Moduel 8: A summary of all we have explored.
Let’s do a quick review and then talk about ways that you can build on what you’ve learned, and hopefully charge your batteries even more so that you can cheer for institutional policies and habits that support our wellbeing, and use our armor to fight the good fight: to change institutional practices that focus on profit over patients and our wellbeing. One HR representative at an institution that shall go unnamed told me that it costs them a whopping $1 Million to replace a physician that has left their employ. Speaking of money, here’s another fun fact: monetary incentives don’t work to prevent or remedy burnout. In fact, half of the doctors in one survey said that they would give up at least $20,000 in annual income in exchange for reduced work hours.
In a New England Journal of Medicine commentary written in 2020, Pamela Hartzband and Jerome Groopman summarized seminal work by Gagne and Deci on workplace motivation. Motivation can be broken down into extrinsic and intrinsic motivation. Extrinsic motivation can be summed up as receiving the rewards of an activity, whereas intrinsic motivation comes from the satisfaction of doing the activity itself. Think of your workday as being similar to a car trip. Getting to the destination is that extrinsic motivator that is rewarded by arriving. Enjoying the ride is intrinsic. So extrinsic motivators would include your income and intrinsic motivators would be related to how much you enjoy doing your work.
Gangne and Deci talk about 3 pillars that support intrinsic motivation, and relatedly, psychological wellbeing: autonomy, competence and relatedness. Having control over your time and how you treat your patients feels a lot better than someone dictating these for you. Competence has been shifted from medical knowledge and wisdom to how well we comply with various metrics, which as Hartzband and Groopman point out comes down to checking off boxes in the electronic health record. Relatedness basically boils down to how much we connect with and relate to others within our organization –not just our peers but administrators, support staff and so on. They also make some straightforward suggestions for how to restore these pillars of wellbeing. Giving physicians flexibility in scheduling and treating patients, reconfiguring electronic health records to work for us rather than “forcing physicians to work for it,” as Hartzband and Groopman put it, and relatedness can be restored by institutions walking the walk not just talking about aligning the system’s values with healthcare professionals. But we can’t fight to change the machine if we’re so ground down by it that we don’t have the energy to think and act.
So it is really important to identify where we are tripping ourselves up, as compared to being tripped up by the system. And recognizing related habits is essential for freeing up our energy to support change. For example, if we’re burnt out and spin our wheels cynically complaining about the system to our families or ranting on social media, we’re wasting that time and energy, and ironically, compounding our burnout. Let’s review some of the individual factors that you do have control over.
Over the past week, hopefully you’ve learned something about yourself and how your mind works. Perhaps you’ve started identifying unhelpful empathy habit loops, such as over-empathizing, rushing to fix or prescribe, taking your patient’s struggles home with you and other unhelpful patterns.
Remember the river analogy–someone getting washed downstream that I talked about in module 2? Hopefully you are better at identifying when you are stepping into your patient’s story of suffering and what it feels like to focus on the simple fact that they are suffering, so you can walk alongside them instead of getting swept downstream with them. Remember module 3 which was about recognizing and noting intrusive thoughts? Just like getting washed downstream in the river of suffering, it is easy to habitually hop on the thought train and get taken for a ride. It only takes a moment to note them. And this gives you the power to step off whenever you like. In module 4, we zoomed in on self-judgment. How many of us are in the habit of hitting ourselves with that stick, thinking it will help, when in fact it does the opposite? Instead of bruising yourself, can you let that black and blue heal? How about the carrot? Have you tried the red pill of curiosity and kindness instead? Have you tasted how much better it feels to simply be kind to yourself ? Module 5 was all about uncertainty and anxiety. It’s really prevalent in our profession. Remember my lab’s results? We found that anxiety is highly correlated with physician burnout. We found that mental training, like this one can help. We covered social contagion in module 6. Hopefully you have had your own experience of the impact of self-compassion and are on your way to curiosity and kindness zombification, infecting others along the way. And how about pain? Do you have a greater appreciation for all of the factors that we bring to the experience of assessing our patients’ pain? And perhaps you have a sense of how you can use curiosity and kindness to shift into a compassionate stance when diagnosing and treating your patients so you don’t get caught in the emotional pain cycle yourself.
Notice how just like in the movie the Matrix, once you swallow that pill of awareness you can’t go back. You can’t unsee the fact that you’ve developed unhealthy habits. You can’t go back to some type of contented ignorance and pretend you don’t know that stress or anxiety doesn’t really affect how you treat your patients. Being stressed is not the same as working well under pressure. Backburnering your wellbeing burns everyone. Shoving your anxiety in the closet only fills it up. That pressure builds until you blow your top and leave. A JAMA article in 2022 highlighted how with burnout approaching 50%, more than 1 in 5 physicians intends to leave the practice in the next two years, 24% to be exact. For nurses, ready for this? 40% of nurses plan to head out the door.
So don’t become a statistic. Don’t let the system turn you away from something that you love: helping people. If you run away from the suffering by quitting, you’ll add more burden to those that stay. And then when you get sick or need care, guess who you’ll have to see? Yup, that doc that stayed and is even more overworked because of the shortage of docs.
So take one for the team, and start with yourself. Short moments, many times, that’s how any habit is formed. Build those habits of kindness and curiosity. See what habits you can form in the name of practicing good medicine. By helping yourself, you’ll be better at supporting your family, helping your patients, and helping your profession.
References:
Hartzband, Pamela, and Jerome Groopman. "Physician burnout, interrupted." New England Journal of Medicine 382.26 (2020): 2485-2487.
Gagné, Marylène, and Edward L. Deci. "Self‐determination theory and work motivation." Journal of Organizational behavior 26.4 (2005): 331-362.
Kane, L. Medscape national physician burnout and suicide report 2020: the generational divide. Medscape. January 15, 2020.