Jan-Feb 2013 Table of Contents

Physician Resilience and Burnout: Can You Make the Switch?



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Recognizing the signs of professional exhaustion is the first step to reintroducing joy and purpose to your career.

Fam Pract Manag. 2013 Jan-Feb;20(1):25-30.

This content conforms to AAFP CME criteria. See FPM CME Quiz.

One-third to one-half of physicians meet burnout criteria,1,2 leading to very real suffering among physicians and their families.3 Women physicians are 1.6 times as likely as men to report burnout, with lack of work control being a strong predictor of burnout in women but not men.4

Beyond the personal impact, physicians' self-reported satisfaction is strongly linked to patient satisfaction as measured through standardized patient satisfaction surveys.5 Physicians' sense of professional fulfillment positively correlated with patients' adherence to medication, exercise, and diet regimens.6 Physicians' job dissatisfaction is likely the most powerful predictor of “departure.”7 Work hours or a lack of career fit to one's values, life goals, or passion appears to further increase risk of dissatisfaction.2

These studies and others confirm the importance of developing resiliency skills and providing resiliency training to medical students and residents to optimize workforce retention, clinical outcomes, and patient safety and satisfaction. However, little has been written about successful interventions to prevent or reverse physician burnout. Krasner and Epstein describe one program for primary care physicians incorporating mindfulness, appreciative inquiry, and narrative that suggests benefit.8 Studies of burnout often point to the culture of medical practice as a causal factor, suggesting it must be changed for physicians to heal themselves and train the next generation in more high-functioning ways. It is true that larger patient panels, higher productivity requirements, shrinking resources, and other external factors are making practice more difficult. However, the focus of this article is on the internal challenges that make physicians vulnerable to burnout and on the development of specific skills that might help them “inoculate” themselves from inherent risks within the medical culture.

The seeds of burnout

Burnout can begin during medical training or even before. In a recent large study conducted by the Mayo Clinic, 53 percent of medical students had symptoms of burnout.9 This burnout was associated with self-reported unprofessional conduct and less altruistic professional values among medical students at the seven U.S. medical schools included in the study.

Physician burnout, often defined as emotional exhaustion, ineffectiveness, and depersonalization, may be linked to four values characteristic of physicians and reinforced in medical training: service, excellence, curative competence, and compassion. Although each one is a virtuous strength and source of pride for physicians, each possesses a destructive “dark side” – deprivation, invincibility, omnipotence, and isolation.

Most physicians are first drawn to the calling, or service aspect of medicine. The ability to make a difference in a person's health is compelling and rewarding. This expectation of service is reinforced repeatedly throughout training, starting with the Hippocratic Oath. Yet early in a career this sense of service may begin to feel more like duty, and the personal sacrifice it requires may feel more like deprivation, even victimization or martyrdom, when self-sacrifice becomes exhausting. Medical students regularly accept the sacrifice of rigorous and extended training, denying their personal needs, such as sleep and food, to be of service as healers. This expectation of sacrifice can extend to physicians' families, who are likewise trained to understand the interruptive priority of a medical career. If feelings of deprivation surface, so can a sense of entitlement and an “I deserve it” attitude, which may lead to destructive financial or relationship decisions.

Physicians are committed to the highest standards of excellence, and others expect this of them. In the information age, infinite reservoirs of knowledge and memory are assumed. Zero tolerance for mistakes is common. These expectations breed perfectionism, and the associated lack of acceptance of the potential for error can lead to feelings of invincibility. Safe venues for admitting and discussing error or harm, inadequacy, or loss of control are not common in medical culture. Eventually, physicians who do not discuss their errors with anyone may deny it to themselves, arriving at some other explanation for the outcome.

Physicians value curative competence, and they take responsibility for patient outcomes. But sometimes that outcome is not within the physician's control. Surgeons are valued on their success and complication rates, often independent of patient complexity; hospitals rely on such measures to enhance their reputation. Such pressures and physicians' drive to cure can lead to urgency, forcing action when a diagnosis is unclear or fostering discomfort with ambiguity in a clinical presentation. One potential downside of this expectation is a sense of omnipotence and intolerance for ambiguity. Patients who challenge a medical diagnosis or question a treatment plan may be viewed as “difficult” or “noncompliant.” At the same time, mentors and evaluators reinforce the medical student's self-criticism if he or she is not meeting internal or external standards of competency. Answering “I do not know” is rarely rewarded by educators or patients. Fear of exposure, or “imposter syndrome,” and a sense of inadequacy haunt medical trainees and young physicians. The ongoing emotional distress this tension can create may lead to embracing omnipotence to resolve the cognitive dissonance between expectations and the physician's recognition of his or her own limitations.

Framework for linking cultural norms in medicine with burnout factors and potential interventions

Positive value Negative potential Burnout factor(s) Potential mental training interventions

Service

Deprivation

Compassion fatigue Entitlement

Reframing Appreciation and gratitude

Excellence

Invincibility

Emotional exhaustion

Mindful self-compassion Inner critic awareness

Curative competence

Omnipotence

Ineffectiveness Cynicism

Self-awareness Generous listening

Compassion

Isolation

Depersonalization

Connection and community Silence as energizing

Framework for linking cultural norms in medicine with burnout factors and potential interventions

View Table

Framework for linking cultural norms in medicine with burnout factors and potential interventions

Positive value Negative potential Burnout factor(s) Potential mental training interventions

Service

Deprivation

Compassion fatigue Entitlement

Reframing Appreciation and gratitude

Excellence

Invincibility

Emotional exhaustion

Mindful self-compassion Inner critic awareness

Curative competence

Omnipotence

Ineffectiveness Cynicism

Self-awareness Generous listening

Compassion

Isolation

Depersonalization

Connection and community Silence as energizing

Physicians value compassion, which requires a delicate balance of empathy and appropriate emotional boundaries with patients and their families. Medical trainees may witness fetal demise, childhood chemotherapy, suicide, and chronic disability, as well as the effects of homelessness, addiction, prostitution, and war. The tender heart committed to service and sacrifice and focused on excellence and a commitment to cure quickly learns to set aside the typical empathetic human reaction to such suffering. Yet often we cannot fully forget the face or the profound emotional experience. The discomfort of this reaction may result in suppressing emotions, positive or negative, to the point of what many physicians describe as emotional isolation, a sense of “people all around yet feeling completely alone.”

These values of service, excellence, curative competence, and compassion are interconnected and implicit in medical culture. Physicians retain high levels of public respect because of these values, and they are key to finding meaning and joy in medicine. They also create unspoken expectations, commonly referred to as the “hidden curriculum,” that if unchecked can destroy a career. The table above links these values, or cultural norms, with the potentially destructive aspects of each as they relate to physician burnout. It also lists interventions that can foster resiliency, a key to combatting burn-out.

Resiliency training

To fight the dominant symptoms of burnout, practical mental training can increase physicians' resiliency to their medical practice environment and develop their sense of insight. The key is to recognize that thought patterns are deeply and consciously developed, and rewiring them requires regular practice.

Think of this process as being similar to physical strength training. Lifting weights requires learning techniques and proper form to build capacity and avoid injury. Failing to maintain that fitness can cause the muscles to atrophy. In the case of our minds, developing healthy patterns of thinking also requires regular and skillful workouts, or the mind reverts to its default mental and emotional states.

For example, a physician who struggles with elements of perfectionism, fear of failure, or inadequacy to the demands in his or her life could begin retraining his or her thinking by recognizing these thoughts throughout the day, acknowledging them, and then using self-compassion phrases to balance his or her reactions. In this case, suppose the physician promised to get to his son's soccer game on time but his last patient of the day is suicidal. The physician may develop a feeling of hopelessness, believing he can't adequately assess the patient and keep his promise to his son. This can lead to a negative cycle of irritability and self-criticism. In response to these feelings, he could insert self-compassion phrases, such as “Every day I do the best I can. I love my son. I am a good parent. My son knows I love him.”

Reframing is another technique that can be helpful in this situation. A normal reaction would be for the physician to identify himself as a victim or martyr or take on a sense of entitlement. For example, “Why me? Why are the difficult patients drawn to me? I should be able to see my son play soccer! It always turns out this way when I make a promise to my son.” He could reframe the situation like this: “I am going to start blocking the last appointment of the day on soccer game days and see that patient over lunch to prevent this from happening. I am grateful the patient acknowledged the suicidal thoughts in the appointment. Think how horrible I would have felt if the patient had attempted suicide. I would have carried guilt that I perhaps appeared rushed or distracted due to trying to get to the soccer game.”

Another mental training technique is practicing appreciation and gratitude, perhaps most eloquently described in Dr. Lee Lipsenthal's book, Enjoy Every Sandwich: Living Each Day as If It Were Your Last (see “Suggested reading”). One helpful method can be ending each day by listing three things that happened that day for which you are grateful. Lipsenthal writes that requiring this of himself led him to focus on the positive throughout the day and even brought more positive events into his life. It's an approach shared by this article's lead author, who, in her darkest professional days, found that the mental discipline of listing such gratitudes was central to staying in the profession. The practice of repeated appreciation balances the hard work, long hours, tedium, and dedication to service and sacrifice that can lead to burnout in our profession.

Self-awareness and self-care are required for regeneration. For introverts, this may require the discipline of creating time for themselves. This can be challenging for those already feeling guilt for being absent from family life or social activities. But combining exercise with another stress outlet, such as music or other forms of creativity, can be exponentially effective at stopping the mental drain of feeling constantly “on stage” in the profession. This recognition also limits the risk of depersonalization, or constantly faking one's emotions, that is frequently the coping strategy for the intense demands of medical interaction with patients and colleagues. Extroverts may need to make time for strong connection to community, whether it be attending faith groups or clubs or pursuing group hobbies. Finding the most efficient way to regenerate the mind, combined with a commitment to make it a priority, will restore the physician spirit. Self-care practices such as getting adequate sleep, nutrition, and exercise, seeking out social support, and being vulnerable and real with trusted confidants are known as coping “insurance.”

An individual's self-awareness and ability to recognize when his or her attitudes are deteriorating, and then do something about it, may be a key difference between those with a healthy engagement in the practice of medicine and those suffering from burnout. Asking diagnostic questions can aid in self-reflection and suggest appropriate resiliency practices. Similar to the medical model, a correct diagnosis will lead to a more effective treatment plan.

Diagnostic questions for self-reflection, self-care, and alignment to values

How can I take care of myself so that I can be of service to others?

How can I strive for excellence and at the same time have compassion for myself when I don't have all the answers or I make a mistake?

How can I offer my expertise in order to cure illness and at the same time stay open to what my patients have to teach me about their own healing?

How can I maintain an empathetic connection with my patients and at the same time protect myself?

A new curriculum

We anticipate that thriving within health care will be easier for physicians who receive resiliency training (read about one such program below). Emphasizing resiliency training throughout medical education, rather than expecting physicians or medical culture to change on their own, will likely help physicians become who they wish to be in their professional lives and create a medical culture that allows that to happen.

Oregon Health & Science University's integrative self-care initiative for students

The competencies and skills that could help to increase resilience and prevent burnout among physicians are absent in most medical training programs. Ideally, such skills should be initiated at the beginning of medical education and reinforced throughout training. There are likely multiple ways these skills can be taught. One program, Oregon Health & Science University's Integrative Self-Care Initiative for Students (ISIS), has created the following competency goals:

  • Providing a context for authentic and confidential connection with a group of peers and mentors to counter isolation,

  • Practicing mindful self-awareness using a variety of techniques aimed at emotional knowledge and self-compassion to foster intervention earlier in the stress response (e.g., insight training),

  • Learning cognitive reappraisal skills to expand perspectives, embrace complexity, and increase coping (e.g., values alignment),

  • Learning holistic self-care and positivity skills to expand resiliency,

  • Practicing empathy with an emphasis on professional models of “exquisite empathy,” which allows heartfelt and sensitive engagement with those who are ill but with boundaries that allow for regeneration rather than depletion.

These competencies are taught through skills training and small group experiences to accommodate various learning styles. Skills include mindfulness meditation, guided imagery, creative expression, journaling, laughter yoga, appreciative inquiry, biofeedback, social support, and others.

ISIS is a first- and second-year elective class led by two senior physicians who meet with 10 medical students for 2.5 hours a week for eight weeks in a confidential, emotionally safe environment. Evaluations have confirmed that students value both the shared peer support experience and the faculty mentoring. Labeling the cultural norms discussed in this article combined with training in self-awareness and self-compassion allows the emerging physician to determine the extent to which medicine will invade his or her psyche rather than taking an unconscious path to a negative outlook.

For practicing physicians currently experiencing decreased satisfaction in their work or who want to become “unstuck” from a day-to-day, downward spiral, we propose asking the following questions to raise self-awareness, allow reflection, and take the first steps to building resiliency:

  • What did I learn today? Would I do anything differently?

  • What three things am I grateful for today? What inspired me?

  • How did I talk to myself today? Did I take myself too seriously? Did anything surprise me?

In addition, we propose the following action steps to improve overall quality of life:

  • Find ways to add humor and laughter into your day and week,

  • Choose to live less financially affluently,

  • Plan a daily self-care activity (recreation, exercise, a shared meal with friends or family, massage, spiritual practice, etc.).

It may also help to think of resiliency as a triad of beliefs used to weather the storms within the profession. These include aligning your practice with the values that support meaning or purpose in your life; providing the self-care of adequate nutrition, sleep, exercise, and social interaction; and developing insight into the behavior and motivation of yourself and others.

Resiliency triad

This diagram, developed by the lead author, shows the interaction between a physician's values, level of insight, and dedication to a healthy lifestyle that makes him or her better able to cope with the challenges of the medical profession.

Resiliency concepts and skills can help you to retain that balance of meaning and satisfaction in one of life's most rewarding professions without succumbing to the destructive aspects of burnout.

Suggested reading

Enjoy Every Sandwich: Living Each Day as If It Were Your Last. Lipsenthal L. New York: Crown Archetype, 2011. (Book includes reflections during the author's last two years of life on his medical career, work-life balance, personal practices, and relationships.)

The Mindful Path to Self-Compassion: Freeing Yourself from Destructive Thoughts and Emotions. Germer C. New York: Guild-ford Press, 2009. (Book includes practical meditative exercises.)

Your Brain at Work: Strategies for Overcoming Distraction, Regaining Focus, and Working Smarter All Day Long. Rock D. New York: Harper Business, 2009.

About the Authors

Dr. Nedrow recently transitioned from her position as an associate professor of medicine at Oregon Health & Science University (OHSU) in Portland, Ore., and medical director of the OHSU's Integrative Self-Care Initiative for Students to associate director of Duke Integrative Medicine in Durham, N.C.

Dr. Steckler is an associate professor of management in the OHSU School of Medicine.

Dr. Hardman is an assistant professor at OHSU, associate program director of the internal medicine residency program, and medical director of the OHSU internal medicine residency practice. Author disclosure: no relevant financial affiliations disclosed.

Send comments to fpmedit@aafp.org, or add your comments below.

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9. Dyrbye LN, Massie FS, Eacker A, et al. Relationship between burnout and professional conduct and attitudes among U.S. medical students. JAMA. 2010;304:1173–1180.

 

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