I've been river rafting just one time in my life. We paid for a guided trip down Idaho's famous River of No Return, the Salmon, and spent the day traveling stretches of rapids and stretches of calm. It was exhilarating enough for a newbie but not enough to ever feel like my life or livelihood was seriously at risk.
But I've also seen that same river at flood stage and it is downright scary looking. There is simply too much water in the riverbanks going too fast, too many rocks underneath shaping the rapids, and too much uncertainty about which way your raft might go. Even an experienced guide who has shot Class VI rapids might not have the skill or strength to ensure the passengers of their raft would make it through at that stage.
In many ways, this is where doctors, other medical providers, and sometimes even clinic administrators are at right now. The "rapid" pace of change in the healthcare industry is so volatile, so uncertain, so complex that it has created Class VI monsters ready to swallow doctors whole. In the past, this river used to have some dangerous places that could be anticipated and planned for, followed by smooth waters to recover in before the next rough patch. But no more – it's just one giant raging tumbler after another.
Unfortunately, many physicians consider themselves as failures for being unable to paddle hard enough.
Thinking about the last 10-15 years of change in this industry, does anybody expect it to get slower, calmer, or more predictable any time soon? Hardly. No wonder physicians are just flat out exhausted. If the river current is the pace of change in industry, then the banks are the medical culture this river runs between. This long-established and stubborn-to-change culture often contributes to the occupational hazards physicians face. For example,
Is there any hope of changing the banks of this riverbed, removing some boulders, or adjusting deadly vortexes?
I say yes.
In fact, if there is any time in history to do this, it is precisely when there is a lot of water in the riverbed. . Now is the time to identify the perennial eddies and the hazards that capsize or waylay physician careers and personalities; to put effort into the way medicine is taught, modeled, and reinforced; to demand change from healthcare systems and employers and not settle just for safety-nets in front of the waterfalls.
Medical education is a great place to begin and I'm intrigued by some of the ideas the Idaho College of Osteopathic Medicine is implementing as it opens this fall. This summer, I took a tour of the new facility with Dean Robert Hasty, DO who proudly showed off the student nursing mothers' lactation rooms where they can still watch lectures and the unified faculty-student lounges to promote more interaction. They're even planning to close the building before midnight in the hopes that students can learn to get more sleep. As Dr. Hasty has told me, "I can't force them to sleep when they're off campus, but I can keep them from staying on campus to study all night."
I appreciate that sentiment from one of the "new river guides" in our medical community. We need enlightened leaders who are as much or more devoted to the peak performance of the individuals who make up the organization than the peak performance of the organization itself, knowing they'll get that if they focus on the former. And while ICOM's ideas on this particular issue are a great start, it will only make a lasting difference if self-care and permission to be human is supported by the faculty, the mentors, the preceptors, the attending physicians they round with, and ultimately, the institutions they work for.
I challenge you to look at the swift currents of change in this river as an opportunity to reshape the culture of medicine so that it isn't so dangerous and deadly. We will always need to teach individual survival skills and institute safety-net programs like our counseling services. But while we can't paddle back upstream to the old way of practicing medicine, we do need to do a much better job working to make this a safer river to be on in the first place. The old mantra of "well that's what I had to go through" and the new mantra of "we just need to teach doctors the joy of working hard" rings hollow. This isn't about getting soft on students, residents, or physicians - this is about making sure we have any doctors left when we all need geriatric care.
It was at the top of Haleakala on Maui, watching the most incredible sunset in my life at 10,020 feet, that my wife leaned over and said, "Now this is cultivating awe and wonder!" You might have heard this phrase before, a practice of mindfulness that is intended to strengthen individual resilience. I don't know who coined it for our modern times, but it is certainly an ancient concept.
As a physician, you may find yourself practicing medicine in a way that grinds the joy out of you, whether it is in a private clinic or in a hospital. With so many administrative burdens that "get in the way" of seeing patients, it can be easy to lose sight of all the amazing things that happen in our world. Cultivating awe and wonder on a regular basis can help restore and retain a sense of humility and gratitude for the short lives we live and the people we interact with. Here's a few sources you might consider:
Nature/Creation – This one is intuitive since most people I know love to get out of their urban environment to reconnect with the natural world. For me, sitting and looking at the moonlike Haleakala crater – which is 5-6 miles wide and rich with green, brown, gray and red tones – was simply astonishing. Watching last fall's total solar eclipse in Cascade (and my family's reaction to it) made me understand the "umbra-chasers." And it's still hard for me to fathom the rivers of lava and car-size boulders flowing on Hawaii's big island right now, right through a lush green neighborhood my wife and I got turned around in by GPS just eighteen months ago. But Hawaii and solar totality don't happen every day, so we need to settle for smaller joys even if it is just biking the Greenbelt, hiking the foothills or stopping to smell the flowers.
The Human Body – You all have much more of a front row seat to this than I do and get to see extraordinary things like hearts pumping blood, and cellular activity, and even a crying newborn fresh out of the womb. Perhaps you see it too frequently to appreciate it, but I am constantly amazed at things like my own body's ability to heal itself with clotting and scabs. I remember the tiny fingers of my children when they were babies. And even as I age, there is definitely a sense of wonder about the different kinds of hair emerging from various places on my head.
Giving Gifts – It is Christmas morning and you sit in the dark waiting for your kids to walk their sleepy selves into the living room. As you sip your coffee and they suddenly recognize the smorgasbord of gifts you've prepared, you get to watch the wonder in their eyes and appreciate their gratitude. Indeed, a well thought out gift or even a well-timed word of encouragement brings its own reward when it lands just right in the heart of the recipient. Random acts of kindness like paying for somebody's dinner anonymously allows you to snicker and grin as you think what their reaction is going to be when they find out.
Children – Sure, it may be a little irritating if your own 3 or 4-year-old won't stop asking "why" questions, but we could all stand to regain our sense of childlike curiosity. I suppose learning the scientific method can have the effect of reducing our big questions to a dull academic pursuit of more knowledge. So, if you've lost your sense of wonder in the world, it is easy to reawaken it by being around kids who are just opening their eyes to how big it is and how much they don't know. But it can also be something like seeing yourself in their features or seeing your sense of humor reflected in their punishing attempts at wordplay.
I'm wondering: what kind of things do you do to cultivate this sense of awe?
Usually when you find your state or community in the #1 spot on any list, you feel pretty good about it, as in "Boise: The Fastest Growing City in the Nation." But when Idaho fell from #4 in 2016 down to #20 in Medscape's 2018 Best and Worst Places to Practice, the blame was one on thing: physician burnout, which is reported as 51% in our state and puts us on top of the list nationally.
What the heck?!
As the director of Ada County Medical Society, which represents more than half of the state's physicians, I could take it as an organizational failure that all our efforts over the past three years around physician vitality seem to have been for naught. The optimist in me wants to spin these survey results as just being the most honest state in the nation about our burnout. After all, most national polls put physician burnout across specialties at least 50% or more. So, if our state physicians are reporting that same average (but no one else is higher than us), maybe we're finally just feeling comfortable saying what is really going on here.
I probably would have made a poor statistician.
The one thing that we can point to is a growing, medical community-wide conversation about the challenges of the profession in our state where:
In May we sponsored Dr. Dike Drummond, the editor of thehappymd.com and a national expert on physician burnout. He spoke to a blowout crowd of 120 gathered at The Riverside Hotel for his workshop. Afterwards, as we talked about all the things happening in our medical community around physician wellness, he said our little "hotbed of activity" was quite impressive and something we should draw hope from.
There are some great upcoming opportunities to participate in including the remainder of our Physician Vitality series featuring Dr. Paul DeChant and Dr. Colin West in July and September respectively. Dr. Deb Roman has organized a very impressive speaker and topic list around on Meaning in Our Work to be held at the end of September at the JUMP Building. And ACMS just launched the website PhysicianVitality.org to push its growing list of resource out beyond our own local audience.
But I think one of the best tactics for chipping away at our unenviable #1 spot is to start more personal conversations with colleagues whose light has been little dim lately. It might start like this:
Question: "How are you doing?"
Answer: "Fine," (with a flat affect.)
Response "No, how are you really doing? You want to go get a bite to eat and talk about it?"
That level of caring reflects the kind of compassion our medical community is known for, regardless of what the statistics say.