Small changes can make a big difference in how you deal with the pressures of practice.
Fam Pract Manag. 2002;9(4):35-38
Just recently, I listened as two physicians explained that practicing medicine today is literally killing them. I’m certain some of you can relate. In the 20 years that I’ve been facilitating physician support groups, I’ve seen some physicians continue to thrive despite their environment and others become depressed, failing to notice how their responses to their environment add to their stress levels. In this article, I’d like to share some positive strategies to help you deal with the pressures medical practice imposes on you. What I share here is based on the years I’ve spent working with and listening to physicians as well as my own experience as a pastoral counselor.
1. Do more than commiserate
The first support group I was asked to facilitate was created by seven family physicians who found their natural mentors (i.e., physicians 10 to 15 years older) to be cynical, authoritarian and aloof. They feared that if they didn’t do something differently, they would eventually end up the same way. Without regular peer support and proper self-care, I fear that some of you will join your colleagues in the game of “ain’t it awful.” Certainly, there is real pressure on you from many sides. It’s very difficult to say “no” to requests on your time and to declare your limits. But some of you do it, so it can be done. Consider as your mantra: “I have the power to make choices that are right for me.” It tends to be self-fulfilling.
2. Avoid cynicism
As much as we’d welcome it, our health care system is not going to change overnight. For the foreseeable future, it will continue to grind down and burn out those physicians who let it. In fact, today’s health care system may be more harmful to physicians, who deal with it daily, than to most patients who companion with it only occasionally. Some of you defend yourselves against the system by adopting a “me against them” attitude. As understandable as that is, succumbing to cynicism will only add to your suffering by closing the door on the meaning and creativity in your calling.
To those of you who feel you’ve already lost the meaning in your calling and that the practice of medicine is now an odious job, I suggest reading Kitchen Table Wisdom, Stories that Heal by Rachel Naomi Remen, MD. Physicians in my support groups have found it extremely valuable. Dr. Remen also facilitates physician retreats and training programs for recapturing meaning in medicine. (More information is available atwww.commonweal.org.)
3. Do some reading
As family physicians, you’ve no doubt counseled patients on the effects of stress and on stress reduction, but have you taken your own advice? A delightfully humorous read and an excellent resource for understanding the science of stress is Why Zebras Don’t Get Ulcers: An Updated Guide to Stress, Stress-Related Diseases and Coping by biologist Robert M. Sapolsky. This primer about stress, stress-related disease and coping with stress may be helpful to you as well as your patients.
If you’ve identified the source of your stress as your marriage or your relationship with your family, you may want to read The Medical Marriage: Sustaining Healthy Relationships for Physicians and Their Families by Wayne M. Sotile, PhD, and Mary O. Sotile, or Doctors’ Marriages: A Look at the Problems and Their Solutions by Michael F. Myers, MD.
If you know you have unresolved problems and/or are a problem for others, but therapy seems too threatening at this point, consider reading Learned Optimism: How to Change Your Mind and Your Life by Martin Seligman, PhD. In spite of its superficial-sounding title, the book provides insight into the unconscious thinking processes that lead to and prolong depression as well as instructions for relieving and preventing depression.
Another book I recommend is I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression by Terrence Real. Many men (and women) have recognized themselves in the author’s stories and, as a result, have been moved to get the help they need.
Dealing with the demands of medicine by becoming cynical only serves to diminish creativity and the meaning of medicine.
Physicians will be better able to cope with the daily pressure of practicing medicine if they acknowledge and care for their physical, emotional and spiritual needs.
Physician support groups and individual therapy are not for impaired physicians only. They are a safe place for healthy, stressed physicians to work through professional and personal problems.
4. Join a support group
Physician support groups are an excellent resource for healthy physicians to release stress and connect to other physicians. What is discussed in physician support groups is confidential, making them a safe place to talk not only about professional concerns, such as errors in clinical judgment, being sued or dealing with difficult patients or colleagues, but also personal matters. Group members often form deep friendships with colleagues, a needed shift from the tendency to view colleagues as competitors and critics. (See the box on page 37 for reflections from members of some of my groups.)
Although the physician support groups I facilitate are regularly therapeutic, they are not “group therapy.” Participants are healthy, stressed physicians who attend voluntarily.
If you decide to join a physician support group, look for one with an experienced facilitator and be aware that groups have different dynamics. You may have to try more than one before you find a group that works for you. If you decide to form your own support group, see “Physician Support Groups: A Place to Turn,” FPM, October 1995, page 26, and “Physician Support Groups,” FPM, October 2000, page 76. These articles share possibilities, challenges and pitfalls of such groups as well as the structure to be followed and the characteristics of an effective facilitator.
5. Consider therapy as a positive resource
Journal articles on physician wellness tout the need for exercise, family time, recreation and relaxation to bring balance to one’s life and reduce stress. But rarely do such articles mention therapy as a tool for those other than impaired physicians. To be moderately depressed or chronically stressed doesn’t mean you are sick or impaired; nor does having conflict that you can’t seem to resolve with your spouse or your children, or having unfinished business with your parents. Therapy can help physicians address these issues.
I’m a pastoral psychotherapist and in my field, therapy is not seen as a red flag, but rather as a resource for staying centered and connected to the self, enabling us to relate to our patients with more empathy and insight. Chronic stress can cause an otherwise healthy individual to start feeling helpless and depressed. Emotional or spiritual isolation can intensify those feelings. Individual therapy, like a support group, provides an antidote to isolation, loss of meaning or autonomy, or low self-esteem. After resolving some professional and personal conflicts in the group setting, some of the physicians in my support groups have followed up with individual, couples, family or sex therapy. These physicians often share with other group members (without shame!) that they are seeking this therapy for their growth and satisfaction.
SHARING WITH THE GROUP
The following statements made by physicians participating in Dr. Zeckhausen’s support groups suggest the potential richness and effectiveness of physician support groups as a tool for managing stress and addressing burnout:
“My self-understanding as a doctor, husband, father and son has been nurtured by the intimate connections of our support group. I have weathered a malpractice crisis, come to accept the learning needs of my children and more realistically and lovingly appreciated my wife, in large part because of the work of our group.”
“I entered medicine thinking that doctors as a group were hard and unfriendly, and with that attitude, kept myself somewhat apart from them. I expected when I became a doctor to receive support, but not from other doctors. The support I find from fellow physicians in group is wonderful. I now see physicians as being compassionate and I feel positive about myself as doctor.”
“I enjoy the camaraderie we have in the hospital. We feel closer and trust each other as a result of group. And I like the fact that we have the spontaneity to physically touch one another occasionally with a hug or a hand on the shoulder.”
“I find it so much more satisfying to be able to share my feelings in the safety of group, rather than doing what I used to do; that is, cry alone on a back stairwell after a patient died.”
6. Attend a wellness conference
Physician wellness conferences often offer continuing medical education credit and take place in beautiful locations ideal for family vacations. For example, David Elpern, MD, has been coordinating conferences for 15 years in places as far-flung as Hawaii and Cuba. (More information is available online at hello.to/drelpern). These conferences offer the opportunity to learn more about self-care and to steep yourself in meaningful interaction with other physicians. I have heard physicians who avoid such conferences say they don’t have the time or don’t learn from them. Such a self-defeating perspective is sad, as I consistently observe physicians at these conferences excited by their learning, being renewed, making contacts that continue after the conference, and in general, having a wonderful time. Please think twice before “deep-sixing” the fliers you receive for wellness conferences!
7. Strengthen your communication skills
Strong patient relationships are often the most rewarding aspect of a medical career. Most of you are keenly aware of the profound satisfaction that comes from skilled, “care-full” patient relationships as well as of the stress of trying to relate to patients without well-honed interpersonal skills. I’ve heard several physicians in my groups lament about not having received more of this training in medical school. It isn’t too late. If poor interpersonal communication skills are adding stress to your life, check into the continuing education offered by the American Balint Society (familymed.musc.edu/), the American Academy on Physician and Patient (www.physicianpatient.org) and the Bayer Institute (www.bayerinstitute.org).
8. Address your patients’ and your own spiritual needs
Finally, take spirituality seriously. Some polls indicate that patients, religious or not, wish their physician would inquire about their spirituality in the event of a grave illness. They experience this as physician concern for them as people, as well as diseases.1 The polls also show some physicians feel inadequately trained to address patient spirituality and some feel it isn’t appropriate to their role. Though controversial, studies also exist that indicate a positive correlation between spirituality and healing.2
There are some practical principles and guidelines you can follow in addressing your own and your patients’ spirituality. For example, Larry Dossey, MD, a well-known author on the subject of prayer and healing believes that the power of prayer is scientifically proven and he prays for his patients. But as to praying with patients, he writes: “I emphatically do not believe that physicians should impose their spiritual beliefs on their patients. After all, we do not allow priests and ministers and rabbis to perform appendectomies; neither should we expect physicians to regulate the spiritual lives of their patients, as if a white coat, stethoscope or scalpel conferred on them some special spiritual expertise.”3 Another valuable resource is the recently published book by Jeff Kane, MD, The Healing Companion.4 Twenty-five years ago, Dr. Kane shifted his practice from working toward curing his patients’ cancer to being present for them and listening to their expressed suffering and other subjective responses. He did this to help them progress toward healing, or wholeness, whatever the outcome of their cancer.
If you decide you want to better relate to patients’ spiritual needs, consider consulting with a clinically trained pastoral counselor or accredited chaplain supervisor. You can contact the American Association of Pastoral Counselors (www.aapc.org), the Association of Clinical Pastoral Education (www.acpe.edu) or the College of Pastoral Supervision and Psychotherapy (www.cpsp.org) to find resources in your area. These professionals have received extensive training and supervision in relating sensitively to patients’ psychological and spiritual needs and are prohibited from imposing their own spiritual views on others.
Perhaps the most effective way to help patients with their spirituality is to pay attention to your own. For example, meditation, in addition to relieving stress, has been found to deepen the spiritual centering of people who consider themselves spiritual seekers. Even some atheists or agnostics, after meditating regularly, have sensed a presence they call God or a higher power.
Those of you who already know yourselves to be spiritual and find spirituality in your religious tradition don’t need suggestions from me. Those who don’t feel your spiritual needs or awareness are tied to a particular religion may find guidance and principles in any of the various traditions, such as Christian, Jewish, Buddhist, Islam or Native American. You might also consider the possibility that making a commitment to your own well-being and wholeness – which also benefits your patients and all your important relationships and is motivated by your commitment to life – is profoundly spiritual.
For your own sake and that of your significant others, make a commitment to prioritizing your self-care. In closing, I put my hands together in Hindu prayer form and bow my head slightly toward you in recognition of the God within you, and in recognition of your calling.