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Three Simple STEPS for Diagnosing Your Own Mental Patterns

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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.

Kevin Hopkins, MD: Hello everyone, and thanks for joining us for this AMA STEPS Forward® podcast. My name is Dr Kevin Hopkins. I'm a family physician at Cleveland Clinic, a primary care medical director for Cleveland Clinic Community Care, which is the Cleveland Clinic Primary Care Health Institute. I also serve as a senior physician advisor to the AMA for Practice Transformation, and I'll be your host for today's podcast.

Our guest today joining me is Dr Gail Gazelle. She is faculty at the Harvard Medical School. She's a former hospice physician. She's a career coach for physicians and a leader at the forefront of the movement fighting physician burnout.

Over the past decade, Dr Gazelle has coached over 500 physicians and physician leaders and is the author of "Everyday Resilience: A Practical Guide to Build Inner Strength and Weather Life's Challenges," which was published in August of 2020. Her new book, "Mindful MD, How Mindfulness Restores Autonomy and Cures Healthcare Burnout," comes out in early 2023.

Dr Gazelle, welcome. Thank you for being with us today. We're glad to have you. Can you tell myself and our listeners a little about you and your background?

Gail Gazelle, MD, MCC: It's a pleasure to be here today. Thank you so much for having me on the show.

Yes, I, as you said, was a hospice physician for most of my career. I had volunteered in a hospice as an undergrad in Cornell, and really enjoyed the connections that I had with patients, and being a participant in this very sacred journey that people are on as they're facing the end of their lives. I went to medical school in the hopes that I could be a hospice physician, but that was actually in the 1980s. We didn't have a field of palliative care at that time, so I did a medical ethics fellowship here at Harvard Medical School and that really helped immerse me into the world of end-of-life care. I got my first job working in hospice, and then I went on to develop and direct the palliative care program for what was then Harvard Vanguard, a large HMO here in the Boston area.

My training was in internal medicine. I grandmothered into hospice and palliative care about a decade ago. As we were understanding more about burnout, I pivoted in my career. I had gotten coaching, myself, which I found enormously helpful, so I decided to go back into training and become a coach. I've done that for the last decade, helping physicians who are struggling with burnout, who maybe don't have a lot of emotional intelligence learning in their training, are struggling with conflict management, teamwork, or leadership development. That's what I've done for the past decade. Along the way, I deepened my own interest in mindfulness, and did a two-year intensive training and I'm now also a mindfulness meditation teacher.

That's a little bit of my background that I hope can be helpful for you and for your listeners.

Dr Hopkins: Thanks. I think that is very helpful to understand the background from which you're coming. Each of us comes to these topics and conversations with backgrounds that are different in variable and different life experiences. I love how you used the phrase, 'the sacred journey' in working with patients through end-of-life care. I often say that what takes place in the primary care exam room, my clinical space, is a sacred space, and we're invited into the most intimate aspects of patients' lives. They'll certainly tell us things that they might not tell anybody else, and maybe even shouldn't tell us, but they do. I love the intimacy and the sacred relationship that develops between patients and their physicians.

Dr Gazelle: Very definitely, Kevin. For me, working with such a vulnerable population of patients, it was interesting to pivot and work with what I think we can call a similarly vulnerable population, which is physicians, in our very complex and dysfunctional health care system, not just in the US but in many western nations. There's a vulnerability that we have where we're now asked to do so many tasks that are obviously below the grade of what we learned in our training, and so many things that are really outside of our scope, and we don't necessarily learn the skills as part of our training to be able to weather all of the challenges that we face.

I feel very privileged, now, to work as a life and career coach with colleagues, helping them build that skillset so that they can stay in the game and do this thing that they've sacrificed so much to do, and has so much meaning for each and every one of us.

Dr Hopkins: I'm not sure that many physicians recognize or understand themselves to be part of a "vulnerable population," right? We think about that in terms of our patients, elderly or very young children, people like that.

What do you see as a response or reaction, if you talk about physicians as a vulnerable population, how can we as physicians see ourselves as truly vulnerable?

Dr Gazelle: It's an interesting question, isn't it, because part of our training is to be invulnerable. To always have the answer, to be the captain of the team, to always be perfect. That actually takes quite a toll on us, doesn't it? I think it catches up with us, and is one of the many predisposing factors toward burnout.

Some physicians can appreciate that we are vulnerable in this health care system where we're certainly no longer on top, and we're no longer seen as the special, caring experts that of course we are. We're just, in many cases, another employee. I don't know if this resonates for you and your listeners, but I've had so many physicians say to me, "I just feel like a cog in the wheel. I feel like I'm replaceable; that people don't see how hard I'm working. They don't see how much I care about patients, and how much I sacrifice, every day, to really help the vulnerable patients under my care."

When I talk about vulnerability, that's what I'm saying. We're unsure what our place is in this new health care matrix, so to speak. I don't know that we're comfortable with that place, because it's different from what we were trained to expect.

Dr Hopkins: If we wanted to be part of a production line, we probably would've picked a different career. Instead, we count on patients to come to us as an individualized solution shop that we can provide help for them in that way. Some of the disenchantment of getting into a career in medicine, and realizing that, in some respects, it is addressed as sort of a production line, can lead to burnout.

You mentioned burnout a little bit. One way to help prevent and mitigate burnout is to build personal resilience. Certainly we see resilience in the form of organizational resilience as well. Your book that came out in August 2020, "Everyday Resilience: A Practical Guide to Build Inner Strength and Weather Life's Challenges," what was the genesis behind that book? How did that come to be?

Dr Gazelle: I spent a lot of my time thinking about resilience, and I think that's because of the work that I did in hospice, seeing the different trajectories that people were on in terms of how they spent this last and very vulnerable period of their lives. Most of us, as physicians, have seen people enter the terminal phase of their lives, and many of them are in denial. They're angry. They're thinking, "Why me? This couldn't have happened. It shouldn't have happened. I believed in God. I was a hardworking individual. Why is this happening?" Very normal, human responses, and yet sometimes what we see is people getting locked in that mindset, and not having the incredibly important conversations with their loved ones and with their providers, all of us on the medical team, and they end up dying in an ICU, hooked up to machines, not having family close by, not having closure with those who are deeply important to us.

On the other hand, we see individuals who demonstrate a different kind of approach to this end-of-life period. Now, of course, nobody's happy when they get a diagnosis of a terminal illness, I'm not trying to suggest that. But we see patients who come to a place of acceptance: of realizing that they've been dealt a challenging hand of cards, so to speak, but who move forward in a different way. I'm sure you can resonate with this, as a frontline clinician, Kevin. We see them mobilizing the psychosocial elements that allow them to navigate this period with more grace and fortitude, and to have the kind of forgiveness, permission and closeness with those who are most important to them.

My whole time, 15 years taking care of thousands of terminally ill patients and their loved ones, I feel like I saw a lot of resilience and I learned a lot about resilience.

When I pivoted and became a coach and had the incredible pleasure and privilege of working closely with many colleagues, I saw that same resilience. We know that physicians have resilience. There's no shortage of resilience, but we don't always learn how to apply that resilience to the difficulties that we face in our practices. I'm in the business of helping physicians do that. Helping them harness their inner well of resources, which is how I think about resilience, and apply that so that they can weather the difficulties and challenges that come their way in the practice of medicine, without unnecessary physical, mental, emotional or spiritual distress.

It's not that the practice of medicine will become easy. It's not that the EMR will go away and that non-clinician administrators will not be a part of our lives. That's not what we're talking about. We're talking about some skills and strategies that allow us to weather this with less duress, with less difficulty in our lives.

It's a topic of tremendous interest to me, I think as you can hear. I really had a great time writing "Everyday Resilience," and I've also had a great time writing my forthcoming book, "Mindful MD."

Dr Hopkins: Terrific. I can hear the passion in your voice, and I share that same passion. When you use words like resilience and mindfulness, those probably conjure up different meanings in different people's minds. How do you define that? Because some people may think, "Resilience, mindfulness, that has a negative connotation." What do those specific words mean to you, and how do they directly relate to burnout?

Dr Gazelle: It's such an important question. The medical system is so challenged at present, and there's so many difficulties that we physicians face and, really, everyone in health care is facing.

Sometimes, I think when physicians hear the word resilience, they think to themselves, "Now, wait a minute. We can't let the system off the hook. Aren't you telling me that I need to be more resilient, that I need to do something differently, when really it's the system that's broken?" I think we really have to think about a "both, and" here; there's no question of how dysfunctional the US health care system is, and again, it's not just in the US I've coached plenty of Canadians and individuals in European countries, as well. This is a pervasive international problem in developed countries.

We're not thinking about letting "the system," so to speak, off the hook. There are plenty of people at the AMA and elsewhere who are deeply involved in fantastic ways to help mitigate the problems that a broken health care system brings to the average working physician.

That is of the utmost importance, but I'm a pragmatist, Kevin, and I think to myself, "Well, how soon is it that our health care system is going to improve? Is that going to happen tomorrow? Is that going to happen in a year?" Maybe things are actually going to become more problematic before they get better.

As a pragmatist, I'm thinking about every physician out there. What are they going to do today? What are they going to do tomorrow?

If I'm giving a keynote or a talk at a health system, when I pose the question, "Do you think your health care system's going to fix all these problems in the foreseeable future?" They all shake their heads and sigh and laugh and say, "Well, of course not." They know that. So what do we do? Do we just retire early? For some physicians, that's an option. Do we sadly develop disruptive and dysfunctional behaviors? I hate to say that, sometimes, that happens as well. Do we come home and rail against a broken system, and not be present with our loved ones and become irritable and withdrawn?

These are all things that we see. For me, resilience and mindfulness are all about practical strategies that physicians can learn and can practice on a day-to-day basis to reduce their own distress and level of suffering. That's something that we can all learn. We don't learn it in our training, by and large, but we can, and it can greatly improve our quality of lives.

Dr Hopkins: You're absolutely right. When you and I trained, it certainly was a much different atmosphere from what it is today. "Keep your head down; don't complain."

Many physicians probably today think, "Well, if I've got to build resilience, if I'm going to practice mindfulness, isn't that a sign of weakness?" Most of that was bred out of me during my training, so it doesn't come naturally to us.

What are some steps that physicians can take, to not just survive in the current environment that we find ourselves in health care, but to actually thrive? I know you described three steps that we can take to do that. I think it's important to outline those things so that we can take healthy steps aimed at preventing and mitigating personal burnout. Like you said, a lot of people are retiring early, or they're reducing their FTE just to help themselves cope.

What are some steps that we can take to actually thrive in this environment?

Dr Gazelle: As I talk about steps, I want to just say one thing about the "m" word, mindfulness. It can conjure up images of monks meditating on mountaintops, or maybe aging hippies talking about Woodstock. What's important to realize is that another way to think about mindfulness is actually mind training. Our minds are very busy places. When we pause and spend time in meditation, or just quietly observing our own mind, it can really be astounding, particularly to busy, overtaxed physicians.

It can be astounding what's going on in our minds; the sheer number of thoughts that we have, the judgments we have, the comparisons we make, the emotions that go on in our mind. With mindfulness, it's not so much sitting and naval gazing, so to speak. It's about getting to know our own mind, so that we can work with it most productively.

In terms of some steps, I'll mention a client, whom I'll call "Susan." Susan is really a composite of individuals that I've coached.

Susan was an internist, struggling to stay on top of her charts. Great physician, beloved by her patients, well-respected by her peers; but like many physicians, the Achilles' heel of sitting down and getting the charts done. In fact, Susan was 150 charts behind. We did something that I've developed, it's a bit of a "charting audit," really putting under the microscope what is going on for the physician that's getting in their way.

When Susan sat down to chart, two interesting things occurred for her. One, was she had so much frustration and really, anger towards the administrator in her practice. She would sit down to chart and her mind would go to how unfair this was, to these nasty grams that she was getting from this administrator, and how could she be asked to do this? This was so below her pay grade.

At the same time, the second thing occurred for her, which was a lot of self-criticism. When she sat down to chart, she started thinking to herself, "I'm not very good at this. Other people are better. I'm not as efficient as others. In fact, maybe I'm not even as good a doctor as others." Her mind would just be besieged with all of this harsh self-criticism.

What I've seen in the over 500 physicians that I've coached is a similar pattern; that our mind is busy with unprocessed emotions, with stories, with harsh self-judgment that make it very difficult for us to be productive, and certainly to feel satisfied and fulfilled.

When you talk about three steps, the first step that I worked, with this client and many others, is that we have to get to know what's going on in our mind. We have to be more mindful. How do we do that? Well we can do that by sitting quietly and meditating, even for five minutes. We become very familiar with our mental patterns, our thoughts, our stories and judgments. That's the first step is getting to know and diagnosing our own mental patterns, why we can't intervene until we diagnose, right? We're doing the same thing with our own mind.

The second step that can be critically helpful is something that I call the purposeful pause. Our days are so busy, right? Double booked, triple booked, charting, callbacks, getting prior auth, everything that has to be done to stay on top of a busy practice. We're going at 90 miles an hour, never stopping, not even pausing to eat lunch. That's too much. That, in and of itself, predisposes us to burnout. So, we can stop. We can pause, even for as long as it takes to take three slow, deep breaths. We can take our own emotional temperature. Once we do that, we can settle ourselves, maybe have a cup of tea, or walk around the practice or walk around outside for a minute or two, something that helps to reduce our emotional temperature so we can stay steady and focused, and be productive, get through our days.

The third step is something else that you heard with Susan, which is, quieting the inner critic, developing self-compassion. We learn to be very harsh with ourselves in our training. Most of us, I think, can relate to that. We criticize ourselves, we play things over and over, any slight mistake. We could have 10 things that go great, but that one thing we replay and we ruminate. We can learn to be kinder to ourselves, to remind ourselves that we're working hard, and that we're doing the best that we can.

So three steps. Getting to know the busy mind; diagnosing our own patterns. Two, building purposeful pauses into our days, kind of as a way of pacing ourselves. And three, developing the muscle of self-compassion. I've seen those three steps be incredibly helpful for many physicians.

Dr Hopkins: That's a great outline. I don't know why, but it is so hard for many of us to be kind to ourselves and show ourselves a little bit of grace. Yet, that goes a long way towards building that personal resilience.

Dr Gazelle: I think we learned these patterns of self-harshness in our training. Kind of never good enough, right? Being compared to our peers. We were always focusing on, and having ourselves focused on, where we're coming up short. We really don't learn these things. There are things that we learn in our training that make it very difficult for us to cope well, with all the difficulties that we face.

Dr Hopkins: Absolutely. Part of the importance that you point out in this, Dr Gazelle, is that it's so important to note that we recognize and identify burnout as, often, a system problem, because it is sort of built into our systems. And yet, things don't necessarily happen quickly. You and I both work for large academic medical centers. Nothing happens quickly. What do we do while we're waiting for those cultural, systemic changes to come, that are going to help with burnout mitigation? These are things that we can do that are very practical and pragmatic, to use your word, to help us not just survive our day, but to actually thrive.

As you were talking about Susan, and being kind to ourselves, it made me think about, how does imposter syndrome contribute to a lack of confidence or joy in the practice of medicine? What's the connection between imposter syndrome and burnout?

Dr Gazelle: Isn't it fascinating how many physicians walk around accusing themselves of being an imposter? My name is Gail, and I feel like an imposter at times. I'm here at Harvard Medical School, it's like the Harvard Olympics, and there's always people you can compare yourself to that have published 10 times as many articles, and have a great life outside of work, and on and on and on. We learn to make those comparisons, again, early on. We, who go into the practice of medicine, stand out because of our academic aptitude. We're good at taking tests, we're good at learning, and we love to learn. We get labeled early as being the smart one. That, unfortunately, I've seen in many of the individuals that I've coached, actually sets the stage for the imposter syndrome. It's almost like that Jimmy Cliff song, "The Harder They Come," the harder they fall.

We worry that we're going to be found out, that we're not as smart or as good as people think we are. I've heard that from so many physicians. We can also feel like an imposter because of all the comparisons that are part and parcel of our trainings. The ratings and rankings and comparisons; we're always being compared to our peers. That can also leave us feeling like, "Uh oh, what if I'm not as smart as them? What if they know something that I don't know?"

The imposter syndrome can really hound us, and of course it erodes our sense of well-being. It erodes our ability to feel good about what we are doing. It keeps us focused on something that may not be going well, even if it's something small.

What I find very interesting about the imposter phenomenon is that it's actually just a thought process. Really. It's not based on fact, it's based on subjective assessments of feedback that we're getting. We could give a talk and everybody could be smiling and engaged, but there could be one person who's looking down at their device, and we may focus on that person and think, "Ah, I'm giving a boring talk. What's wrong with me? Everybody else can give a better talk."

It's a very subjective phenomenon that really trips us up. When we begin to realize that the imposter phenomenon is actually just a thought process, we can start laughing a little at it. We can realize we're all walking around feeling like an imposter, and that we don't have to buy into this story that our mind seduces us as the truth.

I have a lot of free resources on my site and one is actually called "Imposter No More." It's a very brief guide, but I go into some of these issues that can set us up for feeling like an imposter, and, similarly, some strategies that can liberate us. Once we do liberate ourselves from feeling like an imposter, our days are lighter. We can actually be more productive because we can be more focused. Our mind isn't over here with all these accusations and judgments. Our mind can actually focus on the patient, the chart, the inbox, whatever it is that's at hand. We can live less dogged, in a sense, less kept down by these thoughts that there's something wrong or inadequate about ourselves.

Dr Hopkins: Are there any really specific examples that you have, either from your own life and practice, or from the physicians and physician leaders that you've coached, as far as techniques or methods to build that inner resilience that you'd be willing to share?

Dr Gazelle: I'm thinking about an academic leader that I coached, an unnamed individual, just a fantastic person, had risen up the ranks and become this leader. A department chair, actually. Nobody really knew how much anxiety he was living with, and how much of a sense of catastrophic thinking he suffered from. Many of us can have catastrophic thinking, right? "What if this patient dies?" Or, "What if I didn't get the right diagnosis?" Or, "Uh oh, did I get the right dose of lisinopril?" Or whatever it is.

He had a lot of thoughts of being an imposter. The good news is that he, like so many of us as physicians, loved to learn, but the lens of learning had never been on himself. The lens of learning had all been about the latest developments in his field. So, when he had had the opportunity to learn about himself, he followed some of those steps that we just talked about.

He got to know his own mental patterns. Believe me, he was shocked. We started with a simple exercise of counting your thoughts for five minutes. I don't know if you've ever done that, Kevin. It's amazing how many thoughts we have. We can have hundreds of thoughts in a five-minute period. He was shocked. He said to me, "It's kind of crazy up there, Gail. What's going on?" But once he got to know how busy his mind was, once he could spot those thoughts, he had much more ability to work with them again, like making a diagnosis. He could diagnose his own mental patterns. That in and of itself gave him much more ability to work with them.

He also started doing what I talked about around those purposeful pauses. He could take his emotional temperature when anxiety, catastrophic thinking, and imposter thinking was coming to the fore. He could take his emotional temperature, and when it was elevated, institute a purposeful pause. He learned that ability to modulate himself again, to pace himself emotionally, over the course of his busy days.

Then that third step. He was not somebody who had learned to be compassionate with himself. He had been the product of challenging training, just like all of us. He had a lot of harsh self-criticism, but there were some specific practices that he used that were very helpful to him, to build this long atrophied muscle of self-compassion. Really, what I'm saying is, that it took work. This didn't happen overnight. These are long established patterns that we have. Yet, over time, his anxiety decreased significantly. He was much more able to focus on the task at hand, rather than getting distracted by worries and what ifs and fears.

His wife told him that he was a lot more calm and that he was doing better with their teenage kids.

That's what we're talking about, these very practical steps. It's not this "woohoo" thing of resilience and mindfulness, and it's not letting a broken system off the hook. Our systems need repair. There's no question about that. And at the same time, there are steps that we can take, simple steps, that don't involve hours of extra time. We can actually incorporate them into our day, so that we can live with much more calm in our days, much more productivity, and really end our days with that sense of satisfaction, meaning, and fulfillment that we all certainly deserve to have.

Dr Hopkins: Great points for us to consider. When we think of it clinically, that's why sleep's so important. Our brain repairs itself during sleep, and the files get rearranged and all of that. I liken it to my kids. One time, I was talking about my smartphone battery dying quickly, and one of my teenagers said, "Well, let me see your phone, dad." I handed it to her, and she started closing all the apps because I had way too many apps running at the same time. She said, "Well, no wonder your battery is dying quickly." No wonder my mind is so muddled when I've got so many apps going at the same time throughout the course of a typical day.

There was research, I think out of Cornell, that the average person makes over 30 000 conscious or subconscious individual decisions throughout the course of a day. If we can reduce that by being mindful, keeping ourselves in the moment, and being intentional about how we approach that, think how we might be able to reduce our stress and build our resilience.

This has been a fascinating conversation. I've really appreciated it. Any last thoughts you'd like to share with our listeners before we wrap up today?

Dr Gazelle: The main thought, Kevin, is that there's hope. So many physicians are struggling to get through the day. So many physicians are struggling with burnout, with loss of sense of meaning and purpose. It's just important to remember that there is hope. Whatever happens in the medical system, we can develop these tools and strategies that are not that difficult to develop, that really have huge payoff for us. Not just when we're at work, but equally important, if not more important, when we're home. When we actually have that time to be the full human that we are.

I'd also just like to say, if I can be a resource to your listeners, my email is info@gailgazelle.com. Again, I have a lot of free resources on my site. I have the "Imposter Guide." I have something that I call "Charting Your Life." I have something that I call the "Daily Dose of Calm," a "14-Day Mini Mindfulness" course, and quite a few other resources. I just want to encourage your listeners, if that can be helpful to any of them, please feel free to go to my website, gailgazelle.com, and download anything that can be helpful to you.

Dr Hopkins: Dr Gail Gazelle, thank you for joining us today. It was a fascinating and enlightening conversation. Thanks for sharing your expertise. Thank you so much.

Dr Gazelle: Thank you, Kevin. It's been such a pleasure speaking with you.

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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Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.


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