Rest

Notes from a Family Meeting, Vol. 4, No. 11

Medical training does not teach you how to rest. That might seem like a silly educational requirement, but it’s something I’ve needed to learn how to do. Training uses the altruism of trainees as fuel to make them as productive as possible. That carries over into whole careers. The days off, few and far between, are offered as means of recharging so one can return to work. When the novelty of my first job after training wore off, I felt like I was standing on the border of a bleak desert: “This could be the rest of my life.” The hours were very similar to my training, and at times worse, but with less structure to accommodate sick days and vacation. It wasn’t good. How could I learn to rest?

Restlessness accompanies a family of ailments that haunts the modern healthcare workforce. These are things like burnout, moral distress, moral injury, compassion fatigue, depression, anxiety, and demoralization, to name a few. I’m not lumping them together to claim they have a common etiology nor that they should have a common response. Rather, I think restlessness - both lack of rest as well as the subjective unease one has with being still - accompanies and exacerbates all these states. I’m not going to suggest that rest can exorcise them, but a culture that has a healthy, appropriate appreciation for rest is probably better equipped to address them - if only because it’s better rested!

One common institutional response to the aversive symptoms that accompany most, if not all, of these states is to improve “self-care.” Self-care is a buzz concept in medicine. Woven throughout education on burnout is the importance of caring for oneself. If you’re not well, how can you care well for others? Prominent clinicians will share on their social media accounts of vacations spent with families: “Recharged for next week!”

As we’ve come to behold the systemic roots of these maladies, more people have pushed back on “self-care” as an appropriate response. It places too much of the burden of “resilience” (another buzz concept) on the individual in an ailing culture. Systemic problems - like administrative burdens, malignant culture, and bureaucratic barriers to care - certainly contribute to these maladies, and addressing them will require systemic responses. So others discuss “wellness,” divorcing the concept from any suggestion that this is meant to restore you for work. “Wellness” language might accompany a bigger project of dismantling the “calling of medicine.” Work in healthcare is just a job. Nothing about it places a special claim on clinicians. “Calling” language, as some claim, has for too long be used to make clinicians work more for less. Part of the wellness revolution is to reorient healthcare work within the broader context of individual workers’ lives.

Another ill still lurks in the shadow, though, and neither “self-care” nor “wellness” reckons with how to see it, let alone ameliorate it.

Machines Don’t Rest

Technology reveals our hopes and fears; our vision of what humanity is and should be; our dissatisfaction and expectation for the world. Technology brings an apocalypse. Some medical technologies, like the humble stethoscope, reveal a desire to push through the layers of the body to discern what’s hiding underneath. Where’s the lesion? Can the clinician hear its whisper? That desire isn’t at all bad, but it can lead to ironic stories of foolish clinicians who, when their patient tries to speak during a exam of their lungs, chide them saying, “Shh, I can’t hear you while I’m listening.”¹ The stethoscope directs the clinician’s attention in ways that are different and sometimes contrary to what their patient desires and even needs.

Machines offer tremendous reliability and are subject in almost every way to measurement, reproduction, and efficiency. The stethoscope, like most other tools, does not rest. It has limits and can break, but it can keep listening to hearts and lungs (or testing reflexes, to the disdain of neurologists) long after its clinician has left to seek “self-care.”

Neil Postman wrote that the power of the machine tricks us into believing that “we are at our best when acting like machines, and that in significant ways machines may be trusted to act as our surrogates. Among the implications of these beliefs is a loss of confidence in human judgment and subjectivity.” This is one of the hidden philosophies of technology Postman wrote about elsewhere, remarking, “Every technology has a philosophy which is given expression in how the technology makes people use their minds, in what it makes us do with our bodies, in how it codifies the world, in which of our senses it amplifies, in which of our emotional and intellectual tendencies it disregards.”

Our tools promise to expand our agency. With the menial tasks dispatched, we can now do other things. We’re free. Perhaps we can finally rest? But somehow that hasn’t happened. Instead we find ourselves restless. Oliver Burkeman writes:

“The reason that technological progress exacerbates our feelings of impatience is that each new advance seems to bring us closer to the point of transcending our limits; it seems to promise that this time, finally, we might be able to make things go fast enough for us to feel completely in control of our unfolding time. And so every reminder that in fact we can’t achieve such a level of control starts to feel more unpleasant as a result.”

It’s worse than this, though. The machine sets the standard for the expectations we have for ourselves. It’s not just that our tools don’t live up to our expectations, but we ourselves don’t either. Machines don’t rest, neither should we. We’re continuously contending with this limit. Administrators and clinicians themselves allow the bare minimum for makeshift rest - that is, something that restores you physically and perhaps mentally for a return to work - because we haven’t figured out how to crack this nut, but staffing margins are still razor thin. Rest costs money. Most Americans don’t see it as a worthwhile investment.

The tragic irony is that our attempts to remediate this problem through interventions like “self-care” belie a belief that further exacerbates the restlessness. “Self-care” bends everything in one’s life toward the purpose of restoring one to work. Playing with your kids is no longer an end unto itself but “self-care” to get you back to work on Monday. Kite-flying should aim for your renewed vigor in clinic. Woodcarving should reinvigorate you for rounds. The fact that these things often do restore us for work make it all the more insidious. “Self-care” hides a revolutionary power.

There’s a similar problem with “wellness” and the accompanying project of dismantling the “calling of medicine.” Bound up in that calling is the profession of medicine. When we start to pick apart this institution for the sake of wellness, we may lose sight of what medicine is for. I’ve written about this previously in terms of caring for the whole person. We can also slide into merely efficient practices of thoughtless medicine by attempting to wrest ourselves from burdensome entanglements with an institution that places claims on us, sometimes at the risk of sacrificing “wellness.” As it relates to rest and restlessness, such disentanglement won’t restore us to a healthy relationship with our work because we’ll be less prepared to endure repeated and prolonged exposures to the suffering of others. It’s within the profession of medicine that a community is formed which can sustain and cultivate the characteristics necessary to orient medical practice toward health.

Rest for the Restless

There’s a place for simple renewal and respite. I’m not suggesting there isn’t. Simple time off is necessary. However, I do want to suggest that it’s insufficient. There might be two other ways of thinking of rest that we don’t fully appreciate in our current rhythms of work.

First, rest can offer space. In the regular flow clinical work, there’s little space to stop and reflect on what’s happening, either on one’s own or with others. There’s little space to simply look up. Some days there isn’t even the space to eat! Some physicians work 28 hours without sleep. Every living creature needs space, and humans need more than one kind of space: physical space, yes, but also social space, mental space, emotional space, spiritual space. Restlessness constricts space. Our bodies know the dangers of constriction: we can’t breathe unless our lungs have the space to inhale and exhale, and our hearts need the space for systole and diastole.

By its very nature, “space” can’t be too strictly defined or prescribed. For some on certain days, it might mean a walk. For others at different times, a nap. Elsewhere and for still others, an opportunity to journal. The content with which one chooses infuse the space is worth considering another time, but what comes first is the space itself. However, the space is never empty; at the very least, I inhabit it. Perhaps I’ll inhabit it with someone else or a group of other people. We bring ourselves, with our preconceptions, worries, and hopes into the space. Insofar as the profession of medicine is formative at all, it also helps give shape to the space. What does it look like for a “good clinician” to create and inhabit space?

Second, rest also repudiates a merely utilitarian telos of human living. Of course it’s good if your “self-care” reinvigorates you to return to work, but that isn’t what makes rest great. Perhaps the greatest message of resting is that there are times, relationships, and spaces we don’t need to earn. The greatest of these things are unearned, a pure gift. This is a challenging, even rebellious, perspective in the workplace because our relationship with our work, colleagues, and patients (or, if not in direct patient care, clients) is instrumentalized. So too are we. You don’t need “Josh Briscoe” with all my idiosyncrasies; you need anyone competent enough to execute the duties of my office. Work will always bend toward ceaseless, restless utilitarianism under this perspective.

I’m not claiming that we shouldn’t strive for excellence in our work, nor should we not be held accountable for poor work. We certainly earn our jobs and our wages. However, rest helps to reorient us to the fact that this isn’t the whole of human living. I don’t earn my dignity or my humanity. The human person doesn’t exist for economic productivity. Work is good, but we exist prior to our work. The purpose of our living cannot be reduced to how much pain we assuage, how many surgeries we do, or even how many lives we save. To the extent that we have trouble disentangling our worth from our work, we might come to see how we’ve submitted ourselves to an economic standard for our lives.

When we rest, we testify that the world can go on while we’re doing other things. We testify that we can appreciate the world as is. We testify that we can receive our lives as the gifts they are. We’re not going to let the machine set the standard. We’re human and it’s good to be human. Some people don’t have this privilege. They feel enslaved (in some parts of the world maybe they’re literally enslaved). I’m not in a position to offer advice there, but maybe a bit of encouragement: just because you can’t rest doesn’t mean you’ve become a tool. You’re still a human person worthy of respect. Rest is a profound repudiation of slavery - literal or metaphorical. To the extent that you can aim for it in any small way or at any time, you testify to the inherent dignity of your humanity. To the extent that others can provide for it, they fight for the freedom of those who can’t rest.

Here’s some hard news, though. Both of these approaches to rest require work. Rest is resistance. Some Jewish people, who prepare for Shabbat before the hour comes, know what it means to work for rest: getting meals ready, settling projects, finishing chores. In that way, rest may not feel like a vacation - at least not in the beginning, not when one is preparing to rest. Making a space where there is no space can feel like mining - dark, cramped, lonely. Resisting dehumanizing utilitarianism might mean figuring out ways to be humanely inefficient by saying “no.”

None of this is an excuse to be lazy and avoid work. It’s good to work. In healthcare, it’s good to be able to serve others and help them restore and sustain health. And, at the same time, rest is necessary. There will always be another patient. Someone will always have another need. Suffering and illness are endless. We ourselves are not endless to meet that need. In a system that demands machine-like efficiency, going for a walk in the middle of the day might be unacceptable. It might look lazy and you don’t have the clout to do it. If that’s the case, you might start carving out the space with a pick-ax (i.e., stretch in your office, journaling a few sentences), or even your own hands (i.e., pushing for an adequate lunch break), instead of using the dynamite. Stretching and journaling might still sound like “self-care,” but it’s the posture with which you engage them that makes it different.

Maybe you’ll grumble that this places the onus back on the individual when it’s the system itself that’s rest-stealing and corrupt. To that I would say we only have our locus of control. Some are leaders and have a broad locus of control, others are very limited in what they can do and influence. You can influence spaces and testify to humane work regardless of your role, though it may look different and the expectations more or less ambitious. It wouldn’t be the first time in history where workers, without the cooperation of their leadership, took steps to change the culture of their workplace. When groups of people come together who appreciate the importance of rest, we might start to see a culture change.

Working for rest is worth it.

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Christopher Nevinson. “The Old Battersea Power Station.” 1938.

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Trajectories

Following a meandering reading-path, sharing some brief commentary along the way.

“The hidden harms of CPR”

A helpful reflection on code status from palliative care physician Sunita Puri. She highlights, and this is my practice too, that code status should only be discussed in the broader conversation about the goals of care and prognosis. Yet the other challenge that we haven’t begun to address is that conflicts about code status at the bedside also reveal that we have no shared understanding of what it means to be “dying.” This is because dying is a sociocultural constructed role, not just a physiologic process.

“Procrastination in art”

Seth Tummins

helpfully describes his artistic process as having a purpose, an idea, and a mess. If it misses any of these components, things go awry. I agree that this also applies to writing (mine, at least), and it might apply for you in your work too. I’m tempted to skip the mess: make my first draft the last draft. But I’m learning to trust that if I just throwing words on the page, and allow those words, almost as if by gravity, pull themselves into sentences and then paragraphs, I feel my way along until the whole thing is written.

“The Project on the Good Surgeon”

Led by pediatric surgeon Ryan Antiel at Duke, this is a new program to help cultivate positive formative experiences for surgeons. Not being a surgeon myself, I can’t speak to some of the unique aspects of the hidden curriculum found there, but I appreciate how some are trying to figure out a better path forward.

“The hospice industry needs major reforms. It should start with apologies.”

Ira Byock takes the leading hospice organizations like AAHPM and NHCPO to task over how poorly they’ve guided and regulated the out-of-control hospice industry over the decades. Despite being an early and prominent voice in hospice and palliative care, Byock has struggled to bring this conversation into the mainstream, despite the assistance of a major article in the New Yorker last year which he cites. The field is highly conflicted (e.g., many members of AAHPM are medical directors for for-profit hospice agencies). Regulation is hard. And yet, it’s ironic that this is a group of clinicians who, when at the bedside, are experts in hard conversations, but can’t bring themselves to have this hard conversation.

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Eric Ravilious. “Chalk Paths.” 1935.

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Closing Thoughts

“I heard a preacher say recently that hope is a revolutionary patience; let me add that so is being a writer. Hope begins in the dark, the stubborn hope that if you just show up and try to do the right thing, the dawn will come. You wait and watch and work: you don't give up.”

Anne Lammot, Bird by Bird

1. As far as I know, this story is apocryphal. I don’t know to whom it might be attributed. If someone knows its source, please let me know.