Coaching is Vital to Preventing Burnout in Physicians

From the May 14, 2021 issue of the Transformational Times (Suicide prevention issue) 

Coaching is Vital to Preventing Burnout in Physicians

Brett Linzer, MD

My internal medicine/pediatrics friend, Alex Djuricich, MD, killed himself a few years ago. He was one of my resident partners and eventually became the internal medicine/pediatrics program director at the Indiana University School of Medicine. He was a mentor to many internal medicine/pediatrics physicians and a father of two teenage daughters. When he died, I promised myself that I would do what I could to help other physicians...

It has taken me a long time but, with some of the work I am doing, I feel as though I am making good on that promise. I spent years trying to figure out why doctors hurt themselves. I am not sure if I have figured out much, but I have learned a lot along the way.

One of the most important things I have learned is that I do not have all the answers to my life. But I found a lot of the answers through coaching.

Why is coaching important?

The idea that we, as physicians, can figure everything out on our own and not rely on others to help us is, at best, a poor strategy for success and, at worst, a dangerous myth. Physicians are highly trained and skilled in certain areas but may lack mastery in relationships and communication. After residency, there is little emphasis on personal growth and especially emotional development. Coaching can bring wide-ranging benefits to any organization. Most experts agree the cost of replacing one physician, including lost revenue, can be around $1M. A well-coached physician is more likely to stay in their current position and, therefore, save the cost of recruiting a replacement. In addition, there is less physician burnout, improved mental health, more effective physician leadership, and more balanced and engaged physicians. When physicians are at their best, everyone wins.

The struggles hit close to home

During my training, I was no stranger to suicide. A medical school classmate killed himself. Then, an international graduate with two children and a family in China hanged himself during the second week of our internship. We all knew he was struggling but had not known what to do. We were treading water ourselves. 

The next morning, the residency program director brought our group of ten interns into a room and talked to us. "This is bad,” he said. “We care about you. Here is the card for the psychologist. Call if you need help." I looked around the room at the other confused faces and honestly thought, what does he mean by “need help”? I said to myself, Look Brett, screw your head on straight. You are on call and have a busy service. You need to get back to work. 

Two years later, my chief resident shot himself. I thought he had all the answers. He was a smart guy and had a desirable GI fellowship lined up. At the funeral, I went up to people I knew. Do you understand this? Can you explain this to me? Can you please tell me he had some label or diagnosis or something that I do not have? Chronic depression, alcohol abuse, or schizophrenia? Something? Anything? How do I know I am not next in line? There is always a line. 

On average, one physician commits suicide every day in America. Every day! 

But I was not next in line. Next in line was my friend Alex. He was considered by many to be the ideal internal medicine/pediatrics academic physician. I went to his wedding. He met his wife when she was a fellow intern with me and Alex was our resident. He had a family. He even looked like me. How are they different than me? How close was I to where they were? Look Brett, I said to myself. Screw your head on right. You have a lot of … wait … it is not working. You cannot figure it out. Who's next in line? 

Then, one of my best friends and close partners left our organization. I had difficulty understanding why he left and felt the effects even more acutely when I had to absorb a number of his patients. This was the height of the opiate epidemic and some of the patients were very difficult. I did not know how to manage them well. In addition, I had an unmotivated, depressed medical assistant working with me and I did not know how to communicate with her. The triage nurse in our small clinic was not motivated to do her job. I was not comfortable with conflict, so I avoided her and did extra triage work. The clinic manager was too scared to confront the problems. The administration was well-meaning but not helpful. 

I felt like I was playing a new game and I did not know how to play it well. I did not even know how to tell if I was successful. Press Ganey surveys did not do it for me. 

About this time, Epic came online, and I struggled with efficiency. My wife had chronic debilitating migraines and we had three teenagers at home with no family support. I had extended family challenges. I was cut off from my emotions and I unknowingly built walls to contain them, not knowing I was cutting off my good emotions as well. 

A turning point and finding help

In 2014, my survival skills were not serving me. Life was closing in. I was tired, frustrated, angry, irritable, confused, fearful, and more. I took care of depressed patients and I prescribed SSRIs for them. Would an SSRI help me? I did not even have a doctor. Maybe counseling would help, but I did not know where to turn. I did not have the time.

I was too scared. During one particularly rough patch, I asked myself if I was suicidal.

One night, I was sitting at home and finishing Epic charts. My wife handed me a card that said, "I think you need some help." 

I looked at the card that suggested I contact Dike Drummond, MD from the burnout prevention program, www.TheHappyMD.com I said to her, “Don’t worry. I just need more time. I can figure this out on my own. I just need to work harder.” My wife had heard me say this before. She was losing patience and my words were not as convincing to me as they had been before.

I asked myself, “Am I depressed?”

I called Dike and set up a discovery session. This is a free one-hour “get to know you” session with the burnout counselor. At that point, I still did not trust him or anyone else. More than once, I almost cancelled the call. I thought, he does not know me. I am a very private, introverted person with my special problems.

The next week, I completed the call and was shocked to discover within twenty minutes that he could see right through my walls and defenses. He saw the scared kid behind the walls. He saw and knew my patterns of behavior and thought. He knew where that place was because he had been there. I broke down and agreed to work with him.

Dike explained that many of my patterns of behavior and emotion were not unique to me. There are patterns that are unique to physicians and emerge from our training. Many of these are survival adaptations. This stunned me and was so reassuring. He told me I was not broken. There were patterns I could learn about and then modify. Here are some of the typical patterns and misconceptions that Dr. Drummond described that physicians adopt that lead to burnout:

• If I just work harder, things will work out.
• I am a smart guy/girl, so I will figure it out.
• I need to do it all by myself.
• I do not want to deal with this difficult patient, nurse, etc.
• Compassion is important for other people but not for me.
• My emotions are not safe. I need to protect myself.
• I feel like an impostor.

My work with Dike centered around twice-a-month one-hour coaching calls where we worked on emotional and skill development. We started every call with five minutes of gratitude and appreciation. What would I like to congratulate myself for? What did I do right? This was actually hard for me because I was more in the habit of beating myself up for what I had done wrong. I could easily list all the negatives, but I had trouble seeing the positives. 

After that, we would complete the work for the day. Some of the emotional work involved processing difficult emotions like shame, fear, anger. I realized I had a lot of shame. For example, we discussed:

• How to gain better access to my emotions and feelings. How to trust myself and others.
• How to have more self-compassion and more compassion for others.
• How to absorb positive feedback and not deflect it away.
• How to have a soft front and a strong back.

The area of skill development was wide-ranging. Communication skills were huge. I realized if I could be a better communicator, I could save a lot of time and prevent a lot of negative emotions. As I became better, I noticed how ninety-minute disagreements could turn into fifteen minutes. Three meetings could be one if I was more effective. Three-day arguments could be resolved in thirty minutes with deep listening and full presence. We did in-depth personality testing and self-awareness, and I learned how to interact with different personality types more effectively. I learned how to deal with difficult people like the nurses and patients. We did role-play and scripting.

I realized that as I took more responsibility for the interactions, I developed new skills and the nurses changed their behaviors. In the past, I had believed that my role was to give the right answers, but I learned it was more important to develop the art of asking the right questions. I discovered how to run an effective meeting. What is the goal? How do we know if we achieved the goal? Can we stop after thirty minutes and consider it a success if we reached our goal? 

I mastered Epic documentation techniques, created succinct, appropriate notes, learned stress management breathing techniques, mastered time management and batching approaches, practiced delegation, adopted marriage skills, enhanced my communications, and made firm dates on the calendar. I had been transformed.

Emerging from the other side

Coaching has changed me. When physicians are at their best everyone wins. As physicians, we need to trust, ask for help, and be supported along the way. We need good leadership that makes coaching easily accessible, affordable, and encouraged. We could spend one-tenth the amount it takes to replace one physician and invest it in the few hundred we already have. It is critical to understand that coaching programs are not just for impaired or problem physicians. These approaches are for growth minded, striving physicians who want to improvetheir lives and the lives around them. Highly achieving people in many fields have coaches. Every sports superstar has a coach. Most high-level business leaders have coaches. Every coach I know has a coach of their own. And the people at the top - the ones who train the other coaches - have networks of support and growth systems around the country.

It starts with each of us

Here is what you can do. It all starts with you. Take care of yourself and trust that others may be able to help you. Realize that you may not have all the answers to your life. Reach out to others for connection and for mutual support. Consider coaching for yourselves. 

Brett Linzer, MD, is board-certified in both internal medicine and pediatrics. He has been in practice with ProHealth Care for over twenty years. He has been a part of the Medical College of Wisconsin for 18 years as a preceptor and mentor to fourth-year students in his ambulatory clinic in Oconomowoc. He is the recipient of the Marvin Wagner Preceptor Award, ACP Wisconsin Community Physician and mentor award and the Milwaukee Academy of Medicine award for excellence in teaching. He can be reached at balinzer@phci.org

Dear Loyal Readers of Transformational Times

 From the November 10, 2023 issue of the Transformational Times

Dear Loyal Readers of Transformational Times 

As we continue our Under Construction work on the new platform for TT 2.0, we wanted to take a moment to thank you all for the feedback provided in our recent Reader’s Survey, and to share a few brief announcements about exciting news from our team.   

The editorial team has been hard at work behind the scenes, as we plan a major metamorphosis for TT 2.0. We greatly appreciate the 72 responses to our survey; they brought renewed vigor and clarity about our task ahead. 

The survey revealed that what readers appreciate most is the personal, story-like, nature of the perspectives and opinions that are published. Additionally, it was validating to discover that each segment of TT was appreciated by many readers (directors’ corner, perspectives/opinions, questions of the week, announcements about events, as well as the poetry section). Several individuals gave us reason to pause and consider additional new features, for example audio visual media (including podcasts and visual art.)  

It was humbling to learn that we need a more diverse representation of viewpoints, and that we have tended to be "medical school" and "physician" heavy thus far. We plan to be intentional about embracing and operationalizing this constructive criticism. 

Please look for these (and more) changes soon, and we greatly appreciate your ongoing investment in TT, which is as much yours as it is ours! 

 

Sincerely, 

The co-editors-in-chief of Transformational Times

Wendy Peltier, MD 

Himanshu Agrawal, MD, DF-APA 

Dr. Kalet Wins the 2023 AAMC Award for Excellence in Medical Education

From the November 10, 2023 issue of the Transformational Times

Our Friend, Dr. Kalet, Wins the 2023 AAMC Award for Excellence in Medical Education

By the Transformational Times editors

Sometimes, it turns out that our friend is pretty spectacular. 

Our editorial group, including Adina Kalet, MD MPH, developed the Transformational Times during COVID and has kept TT’s wheels on the tracks over the past three years. As we did so, we became accustomed to Dr. Kalet’s insightful comments and wise direction at our weekly virtual meetings. We devoured her Director’s Corners. We tracked down content contributors that she suggested. With her unfailing humor and insight, she talked us through each issue and kept things moving forward. 

Sure, we knew that she had other responsibilities. After all, she was running the Institute. She had published three books, fourteen book chapters, and over 200 highly cited scientific articles. We knew she was principal investigator on NIH and NSF grants. Of course we were aware of her multi-institutional educational trials. Yeah, she seemed to know absolutely everyone in medical education on every continent. But, to us, she was just Adina, y’know? 

Of course, we probably should have had a clue that she was a superstar. After all, she did receive the National Award for Career Achievement in Medical Education from the Society for General Internal Medicine in 2019. She was given the National Board of Medical Examiners John P. Hubbard Award in 2023, recognizing her extensive contributions to the field of assessment in medical education. But, during our weekly meetings, she remained the epitome of a collegial servant leader.

The AAMC’s most prestigious award

It turns out that our friend is pretty amazing. On October 25, 2023, MCW gathered to watch as Adina’s reputation and body of work were recognized by the American Association of Medical College with the AAMC’s Award for Excellence in Medical Education. The award recognizes the “highest standards in medical education,” and honors an individual or a team “whose contributions have had a demonstrable impact on advancing medical education. It “recognizes the highest standards in medical education.” 

More than once, we heard that the Award for Excellence in Medical Education is the AAMC’s “most prestigious award.”

Adina’s comments

Unsurprisingly, Adina’s prerecorded acceptance comments focused on students, colleagues, and learners rather than on herself. “We are educating physicians,” she said. “That matters.”  She continued that, “academic medicine has been so good to me because I could be a physician, leader, scholar, and innovator all within the same career. That’s really a gift of the academic medical center environment.” She added, “I’m very moved to have been nominated. If you look back at the numerous people who have won this award, they are my heroes and role models. It is the team I want to be on.” 

It was delightful to see our friend’s effectiveness, thought leadership, and hard work recognized by her peers in medical education. She really is a superstar working among us and, we are certain, she is nowhere near the peak of her remarkable path. We are fortunate to have front row seats as she continues on a journey that will improve physician education now and far into the future. 

From the rest of the Transformational Times editorial team, including Himanshu Agrwawal, MD, Wendy Peltier, MD, Bruce Campbell, MD, Kathlyn Fletcher, MD, Karen Herzog, and Joy Wick.

Lessons Learned While Caring for Dying Veterans

Originally published in the July 22, 2022 issue of the Transformational Times (Focus: Geriatric and Palliative Medicine)

Lessons Learned While Caring for Dying Veterans 

Adrienne Klement, MD

Dr. Klement, who completed a fellowship in Hospice and Palliative Medicine, cares for Veterans at the Zablocki VAMC in Milwaukee. As we approach Veteran's Day, she shares two stories from the COVID-19 pandemic that show some of the lessons she has learned caring for her patients…

“These doctors have the hardest job in the world.” It was a cold January evening during the pandemic, and the Milwaukee VA ICU was buzzing with a symphony of ventilator alarms, bedside monitor alerts, the closing and opening of isolation carts, and staff conversing about patient care needs. 

Visitor restrictions were in full force. Despite the noise, the unit felt empty and stark with closed doors and without families at bedside, except for one room. I gowned up and greeted our dying patient, Mr. D, and his family. 

There were several grandchildren joining on Facetime. We (they) had twenty minutes. We all had to speak loudly through our N95s to be heard over the Vapotherm. Mr. D acknowledged he was very sick. We talked about his hopes and wishes, and he gave his loving family all the appreciation he could muster. He just wanted to hug his grandchildren. At the end of the conversation, his son hovered in close to him and said, “Dad, these doctors have the hardest job in the world—they have done everything they can to help you. You are going to die soon, we are here now, and we love you.”

Lesson number one: Sometimes, the best way to reach a patient is through a trusted and familiar face.

I could tell Mr. D was holding back tears throughout our conversation. I wondered if this suppression of emotion was something he had learned in the military, and what trauma he had been through in the past. Was it a sign of weakness to admit feelings of fear or sadness? Was he trying to stay strong in front of his family as a way to bear their grief? I noticed a few quiet tears of my own while in the room, and I couldn’t help but wonder if my reaction was acceptable, or if it was detrimental to my roles as comforter and healer. 

When I got home later that evening, I started to unpack my (unexpected) reaction further, realizing that my tears were complex. They were a reflection of empathy, as I recalled holding my mother’s hand as a teenager when she took her last breath. They embodied frustration with the end-of-life isolation protocols. And they were tears of immense gratitude for the life of service Mr. D gave to our country, and for the care given by his Oncology and ICU teams.

Lesson number two: Showing emotion in front of patients, colleagues, or families is part of healing, for all of us.

The appreciation given to us by our Veterans and their families is transformative. Medical training is a long road that comes with many sacrifices, but also deep bonds and human connection. 

I had the privilege of helping to take care of Mr. R, who had end-stage leukemia, in both a consultative role, and also as his primary Medicine attending. It was so special to me as a teacher, to witness my resident-in-training also provide exceptional care and supportive listening. Mr. R and his wife expressed their deep appreciation for the unique care that he gave, and all that our VA providers gave through to his dying day. 

As an educator, I felt fulfilled in witnessing our team experience the most rewarding aspect of practicing medicine, relationships with patients. Mr. R’s military and life stories were therapeutic for all of us, and he reminded us daily that we are caring for some of the most selfless and resilient servants in the world.

Lesson number three: Reflecting on our Veterans’ acts of service and life experiences through attentive listening and presence cultivates gratitude for our work.

I am grateful every day for the meaning that my work brings me. I am most thankful for our Veterans who have served our country, and from whom we have much more to learn.

Adrienne Klement, MD, is an Assistant Professor in the Department of Medicine, and is a faculty member in the Division of Geriatric and Palliative Medicine at MCW. She attends on the inpatient Internal Medicine and Palliative Care consult services at the Zablocki VAMC, where she was recognized in 2022 as "Employee of the Year."

Being a Parent and a Pediatrician

Originally published in the October 22, 2021 Transformational Times newsletter

Being a Parent and a Pediatrician

Cassie Ferguson, MD

Every weekday morning, I am confronted with my failure as a parent. Instead of filling my three kids’ lunchboxes with a colorful array of washed and cut, 100% organic, GMO-free fruits and veggies and a lean protein-packed sandwich cut into a dinosaur shape, I am typically frantically grabbing for a Dole fruit cup, an unnaturally colored yogurt tube, and a bag of Fritos. Guilt inevitably washes over me every time I shove a PB&J made with Skippy and grape jelly on white bread into their lunch boxes, and I cringe thinking about the teachers seeing what I knowingly

feed my children.

What you are to be, you are now becoming

–Carl Rogers

I don’t know if I feel this guilt more acutely as a pediatrician—as someone who spent nearly a decade learning about how to keep kids healthy and should “know better”—because I don’t have a different perspective to which I might compare. My first son, Ben, arrived two weeks after I graduated from pediatric residency. Will arrived as I finished my pediatric emergency. medicine fellowship, and Nick three years after I became an attending in the emergency department (ED) at Children’s. I became a mother as I learned to become a pediatrician.

While the guilt may be sharper, there were advantages to my training when it came to caring for my kids when they were little. The nurses in the well-baby nursery taught me how to swaddle a baby so that they couldn’t free their tiny little arms. I knew that 100°F was not a real fever. And I could assure my husband (and myself) that our child would eventually learn to pee in the potty.

There were distinct disadvantages, as well. I also learned about the randomness with which a four-year-old is struck with leukemia. About what it sounds like to hear a mother’s heart shatter when she learns her sixteen-year-old has died in the car crash. The health and safety ofmy own kids can feel so fragile; regularly witnessing the suffering of kids and their families makes it difficult to believe that my own kids would be spared, no matter the real odds.

Every system is perfectly designed to get the results it gets

–Arthur Jones

Most of the suffering that we witness as pediatricians, however, is not a result of random chance. Disparities in the utilization of health care services and in overall health spending, structural racism, and residential segregation that limits access to good schools, jobs, healthy food choices and green spaces for the majority of Black and Latino or Hispanic Americans directly translates to poor health outcomes for the families for which we care. Kids dying from gunshot wounds, physical abuse, asthma exacerbations, drug exposures; these deaths are not random. They are a result of the systems we have purposefully built in America and continue to support with our inaction.

A friend once described having a child as forever walking around with your heart on the outside of your body. As a mom and a pediatrician, I’ve discovered that my heart can be broken not only when my own child falls and breaks their arm, or is bullied at school, but by anything that harms children anywhere. I have come to see this as our superpower—this tenderness and vulnerability spurs my colleagues to fight courageously for the radical redesign of our systems.

We are called to disrupt the cycle of interpersonal violence in our communities, to address food insecurity in our ED, to protest the attempt to ban books about racism from our schools, and to ensure that the way we treat acute pain is equitable.

Hope is the thing with feathers

–Emily Dickinson

This calling can feel overwhelming, particularly when I am in the ED managing twenty very sick patients and a full waiting room, and then receiving a page heralding the imminent arrival of yet another child with a gunshot wound. On those nights nothing we do feels like enough; it feels as if we are digging a hole in the sand as the walls are caving in around us.

On those nights, I come home defeated, or angry, or fearful; overwhelmed with the perspective on how dangerous the world can be for our most vulnerable citizens and feeling powerless to protect both my patients and my own kids.On those nights I come home to my kids and peer into their dark bedrooms, staring at their sleeping forms from the door, surprised at how easy and regular their breath comes. I renew

my vow to do what I can to make them feel safe and loved and find grace in the belief that this love is perhaps more communal than I realize.

Cassie Ferguson, MD, is an Associate Professor of Pediatrics (Emergency Medicine) at MCW. She is the Associate Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.