The stresses of medicine are not new and are likely to persist and possibly increase as pressures intensify to provide more care to more patients. So how do some doctors maintain a positive attitude and joy while others find themselves becoming cynical and discouraged?
There is limited literature on this topic, and even more limited research, but some effort has been made to identify protective factors and strategies. Several studies surveyed or interviewed physicians to determine successful coping strategies.13-16 In addition, innovative programs have been created to strengthen physician resilience.17,18 A number of themes emerge from these studies.
Seek control. A central theme in much of the burnout literature is that burnout is often associated with experiencing a lack of control. Finding ways to increase one’s sense of control improves resilience. With the increasing demands on physicians, control may seem a more and more elu-sive goal; however, certain strategies that increase a sense of control have been identified.
An innovative approach to enhancing control was designed by the leaders of a group practice in Oregon. Dunn and colleagues17 describe a program intended to enhance physician well-being. One of the core principles was to increase physician control over his or her practice. Strategies included soliciting physician input during group meetings and accommodating scheduling wishes (eg, length of sessions) and other practice preferences (eg, case mix). The program also allowed flexible work schedules, such as part-time and job share options. Physician satisfaction improved and burnout scores decreased after interventions increased physicians’ influence over their work environment.
Setting limits is another way to exert control. Many physicians are reluctant to say no to requests from others and consequently may find themselves drained or resentful. Giving oneself permission to set limits without guilt can be an important ingredient in achieving balance.
Another study interviewed 17 physicians who had a reputation within their community for being resilient.14 These physicians identified the importance of setting limits both professionally and personally as keys to their positive attitudes. Within the professional arena, this may mean changing the way they practice or reducing their hours. On the personal level, setting limits may include making healthy behaviors a priority, such as scheduling time off, exercising, and relaxing. Recognizing that by setting limits one is saying yes to healthy behaviors (and not just saying no to a request) may help physicians understand the choices they face and adopt self-care behaviors.
It is important to remember that the perception and interpretation of circumstances in large part determine how stressful those circumstances become. Physicians can fall prey to cognitive errors, such as catastrophizing, all-or-nothing thinking, and discounting positive events.
Perfectionism is a trait that is shared by many in the field of medicine. Resistance to acknowledging personal limits and fallibility can lead to impossible expectations or defensive behavior. It may also lead to an unforgiving response when mistakes inevitably occur. Correcting these cognitive distortions can improve flexibility; decrease feelings of victimization; and improve problem solving, self-esteem, and professional relationships—all of which protect against burnout and increase one’s sense of control.
Interpersonal support. Another element that is often cited as a source of strength and resilience is having adequate support from others. The practice of medicine is often a lonely one, and many doctors find that over time they become isolated. This isolation may be especially pronounced for physicians who begin to feel down or burned-out. A “conspiracy of silence” has been described among physicians, in which a “macho mentality” leads doctors to the implicit assumption that they must always be strong and care for others and that they would be perceived as weak if they were to acknowledge their own vulnerabilities.6