Professional Health and Wellness: “Be a Grace Note”

Becoming a physician is to embark on a journey of transformation that produces an almost alchemical change in identity; from a person who wishes to be a physician, into a person who is a physician. It is a journey where one walks the path of mastery moving from novice to expert, becoming a new person along the way. It’s a journey of “Awe” that is trodden on a pathway as arduous and wondrous as any quest described in old myths and ancient legends.

“Awe” is an interesting word. It contains both the feeling of a surprising sense of reverence and wonder, and a powerful, overwhelming feeling of dread. In fact there are two words that have the same definition yet have very different meanings: “awesome” and “awful.” The entomology of both mean “full of awe,” yet one is about feeling sheer overwhelming joy and the other about feelings related to dread, despair, and disaster.

Medical students, fellows, and practicing physicians live in a world filled with awe in all its various forms and with all its continuum of meaning: it is like balancing on a tight rope: awesome on one side, awful on the other. Becoming a physician is no ordinary adventure. It is easy to get lost on this journey. The steepness of the climb and the responsibility one has for the lives and health of patients feel overwhelming and exhausting at times. Endless hours of studying; long hours in the hospital or other clinical settings; running toward what others run away from; disease, emotional distress, difficult sights and smells, death, dying. All this and the need for continual peak performance are but a few things that make this path so very difficult.

Walking this path can lead to a life that is wonderful, rewarding, and deeply meaningful. Few individuals are as privileged as physicians to connect with people at the nexus of the most meaningful junctures of their lives, shepherding them through births, sickness, healing, tears of joy and sorrow, and toward health and cure. Physicians touch hearts and lives in ways that few can imagine. Yet, if we don’t attend to our own lives and hear the cries of our own souls, the consequences can be dramatic and tragic.

In fact, Lotte Dyrbye, MD, MHPE, FACP, and colleagues (Dyrbye et al. 2014) found that at orientation, medical students are psychologically healthier than their age comparison peers while shortly thereafter levels of their stress rate and burnout go up.

Srijan Sen, MD, PhD, and colleagues (Sen et al., 2010) have found that interns at orientation across specialties have rates of depression of 3.9% and those rates rose to over 25% at three months and stayed constant for the rest of the year. The burnout rate of practicing physicians exceeds that of the general population (Shanafelt et al., 2019). And most tragic of all, it is estimated that up to 400 physicians at all stages of the profession take their own lives by suicide annually.

The nation has taken notice of the potential toll the journey can exact and has taken steps to address the issue. The Institute for Healthcare Improvement’s concept of the Triple Aim has been expanded by some to include a fourth element: Attaining Joy at Work. The National Academy of Medicine has established an Action Collaborative on Clinician Well-Being to provide tools and inspiration to prevent caregiver suicide, burnout, depression, and stress and to increase well-being and joy in practice.

Thomas J. Nasca, MD, MACP, CEO, and President of the ACGME, has noted:

1. Physicians who care for themselves provide better care for others.

2. They are less likely to make errors or leave the profession.

3. Habits of practice to promote well-being and resilience need to be cultivated across the continuum.

4. A healthy learning environment will lead to improved health care for both providers and patients.

The importance of attending to the “you” along this path of mastery cannot be overstated. You must pay attention to you … as much as you do to your patients if you want to become the physician your patients truly want and truly need. In order to do that while you are working so hard and learning so much, there are at least three areas you need to focus on with intent and vigilance:

1. Taking care of “you.”

2. Connecting with others.

3. Connecting to meaning.

Taking care of “you” is both a confession and a task. It starts with admitting you are human, and you have the same human psychological, physiological, and emotional needs that any human has. Recognizing this truth, you need to make sure that to the best of your ability, you attend to these needs. Taking the time to take your own “pulse” relative to self-care is vitally important. Exercising, eating nutritiously, sleeping when you can, learning and practicing letting-go techniques like meditation, yoga, mindfulness, that elicit what Harvard physician Herbert Benson, MD, called the relaxation response. You also need to practice challenging thoughts that distort reality and might otherwise prevent you from reaching your goals by leading to self-defeating behavior like maladaptive perfectionism and imposter syndrome. It is important to celebrate your strengths and work toward increasing them. It is equally important to acknowledge your flaws and work toward reducing them. Appreciate who you are and the uniqueness you bring to the profession. Grow, develop, and cultivate mastery. Reduce the urge to punish yourself for being human. You know the golden rule: “Do unto others as you would have them do unto you.” Turn it around—“Do unto yourself as you would do to others.” Most important, never, ever hesitate to reach out when you need help, support, and care. It is not a sign of weakness to reach out. Rather it is a sign of strength and maturity. No one has ever walked the path of mastery without falling and needing help and assistance to rise again.

This brings us to the second point, the importance of connection. Research has shown that human connection and positive social relationships are crucial to joy and well-being and that one of the most insidious features of burnout is loneliness. Connection has been found to be one of the most important factors in work happiness and satisfaction. It is important that you create and nurture positive connections with colleagues, role models, faculty, healthcare team members, friends, loved ones, helpers, and so on; seek those with whom you can interact with at the deepest levels, sharing your joys, frustrations, dreams, and fears in order to create the network of support that you’ll need to walk this path and navigate it well. It’s also important that you be that colleague, role model, and friend to others in your life in order to begin to shatter the code of silence, and help create the connected environment that fosters the health of individuals, teams, programs, and institutions, in order to better care for the patients you serve.

The third element is crucially important. Victor Frankel reminds us in his seminal work Man’s Search for Meaning that the primary positive motivation in life is found through meaning. A psychiatrist and contemporary of Sigmund Freud, Frankel survived a horrific experience in Auschwitz, a concentration camp, during World War II. From intense reflection on his bitter experience, he concluded that meaning, described as giving ourselves over to something greater than our self, is essential to surviving and thriving in one’s circumstances. When the journey gets long and starts to weigh on your soul, it is important to remind yourself (in self-reflection or with others) why you began this journey in the first place. Perhaps it was the healing connection with patients, the calling to do something special for the world, the desire to join with others in what are citadels of awe. To be where people take their first breaths … and their last … Where people cry tears of joy for a baby born, a cure found, a wound healed. Where people cry tears of sorrow for life altered, a cure not yet discovered, a loved one’s fate. This is what it means to be in a place of awe. In every instance you are there in your white coat (metaphorically or otherwise), no matter your specialty, caring for someone every step of the way. A touch of concern, a kind word, a compassionate presence; you are a symbol of hope and love. In the broadest sense of the term, your presence with your patients is to stand on holy ground.

All of us are writing a narrative with our lives, authoring a novel, a play, a short story with “me” as the protagonist. Only rarely does the pen get shared. The sharing of the pen to help co-author the books of your patients’ lives comes during the most thunderously meaningful time of Awe in their lives. That co-author will be you. You will help write the next sentence; the next paragraph; the next chapter. That gift you give and that you receive is what it means to work as a physician. I can’t think of any job more deeply meaningful than that.

It is now time to embark on this journey. This book will help you in both concrete and profound ways. It contains an essential roadmap for success. Remember as you walk this wonderfully transformative road to take care of yourself, connect with others and stay focused on the North Star; in essence, the meaning of medicine in your life.

I leave you with this. LaSalle Leffall, MD, was one of the most important physicians of our time. A master surgeon, a master educator, and among other achievements, the first African-American President of the American College of Surgeons and the American Cancer Society. He was a Full Professor and Chairman of the Department of Surgery at Howard University‘s College of Medicine. He died on May 25, 2019 at the age of 89. I had the great pleasure to meet, share a meal, and talk with him at a white coat ceremony in the early part of the century, and he shared a story with us that I have never forgotten and that I will paraphrase here. Not only was Dr. Leffall a surgeon’s surgeon and a beloved master physician to his patients and colleagues, he was also a great lover of jazz. One day he was listening to a recording of John Coltrane with his good friend, the jazz great, Cannonball Adderly. At the end of the piece Cannonball Adderly asked Dr. Leffall a question. “Did you hear that?” Dr. Leffall exclaimed, “Oh yes. What a wonderful record”. Cannonball Adderley replied somewhat quizzically, “No I mean - did you hear that; the grace note?” “What’s a grace note?” responded Dr. Leffall. Cannonball Adderly replied something like this (I may not recall the exact words). “A grace note is one extra note that the musician puts in the measure that does not affect the rhythm of the measure. It’s a beautiful gift, a little something extra, just to delight the soul of the listener.” Dr. Leffall told us that day that this is a metaphor for what it means to be a physician; to be a grace note to your patients by doing your best, and then adding that little extra something to let your patients know you genuinely care about them, not just for them. I ask you to extend the metaphor as you take this arduous next, yet extremely rewarding and wonderful journey. Be a grace note … to your colleagues, to all members of the healthcare team, to your faculty, to your patients, and to yourself. If everyone who has read this far in this books forward commits to being a grace note, the “awful” times become not only bearable but also can galvanize a community, and the “awesome” times become transcendent.

Be a Grace note. Happy reading. Have a wonderful joyous journey.

Timothy P. Brigham, M.Div, PhD.

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