Hello, my name is Dr. James O'Shea, I'm an emergency physician and member of the SCCM emergency medicine section. Thanks for joining me for this short talk on coping skills and burnout. If you're engaged in clinical work, you're already expertly using a myriad of coping strategies. We use coping strategies when there is an imbalance between the demands of a situation and the perceived resources available to manage it. Many coping strategies are not intrinsically good or bad, but are more or less skillful depending on the context. Less skillful coping strategies are generally avoidance behaviors such as excessive alcohol use and involve decisions that lead to being less present for yourself, the job, and others. More skillful coping strategies would include activities that promote engagement, again with yourself and your needs, with the job and its demands, and with patients. Burnout is an occupational syndrome characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment. The most recent data from the annual Medscape survey of burnout in medicine shown here reveals high levels of burnout across the front lines of medicine, with ICU physicians reporting 59%, up considerably from pre-pandemic levels. COVID has been a marathon, with many physicians already exhausted at the pre-pandemic starting line and with no finish line in sight now. In light of this, it is more important than ever that we take care of ourselves and each other. Burnout has organizational roots, and the key interventions to manage and avoid it are therefore also organizational. But it is still experienced at the individual level day-to-day on shift, and so while we strive for organizational change, it's also imperative to practice self-care as a physician. In developing this talk, it would be great to have more evidence to lean on. Unfortunately, despite the need, there are no large randomized control trials that have examined strategies to prevent or treat burnout in critical care physicians. In the early days of physician wellness, there was a heavy focus on increasing the personal resilience of physicians. In this Stanford model, you can see that personal resilience is at the bottom one-third of the pie, but not that long ago, personal resilience was the whole pie. The message was, if you can't stand the heat, get out of the kitchen, or at least become more heat tolerant. Now there's a greater understanding that healthcare organizations have a responsibility to redesign the kitchen, rather than focusing on what individual physicians need to do. This type of kitchen redesign, if you will, might translate into organizational interventions such as altering the ICU environment, creating efficient workflows, making lean and sensible EHRs, building structures of support for staff, managing schedules with appropriate staffing levels, managing conflict, optimizing end-of-life care, minimizing futile care, and fair compensation structures. While we will touch on organizational factors in this talk, this topic will be dealt with elsewhere in the series, and our remit today is to focus more on the individual coping skills one can use. So now that we've set the scene, as it were, we're going to roll onto another wheel. A basic but actually pretty comprehensive approach to individual wellness in general is to consider the seven spokes on this wellness wheel. While there are many similar versions of the wellness wheel, I particularly appreciate this version from ASAP, because it builds in both personal and organizational components for each spoke, underlining the importance of organizational change in addition to the hard work you do as an individual to keep yourself functioning optimally. The seven spokes are emotional, remembering that while there is a physical and cognitive labor involved in ICU work, there is also emotional labor, physical, with the basics of exercise, sleep, diet, and health maintenance, occupational, keeping meaning in your work, financial, managing debt and planning for a comfortable future, possibly with financial advice, spiritual, which could be humanistic, secular practices such as gratitude, mindfulness, or keeping in touch with the faith that sustains you, social, maintaining a healthy personal and professional community and culture, and intellectual, tending to your professional development and education, growing your niche interests. The slide is fairly busy, and you can read it in detail at your leisure. In this talk, I'm just going to draw out a few points from each spoke to look at further. The first spoke is concerned with emotional factors. It doesn't take much time spent in an ICU to know that while there is considerable cognitive and physical labor involved, there's also emotional labor that has to be worked through and managed. This emotional labor can be facilitated by mentoring and peer support, training both formal and informal in conflict resolution, and our own unique styles. The secondary trauma is quite significant in a speciality that deals with end-of-life care and critical decisions. One aspect of emotional labor that is important to have a working knowledge of is the difference between empathy and compassion. Research in this area is complicated by the variety of definitions, but put simply, empathy involves actually feeling the pain of another person, involving neural pathways that elicit a pain response, and this is accentuated when the difference between other and self is blurred by over-identification. Compassion, on the other hand, is a desire to help and increase activity in areas of the brain involved in dopaminergic reward and oxytocin-related affiliative processes, and enhances positive emotions in response to adverse situations. Empathy is very important, and it may provide the human spark to motivate helping, but it should be handled with care, with a mindfulness of the other's self-distinction and a focus more on compassion, the desire to help, within the limits of what is possible for you as an individual situated in a constrained environment. It's interesting to note that the schools of Buddhism who have spent a few thousand years thinking about compassion consider empathy as exhausting, and compassion as positive and limitless. In this formulation, compassion fatigue may be better termed as empathy fatigue. In terms of resources for this emotional skill, the Emory Center for Contemplative Science and Compassion-Based Ethics offers a well-validated course called Cognitively-Based Compassion Training, and the Center for Mindful Self-Compassion, directed by Dr. Christine Neff, also offers courses for healthcare providers, and interestingly, Dr. Neff has one of the most viewed TED Talks in history, and is available on YouTube if you have a minute to look at it. If a primary care doctor has a physician as a patient, I would wager they wouldn't be able to pick them out of a lineup. Doctors are often strangers to their own doctors. My own qualitative research in frontline doctors points to a professional culture that encodes a dichotomy of strength and weakness, with strength associated with patient care and productivity, and weakness associated with self-care. The irony is that our patient care and productivity are, of course, heavily influenced by our self-care as physicians. As physicians, we may benefit from having the mentality of a professional athlete to things like eating, drinking, and sleep. Chest compressions don't count for the exercise component, although they probably should. Sleep is always an issue in shift workers, with circadian disharmony and intense, tiring work. It is important at an institutional level to have scheduling that supports the healthiest possible sleep pattern, and on a personal level to maintain sleep hygiene. One trick that can be additionally helpful is to set an alarm to go to sleep, not just to wake up. The occupational spoke is key, and it is important to connect with why you do this type of work and the meaning you take from it through ongoing reflective practice. The occupational spoke is also vital simply because you spend so much of your time either at work or recovering from work, and as physicians it is a key part of our self-identity. I won't mention work-life balance, but perhaps we can agree that optimising work-life interaction is a goal to work towards. It can be helpful to have checkpoint rituals for entering and exiting work, something you do that signals to you that you are now leaving work, not just physically, but mentally. This could be as simple as placing a personal significance on the action of closing your office door, or taking off your ID and placing it in your bag, or how you utilise the time in your journey home so that when you are home, you are really there. COVID has brought focus onto these transitions as we tried to protect our families from infection by performing cleaning routines after work. While this was no fun at all, it has an interesting potential in ritualising an important transition, and perhaps our experience with it could be used for some good. Financial wellbeing is not just about dollars and cents, it is also about value, and fair and equitable pay is a key part of feeling valued. Financial wellbeing also speaks to our sense of security, for us and those we love, and is a very important aspect of our wellbeing. In a way, if our financial wellbeing is tended to, it should fall into the background, and is really about having the structures in place for a secure future. Some physicians are excellent at this aspect and understand it, I confess that I do not, and so I outsource this expertise and use a professional financial planner that only works with doctors. The spiritual spoke is highly personal, and could involve keeping in touch with a faith that sustains you, but could involve humanistic secular practices such as gratitude, mindfulness, or creative practices such as narrative medicine, medical writing, or art. In an interesting study from Duke University, Dr Brian Sexton developed an intervention called The Three Good Things. You simply ask yourself before going to sleep, what were three things that went well today, and what was my role in making them happen, and then do that for two weeks. When this intervention was studied, there was a significant reduction in emotional exhaustion in healthcare workers, including NICU staff at one, six, and 12 months. Meta-analyses of burnout interventions in physicians also consistently point to secular mindfulness practices as useful. Stimulus is awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally. It is a state of mind that you naturally employ as a human being, and practicing it just makes more accessible and frequent. It creates a little space between stimulus and response where you can become aware and choose the most skillful path forward. In a recent article written by Dr Adawi Audish, who is an intensivist, she describes an incident where she was faced with a patient who pulled down her hospital-mandated mask and asked the physician to do the same, as this was all a money-making scheme. Despite the anger and pain she naturally experienced, she was able to pause, take a breath, and in the pause, she said, I found a millimeter's worth of distance between her emotions and what mattered most in that moment. In a gesture of solidarity, Dr Audish joined in the patient's hope that this could all go away, and then asked about the patient's pain with openness and curiosity. This disarmed attention, and they returned to a shared understanding and worked productively together. This story really captures many of the benefits of mindfulness. It's about using your introspective awareness of what you are feeling, your reactions, in order to create a space within which a skillful reaction can arise. There are many excellent, well-studied mindfulness trainings on offer, such as the Mindful Medicine Workshop by Drs. Crasmer and Epstein at the University of Rochester, or a mindfulness-based stress reduction workshop from UMass or Brown University, which are all available in person or online. The social spoke is important both professionally and personally. In the longest-running longitudinal study in history, the Harvard Study of Adult Development, social connection was found to play a significant role in health, quality of life, and longevity. Recent research has also found that loneliness can be as bad for your health as smoking. We are social animals, and we rely on each other to get through the day. If you put a subject at the bottom of a hill and ask them to estimate how steep the hill is, their answer depends on who is standing next to them. If they view the other subject as a social resource, someone who will help them, then the hill will be rated as less steep than it actually is. We have mountains to climb every day at work, and we need to cultivate relationships and the feel of the team environment in order to leverage these social resource assessments that we make of each other all the time. It is an interesting thought experiment to imagine a member of your team at the bottom of the hill. When they look at you and then grade the slope of the mountain they're about to climb, how would they assess you? Intellectual spoke is also of key importance to physicians. While this has important personal components, such as the development of your own niche, keeping up to date, and engaged in the aspects of your field that really interest you, it also has broader significance across the team, and in particular for patient safety. For example, the ICU places a high cognitive load on physicians, which burdens our finite working memory. This can be exacerbated by the frequency and urgency of distractors and interruptions, which can create opportunities for error to occur. It is important to manage that cognitive load, offloading tasks where appropriate. This delegation is no more than a recognition that your cognitive load is actually not yours alone, but needs to be distributed across the team. In each of these areas of the wheel that we have looked at, it is better to avoid large commitments to sweeping change, as this can be unsustainable. A marginal gains attitude can give good returns over a reasonable timeframe. Rather than thinking how you can increase your social well-being by 50% today, think what you could do today to make it 1% better. Rather than thinking how you can go from a financial dumpster fire to total fiscal control, target something that you can make 1% better today, like making an appointment with a financial advisor. If you are not where you would like to be physically, skip the boot camp, and instead make a small, sustainable change. The aggregate of small 1% gains across the seven spokes can move you to a noticeably different and better place over a short time. Coming to the end, I would like to leave you with this slide, which combines the Stanford model of physician wellness with the wellness wheel that we have taken a tour of together. Thank you for your time. As you look to increase your well-being, remember above all else to practice self-compassion. You are amazing, and you do an incredible job that really matters. Thank you.

coping skills

burnout

healthcare professionals

organizational interventions

wellness wheel