In a recent episode of the AMA STEPS Forward podcast, Gail Gazelle, MD, MCC, a leader at the forefront of the movement fighting physician burnout, discusses three mindfulness and well-being steps physicians can take to thrive.
Gail Gazelle, MD, MCC, author and physician coach, leading Harvard Institute of Coaching
Kevin Hopkins, MD, family physician, Cleveland Clinic, a primary care medical director for Cleveland Clinic Community Care
AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Transcript highlights. Click HERE to read the full transcript
Dr. Hopkins: I'm not sure that many physicians recognize or understand themselves to be part of a "vulnerable population," right? We think about that in terms of our patients, elderly or very young children, people like that.
What do you see as a response or reaction, if you talk about physicians as a vulnerable population, how can we as physicians see ourselves as truly vulnerable?
Dr. Gazelle: It's an interesting question, isn't it, because part of our training is to be invulnerable. To always have the answer, to be the captain of the team, to always be perfect. That actually takes quite a toll on us, doesn't it? I think it catches up with us, and is one of the many predisposing factors toward burnout.
Some physicians can appreciate that we are vulnerable in this health care system where we're certainly no longer on top, and we're no longer seen as the special, caring experts that of course we are. We're just, in many cases, another employee. I don't know if this resonates for you and your listeners, but I've had so many physicians say to me, "I just feel like a cog in the wheel. I feel like I'm replaceable; that people don't see how hard I'm working. They don't see how much I care about patients, and how much I sacrifice, every day, to really help the vulnerable patients under my care."
When I talk about vulnerability, that's what I'm saying. We're unsure what our place is in this new health care matrix, so to speak. I don't know that we're comfortable with that place, because it's different from what we were trained to expect.
Dr. Hopkins: If we wanted to be part of a production line, we probably would've picked a different career. Instead, we count on patients to come to us as an individualized solution shop that we can provide help for them in that way. Some of the disenchantment of getting into a career in medicine, and realizing that, in some respects, it is addressed as sort of a production line, can lead to burnout.
You mentioned burnout a little bit. One way to help prevent and mitigate burnout is to build personal resilience. Certainly we see resilience in the form of organizational resilience as well. Your book that came out in August 2020, "Everyday Resilience: A Practical Guide to Build Inner Strength and Weather Life's Challenges," what was the genesis behind that book? How did that come to be?
Dr. Gazelle: I spent a lot of my time thinking about resilience, and I think that's because of the work that I did in hospice, seeing the different trajectories that people were on in terms of how they spent this last and very vulnerable period of their lives. Most of us, as physicians, have seen people enter the terminal phase of their lives, and many of them are in denial. They're angry. They're thinking, "Why me? This couldn't have happened. It shouldn't have happened. I believed in God. I was a hardworking individual. Why is this happening?" Very normal, human responses, and yet sometimes what we see is people getting locked in that mindset, and not having the incredibly important conversations with their loved ones and with their providers, all of us on the medical team, and they end up dying in an ICU, hooked up to machines, not having family close by, not having closure with those who are deeply important to us.
On the other hand, we see individuals who demonstrate a different kind of approach to this end-of-life period. Now, of course, nobody's happy when they get a diagnosis of a terminal illness, I'm not trying to suggest that. But we see patients who come to a place of acceptance: of realizing that they've been dealt a challenging hand of cards, so to speak, but who move forward in a different way. I'm sure you can resonate with this, as a frontline clinician, Kevin. We see them mobilizing the psychosocial elements that allow them to navigate this period with more grace and fortitude, and to have the kind of forgiveness, permission and closeness with those who are most important to them.
My whole time, 15 years taking care of thousands of terminally ill patients and their loved ones, I feel like I saw a lot of resilience and I learned a lot about resilience.
When I pivoted and became a coach and had the incredible pleasure and privilege of working closely with many colleagues, I saw that same resilience. We know that physicians have resilience. There's no shortage of resilience, but we don't always learn how to apply that resilience to the difficulties that we face in our practices. I'm in the business of helping physicians do that. Helping them harness their inner well of resources, which is how I think about resilience, and apply that so that they can weather the difficulties and challenges that come their way in the practice of medicine, without unnecessary physical, mental, emotional or spiritual distress.
"We know that physicians have resilience. There's no shortage of resilience, but we don't always learn how to apply that resilience to the difficulties that we face in our practices."
It's not that the practice of medicine will become easy. It's not that the EMR will go away and that non-clinician administrators will not be a part of our lives. That's not what we're talking about. We're talking about some skills and strategies that allow us to weather this with less duress, with less difficulty in our lives.
It's a topic of tremendous interest to me, I think as you can hear. I really had a great time writing "Everyday Resilience," and I've also had a great time writing my forthcoming book, "Mindful MD."
Dr. Hopkins: Terrific. I can hear the passion in your voice, and I share that same passion. When you use words like resilience and mindfulness, those probably conjure up different meanings in different people's minds. How do you define that? Because some people may think, "Resilience, mindfulness, that has a negative connotation." What do those specific words mean to you, and how do they directly relate to burnout?
Dr. Gazelle: It's such an important question. The medical system is so challenged at present, and there's so many difficulties that we physicians face and, really, everyone in health care is facing.
Sometimes, I think when physicians hear the word resilience, they think to themselves, "Now, wait a minute. We can't let the system off the hook. Aren't you telling me that I need to be more resilient, that I need to do something differently, when really it's the system that's broken?" I think we really have to think about a "both, and" here; there's no question of how dysfunctional the U.S. healthcare system is, and again, it's not just in the U.S. I've coached plenty of Canadians and individuals in European countries, as well. This is a pervasive international problem in developed countries.
We're not thinking about letting "the system," so to speak, off the hook. There are plenty of people at the AMA and elsewhere who are deeply involved in fantastic ways to help mitigate the problems that a broken healthcare system brings to the average working physician.
That is of the utmost importance, but I'm a pragmatist, Kevin, and I think to myself, "Well, how soon is it that our healthcare system is going to improve? Is that going to happen tomorrow? Is that going to happen in a year?" Maybe things are actually going to become more problematic before they get better.
As a pragmatist, I'm thinking about every physician out there. What are they going to do today? What are they going to do tomorrow?
If I'm giving a keynote or a talk at a health system when I pose the question, "Do you think your health care system's going to fix all these problems in the foreseeable future?" They all shake their heads and sigh and laugh and say, "Well, of course not." They know that. So what do we do? Do we just retire early? For some physicians, that's an option. Do we sadly develop disruptive and dysfunctional behaviors? I hate to say that, sometimes, that happens as well. Do we come home and rail against a broken system, and not be present with our loved ones and become irritable and withdrawn?
These are all things that we see. For me, resilience and mindfulness are all about practical strategies that physicians can learn and can practice on a day-to-day basis to reduce their own distress and level of suffering. That's something that we can all learn. We don't learn it in our training, by and large, but we can, and it can greatly improve our quality of lives.
Dr. Hopkins: You're absolutely right. When you and I trained, it certainly was a much different atmosphere from what it is today. "Keep your head down; don't complain."
Many physicians probably today think, "Well, if I've got to build resilience if I'm going to practice mindfulness, isn't that a sign of weakness?" Most of that was bred out of me during my training, so it doesn't come naturally to us.
What are some steps that physicians can take to not just survive in the current environment that we find ourselves in healthcare but to actually thrive? I know you described three steps that we can take to do that. I think it's important to outline those things so that we can take healthy steps aimed at preventing and mitigating personal burnout. Like you said, a lot of people are retiring early, or they're reducing their FTE just to help themselves cope.
What are some steps that we can take to actually thrive in this environment?
Dr. Gazelle: As I talk about steps, I want to just say one thing about the "m" word, mindfulness. It can conjure up images of monks meditating on mountaintops or maybe aging hippies talking about Woodstock. What's important to realize is that another way to think about mindfulness is actually mind training. Our minds are very busy places. When we pause and spend time in meditation, or just quietly observing our own mind, it can really be astounding, particularly to busy, overtaxed physicians.
It can be astounding what's going on in our minds; the sheer number of thoughts that we have, the judgments we have, the comparisons we make, the emotions that go on in our mind. With mindfulness, it's not so much sitting and naval gazing, so to speak. It's about getting to know our own mind, so that we can work with it most productively.
In terms of some steps, I'll mention a client whom I'll call "Susan." Susan is really a composite of individuals that I've coached.
Susan was an internist, struggling to stay on top of her charts. Great physician, beloved by her patients, and well-respected by her peers; but like many physicians, the Achilles' heel of sitting down and getting the charts done. In fact, Susan was 150 charts behind. We did something that I've developed; it's a bit of a "charting audit," really putting under the microscope what is going on for the physician that's getting in their way.
When Susan sat down to chart, two interesting things occurred for her. One, was she had so much frustration and really, anger towards the administrator in her practice. She would sit down to chart and her mind would go to how unfair this was, to these nasty grams that she was getting from this administrator, and how could she be asked to do this? This was so below her pay grade.
At the same time, the second thing occurred for her, which was a lot of self-criticism. When she sat down to chart, she started thinking to herself, "I'm not very good at this. Other people are better. I'm not as efficient as others. In fact, maybe I'm not even as good a doctor as others." Her mind would just be besieged with all of this harsh self-criticism.
What I've seen in the over 500 physicians that I've coached is a similar pattern; that our mind is busy with unprocessed emotions, with stories, with harsh self-judgment that make it very difficult for us to be productive, and certainly to feel satisfied and fulfilled.
When you talk about three steps, the first step that I worked, with this client and many others, is that we have to get to know what's going on in our mind. We have to be more mindful. How do we do that? Well we can do that by sitting quietly and meditating, even for five minutes. We become very familiar with our mental patterns, our thoughts, our stories and judgments. That's the first step is getting to know and diagnosing our own mental patterns, why we can't intervene until we diagnose, right? We're doing the same thing with our own mind.
The second step that can be critically helpful is something that I call the purposeful pause. Our days are so busy, right? Double booked, triple booked, charting, callbacks, getting prior auth, everything that has to be done to stay on top of a busy practice. We're going at 90 miles an hour, never stopping, not even pausing to eat lunch. That's too much. That, in and of itself, predisposes us to burnout. So, we can stop. We can pause, even for as long as it takes to take three slow, deep breaths. We can take our own emotional temperature. Once we do that, we can settle ourselves, maybe have a cup of tea, or walk around the practice or walk around outside for a minute or two, something that helps to reduce our emotional temperature so we can stay steady and focused, and be productive, get through our days.
The third step is something else that you heard with Susan, which is, quieting the inner critic, developing self-compassion. We learn to be very harsh with ourselves in our training. Most of us, I think, can relate to that. We criticize ourselves, we play things over and over, any slight mistake. We could have 10 things that go great, but that one thing we replay and we ruminate. We can learn to be kinder to ourselves, to remind ourselves that we're working hard, and that we're doing the best that we can.
So three steps. Getting to know the busy mind; diagnosing our own patterns. Two, building purposeful pauses into our days, kind of as a way of pacing ourselves. And three, developing the muscle of self-compassion. I've seen those three steps be incredibly helpful for many physicians.
Dr. Hopkins: That's a great outline. I don't know why, but it is so hard for many of us to be kind to ourselves and show ourselves a little bit of grace. Yet, that goes a long way towards building that personal resilience.
Dr. Gazelle: I think we learned these patterns of self-harshness in our training. Kind of never good enough, right? Being compared to our peers. We were always focusing on, and having ourselves focused on, where we're coming up short. We really don't learn these things. There are things that we learn in our training that make it very difficult for us to cope well, with all the difficulties that we face.
Dr. Hopkins: Absolutely. Part of the importance that you point out in this, Dr. Gazelle, is that it's so important to note that we recognize and identify burnout as, often, a system problem, because it is sort of built into our systems. And yet, things don't necessarily happen quickly. You and I both work for large academic medical centers. Nothing happens quickly. What do we do while we're waiting for those cultural, systemic changes to come, that are going to help with burnout mitigation? These are things that we can do that are very practical and pragmatic, to use your word, to help us not just survive our day, but to actually thrive.
As you were talking about Susan, and being kind to ourselves, it made me think about, how does imposter syndrome contribute to a lack of confidence or joy in the practice of medicine? What's the connection between imposter syndrome and burnout?
Dr. Gazelle: Isn't it fascinating how many physicians walk around accusing themselves of being an imposter? My name is Gail, and I feel like an imposter at times. I'm here at Harvard Medical School, it's like the Harvard Olympics, and there's always people you can compare yourself to that have published 10 times as many articles, and have a great life outside of work, and on and on and on. We learn to make those comparisons, again, early on. We, who go into the practice of medicine, stand out because of our academic aptitude. We're good at taking tests, we're good at learning, and we love to learn. We get labeled early as being the smart one. That, unfortunately, I've seen in many of the individuals that I've coached, actually sets the stage for imposter syndrome. It's almost like that Jimmy Cliff song, "The Harder They Come," the harder they fall.
We worry that we're going to be found out, that we're not as smart or as good as people think we are. I've heard that from so many physicians. We can also feel like an imposter because of all the comparisons that are part and parcel of our training. The ratings and rankings and comparisons; we're always being compared to our peers. That can also leave us feeling like, "Uh oh, what if I'm not as smart as them? What if they know something that I don't know?"
The imposter syndrome can really hound us, and of course it erodes our sense of well-being. It erodes our ability to feel good about what we are doing. It keeps us focused on something that may not be going well, even if it's something small.
What I find very interesting about the imposter phenomenon is that it's actually just a thought process. Really. It's not based on fact, it's based on subjective assessments of feedback that we're getting. We could give a talk and everybody could be smiling and engaged, but there could be one person who's looking down at their device, and we may focus on that person and think, "Ah, I'm giving a boring talk. What's wrong with me? Everybody else can give a better talk."
It's a very subjective phenomenon that really trips us up. When we begin to realize that the imposter phenomenon is actually just a thought process, we can start laughing a little at it. We can realize we're all walking around feeling like an imposter, and that we don't have to buy into this story that our mind seduces us as the truth.
I have a lot of free resources on my site and one is actually called "Imposter No More." It's a very brief guide, but I go into some of these issues that can set us up for feeling like an imposter, and, similarly, some strategies that can liberate us. Once we do liberate ourselves from feeling like an imposter, our days are lighter. We can actually be more productive because we can be more focused. Our mind isn't over here with all these accusations and judgments. Our mind can actually focus on the patient, the chart, the inbox, whatever it is that's at hand. We can live less dogged, in a sense, less kept down by these thoughts that there's something wrong or inadequate about ourselves.
Dr. Gazelle: The main thought, Kevin, is that there's hope. So many physicians are struggling to get through the day. So many physicians are struggling with burnout, with loss of sense of meaning and purpose. It's just important to remember that there is hope. Whatever happens in the medical system, we can develop these tools and strategies that are not that difficult to develop, that really have huge payoff for us. Not just when we're at work, but equally important, if not more important, when we're home. When we actually have that time to be the full human that we are.
I'd also just like to say, if I can be a resource to your listeners, my email is firstname.lastname@example.org. Again, I have a lot of free resources on my site. I have the "Imposter Guide." I have something that I call "Charting Your Life." I have something that I call the "Daily Dose of Calm," a "14-Day Mini Mindfulness" course, and quite a few other resources. I just want to encourage your listeners, if that can be helpful to any of them, please feel free to go to my website, gailgazelle.com, and download anything that can be helpful to you.