My workdays are just insane!” Thus began a recent conversation with a colleague who was struggling with some of the harsh realities of clinical practice, which have been exacerbated by the COVID-19 pandemic. He continued, “Sure, I enjoy being a physician, but lately it's felt more like a grind than a privilege. I've not shared this with anyone before, but I'm not sure I can keep this up.”
If you have ever found yourself feeling similarly, know that you are in good company. Know also that there are compelling reasons you should not be navigating these challenges alone. Intentional peer connection is a powerful way to increase our resilience and to support and encourage each other on our professional journey — not as a substitute for the support of friends and family, but as an essential ingredient recognizing there are some aspects of our professional lives that only colleagues can truly understand.
Now, I know what you're likely thinking: Peer connection won't fix the underlying problem — a broken “system.”1 That's true. System change is badly needed, but it is unlikely that we will see a fix any time soon. Therefore, making system change a criterion for our own professional well-being is sentencing ourselves to a life of professional (and personal) misery. But peer connection can help us now to deal with the emotional toll of working in a dysfunctional system, and even to thrive as we fight for a better system.
Because of professional socialization and scripting, and the present pace and intensity of clinical practice, physicians have limited down-time and limited opportunities to establish meaningful connections with colleagues.
Lack of professional connections can lead to a “soulless efficiency” and professional isolation, making it harder to care for others and deal with the emotional toll of working in a dysfunctional system.
Intentional peer connection is a powerful way for physicians to increase their resilience, support and encourage each other, and thrive while fighting for a better system.
A TALE OF TWO EPIDEMICS: BURNOUT AND LONELINESS
We've heard the staggering numbers so often that I fear we've become numb to them. Over the course of three national studies done at three-year intervals starting in 2011, the burnout rate for family physicians has stayed consistently above 50%.2 This rate, while alarming in itself, does not even include other manifestations of professional distress, such as depression, anxiety, compassion fatigue, moral distress/injury, change fatigue, relational dysfunction, and just plain weariness. And these numbers do not capture the sense of professional disconnection and isolation that many of us are feeling as we try to navigate the increased complexity, regulation, and pace of medical practice, often feeling quite alone in our struggles.
Yet, in many ways, this epidemic should not surprise us. Professional burnout is the condition that results from the chronic inability to emotionally recover from the distress of work in downtime. Many of us have little downtime during which to recover, so it's no wonder we feel helpless to mitigate the onslaught of distress-producing circumstances in our work. It's exhausting to live in an almost constant state of internal distress and experience a myriad of accompanying feelings, including shame, guilt, embarrassment, despondence, cynicism, exhaustion, meaninglessness, and grief.
In the midst of this system dysfunction and personal distress, there is a strong temptation for physicians to assume a posture that indicates to the outside world that we have it all together. That's what we're trained, socialized, programmed, and expected to do. In many ways, it's our “badge of honor” — that somehow we're invulnerable to the tragedy, suffering, and seemingly endless need we're surrounded by each day (not to mention all the administrative pressures of our practice). As Dike Drummond, MD, describes it, our programming to be a “workaholic, superhero, perfectionist, lone ranger” and our drive to follow the medical culture's directives that “the patient comes first” and “never show weakness” create the perfect storm for this epidemic of distress.3 All the while, on the inside, many of us are quite far from OK. Yet even when colleagues tentatively reach out to offer support, we all too often rebuff them with the practiced response, “I'm fine,” and keep them at a distance while feeling painfully alone and isolated.
In 2017, former U.S. Surgeon General Vivek Murthy, MD, declared that loneliness (the state of emotional distress from lacking desired interpersonal relationships) was among the greatest public health threats to our country. Although we live in the most technologically connected age in the history of civilization, our rates of loneliness have doubled since the 1980s. Today, more than 40% of adults in America report feeling lonely, and the actual number may well be higher.4 Additionally, the number of people who report having a close confidante in their lives has been declining for the past few decades.4
Loneliness and weak social connections are associated with a reduction in lifespan5 and correspond with worse outcomes for chronic physical health conditions (such as hypertension, heart disease, and diabetes) as well as mental health conditions, including depression, dementia, and suicide.6 At work, loneliness decreases performance, limits creativity, and impairs other aspects of executive function, such as reasoning and decision-making.4 Yet despite this information being known for more than a decade, the profoundly negative consequences of loneliness and social isolation are only starting to be appreciated.
There is evidence that physicians are not immune to the epidemic of loneliness and social isolation. Research has revealed that graduate-degree holders report higher levels of loneliness and less workplace support than people whose highest degree is an undergraduate degree or high school diploma. Physicians (along with lawyers) are among the most isolated of professionals, reporting levels of loneliness 25% higher than those with bachelor's degrees and 20% higher than those with doctoral degrees.7
This should not be surprising. Based on our professional socialization and scripting, and the present pace and intensity of clinical practice, we have limited opportunities to establish close, meaningful connections with colleagues. An emphasis on patient care at the expense of team interpersonal connection can reinforce this pattern.8
Most physicians hunger for enhanced professional connection. In my quarter century of medical practice and medical education, the things recently graduated residents have most often told me they miss from residency are the camaraderie and relationships, including discussions about challenging or interesting patients, and sharing the joys and challenges of medical practice with colleagues. Even though we often work right beside each other, professional connection seems to be treated as more of a luxury than a necessity. And the consequences are quite real. As fellow family physician John Frey, MD, wrote in his essay about professional loneliness, “Not valuing time with other physicians or allowing for informal conversations leads to a soulless efficiency and professional isolation that drains physicians of our ability to help ourselves, help each other, and help patients.”9
HOW TO CREATE INTENTIONAL PROFESSIONAL CONNECTIONS
What can be done to address the epidemic of professional loneliness and isolation that seems to be getting worse in the face of the increased demands of medical practice?
First, if you find yourself concerned about burnout or depression, reaching out for professional help may be an appropriate step. Doing so is not a sign of weakness, but rather an expression of wisdom. I sought help at a point in my professional life when I was struggling emotionally, and it gave me my life back.
Second, if you desire connection, go first. Don't wait for others to approach you. Approach them. This could mean contacting a colleague who would be willing to connect with you, joining a formal peer-support group, taking part in casual social gatherings, or joining an online forum. (See “Professional gathering spots.”)
Informal approaches tend to be simpler, deeper, and more personal. But they don't always offer the structure, reminders, and accountability of a more formal program. And of course, each of these options takes time and a deliberate intention to invest in yourself and your professional relationships, although the time involved is probably much less than you think and the return on investment much more. Our professional scripting has caused many of us to believe that taking time for ourselves is selfish, but it is actually good stewardship, because you can't give what you don't have.
A PEER CONNECTION EXPERIMENT
In an effort to combine the best of both worlds — the simplicity of one-on-one connection with the structure of a more formal program — I recently conducted a simple, eight-week, peer-support pilot with 30 clinicians in my community. The goal was to provide structured support to help them foster professional connections and advance along the “burnout to thriving” index — from “burned-out” to “survival” to “fine” to “well” to “thriving.”10
In the pilot, self-selected clinician pairs agreed to receive weekly e-mail reminders with guiding questions to prompt reflection and discussion at the following check-ins:
As little as 90 seconds each week, check in by e-mail, text, phone, or in person to provide mutual support and encouragement. Sample questions include the following: How are you doing? What is one specific thing I can do to help/support/encourage you this week?
Thirty to 90 minutes each month, have a more in-depth connection. Sample questions include the following: What is one thing that's going well? What is one thing you are struggling with? What's something that's really important to you right now? What is one specific personal or professional goal for the next 30 days, and how can I help/support/encourage you to achieve it?
All check-ins in the pilot were optional, and the suggested times were intended as guides. Not included in the eight-week pilot, but recommended, was an additional check-in:
Up to 90 minutes every 90 days, do a quarterly review of the previous 90 days and set goals for personal/professional well-being for the next quarter. Sample questions include the following: How are you living out your values? What are your goals for the next three months? What are your dreams, both personally and professionally? When is your next vacation/adventure? How can I help/support/encourage you?
Similar “buddy systems” have been used in the U.S. Armed Forces (e.g., “wingmen” in the Air Force, “battle buddies” in the Army, and “shipmates” in the Navy), as well as the Boy Scouts, the Girl Scouts, and the YMCA swimming program (“buddies”).
At the end of the eight-week pilot, the group well-being index average had increased from 2.2 to 2.6 out of 4, and participants uniformly rated the experience as positive. Participants used words such as “renewing,” “uplifting,” “decompressing,” and “fun” to describe the program's guiding questions. Although some participants initially expressed concern about the time commitment, the majority were able to find the time to check in, even when one of them was on vacation. Participants also said the weekly reminders served as a helpful nudge for connecting — something they had desired but previously did not follow through on in the midst of the busyness of daily practice.
Given the encouraging results of the pilot, I created an online version of the program: PeerRxMed.com (or PRx90 for short). Self-selected pairs of clinicians can use this free platform to facilitate connection, encouragement, accountability, mutual support, and growth as they move toward optimal well-being, however they define that state for themselves.
PROFESSIONAL GATHERING SPOTS
AAFP discussion forums focused on interests such as the following:
Independent Solo/Small Group Practice,
International Medical Graduates,
Lesbian, Gay, Bisexual, Transgender Issues,
New Physician Issues,
Practice Management Issues,
Private Sector Advocacy,
Local activities: Create local groups of physicians to share a meal, participate in volunteer activities, or pursue common interests together.
WHAT ARE YOU WAITING FOR?
We can all hope for — and need to continue to work for — constructive health care reform and relief from the dysfunctional aspects of clinical practice.11 But challenges that lead to significant professional distress will likely continue for some time. It is therefore imperative for us to take ownership of our individual and collective professional well-being. Those of us in family medicine can take the lead in helping to address the epidemic of loneliness and isolation, starting with ourselves.
It is indeed a tragedy that any of us try to navigate the challenges of our professional lives alone. With many options available for peer connection, the next step is ours to take. Who might you reach out to today to deliberately and explicitly make sure you both are regularly feeling supported, encouraged, and connected? What are you waiting for? When it comes to our professional work, let's not leave something so vital to chance. Let's together ensure that no one cares alone.