Physican Wellness
We are professional healers (Physicians, Nurse practitioners, Physician assistants). Our job is unique, very few jobs exist that have the same demands and expectations that ours does. We have to be experts at a lot of things in order to be successful healers. The stress that comes along with these demands is great, as is the energy needed to meet them. Wellness is essential in order for us to meet these demands and perform at our maximum potential.
Wellness Misconceptions & Truths
Others think of “Wellness” as fluff, not important and/or not needed. Many shy away from “Wellness” because it makes them feel like they are vulnerable (i.e. it challenges their superman self-image and their “I’ll just tough it out” mentality).
The truth about “Wellness” for professional healers it that it’s the only way to survive the current state of health care. This is why “Wellness” is included in the ACGME milestones for residency training.
Wellness is not fluff, it is very important, and it is needed. In reality, “Wellness” is the only way to become superman and the only way to actually have the ability to “tough it out”.
Wellness does include escaping (going on vacation to get away) but this is only a small aspect of wellness. The majority of “Wellness” centers around developing and practicing proactive and reactive strategies that allow us to both survive the stressors that come with our job (i.e. build resilience) and change the landscape of our job in a way that eliminates the modifiable stressors (make our environment better).
Wellness utilizes “escaping” to get away so we can charge our batteries, but if that’s all we do for wellness, we will come back to the same negative work environment that we escaped from. True “wellness” allows us to change our work environment, and healthcare, for the better and it allows us to survive while we are working on making this change.
Burnout
What is Burnout?
In order to fully understand “Wellness”, you must first understand burnout. Let’s provide some insight regarding burnout. Every day our job drains our batteries, but at the end of the day, when we are off, we can recharge them. When we can’t recharge our batteries we are burned out.
The engagement continuum
Engagement is feeling of career fulfillment & satisfaction, feeling that your work makes a positive difference in people’s lives, and the feeling that your career has true meaning. Engagement is the emotional gold standard for career success. There is a continuum that exists. On one end, there is engagement (where we all start), on the other end there is burnout. We are constantly getting pulled towards the burnout end of the continuum. The pull is driven by the little stressors we experience every day.
Mechanism of Burnout
Imagine it snowed. Think of the daily stressors of our job as little snowballs. What happens is that these snowballs pelt us throughout the day. We don’t see it happening because we are so focused on taking care of our patients. Because most of us are unaware this is happening, it ends up being a one sided battle. As this goes on, we get pulled toward the physician burnout end of the continuum. Eventually, we can’t recharge our batteries and we are burned out.
The four “Stressor” domains
The daily stressors that drive burnout (the “Snowballs”) can be grouped into four domains.
- Domain 1: The clinical stressors of medicine. These are the stressors that come along with providing health care to those who are sick and injured.
- Domain 2: The non-clinical stressors of medicine. These are the non-clinical stressors that we face in our job.
- Domain 3: Work-Life balance. This domain includes the stressors of our personal life that challenge us everyday.
- Domain 4: The four horsemen of the burnout apocalypse. The horsemen are “Superhero”, “Perfectionist”, “Lone Ranger” & “Workaholic”
The four horsemen of the burnout apocalypse are a set of attitudes and behaviors that are expected of us while in training. They are automatic by the time we are attending’s. In training these behaviors allows us to be functional. They are even essential. They get us through rough call nights & clinical rotations. But they also set us up for burnout (especially when we are done with our training). The horsemen throw fire on the other stressors. They are the accelerants of burnout.
Stages of Burnout
Burnout has 3 stages.
- Physical & Emotional Exhaustion: You are emotionally drained, depleted and worn out by work and not able to recover in your non-working hours
- Depersonalization: The development of a negative, callous and cynical attitude toward patients and their concerns
- Reduced Sense of Personal Accomplishment: The tendency to see your work negatively, without value or meaningless (“what’s the use?”) and see ourselves as incompetent.
Men & Women can experience the stages of burnout in a different order.
Women: Women often (but not always) feel emotional exhaustion first, then depersonalization & cynicism and finally reduced accomplishment
Men: Men typically first feel depersonalization & cynicism, then they feel emotional exhaustion and lastly they feel reduced accomplishment. However, in a lot of male doctors, the “Reduced Accomplishment” stage is absent. Male physicians are also far less likely to feel that the symptoms of cynicism and emotional exhaustion affect the quality of the care they offer.
What are the consequences of burnout?
- Burnout decreases physician’s professionalism and the quality of medical care they provide
- Burnout increases medical errors and malpractice rates
- Burnout lowers patient compliance and satisfaction with medical care
- Burnout increases rates of physician substance abuse, intent to leave practice, and suicide.
BASICS Wellness Model
The solution to burnout is Wellness. We can achieve Wellness by going back to the BASICS. Below are links for each of the six BASICS wellness domains. Click the picture to follow the links.
Body
B is for Body. This is the domain dedicated to wellness of the body. This is physical wellness. It has four main sub-categories.
- Exercise
- Diet & Nutrition
- Sleep & Fatigue
- Preventative care
Each of these sub-categories of B is for Body is important for physical wellness. Below we will explore each area in more depth.
Click tabs below for more information
You’re a doctor. I don’t need to tell you how important exercise is…but I will anyways.
Benefits include better sleep, improved sense of energy, reduction in physical and emotional tension, fewer feelings of depression and anxiety, lowered risk of many physical illnesses, including cardiovascular disease, and much, much more.
As doctors, we know this. So why don’t we all exercise regularly?
- Not enough time—patients and family come first.
- Not enough energy — the long work day leaves little reserve for much else, let alone exercise.
- Not enough motivation—the inertia of a sedentary existence just can’t be overcome.
- Not enough expertise— we aren’t already the best at running, rowing, dancing, or whatever.
There are ways to overcome these barriers to an active lifestyle. With strategic planning, exercise can be built into everyday routines.
You can integrate exercise into your workday.
Idea 1: Travel Differently
Exercise while going to work:
- walk to work
- jog to work
- biking to work
- Using the stairs at the hospital
- If there is a gym, pool or workout room where you work, use it during any down time in your day.
Idea 2: Make it Fun!
Have fun! Join a doctors’ basketball or softball team.
Some find joining a gym or fitness facility, and using the services of a professional trainer, motivating.
Idea 3: Two birds with one stone!
Hold occasional journal club meetings in association with a physical activity, such as yoga or swimming.
Build dedicated physical activity, such as group walking, into professional meetings.
Idea 4: Keep it small
The trick is to start small. Commit to a few minutes two or three times a week.
Eventually try work up to an exercise routine of 15 or 20 minutes duration.
Don’t listen to the four horsemen of the burnout apocalypse. In this situation, these traits are your enemy.
Give yourself permission to be slow and inept at first. Understand that there might be a little discomfort, very soon offset by the many, immediate benefits. Then, gradually build on those initial gains. Before you know it, you’ll be the beneficiary of an active lifestyle you won’t want to part with.
Healthy eating decreases allostatic burden and increases resilience and our ability to cope with stress.
Tip 1: Timing
- Eat breakfast—even if you round at 0700! It’s an important meal.
- There is no sense in starting the day without quality fuel in the tank, relying instead upon the “supercharged” effect of caffeine, fat and sugar in your morning “double double.”
- Avoid heavy eating before sleep.
Tip 2: Choices
- Consider yogurt, high-fiber cereals, fruit, cottage cheese, or eggs.
- Avoid the muffins. If it’s white and fluffy or greasy, avoid it.
- Choose the salad bar at the hospital cafeteria more often.
- Choose the burgers and fries less often.
- In general, all the authorities agree: variety is good, fad diets are not so good.
Tip 3: Portions
- Eat smaller portions more often— every three to four hours during the day. Keeping blood sugar and insulin levels steady is preferable to the peak and trough effect of occasional eating of large meals.
- It’s probably a good idea to have a healthy snack mid-morning (especially if breakfast is very early), late afternoon or in the evening before bed.
- Consider fruit, vegetable sticks, cheese, whole grain bread, crackers or cereal.
- It’s easy to throw an apple and an individually wrapped piece of cheese into your bag in the morning and take it with you to the office or hospital. Be especially certain to do this if expecting a long, stressful day with the possibility of having to work through lunch or supper.
Tip 4: Call & Overnight
- If on-call and sleep is not so likely, be sure to have an overnight snack. Bring something with you to the hospital in order to avoid the vending machine with the tempting junk food when the cafeteria is closed.
Sleep loss is associated with increased irritability, anger, depression, sensitivity to criticism, decline in cognitive performance, including the ability to solve problems and learn new skills, daytime drowsiness (nodding off), and more.
Losing sleep impairs psycho motor function. In fact, it has been shown that four hours of sleep loss results in the kind of impairment usually associated with a breath alcohol level above the legal limit for driving in most jurisdictions. In short, being sleep deprived hurts — us, and potentially those we serve.
Tip 1: Listen to your Body
Listen to your body’s rhythms. There are times when falling asleep is easier because it’s natural to do so.
Plan bed-time and naps to coincide with your body’s natural sleep rhythm.
To the best of your ability, don’t let anything else interfere with this schedule.
Tip 2: The 3S sleep schedule
Sleep schedule: Develop a bedtime routine pattern of behaviors, even post-call, that facilitates the onset of sleep.
1. Soften Stimuli: “Close shop” sufficiently early in the evenings to give your mind a chance to wind down.
Avoid work-related e-mails, calls, journal reading, paperwork and so on for a few hours before sleep.
- Avoid heavy exercise right before sleep.
- Avoid caffeine right before sleep
- Avoid excessive fluid ingestion or a heavy meal right before sleep
2. Signal Sleep: Engage in activities right before going to bed that signals sleep is coming.
- Make sure the activities are relaxing!
- You know what works for you: listening to or playing music, taking walks, reading a novel or other non-work related material (However, reading Rosen’s always put me to sleep).
3. Set Support: Arrange your sleeping quarters to support your sleep.
- Light level: Dark for most (many use a face mask)
- Noise level: quiet for most
- Temperature optimization.
- A light snack can help prevent overnight hunger.
Idea 4: Things to avoid
- Generally, avoid sedative drugs for sleep, unless for short periods and as prescribed. This includes over the-counter preparations. Never prescribe sedative hypnotics for yourself.
- Avoid alcohol.
Idea 4: Bounce Back
If at all possible, grab a quick nap (about 45 minutes) during the day prior to an overnight shift or call.
Be sure to get extra sleep on days off. This is the way to achieve sleep homeostasis, that is to repay the “sleep debt.”
A fundamental of self-care is that we have a personal physician and use him or her as others would.
We should make time to see the dentist and eye doctor as well as our physician.
Affect
A of BASICS is the domain dedicated to wellness of the mind. This consists of mental, emotional and psychological wellness. A also stand for Assets which is financial wellness.
The four horseman of the burnout apocalypse are very destructive to mental, psychological and emotional wellness.
Click on tabs below to learn more about this domain.
At least one study has measured perfectionism in a population of health professional students (medical, dental, pharmacy and nursing) and notes it to be prevalent, and, not surprisingly, highly correlated with symptoms of psychological distress.
There is a strong association generally between perfectionism and increased risk for depression, anxiety, obsessive compulsive symptoms, and even suicide.4
The perfectionist horseman of the burnout apocalypse does most of his work by setting expectations that result in perfection. These expectations are often unrealistic. This horseman works in many ways:
- Filtering: Perfectionists tend to select certain details they will focus upon — usually negative ones. Expecting perfection, they tend to discount the impact of positive feedback. The result can be an obsessive and upsetting preoccupation with criticism that is not balanced by the appreciation of compliments or a job well done.
- Mind reading: The perfectionist, especially one who is socially prescribed, will think he or she knows what others are thinking of them. And all too often they will believe that others are judging them harshly.
The perfectionist horseman often drives physicians to place unrealistic demands upon themselves. This is behind the feeling that no mistake is acceptable. This horseman also leads to physicians imposing these same impossible expectations onto others. This horseman also drive the common physician perception that others expect them to be perfect. The expectation that others expect perfection is highly associated with distress.
The superhero horseman of the burnout apocalypse makes physcians feel that they can meet all the unrealistic expectations set by the perfectionist horseman.
Some common manifestations of the superhero include…
- Over confidence: This is one manifestation of the Superhero trait. The superhero trait often causes doctors to have the sense that they are in greater control of situations than they realistically are. So, when outcomes don’t match expectations, the tendency is to blame oneself. Anger, frustration and guilt are common feelings that result.
- Over responsibility: The superhero trait also causes doctors to falsely assume that their role is to stamp out disease, suffering and death.
- Over inflated ego: The superhero trait also causes doctors to often assume that they are is indispensable to patients and profession. It also leads to the assumption that no patient could ever be angry with you, or leave your practice.
The Lone Ranger horseman of the burnout apocalypse drives many physicians to work alone, disconnect from others, and have a self-centered viewpoint.
It manifests in many ways, including:
- All or nothing approach: The Lone Ranger horseman drives a form of self-centered thinking that often leads to a false dichotomy mindset. This mindset causes people to see only two ways about anything… Their way or the wrong way. All or nothing thinkers will, of necessity, face frustration trying to navigate a world of uncertainty and shades of gray.
- Isolation during stress and/or uncertainty: The Lone Ranger horseman often drives us to disconnect from others during times of stress and uncertainty. This can be very destructive since the best solution to uncertainty and stress is to connect with others for partnership and support.
The Workaholic horseman of the burnout apocalypse drives the feeling that the impossible expectations set by the perfectionist can be achieved with hard work. This horseman says that not meeting an expectation only happened because of lack of hard work. Physician’s often project this mindset on themselves and others. They also feel that other’s feel the same way about them.
A really dangerous expression of this trait is catastrophizing.
Catastrophizing: This involves the magnification of negative outcomes coupled with the sense that they can be prevented or managed with hard work.
The first “S” of BASICS is Social wellness. It is the domain dedicated to wellness of the people in your life outside of work. It focuses on the relationships with your friends, family and significant others.
Below we will explore social wellness in more depth.
Click on tabs below to learn more about this domain.
Supporting and sustaining relationships with your spouse, significant other or partner is critical. Eventually you will fall and these are the people who will pick you back up.
You need to be present for your family and children. Absence is very destructive. You may be saving lives with your presence at work while destroying lives with your absence at home.
- Maintain friend contact with phone calls, email and visits.
- Join health clubs or other mutual interest organizations to make friends based on common interests.
- Seek opportunity to develop closer friendships with people at work, and cultivate nonmedical friendships as well.
Intellectual & Occupational
The first consideration is diversion from the day to day demands upon our intellectual abilities. The second is developing skills that make work easier.
Click on tabs below to learn more about this domain.
Supporting and sustaining relationships with your spouse, significant other or partner is critical. Eventually you will fall and these are the people who will pick you back up.
Community
Wellness of the community is wellness of your work family. It includes your staff, your partners, your superiors, and your subordinates. It is your team. It also includes other teams you interact and depend on to do your job.
A good way to understand “Community” is by thinking about the opposite of a community, an anti-community. An anti-community is like a shark tank. In the shark tank anti-community, any unidentified colleague is a shark until proven otherwise; in this type of environment a person can’t bleed because it attracts more sharks; get out of the water if someone else is bleeding; counter aggression with more aggression. In this type of anti-community, the members eat each other if they sense weakness or failure.
A community needs to have three things in place in order to be “Well”
- Mutual Respect
- Mutual Purpose
- Mutual Weaknes
Mutual Respect is built through trust. An effective strategy for creating mutual respect is to create trust. Without trust, there is no respect. Once trust starts to form, respect will follow.
Mutual Trust is built through Team building and Mutual weakness allows for Task building.
Click on tabs below to learn more about this domain.
Spirit
Wellness of the Spirit can encompass many things. Many think of religion and faith, when they hear the term “Spiritual wellness” which makes sense, religion and faith are part of spiritual wellness for those who are religious.
It is important to understand that religion and faith are not the only components of this spiritual wellness.
Spiritual Wellness centers around the elements that humans need to keep their spirit strong. The human spirit drives our engagement, perseverance, resilience, fight and fulfillment. When “Wellness of the Spirit” becomes impaired we lose the will to fight and we stop caring.
Below explores the components of spiritual wellness.
Click on tabs below to learn more about this domain.
The human spirit needs several things in order to be well.
These can be remembered by SIC4 Spirit (SIC for Spirit). These are listed in the tabs below.
S = Safety & Security: In order to be well, the spirit needs Safety & Security. This need drives our need for trust and respect.
I = Identity: The spirit needs Identity. Our values, beliefs, convictions, and self image are related to this need.
C1 = Choice: This is Choice & Control. The spirit needs these for wellness.
C2 = Certainty: The spirit needs a lot of certainty.
C3 = Connection: The spirit needs connection. This drives the need to belong and be together.
C4 = Contribution: The spirit needs to be able to contribute.
Behaviors that increase any of the above SIC4 generally bring us pleasure & behaviors that decrease them generally bring us pain. These would be threats to Safety/Security, Identity, Choice (free choice), Certainty, Connection and Contribution.
Sometimes these elements interact in surprising ways often following and dynamic hierarchy of importance. For example, sometimes people do things that directly threaten then need for safety and security, like parachute, rock climb, race cars, which does not make sense. It only makes sense when you realize that these behaviors are often driven by the need for accomplishment (driven by need to contribute), the need to experience (driven by the need for certainty), and the need for identity.
In reality we also need balance. We do need a little of the opposite of the SIC4 needs. We need a little insecurity, we need a little identity confusion, and we need some uncertainty. Sometimes we need to have choices made for us, sometimes we need to disconnect and sometimes we need to be non-contributors. It is important to remember that these things should only be in very small amounts relative to the SIC4 needs.
Some things are special threats to spirit, because they threaten multiple elements of SIC4 at the same time, these special threats are:
- Loss of control (potentially decreases free choice, safety & security, and certainty)
- Change (potentially decreases free choice, safety & security, and certainty)
Social