I became an ice hockey fan when a new franchise was started in the Washington, DC, area when I was 10 years old. There were low expectations for this team, and indeed, their inaugural season was the worst ever in the NHL. Nevertheless, I celebrated each of their eight wins, and I savored my satisfaction with the better-performing teams in the Washington area (football and basketball). This year’s Washington Capitals exceeded expectations, playing better in the playoffs than they did during the regular season. In each case (the 1974 team and the 2012 team), my experience was framed by my expectations.

Pros and cons of routines
The goaltender for this year’s Capitals team, Braden Holtby, has many rituals before each game, one of which involves taping his stick in the same exact way and at the same exact time before the start of the game. In oncology, we have our own rituals. Maybe you do certain things before or after you write chemotherapy orders or before you dictate your clinical notes, for example. The argument in favor of Holtby’s ritual (and other rituals, perhaps) is that taking the variation out of some aspects of his preparation helps him focus on key aspects of the game at hand. The downside is that disruption of his routine, if it were to occur, might be unsettling for him. Some of Holtby’s coaches deliberately disrupt some aspects of his routine to help him develop sufficient flexibility in his preparation so he is ready to perform under any circumstances.

Using buoyancy to combat stress
Rituals are put in place to help us find a comfort zone with common activities, but they can also create expectations that make us vulnerable to stress. For the ASCO Annual Meeting this year, I was invited to contribute on the topic of stress and burnout. In medicine and science, we rely on conceptual models to further our understanding of complex topics, and I sought to find a conceptual model that helped me make sense of this topic. Rather than a model of stress and burnout, I sought to model the opposite—that force, “buoyancy,” that holds us up and keeps us from sinking in the face of the inevitable stressors that life and work send our way on a daily basis. I thought about buoyancy as if it were the dependent variable in a multivariable model and tried to imagine what the key parameters of such a model might be. I also imagined the model to be dynamic, such that one’s buoyancy was constantly changing (usually in very small ways) and each parameter weight also varied. I have included the buoyancy model here; more information on the model and its parameters can be found in the article I authored for the 2012 Educational Book, “Buoyancy: A Model for Self-Reflection about Stress and Burnout in Oncology Providers.”

Buoyancy model from ASCO's 2012 Educational Book

Managing expectations
The buoyancy parameter that the hockey example brings to my mind is “appreciation of change.” We are confronted with this issue in our lives and careers regularly, and also with our patients as they face uncertainty, grief, and loss if the face of illness. In professional life, here are some examples of statements related to expectation that might resonate with you:

• When I came here, they told me I’d have five half-day clinics per week but now I have seven.
• When I began dictating my notes in between patients rather than at the end of clinic, I was very unsettled.
• When we recruited that fellow with an MD, PhD, we expected to be developing a physician-scientist, but now he/she is asking for more clinical rotations and wants to go into clinical practice after fellowship.
• I expected my career to advance when that program leader retired, but the retirement hasn’t happened and my career is stuck in the mud.
• [From a patient] I thought that I heard that most people were still able to work while taking this more gentle oral cancer therapy, and I am totally wiped out.

It seems impossible to proceed in life without developing a myriad of expectations. But whether you are a clinician, fellowship director, physician-scientist, or patient, the way you handle expectations and adjust to change can make a major difference in your buoyancy and your risk of burnout.

I have no antidote that will provide me or anyone else with immunity to disappointment in the face of change. But here are three small steps that might be useful:

1. Simply notice your expectations and their impact on your experiences. Take pause before you respond to the situation at hand;
    
2. Reflect on what options are available and what is reasonable. For the goaltender, Holtby, this might mean reflecting on how he might respond to having his stick taped up at the last minute. For the patient starting cancer therapy, this might involve rehearsing in his/her mind possible impacts of starting new therapy, some much better or worse than one usually expects; and
    
3. Keep in mind the broader concept of buoyancy. Notice that “appreciation of change” is but one parameter in your personal buoyancy model. When that “stock” takes a downturn, even transiently, you may find that you can shift other parameters upwards (like those related to gratitude, key relationships, autonomy, etc.) and thus maintain your buoyancy. It is not simply “counting your blessings,” but also dynamically adjusting the parameter weights of the various blessings that constitute your buoyancy model—in essence, striving towards mindfulness, reflection, and resilience.

For more information, please read the complete 2012 Educational Book article, “Buoyancy: A Model for Self-Reflection about Stress and Burnout in Oncology Providers.”