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ER Physician Warns Under-Diagnosed Emergency Among Providers

USDSM Graduate Recognizes Hidden Threats of Medical Professional Burn-Out and Why Connection Is The Best Treatment

I recently spent a long weekend with a fellow physician friend who revealed insightful thoughts about the profession. After we spoke, I asked if I could get him "on the record" with an interview. He replied with this beautifully written letter. Thank you Dr. Harden!

- Dr. Beth Jensen, Lead Physician of South Dakota Physician Well-Being Program




Hello South Dakota! I love and miss you all. My name is Niels Harden and I am an Emergency Medicine physician practicing in Bozeman Montana (by way of USDSM ‘07, residency Mayo Clinic ‘11, Spokane WA full time doc and medical director for a decade). As physicians we all have seen a lot and “felt” the burden of our communities; particularly over the last 3 years. I write the following to encourage you and remind us of the importance of landscape and purpose. That said, I jumped at the chance to write this article using my specialty and experiences to reflect on burnout.


By the time I finished medical school at USD in 2007 I had lived a decade in the Sioux Falls area. As I have worked around the US, Kenya and Haiti I have practiced everywhere from Mayo Clinic to Big Sky Montana to under candlelight in subSaharan Africa. Reflecting on this I am amazed to see that people are as similar as the medicine is varied. We all need the same thing and often don’t have it.

Any time off during medical school I travelled to Haiti to run a medical clinic. With other USD medical students we ran a very rural and limited resource clinic seeing 300 or more patients a day with weekly dental clinics. My medical-adventure spirit lead me to finished the last 6 months of med school in rural Kenya (Kapsowar) at a mission hospital working in the surgical theater and men’s/women’s/children’s medical wards. I then went to Rochester MN and completed emergency medicine residency at Mayo Clinic. This included access to more subspecialty clinics than I can pronounce and the most supportive and professional and connected medical community in the world. Following residency I took my first full time position in Spokane WA and divided my time between a downtown hospital and more suburban hospital as the co-medical director and full time doc. After 10 years in Spokane we moved to Bozeman to be close to family and enjoy the sun and high alpine.


Spanning nearly 20 years and 2 continents and all socioeconomic levels I have seen diseases of “deficiency” contrasted with diseases of “surplus”. In that I have seen what Paul Farmer calls “the preferential option for the rich” with a vast difference in access to care and education. This has illuminated the “cost” of wealth with its unique subset of mental health struggles and pathology. The differences in emergency care across this spectrum is so great it feels like practicing different specialties. Whether its protein, vitamins or education in poverty or the isolation, stress and self-sufficiency of wealth we all need to connect. This connection to basic nutrition and providers is no less essential than our connecting to family and community. I am seeing the affluent side of humanity (the US) is not getting better. Mental health indicators suggest we have failed the stress test of this pandemic and as physicians, to this we are not immune.


The differences in emergency care across this spectrum is so great it feels like practicing different specialties. Whether its protein, vitamins or education in poverty or the isolation, stress and self-sufficiency of wealth we all need to connect.

In 15 years of seeing patients I have never seen a scheduled patient, no airway intervention was ever planned, I have no control of my patient panel or daily volume and very rarely do I have a full medical history at the time of evaluation. I deal with abuse of every type and disease of every age and organ system. I am an honorary “nauseologist” and by necessity an “adaptologist”. I am a jack of all trades and master of 2 (bad airways and resuscitations). That said I love my job. I have the privilege and burden to be “with” people. I have had many instances of “chewing the fat” with patients when I realized they store their insulin on the dash of their car precipitating recurrent DKA or they think antihypertensives are prn meds.


Working with nurses, techs, registration, housekeeping, social workers, mental health specialists, child advocates, women advocates, EMS, law enforcment, hospital administration, APPs and physicians I have the chance to build a team and care well for them. This is why I do what I do. I wouldn’t do it if it was easy. I wouldn’t do it if it was straightforward and honestly I don’t think I would do it if I had it mastered. I think, because I am so far short of mastering my specialty I am driven to it. All this to say, burnout is an ever present reality. In my denial and “affluent” state I operate under a presumption of self sufficiency. This personally creates a continuum of mental health that predisposes to denial and self ignorance. We cannot presume to be above disease (or our patients). We are not made of a different cloth. We are not the mental health equivalent of a perpetual motion machine. As with the art of Maurits Cornelis Escher we are not as we appear and cannot violate the laws of physics.


In my denial and “affluent” state I operate under a presumption of self sufficiency. This personally creates a continuum of mental health that predisposes to denial and self ignorance.

To conclude I am as compelled as I am unqualified to make comments on burn-out management. My only hope and help has been from my “team”. As a Christian I have seen God work in my life through my wife and colleagues and work “team”. Knowing the ontological argument for the existence of God (and naturally, myself therein) I see that I did not make myself and cannot sustain myself anymore than Oscar the grouch could lift the garbage can he was standing in. In the darker hours of my life my wife will ask “why that physician offended me” or “why I think my perseveration can impart a cure”.


Connect! Now as much as ever we must connect more.

I know we all know what I am about to say but I still have to say it. Even as I say this I think I am above it as I can point it out to you. I need this as much as you. Connect! Now as much as ever we must connect more. We must take an extra minute to “chew the fat”. You have that time. Like an MVP player we must box out distractions and maintain the priority of family and community. We must keep first things first and seek accountability in it. Find your source and “go there”. Stay there. We are not as big as we think and we are not as far from “it” as you fear. That is my answer to burnout: We must connect more. Thank you for boxing out time to read this. Now live differently or nothing will change.




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