Joshua Russell, MD, MSc, FCUCM, FACEP

A colleague, Dr. Mitchell we’ll call him, told me about a PA that he was supervising recently who made a great catch in a patient with a swollen, blue finger: Achenbach syndrome. When the PA presented the presumptive diagnosis, Dr. Mitchell, unfamiliar with the condition, had to Google it before seeing the patient. Our PA was right, though. The patient walked out of clinic, happy to have a benign explanation for her symptoms, the PA beamed with pride at his diagnosis, and Dr. Mitchell sat wondering how many cases of Achenbach he’d missed over the years.

That’s how it works, though. We might be seeing case after case of a certain disease, but until we learn its name and presenting symptoms, we’ll never identify the pathology. I’ll confess this happened to me recently, as well, and the number of cases I’ve seen since learning about the condition are staggering. The diagnosis: toxic positivity. Allow me to explain.

The arrival of a new year naturally forces us to take stock. What I’ve realized this year is that being a doctor is harder now than ever before in my career. Medicine as a science may have seen impressive advancements over recent years–the rapid development of new vaccine technology against a novel human pathogen chief among them—however, medicine as a practice undoubtedly has become much more difficult.

In urgent care, we saw rapid resolution of the low patient volumes seen early in the pandemic; a trend that had some of us (myself included) quite worried. It seems silly in retrospect and like a good problem to have nowadays. Caring for high volumes of frustrated patients who may or may not be spewing particles of a deadly virus and who can’t seem to access healthcare in any other setting has become the daily status quo. It’s exhausting.

If you can relate to this feeling, you’re not alone. Approximately 20% of healthcare workers have left their jobs since the beginning of the pandemic.1 While the reasons behind each departure were specific to the individual, the trend speaks to a widespread sense that the practice of medicine has gotten significantly harder. The days of the “healthcare worker as hero” narrative seem to be firmly behind us.

But if you’re reading this, I suspect you’re among the vast majority of medical providers who’ve chosen (for now at least) to push on despite the challenges. This deserves recognition. However, it seems that patients are not the only ones who undervalue the sacrifices clinicians continue to make on a daily basis just by showing up at work. I’ve heard countless complaints from colleagues of a pervasive sense of being underappreciated by those tasked with supporting their ability to practice medicine: their administrators.

Based on the stories they share, these complaints are well founded. I’ve seen providers asked to work more shifts, longer shifts, and see more patients, faster without any commensurate increase in pay or acknowledgment of the tremendous toll this has taken (or even that fatigue might be expected at all).

Ingratitude from patients is one thing. Caring for our patients is like caring for our children. We don’t expect abundant or effusive expressions of gratefulness from them, but a heartfelt one can make our day.

Lack of appreciation from healthcare administrators is far more  disconcerting. It belies a certain blindness to our daily struggles that reveals a problematic lack of empathy—especially from those who so consistently remind us to show more compassion towards our patients.  Austerity staffing measures were tolerable when patients were staying at home. But now that volumes (and revenues) have soared, compelling a clinician’s optimism or stiff upper lip strikes a decidedly dissonant chord.

Psychologists refer to this phenomenon as toxic positivity; this is actually the epidemic that is decimating the healthcare workforce, not COVID. Optimism, when self-inspired, offers tremendous benefits for mental health. Conversely, optimism imposed by others has a pernicious effect on psychological well-being and reflects the polar opposite of compassion.2 And this forced optimism comes almost exclusively from above and not our flanks.

If you’re like me, toxic positivity may be new to your vernacular, but you’ve certainly experienced it. Those practicing toxic positivity ask us to deny or repress our negative emotions and focus on the woefully insufficient “good” in a situation. And unlike Pollyanna, people don’t respond well when they’re told they should play “the glad game.” 

An example may be helpful. Administrators commonly blast emails to the entire staff encouraging feelings of pride after a complementary patient review is received, while simultaneously leaving providers to rely on their own resilience to cope with the much larger constituency of rude and demanding patients. Worse still, if any of those disgruntled patients proceeds to post uncomplimentary feedback online, your upbeat administrator’s sunny disposition will most likely evaporate when they approach you to discuss the case.

Practices such as these are based in callousness and obliviousness. An unexpected pizza delivery for lunch does not compensate for month upon month of moral injury. In fact, like an absentee parent returning at Christmas with a gas station-bought action figure, it’s usually more insulting than no gift at all.

The psychological effects of toxic positivity are many—and none of them are good. Victims of toxic positivity commonly suffer from guilt or shame because they’re experiencing negative emotions that they’re told they shouldn’t have. Alternatively, people may repress their emotions and become numb and resigned.3 When these negative effects occur, they’re rarely restricted to work-life. And this explains much of the exodus from healthcare: if your profession demands your humanity, people are left to choose between their job and their life.

In recent years, toxic positivity has largely been a silent killer of healthcare careers. I believe much of this is because the disease is under-recognized. Like Dr. Mitchell’s experience with Achenbach syndrome, it’s only after you’ve learned the name of the pathology and its symptoms that you can hope to make an accurate diagnosis. Until the problem is appropriately identified and acknowledged, there is little hope for cure.

So, if you work in administration and realize that you’re guilty of practicing toxic positivity, replace token gestures with genuine expressions of gratitude. Your staff is more likely to push forward if the harsh realities of healthcare work at this moment in history are acknowledged. Clinicians are a resilient and self-motivated bunch. And when we are struggling, we don’t need forced optimism. We need real support.

Finally, and most importantly, if you’re a healthcare worker and you’re experiencing any of the distressing symptoms mentioned above or other symptoms of burnout, you’re not alone; 60% to 75% of clinicians report experiencing adverse mental health consequences as a result of working during the pandemic.4  And as much as grit is part of our group identity, there’s wisdom, not shame, in asking for help when we need it.

The National Alliance on Mental Illness (NAMI) offers extensive, free resources for healthcare workers trying to cope with burnout, stress, and moral injury during this very difficult time. The NAMI HelpLine can be reached between 10 am and 8 pm (Eastern) at 1-800-950-6264 for confidential support. In addition, 24/7 assistance is available by texting “SCRUBS” to 741741.5

REFERENCES

  1. Yong E. Why health-care workers are quitting in droves. The Atlantic. Available at:  https://www.theatlantic.com/health/archive/2021/11/the-mass-exodus-of-americas-health-care-workers/620713/. Accessed December 7, 2021.
  2. Cherry K. What is toxic positivity? Verywell Mind. Available at: https://www.verywellmind.com/what-is-toxic-positivity-5093958. Accessed December 7, 2021.
  3. Villines Z. What to know about toxic positivity. MedicalNewsToday. Available at: https://www.medicalnewstoday.com/articles/toxic-positivity. Accessed December 7, 2021.
  4. Levine D. U.S. faces crisis of burned-out health care workers. U.S. News & World Report. Available at: https://www.usnews.com/news/health-news/articles/2021-11-15/us-faces-crisis-of-burned-out-health-care-workers. Accessed December 8, 2021.
  5. National Alliance on Mental Illness. Health Care Professionals. Available at: https://www.nami.org/Your-Journey/Frontline-Professionals/Health-Care-Professionals. Accessed December 8, 2021.
An Underrecognized Epidemic: Toxic Positivity in Medicine
Joshua Russell, MD

Joshua Russell, MD, MSc, FAAEM, FACEP

Quality and Provider Education, Legacy - GoHealth Urgent Care, is affiliated with the University of Chicago Medical Center in Vancouver, WA, and is Editor-in-Chief of JUCM.
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