Issues in Depth

A Meaningful Work

Vital Signs » Winter 2017

Uniting in the face of a trying profession, physicians come together to find improved resilience and meaning in their work

Our drive to continue in the face of struggle and difficult times is a hallmark of what makes us human. For ourselves, and for those around us, this march forward through the fickle headwinds of life is a source of inspiration.

Our ability to work together, to hold others up, and to encourage each other is another one of our great strengths. But sometimes, we don’t have to be so vocal — all we have to do is listen. Quietly supporting a friend or colleague can lift their spirits and help them weather the storm.

In the past few decades, physicians dealing with the difficulties of their profession have realized these truths. They’re coming together, both for themselves and the patients they treat.

“There’s a deep river of meaning that runs through stories of physicians—it’s untapped,” said Evangeline Andarsio, M.D., ’84, director of the Remen Institute for the Study of Health and Illness (RISHI) at the Boonshoft School of Medicine. “There’s something about being with other doctors. It’s a safe space.”

Burnout and compassion fatigue

Numerous studies back up the fact that it’s not easy being a doctor.

A 2012 study surveying more than 27,000 physicians, published in Archives of Internal Medicine and led by doctors at the Mayo Clinic, found that 45.8 percent of the respondents reported at least one symptom of burnout. Professional burnout is characterized by a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.

Other studies have found higher percentages of physicians who reported having at least one burnout symptom. Those working at the front lines of care—family medicine, general internal medicine, and emergency medicine—reported the highest rates of burnout. The numbers held up when compared to differing education levels and other factors, leading authors to conclude that burnout is more common among doctors than other workers in the United States.

What that means for patients, unfortunately, is that the doctors treating them may be distracted when providing care. The data are unclear to the extent, as studies asking physicians to self-report errors yield low response rates and it is difficult to pinpoint a correlation between fatigue or distress and errors reported.

“Being a physician can be a soul-crushing experience. We have opened our hearts to care for people. We use all our knowledge and talent. We are the kind of folk that want to get it right every time,” said Thaddene Triplett, M.D., ’91. “Yet, we can get overwhelmed with it all. We are human.”

Suicide risk

The numbers on suicide risk are exceptionally stark.

Compared with other professions, the study reports that a male physician’s proportionate mortality ratio from suicide is 1.5 to 3.8 times higher. For female physicians, the difference is more: 3.7 to 4.5 times more risk.

“Unfortunately, the culture of medicine usually accords a low priority to physician mental health despite evidence of a high rate of untreated mood disorders and an increased burden of suicide,” study authors wrote. “Too often, depression remains unrecognized or untreated until a physician’s personal distress compromises his or her capacity to care for patients.”

It may also be that doctors hide their problems for fear of losing their licenses, hospital privileges, or pathways to advancement. And so physicians may pass on care even though they have more access to it than others.

Presenters from the 2016 International Conference on Physician Health shared story after story depicting suicidal struggles that impact physicians and their families. The anecdotes are haunting.

One tells how a doctor killed himself with scotch and pills that he prescribed himself. Another came from a mother lamenting a lack of communication between a psychiatrist and therapist treating her physician son who would later die from suicide.

“Not much of a relationship despite the awesome responsibility. It’s his therapist who really knew him,” she said. “I think our boy fell through the cracks of psychiatric practice of the 21st century.”

And another comes from a physician’s son struggling with the changes that he saw in his father before the worst.

“My dad was kind, funny, smart, and sweet. He was a radiologist. He was 42 when he killed himself. I was 16. The summer before he died, he lost his sparkle, he became more and more a shadow of himself,” he said. “I remember sitting with him one evening and he wasn’t making any sense. He was seeing a psychiatrist and he was prescribed medication, but I don’t know if he was taking it. He hung himself in the basement of his office.”

Physician shortage

Despite horrific data sets and news articles depicting the inner troubles that doctors face, it’s difficult for the average person to sympathize. Medicine is viewed as a field of privilege after all, and doctors reap tremendous rewards for their efforts.

Because of that, people working in other professions wonder why burned out doctors don’t just retire early. Many could do so comfortably.

“If that was true, we’d have only one half our physicians. What it comes down to is patient care and safety,” Andarsio said. As director of RISHI, as well as its national Healer’s Art program for medical students, she helps support many methods that aid in the prevention — not treatment — of burnout. “To ignore that and say that everyone should quit —physicians just can’t. Physicians are needed in the health care workforce for the care of patients. Now more than ever, physician burnout needs to be addressed.”

This is especially true because of the looming physician shortage predicted to occur in the next decade. The doctors of today need strategies to help prevent burnout to ensure continued quality care for their patients. In the future, the methods can help to buffer the shortage.

There are more than just a few factors feeding the physician shortage. Great financial promise of the IT world is pulling bright, young people away from the medical profession. In addition, more than 50 percent of medical students in America over the past decade have been young women whose life goals and professional goals are different than in the past. This percentage continues to grow.

Other factors, highlighted in a study commissioned by the American Association of Medical Colleges, include an aging United States population, changes to the insurance marketplace, and rising retirements among doctors older than 55.

For patients, there’s plenty of reason to be concerned. A shortage means longer wait times to get appointments, difficulties seeing specialists, and less personal time with physicians to discuss health issues.

For doctors, it unfortunately means an increasingly hectic workload on top of their already stressful positions that have for years yielded them higher rates of burnout, depression, and suicide risk than other occupations and education levels.

“Doctors can hurt a lot inside, yet there are few places for them to heal that hurt,” Triplett said. “We experience a lot of loss.”

It’s just one reason the Boonshoft School of Medicine welcomed the institute to its new home at Wright State University. Its forebearer, the Institute for the Study of Health and Illness (ISHI), was founded by Rachel Naomi Remen, M.D., at Commonweal, a center for healing in Northern California.

“We are committed to RISHI’s dream of making this kind of education for professional resiliency available to all health professional students, residents, and practicing health professionals,” said Margaret Dunn, M.D., M.B.A., FACS, dean of the medical school. “We want to develop health professionals who not only have the necessary scientific knowledge and superb technical skills to cure, but the heart to persevere through challenges, inspire others to embrace their calling, and to make the bedrock values of health care as tangible in our hospitals as the science of health care.”

RISHI works to help caregivers

There is no one-size-fits-all solution. Many doctors turn to practices like yoga or tai chi to help manage stress and prevent burnout. Some get more out of other methods. What works depends largely on personal choice and comfort.

For practicing doctors, RISHI supports Finding Meaning in Medicine (FMM) groups. These are small, intimate cohorts whose members share their personal stories as the price of admission.

Meetings of these groups take place throughout the world. One, comprised of doctors connected to the Boonshoft School of Medicine, has been meeting for years in the Dayton area.

“I have been a member since the beginning. I had seen the burnout, with some of my classmates leaving medicine within 10 years of graduating,” Triplett said. “I knew that we as doctors needed help, or a way to help each other.”

A few rules govern FMM group interactions. Everyone respects and maintains the confidentiality of the group, understanding that the purpose of the gathering is to be respectfully attentive to what others share and not to offer advice or attempt to solve a problem.

“These groups use the self-discovery model of learning, following the guidelines of generous listening. Group members offer no advice. They are just listening to others reveal their truth,” Andarsio said.

The acceptance felt in the small meetings helps physicians to open up and remember what drew them to medicine in the first place.

“I’ve seen it be a great resource for some of my colleagues,” said Dean Parmelee, M.D., associate dean of the Office of Medical Education and professor of psychiatry and pediatrics at the medical school. “What keeps me continuing with it is the strength and support that I gain from it. It provides a safe and supportive place for sharing our challenges and often getting a helpful perspective.”

Techniques used in the groups nurture self-exploration and mindfulness. Some involve sharing selections from classic world literature or reading personal poems. Just presenting problems to the group has helped doctors to see that they share many things in common.

There are certain experiences that only other physicians can fully understand. The ability to share with one another in a safe place is incredibly fulfilling and inspires a greater sense of satisfaction and meaning in their work.

“I hear people tell stories that are truly shocking. And you think, ‘Wow, how’d you get through that? Where did you find the strength to go back into that room?’” said John Donnelly, M.D., professor of family medicine and associate professor of population and public health at the medical school. He wrote the original grant proposal to support the Healer’s Art course for Boonshoft School of Medicine students. “It’s a respectful and supportive environment. It’s inspiring and powerful for the person sharing but also for the people listening.”

Donnelly and many colleagues discovered the group well into their careers. One of the hopes behind bringing the Healer’s Art course to the Boonshoft School of Medicine, in collaboration with Andarsio, Parmelee, and Bruce Binder, M.D., Ph.D., was to offer medical students a head start in nurturing resilience throughout their careers as physicians.

“We were working to safeguard students from cynicism. It was sort of an epiphany to give them the tools to pre-empt that,” Donnelly said. “Down the road, we wanted them to have preparation.”

Another aim was to provide students tools to get through the arduous experience of a medical education.

“It was nice to see that you weren’t the only one going through stress and difficult times during medical school. It was reassuring and a great way to build and strengthen bonds with your peers,” said Kareem Atwa, a second-year Boonshoft School of Medicine student who took the course his first year. “Whenever we feel pressure or need some guidance, we can always look to each other.”

The course offers a safe learning environment for a personal, deep exploration of the values of service, compassion, healing relationships, and reverence for life. The curriculum fills a gap left in traditional medical training that leaves out important human dimensions of practicing medicine such as deep listening, presence, acceptance, loss, grief, and healing, as well as relationships, self-care practices, and encounters with awe and mystery.

More than 75 percent of first-year students at the Boonshoft School of Medicine enroll in the elective course that was first offered in 2006. It has helped many gain perspective and an appreciation for connecting with those around them.

“You realize that you have to make time for yourself, to collaborate with people and get to know your classmates. With medical school, you think you’ll be studying all the time but you realize that you’ll burn out if you do that,” said Jennifer Barbadora, MS2. “You’re developing a different aspect — that’s unique to Wright State’s medical school. You begin to feel that your time spent studying is more efficient by also making time for the relationships and hobbies that you value.”

Designed by Remen in 1991, the course has spread to more than 100 medical schools worldwide. Through the Center for the Study of the Healer’s Art, established in 2005 at University of California, San Francisco, more than 15 peer-reviewed studies and general articles have been published showing the course’s effectiveness.

“It brings a certain aspect of humanity back to our studies. I think sometimes we are so stuck in studying the science that we almost forget the human aspect of their story,” said Joycelyn Akamune, MS2. “I’ve learned you don’t really know about a person until you talk to them — where they come from, who they are, what people have gone through. You have to be an active listener and cultivate an environment so that people will open up.”

“I hope to give students the assurance that they are not alone,” said Triplett, who helps with the course as a clinical assistant professor of pediatrics at the medical school. “Medicine has its crappy days, sometimes endless crappy days. However, the mystery, awe, and the service of being a physician will also be there for them and we can be there for each other.”

The course has been taught for more than a decade at the medical school. In that time, numerous students have followed up after graduation to let faculty know how the training has helped shape their development as practicing physicians.

For Boonshoft School of Medicine students entering their third and fourth years, when they begin clinical rotations, there is another Finding Meaning in Medicine group. It is led by students alongside faculty members who serve as guides.

“It’s more informal. The first hour is a social gathering, with food and drinks. Then we reconnect,” Donnelly said. “The student leading it will introduce a topic, we lay out the guidelines for the discussion, and off we go.”

RISHI also supports many other types of Finding Meaning in Medicine groups, including gatherings for residents and registered nurses. There also is the Power of Nursing program for those still in nursing school seeking better resilience and strategies to prevent burnout. Launched in 2012, it has spread to seven nursing schools and nursing residency training programs.

Nurturing resilience

In their everyday lives, many doctors lack the support and perspective gained from coming together. The simple act gives them an outlet for the pains their work can inflict.

“I hear their stories, they have listened to mine. They are thoughtful, loving people who often have no way to express that. We can look after each other. We can walk each other home,” Triplett said. “I feel encouraged as a physician to continue in my work after these meetings.”

The groups lend physicians more strength than going it alone. Through reflection and self-exploration, doctors also begin to learn personal strategies that help them improve their resilience.

The beauty is that there is no right or wrong way to get there. For some physicians, just analyzing difficult situations to identify stressors can give them the perspective they need for renewed strength. Others have special rituals that they use to maintain the right frame of mind and clarity of purpose.

One key is finding meaning in their work, an important part of continuing in medicine over the long term. The sentiment is powerfully illustrated by an old Sufi parable about three stonecutters that Donnelly shares with his students.

Finding meaning

As the story goes, everyone can see the stonecutters are all doing the same task. People bring them rocks, they cut them into blocks, and then someone comes along to take the blocks away. The process repeats itself over and over again.

Imagine that we walk up to the first stonecutter to ask him about his work. 

He responds with hostility, saying, “Idiots, you can see what I’m doing. I am cutting rocks into blocks over and over again. I’ve been doing it from the moment I started working. I’ll do it till the day I die. Why are you asking me such a stupid question? Use your eyes!”

When we go up to the second man to ask what he’s doing, he greets us with a smile.

“I’m earning a living here for my beloved family,” he says. “There’s good food on the table and a roof over our heads and the children are growing strong.”

Talking with the third man, we find something different in our exchange. He has a perspective all his own.

“Ah. I am building a great cathedral, a holy lighthouse, where people who are lost and frightened can come and remember that they are not alone,” the stonecutter says. “And it will stand for a thousand years.”

What is powerful about the parable is its clear depiction of someone who has given himself a purpose. Though his work is hard and repetitive, it is his attitude that makes all the difference. He has taken charge of the hopeless situation he’s in and found meaning for his daily walk.

“How can you expect someone to work so hard without meaning?” Donnelly said.

Finding one’s meaning is something that is deeply personal. But uncovering it can be a great source of strength.

“The passion that I had for delivering babies, I bring that same passion to this work — prevention of physician burnout,” Andarsio said. “It’s all about patient care and safety, and a part of that is caring for physicians.”

 

Last edited on 03/22/2017.