6: Practitioner Well-being

Primary care practice can be both an enriching source of personal growth and meaning and an unmerciful and depleting taskmaster. It provides us with access to a broad range of human experience—an intimate view of the characters and stories of a thousand novels—and an opportunity to have our very presence matter to others. At the same time, it makes constant demands and surrounds us with perpetual uncertainty; it relentlessly confronts us with our limitations of time, energy, knowledge, and compassion. It is a job that is never done; at best, problems are stabilized until something else goes wrong.

The balance each of us strikes between our own enrichment and depletion is critical to our own physical, emotional, and spiritual health and to our ability to care for others. All too often, however, we lose sight of this balance. We become so outwardly focused, attending to clinical problem solving, that we do not tend to our own renewal. This lack of balance is not surprising, our education has taught us much more about how to care for others than how to care for ourselves. The socialization processes of medical school and residency have cultivated a variety of unrealistic self-expectations and attitudes, especially concerning control and self- sufficiency.

Over time, this imbalance can produce a vague but increasing sense of demoralization, in which the joy of work is lost and patients seem increasingly annoying and adversarial. Work becomes the means to some other end—skiing trips or a vacation house—rather than meaningful in its own right. When the root causes of this dissatisfaction are invisible to us, we blame external sources such as the government, insurance companies, or lawyers. Although there are many legitimate complaints about restrictions and bureaucracy, the most fundamental determinants of satisfaction and well-being are not external but rather are found within.

In this chapter, we will examine important values, attitudes, and skills that affect our well-being. We will also consider the subtle but powerful effect of our work environment and personal practices that can keep us healthy.

The foundation of our well-being is the acknowledgment that we are human, that we have needs and limits, and that to keep on giving we must know and have reliable access to those things that sustain and revitalize us. Unfortunately, the notion that clinicians have needs has been put off-limits by traditional professional ideals. An excessively narrow interpretation of the scientific model calls on us to be detached and objective observers, leaving no room for our own subjective experience. We are also exposed early, and often, to the ideal of the clinician who is selfless, invulnerable, and omnipotent.

In actuality, each of us has a variety of needs, both universal and neurotic, that cannot fail to assert themselves. Our health and well-being depend upon the degree to which we are aware of and attend to them consciously and purposefully.

Among our most fundamental needs are those for human connection, meaning, and self-transcendence—experiencing ourselves as part of something larger than we are. Clinical work is particularly rich with opportunity for human contact and appreciation. Many studies have shown the patient–clinician relationship to be the single most important factor contributing to physician satisfaction (mirroring its central importance to patients). When we are working under excessive pressure or in situations for which we are not adequately prepared, however, clinical work can interfere with the satisfaction of these needs resulting in depersonalization and alienation from and hostility toward our patients.

Clinical work can also threaten the fulfillment of transpersonal needs through family and community life. Family and career often compete intensely for time and attention, too often to the detriment of the former. Moreover, we sometimes have difficulty shedding the white coat—leaving our professional caretaking role and expressing the spontaneity and vulnerability necessary for intimacy. As tensions build at home, putting more time into work can provide a short-term escape. In the long term, however, avoidance of difficult relationship problems leads to alienation and potentially to the breakdown of crucial personal support systems.

In addition to our universal needs for connection and meaning, we also have very individual neurotic needs—born of pain and conflict—that are intimately related to our medical work. These needs influence both our motivation to go into medicine in the first place and the way we practice. Out of a need to feel loved or appreciated, we often find ourselves in the role of overfunctioning caretakers, and our difficulty saying “no” quickly leads to over commitment. Feelings of impotence engendered by childhood experiences of illness—our own or those of a close friend or relative—may be relieved through our work with patients, but the wishful fantasy of controlling disease is constantly challenged by reality. Voyeuristic desires, fear of death, and the fulfillment of parental expectations are other factors, conscious or unconscious, that can motivate our careers.

These darker, neurotic needs are no less legitimate than those less hidden; they, too, are a normal part of life. When these needs operate outside our awareness, however, they can drive us to work excessively, assume unrealistic degrees of responsibility, and otherwise distort our work lives, thereby causing us to suffer. If we invest ourselves in unrealistic solutions that must inevitably fail, we risk chronic anxiety, substance abuse, and even suicide. Through various processes of self-exploration (such as psychotherapy, peer support groups, or mindfulness workshops) we can become more aware of these needs that underlie our work and find healthier ways to satisfy them. We ignore them at our own peril.

Another important but under-recognized determinant of our well-being is our personal philosophy—the deeply held beliefs and values that address the most fundamental questions of our lives: the meaning and purpose of life, death, joy, and suffering; why things happen the way they do; the nature of our relationship to other people and to the world; and the nature of our goals and responsibilities as human beings. Our personal philosophies define our expectations of ourselves and other people. They guide the way we perceive and respond to our world and help us identify our place in it. They define the framework by which we imbue things in our lives with meaning, joy, or pain and by which we determine what seems right and what seems wrong.

Developing a personal philosophy tends to be a subliminal process—a gradual internalization of attitudes and values from family, culture, education, and life experience. This process makes it possible for us to be entirely unaware of our core beliefs as an ideology; we may take them so completely for granted that they just seem to be part of the way things are. If we do not understand how these beliefs filter our perceptions and shape our behaviors, then we are unable to subject them to critical reflection and to decide which parts work well for us and which parts need to be changed.

The Control Model

An aspect of personal philosophy with special importance to clinical practice is our attitude toward control. Through the influence of Western culture in general and medical culture in particular, we often perceive being in control (of diseases, patients, and the health care team) to be the ideal state (Table 6-1). We use specific intellectual tools for gathering and applying knowledge: reductionism—“Sickle cell anemia is attributable to the substitution of a single nucleotide;” linear causality— “A causes B;” and generalization— “Asthma responds to bronchodilators.” All have a distinctly controlling, outcome-oriented focus, that is, to manipulate A so as to control B. Although this approach has led to important technological advances, it also has important adverse consequences.

The control model creates unrealistic expectations that limit our opportunities to feel successful. Consider, for instance, how our expectations of good control in caring for a diabetic patient allow us to feel successful only when the blood sugar is tightly regulated. The patient’s blood sugar, however, is influenced by many factors over which we have no control, the patient’s own behavior being foremost among them. We become angry at the patient whose noncompliance stands in the way of our success. If success for us is defined only in terms of controlling disease, we are precluded from feeling successful in many, if not most, situations. Accepting responsibility for outcomes over which we have little or no control is highly stressful and leads us to feel helpless, anxious, and angry.

Our quest for control also creates distance and detachment in the patient–clinician relationship, which, as we have already seen, is an important factor in professional satisfaction. A strong orientation toward control leads to hierarchic relationships. This, coupled with the reductionism and labeling inherent in medical thinking, turns patients into objects, and we find ourselves working more with things—organs, diseases, medications, and tests—than with people. We, too, become depersonalized in this process, leaving no room for our own subjective experience.

The Relational Model

An alternative philosophy that avoids many of these problems emphasizes relatedness rather than control. This model does not reject the insights of reductionism, but rather builds on them by adding an appreciation of context and relationship. Therefore, although A may seem to cause B, there are also other mediating factors and bidirectional interactions (A and B influence each other). For example, the tubercle bacillus causes tuberculosis, but not everyone who is exposed to this bacterium becomes ill; environmental and socioeconomic factors also contribute to the process. The illness, in turn, affects those contextual factors; no portion of the system exists in isolation.

In the relational model, we seek to be with and to understand the patient in a number of dimensions simultaneously—biological, experiential, functional, and spiritual. As we come to understand patients’ experiences, we may or may not identify opportunities to recommend strategies or undertake treatments to ameliorate their suffering. We are mindful that patients are ultimately responsible for their own lives; they may or may not accept our suggestions. In some cases, we may have no suggestions or treatment to offer, but we can still find success in offering, in the words of Arthur Kleinman, “empathic witnessing,” honoring the patient’s need for connection—a healing intervention in its own right.

This relational model helps us avoid unrealistic expectations of ourselves. It offers us the opportunity to feel successful in situations, such as untreatable illness or a patient’s refusal to accept our good advice that would seem like failures under the control model. The relational model also leads us to more effective action. In contrast to the control model, which attends exclusively to outcomes, this model calls for explicit attention to process, to the quality of communication, and to the values enacted in the way we work together. Paradoxically, it is by letting go of outcomes and focusing more on making the process as good as possible that we achieve the best outcomes. The relational model also gives us more room to look outside ourselves for guidance and solutions—and to admit our own limitations or powerlessness.

Whereas the control model creates barriers between clinicians and patients, the relational model keeps us closer to the experience of both our patients and ourselves, thereby increasing the opportunities for our work to be meaningful and decreasing the potential for frustration, alienation, and burnout.

There are a number of skills that can make the difference between depletion and thriving in practice.

Time Management

These skills are essential both within the office visit and in arranging work schedules. For example, negotiating an agenda at the start of each visit focuses attention on the issues that are most important to the patient and the clinician, minimizes time spent on unnecessary tasks, and drastically reduces the frequency with which new topics emerge late in the visit (“Oh, by the way, Doc, I’ve got this chest pain …”) that lay waste to office schedules. Informing patients at the outset how long their visits will last and reminding them a few minutes before ending allow them to share responsibility for using time effectively. On a more global level, time-management skills can help preserve the balance among work, family, community, and recreation that is so important to life satisfaction. Keeping time logs for several days can help us discover whether we are apportioning our time in accordance with our personal goals and priorities. Time logs can also point out time wasters in daily work habits and help us devise more efficient office procedures.

Communication

Given the important contribution of the patient–clinician relationship as a source of meaning, the communication and relationship skills described elsewhere in this book become critical tools for well-being as well as for good patient care. Learning to be with the patient requires broadening the goal of the interview from making a diagnosis to understanding the story of the patient’s illness as a lived experience. We need to understand the meaning of the illness to the patient—why this disease in this particular patient at this particular time, how it is affecting the patient’s function, and what role it might be playing in the patient’s life. Thus, we need skills for eliciting deeper levels of patients’ stories and responding to their emotions. As we become more able to do this, it becomes apparent that there are no longer routine or uninteresting cases—each patient is unique. The patient’s personhood enriches our own.

Coaching & Negotiation

Sharing responsibility more effectively and more realistically with patients requires both coaching and negotiation skills. Specifically, we must know how to facilitate patients in articulating their own values, goals, and opinions, including their feedback about their medical care. We must be willing to relinquish our traditional—and burdensome—role of unquestioned authority and adopt instead a more flexible stance, trying to combine synergistically our own knowledge of medicine with patients’ knowledge of themselves and the patterns, problems, and balances of their daily lives. We must learn to see patients’ increasing capacity for gathering information and making their own decisions as a valuable resource and a sign of our success rather than as a challenge to our competence and authority. Knowing how and when to set firm boundaries without being judgmental and how to discuss communication and relationship problems openly can help resolve impasses with many seemingly difficult patients, making their care less frustrating and more rewarding. We also need to know how to recognize when we are over-functioning, hooked by unrealistic hopes or expectations of control, and to respectfully, but clearly, give responsibility back to the patient.

Self-Reflection & Self-Care

We need to be able to reflect on our own feelings and actions, to acknowledge our vulnerabilities and needs, to seek and courageously follow our sense of calling, and to act in support of our own health. Rather than judging and shutting out such feelings as anger, attraction, or insecurity that inevitably arise in us, we can learn to accept them with self-compassion, to manage them appropriately, and to harvest from them insights about ourselves and our patients. Through solitary reflection and honest conversation with trusted colleagues (informally or in more organized formats such as Balint groups, workshops, executive coaching, or psychotherapy) we can attend more closely to what our hearts are telling us about the state of our lives. Shedding the mask of omnipotence and invincibility and recognizing our vulnerabilities are essential for working amidst uncertainty and coping with mistakes. And finally, we can thoughtfully examine our lifestyle choices, starting with our work hours. Simplifying our material needs to reduce financial pressures can give us more time for exercise, healthy eating, social interaction, pursuing diverse interests, and whatever else it is that truly gives us joy and meaning.

Collective Self-Care

Over the past 10–15 years the attention given to clinician well-being has grown enormously. Early pioneers such as the Foundation for Medical Excellence and the Institute for the Study of Health and Illness have been joined by larger mainstream organizations such as the American Medical Association (AMA), Canadian Medical Association (CMA), and American Hospital Association in offering programs and resources. There is now a biennial international conference on physician well-being sponsored by the AMA, CMA, and British Medical Association. Nearly all hospitals and many medical societies in the United States and Canada offer wellness programs of some sort and excellent online resources are available.

These programs may be effective not only by virtue of the education they offer but also because they convene healing communities. Most practitioners experience high levels of isolation, even when they work as part of busy group practices. They seldom talk about their patients in any depth with colleagues and almost never talk about their own responses and struggles. Participants in a program on mindfulness and communication valued the connection and validation that came from honest conversations with peers (“I’m not the only one”) as much as the new skills and insights that they gained. The most effective self-care may be that which we pursue in concert with others.

Our workplaces have an important effect on our well-being. The local culture of the institutions in which we work—be they hospitals, individual practices, or medical communities—subtly reinforces values through both formal educational processes and everyday policies and practices. The local culture can determine whether we feel able to disclose uncertainty and vulnerability to one another or feel constrained always to maintain the iron man façade; whether we act and negotiate collegially or retreat into always protecting our “turfs” against other disciplines; whether we can discuss mistakes and ask for help or be forced to work in perpetual isolation; whether we receive encouragement and respect for setting reasonable limits on our workload so we can be present in our families or feel shamed for being “lazy.”

Surveys from both industry and academia have identified common characteristics of organizations with greater employee well-being. Organizational cultures that promote employee trust, engagement, and thriving are characterized by collaborative decision making, ethical behavior toward employees and customers, mutual respect between members, growth, and learning toward increasing competence, and a reasonable work–life balance. In contrast, organizations that ignore employee input, are riddled with political favoritism, and tolerate rudeness appear to breed employee apathy, cynicism, and burnout. Employee trust and engagement—i.e., commitment to the organization—correlate positively not only with the well-being but also with the organizations’ financial and operational success. Studies of hospital work environments have yielded similar results.

Creating environments that support relationship-centered care is a large topic; a few general principles must suffice for this discussion:

• As clinicians, we tend to treat patients in the same way that we ourselves are treated within our institutions. Core values such as respect, partnership, honesty, and accountability must be explicitly articulated and embodied in institutional policies and procedures. Clinicians and administrators alike may need to learn new communication and relationship skills, and redesign processes for making decisions and maintaining accountability.

• The principle of reciprocity governs much of human interaction. Mutually helpful behavior and camaraderie creates a virtuous cycle in which employees thrive and succeed. Reciprocity can also tear an organization apart. A few acts of unchecked incivility can spiral into widespread acrimony. Incivility at work has been linked to a lack of job satisfaction, decreased organizational commitment, and impaired job performance. Organizations can foster civility through hiring policies that specifically screen for interpersonal skills, team-development activities, and codes of conduct with meaningful (and respectful) accountability. Respecting values and attending to the quality of process must be embraced as the most effective means to high-quality outcomes at the organizational level, just as at the clinical level. This requires a departure from traditional, hierarchical approaches of top-down decision making and control of the work process.

• Clinicians in the “front lines” providing patient care, but not in leadership positions, may feel helpless to change a dysfunctional organization. The feeling of helplessness reflects the false belief that only the leaders are responsible for organizational culture. Leaders co-create an organizational culture with followers. If leaders are unable or unwilling to promote teamwork, clinicians need not passively react by fragmenting into insular, self-serving cliques. Instead, clinicians can choose to reach out across specialties and disciplines to promote a culture of mutual respect and accountability. Offering appreciation and “going the extra mile” for colleagues, particularly from other disciplines, can begin a virtuous cycle of civility. Physicians unhappy with an organizational culture can work on “being the change” they seek. Finding like-minded colleagues can create a mutually supportive group that catalyzes creation of a better culture.

• We can replace the current culture of rugged individualism with a culture of teamwork, accountability, and mutual support. Support groups for all staff, including physicians, may encourage self-awareness, increase sensitivity to patients’ concerns, and diminish the isolation and depersonalization that both characterize and accelerate burnout. We can be vigilant to ways in which the local culture reinforces work addiction and inhibits collaboration and work to improve it.

In this time of concern about health care costs and patient safety, clinicians, administrators, patients, and families need to work together in partnership to redesign our medical institutions, making them more respectful and humane, more collaborative in terms of care, and more responsive to the needs of the people they serve and the people who work within them. Clinical outcomes, financial performance, patient satisfaction, and staff satisfaction have all been associated with factors that create healthy work environments for health care providers; thus, institutions have a direct stake in maintaining the well-being of their clinicians and staff.

Whether the rigors of clinical work become sources of meaning or exhaustion depends on a number of factors. We must be able to know and address mindfully the personal needs that affect our work. Fulfilling our needs for connection and meaning is particularly sustaining. Unrealistic expectations of control interfere with connection and confront us with an ongoing specter of inadequacy and failure. Instead, we need a more mature perspective of balance, acceptance, and relation. We need skills for working with uncertainty, sharing responsibility, and promoting relationship. We need personal disciplines of reflection and self-care, supported by participation in a healing community of peers. We must become more attentive to the values expressed subliminally but powerfully in our work environments and begin to make necessary changes so that these environments call forth the best and healthiest of what we have to offer, both as professionals and as human beings. These approaches can help us to appreciate fully the privilege of caring for patients and to realize our best potential for personal fulfillment and growth.