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is a practice improvement initiative from the AMA designed to empower teams like yours to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment. Wherever you find your team on the practice improvement continuum, the American Medical Association can help you take the next steps – the right steps – to improve your practice. Learn more
Simple, evidence-based solutions to enhance your joy for practicing medicine and to mitigate stress
A list of resources to help you further develop resiliency
Resiliency is the ability to adapt to and bounce back from the stress of the training and/or clinical environment. Physicians who practice resiliency are better equipped to handle the many challenges presented in medical training and when providing patient care and, therefore, are less likely to experience burnout. Promoting the well-being of physicians translates to benefits for patients and the practice as a whole.
What steps can I take to enhance my resiliency?
We all know that any change in behavior is hard. There are multiple small steps that you can take to help boost your personal resiliency.
These steps range from the basics, such as ensuring adequate nutrition, sleep and exercise, to more deliberate reflective approaches, which include narrative practices, mindfulness practice, reconnection with purpose and meaning and peer group interaction.
What is resiliency?
Resiliency is the capacity to recover from difficulties, the ability to spring back into shape or the ability to withstand stress and catastrophe. Generally, resiliency improves with age as we are exposed to challenging situations and learn to solve problems. We can also deliberately enhance our resiliency by learning self-management skills and connecting with the meaning and purpose in our lives.
Reduce burnout and identify signs of burnout early
Increase compassion and empathy
Reconnect with the joy and purpose of practice
Improve physical and mental health
Less staff turnover
Reduce costs to recruit and replace burned out physicians
Increase patient satisfaction
Fewer medical errors
Improve work environment
Less need for disciplinary action
Start small. Choose one item from the steps below and spend the next 30 days checking in daily (even if only briefly) to measure your progress. If you don't feel like you're improving, be patient and reassess tomorrow. If you are making progress, give yourself a pat on the back and keep up the good work. Consider focusing on another item once the previous one is firmly in place.
Take a deep breath and get organized
Think about your practice or training from a different perspective
Think about the big picture
Find support and guidance in outside groups
Find meaning outside of work
Last but not least…don't forget to have fun
Schedule essential personal items before you schedule work items 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, consider prioritizing your activities.
Why does my state of well-being matter?
There is evidence that stressed, burned-out physicians have:
Lower patient satisfaction scores
Higher rates of malpractice suits
Higher likelihood of leaving the profession1- 3
A tendency to make more medical errors
A greater likelihood of exhibiting disruptive behavior3
Overall, physicians also have a higher risk of suicide than the general population despite similar risks of depression and anxiety.4 For male physicians, the risk of suicide is up to three times higher than for age-matched non-physician controls. For female physicians, this risk increases to five times that seen with age-matched controls.4
There is also evidence that medical students are more likely to engage in “dishonest and unprofessional behaviors” when they are feeling depressed or burned out, for example:
Reporting a lab exam as pending when they knew it wasn't ordered
Marking a finding as normal on a physical exam when they knew it was actually omitted
Considering self-prescribing anti-depressants to themselves or a spouse as acceptable behavior
What risk factors are associated with burnout?
Common risk factors for burnout include:
Number of nights on call
Having a partner who is also a physician
Having recently made a medical error
Being a mid-career practitioner
Spending less than 20 percent of time on the most meaningful aspects of your work
Moving to a new environment with little support
Begin with an initial “moral inventory.” Fearless moral inventory is a term used by Alcoholics Anonymous® that encourages you to take stock of your own role in any of the problematic areas of your life. This exercise is not intended to place blame or be used as an opportunity judge yourself but rather to examine how you may be contributing to your own stress.
With this inventory, you can begin to realize how these factors influence your happiness and well-being. Remember that personal resiliency is at the root of physician resiliency, and making the time to deal with personal issues and prioritize yourself will enable you to address workplace stressors as well.
This self-examination should focus on the role of your own emotions, thoughts or actions in perpetuating your feelings of stress or burnout. This is intended to help you find things that are within your power to change. You may choose to perform this evaluation each week, each month or on an annual basis.
For example, if you wish you had time to meditate but never seem to get around to it, examine the thoughts, emotions and actions that get in your way. You may find that sadness and feeling a lack of control (thoughts and emotions) lead to time spent surfing the internet (action) that takes up time you would otherwise use to meditate. Another example may be wishing that your child would tell you more about his/her life and finding that you spend very limited amounts of time (action) paying only partial attention (preoccupied with other thoughts) to what your child is saying, which may lead to less communication.
What are the common sources of physician and trainee stress in medical practice?
Physicians are faced with numerous stressors throughout their careers. Some are expected, such as prolonged, intense training and exposure to tragic outcomes during medical practice. Others are the result of the evolving practice environment, including implementation of electronic medical records and increasing regulatory demands. Learning resiliency gives you the tools to not only appropriately react to these stressors, but helps you develop skills to prevent them from taking a toll on your personal well-being.
Even changes in your practice that are designed to improve your quality of life can be very stressful, especially those made without your input. It is useful to bolster your individual capacity to cope to make it easier for you to adapt to any changes made on a system-wide level. Learning and utilizing some techniques to foster your own stress tolerance and hedge against burnout will prove useful during times of rapid change.
Medical training is also stressful. Medical students, residents, and fellows are frequently exposed to loss in the clinical environment, but have several stressors outside of the clinical practice as well. Grades, medical school debt, and a disorganized learning environment are often sources of stress for trainees.
What is physician burnout?
Physician burnout is defined by Shanafelt et al3 as “a syndrome encompassing three domains: depersonalization, emotional exhaustion and a sense of low personal accomplishment.”
How can I tell if I am burned-out?
A useful self-assessment is to ask yourself: “How often have these statements felt true to me in the last year?”
“I feel less enthusiastic about my work than before.” (evidence of possible emotional exhaustion)
“I have become more insensitive toward people since I took this job” or “I have become more callous over time in my current role.” (evidence of possible depersonalization)
“I can't remember why I wanted to become a doctor.” (evidence of possible loss in sense of purpose)
If your answer is “more than a few times a year” for any of these statements, you are more likely to fall into the relevant sphere of burnout in a formal assessment. The third domain of burnout, low sense of personal accomplishment, is more difficult to measure and there is no single question that can give insight into this domain.5
In you are a practicing physician, another option is to use the seven-item Physician Well Being Index developed by Dyrbye and colleagues. A score of greater than or equal to four positive answers on the Index correlates with lower mental quality of life, a lack of well-being and other markers of physician distress. The Index takes very little time to complete and the information obtained from answering the questions may be useful as a personal reference point.6 You may also consider using the validated mini-Z questionnaire on an organization-wide level to reliably measure staff burnout. Regular measurement and response to burnout should become an institutional best practice, a “vital sign” for organizations.
Start by making a list of the values you hold most dear. If you need to stimulate your thinking, sample lists of values can be easily found online. Ask what your priorities are at this stage of your life. The priorities will vary from person to person and from stage to stage in your 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.
Once you have performed this assessment and have a list of core values and priorities, look at how you spend your time, attention and money. Is there a mismatch between your list and your spending? It is sometimes useful to look at how you spend every hour in your week and how you spend your income. If you value a life of human connection, family time and time outdoors but spend your days rushing from one patient to the next, getting home too late to talk to your partner and spend all weekend indoors, there is a mismatch. Ask yourself if there are tasks you can outsource so that you have more time to focus on your values and priorities. Are there areas you would like to devote more time, attention or money to? Areas where you would like to devote fewer resources?.
What do you stand for? 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.
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 inevitable emotions stirred up by some patient contact.
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. Of course, 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. Seek legal advice if you wish to have your work read by a broader audience.
Deciding how you wish to be remembered may help spur changes in the way you currently live. An exercise described by Stephen R. Covey in his seminal work, The 7 Habits of Highly Effective People, is to imagine what a member of your family, a personal friend, a person from your work place and a person from the broader community may say about your life at your memorial service.7
Write down three 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; others prefer to do it first thing in the morning. This easy practice has been shown to increase self-reported happiness and prevent burnout.8
Physicians have extensive training in the practice of medicine but often have very little 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. Two of the most popular and reliable time management approaches are the “Getting Things Done” approach by David Allen and the FranklinCovey method. If financial management is a stressor, make an appointment to meet with a local financial advisor.
Having a spiritual practice appears to be protective against burnout. Spiritual practices are not always a formal religious practice. For example, you may find that regular time alone in nature serves this purpose.
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: Balint groups, mind-body medicine groups or faculty training, Finding Meaning in Medicinegroups and Parker Palmer courage and renewal groups. If none of the groups listed here are available in your area consider attending training to start your own.
Healthcare providers are frequently exposed to extremely unsettling events (such as the death of a child) and may be involved in adverse outcomes. To help providers cope with these situations, Dr. Jo Shapiro of Brigham and Women's Hospital in Boston initiated a peer support program for her colleagues. This program consists of a group of physicians trained to provide a sympathetic ear to their distressed colleagues.
In the event of an adverse outcome or medical error, peers in the Brigham and Women's Hospital group are available to lend support and direct colleagues to additional resources. This program has helped to transform the culture of secrecy and shame associated with adverse outcomes and provides resources to affected physicians. Other institutions, such as The University of Washington School of Medicine and University of Virginia Health System, have also recognized the value of peer support and are creating their own programs. Some major insurers, such as Physicians Insurance, are also developing similar programs to give litigation support.
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 among this group.
If you are a medical student or 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 resiliency and foster professionalism among medical students.
Where in the healthcare ecosystem should burnout be addressed?
Burnout can be addressed at multiple levels:
Individual (addressed in this module)
Microsystem (e.g., the office practice, which is addressed in several STEPS Forward™ modules on various aspects of workflow and teamwork)
Mesosystem (e.g., the organization or institution)
Macrosystem (e.g., the health care system, which is addressed through policy, regulation, research and technology)
The AMA is working at all four of these levels. This toolkit is focused primarily at the individual level. To learn more about burnout, see the STEPS Forward™ physician burnout module.
Are you one of the many physicians, trainees, or medical students who do not have their own primary care doctor? If you are concerned about your physical health, find or 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.
Your institution 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.
Although it seems 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.
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 therefore less engaging. Consider quenching your thirst by signing up to learn something new. This does not have to be medicine- or career-related.
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 is eight weeks long for approximately two hours per week. There are now offshoots for specific issues, such as eating disorders, relapse prevention for substance use, management of recurrent depression, etc. There is growing literature that mindfulness-based approaches are very useful in mitigating the stress experienced by healthcare providers.9- 11 In fact, some institutions now have courses specifically for healthcare providers. Both the University of Massachusetts and the University of California, Los Angeles have well-respected mindfulness training programs.
It is healthy and important to find time for regular exercise. However, some specific forms of exercise, such as yoga, tai chi and Qi gong, foster a strong mind-body connection.
Whether you are passionate about gardening, dancing, watching reality TV or traveling, remember to schedule (and keep) time to enjoy yourself.
“Lead by example — avoid physician burnout and take a proactive approach to your own wellness. #STEPSforward”
When you are focused 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 resiliency will help you have a longer, more satisfying career and reduce your risk of burnout. Improving your personal resiliency may also have a positive impact on your team, your family, and all the patients with whom you interact.
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Target Audience: This activity is designed to meet the educational needs of practicing physicians.
Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork and quality improvement.
Rita LePard, AMA CME Program Committee
Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA
Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA
Claudia Finkelstein, MDCM, Director of Faculty Wellness Programs, University of Washington School of Medicine
Claudia Finkelstein, MDCM, Director of Faculty Wellness Programs, University of Washington School of Medicine; Kathi J. Kemper, MD, MPH, Professor of Pediatrics and Director of the Center for Integrative Health and Wellness, The Ohio State University; Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA; Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA; Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.
Disclosure Statement: The content of this activity does not relate to any product of a commercial interest as defined by the ACGME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.
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