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Setting Boundaries

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Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at STEPSForward.org

Jill Jin, MD, MPH: This is Dr Jill Jin. And today I'm speaking with Dr Kevin Hopkins, who is well-known to this podcast and to our team. Dr Hopkins is a practicing internist and the primary care medical director at the Cleveland Clinic, as well as a fellow senior physician advisor here at the AMA. Thank you, Kevin, for joining me today.

Kevin Hopkins, MD: Thanks, Jill, it's a pleasure.

Dr Jin: So, our topic today is how to prevent fatigue and build personal resilience, or essentially how to practice self-care as a clinician. And as everyone here knows, we, the we being AMA STEPS Forward®, has always placed an emphasis on system-level approaches to reducing physician burnout and improving well-being. But that doesn't mean that individual self-care is not an important part of our toolkit. It almost feels like in recent years, the concept of personal resilience and self-care is a little bit shunned in the wellness field because we want the focus to be so much on the systemic and organizational level. And we know that physicians, by nature, are already highly resilient individuals. That's how we got here in the first place. But Kevin, I was listening to your webinar that you gave recently on this topic. And you said a fact that really shocked me, which was that every day on average, a physician commits suicide, which is crazy. I mean, clearly, this is a problem.

Dr Hopkins: Yeah, you're right. It's a huge problem. Yeah. In the US, on average 300 to 400 physicians take their own lives each year, which is a rate that is more than double that of the general population. And beyond that, just the rate at which physicians are satisfied with their work-life balances significantly less than the general population. So, you're right. It's a huge problem. And it's something we need to talk about. And system changes, while they're incredibly valuable, they tend to take a long time. And so, what do we do while we sort of wait for that sort of help to arrive? Skills that we can learn to build personal resilience and margin to combat fatigue and prevent and mitigate burnout. Those are skills that are adaptable across all aspects of our lives for all time. So, it's really good for us to think about adapting to those skills into our everyday life, anyway.

Dr Jin: Exactly. So maybe let's just start with defining what does self-care and personal resilience mean to you?

Dr Hopkins: So, I'll start with the second word. First resilience to me means somebody who's able to withstand or recover quickly from difficult conditions. In my mind, I picture a rubber band, and a rubber band, if you stretch it out too far, it breaks. If you stretch it out, not quite that far, but you do it too many times, it starts to lose its shape and its elasticity. And it's no longer able to recoil or spring back like it used to be. Well, people are kind of the same way. The more we're stretched, the more we're compressed, or we're bent, higher the likelihood is that we lose some of that resilience over time. So, resilience is what allows us to spring back from stress to get back to our normal level of functionality. Self-care is certainly the means to build resilience. So how do you take care of yourself? Whether that's being into regular exercise, making sure you get adequate rest, you're spending time with family and friends, and adequately disconnecting from social media, those types of things. Those can all be considered self-care. So in my mind, self-care is a means to build personal resilience.

Dr Jin: Got it. And as I understand it, you like to group these approaches to self-care into three main buckets. So, correct me if I'm wrong, but they are setting boundaries, limiting decisions, and limiting distractions.

Dr Hopkins: Yeah. I think there's a lot of bleed over and crossover in those, but in general, yeah, we all need to set some personal boundaries in our lives. Some people are naturally better at that than others. Some people are also naturally better at respecting and honoring those boundaries than other people are, but some ways that we can do that. So, to think about boundaries is limiting our commitments, limiting the number of decisions or the types of decisions we make, and distractions. We all know that the cost of being distracted in multiple settings, including distracted driving, certainly something we hear about regularly, which has consequences. And so, how can we think about going through our work days by limiting commitments, limiting the amount of decisions we have to make, and limiting distractions? That can help us to build bandwidth to be more sustainable, healthy mindset.

Dr Jin: Perfect. So I do want to take a moment to dive into each of these buckets. So, the first one that you talked about is- so how do you set boundaries? Can you give us some specific tools or strategies to do that?

Dr Hopkins: Sure. So recently, we were on vacation with the kids. We have three kids, 15, 13, and 11. And last week we went to Florida and we were in Disney World. And I think about this every time I fly, because when you get on an airplane, they give the safety speech beforehand. And one of the things they always say, when they're talking about the oxygen masks, is put your own mask on first before trying to help others. Well, by nature, all of us are fixers, and we want to fix other people and their problems or their complaints and issues. But we can't do an adequate job of that if we don't take care of ourselves first. So I think of it in the context of putting your own, your own mask on first. And then, when I try to think about what boundaries might be most impactful to helping to build personal resilience, I encourage people to just start making a list. Make a list of actions that, if you were to implement them, they have the potential to create more margin in your life because those same choices are likely going to increase resilience.

And then, as you look at that list, start to prioritize, maybe rank order the list from potentially most impactful to least or easiest to implement to most challenging. However, you decide to prioritize them. Once you've prioritized them, pick one to two to start with, but start small so that you have some initial success. And then once you decide on one honor, that priority, respect it. Be firm, but not necessarily rigid, overly rigid, but we have to honor it when we try to set a boundary because if we continually cross that line, then it's really not a boundary at all. And then the final step in that is, is maintaining it, committing to regular future check-ins. Thinking about blocking some time on your calendar to really sit with it and think about it. How am I doing it, respecting this boundary or these boundaries in my life? Am I doing well at that or not? If not, how could I do it better? And then, as you start to build boundaries into habits, consider what to add next.

Dr Jin: I like that concept of prioritizing your to-do list, or I guess, triaging it almost. I mean, we're so used to doing that for our patients, you know, triaging how acute or how sick patients are and prioritizing that way, but we could do the same with our to-do list, and that, I guess, makes it less overwhelming. If you really pick the two things that you need to do today and everything else is kind of noise.

Dr Hopkins: Yeah. I do a to-do list and I try to keep it. And there's certain things that just never get crossed off my list. There are other times that I add something onto the list that I've already done, just for the she pleasure of crossing it off. You know, I've read about, and I've started trying to do this to sort of prioritizing that to-do list. Things I must do, things I should do, and things I could do. The things that I could do, they'd be nice. I don't always get to all of them, but it helps me to identify what are the one, two, or three things that I absolutely must get done today. And then, if I can accomplish those, I feel like I've had a successful day. Where this came from was every day I'd come home from work, and my wife would say, how was your day? And I'd say I didn't get anything done today. And the truth was I got stuff done, but it was putting out fires as they popped up or trying to triage more incoming data points rather than accomplishing the things that I had set as a priority. And by doing those things, I could feel like I was more productive.

Dr Jin: And I think you touched on this as well, but you need those boundaries to actually have time to think and to mentally organize your life. Because if you're constantly trying to get to everything on your to-do list, you really don't have time to think or be a good leader or be a good clinician.

Dr Hopkins: That's right. It gets to the concept of limiting our commitments to really make it okay for yourself to say no to things, to take your vacation time. I know a lot of friends and colleagues who don't take their time off or time away, but you don't need to be a martyr. Trust me if you don't take your vacation time. No, one's going to remember that you did that except for you and your family, and it's not going to be a pleasant memory, but schedule personal time, put it on your calendar. If you don't schedule it, it probably won't take place. Once you put stuff on your calendar, then you need to honor that and respect it as an appointment or commitment that you've made to yourself.

Dr Jin: Exactly. So the second bucket, so to speak, it was about how do you limit decisions. And I liked that concept a lot as well, because again, just paralleling it to clinical life. You know, as a primary care physician, every patient you see, you have so many decisions you have to make about their clinical care. And it's, it's often on the fly, and it's tiring. It's mentally very, very challenging. So, the idea of limiting decisions outside of your clinical life, it shouldn't be so novel, but I mean, it is, and I can see how it would make a huge difference.

Dr Hopkins: Yeah. Every decision point that we have in our lives creates a little bit of stress. So how can we create some margin and resilience by just limiting the numbers of decisions we've got to make in a day. There was an article that was published in 2013 that says the average adult makes about 35,000 remotely conscious decisions each day. I don't know how they track that or figured that out, but that's an enormous number, and you're right, Jill. I think of all the decisions we make throughout the course of a clinical day, and they're decisions that don't just affect us, but they affect other people and their families and the people that they love and care about. So how can we limit the number of decisions that we make to try to build personal resilience and margin? One idea of how to do that is to think about personal policies and what I mean by that is predetermined decisions to guide our action.

So some examples of that might be, I'm not going to look at my phone in the morning for the first time until after I've eaten breakfast because that's something that's important to me, or I'm going to make sure that I get eight hours of sleep each night and I'm going to do whatever it takes to make sure that that happens so that I don't have to choose. What time do I go to sleep? Well, I know if I have to get up at 6:00 AM, I have to go to bed at 10:00 PM, or by 10:00 PM if I want to get that amount of sleep. So thinking about opportunities to sort of set personal policies, and then when you're faced with a decision, if there's really no right or wrong answer, just be decisive about it. A topic of conversation often in our family, usually in the car while we're driving, is where do you guys want to go to eat? And the response is always the same. Oh, I don't care. So if you really don't care, just pick a place and do it. We could do that in lots of areas of our lives to just be decisive and make a decision rather than belaboring it, because it's going to increase your overall stress.

Dr Jin: That's such a good tip. I think that we're still conditioned, or at least I am, sometimes, to maximize every decision. Like we have to pick the best place just to maximize life instead of, you know, choose something that suffices, but it doesn't matter. You know, we don't have to maximize all the time. We can just make a decision and it won't matter. So, I like that tip a lot.

Dr Hopkins: Yeah. That's, like I said, a hot topic of conversation in our household. And so, what happens is somebody will throw out a couple of options. I'll make a decision, and then invariably, somebody says, well, I don't want to go there. Well, you said you didn't, if you really care, then you should express your opinion.

Dr Jin: And we have such easy access to looking up options. I think that's also part of the problem, which I guess segues into the next topic, which is how do you limit distractions?

Dr Hopkins: I'm terrible about this. You think of all the ways that we receive information today. So, I was in clinic this morning, got stuck coming into my, in-basket, in electronic health record. I've got emails coming in at a rate of about two per minute. My phone is dinging because I'm getting text messages. The chat feature in our electronic health record is popping up on my screen because somebody wants to instant message me that way. We've got another instant message tool through another virtual meeting platform that's popping up. And so when you're doing that, it just makes it impossible to be focused. I mentioned earlier, distracted driving. Well, if distracted driving is consequential, think about distracted doctoring. Think about distracted parenting, distracted spousing. Anytime we're trying to do more than one thing at a time, our attention is divided. I will talk about my wife, is an amazing multitasker, but to me, multitasking is actually a myth. It's really just multiple variable levels of distraction for each, and to do anything well to do it our best. It really requires focused attention. So thinking about turning off notifications on your phone, controlling your desktop on your computer, turning off notifications, you don't need to see every time a new email pops up. There's enough distractions going on in our world, that if there's some of those things that we can control, it'd be a good idea to try to get some control of them.

Dr Jin: Sorry, Kevin, going back to the limiting decisions. Was there anything else you wanted to say on that one?

Hopkins: These are hard for me to try to limit decisions as well because I have the best intentions, and I'll say, okay, I'm going to make sure that I take a 30-minute break at noon each day, whether I'm going to eat lunch or I'm going to go for a walk around the building and then noon comes, and there's something else pressing. And so, I don't do it. And so, if you're going to try to leverage this type of tip, then you really have to be honest with yourself about it and commit to it. It has to be a priority if it's going to make any impact. Otherwise, it's just going to fall by the wayside like any new year's resolution does, right? So, you have to think about how we can make a commitment to ourselves and stick to it. And if you don't do it for yourself, do it for your patients, do it for your family, because they're the ones that are going to be most adversely affected if you don't.

Dr Jin: And I guess it is similar to the clinical guidelines or the standing orders or protocols we have in place to try to minimize the clinical, the number of clinical decisions we need to make. Your whole idea of setting policies or rules, or I guess protocols, you could call them for yourself. It also just automates it to a certain extent.

Dr Hopkins: Exactly. So, any time we can do that, kind of put some things on autopilot that can be helpful, and it takes repetition and practice in order to make it a habit. But it's something that if you want to prioritize, you can manage and do.

Dr Jin: I think that is a key point that it does take practice, and you'll probably fail a lot the first few days or weeks that you try it. How long do you think, in your experience, it takes to kind of get to the point where these things become more second nature.

Dr Hopkins: Well, before it starts to really become a thing that you don't have to think about, it's going to take at least two weeks of doing it routinely every day. And it's probably going to take on the order of one to three months for it to really become habit where you really, it doesn't take that degree of effort. So, it's going to take some time. You think of how long it takes patients to break the habit of smoking or anything else that they're addicted to and to change behavior. It takes effort, and it takes time. But we do this all the time with our patients. We talk about taking care of themselves so that they can take care of in their lives that matter most. I think of working single moms, people who are sort of the sandwich generation that are taking care of their kids and taking care of their parents, and they've got the candle burning at both ends, and they're frazzled and worn out. In the office, we would counsel them that you have to take care of yourself first, before you can be any good to any of these other folks. And yet, for some reason, we, as caregivers, think or understand or fool ourselves into believing that we're immune to that type of exhaustion and burnout that would come as a result of not exercising self-care.

Dr Jin: Right. Which we really are not. I do think there is a sense that physicians are superhuman just based on how both we perceive ourselves sometimes as well as how patients perceive us, admitting that you need to work on self-care, personal resilience, more is something you don't even- one you wouldn't want to talk about with your patients, but also you don't want to admit to yourself in a way, because it makes you feel like less of a physician.

Dr Hopkins: Right, it demonstrates or shows or reveals weakness. If you think of most people in our training throughout the course of med school and residency, depending on your generation, depending on when you went to school and trained, it was sort of like, you know, you keep your head down and just do your work. You don't complain. And you certainly don't admit any weakness because it's going to be a sign that you're not going to be a good physician. And in my opinion, that's totally untrue. It's a lie that we've bought into or fooled ourselves into believing patients want to be taken care of by other human beings, not by robots, not by digital health tools. And that's why, you know, you see our patients who we did so much virtually for the first part of the pandemic, and they want to come see us in the office because people are created and desire human relationship. And so, they want us to connect with them on a human level. And to me, that doesn't demonstrate weakness.

Dr Jin: I agree a hundred percent. And from personal experience, I think that when you do empathize with a patient in a way that shows your own vulnerability, they appreciate that, they trust you more, and it strengthens your relationship. I mean, hopefully, this is shifting, but the whole training mindset of you have to put your head down and just suppress all emotion and weakness. So, I hope that is changing. And that the newer generation of physicians will recognize that self-care is important for everybody.

Dr Hopkins: Absolutely. When we don't take care of ourselves, I also sort of liken it to a repetitive stress injury or overuse in injury in the musculoskeletal context, that if you injure yourself with adequate training, stretching, strength, and aftercare, leads to a quicker recovery, but if you don't do those things, or you have inadequacy of training, stretching, strengthening aftercare, or maybe just older age, that it leads to muscle fatigue. And having that type of repetitive injury without adequate recovery then leads to potentially a tear in the affected muscle tendon or ligament. And now you potentially need surgery to repair that body part. Our minds are really not a whole lot different from that. When there's repetitive stress injury, without time, energy, and effort spent to adequately repair and recover, worse injuries occur as a result.

Dr Jin: Exactly.

Dr Hopkins: When it comes to limiting distractions. Most of us are not very good at leaving work at work. And when you look at the amount of work after work that has to take place or work outside of work, whether it's through the EHR or other means, a lot of us aren't fully devoting our time and attention to our roles when we're at home, because we're too distracted by leftover work that we feel like needs to get done. So thinking about how you can do a little bit better at separating work life and home life, I think that's become increasingly more challenging as we've done more working from home. When I walk past my office, and I see my computer at 10 o'clock at night, and I think, oh, you know what? I need to just do this one thing. And pretty soon, two hours have gone by, and I'm still sitting there.

So, thinking about how you might better separate yourself. So one thing that I started doing when I'm working away from the office, I pull the car into the garage, turn the car off, and I take several slow, deep breaths. And I sort of think in my head that with these breaths, I'm coming all the way home, and I'm leaving my unfinished work at work. It'll still be there tomorrow. And I'm going to be focused now on my roles and responsibilities as a husband, a father, a friend, a family member. And those are really the roles and responsibilities that quite frankly bring me the most engagement, joy, honor, and pleasure in my life. So why wouldn't I want to be a hundred percent focused on those, just like I want to be a hundred percent focused on patient care when I'm in the office? So, thinking about how we can disconnect from our work lives. We've got so many means to get information, just like I was saying about sort of being in clinic and the distractions, the same things at home. So thinking about turning your phone off or plugging it in, or leaving it in a different room if you're not on call, and leaving your laptop closed as much as possible so that you can focus on the other roles and responsibilities that you have at home. I think that's a good challenge for all of us to consider, too.

Dr Jin: I love that. The deep breathing and your mantra with- what was it? With this breath, or with these breaths, I'm coming home. I like that.

Dr Hopkins: I'm coming all the way home. And sometimes, it works. Sometimes it doesn't, it just depends on what's waiting for you on the other side of that door sometimes, but it's at least, yeah. It's at least a conscious, intentional thought and process that I'm trying to use.

Dr Jin: Yeah. And like you said, it's, it's about the practice, and practice makes progress. Not necessarily practice makes perfect, and you know, it's something that you can start today or tomorrow and continue working on and, you know, see how far you get.

Dr Hopkins: That's right. That's right. Because if you don't, if you never start it, it's never going to progress. So think about some of these things that I'd encourage our audience, just to think about some of these things that we've talked about, and think about maybe coming up with your own list of boundaries that you'd be willing to try and put one into play and see how it works. If it doesn't go well or it doesn't have the intended outcome, try something different, but if you continue to do things the same way and expect a different outcome or result, then that's not reality.

Dr Jin: Right, exactly. And just as we encourage pilot teams to implement systemic changes, we just, you know, as individuals, maybe just do one or two things at a time and not try to take on all of these tips you just talked about, but maybe just start by making that list or doing the breathing, but it doesn't have to be everything else.

Dr Hopkins: Yeah. So, I use the phrase sort of like see one, do one, teach one, right? That we probably all heard from our medical training. I think about start one, share one, and study one. So, think of something, a change that you could put in play tomorrow, and this could be true for tips and tricks to build personal resiliency. It could be true for practice transformation topics and workflows, but what could you start doing tomorrow? And then that's the start one. And then share one. Think about sharing one with a colleague, hey, I listened to this podcast, I heard this idea, have you ever tried this before? And then study one for potential future implementation. So, we're all familiar with that see one, do one, teach one. So, I'd encourage everybody to start one, share one, and study one. And it's just a way to get started in the process of building margin and self-resilience so that we can do a better job of taking care of ourselves and taking care of others.

Dr Jin: That was perfectly said. Yeah. I think that we've covered everything that I had on my list. Are there any other pearls, Kevin, or any other parting words you'd like to share with our audience?

Dr Hopkins: I would say this is a, it is a hard time to work in health care, right? And all of us, when we went into careers in health care, we knew it was going to be hard. If it was easy, anybody could do it. But I don't know that all of us expected that it would be as hard as it's gotten to be, especially over the last two years. There are lots of things that are causing stress and burnout among health care providers. And when you layer on a two-plus year infectious disease pandemic that at times is overwhelmed the system and certainly overwhelmed individuals. It could be too much and for too long. I liken it to the super bowl that never ends. So, we need to take care of ourselves, and we need to take care of each other.

Watch out for yourselves, watch out for your colleagues. If you see somebody who seems to be struggling, they probably are. Because otherwise, they would probably kept it hidden from you. Reach out to him, just ask, how are you doing? Are you doing okay? Here's something I've noticed. Boy, are you struggling with this? Because I am too. People need encouragement. We're seeing people leave careers, leaving jobs in health care at an alarming rate, and not only jobs, but people are leaving careers in health care at an alarming rate. And so, I worry about someday, when my kids are grown adults and have families of their own, will there be a health care community to take care of them? And if we don't take of ourselves and take care of each other now, that could very well be a reality.

Dr Jin: You're right. It's the future of health care. Well, thank you so much, Dr Hopkins, for speaking with me today and for providing all those practical, useful, yet essential tips for all of us. For more information on this topic of personal resilience and self-care, Dr Hopkins goes more in-depth into this topic in his webinar. He recorded with the AMA STEPS Forward® innovation academy webinar series.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at STEPSForward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, STEPSForward.org

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