Joseph R. Hageman, MD
You know the feeling! When you are in your office, and your Chairperson calls you to talk about a new idea for a project, which turns out to be more than just an idea, just when you have gotten out from under your notes, billing, and are just off service. And it turns out that he/she would like you to organize the new quality improvement committee, for example. Oh, and how are things going with your research projects? Have you submitted your abstracts for pediatric academic society, yet? What about your idea for the workshop? BTW, I have a great opportunity for you to write a review article or a chapter. And were you thinking about promotion? I am only looking out for your career.
You know they really are looking out for you and your professional life. Then the pager/phone goes off, and you have another patient who you need to see in the emergency department who is going to be admitted, and you are the attending.
How do you once again, rise to the challenge? You are a dedicated physician, right? You care about providing the best care for your patients and their families. Your personal AND the professional expectation is that you will always be ready and be at the “top of your game.”
What is resilience, really? What strategies can you use to bounce back, especially when you are feeling mentally and physically exhausted?
Jensen and colleagues present a study about building physician resilience, which I found really helpful in trying to define and clarify what resilience is (1). They concluded that “resilience is a dynamic, evolving process of positive attitudes and effective strategies” (1). They summarized four main aspects of physician resilience: 1) attitudes and perspectives, 2) balance and prioritization, 3) practice management style, and supportive relations (1). The major categories of each of these aspects are summarized in the Table. I think this is a practical guideline that may be used at regular intervals to survey your “resilience status” in your practice and for you personally.
Moreover, if when you review the table, you find there are areas, for example, maintaining interest, that you are having some doubts, ask yourself “Is this just relative lack of interest just related to the type of clinical problem I am dealing with?” For example, we all have clinical areas that we find much more interesting than others…or that we have a special interest in. When I was a fellow in neonatology, I really enjoyed sitting at the bedside and caring for newborns with persistent pulmonary hypertension of the newborn as their management and clinical course might change from minute to minute (2,3,4). On the other hand, when I was on the pediatric floor as a hospitalist, there were issues related to the social status of a patient and their family that I found important but less exciting. However, if you begin to feel that you are losing your interest and enthusiasm for caring for patients in general than it is important, to be honest with yourself and find someone who you can talk with, as this is a sign of compassion fatigue/burnout (5).
Sometimes, when you are feeling tired or overwhelmed or extra stressed, these feelings or apparent changes in attitude are just temporary. All of us can have “bad days.” It is important to take a couple of minutes, which I usually did after the infant, child or adolescent was finally stable, and take a breath, sit in your office or a quiet room, and relax your mind. I learned mindful meditation and guided imagery in 2007 from David Victorson, a psychologist who offered Evanston Hospital employees “in-services” at 4:30 pm on Tuesdays. This was at the time when I was working on trying to resume clinical practice after having to take time off with a chorioathetoid movement disorder, depression, and chronic pain.. David was terrific, kind and very supportive to whoever came to the auditorium. Boy, do I wish I had learned this about 27 years before this time. The principles come from work by Jon KabatZinn, Ph.D. who pioneered the principle of living in the moment… just enjoying simple things in that moment and letting all of your thoughts move through your mind (6,7). In the introduction in his book, he states “mindfulness is awareness, cultivated by paying attention in a sustained and particular way: on purpose, in the present moment, and non judgmentally” (6).
My early attempts at mindful meditation started with David’s sessions as he was really good at guiding us as we learned to breathe through our nose, attention to our breath, sitting in a relaxed position. It was challenging to be able to genuinely focus and let all of the thoughts going through your mind, especially when things are not going well for you in your professional life. He encouraged just taking a few minutes each day to do mindful meditation but to be consistent in our practice. In a more recent project for pediatric residents, which was organized by Dr. Mallory Taylor with assistance from Dr. Melanie Brown and yours truly, she used the Headspace® app as a tool to help the residents learn mindful meditation (9).
More recently, mindful meditation has become automatic for me. In times of stress, with chronic pain as I spend the day at 3/10 on the pain scale, when I have a couple of minutes in the office or at home. It helps me with my nightly sleep routine, not that I am no longer on call all the time. My guided imagery involves visualizing my home and neighborhood in Evanston. I will pay attention to my breathing when my wife Sally and I are walking with our dog, Stella in our neighborhood.
Other activities that help me maintain my energy level and resilience include reading, especially biographies of writers I respect and admire like Charles Dickens, Mark Twain, Harper Lee, and Stephen King. Now that I am doing a lot of writing, I like to read about writer’s routines and learn how they maintained their productivity. I enjoy making small contributions to the literature and doing a lot of editing for Pediatric Annals, Neonatology Today, and helping the nurses, neonatal nurse practitioners, residents, fellows, and faculty with publications.
Regular exercise in the form of walking, treadmill, stationary bike, stretching, yoga, and swimming really help with the chronic pain, mostly neuropathic, and help keep my mind clear…and generate new ideas.
A good night’s sleep, now that I am no longer on call, makes a big difference as well. I do keep a small yellow pad near my bed to write down thoughts and ideas.
Having a son who is now a Tier X Personal trainer at Equinox, as well as a nutrition counselor is very helpful as well. Patrick makes good suggestions for exercise and diet. In this month’s issue of Pediatric Annals, Dr. Hilary McClafferty is our Guest Editor and one of her authors, Dr. Maria Mascarenhas wrote an excellent article about the Mediterranean diet, and its anti-inflammatory attributes (10). Hilary’s introduction to Integrative Pediatrics provides our readers with some basic principles that we can all use in our practice as well as in our personal lives (11). Dr. Melanie Brown also contributed an excellent article about strategies for dealing with stress and anxiety, and building resilience in children, which I actually found very helpful (12).
If you need a hobby or diversion from your very busy professional activities, there are a variety of things you can involve yourself with including being a collector. I have been collecting old books, especially Dickens for about 40 years and really enjoy it. I also collect baseball cards. But whatever you decide to do, it helps to have an activity to take your mind off of all of your professional responsibilities.
Another piece of sage advice came from Dr. Mickey Caplan, who had to let me go from my position at North Shore University HealthSystem in Evanston in 2007 when I couldn’t make it back to practice. He told me that I need to take care of myself as my top priority as I will be no good to anyone else if I don’t take care of myself. Then I should care for my family, then, my career. In medicine, it is tough to sort out what our top priority is, as it may change from day to day when you are caring for a critically ill infant, child, or adolescent. But as you see in the table, included in the list is “honoring the self,” having positive personal and professional relationships, and developing self-awareness.
Maintaining your professional energy level and your resilience is a dynamic, ongoing, and challenging process for all of us.
References:
- Jensen PM, Trollope-Kumar K, Waters H, Everson J. Building physician resilience. Canadian Fam Physician 2008; 54 722-729.
- Hageman JR, Adams MA, Gardner TH: Trends in the incidence, diagnosis and management of persistent pulmonary hypertension of the newborn. Am J Dis Child 1984; 138:592-595.
- Hageman JR: Mortality of persistent pulmonary hypertension of the newborn. Letter to the Editor. Am J Dis Child 1985; 139:115.
- Hageman JR, Adams MA, Gardner TH: Pulmonary complications with hyperventilation therapy for persistent
pulmonary hypertension of the newborn. Crit Care Med 1985; 12:1013-1014. - Bohman B, Dyrbye L, Sinsky C et al. Physician well-being: The reciprocity of practice efficience, culture of wellness, and personal resilience. NEJM Catalyst. 2017. 1-14.
- Kabat-Zinn J. Mindfulness for beginners. Sounds True: Boulder, Colo. 2016.
- McClafferty H. Mind-body medicine in clinical practice. London and New York, Routledge, 2018. P. 3.
- Epstein RM, Krasner M. Physician resilience: What it means. Why it matters, and how to promote it. Academic Medicine 2013; 88(3):301-303.
- Taylor M, Hageman JR, Brown M. Brief Mindfulness Intervention in Pediatric Residents: Relevance for Pediatricians. Pediatric Annals.2016; 45(10): e373-e376.
- Mascarenhas MR. Pediatric anti-inflammatory diet. Pediatric Annals 2019;48(6):e220-e225 https://doi.org/10.3928/19382359-20190515-02
- McClafferty H. An overview of pediatric integrative medicine. Pediatric Annals 2019;48(6):e216-e219 https://doi.org/10.3928/19382359-20190515-04
- Brown ML. Integrative approaches to stress, anxiety and resilience. Pediatric Annals 2019;48(6):e226-e230 https://doi.org/10.3928/19382359-20190515-05
The author has identified no conflicts of interest.