What is This Wellness You Speak Of?
What is wellness? How do we define it? According to the Merriam-Webster dictionary, wellness is "the quality or state of being in good health especially as an actively sought goal." But does wellness just mean we strive to be physically "well" with exercise and diet? I would argue that wellness is deeper than just being physically well. The American College of Emergency Physicians (ACEP) defines seven "spokes" to wellness: the occupational spoke (are you satisfied with your career); the emotional spoke (what we are feeling); the physical spoke (exercise/diet/sleep/illness); the financial spoke (being financially secure); the spiritual spoke (finding meaning and purpose in life and in our career); the social spoke (our relationships); and the intellectual spoke (what mentally stimulates us). This definition is a much more comprehensive one.
Is it too comprehensive? Maybe wellness is just a lack of burnout. Then what is burnout? Burnout has been defined by a constellation of symptoms: loss of enthusiasm for work, feelings of cynicism, and a low sense of accomplishment. How many of us have felt some of this during medical school? During residency? During our life after residency? I could say yes to ALL THREE! I had days in medical school where I was lacking enthusiasm for studying, where I was convinced that all the work I was putting in didn't matter, that I would never graduate despite all the studying. I had days in residency where I didn't want to be on shift, couldn't find any joy in patient care, and couldn’t offer my patients any empathy. I had days where I was sick of the frequent flyers, and I just wanted to discharge people without listening to their sob story for why they needed narcotics. Am I the only one? Nope. Burnout is a huge problem in medicine. When we look at burnout by specialty, emergency medicine (EM) is the HIGHEST!!! Somewhere between 60-70% of EM physicians report symptoms of burnout. Do we have a burnout epidemic on our hands? Or on the contrary, does burnout even matter?
I would argue that burnout has some pretty significant consequences. Burnout has been showed to affect our patient care. In a study of EM physicians, higher burnout rates were associated with physicians ordering additional lab testing, admitting or discharging patients with suboptimal care to make the ED more manageable, not appropriately treating pain, and not communicating effectively with other physicians or with the patients and family members (see the figure below). Burnout affects our patient care. It affects the cost of health care.
Burnout affects us, as providers. Each year, four-hundred physicians commit suicide in the United States. This number is TWICE the national average. It is the equivalent to three or four graduating classes from a medical school each year. And sadly, because of our greater medical knowledge and access to means, physicians have a much higher rate of suicide completion than the general public. Medical students have equal risks for burnout, depression, substance abuse and suicide as physicians. Female physicians attempt suicide far less often than females in the general population, but their completion rate exceeds the general population by 2.5 to 4 times.
So how do we prevent burnout? How do we find wellness? The answer is resilience. Resilience has been shown to be the central element to physician well-being. It is our ability to respond to stress in a healthy and adaptive way. It is what allows us to bounce back from adversity. If we are resilient, not only do we bounce back rapidly, but we grow stronger in the process. Resilience is something we have to cultivate to help us prevent burn out. I think of resilience like Tigger the tiger. We have to bounce back and bounce better. So how do we cultivate this resilience? How do we learn to bounce?
First we have to be SELF AWARE. We have to be able to recognize when we are adversely affected by stress instead of ignoring warning signs – fatigue, irritability, feeling outside our comfort zone. Self-awareness is NOT innate in us as physicians. In fact, I would argue that our training has TRAINED US to ignore the self-awareness voices in our head and cues from our body. We ignore the voice saying “hey you need to rest.” We blare loud music to tune out the voice that says, “hey you need to relax.” We take extra shots of caffeine to ignore our body's plea for sleep, and then take sleeping pills when our overtired body cannot fall asleep on cue. Medical education and residency trained us to lose self-awareness. So how do we become self-aware again?
We all recognize the importance of debriefing after a medical error. Or after a patient dies. Or before you call time of death in a code. Debriefing is part of our medical training. But how often do we debrief with our self? Try taking a pause on shift for a time-out, a mental break (and maybe a bathroom break too). Use reflective questioning when talking to yourself, for example, “What am I assuming about this situation that may be inaccurate?” Debrief on the ride home – How am I feeling? How was that shift? Don't allow that "Negative Nancy" voice in your head (we all have one!) to start up with criticisms, but use this time to explore your feelings and thoughts. Try to understand your own somatic, emotional and cognitive experiences.
Another way to increase our self-awareness is to consider mindfulness based stress reduction. Mindfulness teaches you to calm your mind and body to help deal with stress or illness. It helps you to focus on the PRESENT moment paying close attention to that one thing, instead of getting lost in worries, regrets, failures, etc. It is a type of meditation. (I recommend the app, Headspace, which has worked well for a novice like me).
So first we have to be self-aware, and then we have to practice SELF-CARE.
This is truly a foreign concept to us, as medical professionals. Our job is to care for others. We are trained to take care of others first, to put the needs of our patients before our own needs. How many times in medical school did a professor tell you to take the day off of studying to take care of yourself? Never for me. In residency - did you get taken off a day of work because you needed to rest? To recuperate? Probably not. We are terrible at this. It is NOT a part of training in fact it is the ANTITHESIS of what we are told to do.
I know this from experience. I underwent in vitro fertilization to conceive and ended up with an ectopic pregnancy. The day I was diagnosed, I had the residency over for a journal club I was hosting and then went to my overnight shift. The day I took methotrexate to terminate my ectopic, I also worked an overnight shift. When I diagnose a woman in the ED with an ectopic, would I ever tell her, "Oh you can go to work tonight and suffer?" Nope. I would give her a work note and encourage her to use it. I would tell her to rest and to take care of herself, physically and mentally. I would tell her I was so sorry. But I NEVER considered asking a colleague to work for me. I NEVER considered canceling my obligation to my residents. I never considered letting myself rest and deal with what I was going through mentally and physically (methotrexate sucks!). Studies show that we, as physicians, find it difficult to ALLOW ourselves to participate in activities that improve our self-awareness and our self care despite recognizing that they improved our resilience and our ability to provide better patient care. Why is this statement true?
Why are we impeding our own wellness? My guess - we are afraid to show any signs of weakness. In the "Good Ole Boys" club that WAS (and hopefully no longer is) medicine, suffering was part of the initiation. "I went through it, so you should too" was the mentality. Needing a day off, needing to sleep, needing a minute to reflect on your thoughts, that need would have been a sign of weakness, a sign that you did not belong. We have to change this culture. Studies show that physicians who care for themselves do a BETTER job of caring for others and are less likely to commit errors, be impaired or leave practice. Like the flight attendants say in their safety lesson, we need to put on our own oxygen mask before assisting others. We have to change the culture of medicine so that self-care is a priority, allowing us to provide the best patient-care possible.
Stay tuned for Part 2 of this series that focuses on Self-Care.