By Pradnya D. Patil, MD, FACP

As I sat down to write this article, my thoughts went back to a time during my early trainee days. As a first-year fellow on the medical oncology consult service, I remember spending days delivering bad news to patient after patient who had their lives turned around by their new diagnoses. At the end of a long day of family meetings to discuss goals of care and watching another young patient—a father of three kids—pass away, I remember going home and questioning how long I could continue to do this.

As I shared my experiences and fears with some of my colleagues, I realized that many of them had also faced similar emotional exhaustion and had a sense of losing their purpose at some point in their careers. While talking to my peers was a great way to dissipate some of my stress, it wasn’t until I attended a resilience-building program arranged by our fellowship program that I recognized that there were habits and behaviors that I could actively inculcate to help me cope better. These habits have proven to be invaluable to me in my career thus far. In this article, I hope to describe some of the steps that have personally helped me recognize and deal with stressors at work and have brought me one step closer toward achieving a healthier work-life balance.

Recognizing signs of burnout

One of the first steps toward building resilience is the ability to evaluate your own state of well-being and recognize early signs of burnout. The syndrome of burnout is characterized by exhaustion, cynicism or depersonalization, decreased efficiency at work and a sense of low personal accomplishment.¹ As hematologists/oncologists in training, we are particularly susceptible to burnout due to the high demands that both the academic and clinical aspects of our training can pose. As many as 34.1% of oncology fellows in the United States reported experiencing burnout in previous studies.² Some early signs of burnout include constant fatigue, the feeling of being burdened by work, irritability, anger, anxiety, or even physical symptoms such as insomnia.³ If you are experiencing some of these signs frequently, it is time to intervene. Spend some time at the end of each day or week reflecting on some of these previously stated emotions and make a note of the situations that precipitated them. By identifying the sources of your stressors, you will be be better equipped to act upon them.

What is resilience and how can I build it?

Resilience is the ability to adapt to stressful situations in a manner that not only allows you to effectively deal with the challenge at hand but also develop coping skills that make you better equipped to handle every passing challenge. While some of the steps in building resilience are more intuitive, such as focusing on different aspects of your personal well-being, others are skills that can be learned and deliberately instilled over time. Here are some of the key steps that you can take to build resilience.

1. Take care of yourself.

Invest time and energy in yourself. Take the time to ensure that you are eating well, getting enough sleep, exercising, and spending time on activities that give you pleasure. The association between sleep deprivation, moral judgement, and cognitive impairment has been well established.⁴ You will find that you are able to accomplish your work-related tasks much more efficiently once you incorporate some of these healthy behaviors.

2. Make a list of what is most meaningful to you and learn to say no.

As oncologists in training, we are often faced with the Herculean task of providing excellent patient care, keeping up with the latest developments in this ever-changing field, being productive at research, applying for grants, writing protocols, and trying to maintain some semblance of a normal work-life balance at the same time. Needless to say, it is almost impossible to excel at all of those arenas at all times. Prioritize what is most important to you, whether it be the young investigator grant application, the time you spend with patients, or something more personal, like time spent learning a new musical instrument. Acknowledge your own limitations and spend time on things that are most meaningful to you. One of the best pieces of advice that I got from a mentor was to learn how to say no. Saying no to a project or task that you know you cannot accomplish within a certain timeframe saves you the frustration of not completing it on time and allows you to focus on others that are more valuable to you.

3. Recognize your emotions.

If you find that you are often frustrated, angry, overwhelmed, or anxious, make note of the situations or instances that led to those emotions. Identifying your stressors can allow you to alter the source of your emotions or, for situations that you cannot control, consciously alter your responses to that particular circumstance. For example, if you are frustrated that you are not able to spend as much time on certain activities you enjoy—such as spending time with family, a recreational activity, your research—make that activity a priority and carve out dedicated time in your schedule for it. Another useful cognitive behavioral technique is mental reframing—essentially, changing your perception and putting a positive spin on an unalterable situation.⁵ For example, think back to the research project that you invested a lot of time and effort into but ultimately did not yield the results that you expected. You probably still learned a lot about the research methodology and setbacks you could avoid in the future. Be conscious about finding meaning and value in frustrating situations.

4. Don’t lose sight of the big picture.

Think about your motivation for choosing this vocation and assess if your current actions are in line with your long-term goal. Make note of the times when you were able to achieve something that gave you satisfaction—a hug from a patient you treated or receiving the coveted grant that you worked hard for. Another practice that is mentioned in the American Medical Association STEPS Forward resiliency program is to start a gratitude journal where you can jot down a few things that you are grateful for each day.⁶ Giving yourself positive feedback by constantly reminding yourself of what you have been able to achieve helps keep all of your hard work in perspective.

5. Cultivate mindfulness.

Mindfulness is essentially a mental state in which one is fully aware of the present moment without letting emotions affect the situation. Over time, these mindful practices can allow you to focus on the task at hand and help regulate your reactions to other distractors. Mindfulness can be a particularly valuable tool in situations where you have to multitask. Some of the most commonly used tools to cultivate mindfulness include meditation and yoga. There is evidence to suggest that incorporating mindfulness practices can lead to an improvement in physician well-being and burnout.^7,8

6. Find your support system.

Last but not the least, find people that you can share your stresses and achievements with. Your support system could include colleagues at work, family members, or friends outside of work. You can also consider joining formal physician support groups that you may have access to, as well as physician social networks online.

Fortunately, national organizations, institutions, and training programs are increasingly starting to recognize the impact of burnout on physician well-being and patient care. Many institutions and training programs now have resiliency-building programs that are being integrated into routine practice. Taking advantage of such programs and instilling some of these practices early in your career can prove to be invaluable in preventing burnout and maximizing personal and professional satisfaction over the course of your career.

References

1. Shanafelt TD, Dyrbye LN, West CP. JAMA. 2017;317:901-2.
2. Shanafelt TD, Raymond M, Horn L, et al. J Clin Oncol. 2014;32:2991-7.
3. Hlubocky FJ, Back AL, Shanafelt TD. Am Soc Clin Oncol Educ Book. 2016;35:271-9.
4. Killgore WD, Killgore DB, Day LM, et al. Sleep. 2007;30:345-52.
5. Nedrow A, Steckler NA, Hardman J. Fam Pract Manag. 2013;20:25-30.
6. American Medical Association. AMA Ed Hub. “Professional Well-Being.” Accessed 20 Dec 2018.
7. Krasner MS, Epstein RM, Beckman H, et al. JAMA. 2009;302:1284-93.
8. Ludwig DS, Kabat-Zinn J. JAMA. 2008;300:1350-2.