Meaningful Recognition From Bench to Bedside Free

Critical care clinical practice and related research are, by nature, challenging fields. Success is never guaranteed, and failure and rejection are commonplace. Both clinical practice and research often value tangible, final outcomes above all else; delayed gratification is the norm, and career advancement may ignore the countless steps toward the milestones most valued in clinical and research roles. Alternative means of meaningful recognition may offer a way of recognizing success in the day-to-day work we do in both environments.

What is a meaningful achievement in critical care? Our practice in the intensive care unit (ICU) is often focused on minute details to give the patient the best chance we can—titration of medications by fractions of a unit, aggressive management of sometimes small margins of modifiable risk, a moment of support to the patient and family. It can be challenging to practice with a microscope and then face a loss on the scale of a skyscraper: the family is angry or hostile, the patient dies, or the patient survives but will never have the same life again. There are many ways that we can “lose” in the ICU, and few large victories to counter those losses. We remember and celebrate those: the patient with cardiac arrest who seems lifeless yet is neurologically intact and pops awake within days; the horrid sepsis that we caught early enough; the beautiful cough after an arduous course to extubation. Those wins are tremendous, but the nature of the ICU is such that they are few and far between.

What defines a successful investigation in critical care medicine? The large, groundbreaking studies that can change the way we practice and are likely to save thousands of lives are rare, and sometimes even those findings are soon overturned. More often, even the best investigations push the boundaries of our knowledge in smaller increments that may seem like a stab in the dark. Every step in critical care research can be challenging, from patient selection and consent to implementation of an intervention, data collection, analysis, interpretation, and dissemination. Many researchers struggle at every step of that process, leaving gaping holes in application to everyday practice. Today’s ICU patients are so complex that they would most likely have been excluded from prior studies. Unlike basic science or areas of medicine that perhaps lend themselves to less confounding, the ICU has innumerable variables at play; many of these factors are difficult to capture and difficult to control. Further, critical care research rarely reveals absolute truths that are generalizable to all ICU environments. The patient characteristics, clinician practice styles and experience, work environment, and local protocols of any given institution can be tremendously different from even the most carefully matched cohorts. Moreover, the environment around medical research has created complicated incentives for investigators, including the need to secure external funding to support their research and to publish and build notoriety to achieve academic promotion. In the best case, funding helps direct investigators toward pressing issues that matter to patients. In the worst cases, researchers abandon the interests they have developed based on their own personal experiences for an endless treadmill of obtaining funding to secure a career in research. Funding for critical care research is not just in jeopardy, much of it has already been lost, especially research for our most vulnerable populations.¹  In such an environment, the questions for researchers are urgent.

In both clinical care and research, it may be helpful to reflect on small wins. Clinically, these wins are often taken for granted: the technically challenging catheter placed quickly and flawlessly; minute adjustments to the ventilator that stave off deeper sedation; the family meeting that went so well, even if the patient’s clinical outcome does not improve. Good things can be taken for granted, while adverse events bring scrutiny and shame. Endotracheal intubation is an example. In the moment of a difficult tube placement, it is the entire world. Once the endotracheal tube is in place, new challenges arise and no one is thinking about that high-stakes moment anymore. What happens if the patient dies the next day? Does it wash away all the victories on the way there? A career in research is similar. The smaller efforts that pave the way for manuscripts and funding are essential yet may be treated as inconsequential in retrospect. The hard work of reviewing manuscripts (thank you, reviewers!) is mostly appreciated by editors and taken for granted by readers and even many aspiring researchers, yet it is a core function for advancing science. Mentorship and service on academic committees are likewise important yet devalued.

In the ICU, we intervene in countless ways to change the natural course of someone’s illness. Our efforts, large and small, slowly but surely reshape their journeys to be safer and more patient centered. Even if the story ends in tragedy, the moments of success on the way there do carry their own merit, and they should be celebrated. In academics, the same holds true, particularly today, when grant funding is in jeopardy at institutions around the country and even the world. Without support for independent academic research, countless patients will suffer and lives will be lost. The advancement of science is stymied by perverse incentives that give rise to paper mills and countless low-quality and irrelevant studies that propose at best clinically meaningless correlations.

We cannot speak for the motivations behind every researcher, but bedside experience may offer perspective. Consider the patient who might still be lucid and communicative but is heading toward a high-risk procedure, or one for whom the early signs of catastrophic organ failure are already evident. We often have conversations with patients and especially families of the critically ill about the precious time they have left. Do not take the now for granted—every minute is a chance for meaningful connection that could be lost tomorrow. That advice applies to all of our lives and certainly to the career of a young investigator. Your opportunities may be limited by external forces, certainly, but a fulfilling academic career is not derived from grants and grand rounds—it comes from studying something deeply meaningful and using that knowledge to change the trajectory of health care to improve the lives of future patients: “health is a means, not an end.”²  Academic research has never been more threatened than it is today. Perhaps the moment can also serve as a wake-up call to focus our efforts, to prize collaboration over competition, and to hold ourselves to a standard for the highest impact from our research.

It feels petty to think about what a good job we did when the patient suffered, and it feels irrelevant to consider those aspects of the pursuit of science that do not directly lend themselves to securing one’s career. But without recognizing those wins and holding these truths together, we find ourselves with fewer and fewer wins and countless tragedies and failures. We do ourselves an injustice. The small wins matter and define us better than the much larger forces at play that determine a patient’s outcome or whether a paper is accepted or a grant is funded. How can we better recognize this meaningful work in both contexts? In the ICU, meaningful recognition should take place at the level of the health system, in the local team, and within the individual as well. Meaningful recognition is the fifth of the American Association of Critical-Care Nurses’ standards for establishing and sustaining healthy work environments³  and may improve the experience of nursing.^4,5  Meaningful recognition can include everything from recognizing an “employee of the month” to formal awards.⁶  Improving meaningful recognition may have larger effects on the work environment, even affecting nurse retention.⁷ 

When considering recognition in nursing, the Daisy Award comes to mind first and foremost. Indeed, the award can have a powerful positive effect in helping nurses feel appreciated.⁸  But recognitions such as the Daisy Award or Alpha Omega Alpha recognition for physicians have inherent challenges in implementation. Such awards have received criticism for being popularity contests and for focusing on individuals instead of the team. In the most extreme example, racial bias has been revealed in induction into Alpha Omega Alpha.⁹  Awards are often granted on the basis of reviews from patients, peers, or leadership. Although these perspectives offer significant value in many cases, they may also mistake satisfaction for quality and are likely to again recognize the largest and most obvious “wins,” which may already be inherently significant. Perhaps most importantly, such awards are also few and far between for any given clinician to rely on for sustained recognition. As such, awards may be a component of meaningful recognition but are unlikely to be independently sufficient.

Meaningful recognition encompasses everything from salary and benefits to career progression and informal private and public feedback and acknowledgment. Most forms of meaningful recognition face the same challenges as awards. For any given clinician, recognition may be quite infrequent. Leaders who take psychological safety for granted may find the recognition backfiring if staff perceive favoritism or other bias. Gift cards or tokens of appreciation can feel impersonal or even devalue the intrinsic motivation for the work.^10,11  Such rewards may raise suspicions about the selection process or create a sense of competition instead of collaboration.

When executed effectively, extrinsic recognition of this sort can focus attention on the small wins every day, which may be more meaningful than recognition of larger infrequent milestones. Meaningful recognition and healthy work environments are intertwined and support each other. But some of the most meaningful praise may recognize clinicians for succeeding despite a toxic or poorly resourced work environment; in such instances, the lack of action to improve said environments may limit the benefit of recognition.

Given that these structural and environmental changes persist, another important form of meaningful recognition for individuals is self-recognition, especially through narrative reflection as we have recently described.¹²  Narrative may be private or public and the author may be named or anonymous. In any case, reflection offers the opportunity to focus attention with intention, taking into consideration the entire experience and not just the headlines.

The importance of meaningful recognition applies to the investigator’s journey as well. The nature of “invisible work” in academics includes serving on institutional committees, serving as a peer reviewer, and serving as a mentor and advisor. These efforts are often far more work than the value they provide toward promotion or publication. Peer review certainly has intrinsic value—critiquing research often informs one’s own approach to investigation; it offers a chance to learn what others in your field are studying and how; it allows one to improve expertise and, ultimately, to make the rare contribution to the advancement of science that offers instant gratification. Although journals such as this one can provide various forms of gratitude to reviewers, these efforts often seem meager compared with the needs of an academic related to promotion. The time it takes to review a manuscript is substantial and may detract from promotion-focused work. Mentorship offers the potential for significant impact, but at an even greater investment of time and effort, often unrecognized by one’s institution. Committee work is similarly time intensive with scant effect on advancing science and little benefit for one’s career, but such service may be mandated. Increasing evidence shows that women and people of color may be more likely to take on these invisible roles, impeding their progression in the academic pipeline.¹³ 

Weakening health safety nets and increasing acuity are putting greater strain on ICUs across the country. Threatened funding, artificial intelligence, and increased governmental and commercial influence are pushing academic medicine into a reckoning. While institutions adapt to these changes, clinicians and researchers should envision systems that support the daily wins necessary to sustain clinical practice and advance the science. In the meantime, providing positive feedback and support to our colleagues and engaging in narrative reflection may offer the fastest and cheapest forms of meaningful recognition.