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
“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.