EP. 72: RESILIENCE AGAINST BURNOUT
WITH GAIL GAZELLE, MD
A physician coach shares how she helps doctors build resilience and confidence in order to overcome burnout and rediscover joy in medicine.
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Episode Summary
According to our guest on this episode, Gail Gazelle, MD, there has never been a more difficult time to be a doctor. Whether or not you agree with this statement, it's true that clinicians today are expected to see more patients in less time than ever before, spend hours on the electronic medical record, and manage countless administrative and organizational pressures. Dr. Gazelle is a physician coach who specializes in helping doctors build resilience and confidence in order to overcome burnout and rediscover joy in medicine. She is the author of the book Mindful MD: Six Ways Mindfulness Restores Your Autonomy and Cures Healthcare Burnout. Over the course of our conversation, we discussed the psychological and organizational factors that contribute to burnout and what we can do to overcome them.
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Gail Gazelle, MD is faculty at Harvard Medical School, a 25-year practicing hospice physician, and coach to over 500 physicians. She is one of the preeminent physician coaches in America. She utilizes evidence-based neuroscience, mindfulness, and physician leadership techniques to not only help combat burnout, but to help physicians develop leadership skills, broaden emotional intelligence, increase their healthcare resilience capacity, and reach maximum potential despite ever-increasing demands.
A longstanding mindfulness practitioner and certified mindfulness teacher, she helps clients become more present and able to meet the many demands they face. Dr. Gazelle helps physicians improve efficiency, manage conflict, and heighten team effectiveness, not only enhancing performance but maximizing fulfillment.
Dr. Gazelle's book, Everyday Resilience: A Practical Guide to Build Inner Strength and Weather Life's Challenges came out in August 2020 and her second book, Mindful MD: 6 Ways Mindfulness Restores Your Autonomy and Cures Healthcare Burnout, comes out in June 2023.
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In this episode, you will hear about:
• What drew Dr. Gazelle into medicine and what eventually led her away from clinical practice - 1:58
• The differences and similarities between coaching and therapy - 7:22
• How much of coaching is about helping people change the narratives of their lives - 9:45
• The kinds of people who seek Dr. Gazelle’s help - 14:18
• The increasing acceptance of coaching in the healthcare profession - 15:51
• The extent to which an individual clinician can address burnout - 24:49
• Reflections on how perfectionism creates overstressed physicians and how to change that - 34:04
• A discussion of Dr. Gizelle’s book Mindful MD and the six ways mindfulness can help physicians - 40:25
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] According to our guest on this episode, Dr. Gail Gazelle, there has never been a more difficult time to be a doctor. Whether or not you agree with this statement, it's true that clinicians today are expected to see more patients in less time than ever, spend hours on the electronic medical record, and manage countless administrative and organizational pressures. Dr. Gazelle is a physician coach who specializes in helping doctors build resilience and confidence in order to overcome burnout and rediscover joy in medicine. She is the author of the book Mindful MD: Six Ways Mindfulness Restores Your Autonomy and Cures Healthcare Burnout. Over the course of our conversation, we discussed the psychological and organizational factors that contribute to burnout and what we can do to overcome them. Gail, welcome to the show and thanks for being here.
Gail Gazelle: [00:01:56] Oh, it's a pleasure to be here.
Henry Bair: [00:01:58] So we've actually spoken with a physician coach before, but this is the first time we're speaking with a physician coach who is herself also a physician. So in that respect, we are looking forward to hearing your perspectives. Can you start by giving us a little bit about your background? How did you get into medicine and how has your career evolved since?
Gail Gazelle: [00:02:21] Wonderful. So I went to medical school because I was interested in end of life care. I had volunteered in a hospice at Cornell as an undergrad, and I was really drawn to this population of terminally ill patients, even though I'd never experienced premature deaths. And I didn't actually really understand at the time what drew me to this specific patient population. But that's why I went to medical school and then I did my residency in internal medicine. This was in the late 80s. Palliative care was not yet an established field. There was nothing in the medical journals about end of life care. So I did a medical ethics fellowship here at Harvard Medical School thinking, Well, there's a lot of ethical issues in end of life care. Maybe this will get me closer to what I want to do. And in fact, I was working as an internist in a large HMO here in Boston. And when they decided to form a palliative care program, they looked around. Well, she knows something about medical ethics. Let's pick her. And even though I'd barely written a script for an opioid in my career, but off I went in my field of end of life care, which I was really passionate about. And then I experienced my own burnout.
Gail Gazelle: [00:03:36] Know, I had a child on my own, so I was a solo parent. I felt guilty when I was at work that I wasn't with my son. When I was with my son, I felt like I should be doing more for my patients and reading more medical journals. So I actually stumbled into coaching and found coaching both career changing and life changing. It was kind of like leapfrogging forward. So that's when I decided to become a coach, and that's 13 years ago. So along that journey, I've had the pleasure of coaching well over 500 physicians and physician leaders around burnout, resilience, communication skills, conflict management, leadership development, all those kind of soft skills, so to speak, that we don't learn in our clinical training. And I've also had a long standing interest in mindfulness. I've had my own mindfulness practice and I've seen the benefit of a mindfulness approach, which we can get into more for the clients that I've coach. So I did a two year immersive training to become a certified mindfulness meditation teacher. So that gets incorporated into the work that I do. And as you've mentioned, I had a book come out actually just in June of 2023. Mindful MD: Six Ways Mindfulness Restores Your Autonomy and Cures Health Care Burnout.
Henry Bair: [00:04:57] So just to clarify for our listeners, are you currently practicing medicine?
Gail Gazelle: [00:05:04] No. Unexpectedly, about ten years ago, my trajectory changed. So I've mentioned that I had a child on my own and he developed Crohn's as a teenager and life suddenly became very medicalized. So I actually couldn't go to work and abruptly ended my career in hospice and palliative medicine, thinking I would go back. My son stabilized. He's doing fine now. He's a healthy 26 year old man. But I didn't end up going back to my profession, which again was completely unexpected. This fork in the road that kind of came in my path.
Henry Bair: [00:05:40] So can you tell us a little bit more about what having to leave medicine was like for you? Like, I mean, I have to ask, as simple as do you miss it? Do you regret not having gone back?
Gail Gazelle: [00:05:53] I regretted it for many years. And, you know, along with my son's illness, I, like many physicians, faced ethical challenges. I think it's fair to say that almost every specialty carries ethical challenges at this complicated time that we're in with the corporatization of medicine. So in hospice and palliative care, well, the big ethical challenge is hospices want more patients. So in my case, they encouraged me to admit people who weren't actually dying, the board members sister who, you know, was maybe morbidly obese, but was kind of frail and was losing. He had lost 20 pounds, which maybe was, you know, barely 5% or even 2% of her body weight. Oh, she needs help. Dr. Gazelle, can't we bring her on to hospice? And I was really getting a lot of pressure. So there were some misgivings that I had. You know, again, this is what doctors experience. I don't have to explain that to either of you. So on the one hand, I missed my career, but on the other hand, I felt a little bit of relief in some ways. And then as I progressed as a coach, you know, I found my work really fulfilling. There were not many physicians becoming coaches, you know, in the early 20 tens, which is when I did. And so people were really hungry for this kind of help that didn't involve the same stigma as, you know, going to see a psychiatrist or a psychologist or a social worker. So it was a gradual process, a gradual process of change.
Tyler Johnson: [00:07:22] So let me ask a question in follow up to that comment. You know, as coaches have become more common and more accepted in the medical community and as I have gotten to know more coaches and have spoken to them about what they do in the role that they play, it's become clear to me that it seems anyway from an outsider perspective, that much of what coaches do seems to resemble in many ways what therapists do to the point that in some ways it has become almost difficult for me to articulate precisely what the difference is, even though, of course, I understand that they come with very different backgrounds and from different training environments and all the rest. But can you just articulate for us what is the difference between the role of a therapist and the role of a coach?
Gail Gazelle: [00:08:12] I think it's a great question and there's tremendous confusion. And let's face it, whether you're a therapist or a psychiatrist or a coach, the substrate is the same. The substrate is the human being that you're helping to affect whatever change and reach whatever goals are important to them. So invariably there will be overlap. But the real difference is that coaching is all about change. It's all about results and forward momentum. And sometimes therapy involves that. But many times as somebody who's gotten therapy herself, it's all about talking and it's all about talking about whatever the difficulty is, the past trauma, you know, childhood issues, divorces, complex relationships and coaching is fundamentally about two things. It's about self-discovery. It's about discovering what pushes our buttons, what our patterns of emotional reactivity are, what our patterns of helpful and unhelpful thoughts are, which is really what mindfulness is all about. What stories we tell ourselves. But it's not just that kind of self-discovery. It's self-discovery in the service of change and results. So if you're not moving forward in coaching, there's something that isn't working. In other words, my job as a coach is to help my clients have a lot of aha moments, aha! Moments where they see things in a very different way and they're able to make sense of the challenges that they're facing. And more important, they're able to see the action steps that they need to take to move in the direction they want to move.
Henry Bair: [00:09:45] Uh, can you share with us perhaps a an example, a story of a physician who you helped coach and tell us how you helped them rediscover what ever had been missing in their in their careers or their lives.
Gail Gazelle: [00:10:00] Sure, Happy to. So let me start with a physician that I describe in the book, Mindful MD. So this is a mid-career internist who was really enjoying their career, I would say, until the pandemic. And the burdens which were all aware of were really too much for that individual. They actually lost a family member who died from Covid. And as the pandemic went on and there was under-staffing and under-resourcing and an increase in below grade tasks, this internist really struggled with burnout. And as we began the coaching. They shared with me that as they went through their day taking care of patients, there was a lot of thought going on, a lot of mental action going on. So go into patient one and this internist would find herself saying, you know, the practice of medicine is really just a mess. It's difficult. They're asking me to see too many patients. This is really miserable. How can I possibly be happy? Then going through the day, a few patients later, going in, somebody with chronic incurable illnesses that the internist had followed for some time, and she noticed that there was the same story. This is really bad. They're asking me to see too many patients. How am I ever going to get my charts done? How am I going to get home to my kids? And so as the day went on, it became clear that there was kind of an internal storyline in addition to the difficulties of the day, in addition to the overscheduled patient volume, in addition to the rotating door of medical assistants and the difficult administrators, there was also a mental story.
Gail Gazelle: [00:11:48] And so when I asked this individual, you know, boy, I can really hear how painful this is for you and how challenging it is. But I wonder if you could just tell me a few things that have gone well. Tell me about any bright spots in patients over the last week, for example, there was a dead silence. She couldn't come up with anything. And what became clear is that she was really focusing on everything that was going wrong, the hold of the negativity bias and what we might even call the vortex of negativity that I think many physicians are getting pulled into in the modern health care system. And the story was really obscuring her view. And when I pushed her, she finally told me about a couple of patients who she hadn't really been able to change the course of their chronic illness, COPD, CHF, whatever it was. But she all of a sudden was able to realize how much good she was still able to do and simply the good relationship that she had with her patients every way that she tried to help their quality of life, even if she couldn't change the quantity. And her face softened as she was telling me about this.
Gail Gazelle: [00:12:56] In other words, she stepped out of the mental story that was really making it difficult for her to have a balanced view of her day. The story was obscuring it, and that to me is what coaching is about, but it's also what mindfulness is about. It's getting to know our mental stories. It's getting to know what we attach ourselves to. And often we attach ourselves more to the mental story than the actual experience, the story about the experience as opposed to the experience itself. So, you know, I'm not going to suggest that she started doing cartwheels every day that she went into work. But when she was able to notice the storyline and diagnose it, so to speak, she realized that she didn't have to attach to it in the same way she could let that story just kind of pass through her mind, much like the clouds pass through the sky. And I find that a very helpful visual that I can use with my clients. And once she detached from that story, she found much greater career satisfaction. Again, the difficulties were still there. I'm not some sort of Pollyanna, you know, who's going to tell you that magically it's all going to get better. But the additional burden of that mental story was decreased, and that made the difference between burnout and actually making things manageable.
Tyler Johnson: [00:14:18] This may sound like a pointed question, and I really don't mean it that way, but I am genuinely curious who employs you, Like who is your boss? And really, the reason I'm asking this is because I'm trying to understand, like, who do you ultimately report to or whose interest is at the top of your mind when you're doing your job?
Gail Gazelle: [00:14:41] Well, I guess my clients are my boss. That's one way to look at it. I would say about 60% of the physicians and physician leaders that I coach come on their own and pay privately. They might use their professional development or CME funds, but it's not like their department is paying. Then there are people who are sent for coaching. Okay, disruptive physicians. I coach somebody recently who, you know, needed some help with anger management, a perioperative physician who threw something one day and he was sent for coaching. Sometimes people are sent for coaching because of charting difficulty. You know, there are 350 or 500 or 750 charts behind, and they just can't figure out a way forward. There are also corporations that because they're really concerned about the well-being and poor morale of the physician workforce who might bring I and my team of coaches in to coach a large cohort of their physicians. But that gives you a little bit of an idea of the breadth.
Tyler Johnson: [00:15:51] Okay. So let me give a little bit more context to the reason that I am curious about who employs you and sort of how you fit into the health care ecosystem. You know, maybe 15 years ago, Atul Gawande gave what I think was actually originally an address at the medical school commencement here at Stanford called The Cowboy and the Pit Crew. And in effect, what he talked about in that address was that it used to be that the model of a of the quintessential physician was of a cowgirl or a cowboy, which was to say sort of a person who was out there largely, heroically acting on their own, who was supposed to know how to do everything and was supposed to be able to kind of swoop in at a moment's notice and basically do anything that was needed. But over the course of the last few decades, especially as physicians have increasingly become hyper specialized, virtually all physicians now understand them to be only one important part of a larger whole, both in the sense that almost all patients have many different physicians taking care of them. And so each physician only plays one part in that multi physician team. And then also in the sense that physicians this is more obviously true in the hospital, but is true in the outpatient setting as well, are just one part of this very complex system that involves physicians assistants, nurse practitioners, nurse coordinators, nurse navigators, physical therapists, occupational therapists, social workers and on and on and on and on and on. At the same time that we have seen that evolution that was described by Atul Gawande, I think we have also seen an evolution in terms of the way that we as physicians and the entities that employ us think about physician mental and emotional health.
Tyler Johnson: [00:17:43] 20 or 30 years ago, at least from everything I can gather, physician mental and emotional health was, for all intents and purposes, not even talked about. So, for example, the idea of quote unquote, physician wellness was just not even on the radar screen. Even if most individual physicians, let alone of most corporate or medical entities, then I feel like we have largely arrived at and in some cases are mostly still in a place where now we sort of recognize that that may be a thing that is important in some cases for some physicians. And so some entities may even make funds available where you can spend the funds that are made available by the institution in many of a number of ways. But one of those ways would be to pursue mental health help or whatever. Whereas now I think that we are actually getting to a place, especially in some training programs, where we almost expect both because just physicians are human and also because of the nature of the intensity of the job that physicians have. We virtually expect physicians to need mental and emotional health help. And whether that comes in the form of seeing a therapist first or doing narrative medicine projects or meeting with a coach or whatever it is, I feel like that is becoming a more common and accepted and de-stigmatized part of being in medicine. And so I guess as someone who is on the ground actually providing that kind of help, I'm curious as to have you noticed that same kind of evolution? And what is it like during this period of change to be there on the ground helping to provide help?
Gail Gazelle: [00:19:21] Yeah, without a question. Coaching has become much more accepted and there are now a number of studies, you know, giving us some evidence that coaching can decrease the level of burnout that physicians are experiencing. So it's become much more acceptable. It doesn't have the same stigma as going to see a therapist or a psychiatrist, etcetera. And I think the good news is that, as you say, large employers, health systems, institutions are becoming more willing to put money into helping physicians maintain their well-being because there's plenty of evidence that we're really doing poorly. Right levels of burnout are high, and the rubber has met the road, I would say, for large health care institutions because they can't retain their physician workforce. So, you know, there's something in it for them obviously to put money into something like coaching. So I think it's a very positive development because it's also it's also true that we're in a period where physicians are very skeptical about wellness activities. Right? So, you know, I give a lot of talks about moving from burnout to resilience, leaving the imposter syndrome. I try not to use the word mindfulness all that often because people think it is an AF. You know what? That is another blank growth opportunity that their institution is telling them, Oh, just go meditate and do yoga and keep. The Gratitude Journal and life will be great. You know, you'll do fine seeing, you know, 500 patients a week. So we have to acknowledge that, that physicians are skeptical of what their health care organizations are doing. But you're describing something very different, Tyler. You're saying that the the organization is saying here, here's some money.
Gail Gazelle: [00:21:11] Here's some professional development or CME funds. Use it as you see fit. If you think coaching would help you, great if you think yoga would help you, great. So I think that's a very different frame than just come to this noon hour session and meditate and everything will be great. And I definitely want to counter that view as well while I'm at it. That, you know, mindfulness for me is not about telling people to go meditate in time that they don't have. It's really about gaining mastery over the instrument that each of us uses in all of our waking hours. Guess what? The mind. Because we don't learn that in our medical training, right? We don't learn how to work with the complicated and often unhelpful thoughts that the mind is very busy producing. We don't learn how to work with our patterns of reactivity or even to be aware of what triggers us into reactivity, like the perioperative physician that I mentioned who through something and with mindfulness, we develop not just that awareness of what our mind is up to, but the ability to regulate where our mind is going. And so to me, you know, obviously I'm a proponent of mindfulness since my book is Mindful MD Um, but I think it's important to understand what it is and not necessarily this whole thing about just go meditate and life will be great. I think I think my clients, I might just add, are often surprised how infrequently I recommend meditation. They're busy. They don't necessarily have time.
Henry Bair: [00:22:46] Yeah, we are all very busy. And I can confirm that, you know, during the onboarding orientation for my intern year, we had four five hours of mindfulness / wellness modules. Well-intentioned, obviously, but it's just of note, you know, it was of note that towards the beginning and then at the end they reiterated again that, you know, they wanted us to be patient as they went through this material because it was like for accreditation purposes, I don't know. It just it was the whole thing was very I don't think it was very helpful. And I don't think many of my peers found it very helpful. Unfortunately, I see the value of a lot of what they're suggesting, but perhaps it's just not delivered in the best way.
Gail Gazelle: [00:23:38] Well, I think there's a lot of box checking and certainly the acgme requirements that might have led to these modules. You know, we all know that. And, you know, I just encourage people to be open minded because so many times it's where our mind takes us That really adds to our misery. And that's what interests me. I'm a pragmatist. And so I'm and I and I came from a background of end of life care. So really, I'm very interested in the experience of unnecessary suffering. Unnecessary suffering. My first article came out in the New England Journal. It was exposing the unethical practice of slow or Hollywood codes. Unnecessary suffering to put a fellow human being through a show or mock code in their last minutes on this earth. I think it's a pretty good definition of unnecessary suffering. And so there's so much difficulty. You know, fast forward now to the modern health care environment. There's so many challenges, so much under-resourcing, so many below grade tasks, so much moral injury. And so what parts of that can we control?
Henry Bair: [00:24:49] That's actually my question. My next question was, I think a lot of times physicians feel skeptical, as you mentioned, about fixing burnout, because the assumption is that so much is not within our control. It's the system forcing me to see too many patients, giving me too few days off or my shifts are way too long. Et cetera. So based on your experience, how much of burnout can we actually address by ourselves as the individual clinician on the ground?
Gail Gazelle: [00:25:23] Well, this is a really important question. There's no question. I would say for myself and many others that the health care system in the United States is troubled, which would be putting it mildly dysfunctional and broken. Right. And if we didn't know that prior to the pandemic, we certainly know it now. And so that's a given. The question in my mind, which I think you're getting at, is do we have to turn over our happiness and career satisfaction to a broken health care system? Because that's what many physicians are doing. And I'm here to say that you don't have to do that. You invested a lot in developing this career, and this is a really rewarding career in many ways that obviously the two of you and your listeners are well aware of. And I want to encourage physicians to do anything that they possibly can. To work on the systems level. Critically important. There's just not even any question about that At the same time. Again, you can still enjoy this career. You don't have to go home and sit at your dinner table and be so irritated and emotionally spent that when your spouse asks you how your day was, all you can do is tell them about all the miseries. And when your ten year old child is sitting there wanting to tell you about his or her day, you're so spent and you're so trapped in the ruminating mind that you can barely attend to that beautiful child's needs, and then you feel guilty and it all goes down, down, down. So what really interests me is how to stop that downward cycle, stabilize it and move it upward. And to me, that's a lot of what the mental mastery of mindfulness helps us do. It's not going to fix the broken system. It's not going to get rid of the non clinician administrators. It's not going to change your ma who doesn't listen after the instructions you've repeated six times over and rolls your eyes when you ask them to do what you've asked them to do all those times. But it can cut down on the additional misery that our mind contributes to.
Tyler Johnson: [00:27:41] Yeah, You know, it's interesting in listening to you because your comments here make me think of something that I often tell, especially to interns that I work with in the hospital, but really to any medical trainees, which is that the two most dangerous things in medicine are either the thing that you don't know, that you don't know, or the thing that you think you know but have wrong or don't actually know. There's nothing more dangerous than unaware ignorance or ignorance that you wrongly think is is knowledge. And one of the things that I have thought about a lot is that when you talk about any form of one person helping another person with their mental health, whether you find that help through therapy or coaching or even just from a friend, what have you. I think that one of the ways to think about what a person is doing, if they receive that kind of help, is it's as if they are being helped to map the territory of their own heart and mind so that they come to a place where they understand, if you will, their inner terrain better. And I think that one of the problems that exists in wider society, but also in the medical community that may help to explain the stigmatization of receiving any kind of help for your mental health is that it almost feels a little bit like magic, right? Like it's so nebulous that it sort of feels as if you're being invited to have a mental health practitioner wave a magic wand, and then after they've waived it, somehow your mental health will be better.
Tyler Johnson: [00:29:25] But if instead you think about it as building a skill set, a person teaching you skills to help you better cope with whatever the demands or difficulties of life or medical practice or whatever are. I feel like that idea of conceptualizing it as building skills rather than having a magic wand waved at you both demythologize and potentially destigmatizes receiving that kind of help. And so I was hoping that you could talk a little bit again as somebody who's on the front lines with this, can you just talk a little bit about do you think that that does that understanding ring true to you? Does that does that kind of fit or make sense?
Gail Gazelle: [00:30:10] Well, that's a very articulate way of describing mindfulness. You could have maybe contributed to my book, Mindful MD. And you know, in the first part of the book, which is a very short part of the book, I describe what I call the roots of burnout that we learn in our training. Perfect. If we're not perfect, we might be deemed a failure, never show weakness, never call in sick. The ever knowing Paragon and captain of the team who always has the right answer even in the early phases of a pandemic when there was no answer. This is these are things that we learn and we also learn in our training to be very harshly critical of ourselves. We get into our lives as attendings, and we don't always realize how some of those roots of burnout have been growing underneath the surface. So I coach a lot of physicians who are struggling to get their charts done. The Achilles heel, you know, of the modern physician, and they've been through being shadowed by the epic person meeting with the efficient charters on their team. They've had the sit downs with their administrator who basically says, just get your charts done. Everybody else can get them done. What's wrong with you? You know, they have all the best hacks that are out there and they still can't get their charts done.
Gail Gazelle: [00:31:36] Well, many of those physicians are closet perfectionists. They sit down to chart and maybe they were an English or sociology major and they never wrote an imperfect sentence in their life. And all of a sudden they've got to write the notes that we all know are not exactly perfect English in 2023, Right? You just have to get the job done. Furthermore, they may sit down to chart and I've really heard so many physicians talk about the harsh inner messaging that they experience. They sit down to chart and no sooner have they opened Epic or whatever the system is, and they're telling themselves things like, you know, I'm not as smart as other docs, I'm not as efficient, I'm not as compassionate. I don't really have what it takes. And then they wonder why they're surfing the web, you know, filing their nails, looking at the family shopping list. And another aspect of the charting inefficiency, which is a little bit hidden from view but comes from the roots of burnout, is that we often feel like we have to prove our worth right. You know, in our training, there's so many comparisons and ratings and rankings. And we in the hidden curriculum of medical training, we learn that we have to act in a certain way.
Gail Gazelle: [00:32:53] So many physicians don't see their note as a note. They see it as proof of worth. Wait a minute. What about when the cardiologist reads my note? I need to sound smart because, after all, you know, this is this is very common. And so it's not magic. It's not voodoo, but it's helping bring into conscious, mindful awareness where you're getting hung up. Because many times we just don't realize the things that are holding us back. And we think to ourselves, you know, with the charting example, what's wrong with me? Why can't I get these darn charts done? And so my job as a coach is to kind of bring some of these themes and patterns out of the shadows and into full, as I say, mindful awareness because it's almost like making a diagnosis. We have to diagnose what our mind is up to and what our patterns are. If we stand any hope of changing those patterns, right, we can't intervene until we diagnose. And it's kind of similar with the workings of our own minds so far from magic. It's a fairly methodical approach, actually, which I think you can hear in this example.
Tyler Johnson: [00:34:04] Yeah. So you know, that that comment makes me think of the fact that I feel like so much of what we end up having to learn as physicians is how to unwire our own wiring, or at least how to fight against our own accumulated cultural expectations. So I'll give you an example of that. I am a mentor at Stanford for medical students and part of a group of people who mentor medical students at Stanford. And one of the things that we have monthly meetings where we talk about things that are on the students minds and how we can better support and mentor them. And one of the things that often comes up in those meetings is that we recognize that at Stanford, as with many other similar medical schools, and I know this was certainly the case where I went to medical school at the University of Pennsylvania, there is this sense that not only do you need to be a fantastic medical student, but it's not enough to be a fantastic medical student. You need to be a fantastic medical student and fill in the blank with whatever a budding CEO or a budding author or whatever. The other thing is, and I mentioned this primarily by way of saying that what we often talk about in these meetings is that we grow concerned that students run themselves ragged trying to meet what often feel like virtually an impossible set of cultural expectations. But at the same time, when we are having these conversations about how to help people to disengage that part of their medical training wiring, inevitably someone will raise their hand and say, Well, yeah, but how fair is it for us to expect that they're going to be able to disentangle that element of their wiring when those students who run themselves ragged in order to accomplish superhuman things are the very kinds of students for whom we select for admission to Stanford Medical School.
Tyler Johnson: [00:36:00] Right? It's like we valorize that act of running yourself ragged. And of course, we communicated in all sorts of informal, unwritten ways while they're students at Stanford to only then turn around as mentors and be worried about the fact that they're doing the very thing that we have implicitly told them is the thing that they should be doing right. In a sense, it is kind of talking out of both sides of our mouths, which is just to say that I think the same thing happens in the way that we train physicians, right? So you talk about one possibility being not being quite as much of a perfectionist in terms of writing your notes. And yet at the same time, that's precisely what we teach all physicians that they need to do as they're coming up through their training, right? They write their notes and then a supervising resident or later an attending scours those notes looking for any mistakes or even places where you just haven't, you know, had as complete of a discussion as maybe you could have and then tells people that they need to improve what they're doing in the notes in, you know, ABC, X, Y, Z ways. And then now we're going to turn around and say, well, okay, maybe you don't have to be quite as detailed and comprehensive and persuasive, whatever in your notes. It's just it's a lot of burden to try to disentangle the stuff that you spent a decade wiring while you were in training.
Gail Gazelle: [00:37:21] I think it's a point very well taken. And I think that we have to be discerning about how we use our internal patterns, like perfectionism, because perfectionism can help us strive for excellence. Perfectionism can also become maladaptive where we're overly concerned about performance, and we're not as concerned about how we take care of patients, but we're concerned about how we're viewed. And there's a lot written about maladaptive perfectionism. What I think is really missing in our medical training, again, is this ability to help trainees discern when a certain skill is useful and when it is not. And I think perfectionism is a really good example of that. Another example of that is harsh self-criticism. In other words, if we have a case that goes poorly, a complication, whatever it is, of course we want to learn from that. You know, we'd be crazy if we didn't want to learn from any potential errors or mistakes. So self-evaluation bordering on self-criticism can be kind of a helpful type of inquiry. After a difficult case, what could I have done better? What could I have done differently? What will I do differently next time? That's a really important part of our training and hopefully our lives as we continue in our careers. When we overuse that same technique of self-criticism, then it really goes awry. And so definitely we could question the admissions process.
Gail Gazelle: [00:38:58] There's a fascinating article that Zeke Emanuel wrote a few years ago. I think it was either in Jama or the New England Journal about should we be looking at EQ as opposed to IQ. Zeke happened to have been one of my mentors in my medical ethics fellowship some years ago, but he brought up a really good point, You know, and I think we can question the qualities that search committees at elite institutions like Stanford, like my institution, HMS, that they look for. And we could really question does that really bring in the right mix of skills and attributes that are going to contribute to a healthy physician workforce and an effective physician workforce? But at the same time, I think it's a both / and. I think as we get to know mindfully our own patterns, we can become more judicious. So for the charting example, we can think to ourselves, Well, is perfectionism really helping me here? Probably not. There just aren't enough hours in the day to write perfect notes on all the many patients you have to see. So to be able to really be very intentional based on your understanding of your own patterns and where you get tripped up, I think that can help all of us have longevity in our careers.
Henry Bair: [00:40:16] The article that you mentioned is a viewpoint piece from the Journal of the American Medical Association. We'll be sure to link it to the show notes of this episode. So, you know, your new book, the subtitle is Six Ways Mindfulness Restores Your Autonomy and Cures Health Care Burnout. So with a subtitle like that, I would really like to know what those six ways are. Would you be able to share with us a glimpse of what those six ways are?
Gail Gazelle: [00:40:44] Yes. Well, the first way we've discussed recognize that you are not your thoughts. In other words, the mind produces all kinds of thoughts, some of which are exceedingly helpful and some of which are grossly unhelpful. And we don't learn in our training that many of our thoughts are not factual and we don't have to believe them all. So that's the first way. The second is stepping out of mental stories. So the vignette that I shared about the internist who had the mental story about how miserable it all was and how they are keeping me from enjoying my career. That story could be 100% true. It could be 100% false. It could be somewhere in between. We have to question our mental stories. The third way is reducing reactivity. We have to understand our own patterns of reactivity. Again, we have to diagnose them so we can work with them. The fourth is to lean into compassion, connection and purpose. Most of us became physicians in the first place because of those three things connection, compassion and purpose. But we lose sight of them and I think they can really help us bring us back to what's deeply important in our roles in health care. The the fifth is a funny one.
Gail Gazelle: [00:42:02] Work with what is and maybe I'll come back to that one in just a minute, because the sixth is the culmination of the other five, which is cultivate upward spirals. Let me go back, though, to work with what is that has to do again with some of the fictions of the mind, what I call the I'll be happy when disease, so I'll be happy when they get rid of this miserable EMR. I'll be happy when I don't have these non clinician administrators dictating the practice of medicine. Similarly, I can't be happy if I have to see X number of patients and I'll only be happy when I retire. Now, some of these again may have kernels of truth, but just think about the stories that you might tell yourself about happiness in the future. So let's go back, as you were talking about Tyler, to admissions to medical school. So you're in college. Oh, I'll be happy when I get into med school. You get into medical school. Wow. I'll be happy when I get the right residency and when I match just where I want to be going. Right. Then you're in residency. And here's the kicker. I'll be happy when I'm in attending.
Gail Gazelle: [00:43:19] And most attendings like really smirk when they hear that one, because we have, again, these illusions about happiness. We're not working with what is. We're working with this fantasy of what might be. And I think that what I've just shared with you illustrates that the mind is a very poor predictor of what's going to bring us happiness. And these stories keep us and this, this, this not working with what is. Keeps us from actually experiencing happiness, satisfaction and fulfillment right here, right now. And the only moments that are truly real because we don't know what the future is going to bring. We don't know whether we'll be happy or unhappy. You know, if I marry the right person, I'll be happy. You know, all these kind of I'll be happy when. So those are the six ways. And I have seen them really be very dramatic in how they have helped physicians restore their sense of autonomy. Not the external autonomy, about how many hours and the working conditions. We have lost control over much of that. But the true autonomy that we can have, which is the autonomy over ourselves and the autonomy over how we respond to the challenges that come our way.
Tyler Johnson: [00:44:36] You know, all of this leads me to think about Henry and I were joking the other week. I was I knew that this was true when I went through my training, and I was wondering if it was still true for Henry. And he affirmed just as he's getting ready to start his intern year, that yes, in fact, it is true. So back when I was a resident once a year by ACGME Fiat, we were forced to watch this video module on the importance of sleep hygiene. Which was all fine and good. Except that, of course, when you're an intern, the one thing that you never do is have healthy sleep hygiene. And it's not because you just suddenly decide that you don't care about sleep. It's because you're working 30 hour shifts or 16 hour shifts or whatever it is, Right? But you're working like 80 hours a week and you there are only so many different ways to rearrange what you're doing and how much you're sleeping. And so it's so funny because you take this this annual Acgme survey where they ask you, did you watch a module on the importance of appropriate sleep hygiene? And the reason that every program has you watch the module is really, if we're being honest only so that you can answer the Acgme survey question in the affirmative that yes, you watched the module, but you watched the module and then you're sitting there thinking and does this mean you're reducing my hours in the ICU? Or like, what am I really supposed to do with this stupid module that tells me how important this thing is that I then can't ever do right? And so by the same token, I can imagine that there are probably people who are listening to this podcast who are like, "Yes, great, really love the idea of coaching or therapy or mapping the territory of my, you know, mental world or whatever.
Tyler Johnson: [00:46:14] But hello, I'm an intern and I'm working 80 hours a week, so you know, how is that going to help me? Because I'm certainly not going to get any, you know, coaching as an intern. I know that some places have started to do that a little bit, but even if they do, it's probably, you know, an hour in your first six months and an hour in your second six months or whatever it is, Right? And so it's just to say that it I think it the irony is that the people who need it the most are the people who have the least access to it just by virtue of the constraints of the training environment. So I guess all of that is to say that if there is some intern somewhere or medical student or whatever who is listening to this and thinking, yes, I totally agree. This is really important, I want to tap into the help that that could offer, but I just don't know how practically to do that right now. What can you offer them in terms of what might be helpful?
Gail Gazelle: [00:47:04] Well, you kind of helped me walk into reading this book mindful because it's an easy read and it's not about going and doing something for hours a day. It's about things that we can incorporate in our busy days without adding time on. And what I hope the book also helps people see is what's in it for them to take control of this instrument through which we experience everything in our lives, our mind. So why do we human beings do anything? Well, we do it because there's something in it for us and for trainees and for attendings. There is such a great deal of suffering going on. There's a lot of misery, right? Physicians retiring, early physicians, unfortunately engaging in self harm. Physicians not being present with their loved ones and feeling really terrible about themselves because they can't be present because they don't know how to turn off the ruminating mind. And what I've really tried to do in the book is to make this very accessible to physicians and really to anyone in health care so that they can incorporate some of these six ways in in a in a way that doesn't require extra time or effort. We don't have that extra time, Right. We're all being pushed to the max in this complicated health care matrix. And yet there are things that we can do very readily. And what I find as a coach and what I really tried to share in the book is that a lot of this has to do with having a-ha moments. We just don't realize in the ways that our minds are tripping us up. And once we realize it, i.e. Make that diagnosis, it's not that hard to intervene. So again, I hope that your listeners will avail themselves of the Mindful MD book. They can download a free chapter at GailGazelle.com/mindfulmd and they can see for themselves if this can be helpful. I think they will be very pleasantly surprised.
Henry Bair: [00:49:10] We definitely will link all the information in the show notes here. Just a quick note. We've spoken with psychologists, psychiatrists, plastic surgeons, pediatricians, deans of medical schools, presidents of big, glamorous, famous medical associations. And we've heard a lot of diverse stories. But I would say if there's one thread that runs across all the stories that we've heard about what makes medicine meaningful, or at least how we can begin to even think about addressing this issue of burnout that we're seeing everywhere, it's actually your your fourth way of the sixth, which is the connection, purpose and compassion. Right? The purpose and the connection part is what we've found to be something that comes up over and over again no matter who we talk to. I found that to be insightful. Well, with that, we want to thank you again, Gail, for your time and for sharing your stories and your insights. I hope that our listeners will find what you have to say deeply valuable and meaningful.
Gail Gazelle: [00:50:23] Well, a total pleasure speaking with you today.
Henry Bair: [00:50:27] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:50:46] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:51:00] I'm Henry Bair.
Tyler Johnson: [00:51:01] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
In this episode, we discussed the Atul Gawande's 2011 Harvard Medical School commencement address, titled Cowboys and Pit Crews, later published in the New Yorker.
We also discuss the article Does Medicine Overemphasize IQ? by Ezekiel J. Emanuel & Emily Gudbranson, originally published in the Journal of the American Medical Association.
Gail Gazelle is the author of the book Mindful MD: Six Ways Mindfulness Restores your Autonomy and Cures Healthcare Burnout (2023); you can download a free chapter at GailGazelle.com.
She also authored the article The Slow Code: Should Anyone Rush to Its Defense? published in the New England Journal of Medicine, which we discussed in this episode.
You can follow Dr. Gazelle on Twitter @GailGazelleMD.
