Physician Wellness and Resilience

Some physicians are endowed with such an abundance of resilience that they resent the mere inference that they should be more resilient than they already are — that they aren’t tough enough or that they lack the mental fortitude to cope with the daily demands of their profession despite all appearances to the contrary.

“I think they feel, ‘Who could be more resilient than most physicians?’ — especially given how they sacrifice work-life balance, trained under conditions that most people can’t even imagine, and have been successful in the face of working 24 hours straight or having people’s lives in their hands,” offers Jeffrey Cohn, MD, MHCM, medical director for Common Practice in Philadelphia, Pennsylvania, and a personal/leadership coach for physicians.

“Some physicians have gotten pretty ticked off with the impression that they or any physician could learn to be more resilient,” he adds. “Resiliency in the minds of physicians is a pretty charged word.”

Dangers of Resilience

Resilience also is an often misunderstood and misapplied concept among driven, overworked physicians who exploit it as a tool — or an excuse — to strain beyond healthy boundaries.

Lisa Herbert, MD, is a physician executive coach who is founder and CEO of an organization aimed at helping women physician leaders redefine work-life balance and advance as healthcare leaders.

“I think that physicians’ perception of what resilience means causes them to push past their challenges, even to the point of physical and emotional exhaustion, which can definitely lead to burnout,” she says. “Physicians are constantly in survival mode and, yes, may appear to be unfazed by the incredible demands placed on them.”

But appearances are sometimes deceiving, and abusing resilience for otherwise noble purposes, she says, can be attributed to a self-destructive lack of self-awareness.

“Self-awareness is an essential part of being resilient,” Herbert says, “because you have to recognize what triggers your internal emotions and when you need help, which is the basis for self-care, and how you respond in different situations so you can better manage your own feelings. Resilience not only comes from how you think, but also from your support system, including the resources, people, and communities that help you recover from stressful situations and in-between challenges.”

Missing the Mark?

As a family medicine physician in Indiana who rebounded from burnout to also become a physician life coach, Errin Weisman, DO, says she has a “love-hate relationship” with the word resiliency, which she defines as a need to be “more equipped” and “stronger to my situations.”

“It’s like preaching to the choir,” she says. “We’re resilient as hell when it comes to being in medicine; that’s not the issue. You’re not dealing with weak-minded people. The study shows that when pre-med students go into medicine they are some of the most healthy student populations that there are. So to me, when we’re doing resiliency training and trying to implement mindfulness techniques, we’re missing the mark.”

What Is That Mark?

“The mark for me is making true, lasting, sustainable change where all can thrive, find joy in medicine, and continue practicing. Focusing only on individuals is not seeing the entire, complex landscape of wellness,” she explains, citing the Stanford WellMD Professional Model that identifies personal resilience, the culture of wellness, and efficiency of practice as the three key factors of physician wellness.

In other words, she says, “Stop pressuring physicians to be tougher and harder yet more flexible and fluid. Resilience training that I’ve been a part of has focused on the individual when I feel a majority of emphasis needs to be placed on modifying the factors causing the physician to utilize resilience they already have. We need to support physicians in personal development, but calling for more resilience doesn’t solve that for me.”

Cohn agrees that resilience by itself is not enough to offset the extrinsic factors that take such a toll on physician wellness.

“It’s possible that physicians may have normalized pushing themselves to or beyond their limit in the service of their patients and profession, and that ‘normalization of deviance’ may be a contributing factor to burnout in some, though they’d likely dispute this, perhaps because they’re in so deep they can’t see what others can,” Cohn says, attributing much of that “deviance” to imposed tasks such as electronic medical records and pre-authorizations “that are not aligned with the physician’s sense of purpose” and test the limits of resilience.

“While much of what’s happened in healthcare has been necessary to bring it into the 21st century, I think a lot of what’s causing the burnout crisis is the introduction of processes that pull people away from what calls them to this job in the first place,” he says.

Resilience to Burnout

When hitting on all cylinders, resilience is the mechanism that enables physicians to address change and challenge rationally, view mistakes as learning opportunities, bounce back from adversity, and lead effectively in the face of stress and pressure.

Its value is irreplaceable but it isn’t bulletproof. The sad but familiar fact is that more than half of all physicians, no matter how resilient, fall victim to burnout — and because of its insidiously incremental nature, most never see it coming.

“Physician burnout is a series of events and stressors that happen over time and build up to a point where physicians feel they can’t escape anymore,” Herbert says. The trick is getting physicians to recognize their own symptoms.

“It comes back to having better self-awareness, which physicians are really good at with other people’s bodies but we’re terrible at our own,” Weisman says, which is at least partly the result of training as far back as med school.

“If you look at the type of people who go into the field of medicine, they’re already in that mindset in college where they’re studying, they’re preparing, and they’re checking one box after the next,” Herbert says. “There’s a high level of competition for getting into the best schools and getting the best grades — and then you take that mindset and that type-A personality and start training, but nothing is done to deprogram you from that mindset that if I work a little bit longer and a little bit harder and fight through this, something’s going to give.”

But often the only thing to “give” is the physician’s health, attitude, and outlook toward the profession and life. “And it continues to get worse unless somebody comes in — organizations and leadership — to help physicians understand that it’s a teamwork approach and it’s OK to ask for help,” Herbert says.

Tick, Tick, Tick

Burnout is like a stick of dynamite with a long fuse; once it’s lit, it isn’t a matter of whether it’s going to blow, it’s a matter of when and how big the blast will be.

On a scale of 1 to 10 — with 10 representing full-blown burnout — how long do physicians typically wait before seeking help?

“My gut says that it’s beyond 10,” says Cohn, his answer consistent with the 8-to-10 range suggested by four others interviewed for this article. “Even when people are totally burned out they may still be head-down and punching the clock” before colleagues recognize the problem and advise them to seek help.

“Unfortunately,” Herbert says, “I think most physicians wait until they’re near or at the brink of total burnout before asking for help [which they view] as a sign of weakness and which usually keeps them in that cycle of burnout and not seeking help until reaching the point where they’ve just had it and either want to quit medicine or just give up.”

That’s exactly where Weisman found herself post-residency.

“Life and practice were supposed to get better after graduation but instead it was more of the same,” she says. “I was already burning out in residency despite the duty hours because of the hidden curriculum of ‘we need to work as hard as the previous residents because that’s the way it should be.’ My program did the requirements from the Accreditation Council for Graduate Medical Education, but there wasn’t a true recognition of burnout or an acknowledgement that it was present in our program.”

“I got to the point that I was done, absolutely,” she admits. “I was leaving not just my job but medicine altogether. I was online looking at how to change my CV to a resume. I actually put in applications to work in different nonmedical settings in my area. The only thing that kept me — and this is what I think traps lots of people — was my loan burden, because there was nowhere else I could go to make enough money to pay down student loans the size of two house mortgages.”

The Breaking Point

Whatever the drain on their wellness, physicians notoriously wait far too long before seeking the help they desperately need. But why?

“Shame. Guilt,” says Jude Pierre, MD, a physician at Access Healthcare Physicians in Spring Hill, Florida, who is collaborating on a wellness project for physicians in Tampa, Florida, and whose own battle with burnout cost him his marriage.

Pierre shares the story about an intern at his medical school in the Bronx telling med students, “If you’re not sicker than the sickest patient on this ward, I expect your behind to be here at 4:30 in the morning changing dressings.”

Pierre looked around the ward at all the sick patients and thought, “Wow, I guess I’ll never call out sick.” And he knew he’d be shamed if he ever did otherwise.

“From the get-go, we’re taught to be invincible,” he says. “It almost becomes normal to go into work sick — normal to not seek help because then it makes you look weak — weaker than everyone else. Physicians are very competitive. We feel as though we have to perform at a certain level, and if we don’t then we feel guilty about it. If you’re not as good as the other guy, then you feel shamed.”

Even then, there comes that breaking point when shame, guilt and pride give way to a desire to restore wellness. “It’s usually something quite big that finally slaps them in the face and they say, ‘Gosh, I’m in trouble here,’ ” Cohn says.

“For me it was the divorce,” Pierre says. “My wife said she’d had enough. She told me, ‘Jude, we did not need all of this’ — meaning two offices, multiple houses, and nice vacations. She had been telling me this, but I wasn’t listening. So it wasn’t until a life event happened that I realized, OK, something’s wrong here. I have to figure this out and work on some habits that need to be addressed.”

It’s that relational disconnect with family, friends, colleagues, and even patients that is a telltale sign of trouble — so obvious to everyone else yet the physician is oblivious.

“The identifiers should be and could be relationships,” Pierre contends. “How good and how strong are your relationships? If you don’t have any relationships and you don’t have anyone that you can talk to about the burnout, that’s actually a red flag. I’m reading a book now called Rare Leadership (Moody Publishers, 2016) about how great leaders live their lives, and one of the first things they talk about is to remain relational. Act like your best self, return to joy, embrace hardship — but remaining relational is one of the key components of decreasing or preventing burnout. If you isolate yourself, which is what I did, it didn’t work out. I used to play soccer; I wasn’t playing soccer. I isolated myself from my family. Those are key indicators.”

Indicators are meaningless, however, unless heeded by the physician, and that frequently fails to happen until it’s brought to their attention.

“It could be that a colleague, family member, or friend who tells them that their behavior is changing, that they’re becoming distant or appear more stressed than normal,” Herbert says.

Still, says Charmaine Gregory, MD, FACEP, an emergency medical clinician at the University of Michigan’s St. Joseph Mercy Hospital and burnout survivor now helping others as a physician coach, “Depending on where you are in burnout, it causes you to pull away from the people that are the most supportive and protective of you. And God forbid if you’re in a situation where you don’t have a home life or the support of someone sticking with it and recognizing that you’re having a hard time and helping you through that. I think that’s when colleagues end up killing themselves.”

Even as a survivor, thriver, and entrepreneur, Weisman admits she still has a propensity for reverting to that mindset that first pushed her beyond the boundaries of wellness, before slamming on the brakes and saying, “Whoa, what are you doing here?”

“What’s most important when I talk with my clients is that [I tell them], ‘Those behaviors served you. That’s what got you through medical school, that’s what got you through training, that’s what got you where you are today, but it’s not sustainable going forward.’ And it’s really hard to change those behaviors, because they were serving you at one time. They were a positive thing until, just like any kind of drug, you get to a certain threshold and it goes from a drug to a poison.”

Stanford WellMD Professional Fulfillment Model

In an initiative to improve the professional wellness of Stanford Medicine physicians as well as their patients, trainees, and medical team members, the Stanford WellMD Center created a conceptual model with three domains it says must be addressed in order to achieve optimal physician wellness and professional fulfillment. Those domains are:

Culture of Wellness. Shared values, behaviors, and leadership qualities that prioritize personal and professional growth, community, and compassion for self and others.

Efficiency of Practice. Workplace systems, processes, and practices that promote safety, quality, effectiveness, positive patient and colleague interactions, and work-life balance.

Personal Resilience. Individual skills, behaviors, and attitudes that contribute to physical, emotional, and professional well-being.

Wellness Tips

Advice on what steps to take if you find yourself exhibiting signs or symptoms of burnout:

Recognize and acknowledge your burnout. “Realize it’s not your fault, there’s no blame, that it’s a series of events that led to this, and take time to self-evaluate and get off that hamster wheel,” executive coach Lisa Herbert says.

Confide. Talk with someone you trust — family, friend, coach, or colleague. “It’s really important to have that village around you to help you to escape from burnout,” Herbert says.

Get coaching. Get help to identify choices you are making vs. other available options that “would be more closely aligned with who I want to be and the values and priorities that I hold most dear,” leadership coach Jeffrey Cohn says.

Seek counseling. Especially for someone experiencing depression or anxiety and whose late stage of burnout is affecting home and professional life, Cohn says.

Change your mindset. Put action behind words. “Realizing I’m not alone, I’m not stuck, change is possible, and this current reality does not have to be my future,” Weisman says. “Then having those small changes lead to bigger, monumental changes, like taking two hours to take a nap, read a book, sit on my porch, go for a walk — and realizing that the world won’t fall apart and the office will be fine if I walk away from my phone.”

Exercise. This is the most popular coping mechanism, according to the 2018 Medscape National Physician Burnout & Depression Report.

Have small-group meetings. Huddles or short cluster meetings — ways to be intermittently but continually reminded of the relational aspects of healthcare — offset things like EHRs that minimize human-to-human touchpoints, Cohn says.

Organizational Best Practices

When Errin Weisman tried to persuade her chief medical officer to change her sleep-depriving work schedule, his reply was, “You’re not even the first physician this week or this day to be in my office telling me about how you’re feeling.” Her reaction was one of anger. If he knew there were problems affecting the health of the staff, why wasn’t he doing anything about them? If you observe or are confronted with signs of workplace burnout, here are some ideas to help your staff:

Lead from the ground floor. “Leaders should know what it’s like in the day of a physician,” Lisa Herbert says. “Ask questions. Talk with your doctors. Ask them what they need. Include them in decision making. Get their feedback. It’s about working with them as a team and also being their advocate. Physicians look for leadership that speaks up on their behalf so they can have a better work environment.”

Remove barriers. “Leaders need to invest in specific improvements and remove barriers — the additional tasks that have been piled on clinicians — that are getting in the way of people being good doctors,” Jeffrey Cohn says.

Lead by example. “What I’m doing in my group of about 10 employees is teaching them what I’ve learned, giving them required readings, and having ‘gratitude time’ during our weekly meetings,” Jude Pierre says, “and I can see a transformation in my office [and hope]it will trickle down to the [other 1,000 in our] organization.”

Go external. “Organizations need to realize that they may not be able to do it all themselves,” Herbert says. “They may need outside help, such as bringing in coaches or counselors or other people to organize peer-group activities to improve the work environment.”

Be careful. “You could actually make things worse if you offer mindfulness or coaching or whatever kind of individual-focused efforts without doing anything at an organizational or systemic level,” Cohn warns. “That could just make people more resentful and make the situation even that much more challenging.”

To emphasize the effect of workplace culture on physician wellness, Weisman uses the illustration of the sick sea turtle that’s in the oil spill: “You take him out, you take him to the recovery center, you get him beefed back up, and there’s no reason why you would return that poor sea turtle to the same ocean with the same oil. And I feel like that is exactly what happens in medicine.” Unless leadership steps up.