Keeping burnout at bay

Mastering stress and preventing burnout in the job search and beyond

By Anish Majumdar | Fall 2011 | Feature Articles

 

Two noises dominate in the sprawling home of physicians Raj and Sonia Pyne: the cries of their new baby, Syan, and the beepers on their kitchen counter. In their early 30’s, he is a radiologist at Rochester General Diagnostic Imaging, and she an anesthesiologist at University of Rochester Medical Center (URMC) in upstate New York. They survived medical school together, specifically choosing their specialties to exercise a greater degree of control over patient loads and on-call time.

Drs. Raj and Sonia Pyne traded big-city stressors for jobs close to Sonia’s family in Rochester, N.Y. Photograph by Lisa Huges

They employ a nanny to care for Syan during work hours, and Sonia’s parents, who live in the area, are invaluable in helping navigate the tricky waters of parenthood. In short, they’re using practically every resource at their disposal to mitigate the stress that comes with being doctors. Yet it has never been more keenly felt in their lives.

“You can either be a good doctor or a good parent,” Sonia says, savoring a glass of wine as only a woman who was restricted for nine months can. “But trying to balance it is where it gets hard. I work 12-hour days and I leave at 6 in the morning. So in the morning I don’t get to see my baby, and when I return, if I’m lucky, he’s up for maybe two hours. So at work there’s a constant sense of guilt at my not being there for him.”

“There was a sense of clarity at work,” says Raj. “No matter how hard it got, I knew this was where I needed to be. This was where I could do the most good. But I don’t have that anymore.” He looks at the infant carrier resting in a far corner of the kitchen. “You’re taught in med school that work is the priority and home life can wait, but for the first time I’m realizing it isn’t true. You’re missing your kid’s life.”

Physician stress and burnout has become a hot-button topic in the medical community. Up to 60 percent of practicing physicians report experiencing symptoms of burnout such as frustration, restlessness and emotional exhaustion. Especially worrisome is the documented link between burnout and poorer quality of care, increasing the risk of errors, lawsuits and patient dissatisfaction. Fortunately, there are solutions. One study, reported in JAMA, followed 70 primary care physicians in Rochester, N.Y., who had voluntarily enrolled in a year-long CME course that included mindfulness meditation, self-awareness exercises, and appreciative interviews. Participants reported both short-term and sustained improvements in well-being and attitudes associated with patient-centered care. According to Michael Krasner, M.D., an associate professor of clinical medicine at the University of Rochester and one of the authors of the study, positive change begins with an admission: “Doctors aren’t invincible. You can’t just keep ‘getting through the day’ without running out of days at some point.”

Krasner knows from personal experience just how debilitating runaway stress can be. Growing up, he witnessed his father, a fellow physician who had ascribed to the “getting through the day” mentality throughout his career, fall privy to the physical and emotional effects of stress and turn to Mindfulness-Based Stress Reduction (MBSR) techniques as a means of coping with them. It fostered a lifelong interest in the discipline, and today Krasner leads MBSR classes derived from his work at the University of Massachusetts Center for Mindfulness, offering physicians and students tools to manage stress before it triggers a crisis.

Identify major stressors

“Being still can be a very difficult thing for doctors,” says Krasner. “We get acclimated in medical school to keep moving from one task to another, and we bring that mentality with us into practice. When you suddenly stop, it can be disorienting. Disturbing, even. But that’s where the work begins.”

Scheduling a few minutes each day to consciously register and list stressors opens the door to managing them. Tracey Marks, M.D., an Atlanta-based psychiatrist specializing in stress management, suggests that physicians be on the lookout for the following:

• Occupational stressors

Is your patient load manageable? Do you receive adequate support with administrative tasks? Do you need to work late hours to get the job done? Do you feel burdened by government or insurance regulations?

• Financial stressors

Do you feel as if you’re working smarter rather than harder? Is your practice a profitable one? Do you feel adequately compensated for your time and effort?

• Personal stressors

Are you spending an adequate amount of time with your family (for both you and them)? Are your personal relationships satisfying? Do you have enough time to take care of personal responsibilities such as paying bills and preparing meals with enough left over for hobbies, friends and social outings? Says Sonia, “I feel a lot of my self-worth now comes from being a mother, which I never expected. I recently had to spend two full days away from Syan while I was on call, and it was nearly unbearable. I haven’t found that balance yet, and in some ways I think I’ll always be seeking it.”

• Physical stressors

Sleep can be a litmus test for gauging your overall health. Are you getting enough? How well do you take care of yourself? How serious are the implications should you fall sick and have to miss work?

“You’ve been up for 24 hours and all of a sudden four pages come in,” says Raj. “You ask yourself, ‘How is this possible?’ And finally you get to go home only the thing is, it’s not home anymore! It’s a baby!” He pauses for a few moments before saying, “Let’s just say we grab sleep wherever we can get it.”

“If a doctor were to see a patient displaying stress indicators, he’d easily diagnose it,” says Alan Rosenstein, M.D., MBA, medical director of Physician Wellness Services (physicianwellnessservices.com). “But when it comes to themselves, the self-awareness often isn’t there.”

Build relationships with your peers

Michael Krasner, M.D., practices Mindfulness-Based Stress Reduction techniques—and teaches them to other physicians. Photograph by Lisa Hughes

“Many of the doctors I counsel have the sense of being alone at work,” says Krasner. “We used to go to hospitals to take care of patients when I first started in practice. Now there’s hospital lists and doctors that work in the office. Many of the colleagues I refer patients to, I wouldn’t recognize them if I saw them on the street, whereas before we’d be chatting in the coatroom, swapping stories. That’s a real loss.” The sense of isolation that results from a lack of community can make physicians feel like the weight being placed upon their shoulders is too much to bear. It’s also only in the particular company of peers that otherwise-taboo issues can be safely discussed…and sapped of their sting.

One of the foundations of Krasner’s stress reduction work revolves around creating an environment where physicians can share experiences and use appreciative inquiry techniques to explore how they worked through difficult situations. Listeners are instructed to avoid interrupting, focus questions to deepen understanding of a storyteller’s experience, and above all, resist placing judgment. “Doctors don’t sit in these groups and recite facts and figures,” says Krasner. “They talk about what it’s like to be with a dying patient. They talk about family problems and plans for the future. In so many ways, we’re no different from our patients.”

Most medical institutions in the U.S. have in-house employee wellness programs that can open the door to forging peer-to-peer relationships. The Internet has also become an invaluable communication resource for physicians, with niche forums devoted to everything from the challenges of being a physician and a mom to maintaining your sanity during residency. Just remember that online contact isn’t a substitute for the real thing.

Krasner keeps the door to his office open throughout the day, a reminder to both himself and the 10 other physicians who work in close proximity that they’re part of a group.

Minimizing stress during a job search

Can the search for a position ever be anything but stressful? According to Michelle Mudge-Riley, D.O., president of Physicians Helping Physicians (phphysicians.com), entering the fray from a position of self-knowledge is the key to not being overwhelmed.

“It’s a two-way street,” she says. “It’s not about finding any job but rather finding one that supports your dreams. Identifying those dreams is the first step.” Mudge-Riley conducts brainstorming sessions with physicians across the country to unearth root desires and create a personal development plan that will lend perspective to the coming search. Major questions to consider include:

• Your life purpose

What gives your life meaning? What inspired you to go into the field of medicine, and what do you wish to be remembered for?

• Beliefs and values

What scruples do you live by? What are and aren’t you willing to compromise on? Do you feel like you’re presently honoring your values? What would you change?

• Mistakes and successes

What errors linger in your memory? What do you most regret? Conversely, where have you succeeded? What accomplishments, professional or otherwise, are you most proud of?

• Short, medium and long-term goals

What does your ideal life look like? What steps are required to get you there? Specificity is key here.

“Use your support system,” counsels Mudge-Riley. “Landing the job you want isn’t going to be as simple as running a Google search. Contact old mentors, stay abreast of industry trends, and if you come across someone who’s doing what you want to do, reach out to them.”

Implementing a system to manage documentation such as multiple CV and cover letter versions, industry clippings and contact information will enable you to effectively manage the job search and apply to positions with minimal stress.

Once you’ve landed an interview, clearly stating your priorities and making sure that they’re honored lessens the chance of burnout down the road. It’s a lesson Sandra McKay, M.D., a pediatrician at O’Fallon Pediatric Partners in Missouri, learned the hard way.

“I was promised flexibility at my last position, but as the months went by the responsibilities just kept piling up,” she says. “I was spending evening after evening stuck in the hospital as opposed to being with my children, which placed an enormous strain on my husband. It was unacceptable.”

When job searching, ask for concrete details regarding on-call hours and working conditions. Take the extra step of contacting your future colleagues to get the real scoop.

Realizing a change was necessary, McKay began networking and researching potential job leads, eventually landing an interview with her current employer. This time there’d be no misunderstandings.

“I said point-blank that I wasn’t missing any parent-teacher conferences!” she says with a laugh. “And I knew I’d come to the right place because the answer I got was, ‘You should never miss a parent-teacher conference. You should be there for your children.’ And they kept their word.”

One of the biggest perks of her current position is being part of a multispecialty group consisting of more than 380 primary care and specialty physicians that lend credence to and support her life’s passion, child advocacy. Yet it never would have materialized had she not first advocated for herself.

Evoke the relaxation response

Though avoiding all stress is impossible, its negative effects can be countered through evoking the relaxation response, a term first coined by Herbert Benson, M.D., founder of the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, to describe a state of profound rest and internal repair.

The relaxation response promotes balance through deepening your breathing, slowing heart rate and blood pressure, lowering stress hormones, and relaxing muscles. Research also points to a host of long-term benefits such as increased energy, heightened problem-solving abilities and relief from chronic aches and pains. Best of all, it’s a state that can be achieved consistently through a variety of methods, including deep breathing, progressive muscle relaxation, mindfulness mediation, yoga and tai chi. Though these techniques can be learned relatively easily, creating the right environment is crucial to success. Marks offers the following tips for physicians:

• Set a regular bedtime and stick to it (even on the weekends). A body requires consistency and routine to perform at peak levels.
• Plan for a “wind down” period before bed. A racing mind can sabotage the needs of an exhausted body. Use the 30 minutes before bed to shut off all electronics and engage in relaxing activities such as listening to music, meditating or reading.
• Set aside 15 to 20 minutes in the middle of your day to meditate. Effective meditation can mean taking long, deep breaths or imagining your ideal vacation. Doing this in the middle of the day helps break up the intensity and offers your mind a chance to reboot.
• Set aside at least one hour over the weekend to do nothing. Put “nothing” on your schedule. While the temptation to make up for a demanding workweek by cramming in an excessive amount of personal activities is understandable, having too much to do causes stress even if the activities are enjoyable.

Learn to accept change

The awesome responsibility placed in the hands of physicians can instill a false belief in their ability to control events beyond patient care.

However, the truth is doctors are not exempt from life’s vagaries, and accepting it is the only way to keep them from becoming traumatic events.

Physician turnover rates are rising, according to the sixth annual Physician Retention Survey from the American Medical Group Association (AMGA) and Cejka Search, with 6.1 percent total turnover in 2010 as opposed to 5.9 percent in 2009. Though a weak economy and lower reimbursement rates are causing an increasing number of doctors to delay retirement, shifting priorities among a younger generation also play a role.

“I didn’t see many happy couples,” says Sonia about the year she and Raj spent in residency in Boston prior to moving to Rochester. “We’d moved there from New York City, working ourselves to the bone, never seeing each other.”

“I got along well with my attending,” says Raj. “We could speak honestly to each other. He knew about the problems Sonia and I were having and told me straight-up that as much as he’d like to see me continue on there, things wouldn’t improve for us.”

Sonia’s hometown of Rochester, N.Y., immediately stood out as a possible alternative, not only for the family support that would be there, but a medical community that was known for offering physicians the means and flexibility to have a personal life. Yet she deliberated before approaching Raj with the idea, anticipating resistance. He’d spent the bulk of his life in major cities and had grown accustomed to their rhythms.

As it turned out, she needn’t have worried.

“I love shopping at the mall,” he says, laughing. “I love driving around and having easy access to things. These all came as surprises to me, and it was hard adjusting at first, but I couldn’t be happier.” He nods out toward the backyard, falling into shadow with the onset of dusk. “Knowing that Syan’s going to have a place to run around and play in makes it all worthwhile.”

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Inside the Stress Reduction Program at the Center for Mindfulness

at the University of Massachusetts

Since introducing meditation into mainstream medicine in 1979, the Stress Reduction Program at the University of Massachusetts has helped more than 18,000 people draw upon their innate resources and abilities to respond effectively to pressure, pain and illness. The central tenet of the program revolves around a form of meditation known as mindfulness.
As described by Michael Krasner, M.D., who trained at UMass CFM and currently teaches its concepts, “Mindfulness is a quality we all have, but it’s also a practice. We use techniques to cultivate awareness and attention and bring it directly into the realm of interpersonal communication and work.”
Major aspects of the course, consisting of eight weekly classes and one day-long class, include:
 
     • Guided instruction in mindfulness meditation practices
    
     • Stretching and mindful yoga
 
     • Group dialogue and discussions aimed at enhancing awareness in everyday life
 
     • Individually tailored instruction and daily home assignments
 
Prospective participants be warned: The course is highly participatory and requires a firm commitment to attend all classes and practice home assignments. The results, however, can be life-altering.
Says Krasner, “I fear what my days would be like if I hadn’t learned these principles. I know that I’d be in much worse shape. While mindfulness-based stress reduction isn’t the only way, in my experience this makes a real difference for docs.”
 
Additional program details can be found at umassmed.edu/cfm/stress. To contact the UMass CFM directly, please call (508) 856-2656 or email mindfulness@umassmed.edu.

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Anish Majumdar (anishmajumdar.com) is a freelance journalist and writer based in Rochester, N.Y.

 

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