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Comment Analysis
A university building in Kharkiv lies in tatters
A TALE OF UNSPEAKABLE HORROR, UNPRECEDENTED UNITY AND UNQUENCHABLE THIRST FOR FREEDOM
The war in Ukraine has exacted an enormous toll on the Eastern European country’s population, with public infrastructure, including medical facilities, deliberately targeted and many procedures postponed, write Andriy Nykonenko, MD, Maksym Karpusenko and Jean-Baptiste Ricco, MD
This editorial was written in the days leading up to April 2.
At about 4 a.m. (Kyiv time) on Feb. 24, Russian President Vladimir Putin announced the start of a military operation aiming to “demilitarize and denazify Ukraine.” A few minutes later, Russian troops crossed the Ukrainian border and started shelling. Russian ships approached the Ukrainian coasts from the Black and Azov seas and bombed Mariupol.
Countless Ukrainians were awakened that day by heavy explosions. While nobody knows for certain where Putin was when his army attacked Ukraine, President Volodymyr Zelensky was at home with his wife and two children. It was they who woke him early on Feb. 24: “They told me there were loud explosions.”
After a minute, he received the signal that a rocket attack was underway. The United States offered him a passage to safety. He chose to stay.
Kharkiv
has been besieged from the northwest, the north and the east, and its outskirts have been shelled indiscriminately. According to Mayor Ihor Terekhov, 1,292 residential buildings have been destroyed, as well as 70 schools, 54 nurseries, 15 hospitals, and 239 administrative buildings, including the university. All but deafened by artillery shelling, anti-aircraft defense systems, machine guns and airplanes, people are forced to hide several times a day. From the very outset, Russians exalting “liberation from fascists and denazification” were shooting and killing. Kharkiv endured huge civilian casualties, including numerous dead and wounded children. As evidenced by video recordings and telephone conversations between Russian military personnel and their relatives in Russia, they were expressly targeting ambulances, private vehicles, residential facilities, orphanages, and hospitals.
Located close to Russia, Kharkiv has been bombarded every day. MK hears the squealing of Russian planes overhead and the sound of explosions. He wakes up trying to determine whether his bedroom was a military target. Since that day, the people of Kharkiv and other Ukrainian cities have spent most of their time in queues for food and drugs. Medicine is very scarce. Many old people have been stuck on high floors in buildings where the lifts are disabled. All the time they hear shells in the distance falling in waves; while MK never imagined that something like this could happen, he feels proud and inspired by the many Ukrainian friends and neighbors who have helped unstintingly.
Despite superb work by local utility services, the city’s infrastructure has been severely damaged, leaving hundreds of blocks without gas or electricity. In some outlying areas, all food shops have been destroyed, which means that elderly and disabled people now rely on volunteers to bring food. One of the few landmarks of the residential district of Saltivka, “Rost” supermarket, was obliterated by a missile, with some Russian media claiming that it was a military warehouse. From the very first day, thousands of Kharkovites have sheltered in underground stations or cellars. Outside, everywhere, even in kindergartens, unexploded shells litter the ground. Evacuation has been organized by the Ukrainian railway and volunteers, carrying primarily women and children to towns in western Ukraine. Fantastic work is being done by charity foundations such as “Dobra Samarytyanka,” which delivers food and medicines, and evacuates residents. With most of its inhabitants more fluent in Russian than Ukrainian, Kharkiv appeared to the Russians to be a pro-Russian city, where they expected to be cheered. Instead, Kharkiv has become an unassailable citadel.
When Putin ordered Russian troops into Ukraine, he was not alone in thinking victory would be swift. By the time the war was entering its sixth week, the side contemplating victory was not conquering Russia, but tearful Ukraine.
Mariupol
Kharkiv was far from the only town hit. In Mariupol, Russian bombardments have cut off the city’s water and power supply. Families have been huddling together for days, freezing in the dark. Dead bodies are reportedly strewn over the streets, with bombs falling. For weeks, hardly anyone was allowed to leave. In recent days, however, survivors have managed to flee, bringing first hand testimony according to which, every building has been hit. Missile casings litter the streets. People spend most of their time underground sitting in the dark, running up at times to rescue babies and the elderly from the ruins. Many have relatives in Russia, some of whom refuse to believe what has been happening. According to the Kremlin line, only neo-Nazis have been hit.
Today, the city is practically ruined, the infrastructure is destroyed, as are hospitals, administrative buildings and factories. Civilian evacuation is blocked on the route to Zaporizhia by Russian checkpoints in Melitopol and Vasilievka.
Zaporizhzhia
In Zaporizhzhia, and elsewhere, the Russian leadership has expressly targeted factories, agricultural equipment, and medical and pharmaceutical plants. That is why Andriy Nykonenko (AN), another of us and a vascular surgeon, had difficulty finding drugs and sterile linen to care for the wounded. Plants in or around Kyiv have been destroyed or were under constant rocket fire and inaccessible. In times of dire emergency, a decisive role has been assumed by volunteer organizations, which in the nick of time appeared in every city. Most consisted of young people with their own vehicles organizing collection of drugs and food. Their heroism was of critical importance in the first month of the war, when healthcare systems were in a state of shock. With the active help of European colleagues, Ukrainian volunteers
developed a network to ensure supply of medicines and medical devices. The third of us, Jean-Baptiste Ricco (JBR), was present at the border. The goods collected by volunteers throughout Europe were being transported by train or truck. The entire continent was mobilized in support of the Ukrainians’ fierce and unyielding resistance.
Under catastrophic circumstances, organization was the key. In Zaporizhzhia, one of us, AN, organized vascular surgery procedures in active warfare zones. The first week of the war had caught everyone unaware. As many patients as possible were discharged from his vascular unit, but some could not go home as there was no transport available or because their towns were occupied by the Russian military. Since wounded persons were expected and the hospital was in danger of being bombed, scheduled operations were postponed. Moreover, supply chains from Kyiv and other centers had been disrupted, and no one had previously experienced such an emergency.
That said, what the Russians did not expect was the unprecedented unity of the Ukrainian people, which prevented them from capturing large Ukrainian cities and destroying the country’s economy.
A nationwide healthcare network
Against his will, AN left Zaporizhzhia with his family for the relative safety of Uzhgorod. The journey to Uzhgorod was a four-day ordeal, with air raid sirens and rockets in cities along the way. When arriving in Uzhgorod, near the Slovakian border, AN discovered a city sheltering more than 600,000 refugees. With the support of a few of us, AN and his colleagues created a nationwide network designed to provide hospitals with much-needed medical supplies. During the first weeks, many had received humanitarian aid—but, in most cases, it was not logistically coordinated and failed to meet their needs. Via the Viber and Telegram messaging services, AN and colleagues organized a first-aid package conveying selected medical supplies to war-zone hospitals for the treatment of all types of injuries, including vascular trauma. A few days later, a report was presented to the Executive Committee of the European Society for Vascular Surgery (ESVS), describing the organization, indicating its needs, and requesting accelerated aid that would circumvent bureaucratic European holdups.
A few weeks later, organizationally-equipped to deal with immediate emergencies, AN and colleagues were performing more complex surgical procedures in safe medical centers. In parallel, they were dealing with chronic pathologies whose evolution required rapid treatment.
Why we believe Ukraine must win
While Ukraine has won the first phase of this war by surviving, more Western help is needed in a context where Presi-
dent Zelensky has stayed with his people, constantly evoking the sanctity of human life, the need for compassion, and the fight for freedom.
The Kremlin initially planned to destroy the Ukrainian army, force the government to surrender, recognize the “people’s republics” and Crimea as Russian territory, change the Constitution and declare Ukraine’s neutrality. From the outset, Russian tactics involved high- and low-precision missile attacks, which caused massive infrastructure and residential destruction, killing servicemen and civilians alike.
This war is a continuation of the conflict started by Russia in 2014 in Crimea and Donbas. The March 2, 2022, U.N. General Assembly resolution condemned the Russian invasion of Ukraine. Nobody knows how this conflict will evolve, and history is littered with wars meant to be short but which dragged on for years. To conclude, we have written this editorial to inform the readers of this publication of the war in Ukraine, the resources deployed to help the population, and the urgent need for European assistance.
ANDRIY NYKONENKO of the vascular surgery and transplantation unit, is chief of the Department of Surgery, Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine. MAKSYM KARPUSENKO is a senior lecturer at the Karazin Kharkiv National University, Kharkiv, Ukraine. JEAN-BAPTISTE RICCO is professor emeritus at the University of Poitiers, France. This editorial was co-published with the European Journal of Vascular and Endovascular Surgery. The authors wish to thank all the Ukrainian volunteers who accompanied them in this struggle for freedom as well as Jeffrey Arsham, who helped in an emergency to translate and to edit the manuscript.
EMOTIONAL INTELLIGENCE
Cognitive dissonance, unhappy physicians and burnout
Bhagwan Satiani, MD, a Vascular Specialist associate medical editor, discusses an often overlooked facet of emotional intelligence: social regulation
EMOTIONAL INTELLIGENCE HAS
been widely accepted as an important element of leadership. The seminal work of Daniel Goldman informs us that the education of leaders involves the four essentials of emotional and social intelligence (self-awareness, self-regulation, social awareness and social regulation). Grunberg and colleagues maintain that healthcare professionals must also gain these skills to lead others to counsel and treat patients, and assist with their physical and behavioral health.1
While the other three facets of emotional intelligence are often discussed, social regulation is often not mentioned in the literature. I have previously discussed self-imposed silence as one cause of burnout. Yet, of the four parts of social regulation, cognitive dissonance is of great importance for employed physicians dealing with burnout.
Cognitive dissonance was coined by psychologist Leon Festinger, who saw it as an attempt to be internally consistent. When we are not, we are psychologically distressed and experience cognitive dissonance.2 As a non-mental health professional, cognitive dissonance seems to me like a struggle between our cognition and our behavior. When I have been conflicted, I have experienced anxiety, mental tension and, occasionally, regret for having chosen a certain behavior. I have discovered that there were others like me who were self-aware but lacked understanding of the science behind the concept. “Cognitive dissonance is ever-present in both the smallest, simplest examples to the deepest layers of humanity that impact the way we interact with each other and view ourselves and the world,” according to Lawlor.3 Stress results when the dissonance occurs frequently, for long periods of time and “involve[s] difficult decisions and a commitment to action.”4
Now, to a couple of examples. One of my own personal life rules has been to avoid participating in fundraisers, and asking friends and colleagues for money. When I volunteered for an anti-domestic violence organization, and then became an officer, I was expected to raise money. The prospect of going “begging,” as I perceived it, was distasteful. Though many friends, relatives and colleagues obliged, the discomfort dogged me throughout. I have been a strong and sometimes partisan advocate for physicians throughout my career. When I was appointed to the board of a large healthcare system, I was advised that I had a “fiduciary” duty to represent the board rather than physicians. I sensed that physicians were expected to mostly watch, listen and stay silent. In contrast, the medical staff expected me to represent their views. I did speak out at several critical junctures representing physicians’ views, but sadly not enough. In four years on the board, I felt bottled up inside. I tried to deal with this by “buttonholing” individual lay board members to better explain our perspective.
Clinical practice also involves some degree of cognitive dissonance, even if we are following our internal ethical voice. An example often cited is that in evidence after research showed no benefit with arthroscopy for osteoarthritis of the knee. The surgeon is wrestling with the cognitive part related to the new research versus the firm belief hundreds of patients were helped (confirmatory bias). This is different from misrepresentation. We may overestimate the positive side of our decisions, justify sub-optimal outcomes, or be reluctant to admit that the benchmark outcomes reported are better.
Physician-leaders can often have two different views of an issue—one for the outside world and one for themselves. As an example, some leaders may not act when they have publicly-stated support for a position, such as advocating for more resources. This duality may be appropriate at times, or seen as hypocritical. Can a leader in this position preserve their integrity and resolve the dissonance?
By recognizing the dissonance, we are provided with an opportunity to clarify our principles and beliefs, and then to decide on a course of action. Some may resolve the dissonance by distorting their cognition through self-justification.5 The leader can either change his or her belief system, or change the action to resolve the dissonance. When neither is possible, they may justify their action. The bottom line is that self-awareness is important in this regard.
Batista advises that, first, we should expect cognitive dissonance with important executive or managerial roles.5 Festinger opines that we either avoid situations that create the dissonance, or recognize it, try to reduce dissonance, and attain consonance to feel more comfortable. Third, we should recognize the stress that the dissonance will create, and have mechanisms ready to deal with it. Finally, good leaders always have trusted advisers, a coach, or a small kitchen cabinet to help settle internal conflict. Self-awareness and understanding of cognitive dissonance also need to be taught in training programs.
