Attending

by Ronald Epstein

  The problem is not only overwork; it’s crisis of meaning, resilience, and community. The toxic combination of high responsibility, low sense of control, and isolation sets the stage for a sense of exhaustion, powerlessness, and helplessness.15 The stresses due to a dysfunctional health care system and the culture of medicine are real, and the health care community has an obligation to fix them. Putting clinicians in morally compromising situations, installing electronic health record systems that are sculpted around billing rather than good patient care, and placing increasing pressure on clinicians to see more patients without regard to quality are practices that need to change.

  THE INNER ENVIRONMENT

  But changing the health care system won’t solve it all. It is important to recognize that burnout has affected clinicians for centuries, and important causes of burnout reside within clinicians themselves. For the first time in memory, perhaps precipitated by the perfect storm of the heavy burden of suffering in the clinic and the increasing dysfunction of the health care system, some doctors are finally paying attention to their inner environment in a systematic way and finding ways to bring greater presence and resilience to the practice of medicine.

  Imagine you’re choosing a doctor or that you’re hiring a physician to join a practice. What qualities would you want the doctor to have? When I ask this question of the general public or groups of clinicians—no matter what their profession or specialty—the answers are always the same. They want someone who is altruistic and hardworking, has excellent technical skills, is knowledgeable, has good judgment, is empathic and caring, and has equanimity in the face of tragedy and loss.

  Yet, even these very desirable personality characteristics make doctors psychologically vulnerable.16 Those who are detail oriented can become compulsive, subjecting patients to too many tests and procedures “just to be sure” and waking at night because they think that they may have forgotten something.17 Altruistic, service-oriented doctors tend to overcommit and then get exhausted trying to follow through. Truly skilled doctors might believe that they can do it all—feeling omniscient, omnipotent, and unable to admit mistakes—a dangerous combination in medicine. Or they feel insecure. When physicians are asked if they ever feel like an impostor, a remarkable percentage (up to 43 percent) say yes.18 Of all personality factors, the most closely associated with burnout is rigidity. When unaware of his rigidity, a doctor might insist that his is the single best approach for each problem, and blame his frustration and ineffectiveness on other people (including patients) rather than looking inside himself.19 Even being empathic takes its toll when doctors don’t recognize their secondary trauma and negative emotions.20 Disturbingly, some clinicians wear stress and burnout as badges of honor, part of the macho culture of medicine that further compounds the anguish and isolation of distressed clinicians.21 Too often, self-awareness is lacking.

  WHY SOME PEOPLE DON’T BURN OUT

  Things don’t have to be this way. Some clinicians, albeit stressed, fare better than others. They not only cope and adapt, they grow in response to challenges so that the next challenge becomes more tractable. In fact, the right kinds and the right amounts of stress can make us stronger—“stress inoculation.” Bones and muscles and brains and hearts grow stronger—more resilient—when you exercise and stress them in the right ways. Bearing weight strengthens bones; without stress, they weaken and crumble. Muscles, too, need exercise or else they atrophy. We thrive on mental challenges, and without them we become dull. Resilience is, in Nicholas Taleb’s words, becoming “antifragile.”22 We develop resilience best when we are at our growing edge—just a hair beyond our capacities.

  We often think about resilience as the capacity to get through a hard time. However, in high-stress professions, the pressures are ongoing and crises are unpredictable; real resilience is being prepared to be unprepared. Only in the past thirty years have psychologists focused on understanding resilience as a positive attribute and not merely a reaction to trauma. However, much of what we know about resilience is from studies of animals in laboratory environments and people who have endured interpersonal violence, a debilitating injury, war, torture, or natural disasters, not those who have voluntarily chosen a lifetime of work that they knew would be emotionally demanding.

  Psychiatrists Steve Southwick and Dennis Charney interviewed former POWs, Special Forces instructors, and civilians who had experienced severe psychological traumas such as rape, sexual abuse, the loss of a limb, or cancer.23 They found that in spite of these extreme events, remarkably few developed depression or post-traumatic stress disorder.24 Southwick and Charney identified ten “resilience factors” that would make sense to most of us: realistic optimism, facing fear, moral compass, religion and spirituality, social support, role models, physical fitness, brain fitness, cognitive and emotional flexibility, and a sense of meaning and purpose. Personality is important too. Just as some personality factors are associated with greater risks of burnout, others confer greater resilience. Psychologists Richard Ryan and Edward Deci point to three qualities: the ability to form warm and caring relationships with others—so-called secure attachment—a sense of personal autonomy, and perceiving oneself as competent and up to the task.25

  Resilience is mirrored in our biochemical and genetic makeup. Those who thrive despite severe trauma are biochemically different from their less resilient peers. They have lower levels of stress hormones and neuropeptide Y, the “anxiety” neurotransmitter. They have higher levels of serotonin, which is associated with positive mood, and higher levels of dopamine in the reward centers of their brains. They have higher levels of “brain-derived neurotropic factor,” which directs the brain to grow new neural pathways.26 Because resilience seems to be affected by caring and trusting human relationships, most likely oxytocin—the hormone associated with love and affiliation—is also involved. It appears that not only do resilient people trigger the release of higher levels of these neurotransmitters and hormones, but they also have more receptors for them. Signals are more easily transmitted. And sometimes the receptors are of a different subtype altogether to which a neurotransmitter binds more avidly.

  We are now just learning what might lead the body to produce more of these substances and to place more—and more avid—receptors on nerve cells. Just as I discussed in chapter 3, it’s epigenetic regulation; social epigenetics to be more precise. Genes that encode for neurotransmitters and receptors turn on when you’re in a supportive and safe environment and turn off when you feel vulnerable and traumatized. Those experiencing secondary trauma, isolation, and lack of support are literally—on a biochemical level—less able to muster the resilience they need. This means that doctors who aren’t allowed time to debrief after a patient death or who submit to meaningless bureaucratic tasks are likely to become less and less resilient. Admittedly, resilience (and gene regulation) is to some extent influenced by past events which cannot be changed, such as prenatal influences and early childhood traumas. But it is tantalizing to consider recent research by psychologist Douglas Johnson at the Naval Health Research Center in San Diego; his research group demonstrated the mindfulness programs for military recruits promoted self-awareness and resilience and, in doing so, enhanced their “healthy” gene expression.27

  TIPPY AND UNFLIPPABLE

  How do people become more resilient? Part of the answer has to do with mental stability. I am not an expert kayaker, but I do enjoy it. A few years ago, I bought a kayak. In the store, the salesperson talked about primary instability and secondary instability. At first, I was confused. Why would I want to buy a kayak that was unstable? He explained. Kayaks with primary instability are more maneuverable, and it takes less effort to guide them around rocks, sharp bends, and standing waves in a river, but they also feel tippier. Secondary instability refers to how easily the kayak will capsize. Because I wanted a boat that was responsive and I had no interest in getting wet when I least expected it, I chose a kayak that had quite a bit of primary instabilit
y and a fair degree of secondary stability.

  Once I had it in the water, it took some getting used to. It felt really tippy. It took me a while to distinguish primary from secondary instability and to have the confidence that the kayak wouldn’t flip over. With time, I came to tolerate feeling “unbalanced” and I could maneuver the kayak more effortlessly, and I realized that fighting the primary instability put me at greater risk than using it to my advantage. I even came to relish the tippiness. I realized that I had made progress when one day, kayaking across a lake with a strong crosswind, I leaned into the wind, so much so that I was at a thirty-degree angle, water coming way up one side of the kayak. I was moving in a straight line and the kayak didn’t flip.

  Mental stability works the same way. It’s a dynamic equilibrium. You’re never completely in balance. Just as I enjoy the tippiness of my kayak, I’ve come to enjoy the unpredictable and chaotic corners of medicine; the next patient could be a day old or one hundred years old, and the patient’s issues could be trivial or life threatening. There’s a certain off-balance thrill to navigating unexpected twists with aplomb.

  REMINDERS

  In difficult times, I keep coming back to three important “reminders” about resilience. The first is that resilience is a capacity that can be grown.28 With training, you can gain more control over your behavior and well-being, relate to stress in healthier ways, and feel differently about yourself. Resilience doesn’t mean hardening the heart; quite the opposite, resilience is about adopting lightness, a sense of humor, and flexibility. You change your personality, just a bit, becoming more focused, more tippable, and less flippable. Participants in our year-long mindful practice program did just that. Over time, they scored higher on two of the Big Five personality factors that relate to focused attention and mental stability—and the changes endured.29 While the party line in personality psychology had been that personality was immutable after age thirty, more recently researchers have studied people whose personalities had changed throughout their lifetimes. Those who changed had three qualities: they were adept at observing themselves, observing others, and listening attentively.30 In short, they were mindful.

  The second reminder is that well-being is about engagement, not withdrawal. This is not intuitive. If a situation is pleasant, it makes sense to stick around and want more. But what if a situation is unpleasant? It’s only natural to want to get away and avoid people you find difficult. While these survival strategies might help in the short run, the same old problems and their maladaptive solutions are still there. Preventing burnout and developing resilience have more to do with presence than escape.

  The third reminder is that mindfulness is a community activity. When I was in Bhutan a few years ago, I walked past hermitages scattered high above tiny Himalayan villages in some of the most isolated spots in the world, in caves and steep ravines, beside glaciers and atop three-thousand-foot cliffs. The monks doing three-year-long solitary retreats might not even see the villagers who would bring them food each week, yet they could do what they were doing because of the knowledge that the villagers were supporting their efforts and that other monks in other hermitages were engaged in a similar effort. Even in isolation they felt—and were—part of a community.

  The same is true for the rest of us; we need a sense of community to sustain a mindful vision. Yet, over the past few years, hospital doctors’ lounges have closed, personal relationships among clinicians have eroded, and in the outpatient setting clinicians know each other only as faceless characters sharing an electronic chart. Creating community requires visionary leadership, yet this vision and the leaders to promote it are lacking in the current health care environment.

  WHAT IS WELL-BEING, ANYWAY?

  I bristle when people say that the key to well-being is achieving “work-life balance.” Those who see “life” as everything outside work, necessitating “balance,” implicitly assume that when you’re at work, you’re not fully alive, a sad state of affairs for those of us who are in a profession that is capable of providing such deep rewards (and that takes up so much of our waking existence).31 It reflects a deeper problem, though. By placing the blame for your unhappiness exclusively on things external to yourself (the work environment), you’re assuming that by containing work—by compartmentalizing, pushing it away, or making it “not-me”—you might be happier. This is a trap.

  Marc Lesser recounts a famous Zen dialogue:32

  The monk arrives at the monastery and says to the teacher, “I’ve arrived. Please give me your teaching.”

  The teacher says, “Have you eaten your breakfast?”

  The monk responds, “Yes, I have.”

  The teacher says, “Wash your bowl.”

  The monk understood. What could be more obvious?

  Marc explains that this indirect and somewhat bizarre answer is intended to free the mind from habitual and monocular views of a situation and instead invite you to look at your current experience, right here, right now. Marc comments, “If you were to ask, ‘How can I find work-life balance?,’ I might be inclined to ask if you have eaten your breakfast. . . . And, assuming you have, I suggest you wash your bowl.”

  Marc continues:

  Attempting to achieve work-life balance, as though something is missing or something is wrong (either with you or with your situation), is a set-up for failure, for stress, and for anything but balance. Instead, experiment by bringing your attention to the activities that make up your work. Notice the activities and notice your inner dialogue, the stories you weave, as well as your feelings. Just this act of paying attention can produce positive change—a bit of slowing down, a little more space—opening up the possibility of change, of more calm, even of more appreciation.

  Marc’s answer invites a deeper and more important question: What is well-being, anyway? We know that when people have a deep sense of meaning and fulfillment, the more superficial trappings—what you have in terms of achievement or pleasure—are less important and may even get you off track. We can tolerate long hours and even welcome stress if work intrinsically brings a sense of purpose, satisfaction, joy, and meaning. That deeper kind of well-being, one that’s worth achieving, is what Aristotle called eudaimonia. Eudaimonia is true human flourishing; it results from and leads to being more fully engaged with one’s work in a healthy and positive way33 while recognizing that the world is messy, chaotic, imperfect, and not always pleasant. Pushing away only makes matters worse.

  THE 20 PERCENT RULE

  My wife, Deborah, tells a story about Mary Pedersen, her extraordinary and somewhat eccentric seventh-grade teacher. Deb was thirteen years old and living in Denmark for a year. Mary asked Deb, “Honeylamb”—she really did say this!—“honeylamb, what do you like? What do you like?” Deb was thunderstruck. No one had ever asked her that question. It got her thinking and led her first to writing, then to Renaissance history, then to seventeenth-century music. Fifteen years later, we visited Mary in Denmark (and she called me “honeylamb” too) in her cottage so overgrown with vines and rosebushes that the patio was reduced to an area just large enough for three small chairs. We learned that she had been a Shakespearean actor; in her youth, she left a secure academic path in England to join a theater troupe. While on tour in Denmark, she fell in love and found a job there at an English-speaking school. Although she worked as an artist, an actor, and a teacher until she was seventy, she felt that she never “worked” a day in her life. We should all be as fortunate as Mary Pedersen. Her capacity for joy was infectious, and Deb caught the bug. She too feels that her career as a musician isn’t “work” in the way that most of us think about it, in part because of Mary’s influence.

  Not many of us have had teachers like Mary who remind us to stop and think, “What, in my work setting, gives me the greatest sense of joy, fulfillment, and meaning?” Think about that question for a moment and then consider—here’s the clincher—“In a typical week, how much of my time do I actually spend doing those activ
ities?” It doesn’t have to be 100 percent; few people are that fortunate. Research shows that if physicians spend even 20 percent of their work time in the activities that they regard as the most meaningful, they’re much less likely to be burned out, meaning that they’re more able to tolerate the difficult moments.34 Makes sense, but most doctors—and others who have some control over their work lives—have never asked themselves these fundamental questions. People shouldn’t wait until they are feeling burned out to reflect on what’s most nourishing about their work.

  THE EARLY SIGNS

  Physicians know that it’s easier to manage any illness during the early stages rather than waiting until it is full-blown. They know the long list of late signs of distress—insomnia, depression, chronic pain, migraines, GI symptoms, drinking too much, relationship problems, and more. They know that early signs are harder to detect, so it takes vigilance. Yet ironically, doctors are particularly at risk for not seeing these early signs because doctors tend to be stoical. They think that stress is a normal part of the job, are notorious for delaying seeking care, and for self-medicating.

  An honest self-appraisal is the first step. During workshops, I’ll ask participants to rate their burnout using Maslach’s burnout scale,35 or the simple diagram on the next page. You’ll see a list of attributes of burnout and well-being and a scale of 1 to 10. Try it. Are you a 1, a 5, or a 10? As you’re doing this, stop, think, and feel the impact of your work environment on your life. Perhaps this might be the moment when you can no longer underestimate your distress.