Fig. 14.1
% Positive responses over time by MSWBI question (composite of all classes). Percentage (vertical axis) of positive (“yes”) responses to each MSWBI question for all students grouped by collection period (horizontal axis). Question 1 measures emotional exhaustion (EE), question 2—depersonalization (DP), question 3—depression (DEP), question 4—fatigue (FT), question 5—sense of feeling overwhelmed (OVRW), question 6—anxiety (ANX), and question 7—major stress-related health impairments (HEALTH)
Fig. 14.2
% At risk (3 positive responses) and burnout (≥4 positive responses) over time (composite of all classes). Percentage of students (for each collection period) who are “burned out” or “approaching burnout” and consequently “at risk” for serious burnout-related consequences (health impairments, dropping out of school, suicidal ideation, etc.). “At risk” defined as 3 positive response to MSWBI questions on an individual survey and burnout defined as ≥4 positive answers to MSWBI questions. Proportions for burnout were calculated as total number of yes responses out of seven on a given survey rather than using question-specific parameters
Our findings indicated that except for anxiety (approximately 30 % of students at orientation report feeling anxious), students begin medical school with a low level of other distress elements. However, by the time they have been in school for only a couple of months, we begin recording increasing levels of depression, depersonalization , and a sense of feeling overwhelmed. What is particularly notable about the data on our students is the periodic effect of life events on their well-being. Although most distress elements seem to diminish during breaks and then increase during times of stress —such as around the time of preparation for the ABMLE step exams (1 > 2)—depersonalization (question # 2 in Fig. 14.1) does not diminish and continues to increase throughout medical education. This suggests that once depersonalized, students remain depersonalized, although anxiety, depression, and a feeling of being overwhelmed may vary depending on other life events. By the time the students reach their fourth year, almost half (44 %) are depersonalized. As a whole, males are also more likely than females to feel depersonalized (26 % vs. 21 %; z value = 2.72) and less likely to feel depressed (22 % vs. 34 %; z-value = 5.2), overwhelmed (24 % vs. 35 %; z-value = 4.9), or anxious (37 % vs. 58 %; z-value 8.6) as they proceed through medical school. In addition, Caucasian (nonminority) students are less likely than non-Caucasian (minority) students to become depersonalized (23 % vs. 29 %; z value = 2.2), and are less likely to feel depressed (27 % vs. 36 %; z-value 2.89) or overwhelmed (28 % vs. 34 %; z-value 2.2) as they proceed through medical school.
Depersonalization invites more than lack of empathy. Depersonalization can contribute to lack of conscience (with implications for professional integrity), lack of the ability to perform self-reflection (a critical quality for leadership and creating emotionally intelligent relationships), lack of imagination, energy, intuition, and moral imperative. This can lead to problems in building trust, working effectively with others, being skillful in action, and in managing moods and emotions—all qualities essential for safe and effective healthcare delivery. In a study of burnout and medical errors among American surgeons, Shanafelt et al. [7] found that whereas a one-point increase in emotional exhaustion resulted in a 5 % increase in the likelihood of reporting a medical error, a one-point increase in depersonalization resulted in an 11 % increase of reporting a medical error. There is ample evidence that feelings of depersonalization are associated with the risk of non-empathic and morally suspect behaviors, as well as with physical, emotional, and mental problems [33, 34].
Students who provide ≥4 positive answers to the questions in the MSWBI meet the criteria for burnout as described in the literature. Previous studies have suggested that once someone has provided a score of 4 or more positive answers, they are also at risk (“15-fold compared to students with no distress conditions”) [23] for serious thoughts of dropping out of medical school [23, 35], having suicidal ideation [23, 25, 27, 28, 36], poor mental quality of life [35], or high fatigue [26, 33]. In our study, we also considered students with at least three positive answers to be an “at-risk” group for burnout. Using this definition, almost half (46 %—combining those students who are either “burned out” or “at risk for burnout”) of our students seem to be at risk for major negative life events by the time they begin their fourth year of school (Fig. 14.2).
The implications of this study are evident. Medical school literally makes people sick. They don’t come in sick, but by the time they near completion of their studies they have experienced progressive emotional exhaustion , depersonalization, depression , anxiety , irritability, and a sense of being overwhelmed. One out of ten students report that they have developed stress-related impairments to their health—a problem that is virtually absent when they begin school. Burnout and distress have a negative impact on quality of life, and both appear and increase inexorably throughout medical school.
These are new, but not surprising data, which indicate that the conditions that result in burnout and distress occur prior to becoming a doctor, and therefore we believe that they should be urgently addressed during medical training, across the entire spectrum of healthcare. Einstein once famously stated “you can’t solve a problem with the same minds that created it.” We would add that you can’t solve a problem that you can’t/won’t acknowledge. Unfortunately, it has been our experience that when the very medical leaders who can influence change are presented with these data, they either diminish or normalize the importance of the information, or claim that this is simply pervasive and not something they can change, (perhaps due to their own depersonalization and burnout ?) In the early 2000s the ACGME (Accreditation Council for Graduate Medical Education ) initiated the Outcomes Project that introduced the requirement that physicians become competent in a variety of areas beyond medical knowledge and patient care—ironically this was implemented as a method to cultivate patient-centered care, reduce medical error, and move healthcare towards a system that was “safe, equitable, efficient, timely, and equitable” [37, 38]. These competencies , as they were termed, included professionalism which required that residents demonstrate “responsiveness to patient needs that supersedes self interest” [39]. This is the conundrum to which healthcare providers are held accountable. How can they take care of themselves when there is always a sick patient in need of attention that would supersede one’s own needs? Of course the patient should always “come first.” And we would remind you, “so should you.” In the remainder of this chapter, we will suggest ways that this can be possible.
Wellness
If our current medical culture promotes burnout and distress , then it becomes incumbent upon each of us to take back control of our lives and create for ourselves a personal culture of wellness. Wellness entails much more than the absence of burnout. That would be like defining health as the absence of disease [39]. Wellness embodies energy and vitality. Wellness embraces joy and playfulness . Wellness promotes resilience , learning, self-compassion, creativity, and relationship. Wellness requires a healthy mind, body, and heart—and the behaviors consistent with those. Wellness encompasses all the important aspects of our lives and exists in numerous dimensions, including mental, physical, emotional, spiritual, and relational. This section will discuss basic tenets of wellness and suggest ways that might help you better manage the demands of your professional life [40].
Medical centers, hospitals, and practices have become increasingly aware of the challenges their healthcare workers face, and this has led to increased efforts to prevent burnout. Some programs have instituted wellness programs [39], including coaching, opportunities for encouraging and promoting physical exercise (the Cleveland Clinic provides pedometers to all employees and encourages them to take 10,000 steps/day—a virtual impossibility for surgeons who stand in one place for extended periods of time), stress management training, and other support systems [39, 41, 42]. Many medical centers are changing their cafeterias to environments dedicated to healthier eating with more transparent nutritional information and some have gone so far as to remove unhealthy items (such as fried foods or foods with high sugar content) entirely from their campus. Others have suggested that wellness become a quality indicator against which to measure the successfulness of our organizations [43]. Despite these efforts, a human dilemma continues to plague healthcare professionals when they are asked (either directly or indirectly) to strictly adhere to the belief that professionalism requires placing the patients’ needs above one’s own needs—creating the unintended consequence of perpetuating a culture of self-denial (food, rest, basic hygiene, self-care) leading to burnout, depression, depersonalization, and unresolved stress with resultant manifestations for our health and even for our survival. The reality is that we are not “limitless resources” [44]. This dilemma summons the challenge of crafting systems of abundance and inclusion that allow for both care of patients and caring for the caretakers—ourselves. In recent years, this has spawned a preponderance of literature addressing concepts of work–life balance —a curious term since it invites us to think that there might be a magical and static formula that will protect both us and our careers from unraveling into a loosely recognizable jumble of our dreams and hopes.
Work–life balance is not possible. There is no formula that will create a balanced life that fits for all of us. Life is challenging, sometimes messy, and potentially invigorating.
Decisions about managing the demands of work and life require choice [14, 40]. How we understand and manage our process for making choices contributes to our ability to be “well.” In the sections below, we provide an overview of some important research that relate to creating a life of intra- and interpersonal wellness. We then offer a few suggestions that may help you begin this journey.
Research Behind Wellness
Flexibility and Congruence: Choice becomes more consistent with wellness (our physical, mental, emotional, spiritual, and relational wellness) when it remains connected to our values. We described this in an article we published several years ago, and we have reproduced part of that article below [40]:
We were once asked to give a talk to a large group of surgeons on how to create a balanced life. We followed an expert in time management. His talk comprised an informative sequence of slides that provided advice on how to be organized and efficient from the time you got up in the morning until you went to bed at night. The audience was busy writing notes on every bulleted point. So were we. Here was a lecture full of useful information. We would never again have an excuse for failing to get our tasks done. And we would be able to expect the same efficiency from others. What a wonderful prescription for success. With the audience now fully cognizant of how much more productive we could all be, we began our talk with a story about time management as we see it. If you take a large jar and fill it with some big river rocks, is it full? “Of course not,” replied this now well-attuned audience. All right then, what if we then took scoops of pebbles and poured them into the jar to fill those spaces between the rocks. Is the jar full? “No,” replied the audience. There is still space. So, what if we then sifted in a bunch of sand and gently shook the jar to make certain it invaded whatever space is left. Is it full? “No.” Apparently the previous speaker had made quite an impression. Well, what if we now fill the jar with water. Is it full? “Yes,” sighed the audience. “We believe you have now filled the jar.” So, we asked, what is the point of all this. Our time management guru, who was still in the audience, blurted out the obvious: “Just what I was mentioning. You can get a lot more into your day than you imagine.” Well, we replied, that would seem to be the case. We offer another thought that we would like you to consider: If you don’t get those big rocks in first, you’ll never get them in later. Those big rocks are the secret for being intentional. They are the core elements of your life. If you lose touch with them, you will lose your foothold on the foundation that can support and balance your life.
Achieving balance in professional life has been a hot topic in the past few years at many medical meetings. We are frequently asked to speak about this, and we are often in the audience as others give their views on the subject. Balance, contrary to the opinions of some, is not about creating equal parts of work and time with the family. Balance is about choice. “Who are you and what do you want?” These seem like such simple questions, but many of us go our entire life and never answer either. The numbing and insatiable addiction to the external validation that comes from performance recognition can have us lose sight of ourselves. Begin to believe that you are defined by your performance, and at some point in your life, you may, having travelled far from who you are and the dreams that you held for yourself, become focused solely on the performance required for the next award. It’s as if you set out to be some thing, and you forgot how to be some one.
There is a classic scene in the movie City Slickers, with Billy Crystal and Jack Palance. Palance plays the part of Curly, a wizened cowboy who takes middle-aged business men on cattle drives to help them get away from the crises of their lives. Billy Crystal (Mitch) is struggling with how to handle numerous stresses in his life and he is riding alongside Curly when he gets a famous dose of Curly’s wisdom.
Curly: “Mitch, How old are you? 38?”
Mitch: “39.”
Curly: “Yeah, you all come up here about the same age. Same problems. Spend about 50 weeks a year getting knots in your rope and then you think 2 weeks up here will untie them for you. None of you get it. (Pause. They stop riding and just look at each other. CURLY continues). You know what the secret of life is?”
Mitch: “No. What?”
Curly: “This.” (He holds up his index finger.)
Mitch: (Trying to be funny, and dismissive of his feelings) “Your finger?”
Curly: “One thing. Just one thing. You stick to that, everything else don’t mean s**t.”
Mitch: “That’s great, but what’s the one thing?”
Curly: “That’s what you gotta figure out.”
That “one thing” might be to figure out your big rocks, those things that give your life a meaningfulness that you feel somewhere in the middle of you. And make choices with them in mind.
Articles by us, and others, have described the dynamic and often competing energy between the needs (hopes, wishes, demands) of ourselves (our own deep wants that we have frequently been taught to suppress as irrelevant), others (with whom we are in relationship—either at home or at work), and our context (the current situation, environment, professional expectation, etc.) [14, 45–47]. This ability to be aware of the needs of self, other, and context and then to be able to manage these needs forms the basis for emotional intelligence and many other important leadership and life management strategies [48–53]. In order to become skillful in this practice, it is critical to develop unflinching self-awareness, empathic openness to others, and an ability to be curious, open, and able to accept without judgment, but rather with the ability to simply love what is present (COAL) [54–56]. Physicians are acculturated to “know” answers which leads them typically to judge (triage, evaluate, interrogate or criticize) and to take action (cure, treat, offer expert advice, or fix something) much more than they are taught to be curious (to “not know”) and simply notice, or explore to understand by asking (without interrogating and by exposing the vulnerability of a “beginner’s mind”) [57–59].
Developing a sense of self is perhaps the most challenging skill for a physician and yet without developing this, wellness is elusive. We are not talking here about the “aggrandized sense of self” that is often wrapped up in the protected cocoon of grandiosity from our acclaim or achievements, but rather the genuine sense of self that sees and accepts all of our self-aspects including our limitations, mistakes, and longings without shame and with compassion and love [60, 61]. It’s that part of us that may keep us awake at three in the morning wondering how our life took the path we now find ourselves on. That sense of self is authentic and it needs to be listened to [62]. It is through attuning to your own voice that you will be able to find and stay on your path to wellness.
Our most current thinking about work and life is what we term, Work Life Flexibility and Adaptability, and is illuminated in a story we published many years ago (when the field around us still tried to encourage the concept of balance) and we were struggling with better ways to teach skills for achieving something that looks like balance but that feels much more congruent with honoring the needs of self, other, and context [14]. Congruent decision making invites and encourages us to stay present and attuned as we explore and hold in regard the complexity of competing and divergent needs. The consequences of ignoring this information, or suppressing it as irrelevant, enhance the likelihood of living with continually unmet needs which is a major contributing factor to burnout and distress [45–47, 58, 63, 64]. When we achieve a sense of congruence, our choices invite us to have greater compassion for the difficulty of what we do. This story (and others) [14, 40] has helped numerous colleagues understand the competing variables that must all be valued and honored in order to make choices that remain connected to the delicate essence of our lives—choices that respond to what is happening in the now, and that don’t get stuck repeating tired patterns that may not serve us well any longer.
In an address to the International Conference on Communication in Healthcare [44], Charles Hatem suggests that attentiveness to wellness can lead to renewal. Renewal is a hopeful term; and that is appropriate because hope is a key ingredient for change. Renewal invites us to return to our self, which can be daunting to healthcare workers who have been taught to ignore their own needs. This invitation to return to our self brings to mind the prophetic words of T.S. Elliot:
We shall not cease from exploration,
And the end of all our exploring
Will be to arrive
Where we started
And know the place for the first time.
Often referred to as the poet laureate for corporate America, David Whyte once wrote [65]:
In effect, if we can see the path ahead laid out for us,
There is a good chance it is not our path;
It is probably someone else’s we have substituted for our own.
Our own path must be deciphered every step of the way.
In healthcare, we have been taught to pay attention to the needs of others and to the demands of the context, but returning to the sanctity of the self is an important theme in the “hero’s journey” that many professionals complete during the course of their career [62]. It is a journey of spiritual awakening among physicians, and it is the journey that leads to wellness. In this sense, spirituality is defined as the reality of our commitment to a larger set of transcendent values as a framework for what we do, and properly acknowledged and incorporated, this becomes a key part of the front-wheel drive in our lives [44, 62, 66].
Integration and the Window of Tolerance
In our work with numerous professionals, including many in highly stressful healthcare endeavors, a common theme we have observed among those who are in distress or who are burned out has been lack of integration. We view integration as an essential skill for achieving wellness.
Integration is the ability to link differentiated parts into a whole that is flexible, adaptive, coherent, energized, and stable (FACES) [56, 58]. You might want to imagine integration as a river (as portrayed so elegantly by Dan Siegel) [56]. The river (which symbolizes your life) is constantly flowing past two banks. On the left bank is rigidity and on the right bank is chaos—neither is an integrated or desirable bank to rest on. In order to stay in the river (of integration), one must avoid becoming overly differentiated (not allowing the feelings, opinions, or information from others to influence us)—which leads to chaos (imagine if your family or team was comprised of people who were totally differentiated and unable to take any influence from (link to) each other—theirs was the only opinion or knowledge that counted—it would be chaos). On the other bank is rigidity, which is the result of too much linkage—where people “fuse” in their beliefs (such as creating protocols and policies that apply to all and from which there is no room for differentiation). In our healthcare culture, we have been encouraged to link to the point of rigidity and deviation (including introduction of wellness programs) is considered irrelevant, at best; and disruptive at worst. When that culture becomes pervasive, we have become grounded on a riverbank and are no longer able to value differentiated parts. FACES reminds us that to stay in the river, we need to adopt the seemingly paradoxical ability to be flexible yet stable [58]. To do this requires we (1) adapt to what is happening now (within (self), among (others), and between (context)) and treat that information with coherence (harmonious connection of equally valuable parts) while appreciating the energy available to us with this awareness. These skills empower us to consider emerging possibilities and free us to make choices that remain stable (connected to our values and goals) while allowing infinite flexibility (potential for creativity and non-automaticity).
If the river of integration symbolizes our journey through life, obstacles that float towards us create challenges to which we have a variety of responses. On some occasions those challenges become intolerable and we react. One way of reacting is to fight (akin to throwing an instrument, or yelling at someone) or flee (we simply leave—perhaps saying who needs to put up with this anymore, I deserve better). Another way that we react to a challenge, when it becomes intolerable, is we freeze or collapse (simply disengage or shutdown). This would be similar to avoiding a conflict or even deciding to quit a job—get a divorce. Each of us has a window of tolerance that we can notice. Our window of tolerance may be big for some people or circumstances, and very small for other people or circumstances. When we get outside our window of tolerance (as manifested by fight, flee, freeze, or withdraw), it is an opportunity to learn and be curious (remember COAL). We insert this to remind you of the advice from Hokusai (see beginning quotes) because the path to wellness doesn’t require perfection; it only requires presence, including that you simply notice. Life, living through you, restores the ability to notice, and use that awareness to treat yourself as one of your own best friends.
Mechanical vs. Complex Adaptive Systems
As mentioned in the earlier section on burnout and distress, our cultural demand for perfectionism and our resultant shame when we can’t achieve that impossible goal are factors that contribute to our inability to be well. Lack of understanding on the part of healthcare professionals and leaders in distinguishing the difference between mechanical and complex adaptive (biological) systems perpetuates and exacerbates this problem.
In their first report, To Err is Human (published in 1999) [37], the Institute of Medicine (IOM) called attention to the difference between mechanical and complex adaptive systems. Not only is it important to understand this difference as it relates to patient safety , but it is also critically relevant to your own safety and wellness. Table 14.1 compares some of the important characteristics of each. Mechanical systems are expected to perform in a predictable and routine fashion. An elevator, car, airplane, or heart lung machine is a mechanical system. When you push the button for the fifth floor in an elevator, depress the accelerator on a car, pull back the throttle in an airplane, or turn up the speed of a roller head on a pump, you anticipate a predictable result. You don’t just anticipate it, you expect or even demand it. If you don’t get that result, you might declare the system to be “broken” and in need of repair, and a repairperson would come and interrogate (analyze), judge (declare the nature of the problem), and fix the malfunction. Mechanical systems lend themselves to task orientation and protocols [67]. Emergent (creative or innovative deviations from protocols) behavior is simply discouraged. You wouldn’t want to push the button on an elevator for the fifth floor and have it take you instead to the third floor because that has been the more popular floor today. Mechanical systems work because of consistency—there is one correct answer—and it is in the owner’s manual. Mechanical systems lend themselves to charts and graphs for measuring results because all the systems are the same and are comparable. Mechanical systems are robotic, not human. How would you like to be interrogated, judged, and fixed? Unfortunately, our medical culture often tries to do this to us. No wonder we become unwell.
Table 14.1
Mechanical vs. complex adaptive systems
Mechanical system | Complex adaptive system |
|---|---|
Predictable, routine | Unpredictable, variable |
Task orientation—valuing of consistency and checklists | Relationship orientation—valuing of differences |
Emergent behavior discouraged | Emergent behavior encouraged |
Interrogate, judge, fix | Explore, understand, join |
Spreadsheets, charts, graphs, protocols to enhance or measure reproducibility and comparability | Collaboration, connection, and inquisitiveness to enhance or stimulate change and growth |
One correct answer (truth) | Multiple possibilities |
Linear thinking | Systems thinking |
Complex adaptive systems are unpredictable and variable. We hope for a certain range of performance and when we don’t get what we desire, our approach is more often to explore (with genuine, open-minded curiosity) in order to understand (learn) so that we can join (connect to) the system in a way that can help us better manage future relationships to it. Farming is an example of a complex adaptive system. The farmer can learn all they can about the characteristics of the soil, the climate, and other factors that would guide them to plant a certain type of crop, and then they have to watch and see what happens. If they don’t get a desirable result, it won’t help them to blame the weather, criticize the soil, or punish the seeds. They are better served by trying to understand what happened and how this might influence what they do the next year. They might decide to try something that others in the area haven’t tried and this could lead to a remarkable outcome. Errors are understood as opportunities to learn rather than failures that create shame [68]. How many of you would like to be explored with genuine curiosity in order to be understood so that your ideas and energy can be connected in a meaningful and appreciated way to the energy of your group? Complex adaptive systems thrive on this type of emergent (innovative) behavior for change and growth, and these systems invite multiple possibilities or solutions—they are life enhancing, not life restricting. In fact, research has suggested that one of the most powerful behaviors for creating vibrant and resonant relationships and teams is the ability of people to accept influence from one another, regardless of their title or position in the hierarchy [30, 69, 70]. Complex adaptive systems are human and welcome all that comes with that—including, and perhaps requiring, wellness.
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