The January 2022 issue of JUCM led off with an editorial by Editor-in-Chief Joshua W. Russell, MD, MSc, FCUCM, FACEP about what he called “actually the epidemic that is decimating the healthcare workforce” and “a silent killer of healthcare careers.”

He was referring to toxic positivity, or the practice of “encouraging” someone—in this case healthcare providers in the midst of the COVID-19 pandemic—to find and focus on the bright side rather than dwell on withering challenges and difficulties. The problem is, those challenges and difficulties need to be acknowledged and dealt with rather than overlooked in the service of soldiering on with a stiff upper lip. (Grief expert and author David Kessler defined toxic positivity in an article published by The Wall Street Journal as “positivity given in the wrong way, in the wrong dose, at the wrong time.”1)

              Dr. Russell’s take on the issue resonated with readers. Some wrote thoughtful (and forceful) responses. We found a couple especially insightful, and are happy to share them with you here.

Things are Bad, but Urgent Care Administrators Aren’t the Problem

Matthew Ajluni, DO

After reading the editorial An Underrecognized Epidemic: Toxic Positivity in Medicine by Joshua W. Russell, MD, MSc, FAAEM, FACEP, with great interest as a physician-administrator leading 70+ urgent care providers at 14 urgent care locations, I felt compelled to share an alternate perspective.

Dr. Russell claims that “toxic positivity is actually the epidemic that is decimating the healthcare workforce, not COVID.” While I agree that provider burn out is in fact an epidemic, I am less inclined to hold administrators as the culprit.

The problems in healthcare are vast, and factors leading to burn out are many, including excessive patient loads, EMR frustrations and “click fatigue,” poor work-life balance, not working at the top of our license, compensation concerns, fear of litigation, underappreciation…the list goes on. Add in a once-in-a-lifetime pandemic, and now the fire is blazing. So, while toxic positivity could exacerbate this red-hot fire burning out our healthcare teams, it is just one relatively small part of the blaze.

The pandemic has stressed our healthcare system to the extreme, and especially our acute care teams, including our UC staff and providers. The going is tough, absolutely. At the time of this writing we have providers in some instances seeing 80-100 plus patients per day in our drive-through testing sites, in subzero temps, for 12 hours per day. It is undoubtedly brutal. Couple that with fears associated with contracting the disease, particularly in the pre-vaccination days, and those shifts truly became yeoman’s work.

With patient volumes surging and disease burden high, we faced the dilemma of how to serve our communities without burning out our teams. This continues to be a conundrum for all of us. Should we say Thanks to our teams? Absolutely. Do we mean it when we say it? Your article suggests the gesture on the part of some administrators is vacuous and insidious in some ways.

The article prompted great introspection and we asked ourselves, “Are we guilty of toxic positivity?” The jury is out, but what we know is this: Our urgent care leadership team and our senior leaders spend hours thinking and considering how we can alleviate the burden on our teams. We say thank you often, in person, on virtual meetings and, yes, by email at times. We devoted an entire section of our monthly meetings called “Gratitude” where we deliberately, intently, and with a deep heartfelt reverence thank our team members. We practice empathy, discuss the hardships, and allow folks the opportunity to share. We’ve increased hourly pay, bonus pay, and reconciliation pay. We’ve brought in breakfasts and lunches intermittently, most recently for 2 weeks straight to all locations. We’ve added support staff where we can (though we aren’t immune to the staffing crisis). We’ve shuttered locations where we just couldn’t find adequate support staff. We got our teams fashionable snow suits for those working in the cold drive throughs. And the list does go on.

Is all that enough? Perhaps not. It is still rough, it is still busy as heck, and it is still grueling work. And so, are we guilty of toxic positivity because we send emails, saying, You are amazing, you are a hero, you are literally saving lives in our community? Are these token gestures, or genuine expressions of gratitude?

What is a genuine expression of gratitude? Do you have to really mean it, is it money, is it fewer patients per shift, is it fewer shifts? What we know is that we’ve all been dealt a tough hand with this pandemic, and it is tough for all, including the administrators. The frontline work is exhausting, but the behind-the-scenes work is staggering, too: constantly changing PPE protocols, testing protocols, monoclonal antibody treatment protocols, managing unpredictable surges in demand, figuring out drive-through testing, dealing with staff shortages due to frequent COVID absences, handling volatile patients and disgruntled providers, and more.

The question is this: Can’t it just be bad without pointing the finger at any one group? Or is it, this is terrible and it’s all the administrators’ fault?

The admins I know work until they drop. They care just as much as anyone, and they love their teams. They want to care simultaneously for their communities and keep their teams well supported and engaged. They aren’t sitting back on easy street firing off emails that say, C’mon guys, you’re the best, keep up the good work. They are tossing and turning at night because they worry for their teams and their ability to keep sites open. The admins I know took training courses as clinical support assistants (CSAs), pulled up their bootstraps, and helped out on the ground at our sites. We had our IT chief rooming and swabbing patients at our clinics, our VP of Strategic Planning doing vitals and intakes at our drive-through locations on nights and weekends, and our Division Directors prepping procedures in our Dermatology clinics and answering phones at our Oncology clinics.

Do they deserve special accolades for stepping up? Not necessarily. But do they deserve to be called callous and toxic because they offer praise? Certainly not.

I can’t speak for all administrators, but I do think they are a convenient scapegoat to pile on, when in reality we are just in a bad situation, and it’s just bad for everyone, no matter your role. So rather than point fingers, I think it is more fruitful to acknowledge the hard work of all members of our healthcare teams and show gratitude and appreciation for all of them and not question or impugn the motives of any one group. Where toxic positivity may exist, with hollow thank you’s and nothing else to back it up, then perhaps there is opportunity to push back—though what I see is struggling healthcare teams and all of us just trying to do the best job we can in the midst of a crisis.

Let’s Act Like We Are in This Together—Because We Are

Arlene Alikian, MD

After reading the recent editorial by Dr. Russell, An Underrecognized Epidemic: Toxic Positivity in Medicine, I felt compelled, for the first time in all my 50 years, to send a letter in response to a medical journal article. What I want to say most is thank you for putting into words the source of frustration that I have been trying to verbalize since the start of the pandemic.

I am a pediatrician and co-owner, with my husband, of a pediatric urgent care center in Southern California. We receive JUCM monthly, but honestly, I haven’t had time to read it much since the pandemic started. Sometimes my husband will see an article thathe knows I should read. He subtly and strategically leaves the journal out and open to the page he thinks I should see. This morning I found the journal conspicuously next to the sink in the bathroom and open to the piece on toxic positivity.

My husband knows me well—it was exactly what I needed to hear.

I have witnessed this pandemic from both sides of the aisle. While I am an urgent care owner, employing a full medical staff, I also work as a staff member at another clinic. So, I see the problems from the administrative and employee perspectives. For almost 16 months, we kept our doors open, paid our staff, and never laid anyone off, thanks to the Paycheck Protection Program. During this time, as owners, we never made a dime, and actually lost money.

Then when schools resumed in-person, we went from seeing virtually no patients to being swarmed, all the while trying to balance pandemic complications and staff morale while delivering the best care we can to our patients. Throughout this whirlwind, I worked very, very hard not to treat my staff the way I was treated as a staff member. In fact, you may count me among the 20% of healthcare workers who quit because of pandemic-caused healthcare burnout and having enough of this sort of treatment.

Based on the hours of our urgent care, most of my staff work part-time for me and have full-time jobs during the day at other healthcare offices. In the past 6 months, more than half of them quit their day jobs because they burned out. These are medical assistants and front-office staff who really need the money. They told me they were at their wits’ end, mentioning supervisors who didn’t help and just kept pushing for them to do more. It doesn’t matter that this healthcare worker—the one who gets called a healthcare hero—cannot get any leeway from her supervisor to simply care for her children when they are sent home for the fifth time this year because of a COVID exposure at school.

These healthcare workers are quitting their jobs and taking jobs outside of the profession, where daily sacrifice is not asked of them. When I ask my staff why they stay with me, they say it’s because I’m “different”; I listen to them; I accommodate their needs for time off whereas others simply make demands. Demands that are being made to those who have nothing left to give.

So we are clear, the healthcare field is losing the staff members who are the hardest working ones. The ones leaving have a full-time job on the weekdays but also put in 10-20 hours extra on nights and weekends to try to support their family. Some are single parents trying to provide. These are the individuals we want to keep in the healthcare field—and we are losing them.

At the same time, other younger pediatricians in my community are already talking about leaving healthcare for similar reasons: jam-packed schedules, constantly covering for staff members who are out due to COVID exposure, more paperwork, more regulations, and more pressure. And…the kicker is that we are expected to continue to do more while insurance reimbursement is less and less. Not to mention, these pediatricians have their own children sent home from school due to COVID exposure, and they have to figure out childcare for them, as well.

I write this because I am as worried as I have ever been in my 21-year career in medicine. Too much has been asked of us as a whole in the healthcare field (hospital workers in particular). The demands keep increasing with little appreciation for how much is already being asked of us. So, we leave. While it is true we are a motivated and resilient bunch, we are still human. We can only take so much. So, many leave. I don’t know what will happen to us as a country when we finally reach the point where there simply are not enough clinicians to do the job.

For my part, I continue to try to take care of those who I have the ability to help. I guess I have been adhering to the idea of “take care of your own.” However, in the grand scheme of things, I feel that “your own” is the entire healthcare field—all of us—and I do not know how to help healthcare workers on a larger scale.

Thank you to Dr. Russell for recognizing it. Thank you for listing the places* where help can be found, and thank you for taking the time to read my rambling response.

*The places Dr. Alikian refers to include the National Alliance on Mental Illness (NAMI) HelpLine, which can be reached between 10 am and 8 pm (Eastern) at 1-800-950-6264 for confidential support, as well as a 24/7 service accessible by texting “SCRUBS” to 741741.

References

If you’ve read something in JUCM that you’d like to comment on, either to our editors or our entire readership, please let us know in an email to [email protected]. Matthew Ajluni, DO is Division Head of Urgent Care and Virtual Medicine at IHA Medical Group —A Member of Trinity Health. Arlene Alikian, MD is President and Founder of After Hours Pediatrics, Inc.


The Original Article

Our Readers Write—and Have a Lot to Say About ‘Toxic Positivity’
Author

Matthew Ajluni, DO

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Arlene Alikian, MD

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