02 Mar Burnout in the Medical Profession Part 4: Lifestyle and Behavioral Change
Understanding the Phenomena of Burnout in the Medical Profession Series
Part 4: Life Style and Behavioral Change
Our world is increasingly volatile, uncertain and complex. As a result, people are leaving in a constant state of flux. Life challenges our work and our needs all the time. We cannot avoid it but the question is how to deal with it. When we experience that our needs are met, the body feels happy and conserves its resources, energy, as opposed to being in a state of flux, disturbance and agitation when the needs are not met.
We encourage trainees to develop resilience while perpetuating many aspects of a toxic system. Medicine as a career attracts people who are driven, perfectionist, self-reliant and proud. Too often our sense of self-worth is defined by our job. Given that medicine is demanding and sometimes full of tragedy, it is easy to assume the blame for the failings of the system or bad outcomes that we actually have no way of preventing. Our training encourages this exaggerated sense of responsibility. The current medico-legal climate and intense scrutiny from our licensing bodies and health authorities add an insidious layer of anxiety about the caliber of our work, and the societal trend to always seek someone to blame when things do not go well often targets the physician. Yes, there are systemic failures and medical errors, but these are not the norm. Yet media and social media, in particular, would imply that the system is rampant with bad medicine and deviant doctors. Professionals are good and effective to activate various states of mind and not always good at installing them as a coping mechanism. Somehow I doubt anyone is more critical than we are of ourselves when we make a mistake.
The bad news is there is no magic bullet for changing your ability to cope effectively. The good news is there are many ways for you to explore and get started with developing your understanding of yourself and relating to the world, the working environment and others. I can make a list and discuss further some aspects.
- Personal or Executive Coaching services.
- Lectures, seminars or workshops on interpersonal communication, relationships and leadership.
- Classes on creative activities such as intuitive painting, journaling, music, cooking, photography or pottery, boarding, longboarding, sailing and so on, as long as it is a restful, happy activity.
- Practicing meditation, yoga, mindfulness, breathing exercises.
- Lifestyle changes such as diet, alcohol, time off, physical exercise-even just a 20 minutes walk per day.
- What is available on the Internet? Use the search words: Communication, emotional intelligence, interpersonal relationship, leadership, awakening, self, insight, coaching, mentoring, personal growth, empowerment, healthcare, medicine, education, empathy and compassion. Search for related topics of interest on Ted’s talks.
What is clear is there is a continuum movement to find ways to feel more in control of our unique stressors and remained connected to our life. But the question is how? A good life is being in a state of balance. Balance is the ability to cope and deal with a positive manner. Exercise, diet and fitness, rest, mindfulness, emotional intelligence, compassion, happiness will lead to a balance in our life where one can enjoy its work. Family life is an important part of our life. It is not necessary for us to sacrifice our own health, family and community for our work even if we think we have no other options. We cannot relieve the suffering of others if we are not taking better care of ourselves. “Physician heal thyself” is terrible advice – we need to look after each other and not be afraid or ashamed to seek help, as too frequently, professionals feel too ashamed of their situation, their inability to cope with the stressors in their life and the potential effect on their career if seeking help.
Studies show that we are not busier than we were 30 years ago. We just feel busier and there are several reasons for it. If we never take a break from our devices, we will rarely get a moment of peace, so our 24/7 connectivity makes our lives feel more crowded. Multitasking ups the pressure as well, because it increases stress and fractures our attention keeping us out of the present moment: remember to practice mindfulness. It is not necessary for us to sacrifice our own health, family and community in order to care for others. A preventive educational approach is now in place in most medical schools. Heightened awareness of stress management and substance abuse through prevention programs, medical community lectures and conferences are available and should be encouraged.
The basic concept of mindfulness is straightforward. As author Jon Kabat-Zinn has put it, “it is paying attention in a particular way, in the present moment, and non-judgmentally”. Over the last few years, there has been a mindfulness revolution. Hospitals across the country are offering programs to staff, to patients, universities across the country are offering courses to students and corporations such as Nike, Microsoft and American Express have also established programs for their employees. The mindfulness field is influencing education, law, business, technology, sport, economics, politic, army. In 2005, there were over 100 papers on mindfulness scientific and medical literature and there were more than 1,500 publications in 2013. Mindfulness-Based-Stress-Reduction (MBSR), was developed in the late 90’s and has been since a growing movement in many fields. It allows people the opportunity for people to work toward greater levels of health and well-being, both physical and psychological. As people face massive information overload, they try to remain connected, to switch to activities at a rapid pace which we call “multitasking”, as an alarming pace. It takes longer to get back to the original task, leading to decrease performance, frustration, stress and mental tiredness.
Mindfulness can be developed through practice, just like other skills. Mindfulness is a way of being, an awareness that is more than just a thought process. Keep practicing as a form of meditation. You will see changes.
Emotional Intelligence (EQ)
Emotional Intelligence is the term given to a group of abilities that enable human interactions to work effectively: the ability to be aware of one’s own experience, the ability to be aware of others experience and the ability to effectively manage one’s self in relationship. Understanding self and the role that self plays in any given interaction is the foundation of emotional competence. Emotional development begins very early in life as we experience attachments with the adults around us. We learn a range of coping strategies to deal with the stress of our emotional self in relationship with others. Coping strategies while relieving stress initially can also become ingrained patterns of behavior that further the stress response and lead to resistant, repetitive behaviors that interfere with developing and maintaining relationships.
Becoming aware of and managing our internal experience, stress and anger, involves a complex interplay of the information we take in from all sources, the way we process and infer from it, and how we take action. Much like the process of communication itself. It is not what we say but how we say it that is often most hurtful or provocative and increases the stress already present. Boyzatsis (2005) suggests that the way to deal with our internal experience is through renewal responses including self-awareness, hope and compassion. Engaging in renewal responses decreases our stress response and allows for greater capacity to relate to another and reply with greater thoughtfulness. Emotional Intelligence is a growing field and the subject of many books, workshops and teachings that are worth exploring further.
Communication is more than ‘speech-making’. It is not just the words we say but also the intention behind them, the meaning we give them and the tone and body language that accompany it all. Many of the physical barriers to communication have all but disappeared in this technological age, however, the psychological aspects of communication remain. Effective communication is a science but more importantly, it is also an art, in the ability to understand one’s self, in the ability to attune to others and in the ability to express one’s self in an authentic, compassionate way. The science of interpersonal relationships, psychology, and neuroscience, can be learned through reading and learning new skills and habits. The art of connection, empathy and compassion must be practiced, sometimes re-learned and embodied as a mindset, rewiring deeply engrained belief structures.
We have now become enlightened to the keys to successful communication and relationships. It involves slowing down our internal world, noticing, observing self and relating to others, adopting practices that keep us in learner mode and responding in a more thoughtful way. In the fast-paced environment of healthcare, it is imperative we find time and space to discover more about our own self. That doesn’t mean plugging into the Internet, checking emails and believing we are connected. That would only be telling a story to our self that we are doing our best to try and keep up with everyone. As a society, we have entered the ‘Age of Distraction” whereby the technology at our fingertips takes us further from relational attunement.
Our healthcare world has also become more technologically savvy with the introduction of electronic health records. The next challenge we face in maintaining effective communication is to be skillful at interfacing with a computer screen and keyboard, all the while being focused and present to our patients. There is a tendency to turn our backs or type and talk, with the occasional ‘uh-huh’, or ‘I see’, or ‘yes’, without even looking at the patient. For the most part, patients view the electronic chart as beneficial to their overall care. Electronic health records can provide greater access to and sharing of information across all service providers potentially aiding in diagnosis and treatment. Addressing concerns about privacy and confidentiality, the accuracy of the information and appropriate sharing of information with key healthcare clinicians is imperative. It is an element of the work we do that speaks to developing trust with those we are in a relationship with.
The Art of Creativity
Engaging in creative arts or creative activities can facilitate the development of thoughtful more evolved responses through a greater understanding of self and identification of triggers. Creative arts of any sort serve as a channel for releasing, elevating and understanding our inner conflicts, fears and intentions as well as our hopes, aspirations and ideals. Creative activities can also help us to see the stories we may be telling our self and others.
Everyone is capable of developing a creative activity. Whether we choose to or not is another matter. There are no rules or techniques that must be followed or “natural” talent required. The key is to experiment and find a form that works for you. Intuitive painting, journaling, meditation, yoga, walking, cooking and playing a musical instrument are all forms of creative activities that allow you to develop insight and self-awareness. You may feel that your work is a form of creativity that brings you to a better understanding of yourself. If this is the case then develop a practice of awareness that acknowledges and integrates the insights you develop about yourself through your work. Integrating what you learn about yourself is an important aspect of developing self- awareness and having it influence your intentions and behaviors. In the words of Brene Brown (2015), “Creativity helps us to move things from the heady space of knowing to the heart work of practicing.”
This follow-through, if you will, of “knowing” into “practice” is akin to what science refers to as knowledge translation. The process of recognizing and translating our knowing of inner self into the way we interact with people and the world around us. It is, in essence, the deep work healthcare professionals need to do.
Rarely do we allow ourselves the time on a regular basis to engage in activities that enable us to see and move off of an “old story”, to open to a greater understanding of what can be and evolve our ability to respond to others in a compassionate and authentic way. In the busy world that we exist in we consistently place developing the self and insight into the self far down the list of priorities. In fact, it is extremely important that we take time each day, even for 10 minutes to engage in some form of creative activity. The challenge for many is that the thought of personal insight through creativity generates anxiety. Consider this a process by which you develop the skills and ability to focus on learning about your self over time. Ten minutes a day translates into a significant amount of time over the years and if it provides a better state from which to function, you may be using your time more effectively in other endeavors.
You can develop the habit of being happy just by practicing acting happy. Your inner being and outer expressions reflect one another. If you feel happy inside, it shows up in everything you do. In the same way, expressing happiness outwardly also affects your state of mind, creating greater happiness inside yourself. During good times, allow yourself to smile; during difficult times, still do your best to smile. It doesn’t even have to be a big, outer smile. Just think, “smile.” Think “contentment.”
Dr. Laurie Santos, a psychology professor and the head of one of Yale’s residential colleges, tries to teach students how to lead a happier, more satisfying life in twice-weekly lectures, called Psychology 157, Psychology and Good Life. “Students want to change, to be happier themselves, and to change the culture here on campus,” Dr. Santos said in an interview. “With one in four students at Yale taking it, if we see good habits, things like students showing more gratitude, procrastinating less, increasing social connections, we’re actually seeding change in the school’s culture.”
Dr. Santos speculated that Yale students are interested in the class because, in high school, they had to deprioritize their happiness to gain admission to the school, adopting harmful life habits that have led to what she called “the mental health crises we’re seeing at places like Yale.” A 2013 report by the Yale College Council found that more than half of undergraduates sought mental health care from the university during their time there.
Living the Good Life
In these times of rapid technological changes, people often feel out of control, powerless to stop change and/or navigate through their way through it. Stress is an epidemic in our society. But aspects that you can control are your attitude and the health of your body. You can decide if you are going to be a positive person and you can decide if you are going to be fit and eat healthily. A commitment to physical activity brings balance to your mind, the intellect and the body. Knowing something is good for you is not enough to make you do it. If you just relax and listen to your body, it will tell you what it needs. Exercise can be a form of meditation by turning your attention away from work and from problems, bringing relaxation and reducing stress. If you exercise consistently 2 hours per week your body will feel better. You will increase your life expectancy by 2 years or more. The images of the perfect body seen in the media and marketing are not real. Magazines and TV make money promoting fitness perfection but this high level of fitness is not realistic. Your exercise regime is not about perfection but about feeling good mentally and physically. Exercise will help you regain control and decrease stress in your life.
It is more important to control your eating habits than be on a diet. I am not a fan of any diet except moderation. A few pounds here and there will catch up with you and your work. Any weight control program that includes an extremely low-calorie diet every day and goes to certain extremes with specific foods should be avoided. Proper weight control is a combination of exercise along with a balanced, healthy diet. This is the best, long-lasting approach. Being under stress and overweight does not allow for “your best performance.” The brain has a greater capacity to deal with the demands of work and tasks if you exercise and are careful with your diet.
A private trainer may sound expensive, difficult to commit to or you may think you can just exercise sufficiently by yourself. But it is a small price to pay if you can, for a substantial investment: your health. He/ she will help you to achieve your goals faster than on your own; you will receive an individualized program for your body type and level of fitness; you will maximize your training; you will be exposed to a variety of training exercises; your trainer can also protect you against injury, you will be stimulated and it is more fun working out with another person.
A good life is being in a state of balance. Balance is the ability to cope and deal with your work and life issues in a positive manner. Exercise, diet, and fitness will lead to balance in your life, where you are not always consumed by your work and where family life can be an important part of the work/life balance.
Spirituality and Wellness
Spirituality is unique to each individual. Your “spirit” usually refers to the deepest part of you, the part that lets you make meaning of your world. Your spirit provides you with the revealing sense of who you are, why you are here and what your purpose for living is. It is that innermost part of you that allows you to gain strength and hope. Spiritual wellness may not be something that you think much of, yet its impact on your life is unavoidable. The basis of spirituality is discovering a sense of meaningfulness in your life and coming to know that you have a purpose to fulfill.
Many wellness behaviors can benefit your spiritual health. Such behaviors include feeling connected with others, feeling part of a community, volunteering, having an optimistic attitude, contributing to society and self-love/care.
You can use spiritual practices to strengthen your body, mind, and spirit. All three are connected. The practices for your body include yoga postures, breathing exercises, taking time for yourself and energy balancing. The practices for your mind include being quiet for a few minutes, meditation, study of spiritual teachings, readings. Spiritual disciplines strengthen your willpower. Gaining more self-control gives you the strength to free yourself from other harmful habits. You can stay focused in your commitment to meditate, this is just like exercising your mind. You can apply this same technique to other willpower situations, such as quitting smoking or maintaining an exercise program. The key is to make a decision and honor it, keeping your word to yourself.
Meditation actually provides more time by making the mind calmer and more focused. Meditation does not mean to sit on the floor with your arms and your legs crossed. You can make meditation part of your day, such as a walk, sitting quietly on the porch, driving somewhere alone. For me, a driving trip alone is my best meditation. A simple ten or fifteen minutes breathing meditation can help us to overcome our stress and find some inner peace and balance. We can learn how to transform our mind from negative to positive, from disturbed to peaceful, from unhappy to happy. Overcoming negative thoughts and cultivating constructive thoughts is the purpose of the transforming meditations found in the Buddhist tradition. This is a profound spiritual practice you can enjoy throughout the day, not just while seated in meditation.
In summary, the physician’s burnout has been a fact of medical practice for many years and much has been written about it. As stated earlier, major factors that act as stressors in our profession are information overload by the rapid advance in information technology, by the information explosion in the literature, on the internet, which is accessible not only to us, as physicians, but to our patients. The rapid advancement of technology has necessitated the development of updated knowledge and skills in diagnostic and therapeutic procedures. Our workload has expanded as well as competition for scarce resources and budget. Other factors include consumer demand and expectations from patients, loss of decision-making, deficiency or lack of educational opportunity, free time ability to ventilate, poor institutional support, inter-personnel pressure caused by managing one’s office, surrounding hospital staff, disruptive meetings and, surprisingly, sometimes having to handle a strong emotional reaction following a patient’s death. It happens to all of us. As the stress builds up burnout can be just around the corner.
Although the medical curriculum has moved from a traditional teaching approach to competency-based learning, there are pros and cons despite the fact that this new learning seems to meet the demand of changing health care for physicians and specialists. In relation to the understanding of burnout in the medical profession, I do not think these changes have increased or decreased the burnout rate.
As good as the Internet can be and provide amazing opportunities in our today’s life, it may affect student performance and behavior. Even children can be found engrossed in their own tablets and cellphones are ever-present in every student hand or pocket. So it’s no wonder why the Internet has immensely woven itself in the lives of people, relying on the ‘net for many things such as socialization, study, entertainment, and current events. For students, spending a lot of time on the Internet can do more harm than good. The internet really affects students both negatively and positively. While the internet can be a reliable resource to help them with homework and school project, things can easily turn downhill when time on the internet overtakes time for study and school.
We can access executive coaching and team building, mindfulness and emotional intelligence resources, resilience training, meditation, diet, exercise, decreasing IPad, email and computer daily time and more, but ultimately, only one action will prevail: the day you decide to make a change and take control of your life, and you can. Establish your priorities, align your decisions with your priorities and start to disconnect.
1. Kabat-Zinn, Mindfullness: Full catastrophe living Bantam Books, Penguin Random, Co, New York, 1990 and 2013
2. J. Levitin, The Organized Mind Penguin Canada Books, Toronto, Ontario, 2014
3. Coleman, Emotional Intelligence Bantam Book Publishing, Random House, New York, October 2006
4. Boyzatsis and A. McKee, Resonant Leadership: Renewing Yourself and Connecting with Others Through Mindfulness, Hope and Compassion. Harvard School of Business Publishing, Boston, Massachusetts, 2005
5. Brown, Daring Greatly Penguin Random House, New York, 2012
6. L. Santos, The Science of Well-Being Harvard School of Medicine, Department of Psychology, Psychology 157, 2016
7. M. Vale, J. Gerlach, R. Hendler, September, 2013, Yale College Council Report on Mental Health, The Harvard Review.