason to stay hopeful: American healthcare is deep into a period of post-traumatic growth. This growth is uncertain, uncomfortable, and at times frankly bewildering and contradictory. And it is evidence that medicine -- an industry steeped in tradition and historically slow to evolve -- is capable of both culture change and adaptation.

For one, we are witnessing a new and refreshing intellectual humility. After all, what could be more humbling than the advent of generative artificial intelligence (AI), which can combine the knowledge base of clinicians past, present, and future with -- apparently -- more empathetic emails? What could be more humbling than the revelation that, after decades of reverence for subspecialty medicine, we are lost without primary care? Or the reminder, on the heels of a pandemic and a tsunami of COVID-19 patients, that it is always better to keep people healthy than to treat their disease?

More importantly, we are witnessing a renewed appreciation for frontline clinical work. This includes a recognition that the beating heart of medicine is the doctor-patient relationship -- even when it occurs on a screen or involves support from AI -- and the long-overdue realization that the best way to improve retention is by improving conditions at the bedside rather than by weaponizing compassion or suggesting clinicians work harder.

In tandem, these early post-pandemic years have been characterized by a new emphasis on clinician well-being and work-life balance, as evidenced by the push for unionization at facilities across the country. As someone who trained 25 years ago when the Libby Zion Law was treated as an affront, this seems nothing short of miraculous: I certainly never expected anyone to tell me to put my own oxygen mask on first.

A Battle Worth Fighting

Clearly, we still have work to do to balance the ledger. We have too many executives and middle managers who don't spend enough time at the bedside and too many frontline clinicians with unsustainable schedules. We also need to mentor the next generation of clinicians in a manner that encourages them to pursue both clinical medicine and their non-clinical interests. But I am convinced we are making incremental progress towards a more resilient healthcare workforce.

For me, rock bottom came several weeks after my boss's email. Eventually, I found my way out and back to the specialty I love. I still have plenty of days when I am tempted to walk out mid-shift. But these are becoming less frequent, and increasingly, there are moments of joy during even the most challenging shifts. It still feels like a constant battle, but it's a battle worth fighting.

For other clinicians who are wondering if it is still worth it to stay in healthcare, I ask you to persevere. Please don't quit. Worse, don't quietly quit. Be a loud and unapologetic voice in support of intellectual humility and clinician well-being. Get abrasive if you need to. I believe this will get better. The history of disasters teaches us that adversity sows seeds, often imperceptible at the time, which bear fruit long after.