Wellness: 2020 Annual Meeting Co-chairs describe balancing act
The hazards of sleep deprivation | Marta Ann Crispens, MD, MBA, FACOG
Fitness into a Specialty | J. Brian Szender, MD, MPH
Wellness Q & A with SGO President Warner K. Huh, MD
Combating compassion fatigue | Kimberly E. Resnick, MD
The case for a healthy night’s sleep | Shannon MacLaughlan David, MD, MS
With Gratitude and Thanksgiving | Wellness Task Force
Is there a ‘good’ time to start a family as a gynecologic oncologist? Melissa A. Geller, MD, MS
No Man is an Island | Kathleen Essel, MD
Saving the oncologist one step at a time: My wellness strategy | Nathalie McKenzie, MD, MSPH
Having More Empathy | Jolyn Taylor, MD, MPH
Wellness: If you feel like you’re going to the dogs | Lyn Filip RN, BSN, OCN
Saying Goodbye to a Patient | Larry Puls, MD
How much is too much? | Linda R. Duska, MD, MPH
The Courage to Leave | Stephen L. Rose, MD
Things aren’t going to get ‘better’ | Nathalie Dauphin McKenzie, MD, MSPH
Wellness found in a mentor relationship | Leigh Cantrell, MD, MSPH
Turning off the Tech | Taylor Turner, MD
The art of saying ‘NO’ | Kimberly Resnick, MD
From Pathology to Positivity | Monica Hagan Vetter, MD
Wellness and cultural change | Shannon MacLaughlan David, MD
The Myth of ‘Effortless Perfection’ | Brittany Davidson, MD
Finding time to be balanced about wellness | Diljeet K. Singh, MD, DrPH
Continuous performance improvement | Marta Crispens, MD
Running on empty: using exercise to combat burnout | Leslie S. Bradford, MD
Preventing burnout through leadership and engagement | Julian (Skip) Schink, MD
Hurry, Scurry, Work and Worry | Jeffrey M. Fowler, MD
The importance of mindfulness | Kimberly Resnick, MD
Years that way: Burnout and gynecologic oncology | Emily K. Hill, MD
Interested in sharing your story? Email us!
How do you balance your professional and personal lives while being mindful of wellness? What happens when extra responsibilities are added to your already busy workload? The Wellness Taskforce asked Kenneth Kim, MD, and Kathleen Moore, MD, co-chairs of the SGO 2020 Annual Meeting on Women’s Cancer Program Committee, to provide a little insight into how they balance their busy lives while managing to stay well.
1. Does being a committee chair have an impact on your current workload? If yes, how so?
Dr. Kim (KK): Yes, definitely–it is absolutely amazing to work with Dr. (Warner) Huh and Dr. Moore and all of the excellent people on our Program Committee, and it’s a true honor and privilege to serve SGO. Balancing clinical work and planning for SGO is critical, and it certainly helps to have amazing partners at the University of Alabama at Birmingham to help. This is always a juggling act, but it is truly invigorating to work together with so many brilliant people, to help synthesize novel information as our field evolves, and to find the best ways to present it while continually advancing educational technologies.
Dr. Moore (KM): Yes–the Program Committee chair position is a tremendous amount of work but it is a great honor and also a lot of fun. It forces me to think creatively and collaboratively about what our membership is most interested in and new ways to present information. Working with our committee is also energizing because they have so many good ideas and are very self-directed in terms of developing content together and thinking outside the box. But I’ve definitely had to be very efficient with my time and scheduling so I can devote the time and attention to the meeting that it deserves.
2. What do you do to include wellness and social activities in your schedule?
KK: In addition to having these responsibilities, as well as having a family with 7-year-old Korwegian (Korean/Norwegian) twins, I make an effort to work out 4-5 times a week at 4:00 a.m. This is (generally) before the day starts, and it’s during a time when I know my family is asleep. At this time of day, I don’t have to choose between working out versus time with my family, and I don’t feel guilty for missing time with them if they are asleep. It’s quiet and provides the time not only to physically work out, but also to mentally sort through everything I need to think about without distractions. After work, the rest of my time is usually monopolized by my family, particularly my twins, which is admittedly pretty glorious and also definitely good for my well-being.
KM: For me, this is a time where I have a lot of programmatic activity going on at our cancer center so I’m not in a position to reduce my current work to make room for being Program Co-chair. I try to utilize a few more hours of my day for exercise and taking care of non-work-related activities. I’ve done this by moving exercise to early in the morning and then using my evenings to spend time with my human and animal family.
3. Do you have a favorite wellness activity?
KK: Golf or tennis with my family. Traveling with my family. Eating with my family. Watching my kids draw. Singing with my twins. Watching movies.
KM: I enjoy going to Orangetheory and riding my Peloton bike. My favorite activity is hanging out with my husband and taking care of our rescue puppies.
4. What wellness advice do you have for members?
KK: Philosopher Alain de Botton once said, “Everything worth fighting for unbalances your life.” Wellness is about balancing these things. It ebbs and flows over time. “Balance” doesn’t necessarily mean “equal” and it is certainly not static. It is not necessarily a destination, but rather a process – the little daily efforts to avoid tipping one way or the other. Bending versus breaking. And what works for someone may not work for someone else. I know I’ve had to make adjustments in different directions when things get out of hand. For me, this is always an ongoing work in progress.
KM: I was least happy when I let work completely dominate my life and time – which it still can at times but I’ve become better at making course corrections when this happens so I can carve out some time to keep me healthier. I’m definitely not the poster child for wellness but I am a work in progress.
A recent study in the New England Journal of Medicine reported that within the constraints of an 80-hour work week, more flexible work hour restrictions for internal medicine residents that did not specify shift lengths or time off between shifts did not adversely affect 30-day mortality or other measures of patient safety.1 A randomized trial of surgical residents similarly found that less restrictive work hours was associated with non-inferior patient outcomes as compared to a more restrictive work hours policy.2 But what if this is the wrong question? Perhaps the question is not how to optimize the 80-hour week, but whether it is possible to reconcile the 80-hour week and 24-hour shifts with the realities of human physiology.
Sleep deficiency, defined as both inadequate and mistimed sleep, is an under-recognized health risk.3 Studies performed in rats and dogs demonstrate that the result of prolonged sleep deprivation is death.4,5 More recent studies in rats have shown that repeated exposure to severely limited sleep results in persistent physiological imbalances.6 In humans, sleep deprivation is associated with major health risks, including cardiovascular disease, obesity, type 2 diabetes, and cancer.3 Sleep deprivation results in impairment of cognitive and motor performance comparable to being drunk.7 The optimal sleep time for an adult is 7 to 8 hours per night.3
Software developers were long known for eschewing sleep and working long hours to complete projects. That is, until it was recognized that long hours led to decreasing creativity and productivity and increasing rates of programming errors. Agile is a set of values and principles for software development.8 The eighth agile principle is sustainable pace, that is a work pace that the team would be able to sustain indefinitely.9 This idea derives from the observation, often attributed to Henry Ford, that productivity declines after 40 hours per week of work – and perhaps 35 hours for knowledge workers.10, 11
More recent academic analyses have confirmed that longer work hours result in employee fatigue and stress that reduces productivity and increases the probability of errors, accidents, and illness.12 There is an irony in the observation that the information technology sector has recognized and acted upon the realities of human physiology before doctors.
We face a number of challenges in medicine including burnout, suicide, and medical errors. Although there are many contributors, sleep deprivation is an important factor. The United States has adopted work hour restrictions for physicians in training that are less restrictive than those imposed for airline pilots or truck drivers.13, 14 There are no work hour restrictions for physicians in practice. There are two main challenges to decreasing resident work hours, the need for more providers to supply patient care and a decrease in educational opportunities for residents. Several countries in northern Europe have successfully achieved reductions in resident duty hours to 48 hours or less with continued provision of safe patient care and satisfactory training.15
There will always be the challenge that patients require care 24/7/365. However, the goals of maximizing patient safety and achieving a healthy work-life balance and better overall health for all providers during and after training require that we rethink the organization of healthcare systems and training to find our sustainable pace.
Marta Ann Crispens, MD, FACOG, is a Professor and Director, Division of Gynecologic Oncology, in the Department of Ob/Gyn and Chair of the Vanderbilt-Ingram Cancer Center Scientific Review Committee at Vanderbilt University Medical Center in Nashville, TN.
- Silber JH, Bellini LM, Shea JA, et al. Patient safety outcomes under flexible and standard resident duty-hour rules. N Engl J Med 2019;380:905-914.
- Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty hour flexibility in surgical training. N Engl J Med 2016;374:713-27.
- Luyster FS, Strollo PJ Jr, Zee PC, et al. Sleep: A health imperative. Sleep 2012;35:727-34.
- Rechtschaffen A, Bergmann BM. Sleep deprivation in the rat: An update of the 1989 paper. Sleep 2002;25:18-24.
- Bentivoglio M, Grassi-Zucconi G. The pioneering experimental studies on sleep deprivation. Sleep 1997;20:570-6.
- Everson CA, Szabo A. Repeated exposure to severely limited sleep results in distinctive and persistent physiological imbalances in rats. PLoS One 2011;6:e22987.
- Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med 2000;57:649-55.
- Agile Alliance. Agile 101.
- Agile Alliance. Sustainable Pace.
- International Game Developers Association (igda). Why crunch modes don’t work: Six lessons.
- Cook D. Lost Garden. Laws of productivity. September 28, 2008.
- Pencavel J. The productivity of working hours. The Economic J 2015;589:2052-76.
- Federal Aviation Administration. Fact sheet-Pilot fatigue rule comparison. December 11, 2011.
- Federal Motor Carrier Safety Administration. Summary of hours of service regulations. March 9, 2017.
- Temple, J. Resident duty hours around the globe: Where are we now? BMC Med Ed 2014;14:58-62.
My residency graduation included the “yo-yo” awards. While this was actually short for “yo-yo, you got this,” whenever I see the plaque in my office now I can’t think help but about what an up-and-down ride my training was, both physically and emotionally. The physical rollercoaster is a major part of why I elected to join SGO’s Wellness Task Force. Between medical school, residency, and fellowship I managed to gain and lose more than 150 pounds, 20 to 30 pounds at a time. I suffered from the classic signs of poor fitness including:
- Excessive fatigue
- Dyspnea after walking up a flight of stairs
- High resting heart rate
- Prolonged recovery heart rate
- Reliance on caffeine or excessive sugar cravings
When I completed my fellowship and started into practice, one of the resolutions I made for myself was to stop this vicious cycle and take control of my health and fitness once and for all.
As a husband, father of four, and early career gynecological oncologist, my time is split (sometimes unevenly) between my wife, children, and my practice. Because there are only so many hours in a day and I cannot overcome the need for at least a few hours of sleep, there isn’t much time between rounds, robots, and rides home with the kids for a regularly scheduled fitness class or a trip to the gym.
I had to get creative with my time and find short intervals throughout the day to elevate my heart rate.
The most effective way I have been able to ensure that I get at least a little exercise in every day is to start from the first time my feet hit the floor when I get out of bed. Five exercises in five minutes helps start the day off on the correct path; no matter what other decisions I make or how little time I have between patients, the rest of the day can’t take away those first five minutes from me.
- The routine starts with a slow walking lunge across my bedroom. This stretches the legs and engages the muscles of the lower body.
- Next, perform 10 slow-count push-ups, taking five seconds to lower the body and one second to push back up.
- The third movement is supine leg raises, holding the feet off the floor about 6 inches for a five count, repeated for 10 repetitions.
- Return to the push-up position and plank for 60 seconds.
- Finally, 10 air squats and you can move on to start your day.
Micro-breaks for exercise can also be extremely useful, whether it is the decision to run up the stairs instead of taking the elevator or performing isometric leg lifts while writing notes, opportunities to exercise abound throughout the day for the gynecological oncologist.
Every location around the country is going to have different local resources for to incorporate fitness into your life, but there are some universally available resources that can help the busy physician reduce any guilt related to “time away from study” in their practice while exercising:
- SGO ConnectED – use the streaming audio/video of last year’s SGO meeting–especially the trainee sessions with seminal clinical trials–as the soundtrack for your workout. Nothing says “run faster” like listening to Dr. Kushner talk about ovarian cancer!
- Research to Practice – offers free podcasts across a range of oncology topics.
- YouTube – There are taped grand rounds, medical lectures, and chalkboard talks.
- Podcasts – Pearls of Exxcellence from the Foundation for Exxcellence in Women’s Health are available for download.
Finally, make sure that any of the above activities are performed with a goal in mind. Remember that you can’t care for your patients if you are too sick or fatigued to do so, but that you were also a person before you became an oncologist and one aim of fitness should be to help preserve that humanity. If you’ve never participated in an organized fitness activity before, consider signing up for a local 5k fun run. Get online, find a weekend that you’re not on call, pay the entry fee, and commit. The National Ovarian Cancer Coalition (NOCC) has 5k races throughout the country, find your local event at http://runwalk.ovarian.org. The National Race to End Women’s Cancer, hosted by SGO’s Foundation for Women’s Cancer, will be held Sunday, Nov. 3 in Washington, DC. https://endwomenscancer.org/
J. Brian Szender, MD, MPH, is a gynecologic oncologist at START Center for Cancer Care in San Antonio, TX.
Warner K. Huh, MD, is the 51st President of the Society of Gynecologic Oncology (SGO). Dr. Huh is a Professor, Vice Chair and Division Director of the Division of Gynecologic Oncology at the University of Alabama at Birmingham (UAB). For this month’s SGO Wellness blog, Dr. Huh describes his favorite wellness activities and how he encourages others to take time for themselves.
1. Do you have a favorite wellness activity?
Squash during the non-summer months and wakesurfing (or taking others wakesurfing) during the summer months
2. How do you incorporate wellness activities into your day?
I try to play squash, workout or take my 4 dogs for a walk while listening to podcasts. I try to make a daily commitment to one of these activities everyday (see reason below)
3. What do you do as a leader for your team in regards to wellness?
Every day at 5:00 p.m., after our shifts have ended, our division gets together with our fellows and residents to do ”sit downs.“ This has been a UAB tradition for over 25 years. The primary intent was to review inpatients for the on-call team, but this has turned into a time to decompress, vent, joke and tell stories. We have been known to crack open a beer or two or have some bourbon or scotch. As a leader, I am just happy to keep this tradition going.
4. What wellness advice do you have for members?
On the day I graduated from my residency, one of my faculty mentors pulled me aside and gave me a small piece of advice: Try to carve out at least 30 minutes for yourself, and only for yourself. His only requirement was to make sure that the time was uninterrupted and spent away from work. I have used and passed on this advice for 20 years and it has served as the cornerstone of my personal wellness. Perhaps the best of advice that I have ever received.
5. What are your goals as SGO President?
Strategies for maintaining balance: Try to carve out time for myself (and myself alone) every day. Also, delegation is important to maintaining sanity but that becomes a delicate balance as well (i.e., balancing with being a servant leader).
Goals for SGO: Promoting and building on the excellent work that the SGO Wellness Task Force has accomplished over the last several years. I would like to see SGO become a leader in this area, for all medical disciplines and training.
“We have not been directly exposed to the trauma scene, but we hear the story told with such intensity, or we hear similar stories so often, or we have the gift and curse of extreme empathy and we suffer. We feel the feelings of our (patients)…Eventually, we lose a certain spark of optimism, humor and hope…We aren’t sick, but we aren’t ourselves.”
-C. Figley, 1995
That beseeching, fearful look. I know this look. These five faces that want answers, any answers—to the complicated scenario I just painted. I glance at my Apple watch. It’s 3:00. Shocked by what we found. Assumed that Ms. X had early stage endometrial cancer. Had to open due to findings. Stage 4 disease. It’s 3:05.
My stomach growls. I continue my litany. Couldn’t have predicted this. No way of knowing. No other symptoms. We took out the cancer in its entirety. It’s 3:07. It’s Valentine’s Day. I was in charge of the cupcakes for the Second Grade class party. I wonder if the boys liked them, wonder if they were too “girlie.” It’s 3:10.
Carcinomatosis, yes, like grains of sand. More treatment, chemotherapy. At my preoperative counseling I always state that we cannot know the exact stage until we operate, does anyone LISTEN to what I say? It’s 3:12. No, not in the liver or kidneys or rectum. Yes, I suppose that is good. But truly the horse is out of the barn. It’s 3:14.
I’ve started intermittent fasting as an attempt at self-care and self-preservation. I haven’t eaten in many hours. I’m reviewing the contents of the refrigerator. Thinking about how to make a low glycemic index dinner. It’s 3:16. More therapy will be needed. Yes. Chemotherapy. She is asleep. She doesn’t know this yet. She doesn’t know this yet.
I’m not burned out. I love what I do. Every day. But it’s lurking. At the door. Compassion fatigue. Mother Teresa knew it well. She mandated that her nuns take a 1 year sabbatical every 4-5 years in order to recover. To heal. In the stress literature compassion fatigue is known to have a more rapid onset than burnout. Burnout emerges over years…decades. Compassion fatigue can occur daily when our emotional bank account is literally empty. Working at the county hospital drains my account daily until…I just…can’t. The poverty, the chronic illness, psychiatric illness, domestic violence, drug use, lack of resources, lack of support staff—and the cancer—how can I not mention the CANCER? The stories wash over me like so many ripples in the ocean until I cannot separate them. The sadness abounds.
This is our call to action. Mine and yours. In every snide comment, every mumble to our nurse about a BMI—we are letting the compassion fatigue get the best of us. Dike Drummond, MD, notes that it is at this point that we need “exquisite self-care.” He suggests:
- Cutting hours to a minimum
- Only charting what is necessary-step away from the EMR
- Take a vacation (or a staycation)
- Get rest, get exercise
- Spend time with YOUR loved ones
In Judaism “tikkun olam” refers to healing the world. As doctors this is NOT our task. We are merely asked to heal one person at a time. The world can wait. Engage in the moment.
- Quote by C. Figley-Compassion Fatigue and Psychological Distress Among Social Workers: A Validation Study. Adams, R et al.
- Dike Drummond, MD – The Happy MD Blog
Kimberly E. Resnick, MD, is an Assistant Professor at MetroHealth Medical Center in Cleveland, OH.
There is nothing more glorious than sleeping in on a weekend. I have always found lazy mornings to be luxurious, and it still baffles my family how I left that out of the equation when forging my career path toward gynecologic oncology. Despite my passion for a good night’s sleep, I function pretty well without it. Or so I thought. Turns out that getting less than seven hours of sleep a night on a regular basis is associated with a ton of health issues, including, but not limited to, obesity, diabetes, metabolic syndrome, heart attack, stroke, depression and—wait for it–death. No wonder the American Academy of Sleep Medicine recommends adults get seven to nine hours of sleep a night. So is every gyn onc doomed to a premature death?
I find myself rationalizing. . . Most of the evidence linking sleep deprivation and mortality in humans is correlative and often confounded by sleep disorders like obstructive apnea. But, at least one prospective study demonstrated in healthy volunteers that sleep debt (four hours a night) for six nights increases night time cortisol, impairs glucose tolerance, and stimulates the sympathetic nervous system. Whether I like it or not, there is a compelling case to be made for getting a healthy night’s sleep.
In case you’re not worried about your own health and longevity, you can’t get around the fact that sleep deprivation is linked to compromised performance, productivity and, in our line of work, safety. Just as the Accreditation Council for Graduate Medical Education (ACGME) has rules about recognizing and mitigating fatigue in trainees, we should probably think about ways a gyn onc can sneak in some restorative sleep from time to time. I don’t have the answers, but I offer here some thoughts and discussion points.
Some people swear by the daytime power nap. Research suggests napping may benefit performance and memory outcomes for some people, but certainly does not replace night time sleep, which has a different physiologic purpose.
So what can you do to maximize the quantity and quality of night time sleep? For starters, put down your phone. And I don’t just mean turn off the ringer. Screen time is stimulating and addictive, and the blue-green light emitted from device screens suppresses the melatonin surge your body needs to fall asleep. This is why sleep experts recommend putting away the tech an hour before bedtime.
If you just can’t do it, at least turn on the Night Shift function in iOS (or Night Mode for Android). These apps minimize the blue light emissions from your smart phone based on the time of day. I also downloaded f.lux onto my laptop for this same purpose. There are also glasses that filter the blue-green light. But none of these things will protect you from whatever it is in the email you insisted on reading before bed, or in the middle of the night, when “you’re up anyway” because someone paged you.
Once you’ve put down your phone, find what helps you relax and declutter your mind. Meditation and deep breathing exercises that reduce your heart rate variability and literally calm your nerves have become very popular for this, and there are a million apps available (but then you risk picking up a device). If meditation isn’t your thing, try this mental exercise that is used by military and pilots to fall asleep in two minutes:
- Relax the muscles in your face, including tongue, jaw and the muscles around the eyes
- Drop your shoulders as far down as they’ll go (i.e., open the space between your head and shoulder) and relax your arms, “scanning” your upper and lower arm, one side at a time. Allow them to feel heavy and weighted into bed (or whatever surface you’re on!)
- Breathe out, relaxing your chest, emptying all the breath
- Relax your legs, starting from the thighs and working down
- Declutter your mind – Focus on one of these images (this can be tailored for what works for you!):
- You’re lying in a canoe on a calm lake with nothing but a clear blue sky above you
- You’re lying in a black velvet hammock in a pitch-black room
- You say “don’t think, don’t think, don’t think” to yourself over and over for about 10 seconds
I am hopeful that the lifestyle of a gyn onc is not going to cause my early demise, but I do believe it’s important to sleep when I can. Remember those sleep-deprived volunteers? Their metabolic anomalies reversed when they were allowed 12 hours of time in bed for a week, during which they slept an average of nine hours. So maybe sleeping in on a weekend isn’t just a luxury, it’s a necessity!
Shannon MacLaughlan David, MD, MS, is a Visiting Associate Professor of Gynecologic Oncology at the University of Illinois at Chicago.
Ready or not, the holiday season is upon us. And while it is traditionally a time of giving thanks, many of us will be on call. Some of us will miss family dinner and holiday traditions, and undoubtedly all of us at some point in our career, have felt guilt over gratitude on Thanksgiving (or any) Day, as we ask our loved ones to sacrifice for the career we have chosen. Here’s the thing that is easy to forget – our loved ones are proud of us and the work we do.
In this special Thanksgiving edition of the SGO Wellness blog, we hear from a daughter and two husbands of SGO members about life with a gynecologic oncologist in the family. We share these with you in gratitude this holiday season, in recognition of your dedication and in appreciation for you and your families. On behalf of the SGO Wellness Task Force, thank you for all that you do. The following are presented with the permission of both the author and the SGO member.
Sean David, MD, SM, D.Phil, spouse of Shannon MacLaughlan David, MD
I met Shannon when she was straight out of her residency, and was about to start her gyn onc fellowship. As our relationship grew, I was struck by the insane hours she worked—up before dawn and home after dark, then back to the OR at 2:00 a.m. for emergency surgeries. There have been sacrifices and challenges for us, including two years on opposite coasts so Shannon could finish her fellowship, before we were married. But we are all enriched by her dedication to her patients. If anything, I regret her feelings of guilt for the times she is pulled away from family events to do her job; but it was never an imposition on us. It’s about family. We just love, admire, and miss her in those times; and there will be open arms and turkey sandwiches in the fridge for her after any Thanksgiving she misses.
Despite the heartbreaks that come with treating cancer patients and time away from family, she never loses her focus or her humanity. She has the equanimity to go from the OR to the theater, change from scrubs to a ballroom gown in the car, or from sharing laughter and tears with patients to bringing groceries to homeless families or blankets and water to families displaced by wildfires. Her heart bleeds for those who suffer, but there is an overflowing well of love leftover for us, her family and friends. Character. Grit. Beauty. Grace. That is my wife.
Jose M Torrealba, spouse of Trevor Tejada-Berges, MD, MSc, FRCPSC, FACOG, FRANZCOG
Trevor and I began dating before he began medical school and well before he even thought of becoming a gynecologic oncologist. Having now lived with him for over 22 years has made me appreciate the little treasures life provides us on a daily basis. Through his experience caring for patients with cancer, and the stories he is able to share, I realize how fortunate I have been to be spending my life with such a giving, caring and generous man. And while this does, at times, mean we need to make sacrifices, it also implies that I am somehow contributing to support his efforts to save a woman’s life or improve her wellbeing. That is a great privilege I would otherwise never have experienced. The work of an oncologist confronts us directly with our mortality and reminds us daily that we are not here forever. As a result, we have learned to value every minute we can spend together immensely, making our bond and relationship stronger, real and, remarkably, fun. I feel absolutely blessed to have Trevor be part of my life, and thankful to life for allowing me to share his path.
Jessie Duska, daughter of Linda Duska, MD
Cancer took over my mom’s life (and the lives of our entire family) – but unlike the way it affects a patient. It consumed her time, her thoughts, and most importantly in my younger self’s mind, the attention she gave me. I resented my mom’s “stupid” job for most of my childhood. Maybe I was being dramatic, but it seemed rational at the time. She obviously didn’t mind waking up in the middle of the night to go into the hospital or being home alone on Christmas in case she needs to take care of a patient.
I have seen my mom upset from a patient passing, passed out on the couch with her favorite child (the dog) from a long day, and working extra hours on weekends “off.” What I failed to see for a long time was why. Why she worked twice as hard as any other parent I knew; why she kept going back and trying her hardest just to face defeat and sadness; why she had missed my super important 5th grade graduation.
One day I was rummaging through her phone like any normal, nosy child and found a picture of her patients. These smiling women—survivors—were the reason my mom has stared cancer in the face every day for the past 25 years.
I realized it was stupid to get upset with her over a missed soccer game. She was helping people in a way that most others could not. She sacrificed her life, her sanity, her time, AND my graduation. She has attacked cancer with scalpel, robot, chemotherapy, and her mind a thousand times over. She’s crazy and–crazy passionate–about fighting to find a cure. I guess she’s rubbed off on me a little.
I thought I never wanted children. I was determined to be a great gynecologic oncologist, and thought children would get in my way. I was 36, advanced maternal age, when I decided it was the “right time” to have children. My initial pregnancy ended in miscarriage, but later that year I delivered a healthy baby girl. Holding that baby for the first time was the best gift I have ever received.
Exactly two years later I was blessed with a second child. Life was busy, I was working furiously to get grants while maintaining a full clinical practice. I suddenly realized that I missed a lot of “firsts”-rolling over, crawling, their first snowfall. I had this nagging feeling that I had to have another child. At age 39 I thought there still had to be time. We tried for many years. Multiple miscarriages later I was sad and angry. Angry that in an attempt to advance my career my reproductive years vanished. Then, unexpectedly, in my forties, I got my miracle.
Coordinating work and family life is difficult for everyone, but for biologic and social reasons, is especially difficult for women. Thus, women with professional degrees are more likely to remain childless compared to their male colleagues with the same level of education and career1. Our survey of SGO members reflected this—51% of women compared to 19% of men desired to have more children than the number they had (presented at SGO 2018). These differences may be due to lifestyle choices, but infertility may also play a role.
The national average age at first childbirth is 26 years, but 29 years among female surgeons;1 in our survey of SGO members, approximately 1/3 reported having their first child after age 35 years. Our OB/GYN background makes us all too aware of the risks of infertility as we delay childbearing. While our background also gives us greater awareness of infertility treatment options, success with in vitro fertilization (if we can fit it into our busy schedules) also decreases with age, with 42% of transfers resulting in live birth for women <35 years of age, but only 23% in women 35-37 years of age, and success rates decrease from there.2 And that assumes viable oocytes can be stimulated and retrieved.
If you manage to have a child, the struggle changes to the constant conflict between being a “good gynecologic oncologist” and being a “good parent.” In the end, we often feel like we are NOT good enough at either.
Despite our work-family struggles, we do have a positive impact on our children. A New York Times article highlighted the benefits of having a working mother (working males are considered the “standard”). A study of 50,000 adults in 25 countries showed that, specifically in the United States, adult daughters of working mothers earned 23% more money, and sons spent 7.5 hours more on childcare and 25 minutes more on housework per week compared to children of stay-at home mothers3.
One of my favorite quotes is from astronaut Pam Melroy: “There is no work-life balance. It’s really more like a see-saw—sometimes you have to prioritize your career, sometimes you need to prioritize your personal life.”
I am at peace now with my family of five. Life is no less busy, but I am in a place where I cherish all the “firsts” and “lasts” despite the demands of my career. If I had my choice, would I have chosen to do it this way? No, probably not. As a gynecologic oncologist there is no “good” time to start a family. But time waits for no one.
Deanna Teoh, MD, MS, also contributed to this article. Dr. Gellar and Dr. Teoh are from the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis MN.
- Turner PL, Lumpkins K, Gabre J, Lin MJ, Liu X, Terrin M. Pregnancy among women surgeons: trends over time. Arch Surg. 2012;147(5):474-479.
- American College of O, Gynecologists Committee on Gynecologic P, Practice Committee of the American Society for Reproductive M. Female age-related fertility decline. Committee Opinion No. 589. Obstet Gynecol. 2014;123(3):719-721.
- Miller CC. Women at Work: Mounting Evidence of Advantages for Children of Working Mothers. New York Times. 5/16/15, 2015.
Over the past year, I have had the distinct pleasure of attending three separate lectures on burnout. At the first lecture, I listened and tried to pay attention to the speaker, acutely aware of my own sleepiness and desire to be elsewhere. During the second lecture, I at least pretended to pay attention in an attempt to show that I wasn’t just there for the free fancy dinner. It wasn’t until the third lecture that I started to pay attention: The risk factors that predominate and are independently associated with burnout in almost every study ever conducted are younger age, long work hours and being female [Ann Surg 2009; 250: 463-71; J Am Coll Surg 2016;223:440]. As I sat listening to these numbers, it finally dawned on me: that’s me.
As physicians, we jump through a lot of hoops to get to where we are. We succeeded through high school, college, and medical school followed by rigorous training in residency and fellowship; we’ve taken board exam after board exam after board exam. In many circumstances it seems like we’ve all beaten the odds. So, I’m not surprised to know that most physicians don’t recognize their own burnout – or even realize that they are at risk.
What is there to do? Our various wellness curricula have a handful of recommendations: awareness, self-care, maintaining a positive outlook, remaining resilient. While all these are excellent strategies, I recently have come to recognize another valuable tool.
“Hey Katie, I just wanted to check in with you. I know it’s been a rough 48 hours, I just wanted to make sure you’re doing okay.”
Half-way through a particularly eventful call week full of sad outcomes, my attending called me specifically to ask me how I was doing. It’s funny how such a simple gesture can mean so much. Over the course of my training, one of my greatest assets and sources of encouragement has been in the camaraderie amongst my co-residents, and now, co-fellows.
I think that if we all made an effort to reach out and care for those around us–our students, trainees, attendings, partners–at some point we would also be taken care of. I think that John Donne put it best when he said, “No man is an island, entire of itself; every man is a piece of the continent, a part of the main.” None of us is ever alone, regardless of how much we might think that for ourselves, or for others.
Kathleen Essel, MD, is a Fellow in Gynecologic Oncology at Stephenson Cancer Center, University of Oklahoma Health Sciences Center in Oklahoma City, OK.
I am a 14-year cancer survivor, the daughter of a cancer survivor and a mid-career gynecologic oncologist. I am therefore ever conscious of the fragility of human life. Yet, I have no fear. With grounded confidence all of us can adapt and persevere.
Ambition, drive, intelligence, and social IQ cannot change certain unfortunate circumstances, but how we proceed—-how we adapt and persevere—could make all the difference. Take, for example, the increasing rates of physician burn out in our society . How can we adapt and persevere in the current physician employment landscape—one that some claim is associated with poor health for our physicians?
Here are some examples of what my husband (an entrepreneur turned life coach) and I do to protect ourselves and our young children from outside pressures. Our strategy is to arm ourselves with some key defense tactics such as enhanced nutrition, physical and mental fitness training, stress reduction and goal setting.
Let’s start with meals. Dodging the plethora of unhealthy drinks and meals offered at work cafeterias, hotels and restaurants was crucial and may have had the single greatest impact on our health as a family. The goal was to eliminate processed foods, fried foods, sugary drinks and those with artificial sweeteners . We soon realized that we had to develop some “On the go” options such as raw vegetables, mixed nuts, fresh fruits, and good fats . Water is our go-to drink.
We then developed a mental fitness strategy incorporating meditation, mindfulness and positive affirmations to stay focused on our goals and reduce stress [3,4]. We immediately saw the positive effects in every aspect of our lives including parenting, marriage, and career. Just 15 minutes to decompress at critical times in the day will have a big impact.
We also started waking up earlier in the morning, before the kids rose, to do a 15- to 30-minute High-Intensity Interval Training (HIT) routine [5.6]. We even have a workout for the beach, hotel room, stairwell at the hospital—no excuses! We have a version for pretty much ANYWHERE.
Finally, adequate sleep . In order to get adequate sleep, however, we had to free up some time. This is where staying focused and efficient comes in. Upon closer examination, I found that many commitments made over time were not getting me any closer to my two-, five-, or 10-year goals. Constantly forcing myself to stay on track and focused now allows me to objectively triage offers and responsibilities and only commit to those that position me on the path to achieving my personal short- and long-term goals.
Although my strategy is just one example of many, I hope that it will serve as a catalyst for some of our readers. I encourage my fellow health care providers to put the same thought, research, and hard work towards optimizing your own overall health and survival as you have done for your patients and while building your careers.
Nathalie Dauphin McKenzie, MD, MSPH, is a gynecologic oncologist at Florida Hospital Medical Group in Orlando, FL.
- Medscape National Physician Burnout & Depression Report 2018, online January 17, 2018.
- Food: What the Heck Should I Eat? Mark Hyman, MD, 2018
- Understanding Stress and Mental Fitness: Techniques for Building Resilience, Jaymie Meyer, corporatewellnessmagazine.com
- Yoga, Meditation and Mind-Body Health: Increased BDNF, Cortisol Awakening Response, and Altered Inflammatory Marker Expression after a 3-Month Yoga and Meditation Retreat. Frontiers in Human Neuroscience, 2017; 11. Cahn et al.
- Where Does HIT Fit? An Examination of the Affective Response to High-Intensity Intervals in Comparison to Continuous Moderate- and Continuous Vigorous-Intensity Exercise in the Exercise Intensity-Affect Continuum, M. Jung PLOS Dec 2014
- Science Shows Only This Workout Can Actually Make You Younger. Jill Brown, Huffingtonpost.com, May 2017
- Why We Sleep: The New Science of Sleep and Dreams, Mathew Walker, PhD, October 2017
I woke up early, rounded and then reviewed the other inpatients I was responsible for that weekend. Made my “To Do” list and started checking off boxes. Made a new list, made new boxes, made new checkmarks. This was the start of my first call as a clinical fellow on a busy service. I felt the pressure. I couldn’t miss anything, I had to do a good job. I had warned my family that I would see them in a week when my call ended.
Then my husband called after rounds. He had brought my father to the ER with chest pain. I tucked in the service then strolled over to the ER to see my father. He was entertaining the staff around him with stories and jokes as usual. My husband and I waited for the discharge paperwork and I checked my phone every few seconds for patient updates. Then three ER staff members came and rushed Dad to the other part of the ER, the “sick” part. The ER physician explained that he had an ascending aortic dissection. Dad was scared and confused while I was in shock. A cardiothoracic surgeon was driving in and he would take Dad to surgery soon. He went to surgery and we all waited. Finally, the surgeon came out and we knew Dad had survived the surgery. He went to the ICU and we all took a breath.
The next two weeks in the hospital were fraught with complications and setbacks. There was pneumonia, a small stroke, atrial fibrillation, wound seroma and repeated aspiration from a nerve injury. We finally brought him home and did all we could to help him recover, but over the next six months it appeared that we would lose him. I watched as he slipped away. Then, after months of decline, my family had the fortune that most of our patients do not: he got better. It has been a year and a half and he has made a remarkable recovery.
I tell my story because it taught me a lot about wellness. In our SGO Fellows Wellness Curriculum we discussed many topics, but two especially resonated because of this experience. The first was to make time for what matters. As trainees, we have limited control over our schedule, but I learned that even so, I could make time in my life for what I decided was most important. We decided what was important to do as a family and prioritized things that brought us joy and meaning. I didn’t believe it was possible before because there were so many check boxes to go through and so much to worry about, but I learned I had had the wrong perspective on “possible.”
The other topic that resonated was how empathy can combat burnout. During this time, when my father was getting worse, I understood the anxious looks from families, the complaints and the questions in new ways. I remembered what it was like to be on the other side of patient care. This understanding and empathy brought deeper meaning and satisfaction to my work and has helped to carry me through when I’m tired after a long week.
It is important that we are discussing burnout. Seeing others who truly believe in wellness and want to make a difference is powerful. I knew I had people around me who cared during the worst days of my father’s illness. Hopefully, working together and supporting each other, we can create a true culture of wellness in medicine.
Jolyn Taylor, MD, MPH, is a Gynecologic Oncology Fellow at the University of Texas MD Anderson Cancer Center in Houston, TX.
There are days when I prefer to hang out with my dog. Dogs don’t just fill your heart; they make it stronger. Studies show that having a canine companion is linked to lower blood pressure, reduced cholesterol, and decreased triglyceride levels, which contribute to better overall cardiovascular health. Herbie, our basset hound, is just that. If I have a bad day, I come home and look at that face, stare into those eyes and I can’t help but feel my heart full of love. It is magic. I decided to take things one step further.
Herbie and I became certified as a Pet Therapy team. Four times a month, sometimes more, we volunteer at the local Ronald McDonald House and two times at the University of North Carolina (UNC) Pediatric Infusion Room. I had planned to work with adults, but as we trained, Herbie steered me in a different direction. He loves everyone but is truly enamored with children. When I say, “Let’s go see the kids,” he runs right into the laundry room for his teeth to be brushed (we have breath standards). Then he sits by the car. Our visits are pure joy. Herbie conducts them with love and grace. He may do tricks or he may just sleep on someone’s bed while being stroked and petted.
How can I go back to the hospital when I spend so much time there? I feel absolute joy upon entering the hospital with Herbie. He is a celebrity. Herbie does a variety of tricks: “Fire” “Stop, Drop, and Roll,” and “Downward Dog” with bacon as motivation. He gives high–actually low– fives and is great at “Sleeping Beauty” – lying on his side. Herbie also does a few tricks in Spanish. When Herbie enters a patient’s room, he transforms it. Smiles appear, hands are reached out to him. A sense of escape and joy is seen in almost every face: patients, visitors and staff. One patient looked down at Herbie as we entered and said, “I prayed for this.” Herbie just wagged away. There was magic in that very room. Herbie was the healer. I just held the leash. At the end of the day, on the ride home I am sure to tell him that he is just the best therapy dog. He knows exactly what I am saying. We both are smiling.
Dog therapy is my passion. Herbie and I are a team. People in the hospital often ask me where Herbie is. Wellness to me is not dependent on hours in the day but my sense of purpose, creativity and passion. I want to experience joy. It is all that and a bit more with Herbie.
Herbie has an Instagram account. When we leave a room and a child asks, “When are you coming back?” they get Herbie’s trading card (provided by UNC) and Instagram account. They can visit him anytime. We go for the laugh each day. Herbie and I receive so much affection for the work he does. Gotta love social media. @herbiethetherapybasset
Lyn Filip RN, BSN, OCN, is an Assistant Professor in the Division of Gynecologic Oncology at the University of North Carolina in Chapel Hill, NC.
I stand at the door—afraid. Take a deep breath. Just another room; one I have been in a thousand times before. Inside a bed, a bathroom, an IV pole, a friend. And while I stand there, my angst grows over the unrevealed information. Still frozen in the hallway, I cannot reach out and touch the door handle. You have to go in.
My conscience compels me across the threshold. There she is on the bed, under the covers. The IV pump making its purring sound. She looks so peaceful. I could not find a more difficult way to start the day. Even now, the important words remain jumbled in my mind. I wish there were another way. But there are no other volunteers. When I look around, pressure mounts, seeing the patient surrounded by an entourage of residents and students begging for some kind of wisdom or insight to do that which screams impossible. Fear overtakes me.
I sit on the side of her bed and touch her on the shoulder. She turns and smiles at me. My friend — this woman who won my heart with her bravery, her kindness, her fortitude. Her sense of humor pops into my mind. All the laughs we had. All the cries we had. They are all in the front of my eyes. You must tell her.
The first words, the easy ones, float delicately from my mouth. I recount all the places we’ve been. Surgery, chemotherapy, surgery again, back to chemo—a game of leap frog… But now, as the hard words are inching up my throat, something unavoidable happens. My eyes speak first—teardrops fall. I see her grasping my anguish, my vacillating heart. I was never good at poker. She knows. The secret has leaked out, albeit unspoken, but audible nonetheless. I see her start to weep. A cancerous checkmate.
I realize this is where life took me as an oncologist. We are not on the sidelines of life, watching everything from afar, but we have been thrust into trenches too often wrought with sorrow. For good or for bad, we are by definition, engaged. And yes, I struggle with that not uncommonly.
Is there a blessing? Our broken hearts remind us of the joy of life, the joy of other souls, even when they are packaged with agonizing pain, carving out deep scars—but healthy and needed ones. Life is a gift and we are blessed to be allowed to savor that gift. Never forget that!
Leaving her room, I reflected on what we do for a living. And I acknowledge yet again that in my own individual life, without my faith, I could not be sustained in such a wrenching moment as this. It upholds me and commands me, to stay in the trenches and pour my heart into the lives of those entrusted to me. So, my encouragement to all of us is that we absorb our fragile emotions, calm our saddened souls, and regroup to serve where we are called.
Larry Puls, MD, is a gynecologic oncologist in Greenville, SC.
I have a habit of over-committing at work. I thrive on new opportunities, love learning new things, and appreciate being asked to lead or contribute. And like many of us, I was raised in an environment in which hard work and over-extension were most valued. I have always wanted to be that person who agrees to add another patient to an already over-full clinic, performs the most surgeries, enrolls the most patients onto clinical trials. Competitive much?
But in all seriousness, in our profession as gynecologic oncologists we are often valued by these metrics, if not in others’ minds then in our own. It is weak to say no, to finish the OR at 4:00 p.m., to have a light clinic. But more than that–I don’t want to turn down opportunities because then people will stop asking me, or stop thinking of me when a new position is available.
A few years ago I had a fabulous opportunity to join the Dean’s office. This position opened up many new doors and possibilities for me in my career. But I made an almost fatal mistake: in my first year in this new (50% effort) position, I tried to keep everything I already had, including maintaining my practice at the same volume. At the end of that first year, I knew I was failing at my new position, in addition to not being the best wife, mother, fellowship director, or let’s face it, person. And I had to give something up if I wanted to keep the position and make a difference at my school.
At some point it all becomes overwhelming. There is just too much to do and not enough time to take a breath. So what is the solution?
Clearly I don’t know, because as I write this, I am wondering how I managed to volunteer to write this blog when I have so many other things I need to do. And yet, it is an important message. None of us can do everything well, and also take care of ourselves. When I’m stressed and pulled in too many different directions, I am not the nicest person to those who are most important to me. And when I can’t do my very best with every task, I am disappointed in myself, and promise myself that I won’t overcommit again. And then I do (of course).
For me, the solution definitely involves prioritizing what is important, learning when and how to say no, and graciously passing opportunities to others. Fellowship Director was a mid-career goal and a job that I loved and was passionate about. It was very hard to give up, but after nine years it was time. I passed that role on to a very competent and wonderful colleague who is already doing a great job, and now I’m thriving in my Dean’s position. I’m not always successful at balancing my commitments though, and each phase of my career has brought new challenges. I’m still working on it.
Linda R. Duska, MD, MPH, is a Professor of Obstetrics and Gynecology in the University of Virginia Health System in Charlottesville, VA.
It was 4:00 p.m. My cases had finished early on a Monday and I was trying to catch up on the roughly 100 emails that had come in that day. I was still tired from a busy weekend of call, and it made focusing on anything difficult. As I read the same sentence six times over, I felt the sun on my back through my window. It was a beautiful spring day in Madison. There was no rain or wind and I knew there were still many hours of daylight. On a whim, I texted my friend Brian, who works in marketing at a local appliance company.
“Any chance you can play this afternoon?”
“I can leave right now!” he replied within seconds.
“Meet you at 5. I will call for a tee time” I answered.
I quietly shut down my computer, grabbed my bag and slinked down the hall to the back elevators, all the while hoping not to see another partner. I even considered for a moment, devising some reasonable excuse for why I was leaving early, but saw no one and averted that dilemma. I am certain had I seen a partner, they would not have cared where I was going. I am lucky to work with an amazing group of people who genuinely care about each other’s’ well-being, but leaving early still turns me in to an 8-year-old trying to steal a cookie from the pantry. Why do I feel the need to lie about taking care of myself? Because I have also been on the other side. I would love to tell you I have never cast a judgmental eye toward a colleague leaving early. The truth is, I have.
It is into this crucible that we have cast wellness.
We are a culture that values hard work. We lionize physicians who can seemingly do it all and are always available. But in this era of what the Accreditation Council for Graduate Medical Education (ACGME) calls “work compression,” where Relative Value Unit (RVU) targets have not changed despite new and different tasks such as Electronic Medical Record (EMR) use, patient satisfaction demands, multiple online safety and compliance trainings, we need to shelter wellness from becoming just another check on our to-do list.
How do we do this? We must change the culture that makes us feel guilty for leaving a few hours early. We must foster opportunities to take care of ourselves how we need to, when we need to. This culture will not change until we appreciate that everyone needs something different to be well. For me, golf is a mindfulness practice. At its core, mindfulness is about the quality of attention that you bring to an activity, not the activity itself. Golf engages my mind and body, allows me a few hours of work-free thought and re-energizes me. For others this might be aviation, cycling, gardening, or simply lying in a hammock, but all of these restorative activities must be met with encouragement, not judgment. Interestingly, while the age-old argument is that you have to work harder to accomplish more, science would tell us that sustained work without rest is actually less effective.
In the book Peak Performance: Elevate Your Game, Avoid Burnout and Thrive with the New Science of Success, authors Brad Stulberg and Steve Magness review the conditions required for sustained success. Chief among their findings is that productivity actually decreases without both short and long breaks away from work. Just as a muscle requires both stress and rest to grow, we require both to perform optimally in our professional lives. Rest is not a one size fits all model and we must allow our colleagues and ourselves reasonable flexibility to meet our needs. This culture change requires work from each of us, but especially from those of us leading divisions who need to model wellness by being more forgiving, more encouraging, and less judgmental. It requires all of us to have the courage to leave from the front elevators.
Stulberg B and Magness S. (2017). Peak Performance: Elevate Your Game, Avoid Burnout and Thrive with the New Science of Success. New York, NY.
Stephen L. Rose, MD, is the Director of the UW Gynecologic Oncology program at the University of Wisconsin School of Medicine and Public Health.
Are you waiting for the “right” time to start a new wellness regime? What IS the right time? Consider that things aren’t going to get “better” any time soon. Instead, accept that the time is now!
I agree that we are all busy–trust me–I get it! In between writing this blog, I will edit some publications, review some clinical trial protocols, fill out a 100-page application pertaining to the fellowship of which I am the director; plan my children’s numerous extracurricular activities, surgical cases, clinic, manage chemo patients, and a plethora of the administrative and personal things that we all have to do—so I get it!
How can you stop using these as an excuse and start demanding that time back? The answer is simple–make it a priority. After all, YOU MATTER. Your wellness is important.
Wellness, however, is not just about resiliency. Wellness is also about adequate deep sleep, activity, meditation, and nutrition. I’d like to start with positive affirmations. Self-affirmations were first popularized by French psychologist Emile Coué back in the 1920s and are still a staple of self-help gurus and psychologists and personal coaches. But do they work?
Similar to the guided imagery that surgeons often use before a surgical case, self-affirmations (or positive affirmations) are tools that can be used to begin the day, throughout the day, and at the end of the day. We now better understand that self-affirmation–the process of identifying and focusing on one’s most important values–boosts stressed individuals’ problem-solving abilities. Those who appear to benefit most are those in high chronic stress situations (sound familiar?). One study showed a brief self-affirmation was effective in eliminating the deleterious effects of chronic stress on problem-solving performance.
In addition, affirmations also affect integrity preservation and “error awareness.” This can be used in academic and other professional settings. The strategy produces measurable neurophysiological effects. Specifically, these effects on attention and emotion could be measured directly in the form of a well-known brain response called error-related negativity, or ERN.
As further proof, a study of resilience and emotions following 9/11, psychologists hypothesized and later found that positive emotions buffer people from crisis situations, and that positive emotions allow resilient people to thrive under any circumstances.
The body of literature on this topic is growing, lending further credibility to this very simple task with a wealth of benefits.
In conclusion, as you start (or resume) your journey to a healthier YOU, consider starting with positive affirmations. This one simple initial step can help you mentally prepare for the other life changes necessary for ultimate wellness. If you look in the mirror and think to yourself that you could do a better job taking care of yourself, then do it! AND start today! After all, your patients look to you to set the example. Some well-known positive affirmation audios or YouTube include presentations by Louise Hay, Meditation Vacation, Dauchsy Meditations, and Power Thoughts Meditation Club.
- David Creswell, Janine M. Dutcher, William M. P. Klein, Peter R. Harris, John M. LevineSelf-Affirmation Improves Problem-Solving under Stress. PLoS ONE, 2013; 8 (5): e62593
- Jaremka, L.M.. Reducing defensive distancing: Self-affirmation and risk regulation in response to relationship threats. Journal of Experimental Social Psychology. 2011;47:264-268.
- Correll, J., Spencer, S. J., & Zanna, M. P. (2004). An affirmed self and an open mind: Self-affirmation and sensitivity to argument strength. Journal of Experimental Social Psychology, 40, 350-356.
- Wood, J., Elaine Perunovic, W., & Lee, J. (2009). Positive Self-Statements: Power for Some, Peril for Others Psychological Science, 20 (7), 860-866 DOI: 1111/j.1467-9280.2009.02370.x
- Legault, T. Al-Khindi, M. Inzlicht. “Preserving Integrity in the Face of Performance Threat: Self-Affirmation Enhances Neurophysiological Responsiveness to Errors.” Psychological Science, 2012; DOI: 10.1177/0956797612448483
- What Good Are Positive Emotions in Crises? A Prospective Study of Resilience and Emotions Following the Terrorist Attacks on the United States on September 11th, 2001
Barbara L. Fredrickson, Michele M. Tugade, Christian E. Waugh, and Gregory R. Larkin
J Pers Soc Psychol. Author manuscript; available in PMC 2009 October 1.
Nathalie Dauphin McKenzie, MD, MSPH, is a gynecologic oncologist at Florida Hospital Medical Group in Orlando, FL.
Seven years ago I joined the faculty of the University of Virginia. Fresh out of fellowship, I was assigned a mentor within my department–someone to help me settle in, learn the ropes and culture and ensure that I worked towards accomplishing all of the tasks needed for promotion. While that mentor was wonderful, it was an artificial relationship. It is the mentor that I gained by chance who has promoted my wellness and helped me deal with burnout. Many colleagues have questioned how a hand surgeon could mentor a gynecologist oncologist and I can’t explain it, but I know it works.
A. Bobby Chhabra, MD, Chair of the Department of Orthopedic Surgery at UVA, and I met during work on an OR Committee and my single request for advice has led to an ongoing mentorship. Little did I know that after several years on faculty the hot topic of burnout would hit a little too close to home and that Dr. Chhabra would offer me the great gift of his experiences. Hearing how he addressed wellness and burnout, the way he balanced work and life (and not always perfectly) was therapeutic.
In my research for this blog, I uncovered data that young faculty (and trainees) benefit from a mentor. A recent article by Wilkes and Feldman in The Lancet on mentoring clinical trainees outlined the four general qualities that make Dr. Chhabra such an excellent mentor:
- The mentee wants to emulate them
- The mentor is approachable and trustworthy
- The mentor can, wants to and will help the mentee
- The mentor makes himself/herself available to the mentee and is responsive
In my own life, I have found mentorship helps combat burnout and promote wellness. While I wish that I could bestow a “Chhabra” mentor to everyone, I realize that I am extremely fortunate to have found, by chance, someone who is both mentor and friend.
As you strategize your wellness, I encourage you to make time for mentorship, both as mentor and mentee. For further information, I highly recommend the articles below. As the Wilkes and Feldman article states:
- “The time constraints that lead to burnout are, ironically, the exact reason you must devote time to create a valuable relationship with your mentor.”
- “Your mentor is not your therapist. However, they are a resource to help you thrive.”
- “Your mentor is your advisor…. mentorship is a ‘replenishing factor’ for the ‘coping reservoir,’ alongside psychological support, social activities, and intellectual stimulation.”
- Wilkes M, Feldman MD. Mentoring clinical trainees: a need for high touch. The Lancet. 2017;389:135-137.
- Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry. 2008;32:44-53.
- Vaughn V, Saint S, Chopra V. Mentee missteps: tales from the academic trenches. JAMA. 2017;317:475-476.
Leigh Cantrell, MD, MSPH, is an Associate Professor of gynecologic oncology at the University of Virginia in Charlottesville, VA.
I turned off all the notifications on my iPhone—except texts and voicemails. For those of you who sleep at night with 3,000 unread emails, it may not help. But for the rest of us, it makes a difference. I worried about new emails, or what else I missed. Was something urgent sitting in my inbox? I got used to it, and now I read my email when I want to read email.
What does this have to do with burnout? When the technology in our pockets or on our desks is taking our free time from us, we’ve lost autonomy. And autonomy correlates with burnout, job satisfaction, turnover, and job performance. Is the technology you use giving you more autonomy? Absolutely not. EMR systems mandate we document in a particular way, in a particular order, using patterns and systems designed by others—others who don’t care for our patients, understand our schedules, or have any idea how our individual minds process data and determine care plans. We are forced to document specific phrases or findings, regardless of their clinical relevance.
Autonomy at work is a big issue, but we can improve our personal autonomy by making the technology in our lives work for us. First, remember technology is not neutral. Every app, website, and platform is competing for your time. Netflix doesn’t start the next episode automatically because that’s what you want, it’s to keep you off Facebook or Google. When Blackberry created push notifications it was only for email, back when email was a new way to communicate, not another chore. Now every app will sound an alarm, send you a message, and leave a little marker telling you there’s something to be done. Why? Because the economy of the web is driven by advertising, and advertisers want your eyes on their ads.
Currently, you can’t get specific notifications only when your spouse or your boss emails you, so you have to find other ways to make the system work for you in other ways. The first step is deciding how you want to work. How important are your emails? Does really urgent news come via text or phone call? When do you have to respond? Are there hours or days when you don’t want to be available? What are the applications that you want to interrupt you, and how do you want to be interrupted? Who are the people who get to interrupt you at home, or at work, or at the grocery store? The devices we carry are often seen as time-saving, or making life easier, but again, this is not neutral. They make certain things easier, and certain things faster, but unless we’re careful, which parts of our lives are made easier will be determined by others.
Give it a try this week. Maybe get real extreme and leave your phone behind. I left mine in my car last week. I wasn’t trying to get away or disconnect. Mostly I was worried about dropping it. I’m an iPhone purist: no case, no cover. But what if I needed to calculate the price per ounce? What if someone broke into my car and stole it? What if someone needed me?
Nothing happened, of course.
I bought some food, I said hello to strangers in the aisles (this is Alabama, so people are nice and that’s how we do things), and I didn’t drop my phone.
Additional resources on autonomy and technology:
- Overload, autonomy, and burnout as predictors of physicians’ quality of care
- Disturbing Trends in Physician Burnout and Satisfaction With Work-Life Balance
- Our Minds Have Been Hijacked by Our Phones. Tristan Harris Wants to Rescue Them
Taylor Turner, MD, is a gynecologic oncologist at the University of Alabama, Birmingham.
Ping. Ping. Ping. The invitations come pouring into my calendar—a meeting, a committee, a conference call. My spouse groans as I accept another commitment. I am the Division Director, Associate Residency Director, swim team mom and first grade room parent. I find my mind flooded with thoughts of swim meet snacks as I prepare the residents’ complicated master schedule.
Travis Bradberry in a Forbes magazine post recently shared an interesting anecdote about President Lyndon Johnson. In 1965, President Johnson was trying to get his chief economist on the phone when he was stymied by his economist’s housekeeper. The housekeeper told the president that her employer was napping and left a message that he was not to be disturbed. When the president asked the housekeeper to wake up her boss, the woman replied that she did not work for the president. The call did not go through.
As we advance in our careers and our lives we find that the requests for our attention and our time become overwhelming. If we are unable to say “no,” research shows that we are more likely to experience burnout and depression. There is a subtle art to saying “no” that we must master if we wish to be successful physicians, academicians, parents and spouses. Mr. Bradberry goes on to discuss that when we say “no” we are actually making a conscious decision to say “yes” to something else. If we decline the committee meeting that happens every other Thursday evening, will we make it to the gym? Can we make dinner for the family? Realize that with every “no” we are prioritizing our life goals and making a statement about what is important in our lives.
I have found a number of helpful and creative “life hacks” in order to help all of us become more successful at saying “no”:
- Get a good night’s sleep: Before you respond to an invitation, sleep on it. We are often times more able to view the invitation in the context of our current commitments and time limitations after a 24-hour period.
- Offer an alternate: When asked to review a manuscript or give a presentation, why not offer the name of a more junior colleague? Consider where you are on your career trajectory and ask yourself if somebody else could more readily benefit from this experience?
- Set your annual limits: Decide at the beginning of the year what you can say “yes” to over a 12-month period. Decide well in advance that you will review 10 manuscripts, serve on one additional committee and volunteer at school four times a year. Once you have reached this personal limit all further requests may be answered with “no.” No justification is needed. Utilize your chair or division director to help you set these boundaries if needed. This individual can serve as backup if necessary.
It is not until we master the art of saying “no” that we are truly able to say “yes” and devote our time, energy and intellect towards the causes and commitments that we truly find worthwhile.
Kimberly Resnick, MD, is the Division Director of Gynecologic Oncology at the MetroHealth Medical Center at Case Western Reserve University in Cleveland, OH.
“The aim of Positive Psychology is to catalyze a change in psychology from a preoccupation only with repairing the worst things in life to also building the best qualities in life.”
–Martin Seligman, PhD, founder of the field of Positive Psychology
As physicians, we are in the business of “fixing things.” We are trained to seek out and identify those things that are abnormal with a laser focus. The problem with fixing things is that it only gets us back to our baseline. We become “not sick” or “not pathologic.” What would it look like if we spent time cultivating habits that allow us to flourish and actually become well? How can we achieve the holy grail of living the “good life?” What characteristics could we nurture to help us reach our full potential?
As we all know by now, burnout is associated with many negative effects for physicians, including personal and professional consequences. We are a population of intelligent, highly motivated problem-solving individuals. Yet, we have not figured out a way to combat burnout in our field.
Perhaps the problem is our perspective. What if we became proactive in our approach to physician well-being? What if we looked at how we could develop our own strengths and capacities to increase our resiliency and happiness?
Positive psychology looks at what makes life worth living. Positive psychologists look at a person’s strengths and emotions to allow them to develop what is best within themselves. They have also looked at institutions as a whole to identify systems that nurture the well-being of their members.
Research topics stemming from the study of positive psychology are broad and include emotions, personality, gender, genetics and education. What I find most interesting and hopeful about the field of positive psychology is the number of interventions that have been developed to improve a person’s well-being. These interventions have been studied empirically using several positive psychology metrics and have been found to improve anything from middle school student achievement to resiliency amongst U.S. soldiers.
There are several resources for those of you interested in learning more about positive psychology. The University of Pennsylvania is home to the Positive Psychology Center. Their website includes information about different specializations in the field, including grit, resiliency and authentic happiness. You can take several assessments to see where you may be able to improve your own well-being. I have listed several books below that are great reads and some of the most commonly cited texts. I also recommend an online course through the University of Pennsylvania through Coursera.org that allows you to obtain a certificate of specialization in the field.
I know your schedule is busy and you may think you do not have the time to learn more about this field, so I leave you with a quick exercise that you can do on your own called “What Went Well?” Tonight, and every night for the next seven days, take time to write down three things that went well today and why they went well. While this seems like a simple, insignificant exercise, this activity has been studied in several randomized control trials. In these studies, they found that a majority of people was able to continue this exercise over a six-month period. At the end of those six months, participants who stuck with the exercise scored higher on life satisfaction and were markedly less depressed.
The subject of burnout is complex, and it is unlikely that there will ever be a “one-size fits all” solution to physician wellness. However, positive psychology does offer us a number of positive interventions that can be adapted on an individual level. I hope that some of you will join me in discovering ways that we physicians can live the good life by further exploring the field of positive psychology.
“The good life is a process, not a stage of being.”
- Flourish: A Visionary New Understanding of Happiness and Well-being, by Martin Seligman, PhD
- Finding Flow: The Psychology of Engagement With Everyday Life, by Mihaly Csikszentmihalyi, PhD
- GRIT: The Power of Passion and Perseverance, by Angela Duckworth
- University of Pennsylvania Positive Psychology Center
Monica Hagan Vetter, MD, is a graduating resident in gynecologic oncology at The Ohio State University in Columbus, OH.
The SGO’s 48th annual meeting showcased wellness in a multidisciplinary way. A plenary session showed us the impact of burnout on productivity. We learned from a hematologist-oncologist about resilience and career fit. A social worker taught us about managing our energy, and we were reminded by a navy seal that medicine is, in fact, a team sport.
So, Dr. Jeff Fowler, congratulations on an amazing presidential year, and thank you for your leadership on the issue of physician wellness. The choir hears you loud and clear, but the choir can’t change the culture on our own, and the culture needs changing.
Full disclosure, I am a reformed wellness skeptic and burnout survivor. Once upon a time I rolled my eyes at those who preached “mindfulness.” I considered those who “put themselves first” selfish. I survived and thrived despite some significant health crises during my training, so I always assumed I was resilient. And I took delayed gratification to such an extreme that I forgot what I was waiting for.
And then, in the most insidious way, a light that once brought me joy in doing what I love burned out, leaving a dark void. There I was. The burned out doctor I never thought I could be. And that’s when I received the following advice:
“Shannon, you’re not in training anymore. No one is looking out for you but you.”
The reality is that 32% of SGO members and 81% of our fellows have reported burnout. If you think you are immune, you are wrong. If you think you don’t know anyone who has suffered burnout, you are wrong. Thirteen percent of gynecologic oncologists have considered suicide. Thirteen percent. In order to make a dent in these staggering numbers, we need to admit that burnout is not a failure of the individual, but a failure of the culture.
The culture of medicine has devolved, confusing patient care with consumerism, and treating physicians, as Dr. Fowler put it in his presidential address, as “interchangeable employees.” As long as that is the case, there will be a persistent and intrinsic mismatch of values between physicians and their work environment.
To effect systemic change in that environment we need the commitment of the chairs, chiefs, directors and presidents who are reading this. You are undoubtedly being pressured by your hospitals to do more, produce more, squeeze more out of your team. I assure you that your team already knows that the EMR orders need signing, and I am confident that no one ever died from a Press-Ganey score of 4. So instead of passing the pressure onto your team, I urge you to use those opportunities to enlighten your organizational leadership about the importance of preventing burnout in your physicians, if not for the wellbeing of your team and their patients, then for the bottom line.
Despite the implementation of a thoughtfully-researched “WellMD” program, Stanford Healthcare reported an increase in physician burnout recently. If they cannot reverse this trend they anticipate losing $88million in the next two years from faculty turnover. Similarly, Dr. Taylor Turner and his team made it real for us at the annual meeting, reporting that physician burnout cost gynecologic oncology 1.6 million RVUs in the first 15 years of practice.
Let me be clear, I am not equating our value with RVUs. But let’s face it, the language of healthcare is heavy on dollar signs these days, and it’s important we speak the language of the culture we want to change.
It cannot be true that no one is looking out for us but ourselves — we must reward comradeship over competition. As gynecologic oncologists we are among the world’s experts in caring compassionately for women in some of their darkest times, and it’s time we use those skills to take care of each other.
- Cass I et al, Stress and burnout among gynecologic oncologists: A Society of Gynecologic Oncology Evidence-based Review and Recommendations. Gynecologic Oncology 143 (2016) 421-427.
- Shanafelt TD and Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
- Stanford Medicine WellMD Center research and resources: http://wellmd.stanford.edu/
- The Way We’re Working Isn’t Working: The Four Forgotten Needs that Energize Great Performance. Tony Schwartz, 2011.
- Schwartz T and McCarthy C. Manage your energy, not your time. Harvard Business Review, October 2007.
Shannon MacLaughlan David, MD, is a Clinical Assistant Professor, Obstetrics & Gynecology – Gynecologic Oncology at the Stanford School of Medicine in Stanford, CA.
I had a healthy fear of GYN/ONC fellowship when I started. My OB/GYN residency wasn’t one I would particularly designate as “onc-heavy” and, while I loved taking care of the oncology patients, I worried whether I would be happy or capable of doing so on a full-time basis. I worried about whether my surgical skills would be up to snuff, whether my attendings would regret ranking me, whether I was emotionally capable to provide these women with the care they needed during one of the most vulnerable times in their lives. What can I say; I worried.
I looked at my mentors and saw them performing a complex dance, navigating the physical and psychological demands of being a gynecologic oncologist, being a present parent and somehow managing to have a successful research career with numerous publications, accolades and grant funding. I, on the other hand, had never operated on the robot, had yet to have a paper published and was trying to figure out how to have a successful two-physician marriage. Everyone around me looked so graceful, “effortlessly perfect,” while I struggled with what felt like two left feet.
During a fellows’ lecture one week, we watched a short YouTube video from the Cleveland Clinic’s Empathy Series, entitled “The Human Connection to Patient Care.” If you have never seen it, please—I urge you—watch it today. This four-minute video resonated with me that day and still does to this day. Meant to encourage care providers to “put themselves in their patients’ shoes,” I felt like I could (and do) apply this to all aspects of my life. When I see a patient, I remind myself that our 20-minute appointment together, while just a fraction of my day, may be the biggest, most important 20 minutes of her week, month or life, even if she doesn’t let on. I need to stay in the present, focus on what is in front of me and, most importantly, be kind—both to those I interact with throughout the day and myself.
Often times we “put on a good face”—for our patients, our family, our colleagues. Though many times the separation of work and life is important to maintain a healthy work-life balance, it’s not as black and white as we’d like. Difficult events are just that—difficult. Life bleeds over into work and vice versa. We like absolutes and concretes in medicine, but we all know, it’s rarely that simple. Try as we might, we’ve all had that unexpected patient outcome or an argument with a loved one. We are all human, we all have struggles, we all make mistakes; many times we opt not to outwardly share these trials and tribulations for fear of judgment or perceived inadequacy. For not being “effortlessly perfect.”
I miscarried towards the end of my fellowship last year and, again, felt the pangs of being imperfect. Most of my colleagues knew I was pregnant since I had struggled with significant nausea and vomiting (not so fun in the OR) from the start. It was one of those times where I thought to myself, “Work stays at work and life stays at home.” But again, it wasn’t that simple. In fact, the immense outpouring of love and support at work that I received during that difficult time helped me to climb out of my “imperfect” funk. The ability to talk about and share this particular struggle with others, many of whom had been through similar situations, was comforting beyond words. It’s taken me 33 years to start to realize that it’s okay to not be “effortlessly perfect” in whatever endeavors I may find myself. The ability to treat everyone, those with internal and external struggles, with kindness, is perhaps the most important. Practicing self-kindness and acceptance is not something I master on a daily basis, but certainly a task worth striving for. Many times I feel that my patients are better at this—acceptance of situations they cannot control, self-kindness as their body changes and strength to persevere through life’s storms. Being “effortlessly perfect” is impossible when you are battling cancer and isn’t even important. Kindness. Kindness to yourself, and others, is really what matters in the end.
Brittany Davidson, MD, is an Assistant Professor of Obstetrics and Gynecology at Duke University School of Medicine in Durham, NC.
When I first learned about the benefits of a wellness approach, my autopilot applied it to my patients and trainees. And when the “practice what you preach” got loud enough in my head, I put it on my to-do list, and whined to myself, “Really? Not only am I supposed to be mindfully treating patients with expertise and compassion, skillfully using the most up-to-date approaches by reading and teaching, thereby curing, etc., but now I need to be Zen about it all?” And to have a healthier “work-life balance,” I need to spend less time doing it?
Of course, there is “life,” i.e., raising the next generation, caring for the previous one, paying the mortgage, contributing to the community and planning for the future? And I can’t forget to spend time with the people I love. I can’t forget to exercise, meditate, live clean, eat locally, you know the drill. But when? And how? What does work-life balance mean? Is it an either/or? How bad is bringing my work home for me? Is it more like champagne or grain alcohol?
And aren’t “we” different? Gynecologic oncology doesn’t seem to lend itself to balance and wellness. Enhanced sympathetic tone is how we operate. Adrenaline allows us to multi-task and respond to crisis but doesn’t serve us when a word alone can stimulate a fight or flight response. Try phrases such as performance metrics, lawsuit, deposition, loss of insurance, uncovered service, or drug shortage.
Being a gynecologic oncologist is different. Every day there’s death and dying and pain and suffering and loss and grief and none of it seems fair. And we still live in the regular world where there is gender inequality, racism, poverty, climate change, violence against women, and injustice.
I struggled with finding “time for wellness” and fretted when hours at work were outweighing my “life” hours. However, working with patients on this topic made it clear to me that wellness cannot be a bullet point on a to-do list and work-life balance is not a math problem. Patients talk with us about what matters to them and goals for their palpably limited time. They are motivated by their diagnosis and prognosis to change an unhealthy home life or leave an unsatisfying job. In my mind I call these “soul goal” discussions, and I found myself applying this thought process to myself. What do I want to do with the time I have in this life? What brings me joy? What are my soul goals?
This was harder than I thought and for me the tricky parts were:
1) Separating obligations from responsibilities. Responsibilities are what we take on, ideally reflecting our goals and abilities.
2) Focusing not on the future achievement of a goal but on the day to day reality of it. (e.g., I want to run a marathon but I hate running.)
3) Letting go of judgment. Hiking on every continent is as worthy a goal as serving humanity.
4) Staying aware of how my soul goals evolve and shift in priority.
5) Giving my goals the time they deserve.
Time management is a learned skill. A week into a “30-day time diary” for a workshop, I realized I spent a lot of time doing things that did not matter to me and that I did not like to do. Delegating, outsourcing and delivery got me back 6 hours a week. Further, building my calendar with my soul goals in mind instead of letting my calendar tell me what to do opened up additional time that I was convinced did not exist. Self-care has been more doable with this “recovered time” and as a result my remaining hours seem more productive and fulfilling.
Being a gynecologic oncologist IS different. This job lets me pay the bills, use my brain and my heart, work with amazing colleagues, witness the strength and resilience of women and their families, help women save their own lives and so fulfills many of my soul goals. I don’t sweat the time I spend doing it.
Diljeet K. Singh, MD, DrPH, is a Gynecologic Oncologist at the Mid Atlantic Permanente Medical Group in McClean, VA.
The patient described here is fictitious, but is based on situations that we have all experienced.
Mrs. Smith is a delightful, 48-year old woman with stage IIIc high grade serous carcinoma of the ovary. She undergoes an optimal cytoreductive surgery, including modified posterior pelvic exenteration with low colon anastomosis. She is slender and healthy. The surgery goes well, except for some challenges with the colon anastomosis. In the end, it is airtight, and all seems well. She is discharged from the hospital quickly, but returns within 24 hours with a pelvic abscess due to a leak from her anastomosis.
Five months, multiple attempts at percutaneous drainage, weeks of antibiotics, a 13-hour operation, and an enterocuteous fistula later, she is discharged home again on TPN. It has reached the point that you dread going to her room, because you know that you will only have more bad news for her. Every time you see him, the husband fixes you with an angry stare. What we do is hard. It can eat your soul. You can tell yourself, “I did not give her the bad cancer,” as you turn and walk away, but it isn’t a satisfactory answer.
Peyton Manning, who played in the NFL for 18 seasons with the Indianapolis Colts and the Denver Broncos, is considered one of the greatest quarterbacks of all time. He holds the NFL record for passing yards, touchdown passes, career wins, AP MVP awards, and Pro Bowl appearances. He led his teams to two Super Bowl wins. Yet, Peyton Manning threw interceptions and lost games. How was he able to come back game after game and continue to play at such a high level, despite bad throws and bad games?
In sports psychology, it is recognized that fear of failure leads to poor performance. Successful athletes know that they will fail. They use their failures to identify their weaknesses and improve their performance. Peyton Manning was well known for his intense game preparation. He would spend hours watching game films, critiquing his own performance. He would then spend more hours out on the field, practicing with his teammates until they had the plays right. And then the next game, he would start the process over again—continuous performance improvement.
We are all going to have bad outcomes, but we cannot be consumed by them. Bad outcomes are not a judgment on us as people or as doctors. Self-abuse only interferes with your motivation and future performance. After the fact, we need to make an honest, dispassionate analysis of the situation. What can we do better the next time?
So you go back into that room, every day. And you tell the patient and her husband the truth, even though it is painful to them and to you. Then, you and your team non-judgmentally analyze the situation—what did we do right? What could we have done better? And every day, you are a better doctor for her and every other patient you care for. You identify your weaknesses and fix them, honing your skills day by day.
“True victory is victory over oneself.”
Morihei Ueshiba, O’Sensei
The Founder of Aikido
Marta Ann Crispens, MD, FACOG, is an Associate Professor and Director, Division of Gynecologic Oncology, in the Department of Ob/Gyn and Chair of the Vanderbilt-Ingram Cancer Center Scientific Review Committee at Vanderbilt University Medical Center in Nashville, TN.
I used to be a runner.
For mile after mile, I would maintain a seven-minute mile pace, feeling the stress melting away. Hearing the rhythm of my feet hitting the road cleared my mind and put me in a sort of trance.
You get it. Perhaps you used to be a runner too–or a swimmer, or a cyclist. You were driven. You knew what it meant to feel pain and to keep going. Your sport taught you discipline and resilience. It pushed you to excel in your field.
But life happens.
About halfway through residency, I’d stopped exercising, and I was feeling the impact. I wasn’t sleeping well. I was cranky (weren’t we all?). My always supportive husband felt it too and bought me an indoor rowing machine—talk about an awkward anniversary gift (“I love you. No, you’re not fat, you just need to exercise”). And I started getting back into shape. I actually looked forward to my 4:30 a.m. row before a long day in the OR. I was exhausted from residency, but I finally felt healthy again.
I managed to maintain this routine through fellowship with early runs through the Boston Common, jumping over cobblestones and sewer rats, but then came kids. A new job. Boards. Grant applications. Clinic. More clinic. A few years into practice, I again found myself feeling cranky and irritable. I wasn’t sleeping, I felt unwell. After a work-related injury requiring physical therapy, and the recognition of classic signs of burnout, both physical and mental, I knew that I had to make a change. I had to make time for ME if I was going to be able to take care of others.
But “Physician, heal thyself” is easier said than done.
The importance of exercise is undeniable, especially as we confront the negative health effects of stress and burnout. In the lay press, exercise is lauded as a “miracle cure,” the “closest thing to a wonder drug,”  and there is data to back up these claims. Exercise improves outcomes in regard to decreasing pain, cardiovascular mortality, glycemic control for diabetics, potentially even improving brain health [2,3]. As A.A. Milne wrote in Winnie the Pooh, “A bear, however hard he tries, grows tubby without exercise,” and as oncologists, we are all well aware of the cancer risk associated with obesity . A recent meta-analysis has also demonstrated that exercise provides significant risk reduction in regard to breast cancer, colon cancer, diabetes, ischemic heart disease and ischemic stroke .
Nnenna Lynch, a former professional runner, wrote of her experience getting back into running after retirement, “I oscillated between intense focus and doing nothing.”  My own pendulum seems perpetually stuck in the “nothing.”
There are always excuses. I took the stairs today (pop open a bag of chips). It was a six-hour case (crack open a beer). Then there is the to-do list, which seems to always get longer. Exercise or finish charting? Exercise or make lunches for the next day? Exercise or sleep? If I do get out for a run, I plod, my knees ache, my lungs burn, and I ache for days. I have tried just about every form of exercise in an effort to get out of this rut. I signed up for a 30-day yoga challenge. I lasted 4 days. On the 4th night, I feel asleep on my yoga mat. The struggle is real.
The SGO has made a commitment to physician wellness, and over the course of the next few months you will read more about colleagues finding wellness. It is crucial to remember that the definition of and means for achieving wellness are very individual. Wellness is a state of mind, an awareness, which in turn leads to physical and mental health. Exercise can be one method for achieving wellness, for maintaining some degree of wellness. But there is a reason it is called “working out”. It takes commitment. It takes going the extra mile. Some element of pain is likely involved.
Personally, I’ve committed to a new, consistent exercise regimen. I often take my kids with me, but find that my arthritic black lab is far more forgiving when I need to slow the pace. My kids, on the other hand, are brutally honest (“Are we actually running?”). An interim analysis of this “experiment,” meaning my spouse’s feedback, is that even this modest amount of activity is greatly increasing the wellness quotient in our household.
I used to be a runner. Maybe I still am.
- Lynch, N. (2016). Advice From a Former Olympic Hopeful: Set the Bar Low. Retrieved September 27, 2016, from http://well.blogs.nytimes.com/2016/08/18/advice-from-a-former-olympic-hopeful-set-your-bar-low/
- Carroll, A. (2016, June 20). Closest Thing to a Wonder Drug? Try Exercise. Retrieved September 27, 2016, from http://www.nytimes.com/2016/06/21/upshot/why-you-should-exercise-no-not-to-lose-weight.html
- Nokia MS, et al. Physical exercise increases adult hippocampal neurogenesis in male rats provided it is aerobic and sustained. J Physiol. 2016 Apr 1;594(7):1855-73. doi: 10.1113/JP271552. Epub 2016 Feb 24.
- Lauby-Secretan B, et al. Body Fatness and Cancer–Viewpoint of the IARC Working Group. N Engl J Med. 2016 Aug 25;375(8):794-8. doi: 10.1056/NEJMsr1606602.
- Kyu HH, et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ. 2016 Aug 9;354:i3857. doi: 10.1136/bmj.i3857.
Rath, K. S., et al. (2015). “Burnout and associated factors among members of the Society of Gynecologic Oncology.” Am J Obstet Gynecol 213(6): 824 e821-829.
Murakami, Haruki, and Philip Gabriel. What I Talk about When I Talk about Running: A Memoir. New York, NY: Alfred A. Knopf, 2008. Print.
National Race to End Women’s Cancer, from http://endwomenscancer.org/
“All I do is keep on running in my own cozy, homemade void, my own nostalgic silence. And this is a pretty wonderful thing. No matter what anybody else says.”
― Haruki Murakami, What I Talk About When I Talk About Running
Leslie S. Bradford, MD, is an Assistant Professor in Obstetrics and Gynecology at the University of Massachusetts Medical School in Worcester, MA.
Early in my career, I had no idea what burnout was, but I certainly knew a lot of burned out doctors. They were disengaged, condescending, mocking patients and learners and referring providers; for a while I thought that was normal, as in “normalized deviance”– the acceptance of something wrong because it is so common. Now physician burnout is in the news, and many specialties report a prevalence as high as 50 percent. While I am not a statistician, that number suggests that either you or one of your partners may be suffering from burnout. With this in mind, I see three steps to decreasing and preventing burnout: Leadership, Physician Engagement, and Reconnecting with Patients.
As the surgical leaders in women’s health, our bully pulpit is the platform for the creation of highly functioning workspaces. We have a responsibility to ourselves and our patients to provide a clear vision of what “great” looks like, and to remove any barriers to greatness. As a leader among physicians, some of your key questions to your colleagues should be: “Do you have what you need to deliver care? How can I help you get what you need and get other things out of the way?” Their answers should provide some great insights into what you can do for them to promote their engagement with healing care, which can safeguard them against burnout.
Leadership alone is no magic solution to this grim reality of burnout, especially within gynecologic oncology. Another key step is promoting physician engagement, which to me is the inverse of physician burn-out. Engagement means promoting anything that helps a physician stay connected to the core reason they practice medicine–delivering healing care. There are just too many diversions from that healing focus for many of us, and it’s my conviction that the less care we deliver the more prone we are to burnout.
I’m fortunate to practice in a health system that has taken three steps to battle burnout and promote physician engagement. One is Professional Coaching, the opportunity to receive objective and insightful guidance on overall professional practice, personal development, and life balance. An outside perspective from a talented professional coach can be an energizing and empowering tool for staying engaged in caregiving. Another step is a physician support service called MyConcierge. It’s a dedicated physician service bureau that tends to an array of non-medical concerns so we can stay engaged in caregiving. Whether those concerns are about home maintenance/repair, life tasks, or work issues, MyConcierge handles plenty of small burdens that enable physicians to focus on practicing medicine. Finally, we encourage our providers to protect their personal time and enjoy time away from work.
The Electronic Health Record (EHR) is often cited as a major factor in burnout; it contributes on two sides of this problem: Physician Engagement and Patient Engagement, looming like an electronic force field between you and your patient. To keep the EHR from interfering with my office encounters, I pre-screen the record before entering the room so I am not referring to the computer while talking with the patient. I honor that “golden minute” to reconnect before ever going electronic. I position the computer to the side and try to only use it as mutual reference in partnership with the patient. This triangulation of the patient, provider and computer retains our trusted and rewarding doctor-patient relationship. In this way, I optimize my EHR tools so I can live my mantra of “Less time charting, more time caring.”
When our patients die, it can feel like failure even when it is inevitable. Over the months and years of treatment, these people become our friends. For the frail elderly and dying, I will make the occasional house call, and it makes us both so much more connected. And when they die, I go to funerals, not always but when I can. There I hear gratitude and closure beyond words. Finally, I celebrate our cancer treatment successes. With permission from my patients I tell their remarkable success stories, and I marvel at the fact that miracles do occur, but only because of what we do.
Maybe I do not have the capacity or wisdom to give any other important mentoring advice to my junior colleagues, but David Cohn, MD, told me that one of the most important words of advice I gave him when he started on faculty at The Ohio State University was, “Just make sure you get a hobby.” Hopefully, I was able to offer more than that in my capacity as his Division Director. Perhaps this was one of the most important pieces of advice young Dr. Cohn received as he was fresh out of fellowship and about to embark on a successful and demanding career in gynecologic oncology.
The practice of gynecologic oncology is extremely demanding, rewarding and complex. It consumes most of our physical and mental capacity. The overwhelming majority of gynecologic oncologists are satisfied with their career choice, but the demands of the job take their toll; One third of Gyn Oncs are burned out. Indicators of psychosocial distress and poor mental well-being are alarmingly high. The wrong mix of perfectionism, self-doubt, fear of failure, compassion, loss of sense of control and exhaustion without proper support and resources leads to burnout and other problems with personal and professional well-being. The recipe for disaster is complicated. Risk factors that contribute to burnout and low career satisfaction will vary amongst individual physicians.
Work-life balance is a difficult concept in our profession; mental and physical time and effort are definitely not a 50-50 proposition. Despite finding meaning in our work and career satisfaction, it is impossible to escape the demands of our professional lives. We cannot punch out on a time clock, and it’s virtually impossible to avoid leaving work behind you when you exit the hospital. “Good” work-life balance prevents the most severe fallout that may result from our demanding careers. Surgeons who incorporate a philosophy stressing work-life balance are less likely to suffer from burnout and have a better quality of life.
An important component of work-life balance is regularly taking the time to relax. Relaxation is defined as any restorative activity associated with the key elements of enjoyment and satisfaction. It should not be an activity where the usually negative personality traits of perfectionism, obsession and extreme competitiveness are dominant, which is ot to say I don’t enjoy beating some of my colleagues in a Ping Pong match!) There is no magic formula except that the activity should be enjoyable and recharge your emotional and physical batteries.
It’s interesting that we have invested so many years into rigorous and competitive education training but we are not very disciplined about self-care. While I’m not the greatest example of work-life balance, perhaps you should have a serious talk with yourself regarding professional versus personal goals. I have learned to take regular time for family, exercise, travel, golf (enjoyable as long as I don’t expect to break 90 every outing) and fishing. It takes discipline, commitment, and advocating for oneself. You have to accept that the unique demands and responsibilities of our job will create peaks and valleys in our self-care schedule.
Harry S. Truman, may have had the most difficult combination of challenges faced by any American president in modern history. As he emerged from the shadow of Franklin Delano Roosevelt in the closing months of World War II, Truman was forced to consider these daunting issues: the use of nuclear weapons against Japan, the reconstruction of Europe (Truman Doctrine, Marshall Plan), the Berlin Airlift,a Cold War with the Soviet Union, the Korean War, and use of nuclear weapons relating to General MacArthur and McCarthyism. In spite of all this, President Truman still understood the importance of rest and diversions from work. One of his favorite quotes was from a plumbing contractor who worked at the White House.
“Every man’s a would be sportsman, in the dreams of his intent,
A potential out-of-doors man when his thoughts are pleasure bent.
But he mostly puts the idea off, for the things that must be done,
And doesn’t get his outing till his outing days are gone.
So in a hurry, scurry, worry, work, his living days are spent,
And he does his final camping in a low green tent.”
And what about Dr. Cohn? I created a monster! He went back to playing the guitar, took up the mandolin, and he is a Cross-fit training triathlete who also loves to fish. As one of my mentors would say, “Just do something!” Go get a hobby….before it’s too late.
- Rath, K. S., et al. (2015). “Burnout and associated factors among members of the Society of Gynecologic Oncology.” Am J Obstet Gynecol 213(6): 824 e821-829.
- Shanafelt, T., et al. (2006). “Shaping your career to maximize personal satisfaction in the practice of oncology.” J Clin Oncol 24(24): 4020-4026.
- Shanafelt, T. D., et al. (2012). “Avoiding burnout: the personal health habits and wellness practices of US surgeons.” Ann Surg 255(4): 625-633.
- Balch, C.M, et al. (2010). “Combating Stress and Burnout in Surgical Practice: A Review.” Advance in Surgery 44: 29-47.
Jeffrey M. Fowler, MD, is the 2016-2017 SGO President and Director of the Division of Gynecologic Oncology and professor of gynecologic oncology at The Ohio State University Wexner Medical Center.
“… Not being lost in thought, not being distracted, not being overwhelmed by difficult emotions but instead learning how to be in the here and now; how to be mindful, how to be present. I think the present moment is so underrated. It sounds so ordinary and yet we spend so little time in the present moment that it’s anything but ordinary.” Andy Puddicome, TED Talk
On Monday morning our clinic in downtown Cleveland was abuzz. Less than 12 hours earlier the Cleveland Cavaliers had won the National Basketball Association title, ending the city’s half century major sport championship drought. LeBron James kissed the ground. Attending physicians looked weary after a late night. At the nurses station, medical assistants watched the final game moments on YouTube. Patients came and went—needing chemotherapy, radiation, and shoulders to cry on.
Mr. X was clearly agitated. He and Mrs. X had been in clinic for two hours already, patiently waiting for her lab results. He grew increasingly impatient as the morning wore on. “I don’t care that the Cavs won the championship,” he declared. “I want Mrs. X to get her chemo!”
Given this situation, what should a clinician do? In this circumstance, practicing “mindfulness” can be a benefit to the patient and her caregiver as well as the health care practitioners involved.
Mindfulness is defined as a “moment-to-moment, non-judgmental awareness or binging one’s complete attention to the present experience…” (1). Originally emerging out of the teaching of Guatama Siddhartha, mindfulness can be practiced free from “-ism” or religious beliefs (1). Jon Kabat-Zinn, at the University of Massachusetts Medical Center, has developed the mostly widely-used mindfulness program for patients who are without hope for treatment for chronic issues (2). There is strong evidence supporting that therapeutic gains made from this instruction persist long after the teaching. But those of us wearing the white coats can benefit from this principle as well.
It is apparent that a mindful clinician, one who is grounded in the present doctor-patient interaction will be more effective at communicating, coping, treating and healing. McGill University in Montreal has undertaken an eight week mindfulness training for health care professionals (2). Pilot data demonstrated that these participants all reported an improvement in psychological well-being and in their ability to disengage from distractive thoughts.
To practice mindfulness, clinicians need to dis-engage to engage, bringing their full attention to each and every patient interaction. On this particular Monday, my wonderful charge nurse was mindful of Mr. X’s needs. She disengaged from the background noise regarding the Cleveland Cavs celebration and allowed herself to interact with Mr. X free from judgment and clatter. Afterwards she spoke of his needs, his fears for his wife, and his need to connect with a provider.
My advice to my fellow physicians would be to start your day with focus–focus on your breath, on your body–focus on what you are “bringing to the table” on that particular clinic day. And try to let it go. Allow Mr. X a centered encounter. You too will feel at ease.
1. Baer RA. Mindfulness training as a clinical intervention: a conceptual and empirical review. Clin Psychol Sci Prac 2003; 10:125-143.
2. Whitesman S. Mindfulness in Medicine – MBSR www.mbsr.co.za › Article
- Mindful Doctors, Happy Patients (University of California, Berkeley)
- Easing Doctor Burnout With Mindfulness (New York Times)
- Mindful Practice (JAMA)
Kimberly Resnick, MD, is the Division Director of Gynecologic Oncology at the MetroHealth Medical Center at Case Western Reserve University in Cleveland, OH.
As a resident and fellow, I had tunnel vision. For those eight years, I refused to let myself think in time increments longer than one week. I remember occasionally thinking about the big picture of the years I had left in training and quickly becoming overwhelmed. I’d dial back, to quiet the panic. For many of us, this works for a while.
It keeps us focused on the task at hand and somewhat oblivious to the sacrifices and stress that this job involves. Just don’t think about the fact that you don’t see your child for days at a time, that you haven’t exercised in years and eat mass-produced cafeteria food every day, that you are watching women die every day. I was fairly good at compartmentalizing all of that.
However, those of us that get good at this denial while in training have a new challenge when we become attending physicians. How do we redesign ourselves to function once this is not a temporary situation, but instead our ”real” life? To me, this has been an unexpected challenge but one that is innate to Gynecologic Oncology. What drew many of us to this specialty, the combination of complex surgery, medically complicated patients and continuity of care, leads this to be a singularly demanding field both technically and emotionally.
This is part of why burnout is so prevalent in gynecologic oncology. Not only are we responsible for the lives of the women on our OR table, but we are then called upon to diagnose recurrence when our treatment efforts have failed. We usher our patients and their families into death, and hopefully treat just long enough and palliate suffering when the time comes. It is an incredible privilege but also a damn hard job. And one that we are trained to do silently and stoically, without admitting the toll it takes on us and our loved ones, as that would be a sign of weakness.
Fortunately, we are starting to acknowledge our humanity and support each other in a way that is new in medicine. That is why I was eager to take part in the SGO Wellness Initiative.
I was fortunate enough to train with Dr. Skip Granai at Women & Infants Hospital, Brown University, in Providence, RI, in an oncology program that combines integrative care, music, art and self-expression, in addition to the traditional science of medicine. As a fellow, I saw this approach to the whole woman benefiting patients and their families. Now I am beginning to see how this can, and should, apply to us providers as well. Below is a poem that I wrote and recited as part of a required exercise during fellowship, which at the time felt torturous. In hindsight, it was a moment of powerful self-expression and recognition of my own humanity.
Years that Way
Emily K. Hill
Pressure cooker. Steam. Heat.
Wake. Go. Sleep brief.
Wants. Needs. Incessant beep.
Smile. Joke. Paper heap.
One week at a time. Years that way.
One day at a time. Afraid to say.
Approve, praise, not disappoint.
Nervous, angry, impending disjoint.
Surrounded by others’ loss and pain.
Petty excuses to drift – insane.
Too much thinking, dark spiral.
Busyness preserves survival.
If they go, why do this all?
Woman vs animal.
- The Epidemic of Burnout, Depression, and Suicide in Medicine, MedPage Today
- Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction, Mayo Clinic
- Three surprising truths about physician burnout, Advisory Board Session Document
“The moments of silence are gone. We run from them into the rush of unimportant things, so filled is the quiet with the painful whispers of all that goes unspoken. Busy-ness is our drug of choice, numbing our minds just enough to keep us from dwelling on all that we fear we can’t change.” L.M. Browning, Seasons of Contemplation: A Book of Midnight Meditations
Emily K. Hill, MD, is a Clinical Assistant Professor in Obstetrics and Gynecology at the University of Iowa Hospitals and Clinics in Iowa City, IA.