Over the past nine years, my journey through the topic of physician burnout has evolved; just speaking about the issue to increase awareness is, simply, not enough. Increased awareness has brought about questions related to individual and—even more so—organizational solutions.
Tait D. Shanafelt, MD, a renowned expert on physician burnout, and John H. Noseworthy, MD, CEO emeritus of the Mayo Clinic in Rochester, Minn., proposed nine organizational solutions to the problem in the Mayo Clinic Proceedings (2017;92:129–146). For the past two years, my resolve to influence and impact has focused on two more: accountability and action. These will be far more effective for the individual physician and provider, as I have found that dialogue on how we experience the burnout spectrum, rather than treating it as a cognitive subject, creates more change. Physicians, advanced practice providers, nurses, and various therapy professionals all need help because, as it turns out, we are all human.
The word “balance” comes from the Middle English, Anglo-French, Vulgar Latin bilancia, from Late Latin bilanc-. Definitions for balance per Merriam–Webster: “the state of having your weight spread equally so that you do not fall; the ability to move or to remain in a position without losing control or falling; a state in which different things occur in equal or proper amounts or have an equal or proper amount of importance.”
Using the phrase “work–life balance” implies that we live lives in which “work” and “life” occur in equal amounts or have equal amounts of importance. For physicians, the state of “balance” is difficult to define and is different for everyone. If we are honest with ourselves, “balance” is an idealistic but unrealistic word for our daily experience. The word is, frankly, contradictory to our training and beliefs as physicians and surgeons. Perhaps those we are training now and future generations will be less at risk for “burnout” as they are being taught awareness of the topic and are already commonly asking just how much “life” their residency training and jobs will afford them. For example, nearly all of the more than 200 applicants to our new pediatric residency program asked what our hospital and program are doing for burnout.
The author with her dog Shiro at Lake Nona in Orlando, Fla.
How do we constructively and delicately share with young, energetic, intelligent, and committed trainees pursuing their dreams to heal others through our noble profession, that the “life” of a physician now has work spilling far beyond 10- to 12-hour days? How do we help them prepare for the immense additional EHR-related clerical and administrative work that likely will make demands on time outside of clinical care? How do you teach residents to possess awareness at home so they can greet their families and pets with their best selves—the same one they gave to their patients and colleagues throughout the day?
In today’s training environment, it is even more critical for us to be role models and incorporate these conversations into education. Undoubtedly, trainees will observe that faculty who participate in a variety of professional activities outside of clinical work—such as speaking and traveling, participation in subspecialty societies and the Academy, clinical research, and everything else that makes up the fabric of our professional career—are kept engaged and have a minimized risk of burnout. For those outside of academic settings, it may be even more important for trainees to observe that one can still experience and practice otolaryngology and all fields of medicine with joy, possible only through awareness, accountability, and action.
Every decision to do more for the sake of our patients, colleagues, and organization, as a part of our job and career and in service of others, comes at a cost. That cost is typically the time we are not spending on self-care to improve our own well being, or not spending with our loved ones. Some of us do better than others; some may be in denial, and some may realize this but believe that they don’t have a choice. After all, how can anyone expect a physician to give less to her patients, career, work, and service to others, especially when our work has such meaning and we actually love what we do?
I, like many, have an unrealistic belief that I need to be “available” to anyone and everyone whenever I am asked to help. It’s so hard to say no, professionally and personally, because it contradicts our very core values of being physicians.
Most colleagues of mine respond to emails far too quickly, likely because they have their phone set to “ding” with incoming texts and emails. Like Pavlovian dogs, many may compulsively check the phone, read emails, and draft replies instead of being engaged with our spouses, significant others, children, pets, and whomever else we are with when we are outside the hospital setting. Texting is clearly necessary, efficient, and easy, but can also rob us and our loved ones of what little life we have left when we are not working. Perhaps we are all victims of anxiety over the endless tasks and to-do lists, and we are already anticipating that there will be no time tomorrow to read emails from today (and yesterday) or deal with tomorrow’s tasks. But we are not living today, tonight, or this weekend when we are constantly living in preparation for tomorrow and the challenges it will bring.
I, like many, have an unrealistic belief that I need to be “available” to anyone and everyone whenever I am asked to help. It’s so hard to say no, professionally and personally, because it contradicts our very core values of being physicians. The idea and habit of trying to “finish” your work must be dispelled. We must first accept and embrace being human ourselves, entitled to all our physiological, mental, emotional, and spiritual needs so that we may move first toward individual well being, and then move to organizational well being.
“Passion can be a gift or a curse,” said Brad Stulberg in a blog in the The New York Times “Well” section, “The Right Way to Follow Your Passion” (Published March 19, 2019.). Who amongst us is not passionate? If you aren’t passionate about your identity as a physician/surgeon, your job, or career caring for humans, does that mean you don’t care? Perhaps you’re already bitter, are disengaged and just surviving each day or, worse, have left medicine altogether. If you are passionate, beware. What seems to be a character strength, without awareness, will create “imbalance” for one’s own “work–life” as we passionately give energy and time to whatever the cause, at the cost of not prioritizing ourselves and loved ones who depend on our very presence and engagement at home.
“Work–life balance” sounds like what we all need, but it’s not possible until we embrace the uncomfortable truth that we too are human. The very thought that we are vulnerable, can get sick, can lose loved ones, may suffer mental health issues, including depression and anxiety, and then develop maladaptive coping mechanisms including addiction, is offensive and perhaps unacceptable. How can this be? It’s not fair. After all, we are the ones who have devoted everything to care for others. Shouldn’t that, in turn, provide us with immunity from suffering, pain, and natural tragedies? Sadly, no.
To improve and practice better self-care and develop new behaviors necessary to optimize our mental and physical well being, we have to change our perspective. No one will exercise more until they believe that physical and regular exercise serves a critical purpose and directly impacts length and quality of life. A great article was published in 2016 by Shawn Anchor and Michelle Gielan in the Harvard Business Review: “Resilience Is About How You Recharge, Not How You Endure” (Published June 24, 2016.). Research found a direct correlation between lack of recovery and increased incidence of health and safety problems. The science simply shows that by allowing our brain to disengage, we will be more effective, think more clearly, increase creativity, and truly “rest” for physical, emotional, and mental well being.
While burnout is epidemic across many professions, in medicine it’s morally unacceptable to exploit a group of highly skilled and trained experts who are the utmost specialists on caring for humans, who are already altruistic unlike any other. Healthcare systems have found the perfect “workers” who can and will be pushed to “produce” more, at the expense of their physical, emotional, and psychological well being, until we move away from a volume-based reimbursement model against constantly reduced reimbursement.
The Nemours Program
At Nemours Children’s Hospital in Orlando, I am grateful for the opportunity to lead and create change. We have crafted a resident and faculty wellness program that likely exceeds ACGME mandates, addressing mental and physical health as our priorities. I am excited to chair our new medical staff health and wellness committee and to engage others who are interested to participate and create palpable programs that will change the conversation and culture. We will partner with HR to ensure that every physician optimizes their benefits, and we will create a formal second victim program to address the daily PTSD trauma endured as a part of being human and bearing witness to death and violence, and sharing in our patients’ and their families’ grief and pain of loss. We are creating access for residents and faculty to a psychologist (who only treats physicians) for 24/7 acute mental health crisis coverage and other counseling needs; because physicians will not use the employee assistance program, they are unlikely to go to a counselor/therapist they don’t know until they hit “rock bottom.” We are partnering with Johnson and Johnson Human Performance Institute to support surgeons and physician leaders to experience a single-day training on “energy management” to optimize mental, physical, and emotional well being for inspired and purposeful living.
None of this is possible without getting buy-in from senior administrative and physician leaders, and I am proud to share that it is possible—slow, for sure, but possible. There is an emerging and rapidly expanding industry of technology focused on psychology and feedback to change our behaviors and improve “wellness,” and I am certain we will all hear more about the various platforms, apps, and potential “solutions” to improve wellness not only for physicians, but for all who work in healthcare. This is necessary because every healthcare organization will realize sooner or later that, in order to thrive, they must optimize engagement, performance, and productivity from their physicians, providers, and associates.
Dr. Wei is director of the NCH Resident and Faculty Wellbeing Program and division chief of pediatric otolaryngology/audiology at Nemours Children’s Hospital and professor of otolaryngology-head neck surgery, as well as chair of otolaryngology education at the University of Central Florida College of Medicine in Orlando. She is also an associate editor of ENTtoday.