Resilience: A New Take on Physician Wellness

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Hello and welcome today to our program on Resilience: A New Take on Physician Wellness. I'm Carol Lambert, Vice President for Practice Optimization here at the Cooperative of American Physicians and it's my pleasure to welcome you today as we explore some ideas about resilience as a constructive and positive and healthy approach to responding to the pressures in the environment and the pressures we create for ourselves. 

 

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I want to set the stage for our discussion today by telling you a story about a physician I worked with years ago. He asked me to help him fix himself, which I thought was charming and insightful and very positive. And he described himself as being demanding and short-tempered, he yelled, he was impatient, and he frightened his staff. And we talked about what he really meant and what he really needed. And what he needed was his staff to be focused, attentive, flexible, responsive as situations changed in the environment. And I suggested to him that in fact he wasn't demanding but had high standards and that he wasn't impatient but he needed them to be flexible and focused and I asked him if he had ever explained to the staff why he needed them to be so attentive and so responsive and he said he wasn't sure that he ever had and I said well why don't you try that and see what action you get.

And of course he tried it and he was very pleased with the response. But he began to think of himself in much more positive terms and that's one of the things I think about when we talk about wellness. Is wellness the opposite of illness? Is balance the opposite of imbalance? What about resilience? And what about developing that flexibility that repertoire of responses that enable us to think our way out of trouble and to create an environment that promotes really our ultimate goals; patient safety, physician safety, and organizational safety. So why are we so concerned with physicians and physician’s ability to respond constructively and positively in a highly charged environment - both regulatory and emotional as well as technical.

Well a simple definition of wellness is the “quality or state of being healthy”. Well that's really very nice but it is somewhat limited because as I said before you get into this thought pattern that health and wellness are the opposite of being unhealthy and being ill and none of us like to think of ourselves as being unhealthy or being ill.

We've talked a little bit about our objectives and we've set the stage with a story about a physician who wanted to fix himself but before we get into the how's and the why's and the what force let's take a look at some numbers because it's remarkable how steady over time concerns about physician wellness and resilience have been and it's not just the flavor of the month it is an ongoing concern and it as I say it is durable over time.

The American College of physician executives did a survey in 2006 and they discovered in their survey that seventy-seven percent of physicians surveyed experienced fatigue. 67 percent experienced burnout and 33 percent experienced depression and family discord and those things seem to be related to low reimbursement, low autonomy, patient overload, and lack of respect.

But here we are in 2016 and the great American Physician survey of 2016 by Physicians Practice reflects in many ways the survey done by a ACPE ten years before.

71 percent of physicians surveyed said they lack adequate time for their personal lives. More than half of the respondents say they have a poor work-life balance. 61 percent would consider going part time if they could and physician stress directly correlated with patient satisfaction and compliance with medical advice. And that reflects very much the AMA statement on physicians who are well, having a positive impact on the patient experience and patient compliance.

So, here are physicians in 2016 saying that thirty-seven percent say there's too much third-party interference. 13.3 percent say there is a declining ability to practice independently. 11.6 percent complain about government regulations. 10.4 percent say that stress is too high and 9.7 percent say that compensation is not high enough and I think you can see if we reflected back to the previous slide those concerns reflected in lower reimbursement lower autonomy and the lack of respect.

In the Journal of Graduate Medical Education as far back as 2009 Eckleberry-Hunt and Associates wrote a piece called Changing the Conversation from Burnout to Wellness: Physician Well-Being in Residency Training Programs. And of course it is very important as physicians undertake the role of physician, in their training, that we look at the things that contribute to resilience, to wellness, to being able to manage themselves, their lives, and their patients as well. So Eckleberry Hunt and Associates found that there was an inherent conflict in balancing personal life with being a physician. Again reflecting the survey in 2006 and the survey recently completed in 2016.

The ACGME which accredits residency programs mandates a competency and professionalism that states that residents must demonstrate a responsiveness to patient needs that supersedes self-interest. Now if that isn't a recipe for burnout I don't know what is.

Brendel, in the Harvard Business Review, challenges us to learn to let go of old ways of thinking. We need a mindset shift. We need to remember that we have proactively chosen our roles as healthcare professionals, as practitioners, physicians, nurses, all the clinical people who are so actively engaged in patient care. So, our roles enhance one another, they don't compete so much as they enhance and inform each other. That we be self-aware, which is as I've said before in this program a very different thing from being self-absorbed. That we're self-aware and able to remain poised and calm in challenging situations or when presented with something completely new to us and then again Brendel talks about the meaning of what we do. Why do we do what we do? Why have we chosen this?

So it it's very much related to another piece in the Harvard Business Review by Acorn Geelan. Resilience is about how you recharge not about how you endure. And by giving yourself the resources to be tough by strategically stopping and creating internal and external recovery periods.

Molinsky, also in the Harvard Business Review, tells us that we are more resilient than we think we are. We are more flexible. We have been adjusting and adapting throughout our lives. We don't think about it because we do it so readily and almost unconsciously. We're braver than we think we are. We make choices and it's an extremely brave choice to choose medicine as a career with its commitments and its demands, but we embrace it joyfully because it has real meaning for us and we have more resources than we think we do. Sometimes we feel very alone but in fact we have mentors’, friends, colleagues, and patients and families to draw upon.

Now when I spoke earlier about our goals of patient safety, and physician safety, and organizational safety. That really begs the question. Why do we worry about how physicians feel and how physicians feel about themselves and about their work? Well the simple and compelling answer is that a physician's well-being a physician's resilience ability to respond to challenges is associated absolutely with fewer medical errors, enhanced satisfaction.

Patients and families are not the only people looking for satisfaction in their experiences. Physicians, staff and certainly the administrators of healthcare facilities are looking for satisfaction as well and creating a positive environment in the workplace.

Someone asked me not too long ago about how we're going to get efficiency, and improved quality, and added value in the workplace and my response was, “We'll have those things when the workplace fosters our best work. When the workplace makes it possible for us to do our best work” and we all have a role in that in creating that healthy workplace, where people want to be and where people achieve satisfaction, and safety, and quality, and value.

So physician well-being positioned resilience is absolutely essential. It is a question of safety and the organization relies on us. Relies on physicians and staff to maintain and improve and promote patient safety. And when you have that approach, when you are aware and insightful about the role your own feelings your own well-being your own ability to respond to challenges, contributes to creating that safe and positive place.

Everyone benefits. Everyone achieves objectives. Everyone has a positive experience. Errors are reduced from the simplest things to the most complex because people are alert and aware and paying attention. So safety first is our organizing principle and our prime objective and that really relies on us all being at our best to do our best.

Another issue is overload and I if I hear it once a day I hear at ten times a day. “I'm absolutely slammed.” “I'm overwhelmed.” “There are not enough hours in the day.” “I'm never going to be able to get all of this done.” “I could work till midnight.” “I could sleep under my desk and start at dawn it would be the same.”

So that feeling of overload physical and emotional exhaustion, that feeling that we have no more to give and that the next person to ask something of us is going to find us exploding.

Another aspect of overload is a development terribly unfortunate development of cynicism. “It's always going to be this way.” “There's really no chance for improvement no matter what I do.” “I'd never make any progress.” And you know something? The thing to do is to care less is to detach myself from the situation.

So you have these components of exhaustion physical and emotional and then we become cynical and we detach ourselves in an effort to protect ourselves and at the end of the day we feel like we've been running in molasses in January as a friend of mine used to describe it.

So what are we working with here? What do we bring to the situation? Well we bring ourselves. We are our resource. We are our strengths.  I always say, and perhaps too often, that our biggest asset is what's between our ears. How we think, how we problem solve, our repertoire of responses that enable us to respond to a variety of challenges and situations, without feeling overwhelmed exhausted or needing to be emotionally detached in order to survive. So we're talking about resource allocation, and utilization, we're talking about ourselves.

How we spend our energy, how we spend our time, how we work with our lives with what we have been given, and with what we have signed up for. Because after all no one made us do what we're doing we have chosen to be in a helping profession for the very reason that we care about others, we care about our world, and our environment, and we want to do the best for it. So if I am my resource if you are your resource. How are we going to allocate our strength, our intelligence, our enthusiasm? How are we going to use those things to achieve patient safety, physician safety, and organizational safety?

So we recognize in ourselves and in our situation that physicians who take care of themselves you who take care of yourselves are better role models for patients. After all you reflect your own concern for your well-being.

I'll tell you another great story. Years ago I was responsible for organizing educational programs, pretty much as I am now only then I was a volunteer, and I had a cardiologist come and speak to a large group of people at a dinner meeting, and it was one of those wonderful community events where the members of the community brought the food including a table of fabulous desserts.

So the cardiologist gave his presentation and there he was not young but slim and clearly fit. Didn't smoke, drank you know little wine here and there, and he gave his presentation and the presentation had some truly terrifying statistics and slides about what happens to cardiac patients who don't take care of themselves. And at the end of the evening people said good night and left. And the dessert table was virtually untouched. So he was a role model and standing in front of us telling us about the risks of not watching our weight not watching our diet and lo and behold all those fabulous desserts were left practically untouched.

But physicians who take care of themselves are better role models for their children as well. We raise a healthy family you set a good example and you share with them your concern for an overall healthy approach to life. Physicians who take care of themselves actually have better patient satisfaction scores. There is no question that you set a tone of health, and optimism, and strength, and resilience, and your patients feel that it's in the air and they respond positively to that. My chief years ago said to me Carol the relationship is part of the treatment program. So a physician who exemplifies all those all those good things about responding positively the environment is a role model for patients and gets better results.

And of course you experience less stress and burnout. The more extensive your response repertoire the more things you have to bring to bear, the less stress and burnout you will feel because you will just feel competent. And it's pretty clear that physicians who are resilient live longer and who doesn't want to do that.

Now the AMA is pretty firm. They have a policy that they want physicians to set a foundation for themselves and their patients by having a physician for themselves. Not a relative, not a friend, but a professional who can speak the truth in challenging times and present you with what you should be doing on your own behalf and work with you to achieve a good health and an outlook that is constructive and positive. You want someone who's objective. Who cares deeply about doing a good job and about you as a patient but who can be objective and talk tough when that moment comes.

Gentry talks about compassion fatigue and resiliency and gives us some prescriptive ideas about how to deal with the challenge of building resilience remaining calm and poised as Brendle says. And accessing our bravery, our flexibility, and our resourcefulness as Molinsky says.

So Gentry suggests that we care for ourselves. How simple is this and how challenging? Put on your running walking shoes three times a week, evolve spiritually, be creative, get good sleep, eat well. I don't know about you as listeners but those things represent a challenge every single day. Connect with peers, share difficulties, and get support. Building a network and asking for help is not weakness, it is strengthening us and it gives us additional resources attend to what we can control and forget the rest. That's mature perceptions keeping a sense of proportion, keeping the bigger picture, in mind all the while when we have to attend to details. Remember that we're choosing, we chose the life as an author recently said. We find the life you love, you need to find the courage to live it. Self-validated, we recognize our value our worth, we recognize what we're doing. We want to be intentional and act out of our principles, our beliefs, our commitments, versus always being responding to the demands in the environment. Structuring our lives, structuring our work, and being alert to how we're feeling. Again self-aware, not self-absorbed, and realizing when we've got our shoulders up around our ears, or we're grinding our teeth, or we've clenched our jaws.

Let's go back and revisit wellness and its relationship to resilience. We've talked about physician setting an example, modeling good behavior, modeling health, having their own physician to care for them an objective and professional way.

But wellness is not just the absence of illness as we talked about very early on. But resilience and life involves being challenged, and thriving, and achieving success in various aspects of our personal and professional lives. We want our lives to be in some ways in an upward trajectory of increasing satisfaction and achievement as we reach our professional goals. And being resilient, being tough-minded, being self-aware, and self-concerned and self-protective, all of those things that we worry about because we're afraid we're going to be called self-centered or self-absorbed when in fact being integrated, being self-aware, is really crucial to responding appropriately and healthily.

So there's a dichotomy that we've been encouraged to think about. To think about work-life balance and how we get out of balance. And I don't know about you but I experienced a touch of imbalance pretty much every day, as I'm challenged to respond to various situations. And I think one of the difficulties with the work-life balance idea has to do with the implication that somehow work is bad and life is good. So that when we're at work we're longing for the rest of our life. And that both detracts from the value and meaning of work in our lives, and the contribution that work makes to our lives, and then loads the rest of our life with totally unreasonable expectations. And I think you have only to reflect on what happens when you go on vacation. That you go on vacation for two weeks and the first four days you're sick because you have worked yourself to a frazzle and by the time you get on the plane or in the car and get to where you're supposed to be relaxing the first thing you do is go to bed and sleep for four days.

So it loads the work-life balance idea can load life with many unrealistic expectations and demands of our self and others because another implication is that life happens elsewhere away from work. And for those of us who care about our work, who are very invested in our work, work is a crucial part of our life. It is an integrated part of our life. Not to mention paying for the rest of our life and it demotes the importance of work.

So we want to be watchful and aware about thinking about balancing things out. Does emphasis shift? Absolutely. The emphasis in our life and our day shifts from one priority to another but that's not the same thing as being in balance and out of balance.

There is a Swiss philosopher named Alain de Botton. He lives in Britain now and one of his quotes, he has many interesting books and many interesting takes on a lot of philosophical ideas. But I really loved his quote that, “there's no such thing as balance, when we're passionate about something it unbalances us,” and I know that those of us who are involved with patient care, with running hospitals, with caring about our communities, find that we are constantly enthusiastic, excited, challenged and you can hardly call that being balanced because we're deeply passionate about what we do.

And then there's a wonderful quote from a pediatrician who wrote an article and I want to be careful to get it right because it is really wonderful. “Can a successful clinician scientist really: 1. eat six small meals a day? 2. Work out four times a week? 3. Attend all family functions? and 4. Spend regular quality time with friends? Now every time I give this presentation people laugh out loud because there's always someone in the audience who says, “Do I really want to attend all family functions?”  But, at any rate, I think it's a wonderful quote and it's a wonderful challenge to our way of thinking about how we have to do it all, all the time in order to feel successful.

So again, Alain de Botton, “there is no such thing as work-life balance. Everything worth fighting for unbalances your life,” and how true that is. You think about the time, the investment of time, energy, and financial commitment to become a physician, to establish a practice, to care about patients, to do work in hospitals, to align yourself with the goals of the community the organization. It's just so so amazing so important work. Such important work and worth fighting for. But you can't by any means call it balanced.

So here's my take on physician wellness. Resilience: it's a more achievable goal because it integrates all of our life and it's a more enduring result.  We develop springboards. We develop ways of responding that call on all that we are, and all that we know, to respond creatively and constructively and at the same time protect ourselves so that we can enjoy the meaning of what we're doing and the meaning of our contribution.

So reevaluating what we're talking about here. We're talking about renewal. We're talking about the capacity to live life to the fullest and face adversity change and challenge with purpose and determination. And those things really characterize those of us who have committed to working with patients and families in our communities and in our healthcare facilities and systems.

Wherever we deliver the care, whatever that constellation of factors looks like. Facing adversity change and challenge, purpose. Purpose and determination. The refusal to give in. The refusal to be beaten down. The refusal to quit to become cynical or detached.

But with the challenges with the emotional challenges of our work with the technical challenges not to mention regulatory requirements, legal requirements, constraints and reimbursement. The kaleidoscope of changes that seem never to settle down but to constantly shift and demand new responses of us. Our purpose, our determination, to live into the meaning of what we do will help us develop the resilience we need to face adversity, change, and challenge.

So the foundation for our being resilient has to do with those very old-fashioned ideas about having a purpose to get up in the morning. Are we going to have terrible days and disappointing experiences? We sure are are we going to lose patients we are. Are we going to have families and patients upset with us yes we are? Are we going to be challenged by administration? What is that going to cost? How are we going to get it done? Do we need more staff? What are the constraints?

But purpose gets us up in the morning. Our drive to make a contribution for the meaning of what we do. Perseverance not giving up. Recognizing of course everyone has hills they are not going to die on. We choose our battles. We choose battles that we think we can win. We retreat from battles where we feel perhaps let's live to fight another day. But perseverance sees us through, our determination to complete a job, to complete the work of quality safety for our patients, ourselves, our staff, our practices, and our healthcare facilities. 

Now equanimity boy is that a hard one. There are days when you just feel like the top of your head is going to blow off. So let's talk a little bit about equanimity because certainly one of the challenges. In addition to just getting up in the morning and being determined to achieve our objectives for that day.  The next thing is maintaining kind of an even keel and equanimity, “keeping us from going to extremes.” Now everybody knows a drama queen and most people know what they would call an ice queen. People who are chilly, and always straight faced, and not warm, and on the other hand you have people for whom everything is what a friend of mine calls the last act of Traviata. Lots of drama and somewhere in the middle there is the person who manages to keep their feet under them all day long - roll with the punches.

They're doing work in Silicon Valley, the research has been underway for a while, about the myth of multitasking. And what we are really doing is serially attending in tiny bursts of time. So we're constantly shifting our attention. And that prompted me to think about something that someone said to me years ago. Everything doesn't come at you at once. That's how it feels but really things are coming at you one thing at a time very, very fast. So stepping back, and boy is that hard to practice, and get in to our routine. But stepping back and recognizing that things are coming at us one thing at a time, and we're going to deal with them one thing at a time. Or if we're lucky enough to be able to delegate we'll delegate. But we're going to keep our feet under us and our heads about us to use all those clichés which really work.

We are skilled. You as physicians if you're watching this. Physician staff whoever you are watching this and listening to this presentation you are a skilled person. You have knowledge. You have experience. You have expertise and those are resources you can draw on. You can rely on yourself and on those qualities and those resources you have developed in yourself.

I'm a big fan of reading. I read a lot, I encourage people to read but not just in our disciplines but as a way of refreshing our minds our ideas of contributing to our imaginative abilities. Because that can help us imagine new ways of working which are better, safer, quicker, more efficient, and more effective. And then knowing ourselves being ourselves. You know I think it was Oscar Wilde, someone will be sure to correct me if I'm wrong, but I think it was Oscar Wilde who said be yourself everyone else is taken. So authenticity - being authentic. We are who we are. We reach into ourselves for our skill, our knowledge, our expertise, our inner strength, and our commitment to do our work to the best of our ability, and to live our lives in a meaningful way.

So you know Randy Newman wrote this song and it's just I love it. Not all of it is immediately apparent in its relation to resilience but one of the things that we need to develop in our lives is at least one good friend. Preferably more but certainly to have a friend to turn to it's part of being resilient having not just within us a repertoire of responses, but having people in our lives that we can turn to and share with, whose shoulders we can cry on, whom we know we can depend on, family, friends, colleagues, trusted advisors. Be a mentor, have a mentor. Teach someone something, learn something every day. But we need the support of other people. And I think one of the things that contributes so greatly to cynicism and detachment is the feeling of being alone with the problem, alone with the work, alone with the challenge. That's why professional societies are so important, community groups, community participation, so important as a way of connecting beyond our own work, our own circle, and being part of the larger community.

The larger whole, receiving new information, and new impressions of being challenged to change our minds about something. To learn and grow always. I really admire there are organizations which commit to providing their employees with ongoing professional education. And we all know that one of the challenges in budgeting and in expense is maintaining staff training and development, but from the largest organization to the smallest to the 1-2-3 physician group. Encouraging lifelong learning. Participating in it as a way of developing mentors and friends and a network so that we can say to each other, “you've got a friend in me and when your miles and miles from your nice warm bed, just remember what your old pals said, you've got a friend in me”.

John Irving said, “if you are lucky enough to find a way of life you love you have to find the courage to live it.” So at the heart of things is our desire, and our commitment, and our drive to commit ourselves to live the life we've chosen. Whether it's in medicine, or nursing, social work, administration, finance, whatever our discipline is and particularly as we relate our work to the crucial crucial aspects of patient safety, and physician safety, and organizational safety. So that through that many changes in our evolving healthcare landscape we don't just survive but we thrive and we help others to do so too. Our reaction our response and our resilience will help us find the courage to live the life we love and find the strength, and the optimism, and the knowledge, and skill to help our patients, and their families, and our communities, and organizations live out their best lives as well.

Thank you so much for joining us today at the end of the slideshow is a list of resources. I commend them to you and one that I don't believe is on the list because it's so brand new is a book called Rest. And the book is about why we achieve more when we work less and it's all about resilience and the development of resilience so thank you again for being with us today.