Self-care of physicians: Strategies for care
Self-awareness and mindfulness help with self-care
Physicians may be operating in burnout mode — or suffering from other maladies related to distress and stress — long before they are even aware of it, according to Michael K. Kearney, MD, one of the authors of a paper published in the Journal of the American Medical Association (JAMA) earlier this year titled "Self-care of Physicians Caring for Patient at the End of Life: "Being Connected … A Key to My Survival."1
In addition to a certain reluctance to discuss or examine personal feelings related to care of such patients, such as grief or a sense of loss, there's also "a genuine problem in not recognizing burnout in its early stages."
"I think oftentimes, it's our colleagues who recognize it before we do — colleagues and family members . . . — who notice the emotional exhaustion, the cynicism, the irritability," Kearney tells Medical Ethics Advisor. "And often, we're the last ones to recognize it ourselves."
Kearney, who practices in palliative care at Santa Barbara Cottage Hospital in Santa Barbara, CA, as well as Visiting Nurse and Hospice Care of Santa Barbara, says that one reason to pay attention to physician self-care and the need for it is that "the figures are really quite alarming — those that show that the prevalence of burnout among U.S. physicians and nurses is about 30%."
That doesn't mean that physicians who are experiencing burnout automatically leave the profession, either; however, he says there is a spectrum of burnout ranging from mild to severe.
"It can get to a point where it's really compromising, and the physician just can't go on," he says.
What is burnout vs. compassion fatigue?
Kearney cites Maslach, who has done a great deal of work on burnout, he says. The three primary characteristics of burnout are: emotional and physical exhaustion; depersonalization, or feelings of cynicism and detachment from one's job; and sense of lack of personal accomplishment, or as Kearney put it, "a sense of not really getting the job done."
Burnout, he says, is generated by stressors related to a physician's work environment, be they work-related stressor or institutional-related stressors — something akin to the administrative hassles, or the daily grind.
It can also result from the clash of one's personal values with the values of the institution or not feeling as if one has control over his or her work environment, he says.
Compassion fatigue, on the other hand, "is very different," Kearney notes. "Compassion fatigue is what results from stresses generated between the clinician and the patient's suffering."
That kind of fatigue is also know as secondary traumatic stress disorder, he says, and it "essentially means that by being close to our patients, physicians and nurses, in an empathic way, are at risk of being traumatized by the patient's suffering."
Compassion fatigue can lead to burnout and its myriad symptoms.
"It's a personal tragedy, but it also leads to a failure of and breakdown in patient care, because of all the features: the exhaustion, the detachment, the cynicism lead to a clinician who is less engaged, who is detached.
"So, to be a patient on the receiving end of that is maybe to be on the receiving end of the physician who is still doing the right thing, technically, but who is not able to be present in an engaged, humane, warm way, because they literally don't have it in them anymore," Kearney explains.
That can lead not only to a question of the quality of patient care, but the effectiveness of patient care over time, he says.
Strategies for care
Care of physicians is not just an individual matter, it's an imperative for institutions to care for their employees and create facilities that promote self-care, Kearney says. Patient satisfaction, staff retention, and the effectiveness of care delivered — those are all reasons that health care institutions should care about the self-care of physicians and other providers, he suggests.
One simple intervention he suggests is to mandate that staff complete a "self-care inventory," i.e., "something that makes [clinicians] think about: well, what is my self-care plan — not just outside of work, but also at work."
Kearney says that a number of institutions "are providing opportunities in the workplace" for staff to practice self-care.
Solutions begin with an awareness of a problem, and there can be no solutions without identification of some problem or weakness. Kearney's paper focuses on self-awareness and mindfulness as the path to self-care.
There are strategies for self-care that can be incorporated into the work day, and Kearney and his co-authors outline several actions physicians can take during their day to keep them focused. The strategies are all from practicing clinicians.
"We said to some of these clinicians: Can you share with us some of your pearls — those things that through sort of trial and error have really worked for you and helped you maintain yourself over the years," he tells MEA.
According to the article, "Physicians with burnout who use self-care without self-awareness may feel as though they are drowning and barely able to come up for air, whereas self-care with self-awareness is like learning to breathe underwater."1
Among some of the strategies that clinicians shared with Kearney and the other authors were:
— "As you walk from your car to your workplace or through the corridors of your workplace, attend carefully to the sensation of contact between your feet and the ground.
— Reward yourself after the completion of a task, i.e., an early coffee break.
— Take a half minute of silence or take turns to choose and read a poem at the beginning of weekly interdisciplinary meetings.
— Stay connected to the outside world during the day, eg., check in with loved ones."1
Factors that mitigate burnout, fatigue
"The personality characteristic of hardiness — a sense of commitment, control, and challenge," has been shown to be associated with a greater sense of personal accomplishment, according to the article.
Other strategies, such as teams with shared decision-making responsibilities, were also cited in the article.
Compassion satisfaction is also a means to self-preservation for physicians, i.e., the "pleasure derived from the work of helping others." Kearney and the authors cite Stamm as identifying compassion satisfaction as "a possible factor that counterbalances the risks of compassion fatigue and suggested that this may in part account for the remarkable resiliency of the human spirit."
But one thing that Kearney particularly notes is "post-traumatic growth and vicarious post-traumatic growth."
As the article notes, "Post-traumatic growth is characterized by positive changes in interpersonal relationships, sense of self, and philosophy of life subsequent to direct experience of a traumatic event that shakes the foundation of an individual's worldview."
Reference
- Kearney, Michael K.; Weininger, Radhule B.; Vachon, Mary L.S, et al. "Self-care of Physicians Caring for Patients at the End of Life: 'Being Connected . . . A Key to My Survival'" JAMA, 2009;301(11):1155-1164.
Source
- Michael K. Kearney, MD, Santa Barbara Cottage Hospital, Santa Barbara, CA. E-mail: [email protected]
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