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Physician Well-BeingProtect Against Burnout and Encourage Self-Care

Learning Objectives:
1. Describe a framework for understanding the role of individual and system level factors related to burnout
2. Review simple, evidence-based solutions to enhance your individual resilience and to mitigate stress while practicing medicine
3. Identify action steps, tools, and resources to help you to further improve well-being
0.5 Credit CME
How will this module help me?

  1. Describe the impact of well-being and burnout at both individual and system level

  2. Implement strategies to promote individual well-being and resilience

Introduction: What Do We Mean by Well-Being and Resilience?

Although there is no unifying definition of well-being, most models of well-being include multiple spheres such as physical, emotional, and financial states as well as roles, skills, and work environment.

Well-being also includes personal resilience. Physicians actively pursuing their own resilience may be better equipped to handle the many challenges presented in a medical career. As such, they are often less likely to experience burnout, and physicians who are not burned out make fewer errors, are sued less often, and receive higher patient satisfaction scores.13 To learn more about burnout, refer to the STEPS Forward™ physician burnout module.

Where should burnout be addressed in the health care ecosystem?

Quiz Ref IDBurnout can be addressed at multiple levels:

  • Individual (covered in this module)

  • Microsystem (eg, the office practice, which is addressed in other STEPS Forward™ modules on various aspects of workflow and teamwork)

  • Mesosystem (eg, the organization or institution)

  • Macrosystem (eg, the health care system, which is addressed through policy, regulation, research, and technology)

The AMA is working to improve physician well-being on all levels; however, the focus of this module is on bolstering individual resilience, while understanding that this alone will not be a complete solution to the issue of burnout. Programs that promote individual resilience do not replace efforts to improve system-level drivers of burnout, as illustrated in the model of professional fulfilment in medical practice developed at Stanford (Figure 1).

The Stanford WellMD Model
Adapted from the Stanford WellMD Model with permission; the Stanford WellMD model remains property of Stanford University. This modified version of the model is not sponsored by Stanford but is considered a derivative of the Stanford Model. Accordingly, requests to use or further modify the derivative work require permission of Stanford University.
What steps can I take to enhance my well-being?

Start by recognizing that your well-being and resilience matter. They matter not only for you on a personal level, but for the well-being and care of your patients, families, and colleagues. Also, recognize that although there are system-level culprits that affect your well-being, there are still things you can control. By working on the things you can control you may become more able to engage in or advocate for system-level change.

There are multiple small steps that you can take to help boost your personal well-being. The steps range from the basics of attending to your own physical health (such as ensuring adequate nutrition, sleep, and exercise) to more deliberate cultivation of emotional health. Creating a life in which you appear on your own calendar requires organization and prioritization.

Seven STEPS to Promoting Individual Well-Being and Resilience

Start by taking a comprehensive inventory of personal needs. Then choose an item from STEPS 2 through 7 below and spend 30 days checking in daily to measure your progress. Logging progress will help keep you accountable to yourself.

  1. Get Organized

  2. Think About Your Physical State

  3. Think About Your Mental State

  4. Connect Socially

  5. Find Meaning In and Outside of Work

  6. Embrace Joy

  7. Reflect and Refine

STEP 1: Get Organized

By focusing on your well-being, you acknowledge that you are looking for solutions. Start with a deep breath to diminish any anxiety of beginning this journey. Some anxiety may arise from a sense of being overwhelmed at the enormity of the “to-do” list. Other anxiety may arise from fear of missing something vital.

Begin with a simple exercise to get organized. The purpose of this exercise is to free your working brainpower by unloading all the tasks that your brain is trying to hold on to. Once all the to-dos are down on paper, you can decide what your priorities are. To perform this exercise, carve out an hour or two to write your to-do list out on paper. Remember to include maintenance (for example, keeping up certification with CME) along with personal and professional items.

Once the list is out you can decide what to do about each item using the system described by David Allen in his book Getting Things Done: The Art of Stress-Free Productivity.4 Place each item into 1 of 4 categories:

  • Do: add it to your calendar

  • Defer: add a reminder on your calendar to think about it again at a later date

  • Delegate

  • Delete

Prioritize

Once you create your list you can begin to prioritize. No doubt the priorities will be shaped by your values, roles, and obligations. It is useful to list the essential roles in your life (eg, doctor, parent, friend, citizen, self, etc.). This list of roles should always include “self” to ensure that keeping yourself tuned up remains on your schedule. Priorities will vary from person to person and from stage to stage in your life and career. For instance, at one point in your life the number one priority may be to get promoted, and at another point, it may be to be the best parent possible. This is why this exercise is worth repeating regularly.

Manage your time and finances

Physicians have extensive training in the practice of medicine but may have minimal training in managing their own time and finances. It may be worth a course or a consultation with a reliable expert to help hone your skills in these areas. If financial management is a stressor make an appointment to meet with a local financial advisor.

Put yourself on your own schedule

Schedule essential personal responsibilities as well as work obligations on your calendar. Your personal schedule may include the number of hours of sleep that are ideal for you, frequency and duration of exercise that you would like to get, downtime strictly for recreation, alone time, and time for attention to nutrition. If you cannot do everything on your schedule, revisit your priorities.

STEP 2: Think About Your Physical State

The culture of medicine has been one of bravado and self-neglect. This combined with the rigors of training led to delayed attention to the effects of lack of sleep, nutrition, and hydration on the performance of (and mental state) of physicians.

Sleep

Although the nuances of the effects of sleep on specific facets of cognitive performance are not fully understood, there is consensus that attention, alertness, and vigilance are adversely affected by sleep deprivation. The effects of sleep deprivation on higher level cognition, such as executive function, are less well characterized; executive function appears to be affected by emotional state. Night shifts, 24-hour shifts, and switching from night to day work each come with attendant effects on sleep. Therefore, organizations have attempted to help trainees overcome this with work hour restrictions. In practice, getting enough sleep will involve effort and tradeoffs. Begin by acknowledging the importance of sleep to help you decide to schedule bedtime so that you can function optimally.

Quiz Ref IDPhysical activity

Once again, existing evidence points to the numerous benefits of aerobic activity. These benefits range from cardiovascular and metabolic effects to preservation of cognitive ability (greater than the effects of existing dementia medications in some studies).5,6 Even a single bout of acute intense physical activity can impact mood regulation.6 Given this, it is incumbent upon us to find a way and time to engage in aerobic physical activity. Advocating for subsidized gym memberships, or ideally an exercise room on site, are possible solutions. Getting exercise on your calendar will also help you be accountable to yourself.

It is healthy and important to find time for regular aerobic exercise. However, other forms of exercise, such as yoga, tai chi, and qigong foster a strong mind-body connection and are also worth incorporating.

Preventive care

Many physicians do not have a primary care physician. Although this trend is changing, there has been a pattern of self-reliance with self-diagnosis and self-prescribing. In the spirit of “keeping your instrument tuned” it is important to take care of yourself and seek preventative care to manage your blood pressure, glycemic control, etc. It is also important to check in with your physician about alcohol use patterns, smoking, weight control, etc. in an effort to build healthy patterns.

STEP 3: Think About Your Mental State

In addition to the emotional work of connecting in many high intensity encounters per day, there is the cognitive load of attending to numerous guidelines and regulations as well as the administrative load of inbox and chart maintenance. It can be easy to lose connection with the purpose of our work. Connecting back to values and meaning can help protect against burnout as can having a safe outlet to process your emotions.

Connect with values: write your individual mission statement

What do you stand for? What are your core values? Write it down. Each time you are considering doing something, ask yourself whether this action is consistent with your mission statement. This may help you decide whether to agree to do it or not. Many CEOs write their own personal mission statements to guide their decisions, which can be a helpful strategy. There are many online tools to help you to get started.

Connect with meaning: write down inspiring patient stories

Regardless of whether you use a formal or personal approach, writing patient stories as narratives rather than for the medical record is a powerful way to connect with emotions stirred up by patient interaction and with the meaning in what you do.

There are formal programs in narrative medicine, such as the one at Columbia University Medical Center. You may find it beneficial to write alone or with a group of peers. Patients should never be named, nor should their stories be identifiable. Do not publish these stories in any form (such as in a magazine or on a blog) without explicit written consent from the patient. This exercise is primarily for your benefit; seek legal advice if you wish to have your work read by a broader audience.

Connect with emotions: take stock of your desires, feelings, and actions

Begin with self-awareness. Often, the attitudes and beliefs that make you an excellent physician adversely affect your happiness if taken to extremes. Perfectionism, a high sense of personal responsibility, and ability to delay gratification are well practiced skills that can serve you and your patients well but may wreak havoc in your personal life. Expecting to be in charge and expecting perfection from others is rarely effective at home. It is worthwhile to understand your own coping strategies and personality traits in order to recognize how they impact your effectiveness and well-being.

Sometimes, an objective outside perspective may be useful to help you to see these traits. Many physicians find that turning to peer supporters, coaches, or therapists to supplement self-assessment tools is useful. There are also practices such as mindfulness, mindful self-compassion, and gratitude that can help. Adding actionable steps towards mastering healthy coping strategies to your calendar and keeping track of your progress are great starting points.

You may choose to perform weekly, monthly, and annual self-evaluation of progress towards your goals and then to ask yourself questions.

For example, if your goal is to meditate but you never seem to get around to it, examine the thoughts, emotions, and actions that get in your way. You may find that sadness or feeling a lack of control lead to time spent on the internet which takes up the time you could otherwise use to meditate. Another example may be the goal of being more involved in the lives of your loved ones, but you find that you spend limited amounts of time with them and are often preoccupied with other thoughts, paying only partial attention to what they are saying resulting in less meaningful communication. This self-evaluation is in service of making progress towards your goals, not self-recrimination.

STEP 4: Connect Socially

Consider a support or supportive group

Many types of group interaction can be beneficial in reducing stress, restoring emotional well-being, and preventing burnout. The general idea is for a group of peers to speak together about the stresses and pleasures of their work. These groups may be peer-led or moderated by a trained facilitator. Examples of groups you may consider include: The American Balint Society, The Center for Mind-Body Medicine, The Institute for Integrative Health Faculty Training in Mind-Body Medicine, and a variety of programs offered by the Center for Courage & Renewal. If none of these groups are available in your area, consider attending training to start your own.

Enlist your peers to provide support

Health care practitioners are frequently exposed to extremely unsettling events, such as the death of a child, and may be involved in adverse outcomes.

To help physicians cope with these situations, Jo Shapiro, MD, of Brigham and Women's Hospital in Boston, initiated a peer support program for her colleagues.7 This model in use at the Center for Professionalism and Peer Support has now been adopted in many medical centers and has helped to transform the culture of secrecy and shame associated with adverse outcomes. In addition to a colleague lending an ear, they often provide resources to affected physicians. Numerous hospitals, health systems, and physician groups have also created litigation support and error disclosure coaching programs.

The Collaborative for Healing and Renewal in Medicine (CHARM) is dedicated to addressing burnout in medical trainees by gathering best practices, promoting investigation of the impact of learner burnout, developing tools for educators to address learners in distress, and advocating for recognition and inclusion of initiatives that foster well-being in this group.

If you are a medical student or are training medical students, consider looking into The Healer's Art program. This program offers curriculum for medical students that focuses on strengthening students' personal values, calling, and service intention. It uses tested principles of adult education, contemplative studies, psychology, formation education, poetry, art, and personal narrative to increase awareness of personal values, increase resilience, and foster professionalism among medical students.

Seek professional help

Are you one of the many physicians or trainees who do not have their own primary care doctor? If you are concerned about your physical health, find and check in with a primary care doctor. For emotional support and help determining whether any serious mental health issues are present, consider a counselor such as a social worker, psychologist, or psychiatrist.

Some health systems have mental health practitioners who specifically manage health care team members. They are discrete and skilled in the specific challenges that physicians encounter.

Connect with local resources

Your organization may have a student or employee assistance program that provides free counseling and referrals. You may also explore wellness offerings from your county or state medical society. In addition, most states have a physician health program (PHP). In some states, the PHP is small and primarily handles substance abuse or disruptive behavior by physicians. In other states, offerings include wellness activities such as sponsored mindfulness training.

STEP 5: Find Meaning In and Outside of Work

Having a broad perspective of life both within and beyond the medical profession can help buffer the daily challenges of caring for patients.

Consider the legacy you want to leave behind

Deciding how you wish to be remembered may help spur changes in the way you currently live. Imagine what a member of your family, a friend, or a coworker might say about you if you move away or at your retirement party.11

Start a gratitude journal

Write down 3 items that you are grateful for each day. Examples include seeing the sunrise, a warm smile from a patient, etc. Nothing is too simple for this exercise. Some people like to do this immediately before going to sleep at night while others prefer to do it first thing in the morning. This easy practice has been shown to increase self-reported happiness and prevent burnout.11,12

Volunteer

Although it may seem counterintuitive to add more to your packed schedule, people who donate their time and expertise in volunteer service often find it easier to attain personal happiness.

Learn something new

In general, people who choose a career in medicine have a thirst for knowledge and intrinsic curiosity. After many years in practice, the problems that were initially challenging may become routine and less engaging. Consider quenching your thirst by signing up to learn something new. This does not have to be medicine-related or career-related.

Develop your spiritual practice

Having a spiritual practice appears to be protective against burnout.13 Spiritual practices are not necessarily a formal religious practice. For example, you may find that regular time alone in nature serves this purpose.

Take a mindfulness class

Mindfulness-based stress reduction, or MBSR, is a program developed in 1979 by Jon Kabat-Zinn at the University of Massachusetts Medical School. This secular program is based on meditation, self- and body-awareness, and communication skills. Initially used by patients with chronic diseases and chronic pain, the applications of this program continue to grow. The basic program lasts 8 weeks for approximately 2 hours per week. There are now offshoots for specific issues, such as eating disorders, relapse prevention for substance use, and management of recurrent depression. There is growing literature that mindfulness-based approaches are very useful in mitigating the stress experienced by health care practitioners.14,15 In fact, some institutions now have mindfulness courses specifically for health care practitioners.

STEP 6: Embrace Joy!

Whether you are passionate about gardening, dancing, watching TV, or traveling, remember to schedule (and keep) time to enjoy those activities that make you happy. Think about when you last had a vacation, a good laugh, or experienced awe. Think about the circumstances under which you experience joy and reproduce them. It may help you to think of this as an act of service to those you care for rather than solely as a self-serving act.

STEP 7: Reflect and Refine

Each week, take some time to look back and plan ahead. Examine what worked and what didn't work, what got done and what didn't get done. Then ask yourself why. Did you make an unrealistic schedule? Did you forget any of the commitments you made to yourself? Again, this questioning is in service of self-awareness, not blame or shame.

Remember your stated values and compare them to how you spent your time

Review your list of the roles, values, and priorities remembering that these will vary from person to person and from stage to stage in your life and career.

Once you perform this review, look at how you spent your time, attention, and money. It is sometimes useful to look at how you spend every hour in your week and how you spend your income. Is there a mismatch between your list of values and your behaviors? For example, there is a mismatch if you value a life of human connection, family time, and time outdoors, but spend your days rushing from one patient to the next, get home too late to connect with your partner, or spend all weekend indoors. Ask yourself if you can delegate tasks so that you have more time to focus on your values and priorities. Are there areas where you would like to devote more time, attention, or money? Are there areas where you would like to devote fewer resources?

Make the next week's schedule with these things in mind and keep your own quality improvement project going by reviewing and refining your schedule week by week.

Conclusion

When you focus on managing the stress of relentless change, it is easy to lose sight of the joy, meaning, and purpose of your profession. Taking small steps devoted to improving your own well-being may help you have a longer, more satisfying career, and reduce your risk of burnout. Improving your personal well-being may also have a positive impact on your team, your family, and the patients under your care.

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STEPS Forward™ presents actionable, practical toolkits and customizable resources that you can use to successfully implement meaningful and transformative change in your practice or organization. See How it Works

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

Renewal Dates: February 22, 2016; May 23, 2019; May 22, 2020

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