The 5 Fundamentals of Civility for Physicians:

#4: Take Good Care of Yourself

By Micheal Kaufmann, MD
OMA Physician Health Program

“That’s not how my mentor puts it,” said the resident. Young and eager, he was sitting forward in his seat, following me closely, challenging. “Surgery is a demanding specialty. If you’re not tough enough to stand it, you should get out,” he added — or words to that effect. Oh no, I thought, he’s swallowed the poison!

That happened during my lecture to a group of residents at a university in Ontario. I was speaking about physician health and risk, burnout and substance use disorders, our vulnerability, and self-care as an imperative.

Later, I found out that the resident who spoke up — which I appreciated — was only just beginning his surgical training. I could see that his process of professionalization was well underway, and it didn’t seem like he was going to be much exposed to a vital message: our health is just as important as our patients’ health.

It seemed to me that he was at risk of following a traditional path of self-sacrifice; denial of his own basic physiological and emotional needs in the name of surgical training and practice. And worse, he would believe that it was a good idea to do so, that it would make him a great surgeon. Maybe.

Certainly he’ll have plenty of exposure to all of the amazing opportunities his training will provide. But one day, taut and exhausted, I wouldn’t be surprised if he lashes out at a colleague or co-worker in a most uncivil way. Tightly wound, he will, as they say, shoot the first thing that moves.

Civility and self-care are linked. As Spath and Dahnke said, “Civility is claiming and caring for one’s identity, needs and beliefs without degrading someone else’s in the process.”1 I’m in a position to interview doctors who have forgotten that. Burned out and perplexed, they’ve drifted away from the awe of medical practice. Instead, they see their patients as problems, their colleagues and co-workers as irritants, at the very least, and sometimes as the enemy.

I even see that transition in the faces and mannerisms of learners: eyes wide with amazement as medical students; spent and jaded by the final years of residency. They are already shouldering a load that is difficult to set down.

Civility And Burnout

What happens when a person has to perform day after day under demanding conditions beyond their personal comfort zones, unable to unburden themselves? Yes, there is learning and growth, to a point. After that, there is fatigue, exhaustion, distress, burnout, illness and, for some, incivility.

We are learning that choosing civility isn’t always easy. Sometimes we have to dig deep to find the respect and awareness required to communicate in a civil and effective fashion. This is especially true at times of prolonged stress, when we’re most likely to fall back on more deeply ingrained modalities of fight, flight, or aggression.

Burnout — a result of unrelieved work-related stress — can impact upon any otherwise healthy individual, and looms as one of the greatest challenges to the medical profession. Nearly half of the physicians surveyed in North America report some degree of burnout.2,3 This is inhumane and unacceptable.

We can examine burnout in more detail. Maslach described the dimensions of burnout as exhaustion (physical and emotional depletion), depersonalization (a cynical detachment from work and co-workers), and a sense of ineffectiveness and lack of personal accomplishment.4

Major antecedents of burnout include excessive workload, perceived lack of control, insufficient reward, poor professional community support, a sense that fairness is absent, and a mismatch between one’s personal and occupational values with those perceived in the workplace.5

Highly motivated doctors with intense investment in their profession are particularly at risk.5 So often have I heard doctors explain their workplace incivility this way: “I do what I do and say what I say only to get the best possible care for my patients!” I believe they are being sincere, even as they are unaware of the paradox: treating co-workers badly has negative impacts upon patient care. Chronic stress related irritability, impatience with others, and failing empathy all predispose to workplace conflict and low morale. As one distressed doctor who contacted us put it: “I just can’t be nice to stupid people any longer.”

The “Self Versus Service” Dilemma

At the Physician Health Program (PHP), we regularly receive calls from doctors who are stressed and feel like they are burning out. Their account often reflects the following pattern: they are feeling overwhelmed by their workload and under-appreciated. Maybe they’re drinking a bit too much, or perhaps a patient has complained about their manner. They’ve approached the chief of their department seeking support and relief, only to be met with a message pushing the problem back upon them — something like, “These are tough times and we all have to work harder.”

The chief is right in some ways: doctors are being pushed to respond to unlimited demands. I’m sure those in positions of responsibility are also stressed by these systemic pressures. Still, a compassionate, active listening response to a colleague in distress would, all by itself, offer a measure of relief. And in the end, how is anyone well served by a suffering doctor, or one who must abandon his or her work in order to seek care?

Personal Resilience

What is the answer? At the least, optimizing our own health and resilience practices is a choice that is within our control. Much has been written about the self-care practices that bolster resilience, including the PHP BASICS series.6,7

Resilience can be thought of as the ability of an individual to respond to stress in a healthy, adaptive way such that personal goals are achieved at minimal psychological and physical cost. Resilient individuals not only “bounce back” rapidly after challenges, but also grow stronger in the process.8 Good personal resilience practices promote civility. Here are some tips:

  • Don’t skimp on nourishment. Eat regular meals whenever possible, and healthy snacks when meals must be skipped.
  • Get some exercise — even if that means using the stairs at work more often.
  • Cherish and protect time for sleep, keeping to regular sleep hygiene habits.
  • Practice mindfulness.8
  • Be sure to spend time with friends, family and significant others.
  • Choose work that matches your temperament and values — even if that means changing jobs.
  • Take breaks to walk on “uneven ground” as often as possible, be it through vacations or other opportunities to enjoy natural environments.

Self-care is foundational. In an environment that demands peak performance from us every day, attending to basic personal needs provides the vitality necessary to go out into the world and apply our skills in a way that enables our genuine connection to colleagues,co-workers and patients.

Beyond the intuitively obvious benefits of taking care of ourselves, we now know that healthy lifestyle practices for doctors translate to better care for patients.10,11 Truly, even for the most dynamic of doctors, paying attention to our own needs makes sense.

Community

A number of years ago, I was invited to attend an evening meeting of a small group of family physicians to talk about physician health and the Physician Health Program. They were all male (in fact, calling themselves the “Mens group”) and, as they had been doing for a dozen years or so, they were gathering at the home of the member host for an evening of discussion and mutual support.

Personal “check-in” took place over the meal prepared by the host, and discussion followed. The discussion focused on topics of mutual interest, but favoured issues of personal importance rather than medical education. Over the years, they had discussed such issues as parenting challenges, loss and grief, resilience and coping, ethical investing, preparing for retirement, and so on.

I really enjoyed my time with the group and told them so at the end of the meeting. “So why not join us?” was the response. I did. And I’ve been joining them every month since, in our homes, on vacations, and for our annual weekend retreat every September in Algonquin Park. These fellows have become valued friends and an important support of my own resilience.

It’s not just me. Resilient physicians themselves say that their professional friendships, alliances and networks keep them healthy.7,12 Doctors come together in many ways that foster genuine mutual support: journal clubs, Balint groups,13 Finding Meaning in Medicine groups patterned upon the work of Rachel Remen,14 and hospital-based peer support groups and services like those developed at the Brigham and Women’s Hospital in Boston,15 are but a few examples, along with groups like the one to which I belong.

Here are some tips in finding/forming a mutually supportive peer group:

  • Choose a few like-minded colleagues interested in sharing at a personal level.
  • Consider how many members of the group would be optimal.
  • Create some “norms” for discussion.
  • Experiment with different meeting formats until you find one that works for all of your members.
  • Be sure to create safety for the discussion of personally sensitive, confidential subjects and experiences.
  • Refresh group membership, structure and norms regularly.
  • Wonder how you ever managed without this kind of support before!

Any professional grouping of doctors and co-workers, like family health teams, hospital or university departments, can be considered as communities worthy of self-care, as long as the door is open to sharing in a safe and meaningful way.

In effective workplace communities, practical decisions about work distribution, remuneration, resource sharing, and so on, are made in a spirit of fairness, friendship and mutual support. Healthy communities are places where conflict, when it inevitably appears, is managed respectfully and effectively.

Professional communities of care are places where doctors can be genuine with one another, sharing their experiences as well as feelings of stress and vulnerability. Compassionate professional communities acknowledge the self-care needs of their members and know how to respond when someone is over-burdened or suffering. These are the kinds of communities where civility prevails.

Civil professional communities are also places where systemic problems can be identified and confronted in a way that preserves the energy and dignity of everyone who works there. This is a matter of leadership, co-operation and imagination.

The Culture Of Medicine

It is ironic that a profession so involved with healing and humanity can often be characterized by incivility. Whether it’s expecting learners to go without food or sleep, one doctor attacking another over perceived slights or unfairness, or entire professional groups railing against others in political or financial combat, the “house of medicine” suffers. I doubt this would be the culture any one of us would support, or deliberately choose to join.

So, just as we need to care for ourselves and our local professional communities, we need to be mindful of the care our professional culture of medicine requires.

The health of doctors, and therefore the health of our profession and the populations we serve, is taking shape as a core professional value. This is described in a widely used CanMEDS competency framework, soon to be updated for 201516

Gone are the days when self-care practices were considered just a good idea for others, but a luxury for which we had neither time nor sufficient motivation. Organized medicine at every level is “weighing in” on physician health through policy and program development.

As my colleagues have said: “Physician health is clearly more than a simple matter of finding an optimal work-life balance; it is a political issue.”17 An issue, I might add, for which we bear individual and collective responsibility.

Self-care is at the heart of a caring and civilized profession. Choose civility.
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Previous articles in “The Five Fundamentals of Civility for Physicians” series are available on the Physician Health Program website at http://php. oma.org.
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Dr. Michael Kaufmann is Medical Director of the OMA Physician Health Program (http://php.oma.org/). Dr. Kaufmann would like to thank PHP colleagues and staff for their suggestions and support in the preparation of this series of articles.

References
1. Spath T, Dahnke C. What is civility? [Internet]. Houston, TX: The Institute for Civility in Government; c2015. [about 2 screens]. Available at: http://www. institute forcivility.org/who-we-are/what-is-civility/. Accessed: 2015 May 19.
2. Shanafelt TD, Boone S, Tan L, Dyrbye Five Fundamentals of Civility 14 June 2015 Ontario Medical Review LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012 Oct 8;172(18):1377-85.
3. Lee FJ, Stewart M, Brown JB. Stress,burnout, and strategies for reducing them: what’s the situation among Canadian family physicians? Can Fam Physician. 2008 Feb;54(2):234- 5. Available at: http:// www.ncbi.nlm. nih.gov/pmc/articles/PMC2278317/. Accessed: 2015 May 19.
4. Maslach C. Job burnout: new directions in research and intervention. Curr Dir Psychol Sci. 2003 Oct;12(5):189-192.
5. Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: “Being connected…a key to my survival.” JAMA. 2009 Mar 18;301(11):1155-64.
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and how to promote it. Acad Med. 2013 Mar;88(3):301-3.
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14. Institute for the Study of Health & Illness. Finding meaning: discussion groupsfor physicians, nurses and all other healthcare professionals. [Internet]. Bolinas, CA: Institute for the Study of Health & Illness; n.d. [about 3 screens]. Available at: http://www.ishiprograms. org/programs/allhealthcare-professionals/. Accessed: 2015 May 19.
15. Brigham and Women’s Hospital. Center for Professionalism and Peer Support. Peer support. [Internet]. Boston, MA: Brigham and Women’s Hospital; 2014 Jul 28. [about 3 screens]. Available at: http://www.brighamandwomens.org/ medical_professionals/career/cpps/ PeerSupport.aspx. Accessed: 2015 Jun 8.
16. Frank JR, Snell L, Sherbino J, eds. The draft CanMEDS 2015 physician competency framework — series IV. Ottawa,ON: Royal College of Physicians and Surgeons of Canada; 2015 Mar. Available at: http://www.royalcollege. ca/portal/page/portal/rc/common/ documents/canmeds/framework/ canmeds2015_framework_series_IV_e. pdf. Accessed: 2015 May 19.
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