Physician burnout persists even as the height of the COVID-19 crisis fades farther into the rearview mirror. The causes for the sadness, stress, and frustration among doctors vary, but the effects are universal and often debilitating: exhaustion, emotional detachment, lethargy, feeling useless, and lacking purpose. When surveyed, physicians pointed to many systemic solutions for burnout in Medscape's Physician Burnout & Depression Report 2023, such as a need for greater compensation, more manageable workloads and schedules, and more support staff. But for many doctors, these fixes may be years if not decades away. Equally important are strategies for relieving burnout symptoms now, especially as we head into a busy holiday season.

Because not every stress-relief practice works for everyone, it's crucial to try various methods until you find something that makes a difference for you, says Christine Gibson, MD, a family physician and trauma therapist in Calgary, Canada, and author of The Modern Trauma Toolkit.

Physician Burnout & Depression Report 2023, such as a need for greater compensation, more manageable workloads and schedules, and more support staff. But for many doctors, these fixes may be years if not decades away. Equally important are strategies for relieving burnout symptoms now, especially as we head into a busy holiday season.

Because not every stress-relief practice works for everyone, it's crucial to try various methods until you find something that makes a difference for you, says Christine Gibson, MD, a family physician and trauma therapist in Calgary, Canada, and author of The Modern Trauma Toolkit.

Symptoms Speak Louder Than Words

It seems obvious, but if you aren't aware that what you're feeling is burnout, you probably aren't going to find effective steps to relieve it. Jessi Gold, MD, assistant professor and director of wellness, engagement, and outreach in the department of psychiatry, Washington University School of Medicine in St. Louis, is a psychiatrist who treats healthcare professionals, including frontline workers during the height of the pandemic. But even as a burnout expert, she admits that she misses the signs in herself. 

"I was fighting constant fatigue, falling asleep the minute I got home from work every day, but I thought a B12 shot would solve all my problems. I didn't realize I was having symptoms of burnout until my own therapist told me," says Gold. "As doctors, we spend so much time focusing on other people that we don't necessarily notice very much in ourselves—usually once it starts to impact our job."

Practices like meditation and mindfulness can help you delve into your feelings and emotions and notice how you're doing. But you may also need to ask spouses, partners, and friends and family — or better yet, a mental health professional — if they notice that you seem burnt out. 

Practice 'in the Moment' Relief 

Sometimes, walking away at the moment of stress helps like when stepping away from a heated argument. "Step out of a frustrating staff meeting to go to the bathroom and splash your face," says Eran Magan, PhD, a psychologist at the University of Pennsylvania and founder and CEO of the suicide prevention system EarlyAlert.me. "Tell a patient you need to check something in the next room, so you have time to take a breath." 

Magan recommends finding techniques that help lower acute stress while it's actually happening. First, find a way to escape or excuse yourself from the event, and when possible, stop situations that are actively upsetting or triggering in their tracks. 

Next, recharge by doing something that helps you feel better, like looking at a cute video of your child or grandchild or closing your eyes and taking a deep breath. You can also try to "catch" good feelings from someone else, says Magan. Ask someone about a trip, vacation, holiday, or pleasant event. "Ask a colleague about something that makes [them] happy," he says. "Happiness can be infectious too."

Burnout Is Also in the Body

"Body psychotherapy" or somatic therapy is a treatment that focuses on how emotions appear within your body. Gibson says it's a valuable tool for addressing trauma and a mainstay in many a medical career; it's useful to help physicians learn to "befriend" their nervous system. 

Somatic therapy exercises involve things like body scanning, scanning for physical sensations; conscious breathing, connecting to each inhale and exhale; grounding your weight by releasing tension through your feet, doing a total body stretch; or releasing shoulder and neck tension by consciously relaxing each of these muscle groups.

"We spend our whole day in sympathetic tone; our amygdala's are firing, telling us that we're in danger," says Gibson. "We actually have to practice getting into and spending time in our parasympathetic nervous system to restore the balance in our autonomic nervous system." 

Somatic therapy includes a wide array of exercises that help reconnect you to your body through calming or activation. The movements release tension, ground you, and restore balance. 

Bite-Sized Tools for Well-Being

Because of the prevalence of physician burnout, there's been a groundswell of researchers and organizations who have turned their focus toward improving the well-being in the healthcare workforce. 

One such effort comes from the Duke Center for the Advancement of Well-being Science, which "camouflages" well-being tools as continuing education credits to make them accessible for busy, stressed, and overworked physicians.

"They're called bite-sized tools for well-being, and they have actual evidence behind them," says Gold. For example, she says, one tools is a text program called Three Good Things that encourages physicians to send a text listing three positive things that happened during the day. The exercise lasts 15 days, and texters have access to others' answers as well. After 3 months, participants' baseline depression, gratitude, and life satisfaction had all "significantly improved."

"It feels almost ridiculous that that could work, but it does," says Gold. "I've had patients push back and say, 'Well, isn't that toxic positivity?' But really what it is is dialectics. It's not saying there's only positive; it's just making you realize there is more than just the negative."

These and other short interventions focus on concepts such as joy, humor, awe, engagement, and self-kindness to build resilience and help physicians recover from burnout symptoms. 

Cognitive Restructuring Could Work

Cognitive restructuring is a therapeutic process of learning new ways of interpreting and responding to people and situations. It helps you change the "filter" through which you interact with your environment. Gibson says it's a tool to use with care after other modes of therapy that help you understand your patterns and how they developed because of how you view and understand the world. 

"The message of [cognitive-behavioral therapy] or cognitive restructuring is there's something wrong with the way you're thinking, and we need to change it or fix it, but in a traumatic system [like healthcare], you're thinking has been an adaptive process related to the harm in the environment you're in," says Gibson. 

"So, if you [jump straight to cognitive restructuring before other types of therapy], then we just gaslight ourselves into believing that there's something wrong with us, that we haven't adapted sufficiently to an environment that's actually harmful."

Strive for a Few Systemic Changes

Systemic changes can be small ones within your own sphere. For example, Magan says, work toward making little tweaks to the flow of your day that will increase calm and reduce frustration. 

"Make a 'bug list,' little, regular demands that drain your energy, and discuss them with your colleagues and supervisors to see if they can be improved," he says. Examples include everyday frustrations like having unsolicited visitors popping into your office, scheduling complex patients too late in the day, or having a computer freeze whenever you access patient charts.

Though not always financially feasible, affecting real change and finding relief from all these insidious bugs can improve your mental health and burnout symptoms.

"Physicians tend to work extremely hard in order to keep holding together a system that is often not inherently sustainable, like the fascia of a body under tremendous strain," says Magan. "Sometimes the brave thing to do is to refuse to continue being the lynchpin and let things break, so the system will have to start improving itself, rather than demanding more and more of the people in it."

https://www.medscape.com/viewarticle/five-resilience-rx-physician-burnout-2023a1000tr1?ecd=wnl_dne1_231130_MSCPEDIT_etid6109442&uac=69465HR&impID=6109442

Eight hundred thousand deaths worldwide were attributed to suicide in 2016.1 In the same year in the United States, age-standardized suicide rates were 21.1 and 6.4 deaths per 100 000 persons, for men and women, respectively.1,2

Historically, data collected up to the 1980s showed age-standardized suicide rates were significantly higher for physicians than the general population, including much higher rates for female physicians and moderately higher rates for male physicians.3 However, more recent data suggest that while female physicians continue to have higher suicides rates than the general female population (standardized mortality ratio of 1.46), male physicians actually have a lower suicide rate than the general male population (standardized mortality ratio of 0.67).4 Further research on this digression based on sex is crucial.

Physicians are not at greater risk for suicide than the general population because they are “weaker” or less resilient; rather, the opposite is true. Despite their high levels of personal resilience, physicians are often placed in situations of recurrent stress. Recurrent stress can lead to physiological and physical exhaustion, otherwise known as burnout.5 Burnout now affects almost half of US physicians.6,7 Physician burnout is often characterized by depersonalization, including cynical or negative attitudes toward patients, a feeling of decreased personal achievement, and a lack of empathy for patients.8 Physician burnout and distress have been associated with higher rates of alcohol use disorder and depression, increased risk for suicide, lower quality of life, reduced cognitive functioning, and poor quality of patient care.9 While burnout and suicide are very much organizational-level problems and not individual ones, this toolkit addresses both individual actions (obtaining and offering support) as well as organizational ones (promoting an environment of wellness).

Even though physicians agree they have an ethical obligation to intervene when they believe a colleague is impaired, many fail to report it appropriately.10 Taking proactive steps to identify and address physician distress can help to ensure the well-being of physicians, reduce the risk of suicide, and support patient care by protecting the health of the physician workforce.11 Although the information in this toolkit may be applicable to other clinical team members, the focus is on physicians' vulnerability and treatment needs. Furthermore, physicians-in-training, a vulnerable population with potentially higher risks of depression and suicide, are not specifically addressed in this toolkit; there are separate toolkits discussing medical student and resident/fellow burnout and well-being.

Four STEPS to Identify and Support At-Risk Physicians

1. Identify Suicide Risk Factors and Warning Signs

2. Promote Care-Seeking Behaviors

3. Train a Physician Advocate

4. Make it Easy to Get Help

STEP 1 Identify Suicide Risk Factors and Warning Signs

Suicidal behavior is a complex problem with no single cause or absolute predictors. Risk factors for physician suicide include13- 18:

• Diagnoses of major depressive disorder, bipolar disorder, alcohol use disorder, anxiety disorder, or borderline personality disorder

• Prior suicide attempt

• Adverse childhood experiences, such as experiences or witnessing violence, abuse, or neglect

• Family history of mental health issues and/or suicidal behavior

• History of physical, psychological, and/or sexual abuse

• Major life events that affect a person's stability and support network

• Relationship problems or domestic violence

• Situational stressors, including:

  • Being named as a defendant in a lawsuit

  • General career concerns (eg, job security, increased demands)

  • License restriction

  • Financial problems

  • Professional isolation

  • Recent patient with a poor outcome

Many physicians closely tie their identity to their professional image, making these physicians more vulnerable to distress when problems arise at work.19 It is important for all physicians to be aware of the warning signs of suicide, which can include19- 21:

• Increased substance (alcohol or drug) use

• Feeling or expressing that there is no reason for living; no sense of purpose in life

• Anxiety and agitation

• Changes in sleep patterns, such as difficulty sleeping or sleeping all the time

• Feeling trapped, like there's no way out

• Expressions of hopelessness

• Withdrawal from friends, family, and society

• Rage, uncontrolled anger, seeking revenge

• Acting reckless or engaging in risky activities, seemingly without thinking

• Mood changes

• Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself

• Looking for ways to kill oneself by seeking access to firearms, pills, or other means

• Talking or writing about death, dying, or suicide

It is vital to take action if you suspect a colleague is demonstrating warning signs for suicide. While not every suicide may be preventable, people with suicidal feelings can be helped. Speaking directly with your colleague is a good first step. You can say, “I'm concerned about you. Have you had any thoughts of harming yourself?”

You do not need to be an expert to offer to help. Often, a simple recommendation to talk with a mental health professional can be an important first step. Facilitate confidential referrals to mental health care professionals by keeping an updated list of local and national resources that physicians can access discreetly (see further guidance in STEP 4). Physicians may be hesitant to talk to a colleague or supervisor because of the stigma or privacy concerns and may be more willing to access help from an outside source.

STEP 2 Promote Care-Seeking Behaviors

Although physicians recognize the value of obtaining treatment, they often are the most reluctant to access medical care and frequently receive poorer care than other patients (eg, fewer laboratory tests, less rigorous medical evaluations).23,24 Thus, it is essential for physicians to recognize the importance of self-care, model wellness behaviors, and encourage others to do the same.

As a practicing physician, start by taking steps to maintain your health, including:

• Get enough sleep, eat nutritiously, and exercise regularly.

• Allow yourself to recharge. Take personal time off and make time for relaxation with friends and family members.

• Learn to say “no” to requests that interfere with personal or relaxation time. Many physicians have difficulty turning down requests from work and the community. Sometimes saying “no” is the best medical care for both the patient and the physician.

• Learn to recognize signs of stress, depression, and burnout in yourself.

• Reach out to colleagues for assistance and support. Sharing your experiences with colleagues may help others in similar situations. Additionally, the support of colleagues can be a great source of comfort during difficult times.

If these self-care tips are not enough, it is time to seek additional help. Physicians should refer themselves or colleagues to internal or external programs that, in most cases, can provide confidential services for voluntary referrals (see STEPS 3 and 4).

As an organizational leader, foster a positive culture within your organization. Communicate widely and often with your team about the need to intervene if they suspect a colleague needs help. You can try some of these strategies:

• Encourage and model support for colleagues

• Support requests for time off for vacations or sick leave

• Support flexibility in schedule

• Provide mental health days, either mandatory or voluntary

• Use appreciative inquiry to create a more positive work environment

• Promote effective and healthy communications with positive feedback and praise24

STEP 3 Train a Physician Advocate

Creating a supportive atmosphere in the workplace can be instrumental in addressing physician distress. You may consider having a person within your organization serve as a physician advocate. Enlist an individual, such as a human resource professional or a hospital wellness committee member, whom physicians would feel comfortable approaching. This individual must be trustworthy, discreet, and knowledgeable.

Training the physician advocate is critical and should focus on explaining internal and external policies and implications regarding privacy, confidentiality, and care-seeking. The physician advocate should be prepared to answer physicians' questions about the potential impact that receiving mental health care may have on job security, medical licenses, medical liability insurance, and disability coverage. The physician advocate is responsible for distributing guidance on physician distress and suicide—and where to find support.

Once a physician advocate is selected and trained, widely communicate this person's role and what type of support services are available.

Forms of support include:

• Screening physicians for depression, distress, and burnout

• Encouraging physicians to establish and use a regular source of health care

• Reducing the physician's patient caseload in the short term

• Developing internal peer network programs and opportunities for physicians

• Referring to internal and external assistance programs (see STEP 4)

STEP 4 Make It Easy to Get Help

Your organization should keep updated referral lists for confidential resources inside and outside your organization and make them readily available to all team members, including physicians. Almost every state in the country has a physician health program (PHP). Although programs vary, physician health programs provide or facilitate in-depth evaluations, appropriate treatment referrals, and, if necessary, monitoring for residents, physicians, and sometimes medical students. Because physician health programs are not affiliated with clinical practices or hospitals, they allow physicians to access private and confidential care. The Federation of State Physician Health Programs maintains a list of state physician health programs with a description of the services each program provides. Display these resources in a highly visible location that does not require a password and assures users that there is no tracing of page visits or downloads.

Identify policy barriers to care-seeking in your organization and take steps to minimize them. Work with organizational leadership to examine and modify (if necessary) your internal policies to encourage care-seeking by physicians.

In this review of organization policies, ask yourself:

• Can physicians receive care confidentially?

• What type of information is recorded when physicians seek treatment?

• If a physician receives care internally, are the records private? Is access to these records controlled?

• Are physicians' jobs secure if they seek extensive care for mental health treatment? If so, is this job security widely known by physicians within your organization?

• Is access to mental health care on par with access to other forms of health care?

• Are physicians in your state required to report a history or diagnosis of mental health illness or treatment when applying for or renewing their medical licenses?

• Are physicians in your organization required to report a history or diagnosis of mental health illness or treatment during credentialing or recredentialing?

• Are your policies visibly posted (online and/or in print) and easily accessible for physicians in your organization to review?

If concerns about confidentiality prevent physicians with distress from seeking care, their condition may worsen. Policies allowing confidential access to treatment are more likely to encourage physicians to seek the care they need. Organizational leadership should consider this factor when developing confidentiality policies, as the risks of untreated physician distress often outweigh the potential benefits of mental health disclosures.

For full article, visit https://edhub.ama-assn.org/steps-forward/module/2702599

Abstract

Although awareness of the importance of physician well-being has increased in recent years, the research that defined this issue, identified the contributing factors, and provided evidence on effective individual and system-level solutions has been maturing for several decades. During this interval, the field has evolved through several phases, each influenced not only by an expanding research base but also by changes in the demographic characteristics of the physician workforce and the evolution of the health care delivery system. This perspective summarizes the historical phase of this journey (the “era of distress”), the current state (Well-being 1.0), and the early contours of the next phase based on recent research and the experience of vanguard institutions (Well-being 2.0). The key characteristics and mindset of each phase are summarized to provide context for the current state, to illustrate how the field has evolved, and to help organizations and leaders advance from Well-being 1.0 to Well-being 2.0 thinking. Now that many of the lessons of the Well-being 1.0 phase have been internalized, the profession, organizations, leaders, and individual physicians should act to accelerate the transition to Well-being 2.0.

Abbreviations and Acronyms:

EHR (electronic health record)

Awareness of occupational distress among physicians and efforts to cultivate physician well-being have crescendoed in recent years. This awareness was amplified by the COVID-19 pandemic, which emphasized the foundational importance that well-being plays in physicians’ ability to serve patients and for health care organizations to achieve their mission.

Although general awareness of the importance of physician well-being has increased during the past several years, the research that defined this challenge, identified the contributing factors, and provided evidence on effective individual and system-level responses has been maturing for several decades. The maturation of this field has evolved through several phases, each influenced not only by an expanding research base but also by changes in the demographic characteristics of the physician workforce and the evolution of the health care delivery system. This perspective summarizes the historical phase of this journey, current state, and insights regarding where we need to go next. The summary of each phase is intended to be descriptive rather than a critique and to illustrate how the field of physician well-being has evolved and matured.

The Past: The Era of Distress

The historical era, or what I will coin the “era of distress,” was characterized by a lack of awareness, or even deliberate neglect, of physician distress. This phase largely described the field before 2005. Although early data on physician burnout and evidence of its potential repercussions on quality of care had begun to be chronicled, the issue of occupational distress was not a meaningful part of the conversation among the profession or society.Evidence from other fields that occupational burnout was a system issue originating from problems in the work environment, rather than a weakness in the worker, was not widely adopted by the field of medicine. Physicians were selected and winnowed through an arduous training process and were, in many ways, expected to be superhuman. Medical school and residency training were characterized by a “rites of passage” mindset that subjected physicians to unlimited work hours, often involving many consecutive days on duty with little sleep, rest, or breaks.

The evolving science on sleep and human performance was not applied to physicians, who were expected to perform with equal excellence throughout the arc of extended-duty shifts independent of whether they had slept. Physicians worked regardless of whether they were ill, and there were few if any backup systems to provide coverage.

 If physicians were unable to report for work, their colleagues “picked up the slack.” For individual physicians, a desire not to shift the burden to colleagues created a powerful disincentive to attend to personal health needs or illness. Individuals who pointed out the inherent problems of this approach were often marginalized as being “uncommitted” or “weak."From the demographic perspective, physicians in this era were predominantly men whose spouses or partners did not have a career of their own. This arrangement allowed the spouses and partners of physicians to devote greater time to “keeping things running on the home front” even though the physician was often absent or devoted little time to these activities. The practice environment was less consolidated, with fewer physicians a part of large group practices.

Electronic health record (EHR) use was not widespread, and measures of patient satisfaction and quality were not routinely assessed. In part because of the different structural characteristics of health care delivery at the time, physicians had greater autonomy, less oversight, and more control over the practice environment. Nonetheless, payers and regulators in this era used a “gotcha” approach to auditing payment and documentation that communicated a lack of trust and questioned the integrity of all physicians on the basis of the unprofessional behavior of a few.At the organizational level, there was limited if any attention to the impact of administrative decisions or regulations on physicians' work life. The concept that quality of care was a system characteristic had only begun to take hold. If medical errors occurred, the default was to blame the individual. This typically took the form of accusatory “root cause analyses” and morbidity and mortality conferences that subjected junior physicians to humiliation and shaming by supervisors and peers. The message conveyed was that the physician should be all-knowing and able to overcome every deficiency of the health care delivery system to ensure optimal care for patients under any circumstance (ie, physicians were supposed to have deity-like qualities).There was inattention to the impact of physicians' personal well-being on the quality of care they provided patients. Institutional needs were prioritized above patient and clinician needs, and there was no appreciation of the economic implications of physician distress on the financial health of the organization. During this time, the professional culture of medicine was characterized by a mindset of perfectionism that reinforced the concept of physician as deity. This framework discouraged vulnerability with colleagues, encouraged physicians to project that they had everything together (“never let them see you sweat”), and contributed to a sense of isolation. To the extent there was dialogue about physician distress, the focus was on individuals rather than the system or practice environment.

Collectively, all these factors contributed to physicians’ professional identity subsuming their human identity. There were no limits on work, and the concept of boundaries between personal and professional life was considered a lack of commitment. To the extent there was attention to “physician wellness,” it centered on the concept of self-care: healthy diet, exercise, stress reduction, and getting enough sleep when not on duty.

The Present: Physician Well-being 1.0

Over time, increasing evidence and research began to change many of these historical paradigms. The “Physician Well-being 1.0” phase, to some extent, began between 2005 and 2010 and largely continues to present day. This phase has been characterized by knowledge and awareness. National studies began to chronicle the prevalence of distress among medical students, residents, and practicing physicians as well as trends in distress over time. Publication of these studies in peer-reviewed journals also began to result in headlines in the widely disseminated physician press (ie, “throw-away” journals; Medscape) with occasional pickup by the lay press. Importantly, the repercussions of physician burnout and other forms of occupational distress (eg, moral injury, fatigue/exhaustion) began to be recognized and to have an impact on conversations within the health care delivery system. The personal repercussions of physician distress (eg, broken relationships, problematic alcohol and substance use, depression and suicide) began to establish a moral and ethical case for action. Research also demonstrated the links between physician well-being and quality of care, including medical errors, patient satisfaction, and professional behavior. This evidence began to bring together a broad coalition of stakeholders concerned with clinician well-being and resulted in expansion of the triple aim of health care (improving patient experience, reducing the cost of care, advancing population health) to a quadruple aim that included clinician well-being. Other studies established links between physician burnout and clinical productivity as well as turnover, which drew attention to the economic costs of physician burnout for health care organizations and society. The demographic profile of physicians in this era evolved, with gender parity among medical school matriculates and an increasing proportion of women among the practicing physician workforce. More physicians were in 2-career relationships that assumed increased involvement of physicians in home responsibilities. The historical pattern of professional identity subsuming human identity shifted to a dual role and the need to “balance” personal and professional identities (ie, work-life balance). In parallel with these demographic changes, tremendous change occurred in the training and practice environment. Residency and fellowship training transitioned to a competency-based framework, and substantial, new limits on work hours were instituted. Consolidation of medical practices occurred, resulting in a majority of physicians working in employed practice models. Use of the EHR became widespread with the passage of the Health Information Technology for Economic and Clinical Health Act in 2009, which defined and tied reimbursement to “meaningful use” of EHRs. Although organizations also began to appreciate the administrative impact of the EHR on physicians the response was to provide opportunities for physicians to learn “tips and tricks” to become more efficient in their ability to use suboptimal technologyIn an effort to quantify performance, organizations began to evaluate physicians using a host of new metrics, including measures of patient satisfaction, quality, cost, and productivity. Physicians became familiar with terms such as relative value unit generation, visit/billing targets, payer mix, service lines, top-box score, and net operating income. This contributed to a perception of misalignment between the professional values of physicians and the motives and priorities of their organizations. At the organizational level, awareness of the system nature of the problem began to develop. The response, however, typically remained focused on individual-level solutions and centered on providing treatment for physicians in distress (eg, mental health resources, peer support) as well as cultivating personal resilience through interventions such as mindfulness-based stress reduction. Despite these efforts, state licensure questions and stigma about mental health conditions remained a barrier to seeking help.

Organizations began to view addressing physician distress as a necessary cost center, but, to the extent they allocated resources to advance physician wellness, they viewed it primarily through a “return on investment” mindset. As they considered addressing defects in the practice environment, organizations viewed the issue as a zero-sum game problem. This mindset suggested that the only way to relieve physicians from excessive workload and administrative burden was to shift this work to others. This framework suggested that system approaches to improve physician well-being would invariably worsen the well-being of other members of the health care team, resulting in inaction.

At the professional level, discussions about a “culture of wellness” began to take hold but tended to focus on a message that encouraged physicians to “take care of themselves and become more resilient.” Physicians began to express frustration that this approach failed to address the underlying problems in the practice environment that were the core issue. Some physicians suggested that health care administrators were the root cause of the problem. That oversimplification was neither accurate nor constructive and led to divisiveness and reciprocal scapegoating (physicians blame administrators; administrators blame physicians) that drove a wedge between physicians and the individuals they needed to work with to improve the practice environment. Although physicians argued about what label best described their occupational distress and how to measure it, there was agreement that the problem was pervasive and that the practice environment was the issue.

 Acceptance that distress was widespread created openness for more physicians to discuss occupational challenges. This helped move physicians who were struggling in isolation to realize they were not alone and created greater willingness to discuss distress with colleagues.

The Future: Physician Well-being 2.0

Around 2017, vanguard institutions began to transition to the Well-being 2.0 phase. This transition has been accelerated by the COVID-19 pandemic, which illustrated the foundational importance of clinician well-being to health care delivery systems and the profound impact that work characteristics have on well-being. The Well-being 2.0 phase is characterized by action and system-based interventions to address the root causes of occupational distress. The focus in this phase shifts away from individuals toward systems, processes, teams, and leaders.  The importance of transitioning to the Well-being 2.0 phase was validated by the National Academy of Medicine Action Collaborative on Clinician Well-being and the formal report from the Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-being released in late 2019.

The scapegoating and finger-pointing that divided physicians and administrators in the Well-being 1.0 phase are replaced with a mindset of physician-administrator partnership to create practical and sustainable solutions. There is acceptance that physicians are subject to the same human limitations that affect all human beings, with attention to appropriate staffing, breaks, and rest as a part of performance. This phase builds from a foundation that burnout is codified as an occupational syndrome by the World Health Organization; harmonized definitions for burnout have been established; instruments to assess the syndrome have been developed, validated, and crosswalked; the neurobiology of occupational distress has been recognized; and the distinction between burnout and depression has been clarified. At the organizational level, the mindset in this phase centers on cultivating well-being and preventing occupational distress rather than simply reducing burnout. Senior leaders, such as Chief Wellness Officers, are appointed to address system-based drivers, and the infrastructure and resources to enable these leaders to drive organizational change are established. The principles of human factors engineering and design are embraced. The organizational focus shifts from patient needs to a people focus that attends to the needs of all individuals in the practice environment as both necessary and mutually beneficial to achieve the desired outcomes. This includes caring for the team and creating an organizational environment that attends to leadership, professionalism, teamwork, just culture, voice and input, and flexibility. The needs of individual clinicians, including sleep and work-life integration, are acknowledged and supported. In the Well-being 2.0 phase, the organization transitions from viewing wellness as a necessary cost center to viewing it as a core organizational strategy. The resource allocation mindset shifts from a return on investment framework to value on investment.From a demographic perspective, it is recognized that there is an equal mixture of men and women physicians and that most physicians are in 2-career relationships with shared duty for personal and family responsibilities. To enable people to meet these responsibilities, organizations create flexibility in the practice environment that allows physicians to meet both personal and professional obligations. This provides organizations a competitive advantage in recruitment and retention and allows physicians to work full-time and still accommodate personal needs rather than having to work part-time to do so. At the individual level, physicians have transitioned from a mindset of balancing personal and professional identities to one of integrating professional identity and personal identity into a single identity that encompasses human, personal, and professional dimensions. The intersection between diversity, equity, and inclusion to wellness is recognized. Although these are distinct domains, promoting antiracism and addressing threats and system factors that undermine diversity, equity, and inclusion are appreciated as foundational to efforts to advance clinician well-being. Consistent with this premise, more authentic conversations about organizational deficits in these domains occur in concert with action.

At the professional level, the emphasis shifts from a culture of wellness to a culture of vulnerability and self-compassion, which acknowledges that physicians are not perfect, that they will make mistakes, and that they need to be vulnerable and support one another. Physicians recognize and acknowledge that they may have an Achilles’ heel as it pertains to perfectionism and self-criticism and dedicate themselves to developing skills to address these mindsets. Supporting colleagues involves creating not only connection but also community involving shared experience, mutual support, and caring for each other.  Training programs embrace these principles and work to actively develop these qualities as core dimensions of competence as well as holistically cultivating residents’ and fellows’ well-being.

Call to Action

We have now internalized the lessons of the Well-being 1.0 phase, and vanguard institutions have begun to move to the Well-being 2.0 phase (Table). The profession, organizations, leaders, and individual physicians should act to accelerate this transition.

TableCharacteristics of the Different Phases of the Physician Well-being Movement

EHR, electronic health record.

• Open table in a new tab

At the broader professional level, physician leaders and professional societies must embrace the physician as human mindset rather than the physician as hero mindset. This mentality should permeate the values transmitted to the next generation of physicians at the earliest phase of training both cognitively and in the structure, design, and expectations of the clinical training process. This will require promulgating the core values of the profession (commitment to patient needs, service, altruism) along with the realities of human limitations and the concept that healthy boundaries, appropriate limits on work, work-life integration, and attention to personal needs are part of professionalism. These values should be embraced by the established members of the profession and care taken to responsibly impart them, along with other core values, to physicians in training. Deliberate efforts to change the professional culture of perfectionism to a culture of excellence in combination with self-compassion and growth mindset must be pursued.

At the organizational level, the transition to Well-being 2.0 requires a shift from awareness to action. It requires organizations to establish the leadership, structure, and process necessary to foster sustained progress toward desired outcomes. This involves addressing system factors that drive occupational distress and reduce professional fulfillment. It includes attention to the efficiency of the practice environment and dimensions of organizational culture that can promote or inhibit well-being.

 Organizations must embrace human factors engineering and pursue system redesign that creates sustainable workloads, provides coverage when physicians are ill, and incorporates appropriate breaks and rest. Health care organizations must deepen their commitment to leadership development, increase receptivity to input from health care professionals, make a more authentic commitment to teamwork and optimization of team-based care, and foster an environment built on trust.

For leaders, accelerating the transition to Well-being 2.0 requires attending to the leadership behaviors that cultivate professional fulfillment for individuals and teams. This includes caring about people always, cultivating individual and team relationships, and inspiring change.

It requires both physicians and administrative leaders to foster a collaborative relationship and to engage in partnership to redesign and implement necessary changes. Working together to develop a shared sense of purpose and to create alignment of organizational and professional values is a foundational step.

At the individual level, the transition to Well-being 2.0 requires mindfully considering how to incorporate self-compassion, boundaries, and self-care alongside other professional values. Physicians must acknowledge that they are subject to normal human limitations and attend to rest, breaks, sleep, personal relationships, and individual needs. They must reject the role of victim, stop blaming administrators, and be part of the solution. This requires casting off the narrative that physicians are powerless to effect change in large health care organizations (learned helplessness), which is not true and is a barrier to creating the system change that is needed. Catalyzing such change requires physicians to work in partnership with operational leaders to improve the practice environment and health care delivery system. Physicians must hold fast to the belief that it is a privilege to be a physician and that honor requires dedication to others and responsibilities that involve sacrifice. That duty to patients and society, however, has limits. Times of intense work must be offset with appropriate time to recharge. Individual physicians are responsible to learn to simultaneously navigate the challenges of their career and attend to personal needs. This includes cultivating self-compassion and attention to self-care (sleep, exercise, rest) and work-life integration. Individual physicians must also preserve a strong commitment to supporting their colleagues. They should strive to create community with one another, including relationships that enable vulnerability and mutual support.

Roadmaps to facilitate these changes at the profession, organization, leader, and individual level have been developed, studied, and published. Organizations and individuals that have not started their journey should use these roadmaps as a place to begin. All physicians should work to accelerate progress in their sphere of influence. Continued research and organizational discovery will enhance current knowledge and provide new learnings to help the Well-being 2.0 phase flourish. As this phase matures, the contours of a yet to be defined Well-being 3.0 phase will inevitably develop.

Conclusion

The last 3 decades have a been a time of tremendous progress for the field of physician well-being. We have moved from the era of distress, characterized by ignorance and neglect, to an era of awareness and insight. Leading institutions have now transitioned from knowledge to authentic action. Robust research and application by leading institutions has been the key to the maturation of the field. The profession, organizations, leaders, and individual physicians should commit themselves to accelerating this transition to the Well-being 2.0 era. Now is the time for action.

https://www.mayoclinicproceedings.org/article/S0025-6196(21)00480-8/fulltext

By Mariah A. Quinn, MD, MPH; Lisa M. Grant, DO; Emmanuel Sampene, PhD; Amy B. Zelenski, PhD

ABSTRACT Purpose: Empathy is essential for good patient care. It underpins effective communication and high-quality, relationship-centered care. Empathy skills have been shown to decline with medical training, concordant with increasing physician distress and burnout. Methods: We piloted a 6-month curriculum for interns (N = 27) during the 2015-2016 academic year at the University of Wisconsin-Madison. The course included: (1) review of literature on physician well-being and clinical empathy, (2) instruction on the neurobiology of empathy and compassion, (3) explanation of stress physiology and techniques for mitigating its effects, (4) humanities-informed techniques, and (5) introductions to growth mindset and mindful awareness. To measure effectiveness, we compared empathy and burnout scores before and after the course. Results: The course was well-attended. Intern levels of burnout and empathy remained stable over the study period. In multivariable modeling, we found that for each session an intern attended, their emotional exhaustion declined by 3.65 points (P = 0.007), personal accomplishment increased by 2.69 points (P = 0.001), and empathic concern improved by 0.82 points (P = 0.066). The course was well-liked. Learners reported applying course content inside and outside of work and expressed variable preferences for content and teaching methods. Conclusion: Skills in empathic and self care can be taught together to reduce the decline of empathy and well-being that has been seen during internship. In this single-center pilot, resident physicians reported using these skills both inside and outside of work. Our curriculum has the potential to be adopted by other residency programs.

INTRODUCTION

Strong patient-physician relationships are essential for effective communication and support high-quality care. Clinical empathy is a critical skill in the cultivation of effective therapeutic relationships with patients. Empathy includes cognitive and emotional components, as well as intentions and behaviors that seek to alleviate suffering (ie, compassion and compassionate behaviors). There is no consensus definition of clinical empathy, but researchers have studied the impact of physician empathy primarily by assessing communication or relationship variables. These studies demonstrate positive outcomes for both physicians and their patients. For physicians, these outcomes include improved diagnostic accuracy, efficiency, self-efficacy and confidence, job satisfaction, burnout, rate of malpractice claims, and the cost of care.1–5 Patient outcomes include improved recall, comprehension, loyalty, trust, satisfaction with care, selfefficacy, treatment adherence in chronic disease management, health status, quality of life, safety, symptom management and function.6–12 In fact, a meta-analysis published in 2014 focused on randomized controlled trials in which the patient-physician relationship was the experimental variable, found a meaningful impact on health care outcomes across multiple disease states.12 There is a nuanced relationship between empathy and burnout. High personal distress and identification with a suffering patient can engender stressful or overwhelming suffering within the empathizer, raising the risk for burnout.13,14 However, research with trauma therapists demonstrates that well-developed empathy helps both patients and clinicians. This work suggests that “exquisite empathy,” described as “highly present, sensitively attuned, well-boundaried, heartfelt empathic engagement” is, in fact, sustaining and protective against burnout and compassion fatigue.15,16 Further, a study examining an intervention aimed at reducing personal distress via cognitive reappraisal compared with an intervention to augment compassion found that while both interventions improved subjects’ altruistic behaviors, it was the compassion intervention that was more protective against personal distress.17 These studies support the growing consensus that well-developed empathy protects physicians against burnout.18 Since progress through medical training consistently has been shown to correlate with reductions in empathy and epidemic levels of distress and burnout, interventions to support empathy skills and personal well-being are a critical necessity in residency programs.19,20.

METHODS

We developed a 9-session curriculum for internal medicine interns to strengthen empathy skills and reduce burnout. We hypothesized that a multimodal, neuroscience and humanities-informed curriculum would improve measures of empathy and burnout in this population and measured the course’s impact by examining burnout and empathy before and after course participation.

Curriculum Development

We performed a literature review to identify pedagogical techniques with relevance to the development of (1) skills in self-care to reduce burnout and emotional distress and (2) skills in effectively caring for others focused on empathic or compassionate care. We reviewed the medical and other health professions literature as well as the education, psychology, and neuroscience literature. Given evidence from prior programs that a one-size-fits-all approach will leave learner subgroups untouched, we decided to employ a multimodal approach.21 Components ultimately included in the curriculum are shown in Table 1. We also taught the concept of growth mindset at the beginning of the course to increase learner acceptance and uptake of content and bolster their confidence in learning these skills. Growth mindset is a belief that with effort, one can improve in a certain domain (eg, empathy).22

Course Logistics

The course included 9 sessions ranging in length from 2 to 4 hours held on Friday afternoons spread over 6 months. We worked with residency program leadership (including program staff, chief residents, and the program director) to determine where in the weekly and daily schedule our curricular sessions would face the least competition and clinical coverage difficulties that could lead to resentment or low attendance. In this pilot year, the intern class was divided into 2 groups so only half of the interns would be gone from rotations at any given time. We randomized men and women separately into the groups to preserve gender balance. The schedule was provided to the interns at the beginning of the year, and we sent email reminders to all clinical teams at the beginning of each rotation with the schedule of sessions. We also sent reminder pages to the interns 1 to 2 hours before sessions. This project was reviewed and exempted by the University of Wisconsin Institutional Review Board as Program Evaluation.

Course and Program Evaluation

All interns (N=28; 22 men, 6 women) were required to participate in the curriculum, but they could elect whether or not to participate in the curriculum evaluation, which all but 1 intern elected to do (N= 27). We gathered data during their orientation period, after 6 months of internship, and in the last month of internship. To protect interns’ privacy, the course creators did not have access to personally identifying information on any of the measures collected; their data were tracked using a nonidentifying study ID. Outcome measures included empathy, using the Interpersonal Reactivity Index (IRI), and burnout, using Maslach Burnout Inventory (MBI). Predictors included Mindset Assessment Profile (MAP)23–25 and an emotional styles inventory (ESI) that was collected during orientation and at the end of internship to understand the relationship among baseline emotional style, burnout, and empathy.26 The emotional styles inventory measures resilience, outlook, self-awareness, social intuition, sensitivity to context, and attention. Domains included in the outcome measures are summarized in the Box. If our curriculum were effective, we would expect to see stabilization or reductions in the MBI domains of depersonalization and emotional exhaustion and a stabilization or increase in personal accomplishment, as well as the IRI domains of empathic concern and perspectivetaking. We tracked attendance at each session. At the end of the course, we also evaluated favored course methods, skills used both inside and outside of work, and ongoing support for the course using free text entry.

Statistical Analysis

All pre- and post-data were analyzed using paired t tests for dependent samples. In order to understand how the course affected burnout and empathy, we performed multivariable modeling including the following predictors: mindset, emotional styles domains, cohort (to capture time of year), and session attendance. Given the correlations between predictors and instruments, collinearity was assessed among the predictor variables and was acceptably low to include all covariates in the model. Although we performed several comparisons between our burnout and empathy outcome variables and our predictors of interest, we did not adjust for multiplicity due to the exploratory nature of those analyses. All analyses were conducted using SAS, version 9.4 and findings were statistically significant at P<0.05 (95% CI)

RESULTS

Of 28 interns, all participated in the course and 27 (96.4%) elected to participate in the course evaluation. The reason for the one intern’s nonparticipation was unknown. At baseline, the 2 cohorts did not differ significantly with respect to growth mindset, empathy levels, burnout, or emotional style, and burnout was present in 41% of interns (scoring high in emotional exhaustion or depersonalization, or both) with average scores in the moderate range for both. Detailed pre- to post-outcome measures, as well as the impact of session attendance on outcome measures, are shown in Table 2.

Intervention Feasibility and Acceptability

nterns attended a median of 7 of 9 sessions in both cohorts. However, there were more interns who attended fewer than 6 sessions in cohort 2 (attendance range 5-8 in cohort 1 and 3-8 in cohort 2). Most interns (74.0%) felt they had the support of other residents and faculty to attend the class. The other 26% reported feeling moderately supported and, of these, most reported that it was difficult to leave on call days or otherwise particularly busy clinical days. At course completion, interns were asked to rate their anticipated level of support for new interns attending the course the following year. The majority (92.5%) reported a high, unconditional level of support for the course in the future. By contrast, 2 respondents reported contingent support. For example, one intern said they would “do (their) best to get (their interns) to the course though patient care will continue to take precedence.”

Use of Concepts and Favored Methods

Interns reported utilizing concepts both in and outside of work. Skills learned in the improvisational theatre sessions, meditation or mindfulness practices, and specific empathic communication techniques were mentioned the most. Approximately 33% of interns specifically commented that naming emotions and the other skills taught as part of the empathic communication mneumonic NURSE (Naming, Understanding, Respecting, Supporting, Exploring) 27 were very helpful, both in their per sonal and professional lives. One stated that it was “extremely helpful in ‘defusing’ angry/frustrated patients.” Many interns made comments that meditation and reflection were very helpful, especially with managing their personal emotions: “When I am about to see a presumably ‘difficult’ patient in clinic, I definitely pause outside the room, take a deep breath, and then knock.” A few interns (14.8%) noted that they started using meditation and mindfulness more regularly. The fixed versus growth mindset was a new concept to many interns and, at the end of the year, 29.6% noted it as a concept that they either recalled or used during the year. One intern in particular recalled the growth mindset stating, “It took me a really long time to realize that I wasn’t alone in feeling kind of overwhelmed and underqualified. I think once I felt okay about not being 100% perfect at my job (and focus on growing, helping patients) I really got a ton better at my job!” Favored methods in the course also varied, but visiting the art museum and the improvisational theatre sessions were the most enjoyed. Many interns said they appreciated the opportunity to get away from the hospital to visit the art museum. The percentages of interns that reported each method as most enjoyable are listed in the Figure; many interns rated equal enjoyment of more than one method.

Empathy and Burnout

The pre- and post-course scores in all burnout and empathy subscales are shown in Table 2. The only measure that changed significantly was depersonalization, which appeared to increase. This could imply a decrease in empathy. However, in the model that included course attendance, there was no signficiant relationship between course attendance and depersonalization (P for beta=0.40). Course attendance significantly predicted reduced emotional exhaustion (P=0.007) and improved personal accomplishment (P=0.001). These findings suggest that without the course, burnout would have worsened over the course of the year, as expected historically. We compared our pilot interns’ empathy levels during the fall of their second year of residency to a group of historical second-year residents in our program who had not participated in the course, but were otherwise comparable due to their training level. The 27 residents who had taken our course vs the 34 historical residents showed improved IRI subscale scores in personal distress: 9.26 vs 11.67 (P= .03). All other domains did not reach significance, including perspective-taking: 21.26 vs 19.74 (P=0.18); empathic concern: 21.33 vs 19.94 (P=0.12); (fantasy, 18.15 vs 16.41 (P= 0.23). Improved empathy is shown on the IRI by increases in perspective-taking and empathic concern accompanied by decreases in personal distress.

DISCUSSION AND CONCLUSIONS

We developed a feasible and well-liked intervention to improve skills in the care of others and self, as measured by improvements in empathy and burnout concordant with course attendance. We found that including multiple modalities supported content delivery. While depersonalization scores, on average, worsened over the course of the year, we found that attendance in our course did not appear to predict this change and was associated with improvements in emotional exhaustion and personal accomplishment, as well as a trend toward improvement in empathic concern. In addition, the course’s effect on empathy was sustained after the course ended—as assessed 3 to 9 months after course completion—in comparison to a historical comparison group. We found that different learners preferred different learning methods. This finding is consistent with the “CHANGES” study,21 which showed that learner characteristics interact with curricular content in ways that are critical for educators to consider. A “one-size-fits-all” curriculum with a single modality is unlikely to be as effective for all learners as a curriculum that includes different “hooks” and methods. We challenged ourselves to integrate a variety of methods and content into our curriculum, in order to increase the likelihood that any curricular arrow would find a target and stick, allowing us to engage all learners. The methods and concepts interns reported as useful, in both work life and outside of work, clustered around emotional intelligence, empathic communication, and mindfulness in the face of stress or adversity. We initially were surprised to find worsening depersonalization pre- to post-course, with no apparent effect of course attendance in multivariable modeling, as well as the apparently stable emotional exhaustion pre- to post-course, with an apparently protective effect from course attendance. We did not observe the historically expected increase in burnout over the course of internship in this group of interns.20 To better understand whether this was simply related to the overall educational environment at our institution, we were able to compare changes in burnout from orientation to mid-academic year for the intern class entering the year after our pilot year to institutional comparisons (other nonprocedural training programs including pediatrics, emergency medicine, psychiatry, pathology, neurology, radiology, nuclear medicine, and radiation oncology). In this group, we saw that between orientation and mid-year, the internal medicine interns—all of whom received our course—had depersonalization change by -0.11 and emotional exhaustion change by -0.91 (P= 0.92 and P=0.7, respectively), while in the other nonprocedural interns depersonalization changed by 1.6 and emotional exhaustion changed by 6.68 (P=0.22 and P=0.005, respectively). Strengths of this study include excellent course participation, which heightens our confidence of the course’s feasibility and acceptability. We also used common and validated outcome measures. Study limitations include the limited power that comes from a small sample size and multiple comparisons made as part of the analysis of this evaluation. The fact that the intervention occurred at a single center by a single teaching team may limit the generalizability of our findings. Finally, we chose for inclusion as predictor variables the subscales of the Emotional Styles Inventory, as published by Richard Davidson, PhD.26 This was selected because we have found it helpful when coaching residents on doctor-patient relationship issues to identify contributors and potential solutions. While it is not a validated instrument, it contains domains we have found pertinent as educators, and our analysis confirms that it maps to important outcomes. An additional limitation is the potential for reverse causation. For example, perhaps less emotionally exhausted interns were more likely to be able to leave their services to come to the sessions. Limitations above notwithstanding, our findings suggest that skills in self and others are not mutually exclusive and that, for physicians, these domains can be linked and fruitfully taught together. Future directions include further development of this course to achieve graduated levels of difficulty so that trainees can retrieve and utilize the concepts learned during the most difficult clinical encounters and practice scenarios, in addition to determining whether other learner groups would benefit similarly from this curriculum to assess reproducibility and generalizability

https://wmjonline.org/wp-content/uploads/2020/119/4/Quinn.pdf

Emotional intelligence (EQ or EI) is one of the strongest indicators of success in business. Why? EQ is not only the ability to identify and manage your own emotions, but it’s also the ability to recognize the emotions of others. This study by Johnson & Johnson showed that the highest performers in the workforce were also those that displayed a higher emotional intelligence. And according to Talent Smart, 90% of high performers in the work place possess high EQ, while 80% of low performers have low EQ. Simply put, your emotional intelligence matters.

Many of my clients often come to me frustrated with their managers, ready to quit because of the poor relationship they have with their boss. When I listen to what’s going on, it’s usually that these leaders aren’t demonstrating high levels of emotional intelligence. Don’t let that be you!

Here are five ways to develop your emotional intelligence.

1. Manage your negative emotions. When you’re able to manage and reduce your negative emotions, you’re less likely to get overwhelmed. Easier said than done, right? Try this: If someone is upsetting you, don’t jump to conclusions. Instead, allow yourself to look at the situation in a variety of ways. Try to look at things objectively so you don’t get riled up as easily. Practice mindfulness at work, and notice how your perspective changes.

2. Be mindful of your vocabulary. Focus on becoming a stronger communicator in the workplace.Emotionally intelligent people tend to use more specific words that can help communicate deficiencies, and then theyimmediately work to address them. Had a bad meeting with your boss? What made it so bad, and what can you do to fix it next time? When you can pinpoint what’s going on, you have a higher likelihood of addressing the problem, instead of just stewing on it.

3. Practice empathy. Centering on verbal and non-verbal cues can give you invaluable insight into the feelings of your colleagues or clients. Practice focusing on others and walking in their shoes, even if just for a moment. Empathetic statements do not excuse unacceptable behavior, but they help remind you that everyone has their own issues.

4. Know your stressors. Take stock of what stresses you out, and be proactive to have less of it in your life. If you know that checking your work email before bed will send you into a tailspin, leave it for the morning. Better yet, leave it for when you arrive to the office.

5. Bounce back from adversity. Everyone encounters challenges. It’s how you react to these challenges that either sets you up for success or puts you on the track to full on meltdown mode. You already know that positive thinking will take you far. To help you bounce back from adversity, practice optimism instead of complaining. What can you learn from this situation? Ask constructive questions to see what you can take away from the challenge at hand.

Emotional intelligence can evolve over time, as long as you have the desire to increase it. Every person, challenge, or situation faced is a prime learning opportunity to test your EQ. It takes practice, but you can start reaping the benefits immediately.

Having a high level of emotional intelligence will serve you well in your relationships in the workplace and in all areas of your life. Who wouldn’t want that?

https://www.forbes.com/sites/ashleystahl/2018/05/29/5-ways-to-develop-your-emotional-intelligence/?sh=5cc64fe6976e

Physicians who experience mistreatment and discrimination by patients, their families, and visitors are more likely to have symptoms of burnout, according to a study published today in JAMA.

These abusive behaviors were more often directed toward female physicians and physicians of racial and ethnic minorities, although these physicians were not at higher risk for burnout.

The cross-sectional survey was conducted by researchers at the Mayo Clinic, who collected data from 6512 US physicians from November 20, 2020, to March 23, 2021. Questions  on the survey were modified from the Association of American Medical Colleges Graduation Questionnaire. Physicians reported the frequency (never, once, several times a year, weekly, and several times a week) with which they had experienced mistreatment or discrimination by patients, families, and visitors within the past year.

Additionally, participants reported whether they had been physically harmed or whether a patient or a patient's family had refused care because of the physician's appearance.

Of the respondents, 37.6% were women, 70.5% were non-Hispanic White, 13.3% were non-Hispanic Asian, Native Hawaiian, or Pacific Islander (AAPI), and 7.2% were Hispanic.

Several specialties were represented, and most (56.9%) respondents worked in private practice. Physicians in specialties with less direct patient contact, such as pathology or radiology, were at lower risk of mistreatment and burnout than those in specialties with more direct patient contact, such as emergency medicine.

Nearly one third (29.4%) of physicians reported being subjected to racially or ethnically offensive remarks. A similar number (28.7%) experienced offensive sexist comments. More than one fifth (20.5%) received unwanted sexual advances, and 21.6% reported that a patient or family member had refused care because of the physician's visible personal attributes.

As exposure to these encounters increased, so did symptoms of emotional exhaustion, depersonalization, and burnout. Overall, after controlling for other variables, the risk of burnout rose from 27% to 120%.

Handling Abusive and Discriminatory Patients

While burnout due to patient interactions has not been thoroughly researched, previous studies have found that physicians of color and sexual minority medical students experience more workplace discrimination. This can negatively affect career trajectory, well-being, and work environments and may exacerbate physician shortages and healthcare disparities.

"Burnout is the result of chronic, high levels of unmitigated stress stemming from the work environment," Liselotte N. Dyrbye, MD, MHPE, who conducted the research while at the Mayo Clinic but is now at the University of Colorado School of Medicine, told Medscape Medical News. "Solutions lie in improving the practice environment and addressing system-level factors causing high stress."

Although any physician may experience mistreatment or discrimination, minority and female physicians are particularly vulnerable.

Indeed, only 22% of White physicians received racially motivated remarks, compared to 55.8% of non-Hispanic Black physicians and 55.4% of AAPI physicians. Among all physicians, 15% were physically harmed. Approximately one third (31.8%) of non-Hispanic male physicians of two or more races reported being physically assaulted — nearly twice that of any other group.

Female physicians encountered unwanted sexual advances and offensive sexist remarks (29.6% and 51%, respectively) at a much higher rate than male physicians (15.1% and 15%, respectively).

"The data highlights that to improve the work lives of minority physicians, we need equitable and inclusive work environments," says Dyrbye. "We need organizational strategies that reduce the frequency of inappropriate behaviors by patients, families, and visitors, and ways to effectively deal with them when they do occur so that we promote a culture where all physicians can thrive."

Some organizations have created patient and visitor conduct policies, similar to one that went into effect in 2017 at the Mayo Clinic, to help staff identify troubling patient behaviors, take appropriate action, and, if necessary, terminate care.

Dyrbye advises physicians to be diligent with regard to self-care. "Ways to reduce your risk of burnout include making career decisions that maximize your sense of meaning, value, and purpose in your work, engaging in coaching by professional credentialed coaches, working fewer hours, avoiding a mentality of delayed gratification, taking your vacation time, and purposefully building social support by taking time to connect with family, friends, and co-workers," says Dyrbye.

JAMA. Published online May 19, 2022. https://www.medscape.com/viewarticle/974248

By Mark Shapiro

As hospitalists, we make thousands of decisions each day, and often hundreds just for one patient. What is surprising is how those decisions impact us. In a famous study about the impact of decision making, published in the Journal of Personality and Social Psychology, researchers asked some participants to make choices between consumer products. Other participants only had to consider and contemplate the products without making any choices. The researchers discovered that those who had to make choices had less persistence when completing simple arithmetic calculations compared to those who didn’t have to make any decisions. Researchers also found that the decision-makers had more instances of procrastination and lower quality of work.

This research, along with other recent studies, has been used as evidence for what is called “decision fatigue.” It’s just as it sounds: the more we have to choose, the more we end up exhausted and drained, leaving us depleted at the end of the day. I’m no stranger to this. Every time I come off service, I try to be deliberate about observing myself and how I am feeling. More often than not, I found that I was simply tired; tired after yet another long day of decision making. While there is definitely more to why we hospitalists go home feeling exhausted each night, decision fatigue is undoubtedly a contributing factor.

For me, a big part of tending to this exhaustion came from finally recognizing that making choices was a part of it. If people had lower work quality and endurance after sifting through grocery products, imagine the result of thousands of high-stakes decisions that we go through? By recognizing decision fatigue, we can take conscious, deliberate steps to address it. To start, here are two reflections I want you to process to help you assess your level of decision fatigue:

1. How many decisions did I make today? Consider how many decisions of tremendous importance you made today. And how many easier decisions did you stack on top of those? It is estimated that the average American makes 35,000 conscious decisions each day. The greater your responsibility (and hospitalists have a lot), the more decisions we are faced with. Each decision is guided by impulse, assessment, risks/benefits, prioritization, and sometimes avoidance and deflection. It can be exhausting! 
2. Ask yourself: How can I minimize the number of decisions I need to make when I’m off?  How can you turn that decision fatigue into decision recovery? The idea is to potentially simplify and reduce the number of things that you have to make decisions about when going off service so that you can get the rest you need. Things like when you will schedule restorative downtime, what meals you’ll eat, and what you’ll be doing with family or friends can all add to decision fatigue. When trying to rest, it’s all about making sure you don’t have to continue to go through the cognitive process of making a decision. When we can simplify the number of decisions we need to make when we are off service, we can rest and recuperate so that we’re ready to make decisions again when we come back. 

Some decisions are unavoidable but can be minimized by doing a little work up front. For example, every weekend you can make a dinner menu for the week ahead, that way you always come home knowing the decision of what to eat has already been made for you. From now on, I encourage you to reflect on your decision load and just be observant of how decision fatigue affects you. Over time, you will notice more and more ways to decrease the choices you make every day. Once you give this a shot, come back and share your story in the comments below or on Linkedin or Twitter.

https://knowledge.practicingexcellence.com/a-two-step-strategy-to-reduce-decision-fatigue/?_hsmi=208360003&_hsenc=p2ANqtz--X_A0aonG2dKin2jzU0MNhmg1gVHJMRT3UgF03DUOYwiTOfZEO8UrKRQ1AmVukQo0AuoNo0cFJiV79Sawv4zcCpuB2H1n2nnxahstjwCsC1rTeyP0

About the Author

Mark Shapiro, MD is a hospitalist for Providence Medical Group in Sonoma County. He is also the host and producer of Explore The Space, a critically acclaimed national podcast that examines the interface of healthcare and society. You can find him on LinkedIn and Twitter.

400. That’s the number of physicians that die by suicide each year. Two graduating medical school classes worth of physicians lost to burnout, depression, and the overwhelming pressure of being in medicine. Not only that, there’s an estimated 13% of total physicians that have suicidal ideation. What’s worse, this was before the COVID 19 pandemic. Before our healthcare system was pushed to the absolute brink. Before clinicians had to see record numbers of patients dying. You can imagine how this number can and most likely will spike soon, especially during such troubling times. 

Like an increasing number of families of clinicians, my family has seen firsthand the toll of the pandemic on health care professionals. My sister-in-law, Dr. Lorna Breen, was an emergency medicine physician in New York City. She returned from a vacation as her ER was overflowing with COVID patients. The pandemic completely changed the world she knew; Lorna described it as returning to armageddon. Beds lined the hallways with dying patients as they lacked the necessary oxygen, PPE, and supplies to support the influx. Working 12+ hour days and fearing the loss of her medical license, Lorna’s well-being took a turn for the worst. By the time she called my wife Jennifer (her sister) for help, she had gone over a week without sleep and was nearly catatonic.

Lorna had no prior mental health issues or a history of depression or anxiety, yet after these events, she was hospitalized for mental health concerns for 11 days. Five days after discharge, she died by suicide on April 26, 2020. 

The intense scrutiny that follows seeking mental health help prevents so many clinicians from raising their hand, which is exactly what happened with Lorna (despite being in a state that does not ask about mental health conditions on state licensure applications). Jennifer and I founded the Dr. Lorna Breen Heroes’ Foundation to reduce burnout of health care professionals and safeguard their well-being and job satisfaction. We envision a world where seeking mental health services is universally viewed as a sign of strength for health care professionals. Now, more than ever, every one of us needs to sound the alarm and raise awareness of the elevated rates of burnout, depression, anxiety, and suicide that our front-line workers face and the absolute necessity of being able to get help when and where you need it. To start, let’s focus on three actions to help respond to the profound stressors that so many are feeling at the clinical front line:  

1. Find self-compassion. There are three key elements of having self-compassion: self-kindness, common humanity, and mindfulness. When you know you’re suffering, give yourself understanding, acknowledge that struggling is part of the human experience, and observe yourself non-judgmentally. Also, don’t be afraid to reach out to others, as they are most likely going through similar struggles, and just opening up could help yourself and them. 

2. Learn about it and talk openly about it. Opening up to a colleague about personal challenges can help. There’s a stigma in medicine regarding mental health in medicine; clinicians are overworked and see tragedy, and yet are expected to handle this without complaint or support. It’s to the point that this expectation leaves many silent to avoid having to report their challenges during credentialing or licensing or a fear of looking weak. This stigma makes it imperative to l understand health care workers’ burdens. By speaking out, we can diminish this stigma and normalize getting help when it’s needed. 

3. If you see something, intervene. Not everyone is going to join this new, pro-mental health movement immediately. There may be people who don’t want to open up or are still too apprehensive to raise their hand. If you see someone who may be struggling, check-in, and see how they are doing with empathy and support. We can’t overlook warning signs when clinicians become short-tempered, withdrawn, or isolating themselves from others. Ask, “I know we are all going through a lot now…how are you holding up?” 

We must create places and cultures where we feel safe and live in a world where seeking mental health services is viewed as a sign of authenticity and strength, embraced by their organizations and their leaders. Join us at the Foundation and Practicing Excellence in promoting clinician well-being and making health care safe for providers and patients.

Practicing Excellence full article: https://knowledge.practicingexcellence.com/400-doctors-per-year/

Physician burnout has long been a problem-one that has been intensified by the ever-changing and emotionally taxing circumstances of COVID-19. It at times has felt like a race with no finish line. Aiming for a constantly moving target.
According to Medscape, out of 5,000 surveyed physicians, almost two-thirds said the pandemic has increased their feeling of burnout, and over half also reported an increased sense of loneliness. 
There are many ways people try to counteract these emotions- the same survey reported that among healthcare workers, there has been an increase in food and alcohol consumption-but it's important to maintain healthy habits even when things are stressful.
As the holiday season ramps up, there's no better time to think about gratitude as a form of resilience. What do we have to be thankful for? According to Dr. Guy Winch, author of Emotional First Ald, "gratitude is an emotion that grounds us, and is a great way to balance out the negative mindset that uncertainty engenders." When there is so much happening around us that we do not have control of, it's important to take time to recognize what we do have control over, and what we have to be grateful for.
Shifting to a mindset of gratitude also has incredible health benefits, including lower blood pressure, better rest, and increased levels of happiness and satisfaction. Expressing gratitude also triggers the release of dopamine and serotonin, the chemicals that help us feel light
and happy. In practice, what does expressing gratitude look like? Try one of these exercises:

• Take five minutes to journal about what youre thankful for.
• Think about someone you miss and reach out to them.
• Think about what things you might take for granted each day, and reflect on how lucky you are to have them.
• Affirm something you are good at.
• Reflect on who you were a year ago: How have you changed and improved?
• Thank someone for something small they did that made your life easier.

Even on our busiest days, taking some time to shift our mindset to one of gratitude can help during times of intense stress and worry.
Our resilience depends on our ability to face hardship day after day, and being intentional about expressing our gratitude is a necessary and helpful step in that journey. 

By Kathy Perno, RN, MBA Gratudate Medical Education Chief Well-Being Officer and Rebecca Yeager, MD Graduate Medical Education Chief Well-Being Officer 

Vitals, Issue 2

Resiliency is one of the timeliest topics of the last 12 months, especially for healthcare providers. As we've had to adapt to stress, trauma, adversity, and fear of the unknown, its more important than ever to build your resilence.
The American Psychological Association recommends a few strategies:

• Build connections. Strengthening our connections with others has been challenging this year. Try to make time for your relatonships, even it that's communicating via Skype, Zoom, or over the phone. If you take stock and notice that you're lacking quality connections. consider joining or forming group to spend time with others who have similar interests. For example, you might join a running club, participate in cooking classes or start a photography group.
• Foster wellness. It's easier to improve you mental health when you are in good physical health. Focus on the habits that help you feel your best: sleep, good nutrition, hydration, and exercise. Practice mindfulness and gratitude every day. Try to avoid using, negative outlets or substances for stress relief, such as overeating or alcohol.
• Find purpose. As a healthcare provider, you are helping others every day, even in the midst of stressful circumstances. Recognize the positive ways you are contributing to others' well-being on a regular basis
• Be proactive. Large tasks or problems can easily overwhelm us. Find a way to conquer larger tasks by splitting them into several smaller ones. This can help make larger problems less overwhelming and help you accomplish your goals
• Embrace healthy thoughts. Research has shown that maintaining a positive outlook contributes to your overall happiness, creativity, and productivity. Change is inevitable- do your best to accept changes and move forward. Embracing that some things cannot be changed helps us refocus our offorts on circumstances we can control
• Ask for help. You dont have to build resilience in a silo, Recopnize your capabilities and limits and ask for help when you need it. This might look like asking a partner or friend to help with extra chores and caregiving, asking your co-worker for support with a big project, or seeking counseling services when its necessary. Whatever your needs, you don't have to go it alone.

By Robert Smith, MD Chief Medical Officer for Kettering Health and Rebecca Yeager, MD Chief Well-Being Officer for Gratudate Medical Education 

Physician Quarterly, Quarter 2 (Spring) 2021

Heidi Erickson, MD, is tired. As a pulmonary and critical care physician at Hennepin Healthcare, in Minneapolis, Minnesota, she has been providing care for patients with COVID-19 since the start of the pandemic. It was exhausting from the beginning, as she and her colleagues scrambled to understand how to deal with this new disease. But lately, she has noticed a different kind of exhaustion arising from the knowledge that with vaccines widely available, the latest surge was preventable. Her intensive care unit (ICU) is currently as full as it has ever been with COVID patients, many of them young adults and most of them unvaccinated. After the recent death of one patient, an unvaccinated man with teenage children, she had to face his family's questions about why ivermectin, an antiparasitic medication that was falsely promoted as a COVID treatment, was not administered. "I'm fatigued because I'm working more than ever, but more people don't have to die," Erickson told Medscape Medical News. "It's been very hard physically, mentally, emotionally." Amid yet another surge in COVID-19 cases around the United States, clinicians are speaking out about their growing frustration with this preventable crisis. Some are using the terms "empathy fatigue" and "compassion fatigue" — a sense that they are losing empathy for unvaccinated individuals who are fueling the pandemic. Erickson says she is frustrated not by individual patients but by a system that has allowed disinformation to proliferate. Experts say these types of feelings fit into a widespread pattern of physician burnout that has taken a new turn at this stage of the pandemic.

Paradoxical Choices Empathy is a cornerstone of what clinicians do, and the ability to understand and share a patient's feelings is an essential skill for providing effective care, says Kaz Nelson, MD, a psychiatrist at the University of Minnesota, Twin Cities.

Practitioners face paradoxical situations all the time, she notes. These include individuals who break bones and go skydiving again, people who have high cholesterol but continue to eat fried foods, and those with advanced lung cancer who continue to smoke. To treat patients with compassion, practitioners learn to set aside judgment by acknowledging the complexity of human behavior. They may lament the addictive nature of nicotine and advertising that targets children, for example, while still listening and caring. Empathy requires high-level brain function, but as stress levels rise, brain function that drives empathy tends to shut down. It's a survival mechanism, Nelson says.

When healthcare workers feel overwhelmed, trapped, or threatened by patients demanding unproven treatments or by ICUs with more patients than ventilators, they may experience a fight-or-flight response that makes them defensive, frustrated, angry, or uncaring, notes Mona Masood, DO, a Philadelphia-area psychiatrist and founder of Physician Support Line, a free mental health hotline for doctors. Some clinicians have taken to Twitter and other social media platforms to post about these types of experiences.

These feelings, which have been brewing for months, have been exacerbated by the complexity of the current situation. Clinicians see a disconnect between what is and what could be, Nelson notes. "Prior to vaccines, there weren't other options, and so we had toxic stress and we had fatigue, but we could still maintain little bits of empathy by saying, 'You know, people didn't choose to get infected, and we are in a pandemic.' We could kind of hate the virus. Now with access to vaccines, that last connection to empathy is removed for many people," she says.

Self-preservation vs Empathy

Compassion fatigue or empathy fatigue is just one reaction to feeling completely maxed out and overstressed, Nelson says. Anger at society, such as Erickson experienced, is another response. Practitioners may also feel as if they are just going through the motions of their job, or they might disassociate, ceasing to feel that their patients are human. Plenty of doctors and nurses have cried in their cars after shifts and have posted tearful videos on social media.

Early in the pandemic, Masood says, physicians who called the support hotline expressed sadness and grief. Now, she had her colleagues hear frustration and anger, along with guilt and shame for having feelings they believe they shouldn't be having, especially toward patients. They may feel unprofessional or worse ? unworthy of being physicians, she says. One recent caller to the hotline was a long-time ICU physician who had been told so many times by patients that ivermectin was the only medicine that would cure them that he began to doubt himself, says Masood. This caller needed to be reassured by another physician that he was doing the right thing. Another emergency department physician told Masood about a young child who had arrived at the hospital with COVID symptoms. When asked whether the family had been exposed to anyone with COVID, the child's parent lied so that they could be triaged faster.

The physician, who needed to step away from the situation, reached out to Masood to express her frustration so that she wouldn't "let it out" on the patient. "It's hard to have empathy for people who, for all intents and purposes, are very self-centered," Masood says. "We're at a place where we're having to choose between self-preservation and empathy." 

How to Cope

To help practitioners cope, Masood offers words that describe what they're experiencing. She often hears clinicians say things such as, "This is a type of burnout that I feel to my bones," or "This makes me want to quit," or "I feel like I'm at the end of my rope." She encourages them to consider the terms "empathy fatigue," and "moral injury" in order to reconcile how their sense of responsibility to take care of people is compromised by factors outside of their control. It is not shameful to acknowledge that they experience emotions, including difficult ones such as frustration, anger, sadness, and anxiety, Masood adds. Being frustrated with a patient doesn't make someone a bad doctor, and admitting those emotions is the first step toward dealing with them, she says. Nelson adds that taking breaks from work can help. She also recommends setting boundaries, seeking therapy, and acknowledging feelings early before they cause a sense of callousness or other consequences that become harder to heal from as time goes on. "We're trained to just go, go, go and sometimes not pause and check in," she says. Clinicians who open up are likely to find they are not the only ones feeling tired or frustrated right now, she adds. "Connect with peers and colleagues, because chances are, they can relate," Nelson says. For more Medscape Psychiatry news, join us on Facebook and Twitter.

https://www.medscape.com/viewarticle/958890?uac=359474DT&faf=1&sso=true&impID=3651748&src=WNL_dne8_210920_MSCPEDIT#vp_1

As the novel Coronavirus (COVID-19) global pandemic continues to unfold and confirmed positive cases in the United States increase, obstetrician-gynecologists (ob-gyns) are on the front lines caring for patients. Financial uncertainties, longer hours caring for sick patients, changing and adapting to new practice structures and guidelines to cut down on transmission, shortages of necessary medical equipment, and adapting to the constant and ever-changing clinical environment have added increased stress to ob-gyns. Further, physicians are faced with increased worry for family, friends, and colleagues that puts additional physical, mental, and emotional stress on themselves. Below, find tips and resources that will help with your mental, emotional, and physical wellbeing during this emergency health crisis.

Ensure your basic needs are being met. • Have you been eating regular, healthy meals and staying adequately hydrated? • Are you regularly getting a full night of restful sleep? • Have you been able to continue maintaining your normal exercise routine, including time spent outdoors? • If you practice mindfulness and meditation, are you prioritizing the continuation of that practice?

Maintain communication with loved ones and colleagues. While maintaining the recommended social distancing practices, you can still regularly check in with your loved ones. Carve out time in your homes to spend quality time with family members each day. Utilize video technology on your phones and computers to maintain communication with loved ones living outside your home. Check in with your colleagues throughout your workday and shifts to ensure they are okay.

Utilize self check-ins to ensure that your health and your wellbeing are not deteriorating. Monitor yourself for any symptoms of increased stress and burnout. Be aware and mindful to ensure you are not falling into using poor coping strategies. If you find that you are experiencing these changes in your mental health and wellbeing, reach out to your loved ones, your colleagues, or a professional for help.

For additional resources, toolkits, and guidance regarding your wellbeing, please visit the following:

• AMA: Caring for our Caregivers during COVID-19 – provides strategies for health systems and leadership that would support physicians and HCPs during COVID-19.

• Stanford Medicine WellMD Center – provides links to wellness quizzes and resources for exercises, burnout, trauma stress, and mindfulness training tailored for physicians.

• NAM: Action Collaborative on Clinician Well-Being and Resilience – provides a comprehensive list of resources on how to support the well-being of physicians and other health care clinicians during COVID-19

Finally, know that you can connect with your ACOG Member colleagues at anytime utilizing the ACOG Engage feature. Engage with your ACOG online community to connect and share tips and ideas for ways you can support your personal wellbeing and ways you can help to assist your colleagues. Please check back as ACOG continues to develop wellness resources for you!

https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/brochures-flyers/physician-wellness-and-covid-19.pdf?la=en&hash=873EAEB5BA866FC09C4C2B468B87157F

4 approaches to cut physicians’ mental workload—and burnout | American Medical Association (ama-assn.org)

It has been shown that physicians with higher levels of cognitive workload have increased rates of burnout. This means that even a small drop in task load can cut the odds of physician burnout. By evaluating the effort and time demand required to complete tasks—and considering ways to decrease or distribute both—physician practices and health systems can cut cognitive workload and rates of doctor burnout.

“Contrary to how we behave, your attention is a limited resource, and you need to protect that,” Elizabeth Harry, MD, said during a recent AMA webinar. “If we don't have space to actually give proper attention to things, we're going to start making mistakes and we're not going to give our best care. … We need to be really cognizant of this.

“One of the best ways to function cognitively is to use up your working memory with a task,” added Dr. Harry, senior director of clinical affairs at the University of Colorado Hospital. “That would be 25 minutes of focused attention and then you take a break, so that working memory is able to replete and all that cognitive load goes away.”

At the hospital, Dr. Harry’s focus is on helping physicians and other health professionals enhance patient engagement while also addressing issues regarding well-being.  She outlined four approaches that health leaders can take to address the system issues that drive physician burnout.
 

Increase standardization

Think about Steve Jobs and his everyday attire of black turtlenecks and blue jeans. He didn’t have to think about what he was going to wear every day, said Dr. Harry. “The other piece that’s really important to know is that every habit you make … comes out of that short-term memory box and goes into long-term memory.

“It is important to be mindful of our habits to make sure they’re all ones that serve us but can actually intentionally build habits and routines,” she added. That is why you should “standardize everything that you can across units and hospitals.”

“In an ideal world, you would walk into a unit and it would be organized exactly the same as the next unit,” said Dr. Harry. “You wouldn't have to spend time thinking about how to do some of these things.”
 

Decrease redundancy

“If you think about high-reliability organizations, they don't have seven different ways that they do the process,” said Dr. Harry. Instead, “they have one highly reliable way.”

For example, if a doctor has a patient with blood cultures and they get notified of results in a different way each time, that is not reliable. There must be one way to get notified every single time.

“A lot of times we think the more redundancy the better, but it can actually get to the point where it’s cumbersome and it makes it harder to get the job done,” she said.
 

Consolidate data

When the plot of a novel is presented in a disorganized way, it takes more energy for the reader to put the story together. It’s the same for health systems and physician practices.

“The idea here is that you bring everything you need for a workflow together in one space,” said Dr. Harry. “This is the idea in many EHRs. There are certain disease-state tabs now where you can click on a diabetes screen and it has everything I would need to think about for my patient for diabetes right there.”

That is an example of “decreasing split attention by consolidating the data,” she said. “Part of this is process coupling too, and that’s part of the making routines and making habits.

“As much as you can couple processes together and make them partner together routinely, then you’ll be able to make that a habit,” said Dr. Harry.
 

Reduce interruptions

It is important “to have an agreement among your team of what warrants an interruption,” said Dr. Harry. “Just because someone else has a thought doesn’t mean it is the moment that we need to talk about it.

“In fact, that may be interrupting a very crucial cognitive process, so let’s have a discussion about what warrants interrupting that crucial cognitive process,” she added. “As much as possible, have blocks of uninterrupted work where you can sit and focus.”

The global COVID-19 pandemic has escalated everyone’s stress levels, especially clinicians caring for hospitalized patients. New pressures have added to everyday stress, new studies have revised prior patient care recommendations, and the world generally seems upside down. What can a busy hospitalist do to maintain a modicum of sanity in all the craziness?

The stressors facing hospitalists

Uncertainty

Of all the burdens COVID-19 has unleashed, the biggest may be uncertainty. Not only is there unease about the virus itself, there also is legitimate concern about the future of medicine, said Elizabeth Harry, MD, SFHM, a hospitalist and senior director of clinical affairs at the University of Colorado Hospital in Aurora.

“What does it look like after an event like this, particularly in areas like academic medicine and teaching our next generation and getting funding for research? And how do we continue to produce physicians that can provide excellent care?” she asked.

There is also uncertainty in the best way to care for patients, said Eileen Barrett, MD, MPH, SFHM, a hospitalist at the University of New Mexico, Albuquerque.

“There are some models that are emerging to predict who will have a worse outcome, but they’re still not great models, so we have uncertainty for a given patient.” And, she noted, as the science continues to evolve, there exists a constant worry that “you might have inadvertently caused someone harm.”

The financial implications of the pandemic are creating uncertainty too. “When you fund a health care system with elective procedures and you can’t do those, and instead have to shift to the most essential services, a lot of places are seeing a massive deficit, which is going to affect staff morale and some physician offices are going to close,” said Elisabeth Poorman, MD, MPH, a primary care and internal medicine physician and chair of the King County Medical Society Physician Wellness Committee in Seattle.

Fear

When the pandemic began in the United States, “fear of the unknown was perhaps the scariest part, particularly as it pertained to personal protective equipment,” said Mark Rudolph, MD, SFHM, chief experience officer and vice president of patient experience and physician development at Sound Physicians in Tacoma, Wash. “For most clinicians, this is the first time that they are themselves in harm’s way while they do their jobs. And worse, they risk bringing the virus home to their families. That is the concern I hear most.”

Anxiety

Worrying about being able to provide excellent patient care is a big stressor, especially since this is the heart and soul of why most hospitalists have gone into their line of work.

“Part of providing excellent care to your patients is providing excellent supportive care to their families,” Dr. Harry said. “There’s some dissonance there in not being able to allow the family to come visit, but wanting to keep them safe, and it feels really hard to support your patients and support their families in the best way. It can feel like you’re just watching and waiting to see what will happen, and that we don’t have a lot of agency over which direction things take.”

There is concern for health care team members as well, Dr. Harry added. “Physicians care a lot about their teams and how they’re doing. I think there’s a sense of esprit de corps among folks and worry for each other there.”

Guilt

Although you may be at the hospital all day, you may feel guilty when you are not providing direct patient care. Or maybe you or someone on your team has an immunodeficiency and can’t be on the front line. Perhaps one of your team members contracted COVID-19 and you did not. Whatever the case, guilt is another emotion that is rampant among hospitalists right now, Dr. Barrett said.

Burnout

Unfortunately, burnout is a potential reality in times of high stress. “Burnout is dynamic,” said Dr. Poorman. “It’s a process by which your emotional and cognitive reserves are exhausted. The people with the highest burnout are the ones who are still trying to provide the standard of care, or above the standard of care in dysfunctional systems.”

Dr. Harry noted that burnout presents in different ways for different people, but Dr. Rudolph added that it’s crucial for hospitalist team members to watch for signs of burnout so they can intervene and/or get help for their colleagues.

Warning signs in yourself or others that burnout could be on the horizon include:

• Fatigue/exhaustion – Whether emotional or physical (or both), this can become a problem if it “just doesn’t seem to go away despite rest and time away from work,” said Dr. Rudolph.
• Behavioral changes – Any behavior that’s out of the ordinary may be a red flag, like lashing out at someone at work.
• Overwork – Working too much can be caused by an inability to let go of patient care, Dr. Barrett said.
• Not working enough – This may include avoiding tasks and having difficulty meeting deadlines.
• Maladaptive coping behaviors – Excessive consumption of alcohol or drugs is a common coping mechanism. “Even excessive consumption of news is something that people are using to numb out a little bit,” said Dr. Harry.
• Depersonalization – “This is where you start to look at patients, colleagues, or administrators as ‘them’ and you can’t connect as deeply,” Dr. Harry said. “Part of that’s protective and a normal thing to do during a big trauma like this, but it’s also incredibly distancing. Any language that people start using that feels like ‘us’ or ‘them’ is a warning sign.”
• Disengagement – Many people disengage from their work, but Dr. Poorman said physicians tend to disengage from other parts of their lives, such as exercise and family interaction.

Protecting yourself while supporting others

Like the illustration of putting the oxygen mask on yourself first so you can help others, it’s important to protect your own mental and physical health as you support your fellow physicians. Here’s what the experts suggest.

Focus on basic needs

“When you’re in the midst of a trauma, which we are, you don’t want to open all of that up and go to the depths of your thoughts about the grief of all of it because it can actually make the trauma worse,” said Dr. Harry. “There’s a lot of literature that debriefing is really helpful after the event, but if you do it during the event, it can be really dangerous.”

Instead, she said, the goal should be focusing on your basic needs and what you need to do to get through each day, like keeping you and your family in good health. “What is your purpose? Staying connected to why you do this and staying focused on the present is really important,” Dr. Harry noted.

Do your best to get a good night’s sleep, exercise as much as you can, talk to others, and see a mental health provider if your anxiety is too high, advises Dr. Barrett. “Even avoiding blue light from phones and screens within 2 hours of bedtime, parking further away from the hospital and walking, and taking the stairs are things that add up in a big way.”

Keep up your normal routine

“Right now, it’s really critical for clinicians to keep up components of their routine that feel ‘normal,’ ” Dr. Rudolph said. “Whether it’s exercise, playing board games with their kids, or spending time on a hobby, it’s critical to allow yourself these comfortable, predictable, and rewarding detours.”

Set limits

People under stress tend to find unhealthy ways to cope. Instead, try being intentional about what you are consuming by putting limits on things like your news, alcohol consumption, and the number of hours you work, said Dr. Harry.

Implement a culture of wellness

Dr. Barrett believes in creating the work culture we want to be in, one that ensures people have psychological safety, allows them to ask for help, encourages them to disconnect completely from work, and makes them feel valued and listened to. She likes the example of “the pause,” which is called by a team member right after a patient expires.

“It’s a 30-second moment of silence where we reflect on the patient, their loved ones, and every member of the health care team who helped support and treat them,” said Dr. Barrett. “At the conclusion, you say: ‘Thank you. Is there anything you need to be able to go back to the care of other patients?’ Because it’s unnatural to have this terrible thing that happened and then just act like nothing happened.”

Target resources

Be proactive and know where to find resources before you need them, advised Dr. Harry. “Most institutions have free mental health resources, either through their employee assistance programs or HR, plus there’s lots of national organizations that are offering free resources to health care providers.”

Focus on what you can control

Separating what is under your control from what is not is a struggle for everyone, Dr. Poorman said, but it’s helpful to think about the ways you can have an impact and what you’re able to control.

“There was a woman who was diagnosed with early-onset Parkinson’s that I heard giving an interview at the beginning of this pandemic,” she said. “It was the most helpful advice I got, which was: ‘Think of the next good thing you can do.’ You can’t fix everything, so what’s the next good thing you can do?”

Maintain connectivity

Make sure you are utilizing your support circle and staying connected. “That sense of connection is incredibly protective on multiple fronts for depression, for burnout, for suicide ideation, etc.,” Dr. Harry said.

“It doesn’t matter if it’s your teammates at work, your family at home, your best friend from medical school – whomever you can debrief with, vent with, and just share your thoughts and feelings with, these outlets are critical for all of us to process our emotions and diffuse stress and anxiety,” said Dr. Rudolph.

Dr. Poorman is concerned that there could be a spike in physician suicides caused by increased stress, so she also encourages talking openly about what is going on and about getting help when it’s necessary. “Many of us are afraid to seek care because we can actually have our ability to practice medicine questioned, but now is not the time for heroes. Now is the time for people who are willing to recognize their own strengths and limitations to take care of one another.”

Be compassionate toward others

Keep in mind that everyone is stressed out and offer empathy and compassion. “I think everybody’s struggling to try to figure this out and the more that we can give each other the benefit of the doubt and a little grace, the more protective that is,” said Dr. Harry.

Listening is meaningful too. “Recognizing opportunities to validate and acknowledge the feelings that are being shared with you by your colleagues is critical,” Dr. Rudolph said. “We all need to know that we’re not alone, that our thoughts and feelings are okay, and when we share a difficult story, the value of someone saying something as simple as, ‘wow, that sounds like it was really hard,’ is immense.”

Be compassionate toward yourself

Try to give yourself a break and be as compassionate with yourself as you would with others. It’s okay that you’re not getting in shape, publishing prolifically, or redesigning your house right now.

“There’s a lot of data linking lack of self-compassion to burnout,” said Dr. Harry. She says there are courses on self-compassion available that help you work on being kinder to yourself.

Get a “battle buddy”

The American Medical Association has a free “buddy system” program called PeerRx to help physicians cope during the pandemic. Dr. Rudolph said that now is a great time to use this military-developed intervention in which each team member checks in with a chosen partner at agreed-upon intervals.

For example, “You can tell that person: ‘If I don’t call my family for a week that’s a red flag for me.’ And then you hold each other accountable to those things,” Dr. Harry said.

The buddy system is another way to harness that sense of connection that is so vital to our health and well-being.

“The simple act of showing that you care … can make all the difference when you’re doing this kind of work that is both challenging and dangerous,” said Dr. Rudolph.

https://www.the-hospitalist.org/hospitalist/article/224085/coronavirus-updates/hospitalist-well-being-during-pandemic

WIESBADEN, Germany - Making physical, mental and spiritual health a priority can help those struggling with the stresses of the COVID-19 pandemic.

“Living through a pandemic is a highly abnormal event, and it can be a roller coaster of emotions and experiences,” said Dr. Jamie Moore, chief of Behavioral Health at the Wiesbaden Army Health Clinic. She noted that although every person’s experience is different,” as a military community, we are uniquely postured to survive and thrive in adverse environments.”

Early on in the crisis, people worldwide rushed out to stock up on toilet paper and other items as their sense of safety was challenged by this new and unfamiliar threat.

“Behaviors like that really come down to a desire to feel prepared and like your needs will be met,” Moore said.

Individuals whose safety, and that of their family members, is a big source of stress may need to focus on what makes them feel safe, she said.

“Structure and predictability increase feelings of safety, so work to create structure in your day-to-day life,” Moore said. “Some people feel safest when they have people around them; other people feel safer when they have an area all to themselves. So that may mean spending more time doing shared activities with the people in your household, asking your partner for more hugs or physical touch, or scheduling virtual daily contact with friends or family.”

Since the COVID-19 crisis began, many people may be experiencing negative emotions such as boredom, loneliness, grief and even helplessness, said Capt. Victoria Cashio, Behavioral Health officer for the 2nd Signal Brigade.

“Throughout our lives we have learned many ways to soothe or subdue these negative emotions,” she said. “Some of these techniques are healthier than others. Some of us look for food, shopping or alcohol to numb. These behaviors are normal in moderation, but performing them in excess may have disastrous consequences that can perpetuate our negative emotions.”

Cashio recommended that instead of externally soothing, people take a moment to notice what’s going on inside their body and express it.

“This may be a good time to try techniques like meditation, journaling, exercise, prayer or talking to someone you trust,” she said. “These activities allow you to take action without losing control. It’s okay to have the occasional cookie binge, but if it is important to you to step away from old habits, take the time to figure out what went wrong and make a plan for next time.”

People can use self-care in multiple aspects of their life to gain resilience in stressful times.

Exercises, sunlight and breathing techniques are three ways to improve physical health that also benefit mental health, said Jason Mohilla, U.S. Army Garrison Wiesbaden Army Substance Abuse Program specialist.

People who don’t normally exercise can start with stretching, which goes a long way, he said. He also noted that Vitamin D is a major factor in keeping a healthy chemical balance. He recommended looking online for videos for stretching and breathing exercises.

“Controlled breathing can help clear the mind, reduce heartrate and lower blood pressure,” Mohilla said.

Exercise also can release agitation and things like yoga, meditation and breathing exercise can be helpful, Moore said.

“There is a reason you are seeing so many recommendations and resources for yoga and mindfulness right now - we know that these things calm the physiological reaction that happens during stress.”

Mental health is interconnected with physical and spiritual health, and a person’s physical health and mental condition can determine how stress affects them physically, emotionally and relationally, said Dr. John Kaiser, USAG Wiesbaden Employee Assistance Program coordinator.

Kaiser uses a 3 + 4 formula to explain the daily things individuals should do for stress management and whole person health:

1. SLEEP – Not sleeping well can cause things such as cognitive impairment and cardiovascular issues. “If you are not getting at least seven hours, you probably need to talk with your physician,” Kaiser said.

2. EXERCISE – Many people working from home may not be getting up and about as much. Getting appropriate physical fitness every day is always important but especially now with teleworking, Kaiser said.

3. NUTRITION – It’s important to eat properly and watch alcohol consumption. “We do know that alcohol affects our sleep,” Kaiser said. People who have problems with drinking may be using alcohol to self-medicate, but we do know that rather than helping, it actually creates more problems, he added.

4. WHOLE HEALTH – The fourth part of the 3 + 4 formula involves the four basic components of health coming together to support the whole person: physical, emotional, spiritual and relational health. This is known as holistic or whole person health.

“The theory behind it is, if you are negatively affected traumatically in one area of your life, you use the strength that you have in those other areas of your life to bring to bear against those things that are challenging you,” Kaiser said. “So that’s how you bring balance and restore yourself from those things that are affecting you.”

There’s no shame in reaching out, Kaiser said, adding that the garrison resources are confidential. For more information on mental health and Task Force Wellness community resources, visit https://home.army.mil/wiesbaden/index.php/coronavirus.

https://www.army.mil/article/236264/self_care_essential_for_maintaining_mental_health_and_well_being_during_covid_19

WIESBADEN, Germany - Making physical, mental and spiritual health a priority can help those struggling with the stresses of the COVID-19 pandemic.

“Living through a pandemic is a highly abnormal event, and it can be a roller coaster of emotions and experiences,” said Dr. Jamie Moore, chief of Behavioral Health at the Wiesbaden Army Health Clinic. She noted that although every person’s experience is different,” as a military community, we are uniquely postured to survive and thrive in adverse environments.”

Early on in the crisis, people worldwide rushed out to stock up on toilet paper and other items as their sense of safety was challenged by this new and unfamiliar threat.

“Behaviors like that really come down to a desire to feel prepared and like your needs will be met,” Moore said.

Individuals whose safety, and that of their family members, is a big source of stress may need to focus on what makes them feel safe, she said.

“Structure and predictability increase feelings of safety, so work to create structure in your day-to-day life,” Moore said. “Some people feel safest when they have people around them; other people feel safer when they have an area all to themselves. So that may mean spending more time doing shared activities with the people in your household, asking your partner for more hugs or physical touch, or scheduling virtual daily contact with friends or family.”

Since the COVID-19 crisis began, many people may be experiencing negative emotions such as boredom, loneliness, grief and even helplessness, said Capt. Victoria Cashio, Behavioral Health officer for the 2nd Signal Brigade.

“Throughout our lives we have learned many ways to soothe or subdue these negative emotions,” she said. “Some of these techniques are healthier than others. Some of us look for food, shopping or alcohol to numb. These behaviors are normal in moderation, but performing them in excess may have disastrous consequences that can perpetuate our negative emotions.”

Cashio recommended that instead of externally soothing, people take a moment to notice what’s going on inside their body and express it.

“This may be a good time to try techniques like meditation, journaling, exercise, prayer or talking to someone you trust,” she said. “These activities allow you to take action without losing control. It’s okay to have the occasional cookie binge, but if it is important to you to step away from old habits, take the time to figure out what went wrong and make a plan for next time.”

People can use self-care in multiple aspects of their life to gain resilience in stressful times.

Exercises, sunlight and breathing techniques are three ways to improve physical health that also benefit mental health, said Jason Mohilla, U.S. Army Garrison Wiesbaden Army Substance Abuse Program specialist.

People who don’t normally exercise can start with stretching, which goes a long way, he said. He also noted that Vitamin D is a major factor in keeping a healthy chemical balance. He recommended looking online for videos for stretching and breathing exercises.

“Controlled breathing can help clear the mind, reduce heartrate and lower blood pressure,” Mohilla said.

Exercise also can release agitation and things like yoga, meditation and breathing exercise can be helpful, Moore said.

“There is a reason you are seeing so many recommendations and resources for yoga and mindfulness right now - we know that these things calm the physiological reaction that happens during stress.”

Mental health is interconnected with physical and spiritual health, and a person’s physical health and mental condition can determine how stress affects them physically, emotionally and relationally, said Dr. John Kaiser, USAG Wiesbaden Employee Assistance Program coordinator.

Kaiser uses a 3 + 4 formula to explain the daily things individuals should do for stress management and whole person health:

1. SLEEP – Not sleeping well can cause things such as cognitive impairment and cardiovascular issues. “If you are not getting at least seven hours, you probably need to talk with your physician,” Kaiser said.

2. EXERCISE – Many people working from home may not be getting up and about as much. Getting appropriate physical fitness every day is always important but especially now with teleworking, Kaiser said.

3. NUTRITION – It’s important to eat properly and watch alcohol consumption. “We do know that alcohol affects our sleep,” Kaiser said. People who have problems with drinking may be using alcohol to self-medicate, but we do know that rather than helping, it actually creates more problems, he added.

4. WHOLE HEALTH – The fourth part of the 3 + 4 formula involves the four basic components of health coming together to support the whole person: physical, emotional, spiritual and relational health. This is known as holistic or whole person health.

“The theory behind it is, if you are negatively affected traumatically in one area of your life, you use the strength that you have in those other areas of your life to bring to bear against those things that are challenging you,” Kaiser said. “So that’s how you bring balance and restore yourself from those things that are affecting you.”

There’s no shame in reaching out, Kaiser said, adding that the garrison resources are confidential. For more information on mental health and Task Force Wellness community resources, visit https://home.army.mil/wiesbaden/index.php/coronavirus.

https://www.army.mil/article/236264/self_care_essential_for_maintaining_mental_health_and_well_being_during_covid_19

Post-traumatic stress disorder (PTSD) is under recognized in physicians, even though it may be more prevalent in physicians than in the general population in the United States. Five types of physicians appear to be particularly prone to developing PTSD: (1) Emergency physicians; (2) Physicians practicing in under served and remote areas; (3) Physicians in training (i.e., medical residents); (4) Physicians involved in malpractice litigation; and (5) Physicians who are “second victims” in the sense that they are indirectly exposed to trauma.

In addition to experiencing trauma, the cumulative stress of practice may cause PTSD. The road to recovery for physicians with PTSD entails proper diagnosis and treatment, which includes maintaining a high index of suspicion for the occurrence of PTSD in predisposed physicians, and individual or group therapy. Physicians in leadership positions should advocate for effective support programs for their colleagues with PTSD.

PTSD affects physicians’ well-being and their ability to care for patients. 

In one study of 212 residents, 13% met diagnostic criteria for PTSD attributed to stresses associated with internship. 2 This percentage is much higher than the 8.7% projected lifetime risk for PTSD in the general population in the United States.3 Recent evidence suggests that PTSD often persists in late life, causing impairment in role functioning, mobility, cognition, and social interactions.4 For physicians, the implications are obvious: PTSD not only affects their well-being, but also their ability to care for patients. 

My review of the literature—most of which is anecdotal rather than based on hard evidence—indicates that certain physicians may be at higher risk for developing PTSD. I consider five categories of physicians most at risk. 

Emergency Medicine Physicians 

Mills and Mills evaluated PTSD in residents in emergency medicine.5 Of the 59 residents evaluated, all reported experience with patient death or dying. Seven residents (11.9%) reported sufficient symptoms to meet criteria for PTSD. Symptoms of PTSD significantly increased as resident level of training increased. The reason for this trend was unknown, but one possible explanation is that, in some cases, PTSD may result from the cumulative effect of stress over time rather than exposure to a single traumatic event. 

Emergency physician Dr. Edwin Leap observed, “A significant number of our colleagues in emergency care . . . become gravely wounded, ironically wounded, one might say, as they try to help and heal. They develop posttraumatic stress disorder. A physician . . . spends decades watching the life-blood drain out of people, giving them bad news, seeing the effects of drugs and violence, and pronouncing people dead...”6 Leap lamented that many physicians with PTSD suffer in silence, and medical stoics consider them “weak for feeling the pain.” 

Physicians Practicing in Underserved Areas 

Ontario family practitioner Dr. Nicola Wilberforce and colleagues evaluated PTSD in 159 physicians practicing in a predominantly rural and remote and medically underserviced region of Canada.7 These investigators found that the prevalence of probable PTSD was 4.4%, which they believed was “unnecessarily conservative.” Physicians identified overwork, insufficient resources, and relationships with colleagues and patients as common stressors. 

Interestingly, a large majority of physicians cited work stress rather than significantly traumatic exposures as causing PTSD, further supporting the notion that continuous stress without specific trauma may give rise to PTSD. Not surprisingly, absenteeism from work was significantly greater in physicians with PTSD than those without it. While work productivity was not directly measured in this study, the authors surmised that PTSD could have “profound impacts on work performance [that] would translate into a reduction in the numbers of patients seen and a higher rate of medical error.” 

Medical Residents 

As previously mentioned, survey-based screening studies of residents in training suggest a considerable (12%–13%) rate of PTSD. One of the most compelling cases of PTSD in residents I have come across is described by Dr. Danielle Ofri in her book What Doctors Feel: How Emotions Affect the Practice of Medicine.8 

Intimidation and bullying may be at the root of some cases of PTSD in trainees. 

Ofri, an associate professor of medicine at New York University School of Medicine, described the story of “Eva,” an intern traumatized when she was forced by a senior resident to enter a supply closet and let a newborn infant die in her arms (the newborn was doomed to instant death due to Potter syndrome). Ofri remarked, “Eva’s residency was truly a traumatic experience in which survival was the mode of operation. And the PTSD that resulted was real.” Ofri, herself, admits to the shame and humiliation of a medication error that nearly killed a patient and her ongoing fear of making another mistake. 

Intimidation and bullying may be at the root of some cases of PTSD in trainees. In Eva’s case, an insensitive senior resident was in command and barking orders, forcing her to act against her will. In Ofri’s case, she was gravely reprimanded by a senior resident in the presence of her intern. Ofri felt like “dying away on the spot.” She often relives the details of her mistake, which are “crisply stored in the linings of my heart.”

Physicians Involved in Malpractice Litigation 

In their book Physicians Survival Guide to Litigation Stress,9 pulmonologist W. Edward Davis and psychologist John M. James make a convincing case that the symptoms many doctors suffer for years after a malpractice suit best fit the diagnosis of PTSD. Physicians who experience litigation stress tend to revisit many of the painful and distressing memories surrounding depositions and, especially, the trial. 

Dr. Thomas L. Schwenk, Dean of the University of Nevada School of Medicine, recently described his experience as a defendant charged with medical malpractice10: “In the courtroom, it is an entirely different experience [compared with the medical setting]. The plaintiff’s attorney makes statements that cannot be challenged, makes scientific claims that are fundamentally false, and accuses me of failures to which I cannot respond. I become so phobic about hearing my name that I almost physically jump each time it is said by the plaintiff’s attorney. Eventually I simply cringe at the sound of his voice.” 

Schwenk continues, “It is simple to ask questions that make me look incompetent and foolish when I have failed to predict the unknowable future. As the jury is given final instructions, I try to let go of my anxiety about the verdict and my frustration at being unable to control the outcome. I want to focus on my fundamental belief that I did the right thing, that I would make the same decision again (which I would), and that, whatever the jury decides, my life as a physician will go on.” 

Unfortunately, for many physicians ensnared in malpractice litigation, ensuing symptoms of PTSD may prevent them from functioning normally again. Functional consequences of PTSD include high levels of social, occupational, and physical disability, as well as considerable economic costs and high levels of medical utilization. Occupational success may be lowered.3 

Second Victims 

“Second victims” are physicians and other healthcare providers involved in unanticipated adverse patient events or medical errors who become victimized in terms of feeling traumatized by the event. Frequently, second victims feel personally responsible for the unexpected patient outcomes and feel as though they have failed their patients. They begin to doubt their clinical skills, knowledge base, and career choice.11 

Second victims are more or less innocent bystanders to trauma. I believe my own PTSD was the result of being a second victim in the sense that I never saw the patient, nor was I asked to see him. I based my treatment on the word of another physician, albeit a physician with less experience than I. I blamed myself for the bad outcome and regretted not evaluating the patient even though the outcome probably would have been the same had I done the evaluation. Nevertheless, I felt ashamed of my inaction, and I imprisoned myself in a world of “what ifs,” constantly second-guessing my decision-making. 

DETECTION AND TREATMENT 

According to Dr. James S. Kennedy, formerly a member of the department of medicine at Vanderbilt University, PTSD is an outgrowth of toxic shame.12 Kennedy commented, “I believe that most physicians have PTSD and that the resulting feeling that physicians ignore most is toxic shame. Shame has been defined as the failure to live up to one’s own expectations. I define shame as a healthy sense that one is limited, and toxic shame as the belief that one is defective.” Apparently, physicians with PTSD are unable to make this distinction. 

The road to recovery for physicians with PTSD is difficult, and a full discussion of treatment considerations is beyond the scope of this article. However, a few points should be emphasized. 

First, healthcare providers need to maintain a high index of suspicion for PTSD in their physician patients. Physicians, themselves, may not be aware they are suffering PTSD even though they may clearly manifest the symptoms. In one study,13 only 2% of primary care patients meeting the criteria for PTSD were given a diagnosis of PTSD by their physicians. Attention to a history of trauma, and querying physicians at risk for PTSD about specific symptoms, could improve the detection of this disabling disorder. 

Antidepressants and other medications may be useful in selected cases. 

Second, cognitive behavioral therapy with a trained psychiatrist, psychologist, or other professional can help change emotions, thoughts, and behaviors associated with PTSD and can facilitate managing panic, anger, and anxiety. In fact, cognitive therapy for PTSD delivered intensively over little more than a week may be as effective as cognitive therapy delivered over three months.14 Antidepressants and other medications may be useful in selected cases to reduce symptoms such as anxiety, depression, and insomnia, and may decrease urges to use alcohol and other drugs. 

Dr. Ellen D. Feld is a physician who helps train physicians’ assistants at Drexel University College of Nursing and Health Professions in Philadelphia, Pennsylvania. When asked about her reluctance to be an organ donor, Feld said her reasons were not rational: “They relate to being a physician and to the trauma of medical training,” she said.15

Feld explained, “‘Trauma’ may sound like hyperbole. But however you describe it, medical education is stressful, exhausting, and eye-opening, and most of us emerge from it changed in crucial ways. After taking part in countless ‘codes,’ for example, many of my fellow residents and I vowed never to allow that rib-breaking violence to be inflicted upon our loved ones or ourselves (we joked about getting ‘Do Not Resuscitate’ tattooed on our chests).”15 

This brings us to the third and perhaps most important point. Group therapy for trainees and practicing physicians, whether or not they have PTSD, can help them learn to communicate their feelings about trauma and stress and create a support network. Few professions carry the same burden of unrealistically high levels of error-free expectations, personal responsibilities, and the day-to-day levels of stress as that of a practicing physician. If significant progress is to be made in recognizing and treating physicians with PTSD, it may be up to physician leaders to highlight the pressing need for effective support programs to mitigate adverse career outcomes. 

Given the vulnerability of medical residents to PTSD, and the potential for symptoms to become chronic, intervention should begin early in training, preferably in medical school. Feld concludes, “Any traumatic experience can have lasting psychological effects, and medical education is no exception. But these effects can be overcome. It is possible to ‘get over it.’”15 

REFERENCES 

1. Persuad R. Post-traumatic stress disorder in doctors. Student BMJ. 2005;13:133-176. 
2. Klamen DL, Grossman LS, Kopacz D. Posttraumatic stress disorder symptoms in resident physicians related to their internship. Acad Psychiatry. 1995;19:142-149. 
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association. 2013. 
4. Byers AL, Covinsky KE, Neylan TC, Yaffe K. Chronicity of posttraumatic stress disorder and risk of disability in older persons. JAMA Psychiatry. 2014;71:540-546. 
5. Mills LD, Mills TJ. Symptoms of post-traumatic stress disorder among emergency medicine residents. J Emerg Med. 2005;28:1-4. 
6. Leap E. Stop sucking it up. Emergency Medical News. 2013;35(8):8-11. 
7. Wilberforce N, Wilberforce K, Aubrey-Bassler FK. Post-traumatic stress disorder in physicians from an underserviced area. Fam Pract. 2010;27:339-343. 
8. Ofri D. What Doctors Feel: How Emotions Affect the Practice of Medicine. Boston: Beacon Press; 2013. 
9. James JM, Davis WE. Physicians Survival Guide to Litigation Stress. Lafayette, CA: Physician Health Publications; 2006. 
10. Schwenk TL. The moment of truth. JAMA. 2014;311:573-574. 
11. Scott SD, Hirschinger LE, Cox KR, McGoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18:325-330. 
12. Kennedy JS. Physicians’ feelings about themselves and their patients (letter). JAMA. 2002;287:1113. 
13. Taubman-Ben-Ari O, Rabinowitz J, Feldman D, Vaturi R. Post-traumatic stress disorder in primary-care settings: prevalence and physicians’ detection. Psychol Med. 2001;31:555-560. 
14. Ehlers A, Hackmann A, Grey N, et al. A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. Am J Psychiatry. 2014;171:294-304. 
15. Feld ED. Time to get over it. JAMA. 

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About 300 to 400 physicians die by suicide each year, averaging one per day. Physician suicide is part of an epidemic—an epidemic of burnout, depression, and departure from medical practice through early retirement or a change to a nonclinical career.

On average, one physician in the United States completes suicide each day. But when the doctor is your personal physician, it paints physician suicide in a different light. Patients rarely are privy to the circumstances surrounding the suicide deaths of their physicians, so these deaths often leave them confused and unable to obtain closure, possibly making it difficult to move on with their healthcare. The causes of suicide are multifaceted, but discussions with bereaved family, friends, and colleagues may reveal clinical insights. Preventing some suicides may be possible by eliminating the stigma surrounding mental health treatment and its disclosure on licensing and credentialing applications. 

About 300 to 400 physicians die by suicide each year, averaging one per day. Physician suicide is part of an epidemic—an epidemic of burnout, depression, and departure from medical practice through early retirement or a change to a nonclinical career. Physicians who complete suicide represent just the tip of the iceberg of clinicians who have had suicidal thoughts at some time in their careers, estimated to be about 10%.1,2 And, like an iceberg, the circumstances surrounding physician suicides may be submerged and shrouded in mystery, which makes it difficult for patients and colleagues to understand and come to terms with the loss. 

“PAGE NOT FOUND” 

I found this to be the case following the suicide death of my neurosurgeon. Less than a week after he died I clicked on his “link” to an affiliated hospital’s website, only to be informed: “page not found.” The neurosurgeon’s online obituary was likewise unrevealing: “Dr. David Thomas Keller (a pseudonym) passed away suddenly. He was 55 years old. He is survived by his loving family . . .” 

Tributes poured in from colleagues and patients, and a memorial service was held at a nearby church. However, there was no mention of suicide or the circumstances surrounding Dr. Keller’s death. Remembrances and condolences posted online were incredibly heartfelt but also silent about the cause of death. One could only wonder why a brilliant neurosurgeon in the prime of his career decided to end it so abruptly. Without knowledge of the events leading up to Dr. Keller’s suicide, how could his patients accept it and move on? How could the medical profession possibly learn from Dr. Keller’s suicide and prevent the same tragedy from happening to another physician, inflicting untold pain and suffering on the family? 

A TRUSTWORTHY PERSON 

Let me be clear. I was Dr. Keller’s patient, not his colleague. I did not know him professionally, and what little I knew about him personally was mostly by word-of-mouth and from his online biography before it disappeared from the Internet. Everything I read about Dr. Keller led me to believe this was a person I could entrust with my life—educated and trained at top institutions, an instructor for the American Association of Neurological Surgeons’ Board certification review course, an honorably discharged naval officer, chief of his hospital’s surgery department, and an overseas volunteer performing brain and spinal cord surgery on people who could not afford healthcare. 

My first appointment with Dr. Keller occurred in 2015. I was experiencing excruciating pain and loss of strength in my right leg. I needed a walker to ambulate. For the past month, I had been seeing a chiropractic doctor who diagnosed iliotibial band syndrome, but I had not improved with treatment. A radiologist’s reading of my lumbar MRI did not pinpoint the source of my problem. When Dr. Keller entered the office he smiled, extended a firm handshake,

and said, “Hi. I’m Dave Keller. What’s going on?” I explained my symptoms and told him they began after bending awkwardly while making some home repairs.

Dr. Keller independently reviewed the imaging study. “The radiologist missed it,” he exclaimed! “See this area here,” pointing to a far lateral lumbar (L3-4) disc herniation. “This type of herniation is uncommon but very painful because the disc sits right up against the nerve root ganglion,” he commented. Dr. Keller correctly diagnosed my disorder as a severe lumbar radiculopathy. He scheduled surgery in three weeks; however, my condition seemed to improve on its own. I called Dr. Keller the day before surgery. He said the phenomenon of lumbar disc herniation resorption is well recognized, and he surmised it explained my improvement. “Let’s cancel surgery for now, start physical therapy, and give it more time,” he recommended. I recovered without surgery.

A GREAT SURGEON

I’ve been told that the difference between a good surgeon and a great one is that the latter knows when not to operate. Dr. Keller certainly fulfilled that criterion. However, a year later, I was unable to escape the fate of surgery. My disc had reherniated. Neither of us believed another spontaneous remission was likely, and I did not want to endure more pain. Dr. Keller performed a microdiscectomy with good results. I was walking within two weeks relatively pain-free. Dr. Keller saw me in follow-up and discharged me from his care in early 2017.

In late 2018, I phoned his office for an appointment to discuss additional back and leg symptoms resulting from progressive degenerative disc disease and spinal stenosis, as revealed on a recent lumbar MRI. The receptionist told me Dr. Keller was on “indefinite medical leave.” Would I like to see his physician assistant, she asked?

I met with the physician assistant in February of 2019. He suggested I try physical therapy before considering surgery for spinal stenosis. “What can you tell me about Dr. Keller?” I asked. The physician assistant replied it was confidential, but that Dr. Keller’s medical leave was for a family member and not for himself. His return-to-work status was uncertain. I reluctantly sought consultation from several other neurosurgeons, each recommending different surgical procedures. It was not until May of 2019, shortly after Dr. Keller’s death, that I learned through the grapevine that he had died by suicide.

STANDING ROOM ONLY

Dr. Michael F. Myers, Professor of Clinical Psychiatry in the Department of Psychiatry and Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, New York, is one of the world’s leading authorities on physician suicide. In 2016, Dr. Myers and I, along with psychiatrist H. Steven Moffic, conducted a standing-room-only workshop at the annual meeting of the American Psychiatric Association. The topic of the workshop was post-traumatic stress disorder (PTSD) in physicians, which we considered a hidden epidemic.3

Physicians are burning out at record high numbers, and medicine now has the highest rate of suicide of any profession.

The progression from PTSD to burnout to depression and suicide is not inevitable, but it is certainly possible. Much of physician burnout is related to “administrative creep”4—the piling on of excessive tasks to physicians who can’t, and won’t, say no, in essence taking advantage of their good will. In addition, practicing with limited resources combined with the burden of electronic health systems, prior-authorization requests, and the omnipresent threat of litigation, contribute to burnout. Physicians are burning out at record high numbers,5 and medicine now has the highest rate of suicide of any profession, considerably higher than that of the general population.

PREVENTION

Whether or not Dr. Keller’s suicide was due to burnout or depression is unknown. However, it is clear that some suicides could be prevented if more physicians were inclined to seek treatment, and if barriers to seeking treatment were removed, especially the stigma attached to mental health treatment. Questions related to mental health treatment are asked on licensing and credentialing applications and frighten physicians who have sought treatment in the past or are contemplating it in the future. Regulators may have concerns that psychiatric treatment might jeopardize physicians’ ability to practice medicine. Public disclosure of psychiatric treatment may lead to shame and guilt, igniting the development of PTSD and depression.

Understanding physician suicide is complex, because the dynamics underlying it are many and varied.

According to Dr. Myers, understanding physician suicide is complex, because the dynamics underlying it are many and varied—a perfect storm of biopsychosocial factors. New research, however, suggests that information on just a few key risk factors may help predict future suicide attempts with a high degree of accuracy.6 Still, there will always be a small percentage of physicians who die unpredictably by suicide and the reason remains a mystery to everyone. “They have taken the answer(s) with them,” remarks Dr. Myers. “Even a psychological autopsy does not yield much clarity.”7

Physicians like Dr. Keller who complete suicide for unknown reasons leave behind grieving family, friends, colleagues, and patients, but also unresolved and unsettling feelings and memories, which makes it difficult for loved ones to find closure. The inability to backtrack and piece together warning signs and know for sure what pushed physicians to the brink impedes emotional healing and accommodation to the loss. Painful endings such as Dr. Keller’s highlight more than ever that physician wellness is indeed the missing quality indicator in medicine today.8 

REFERENCES 

1. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systemic review and meta-analysis. JAMA. 2016;316:2214-2236. 
2. Zisook S, Young I, Doran N, et al. Suicidal ideation among students and physicians at a U.S. medical school: a healer education, assessment and referral (HEAR) program report. Omega–Journal of Death and Dying. 2016;74(1):35-61. 
3. Lazarus A. Traumatized by practice: PTSD in physicians. J Med Pract Manage. 2014;30:131-134. 
4. Ofri D. The business of health care depends on exploiting doctors and nurses. The New York Times. June 8, 2019. www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html. 
5. 2018 Survey of America’s Physicians: Practice Patterns & Perspective. Survey conducted on behalf of The Physicians Foundation by Merritt-Hawkins. https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf. 
6. Zuromski KL, Bernecker SL, Gutierrez PM, et al. Assessment of a risk index for suicide attempts among US Army soldiers with suicide ideation: analysis of data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Netw Open. 2019;2(3):e190766. https://doi.org/10.1001/jamanetworkopen.2019.0766. 
7. Myers MF. The complexity of physician suicide. The BMJ Opinion. August 31, 2018. https://blogs.bmj.com/bmj/2018/08/31/michael-myers-the-complexity-of-physician-suicide. 
8. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-1721.

Arthur Lazarus, MD, MBA

Adjunct Professor of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania

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These days, you’re probably being inundated with information about the progression of COVID-19 and are learning more about the science of viruses than you ever wanted to know.

Understanding the facts about prevention is important and we encourage you to continue following recommendations from the Centers for Disease Control and Prevention, the Illinois Department of Public Health and the World Health Organization. However, it is also important that we do not let our anxiety take over our lives.

Overwhelming anxiety can have a marked impact on the quality of our lives — our overall functioning, our relationships, our work, our parenting abilities and our self-care. At the AMITA Health Behavioral Medicine Institute, we believe that healthy strategies to manage anxiety are critical to our physical health, mental health and general well-being.

Managing one’s reaction to stressors, such as COVID-19, is no easy task, especially when there is such a heightened level of anxiety and concern in our community. During times like these, you might find it helpful to borrow a few techniques from the AMITA Treatment Framework (adapted from Barlow’s Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders) — the same techniques our therapists use to help people focus on better understanding their emotions and identify how their responses to them might be making things worse.

To help you stay centered and “anchored in the present,” we recommend the following:

Manage Your Information Intake

Take breaks from constant exposure to the news, the Internet and other media. It’s allowed.

Focus on What You Can Control, Let Go of What You Can’t

Washing your hands, staying at home as much as you can and spending time with your family are all things that are within your control.

Skip “Safety Behaviors”

A “safety behavior” is an action intended to make you feel safer but doesn’t actually make you safer. A coronavirus example might be the hoarding of bottled water and toilet paper. Typically, these behaviors trigger heightened anxiety rather than lower it. Recognizing them is the first step to avoiding them.

Avoid “Thinking Traps”

Prime offenders include catastrophizing and “black and white thinking.”

Stay Connected

Keep in touch with your family and friends via social media and phone calls. Have you tried a “Zoom party” yet?

Stick to a Routine

Even if you are self-quarantined, structure can be crucial to managing anxiety. Schedule time to exercise, go outside, read that book you always wanted to read but never had time, start a project, reach out to others. You might even find it helpful to write your new activities on a calendar. Pair your routine with a productive sleep schedule, with a consistent bedtime and wake time.

Practice “Mindful Emotion Awareness”

Anxiety often leads us to worry about what happened in the past or what might happen in the future. This tends to make us feel even worse. Focusing on the present may make the situation feel more manageable.

Just a few minutes of meditation, yoga or mindfulness each day will help reduce your reactivity to anxiety. At the AMITA Health Behavioral Medicine Institute, we suggest trying the following anchoring steps:

1. Focus on your breathing
2. Observe what you are thinking, your physical sensations and your behavior
3. Ask yourself if your thoughts, physical feelings and behaviors are consistent with what is happening in the present or focused on the past or future

Rethink Your Thinking

Some anxiety and worry about COVID-19 and the economic situation is certainly warranted. Avoiding or fighting this feeling is a bit like being in quicksand; the more you struggle, the more stuck you get. Instead, examine your immediate “automatic negative thoughts” to see if there are other ways you could think about the situation.

• Instead of: “I will go stir crazy staying home for two weeks”
• Think: “These two weeks will give me a chance to accomplish some tasks I would never otherwise get around to”

Be Kind to Yourself

Try not to be self-critical or judgmental. And if you need help, it’s strength, not weakness, to ask for it. Get support from those around you and don’t hesitate to get coaching from a therapist.

https://www.amitahealth.org/blog-articles/behavioral-health/managing-anxiety-in-the-anxious-world-of-covid-19

The outbreak of COVID-19, commonly referred to as Coronavirus, has many of us on edge. The anxiety you may be feeling is your body's way of alerting you to potential risks so you can take actions to protect yourself. While it’s important to validate these natural thoughts and feelings, excessive anxiety can be disruptive to our lives and negatively impact our physical health. Read on to learn 5 tips for facing your COVID-19 anxieties.

https://www.allencomm.com/courses/covid19_5_tips_to_face_your_anxiety/index.html

Overwhelmed. Anxious. Distracted. Lonely. These are a few words that might describe the feelings of those who are transitioning into different working arrangements, or limited work, during the novel coronavirus (COVID-19) outbreak.

News cycles are dominated by COVID-19 news. While coverage is a pertinent necessity during a pandemic, it can be overwhelming to experience every news outlet abandon their daily beat for serious COVID-19 news only. There is little to no positive news– currently, most pieces of communication are tracking ever-increasing infection and fatality numbers. Sitting on the receiving end of virtually every possible news outlet pushing COVID-19-centric news leads to feeling distracted and overwhelmed. Daily work seemingly hails in comparison to the massive and ongoing stretches of the COVID-19 outbreak.

Ready to focus, experience mindfulness and boost your mood? We’ve got your go-to guide for seven things that can improve your mental health. From free resources to tips to self-help platforms, take charge of your mental health.

1. Help someone else

Helping someone else is a great way to feel more empowered about the impact of your day-to-day life. Psychology Today columnist Eva Ritvo, M.D. reports that helping others can help release the happiness trifecta: dopamine, serotonin, and oxytocin, which causes a boost in mood and several other health benefits. Here are just a few ideas:

• Support your community by ordering take-out options or shopping online. Restaurants and small businesses are really struggling during this time.
• If you see another co-worker or community member struggling, virtually reach out to support and encourage them.
• Send virtual encouraging notes to those who are important to you. Practice gratitude by showing them how thankful you are for them.
• Virtually check on any elderly or vulnerable members of your community.

2. Practice mindfulness

Combat the pinging notifications and things vying for your attention by practicing a bit of mindfulness at the start or end of your day– or even as a lunch time break. According to a Harvard Health article, “practicing mindfulness can bring improvements in both physical and psychological symptoms as well as positive changes in health, attitudes, and behaviors.”

• Check out this mindfulness platform, Headspace, that is offering free meditation practices for providers (physicians and APPs) with an NPI. They also have other free services available
• The Resilient Option is offering free unlimited access to their online program. You can access it here. Please use Resilience100 as the coupon code at the checkout. In addition, Resilient will be hosting a one-hour video webinar every week for the next several weeks.

3. Read a positive book

Whether you choose to read a positive book, a murder mystery or even a manual, reading still has proven health benefits. According to Scholastic, regular reading can decrease your stress levels by up 68 percent and can lengthen your life by up to two years.

• Al.com has created a list of “31 optimistic books for readers in need of a boost right now.” You can read the full list here.

4. Watch a positive movie

Birgit Wolz, PhD., MFT, a psychotherapist at the Zur Institute, facilitates cinema therapy groups. Wolz stated that watching a movie can bring “insight, inspiration, emotional release or relief and natural change.”

• Al.com has created a list of “51 hopeful movies that will make you feel good about life, now streaming on Netflix and more.” You can read the full list here.

5. Limit your sources of news

Especially if you are already feeling overwhelmed, it is good to streamline your incoming news by picking three sites that you will get information from. Unfortunately, social media seems to be acting as an additional news site, so it might be helpful to consider social media when you are thinking through your daily input sources. Also, work emails pertaining to COVID-19 count as a source of news input. Consider a robust news source as you think through your current input list and choose only three that you will tune into:

• Reading work emails and communicatio
• Receiving news alerts on your phone
• Reading local news sites
• Reading your Twitter news feed
• Reading your Facebook news feed
• Reading NPR news site
• Watching local nightly news
• Watching CNN, FOX or NBC news
• Listening to NPR news

6. Get moving and get outside

Restaurants, movie theatres and everything else might be closed, but parks and trails are not! According to the Mayo Clinic, there are several benefits to staying active, including boosted energy and improved mood. Getting moving is a good way to get your mind off of the negative and remember the hope that is just around the corner! Below are a few ideas for staying active during the COVID-19 outbreak.

• Visit your local park
• Mow your grass
• Make chalk drawings in your driveway
• Go for a jog
• Play a game that gets you moving
• Arrange a family walk
• Go on a bike ride

7. Start (or end) your day with gratitude

Taking a moment to remember all of the things that you are grateful for in life can be a great way to focus on the positive. To take stock of the ways in which you count yourself lucky or blessed allows you to re-center on your priorities. It is also good for you! According to Harvard Health, giving thanks can make you happier. Plus, your gratitude can be as small- like a pair of clean socks- or large as you want it to

• • Make a list of the things you are grateful for in the morning or evening
  • Keep a gratitude journal
  • Send your gratitude to loved ones
  • Write virtual thank-you notes

• https://www.uab.edu/medicine/surgery/news-and-events/department-news/1304-seven-things-you-can-do-today-to-help-improve-your-mental-health-amidst-covid-19-outbreak/?utm_source=golink&utm_medium=golink

Every physician I’ve coached this week has shared how much fear and worry they’re living with. An anesthesiologist fearful of COVID-19 exposure in the OR. A radiologist worried after hearing rumors of being deployed to the ICU. An internist with too many at-risk diabetics and COPD patients to safely manage them all. And each also fearful for their children, aging parents, and others. In a time like this, it’s natural for fear to run high. For physicians and for all of us. Our minds can flit from one worry to another, some grounded in reality and many not. We can find ourselves preoccupied with the latest news, worried about what the government will do next, and focusing on what the stock market crash will mean for our retirement.
Many of us are running in sympathetic overdrive—heart racing, breath shallow, body tight. Caught in a fight/flight/freeze response, it’s as if our foot is stuck on the gas pedal. In this state of activation, our ability to manage stress and challenge decreases. We become alarmist, reactive, and irritable, and our ability to cope and execute good decisions erodes. We forget that in this moment we are safe. That in this moment we’re healthy. That right now our loved ones are healthy and safe.
Staying in the present moment provides respite from all the worry and fear. This is not a Pollyanna endeavor; it’s respite grounded in reality. Particularly in difficult times, we need the clarity, focus, and balance that calm provides. It may actually be as essential as hand sanitizer!
There are a number of simple mindfulness-based strategies that can help keep us in the present. Here are three that you can try today.

Stay in the present with a purposeful pause

Intentionally pausing is the simplest yet most underutilized strategy for managing fear and anxiety. Simply pausing and taking three slow, deep breaths has a myriad of benefits. First, it brings you back to the present. And the present is typically a far safer place than the unknown future. In the present, you’re able to breathe, think, and gather yourself to meet the demands you face. In the present you are safe. In the present, fears of a catastrophic future are not the reality.
Second, with a pause, you’re interrupting the cycle of amygdala activation with its cascade of stress hormones. You’ve giving your system a chance to let these biochemicals wash away, removing the high level of distress and alarm. A pause clears your system for a state of calm. Third, pausing and taking three slow deep breaths engages the parasympathetic nervous system. In other words, you’re applying the brakes. Pausing brings almost immediate calm.

Remind yourself what you’re grateful for

In times like this, we can be swept away not only by fear but by a sense that we’ve been dealt a bad hand. That the situation we’re in is unfair. Our minds can be so focused on fear and what’s not going well that it can feel like we have nothing to be grateful for. Yet is that true? Or are there also many things that are going well? Again, this is not about being Pollyanna; it’s about maintaining a reality-based vantage point.
In case you’re struggling to think of things you’re grateful for, here are some options:
Grateful that your health is good right now.
Grateful that you’ve been able to stock up and be prepared.
Grateful that your loved ones are safe.
Grateful that it’s almost springtime so it’s possible to be outdoors in the fresh air.
Grateful that you have a cell phone and can stay in touch with others.
We can have a brief moment of gratitude and then find that our mind has been pulled to fear. The practice of gratitude is very much like meditation. We are reactive and our mind goes to fear and worry. We notice that this has occurred, and we come back to gratitude. Over and over and over, this is what we need to do. There’s no reason to expect ourselves to be perfect or get it right every time. The point is to keep practicing and building the muscle of intentional focus.

Lean into connection

In times like this, the natural impulse is to hunker down. With the need for social distancing, we avoid contact. And fear can also lead us to isolate from others. Maybe if I isolate, I’ll increase my chances of staying healthy. But when we isolate ourselves, it typically simply allows an opportunity for our fears to multiply. Connection is the antithesis of fear. Connection reminds us that we are not alone and that we are truly all in this together. It reminds us that we’re all struggling right now, so it helps put our fears in perspective. All of us are fearful and worried, so maybe I’m actually ok. When I see your smile, I realize that I can smile too. All of us need to remind one another to come back to the present and be grateful for what we have.
The good news is that we all have cell phones and thus there are many ways to stay connected. A video call with a friend. A text to check in on someone who may not have loved ones near. Even a smiley face emoji. In addition, with spring arriving, we can safely be outside with others.

Take action
In summary, I hope you’ll try one of the three strategies we’ve examined:

1. When your fear temperature is rising, pause and take three slow deep breaths.
2. Remind yourself what you’re grateful for.
3. Reach out to someone.

Experiencing fear during this time is normal, so you don’t need to berate yourself when it arises. The key is managing it. And that takes practice. Just as important as social distancing, we can all play a role in containing the fear virus. We can all play a role in maintaining much-needed calm.

https://www.gailgazelle.com/fear-and-worry-three-practical-antidotes-you-can-access-today/

It is natural to feel stress, anxiety, grief, and worry during and after a disaster. Everyone reacts differently, and your own feelings will change over time. Notice and accept how you feel. Taking care of your emotional health during an emergency will help you think clearly and react to the urgent needs to protect yourself and your family. Self-care during an emergency will help your long-term healing.

Take the following steps to cope with a disaster:

• Take care of your body– Try to eat healthy well-balanced meals, exercise regularly, and get plenty of sleep. Avoid alcohol, tobacco, and other drugs. Learn more about wellness strategiesexternal icon for mental health.
• Connect with others– Share your concerns and how you are feeling with a friend or family member. Maintain healthy relationships, and build a strong support system.
• Take breaks– Make time to unwind and remind yourself that strong feelings will fade. Try taking in deep breaths. Try to do activities you usually enjoy.
• Stay informed– When you feel that you are missing information, you may become more stressed or nervous. Watch, listen to, or read the news for updates from officials. Be aware that there may be rumors during a crisis, especially on social media. Always check your sources and turn to reliable sources of information like your local government authorities.
• Avoid too much exposure to news– Take breaks from watching, reading, or listening to news stories. It can be upsetting to hear about the crisis and see images repeatedly. Try to do enjoyable activities and return to normal life as much as possible and check for updates between breaks.
• Seek help when needed– If distress impacts activities of your daily life for several days or weeks, talk to a clergy member, counselor, or doctor, or contact the SAMHSA helpline at 1-800-985-5990.

Look out for these common signs of distress:

• Feelings of numbness, disbelief, anxiety or fear.
• Changes in appetite, energy, and activity levels.
• Difficulty concentrating.
• Difficulty sleeping or nightmares and upsetting thoughts and images.
• Physical reactions, such as headaches, body pains, stomach problems, and skin rashes.
• Worsening of chronic health problems.
• Anger or short-temper.
• Increased use of alcohol, tobacco, or other drugs.

If you experience these feelings or behaviors for several days in a row and are unable to carry out normal responsibilities because of them, seek professional helpexternal icon.

https://emergency.cdc.gov/coping/selfcare.asp

Infectious disease outbreaks, such as the novel coronavirus (COVID-19), create significant distress for the public and strain health care systems tasked with caring for affected individuals and containing the disease. Fear and uncertainty heavily influence public behaviors (1). Concerns focus on personal and family safety, inability to distinguish the new disease from more established and benign illnesses, potential for isolation and quarantine, effectiveness of treatments being used, and trust in institutions responsible for managing the response.

Adverse psychological and behavioral responses to infectious disease outbreaks are common and include insomnia, reduced feelings of safety, scapegoating, increased use of alcohol and tobacco, somatic symptoms (physical symptoms, such as lack of energy and general aches and pains), and increased use of medical resources (2). While media can be a useful tool for sharing knowledge, it also enables rumors and conspiracy theories to be amplified, which can distract public attention from accurate sources of information, reduce participation in health-promoting behaviors, and further community divisions (3). Distress about the infectious disease outbreak is often increased by exposure to traditional and social media content, which is often sensational in nature and may contain misinformation (4).

Health care workers experience additional challenges during infectious disease outbreaks, including concerns about the health of themselves and their family, stigma from within their communities, and managing the distress of patients (5). In more highly affected areas, health care systems are often overwhelmed by a surge in care demand that is simultaneously experiencing staffing shortages. The shortages result from illness in health care workers, the need for health care workers to care for sick relatives, or absence due to fear of contracting the illness (6). Health care workers working with infected patients often experience concern about the adequacy of their personal protective equipment, the use of which can be uncomfortable as well as restrict the ability to communicate and perform work tasks.

During an outbreak, timely and accurate information play a critical role in controlling the spread of illness and managing fear and uncertainty. Knowing what to do helps people feel safer and enhances the belief that they can take meaningful steps to protect themselves. During an infectious disease outbreak, the recommendations below are helpful for patients and their families:

1. Stay informed. Obtain current information about the outbreak from trusted sources, such as the Centers for Disease Control and Prevention at www.cdc.gov and the World Health Organization at www.who.int.
2. Educate. Follow and share basic information about hygiene to reduce spread of illness, such as handwashing and cough etiquette.
3. Correct misinformation. For health care workers, help correct inaccurate information and misperceptions by sharing credible, established public health resources.
4. Limit media exposure. Use media enough to make informed decisions, then turn it off.
5. Anticipate and address stress reactions. Keep in mind that it’s normal to feel stress in reaction to an infectious disease outbreak and be aware of signs of stress in yourself or family members. Take steps to minimize and address stress, such as keeping normal routines, taking part in enjoyable activities, focusing on positive aspects of your life and things that you can control; seeking support from friends and family; and engaging in stress reduction techniques and physical activity.

In addition to the recommendations above, health care workers whose patients are affected by the outbreak should be encouraged to take care of themselves through these additional recommendations:

1. Meet basic needs. Eat, hydrate, and sleep regularly to optimize your ability to provide care for yourself and others.
2. Take breaks. Rest and relaxing activities can provide a helpful distraction.
3. Stay connected. Giving and receiving support from family, friends, and colleagues can reduce feelings of isolation.
4. Stay updated. Rely on trusted sources of information. Participate in work meetings where relevant information is provided.
5. Self check-ins. Monitor yourself for signs of increased stress. Talk to a family member, friend, peer or supervisor if needed.
6. Honor service. Remind yourself (and others) of the important work you are doing. Recognize colleagues for their service whenever possible.

https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2020/02/coronavirus-and-mental-health-taking-care-of-ourselves-during-infectious-disease-outbreaks

The coronavirus disease 2019 (COVID-19) pandemic has upended clinicians' sense of order and control. Such disruption may lead to substantial stress in the short term and higher risk for burnout over the long term. While natural disasters, such as Hurricane Katrina, demonstrated the effectiveness of short-term emergency planning (1), the COVID-19 pandemic poses unique long-term stressors and risks to clinicians' physical, mental, spiritual, and emotional well-being. Leaders and front-line clinicians need to proactively protect the well-being of themselves and their colleagues to avoid adverse outcomes for clinicians and adverse effects on quality of patient care (2). We provide practical suggestions to encourage a culture that will sustain the clinician workforce during the pandemic. Regardless of practice location or size, everyone must commit to supporting the well-being of those involved in patient care.
First and foremost, organizational leaders should provide clear messages that clinicians are valued and that managing the pandemic together is the goal. Front-line clinicians must individually and collectively identify concerns that arise while facing the reality of the pandemic. Leaders must communicate current best practices clearly and compassionately, manage expectations, clarify work hours, and provide sufficient resources and effective personal protective equipment. To better enable clinicians to maintain personal well-being and resilience throughout the pandemic, leaders should aim to monitor clinician wellness and proactively address concerns related to the safety of clinicians and their families.
Leaders should aim for work schedules that promote physical resilience by enabling adequate sleep and providing access to call rooms for hospital-based clinicians working long or multiple shifts. Leaders should also take initiatives to provide basic provisions during work hours, such as easy access to water, healthy snacks, chargers for phones and other devices, and toiletries. Leaders must also designate times for clinicians to take breaks, eat, and take medications. It may also be helpful to advise clinicians working such shifts to bring at least 3 days of their own medications to work and designate a source for emergency refills. Clinicians should also continue using wellness activities that have worked for them in the past and make efforts to support each other during this challenging time.
Reduction of noncritical work activities may help to promote mental well-being. Examples include rescheduling preventive and routine patient follow-up visits and eliminating nonessential administrative tasks. Anxiety can be reduced by providing a central source for updated information and clear communication of well-defined protocols, expectations, and such resources as childcare via e-mails, tweets, and automated calls. When an individual clinician feels well but cannot be present in the clinical setting because of mandatory isolation or childcare, hospitals and practices should aim to redistribute work and have these clinicians participate in computer- and phone-based care while home.
During the pandemic, clinicians should be encouraged to openly discuss vulnerability and the importance of protecting one's emotional strength. Health care organizations can provide information on managing stress, reducing burnout, and identifying mental health professionals available to support clinicians (3). Deploy designated wellness champions in health care systems and practices to field clinicians' concerns, advocate for clinicians, and distribute messages of gratitude and support.
We also suggest fostering spiritual resilience through distribution of positive messaging that emphasizes appreciation for clinicians' dedication and altruism. Disseminating strategies for connecting with colleagues to share stories of success, rather than focusing on failures and stresses, can help clinicians find joy amidst chaos (4). Helping clinicians recognize what they can and cannot control helps to balance expectations with realities.
A supportive work culture is vital to maintaining the resilience of clinicians during a crisis such as COVID-19. We suggest developing an evidence-based menu of interventions, to be carefully selected from, and tailored to various workplace settings. For larger health systems, wellness committees and employee assistance programs are the logical resources to organize these interventions. In smaller settings, appointing a wellness champion could help to elucidate colleagues' needs and implement solutions. Surveys to assess stress points, fears, and concerns can inform leaders and provide insight into areas requiring attention. We also suggest developing plans to back up, cross-train, and rotate leadership to avoid leader burnout.
Sharing challenges and successes will help to meet urgent needs during the evolving pandemic. Examples of settings for such sharing include the American College of Physicians Physician Well-Being and Discussion Forum (5), the Society of General Internal Medicine GIMConnect (6), and the American Medical Association Physician Health (7) resources that members can access. Other professional organizations, or organizations with access to community discussion boards, could develop similar venues for highlighting best practices in wellness.
Emphasizing clinician wellness during the COVID-19 pandemic (8) is necessary to enable them to provide high-quality care. We propose some preliminary, common sense steps toward this goal and encourage colleagues to share strategies they find successful. How we meet the wellness needs of our clinicians may determine how well we survive the COVID-19 pandemic and future public health crises.

https://annals.org/aim/fullarticle/2763592/supporting-clinicians-during-covid-19-pandemic

Adapting to stress and adversity
Psychological resilience is defined as your ability to properly adapt to stress and adversity.
Wellbeing literature asserts that resilience is a component of our make-up that can be harnessed given the right conditions.
This understanding derives from the notion of human flourishing, which embodies autonomy, self-determination, interest and engagement, aspiration and motivation, and whether people have a sense of meaning, direction or purpose in life. Resilience can be advanced through the acknowledgement and development of people’s capabilities.
Here are some key strategies to build and maintain resilience.

Build strong relationships
From medical school onwards, you need to appreciate the nature of a career in medicine and how stressful it can be. While you are busy building a career, working long shift hours, changing locations through rotations, little time is left over for developing strong relationships.
Good relationships with close family members, friends and others are important. Accepting help and support from those around you who care and will listen to you strengthens resilience. Assisting others in their time of need also can benefit you.
In addition to your friends and family, try to have one or two people at work who you feel you can call on for support. This is particularly important if you are doing acute call. If you are having difficulties it is important to remember that you can inform your Trainer without disclosing the details to him/her.

Challenge your language and your thoughts in difficult situations
Pay close attention to words like “this is awful” and “this is terrible” and “I can’t cope” or “I have had enough”.
You can't change the fact that highly stressful events happen, but you can change how you interpret and respond to these events. Try instead to say “this is difficult, but I am resourceful enough to be able to cope” or “this is not the end of the world, however difficult this is for me right now. I have what I need to get through this”.
Note any subtle changes whereby you feel a bit better as you deal with difficult situations. This will build your confidence in your own coping abilities in the future.

Challenge Perfectionism
Perfectionism is a personality trait characterised by a person's striving for flawlessness and setting excessively high performance standards, accompanied by overly critical self-evaluations and concerns regarding others' evaluations. 
There are two types of perfectionism, adaptive and maladaptive.  Adaptive perfectionism can also be called “striving for excellence”.  This drive can motivate you to reach goals, providing they are realistic in the context of the resources available to you.
Maladaptive perfectionism drives people to attempt to achieve unattainable ideals, and because these are unattainable, the person internalises failure which can lead to inaction, self-criticism and at times, depression.

Set goals and plans to attain them
Develop realistic goals and consider using the BSMART method.
Benefits– clarify the benefits of attaining this goal.
Specific– be specific about what you want to achieve.
Measurable– your goal has to be something that you can ‘see’. This could be a number, a title, a position, a location or any measurable aspect you can think of.
Aligned– make sure that you align your goal to your values. If you value being fit and healthy, then your goal of being fit is aligned your values.
Realistic- once you have set your goal you need to ask yourself what you need to do in order to achieve it. You will need to consider your task list and your existing schedule and assess if it is realistic for you to undertake this goal. If the answer is yes, then do something regularly — even if it seems like a small accomplishment — that enables you to move toward your goals. Instead of focusing on tasks that seem unachievable, consider breaking big tasks into small achievable tasks that will get you closer to your goal.
Time Bound– a goal is not a goal unless you set a realistic timeframe to achieving the goal. This will help you in setting your realistic plan to achieve it. You can either set your timeframe first and then align your tasks accordingly or you can write down all your steps, consider your current workload/life style and adjust the timeframe accordingly.

Accept that change is a part of living
Certain goals may no longer be attainable as life takes a different course. Accepting circumstances that cannot be changed can help you focus on circumstances that you can change, and will allow you to recover quicker and re-set your goals.

Act
Act on adverse situations as much as you can. Take decisive but considered actions, rather than detaching completely from problems and stresses and wishing they would just go away.

Look for opportunities for self-discovery
People often learn something about themselves and may find that they have grown in some respect as a result of their struggle with loss. Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vulnerable, increased sense of self-worth, a more developed spirituality and heightened appreciation for life.

Develop your self-confidence
The working environment of doctors can potentially expose them to bullying and harassment, legal challenges, complaints from patients, examination failure, and any other personal failures that could potentially make you doubt yourself.
Developing confidence in your ability to solve problems and trusting your instincts helps build resilience. Ask yourself where you might feel lacking in confidence and address this by considering your goals. Achievements and succeeding in attaining your goals can greatly enhance your confidence and self-esteem.

Keep things in perspective
Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective. Avoid blowing the event out of proportion. It might help to ask yourself, “Will I remember this in a year’s time? What impact is this current situation going to have in the long term?”

Foster hope
If you notice that your brain is attracted to all the negative consequences that can potentially impact on your life, try to entertain the opposite. Consider all the positive and good things that might come your way.
An optimistic outlook enables you to expect that good things will happen in your life. Foster hope and trust that whatever will come your way – it will be ok.

Look after yourself
Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing. Exercise regularly but try and find an exercise that you enjoy. There is little point in selecting an exercise that does not meet your needs.
Selecting an activity that both challenges you and that you look forward to, will make you more likely to stick with it.  It is a great feeling to notice progress in your fitness level, flexibility and strength.
Taking care of yourself helps to keep your mind and body strong and primed to deal with situations that require resilience.

https://www.rcpi.ie/physician-wellbeing/building-resilience/

Health care work is stressful, especially right now.

Working in the health care industry, regardless of the position, is stressful on a normal day. During a pandemic, health care workers are even more susceptible to increased stress due to:

• Higher exposure to risk
• Issues related to PPE (shortage, physical strain of PPE, etc.)
• Changes in approach to care
• Less ability to engage in social distancing at work
• More focus on social distancing outside of work
• Increase awareness/vigilance in work setting; pressure to know new procedures
• Increased acuity in health care setting; increase in severity or poor outcome of cases
• Sense of loss of control
• Conflict between work and personal responsibility

In addition, health care workers experience increased stress because they are exposed to other people’s trauma and distress. This can build, causing secondary trauma (from exposure to another individual’s traumatic experience) or burnout (a feeling of extreme exhaustion and being overwhelmed). 
 
Signs of burnout

• Sadness or apathy
• Easily frustrated
• Irritable/blaming others
• Lacking feelings/indifferent
• Poor self-care/seeking alcohol to cope
• Signs of secondary trauma
• Fear of something bad happening
• Easily startled or on-guard
• Nightmares or recurring thoughts
• Physical signs of stress (racing heart, sweating, etc.)
• Learn to recognize, respond and reduce stress. Knowing that you have stress and coping with it will allow you to stay well and allow you to continue helping those who are affected.

Recognizing symptoms of stress

Responding to disasters can be both rewarding and stressful, so be realistic and reduce the stigma. Stress and compassion fatigue are not the result of problems with the individual, but are an occupational hazard that can affect anyone working in this environment. Acknowledging that everyone, including you, is susceptible to the effects of this environment can reduce your risk and increase your ability to cope. Pay attention to your mind and body. 

• Emotional  - anxiety, depression, moodiness, irritability, loneliness, guilt and shame, hopelessness
• Mental - difficulty concentrating, forgetfulness, self-critical, rigid attitudes, distorted ideas
• Physical - increased heart rate, difficulty breathing, numbness & tingling, migraines, upset stomach
• Behavioral - difficulty sleeping, emotional outbursts, excessive drinking or eating, avoidance,  inactivity

Responding to Stress

• Control what you are able to control, and don’t spend time dwelling on what you cannot control. Remind yourself of what you are doing to help control the spread. “I am not putting myself or those around me in danger. I am trusting others to do their jobs.”
• Get information from reliable sources:

https://www.cdc.gov/
https://www.who.int/
https://www.wisconsin.gov/

• Set limits on your media consumption - avoid having television, radio or other media run continuously in the background. Schedule specific times to check in on the news and set limits on how long you watch or consume news.
• Determine what can reasonably be changed inside and outside of work.
• Adopt a systemic problem solving approach
• Define your problem specifically
• Break it down into manageable components
• Gain support for ideas and changes
• Work on solutions
• Evaluate and rework as needed
• Keep lines of communication open with your coworkers. If you are social distancing, consider using digital platforms like Zoom or social chat groups. Make sure you do not share confidential information in these types of communications.
• Maintain contact with your supervisor.
• Use appropriate communication skills such as “I” statements, listening, and restating.
• Avoid the herd mentality. Anxiety can be contagious – try to avoid getting caught up in others’ distress.

Reducing the impact of stress

• Recognize and accept your own feelings.
• At home
  • Develop an action plan that works for you and your family.
  • Set realistic expectations especially if you have to balance having children at home or other responsibilities. Make decisions about what is right for you and your loved ones and focus on what you can control, as opposed to what you can’t control. It is ok to allow for things to be different, and less than perfect. We can instead strive to create a plan and routine that is good enough. Adopting a “dare-to-be-average” mind-set will allow for some personal forgiveness as you and your family navigate changes. Ask yourself, did schoolwork get done? Did work get done? Did you engage in self-care? The answer to these questions should be, “Yes, as best as I could today.”
• At work
  • Take time out for basic cares such as bathroom breaks and drinking plenty of water.
  • Remind yourself it is not selfish to take a break. The needs of others are not more important than your own needs and well-being. Working all of the time does not mean you will make your best contributions or decisions. There are other people who can help in the crisis.
  • Make sure you are self-monitoring and pacing yourself.
  • Limit the amount of time you work alone during times of crisis.
  • Work in teams if possible.
  • Develop a buddy system where two of you work together to support each other and monitor reach other’s stress, workload, and safety.
  • Use peer consultation and supervision when available.
  • Get to know your team. Talk about background, interests, hobbies, and family. Identify each other’s strengths and weaknesses.
  • If you hear rumors, seek out accurate information from your supervisor.
  • Take deep breaths.
  • Engage in helpful self-talk (i.e., “I am helping others,” and “This will pass.”). 

Engage in self-care activities

• Ensure you are getting enough rest, eating a balanced diet and getting routine exercise.
• Take time for hobbies or interests you previously enjoyed but didn’t have time to do.
• Employ the use of calming, centering and meditative skills. Click here for some calming and mindfulness resources.

Seek professional help when needed
If your mental health is being impacted by the stress of COVID-19, please reach out to your primary care physician who can help connect you with therapy resources. Many things are changing in the field of mental health and telemedicine or phone visits may be an option.

https://www.prevea.com/For-Patients/Your-Wellness/Resources/managing-stress-for-health-care-workers

Physicians and other health professionals are desperately needed during the global response to the COVID-19 pandemic. These individuals also represent one of the most at-risk populations for acquiring COVID-19. However, they face another risk: added stress. During these trying times, it is important to keep well-being in mind and address stress.

The AMA and the Centers for Disease Control and Prevention (CDC) are closely monitoring the COVID-19 global pandemic. Learn more at the AMA COVID-19 resource center and consult the AMA’s physician guide to COVID-19.

“The impact of COVID-19 is overwhelming,” said AMA member Mark Linzer, MD, director of the Institute for Professional Work Life at Hennepin Healthcare and professor of medicine at the University of Minnesota in Minneapolis. “Everybody's wrestling with what's happening and what we can best do to take care of it.”

“I am so overwhelmingly grateful to be part of this medical community,” said Dr. Linzer. “I have so much admiration and just exceptional gratitude for what our community is doing in this crisis.”

While the COVID-19 pandemic is changing by the hour, Dr. Linzer took some time to explain how to address physician stress while responding to COVID-19.

Pay attention to basic needs
In times of crisis and stress, sometimes basic needs go out the window, including food, water, safety and sleep. For example, when physicians work 14- or 16-hour days they may not think about these basic needs. Instead, they might realize they haven’t performed any in the last eight hours, said Dr. Linzer.

“Nobody's regulating well-being at all. It's just everybody's job to figure out how to get it done, and a physician's natural tendency is not to think about that very much,” he said, adding that it is important to

“start with basic needs, which is sleep, hygiene, food, water, healthy snacks, coffee.”

“Pay attention to the basic needs of the people who are working harder than before,” said Dr. Linzer.

Watch number of hours worked
Health systems should pay attention to the number of hours physicians are working and make sure they receive breaks.

“The workload is markedly escalating and it's escalating in a very unusual way,” said Dr. Linzer.

While Dr. Linzer is seeing fewer patients in the clinic, he is still fielding calls and messages to review and reassure them. And with a week of attending on the wards coming up soon, providing breaks and paying attention to hours worked can help balance the workload and reduce risk of burning out.

Share mental health support
During this time, it is also vital that health systems and physicians do not lose sight of mental health support.

“People need to know about the effects of acute and chronic stress and how to alleviate it, whether it's pushing resilience, meditation or counseling,” said Dr. Linzer. “People need lists of mental health resources because this is going to get harder before we stabilize it.”

Compassion and empathy from leadership
There is a common fear of acquiring COVID-19 and giving it to family members, loved ones or colleagues. Additionally, there is also “overwhelming information overload. I now may get 50 emails a day related to this, all of which are high-profile must read,” said Dr. Linzer, adding that a lot of physicians are unsure about “what is required and doing things that are not easy to understand, and the consequences of not getting it right feel pretty severe.”

This is where leadership in clinics, hospitals and health systems can step up and help. Leadership should continue to show compassion and empathy about what it’s like to be on the front lines and acknowledge these fears that can impact physician stress and well-being.

Distribute workweeks effectively
There may be instances when physicians or other health care workers are sent home to watch well children because schools are closed. This might also occur if someone has been exposed to a patient with COVID-19 but is feeling fine and must work from home.

When this happens, workload redistribution can help. This means “the clinicians at home can manage electronic in-basket work for the patients while the people in the hospital can manage the sick people,” said Dr. Linzer.

Maintain a culture of wellness
Throughout the response to COVID-19, health systems and hospitals must look at how to maintain a culture of wellness. This can be accomplished by including leaders in the well-being needs of physicians. They can help reduce stress in the clinicians, and the system must also watch out for the leaders’ needs to refresh and sustain.

For example, Dr. Linzer received an email from his CEO about the COVID-19 response, which was supportive of the work being done and how important it is right now. It was marvelous.

“Leader burnout was very high before we got to this, but right now I can’t imagine what our leaders are going through,” said Dr. Linzer. “They need to talk about cross training, rotating leadership just like airline pilots, and forced time away from the office.”

“This is going to be fully consuming for months and it could be many months. This needs to be the long haul, not a short one,” he said.

New measures of stress will be forthcoming and will include one that is targeted at coping with the COVID-19 crisis.

https://www.ama-assn.org/delivering-care/public-health/6-ways-address-physician-stress-during-covid-19-pandemic

Two decades ago, during a low point in my residency, I was greeted by a banner in the hospital lobby that read "Resident Wellness Day." The entire event consisted of a plate of free muffins. I didn't need a muffin. I needed a psychiatrist. I needed sleep. I needed a reasonable limit on the number of hours I could work in a week. I was suffering, and my institution responded by…offering me a muffin. That gesture, along with so much other rhetoric and literature, left me with a clear message: It was my job to fix my burnout.

Ask any group of medical students, residents, or practicing physicians, "What are you doing to avoid or fix your own burnout?" and you'll probably find yourself in a heated conversation. The available research on physician burnout overwhelmingly suggests that organizational factors are the primary causes. Medical education exposes learners to situations that lack basic psychological safety, and many of us sustain significant emotional injuries as a result. So it's no wonder we get angry when people ask what steps we've taken to fix a problem they caused. It feels like someone throwing us into a fire and then asking what we're doing to avoid getting burned.

But our outrage at misplaced blame can prevent us from accepting and embracing those things that can actually help us. I'm not talking about tone-deaf offerings, like the occasional yoga class or a plate of muffins. Beyond these pitiful homeopathic wellness efforts, there are meaningful actions we can take to help ourselves. I know, because I have found some that have had a powerful impact on my life.

Mind Matters

The first thing we can do to help ourselves is learn to be more aware of our thinking patterns and associated emotions, and how we react to them. As medical students, we aren't typically taught helpful cognitive strategies to combat maladaptive thoughts because our teachers and leaders often don't have those skills themselves. If you think of these strategies in the way that you think of any other highly technical skill, it makes sense that you would need to seek out people with the specialized expertise to teach you.

Mindfulness is one pathway to developing these skills. I'm well aware that mindfulness is a "trigger" word for a lot of medical students, residents, and staff. They say that the practice feels like offering a life preserver to a person who is drowning. A common problem with mindfulness training is that many people's initial experiences are too brief, of poor quality, or not tailored to clinical environments. Perhaps our attitude toward mindfulness would be better if we called it "self-regulation and situational awareness training for high-cognitive- load environments in medicine," because that's really what it is.

Personally, I have trained in an evidence-based, JAMA-published, physician-created and physician-led program offered by the University of Rochester School of Medicine and Dentistry. This taught me how mindfulness, self-regulation, and greater self-awareness can be applied moment to moment in an actual clinical setting. These skills have offered me a way to deal with some of my most challenging emotions. As a result, the program has not only made me a happier and better doctor but also a better administrator. I can more readily withstand working from within those damnable, abusive systemic conditions to affect change for others.

To be clear, an administration that asks its employees or learners to engage with mindfulness has not absolved itself of having to address the root causes of burnout. However, asking learners and staff to take this step as part of a larger strategy acknowledges that individual actions and behavior are part of what create institutional culture. The Gold Foundation is one example of an organization that offers mindfulness training to medical schools.

After working on awareness of our thinking patterns, a second step is to build self-valuation. Mickey Trockel, MD, PhD, describes self-valuation as the "prioritization of personal wellbeing coupled with growth mindset perspective towards personal imperfection." Trockel has found that physicians who score higher on measures of self-valuation have a lower risk for burnout. Tough self-talk is an example of a dysfunctional habit that gets trained into medical students. Learning to see and speak to ourselves with the same constructive empathy and growth mindset that we would offer a close friend is an example of a way we can increase self-valuation.

One concrete strategy to develop this skill is describing difficult events and feelings in the third person. For example, instead of a self-critique of your own performance, you might say to yourself in the third person, "Sarah managed a very tough case just now. She's never dealt with a patient like this before, and she will know how to do it better the next time." This technique can be helpful for managing emotions that can quickly become maladaptive, such as shame, guilt, and feelings of being an imposter. Try using this strategy with classmates and friends when they are stuck in a loop of berating themselves, and ask them to take note of how they feel before and after.

Again, this is not a validation of the theory that we are somehow to blame for our own burnout. It is a practical strategy for building a capacity that has been shown to be protective, and one that can offer benefit in any clinical environment.

Body Matters, Too

Although practices designed to strengthen the mind are critical, taking care of our bodies is just as important. I continue to work on aggressively seeking and following health advice that pertains specifically to physicians. In essence, I try to conceptualize my body as a complex, specialized medical machine. As Trockel has said, it is the most important "instrument of practice."

Maryam Hamidi, PhD, has published extensive information on nutrition that is specific to physicians. One of her research papers demonstrates the optimal time to avoid eating during night shifts in order mitigate sleep-related impairment. Other research correlates dehydration with mild cognitive impairment.

Familiarizing ourselves with such literature makes it much harder for us to embrace cultural norms that encourage us to neglect our basic needs. Again, the system is the largest culprit, and I'm fully aware that autonomy in medical school and residency is often very limited. However, when I was a learner, my own early impulses to ignore physical needs also arose from my personal attitudes and beliefs around self-care. This is yet one more example of how developing insight into my thinking patterns allowed me to take care of myself in a way that has affected my quality of life and the care I provide to my patients. Small changes are additive, and we can benefit from them whether we work in a toxic or healthy environment.

What I've come to believe is this: If we think that the only solution to addressing physician burnout is fixing the system, we risk internalizing the idea that all solutions are entirely out of our control. In that moment, we give away the personal agency to control those things that we can. This isn't about letting organizations and institutions off the hook when it comes to doing their part to address the primary drivers of burnout. It is about embracing what we can do to help ourselves.

More than 3 years after making a serious effort to learn how to apply mindfulness to my clinical life, I have noticed a significant difference. I feel more fully present with patients and colleagues and more accepting of the complex range of emotions that appear for me during a normal clinical day. I treat myself and others with more compassion. I also now teach mindful practice to medical learners, faculty, and leadership across the country, as one of many strategies I have embraced.

The system must change, and we must also work to identify and practice meaningful wellness strategies like our lives depend on it. Because I believe that they do. So when someone offers you a muffin as a cure for your burnout, feel free to reject it. But don't reject the idea that there are things you can do to take control of your own wellness.

Jillian Horton, MD, FRCPC, is associate head of the Department of Internal Medicine , director of the Alan Klass Program in Health Humanities, and a former associate dean of undergraduate student affairs at the University of Manitoba in Winnipeg, Canada. She is a member of the Stanford University Chief Wellness Officer 2019 cohort and is trained in mindful practice through the University of Rochester School of Medicine and Dentistry. Her memoir about medicine and medical education will be released by Harper Collins Canada in February 2021.

https://www.medscape.com/viewarticle/923610_3

While every generation of physicians face varying degrees of burnout, those from generation X (ages 40-54) reported the highest burnout rates in a new Medscape survey.

In the Medscape National Physician Burnout and Suicide Report 2020: The Generational Divide, 48% of Gen X'ers said they were burned out compared with 39% of baby boomers (ages 55-73), and 38% of millennials (ages 25-39).

Midcareer is typically the time of highest burnout," Carol A. Bernstein, MD, vice chair for faculty development at Montefiore Medical Center in New York City, told Medscape. That group is likely also juggling many roles outside work, many caring for children and aging parents simultaneously, she noted.

More than 15,000 physicians in 29 specialties responded to the survey. Overall numbers for burnout have decreased in Medscape surveys from 46% 5 years ago to 44% last year to 42% this year.

Some Specialties Remain at Top in Burnout Scale

However, some of the same specialties have remained at the top in that time: neurology, urology, family medicine, critical care, internal medicine, and emergency medicine.

Urology and neurology were at the top this year (54% and 50% reported burnout, respectively) just as they were last year.

Public health and preventive medicine reported the lowest burnout rate (29%) followed by ophthalmology (30%).

The trend of women reporting more burnout than men also continued this year (48% to 37%).

More physicians were happy in their careers (59% were extremely, very, or somewhat satisfied) than were not. But that is lower than in many other professions.

Last year, a CNBC poll found that 85% of American workers were at least somewhat satisfied in their jobs.

Willing to Trade Pay for Balance

Across all three generations, almost half (49%) said they would be willing to take less pay for better work-life balance. From one quarter (millennials) to one third (baby boomers) said they would be willing to give up from between $20,000-$50,000 in salary for more personal time.

"Expectations about what a career as a physician is in the 2020s is changing," Halee Fischer-Wright, MD, CEO of the Medical Group Management Association told Medscape.

"Physicians recognize that seeing a smaller number of patients may give them more time with patients and the ability to practice medicine at the height of their license, reducing nonclinical hours and enhancing personal satisfaction, which ultimately may decrease burnout and extend their career life," she said.

Top Driver Remains Administrative Tasks

The top driver for burnout again this year was too many administrative tasks for all three generations (54%-57% put it at the top). Baby boomers were the only generation to list "increasing computerization of practice" among their top three concerns. Millennials listed electronic health record demands second to last in choosing from a list of top 10 concerns. All three generations listed spending too many hours at work among their top three stressors.

Baby boomers, who have been a part of the trends from self-employment to employment and paper records to electronic records, were the most likely group (50%) to report that burnout has severely affected their life, compared with 46% of Gen-X'ers and 36% of millennials who answered that way.

However, millennials were more likely to report that burnout has strained their relationships. Among them, 77% said it had affected relationships, vs 69% of baby boomers.

Asked how they cope with burnout, physicians overall listed isolating themselves and exercise as their top strategies (45% each), followed by talking with close friends/family members (42%) and sleep (40%).

Tragically, some reports say that an estimated 300 to 400 physicians each year choose suicide. This survey indicates that 1% of male physicians and 2% of female physicians have attempted it.

Almost one quarter of physicians (23% of male physicians and 22% of female physicians) have had thoughts of suicide but have not attempted it.

The percentages of those who have had suicidal thoughts or have attempted it were very similar across all three generations.

Fix the System, not the Physician

Still, few seek help in any generation. Only from 12%-14% said they are currently seeking help; from 61%-64% said they have not sought help in the past and do not plan to.

Additionally, only 28% of physicians overall said their workplace offered programs to help reduce burnout or stress; half said they did not.

A cardiologist who responded to the survey said, "I don't think burnout is a psychiatric problem or my personal problem. I think it is inherent in the present way of healthcare delivery, at least in the US."

Wendy Dean, MD, a psychiatrist and founder of moralinjury.healthcare, an advocacy organization working to counteract the 'moral injury' of healthcare professions, agrees. The organization's website reads at the top: "Moral Injury – It's NOT burnout."

She told Medscape that although healthcare organizations often focus on wellness for physicians, such as yoga and self-care, "finding solutions requires that we address the problem for what it really is: a challenge inherent in the structure of the healthcare industry."

https://www.medscape.com/viewarticle/923845?nlid=133498_5402&src=wnl_dne_200116_mscpedit&uac=349096PX&impID=2246072&faf=1#vp_2

Asked how often they struggle with grief after a patient dies, 35% of physicians who responded to a recent Medscape poll said they always or often did.

The percentages who answered that way differed by gender (42% of female physicians commonly struggle with grief for patients vs 32% of their male colleagues) and generally increased with years in practice.

While 27% of physicians who had less than 5 years of practice reported that they always or often struggle with grief for lost patients, 43% of those with more than 30 years of practice said they did.

Nurses and advanced practice registered nurses (APRNs) were slightly less likely overall to say they often struggle with grief for patients (31% said they always or often did) and, unlike the trend for physicians, the more experienced nurses were less likely to struggle with grief.

While 37% of nurses with less than 5 years' experience said they struggle with grief for patients, only 29% of those with more than 30 years in practice said they always or often did.

One healthcare provider who commented on the poll theorized about the effect of length of exposure, saying, "Newer healthcare providers (HCPs) may have a more difficult time with more exposure to trauma, death, etc., while more seasoned HCPs may have a more advanced 'tool box' to cope. That being said, more veteran HCPs may either be desensitized or more overwhelmed with the trauma and death witnessed. We all cope (or don't cope) a little differently."

The poll, first posted July 24, received responses from 1366 nurses and APRNs and 654 physicians.

Physicians Much Less Likely to Receive Support for Grief

The poll also asked whether those who have struggled with grief have received help from various sources. Nurses and APRNs were twice as likely as physicians to receive help from coworkers, managers, counsellors, or therapists.

Table. Percentage of Those Who Struggle With Grief and Receive Support

Female physicians who have struggled with grief were more likely than their male counterparts to receive support from coworkers and managers (46% vs 33%) and from professional counselors or therapists (under 5% for both).

Commenters Share Grief Experiences

Respondents to the poll overwhelmingly agreed that healthcare providers need more education and resources on how to handle their grief in a healthy and professional manner. Some shared their experiences in the comments.

A registered nurse (RN) who worked in a neonatal intensive care unit (NICU) wrote, "One NICU [where] I worked had an unfortunate spell of 4 or more premature/non-viable infants die within about a 3-week period. (Congenital herpes, holoprosencephaly, placental abruption, extremely premature twins). We were exhausted from the intensity of the infants, then they died in spite of our best efforts. The manager at the time did call a group support meeting and we could all speak and share our feelings. It was helpful."

A hospice nurse wrote, "As an RN practicing in hospice, all of my patients die. Grief and support are part of our daily practice, but we often are too busy to remember to formally grieve and move forward in healthy ways. We all could use some professional help in this area, and the dismal reality of this poll shows that none of us are leaning on our psychology/psychiatry colleagues for their professional guidance."

The numbers in the poll suggest that many suffer silently. More than half of physicians (56%) and 36% of nurses and APRNs who said they had struggled with grief said they did not receive help from colleagues or from a professional counselor or therapist.

An RN commented, "(Patient) died this morning. Not expecting it. Been seeing her every week for 10 years. Got very close. Feeling very sad tonight but no one knows."

Have You Attended a Patient's Funeral?

One poll question asked whether healthcare providers had attended a patient's funeral. Only a few had done so in their first year. Just 13% of physicians and 17% of nurses and APRNs had done so in the past year; 67% of physicians and 40% of nurses and APRNs responded that they had never attended a patient's funeral.

An RN commented that there's a misconception that healthcare workers should experience grief. She says extended grief indicates that there was something wrong in that provider-patient relationship.

"Sadness, yes; tears, sure, especially sharing moments with the family/friends at time of death (really heart wrenching in pediatrics)," she wrote. "But if a nurse or doctor has protracted grief after a patient dies there is something wrong with that relationship."

However, another RN countered, "With all due respect your comments are a bit harsh and judgmental. I'm not a robot, I have formed relationships with my patients especially after caring for them over three months at times. I have certainly grieved some of their deaths."

https://www.medscape.com/viewarticle/921920?nlid=132837_5461&src=wnl_dne_191202_mscpedit&uac=69465HR&impID=2187527&faf=1

When AdventHealth CEO Terry Shaw's wife was hospitalized following a car accident, he was frustrated at how difficult the process was to navigate, and that led him to implement four major changes at his own health system, Shaw writes on LinkedIn.

An epiphany following the accident

"After 29 years of marriage, the last words I wanted to hear as a husband were, 'Your wife has been in a car accident. She's unconscious in the ER,'" Shaw recalls. "But perhaps even more unexpected was how difficult it was for someone who has spent three decades in health care and who runs a multi-billion-dollar health system to navigate her care."

Shaw writes that the first problem he encountered was finding his wife at the hospital. He had difficulty finding parking and had to wait in a long entry processing line before finally making it up to her room feeling "both scared and aggravated."

That's when a nurse stopped him before he entered his wife's room, Shaw recalls. The nurse told me, "Look Mr. Shaw, your wife has been through an awful lot today, and she can't see you the way you are now." She then helped him calm down and prepare to see his wife.

This gesture "truly touched my heart and helped me re-center before seeing my wife," Shaw writes.

Shaw's wife was taken to and treated at a hospital outside of AdventHealth's system. But Shaw's experience prompted him to re-examine how his health system approaches patient care: "We need to be caring for the whole patient, not just tending to their most immediate medical issue," according to Shaw.

The 4 changes Shaw made to his health system

Shaw writes that following his wife's accident, he implemented four tenets of what he calls "wholistic patient care" for AdventHealth.

1. "Keep me safe": Shaw writes that for most people, hospitals can be foreign and scary, and it's the job of providers to "make patients and their loved ones feel safe and secure in our care." Shaw writes that he showed up to the ED to see his wife "panicked and distraught," and needed the nurse who spoke to him to make him feel safe.


2. "Love me": Shaw writes that "love is an important part of the health care journey." When his wife arrived in the ED, Shaw writes that she was "at her most vulnerable and helpless and she was desperately in need of unconditional love." That's why Shaw wants every patient that comes to an AdventHealth hospital to know that "[n]o matter their circumstances or background, we are going to love them."


3. "Make it easy": After his experience following his wife's accident, Shaw writes that he learned "how hard we, as a health care industry, have actually made it for our 'consumers.'" Health care professionals "can be really bad at making the patient journey easy," Shaw writes. Instead, the process needs to be simplified so "more people are willing to come to us for care instead of feeling afraid or avoiding seeking care."


4. "Own the problem": Shaw writes that the issues faced by him and his wife were not uniquely reflective of the hospital his wife was treated, but rather "indicative of a much larger, farther reaching industry problem." Shaw writes that one of his biggest pet peeves is hearing anyone at Advent say, "That's not my job," because "it's everybody's job. I don't care who you are, including me."

All AdventHealth hospitals now require "wholistic" care training including the four tenets Shaw outlined, he writes. The goal is to educate staff on how to connect their patients with a variety of different resources. The reason: "Because I don't want anyone to experience what I did when my wife was in the hospital, and as a health system CEO I have the ability to change it," Shaw concludes (Shaw, LinkedIn, 11/14).

https://www.advisory.com/daily-briefing/2019/11/25/advent-health?WT.mc_id=Email|DailyBriefing+Headline|DBA|DB|2019Nov25|ATestDB2019Nov25||||&elq_cid=2349863&x_id=003C000001XZBfMIAX

Since we first reframed physician distress as moral injury in 2018, we have heard from scores of physicians—but also from nonphysicians in healthcare for whom that language resonates as well. Nurses, advanced practitioners, first responders, respiratory therapists, and physical therapists all have told us that they feel it too.

In fact, at a recent national meeting of perioperative nurses, more than 80% of audience respondents who reported feeling distressed endorsed the term "moral injury," rather than "burnout," in an informal poll. No segment of healthcare has a corner on distress. We are all suffering.

Why is it so hard, then, to build an advocacy community to fight moral injury across the various healthcare professional groups?

Too often, rather than viewing each other as providing complementary care, different healthcare professionals become factionalized and retreat into protective silos, lobbing thinly veiled hostilities from the safety of that position.

But when we are more interested in making sure other professionals are wrong than in understanding how their positions have merit, we lose focus on the bigger picture: making healthcare better for patients and sustainable for clinicians. Self-righteousness doesn't help us achieve any positive goals.

When resources contract, it is human nature to withdraw into a known protective space, defend territory, or generally become less willing to look at the needs of a larger group. But this dynamic works to the detriment of patients. Good care benefits from multiple sectors of medicine working in concert. And better teamwork leads to higher job satisfaction.

Doctors' and nurses' different perspectives give them unique ways to evaluate how well a team is working. This is partly the result of how different healthcare professionals are trained to think and to communicate.

Physicians think good teamwork is having someone who anticipates their needs and follows directions; nurses think good teamwork is having their input heard and considered.

As Sexton and colleagues wrote when describing interactions in a hospital setting, "Nurses are trained to communicate more holistically, using the 'story' of the patient, and physicians are trained to communicate succinctly using 'headlines.'" As a result, physicians think good teamwork is having someone who anticipates their needs and follows directions; nurses think good teamwork is having their input heard and considered. Knowing this, we can approach cooperation in a way that reduces misunderstandings.

Both physicians and nurses have engaged in behavior that is hostile toward the other. One nurse author writes, "Many of the nurses I know could share their own, dramatic stories of rescuing patients or catching frightening errors by other health care workers, including doctors." The tone drives a wedge between nurses and other professionals.

Nurses, physicians, and hospital administrators are equally to blame for the current antagonism among clinicians. In the past, a physician's ultimate responsibility for a patient's outcome came with the authority to determine a treatment plan, and to guide its execution. It conferred the role of team leader. Unfortunately, some physicians used that role to dictate rather than collaborate, and they denigrated the contributions of other team members.

A Shift in Healthcare Leadership

As team-based care has gained more attention, though, the assumption of physician as team leader has shifted. Leadership is more distributed, if responsibility is not, and consensus—among nurses, doctors, the patient, family, and other professionals—is expected. Some physicians have struggled with that shift. Some resent losing authority without appreciably offloading responsibility. Some feel too rushed and oversubscribed to generate consensus. And a few lash out in response.

Resources of time and money are shrinking in healthcare, which leaves everyone feeling threatened. We are continually asked to do more with less. We worry about patient safety and having the time to provide a compassionate, human experience of care. We worry about the ability to access necessary treatment. And we worry about whether we will have a job, sustain our income, and be able to repay our school loans.

Four Key Steps to Combating Moral Injury

If we want to find solutions to the drivers of moral injury, we need to cross departments and tear down clinical silos to share our experiences, ideas, and lessons learned. We have to bury latent hostilities, whether they arise from insecurities, poor communication, or rigid organizational structures.

How can we do that?

First, we need to create a regular opportunity for communication. Believing that change will occur by itself, without dedicated effort, assures it will not happen. Instead, set up a regular forum to identify common challenges among healthcare professional groups you work with. Create working groups to address the most pressing or widespread challenges, and jointly present the findings and recommendations to hospital leadership or administrators. Ask administration to provide sufficient resources for a task force to address the issues.

Second, jointly sponsor events that address common challenges. Although doctors and nurses often focus on different concerns during encounters with a patient, there are some aspects of medicine today that frustrate us all. Prior authorizations, unaffordable medications, crushing documentation and compliance requirements, intrusive regulations, and licensing challenges are all issues that matter to all of us. Working together to solve them will be much more successful than working in isolation.

Third, intervene when you encounter toxicity, whether in print or in person. Write letters to editors of publications that print divisive work, and give feedback to the authors. Asking doctors who are badmouthing nurses, or nurses who are declaiming doctors, to reconsider their attitude for the good of their patients is uncomfortable yet critical for improving dysfunctional workplace cultures. Sniping and condescension signal a lack of mutual respect. Teams rely on trust and respect to function optimally, and if that is not the culture of your institution, it is yours to change.

Finally, demand that leadership set a collaborative tone and intervene with bullies. Ask for bystander intervention training. The only people who can't choose to walk away from an environment poisoned by superiority complexes and entrenched tribalism, who are powerless to change it, and who are at its mercy are the patients. For their sakes, let's call out the thinly veiled hostility and self-righteousness when it appears. That way, we can stop the distraction and focus on our shared mission of patient care.

Patient care is a difficult job in the current healthcare environment. Each clinician group has a niche role, without which care is compromised. If we respect those differences as necessary to ensure the best care of our patients, then break down silos and recognize each other as teammates rather than opponents. We can create a healthcare environment where clinicians can do good for their patients and be well themselves.

https://www.medscape.com/viewarticle/921148?src=WNL_bom_191124_MSCPEDIT&uac=69465HR&impID=2176677&faf=1