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

Reimagine: It’s Easy if You Try

 From the 1/15/2021 issue of the Transformational Times

Reimagine: It’s Easy if You Try




Balaraman Kalyanaraman, PhD – Professor, MCW Department of Biophysics






This amazing, prescient essay was originally published almost three years ago! We hope you can sense Dr. Kalyanaraman's excitement about Katalin Karikó, PhD and her research. Dr. Kariko and her team were just awarded the 2023 Nobel Prize in Physiology or Medicine for their work laying the groundwork for an mRNA COVID-19 vaccine ...

“Anything you do I can do better, but only if you do it first. That’s because I have no imagination, only a re-imagination.”
–Andrew Keith Walker

Right now, I bet you are telling someone, or have been asked, to reimagine some aspect of your work or life. Or perhaps you are reading about or watching an advertisement focused on reimagining. But what does reimagine mean? According to Merriam-Webster, the first use of the word was in 1825, and it is now among the top 1% of words that are looked up. I don’t know about you, but the word “imagine” makes me happy; hearing it frees up space in my brain. Conversely, the word “reimagine” makes me feel tense and anxious; it sounds task oriented and somewhat contrived! Well, the more I’ve pondered the word “reimagine,” the more I’ve realized I do not have to feel this way!

While trying to understand “reimagine,” I came across this anecdote about imagination from the book The Element: How Finding Your Passion Changes Everything by Ken Robinson, PhD:

An elementary school teacher was giving a drawing class to a group of six-year-old children. At the back of the classroom sat a little girl who normally didn’t pay much attention in school. In the drawing class she did. For more than twenty minutes, the girl sat with her arms curled around her paper, totally absorbed in what she was doing. The teacher found this fascinating. Eventually, she asked the girl what she was drawing. Without looking up, the girl said, “I’m drawing a picture of God.”  

Surprised, the teacher said, “But nobody knows what God looks like.”

The girl said, “They will in a minute.”

The girl was making an image of something she could not feel with her senses but could feel in her heart!

Try to reimagine “Imagine” written by John Lennon and inspired by Yoko Ono:

Imagine there’s no heaven

It’s easy if you try

No hell below us

Above us, only sky

Imagine all the people

Living for today

Hmm, the song is not the same when reimagined, right?

Clearly, reimagination requires a lot more imagination with a lot more passion!
In business, people “think outside the box” and reimagine everything from A to Z! (Do you have a novel idea? Sorry! Amazon already claimed it.) I considered synonyms for reimagine: reconceptualize, re-envision, reinvent, rethink, refine, re-create, reevaluate, or reinterpret imaginatively. It seems that “reimagine” is a word meant to inspire us; it captures the essence of what we need to do together or in collaboration that builds upon our strength.

Below, I’ve given my thoughts on reimagining a few aspects of research and life that are personal to me, but I know there are plenty more that you can reimagine. Some of these also could be applicable to other areas, such as workplaces, social systems, communication, teaching, childcare, sports, and recreation.


Reimagining ideas in research

How does one reimagine research ideas? Here are some ways to get started:

• To find one good idea, you ought to begin with several ideas. It’s important, though, to work on only one idea at a time.
• Become obsessed with your idea. Believe in yourself but be prepared to modify your idea.
• Always be ready to talk about your research ideas passionately at different levels depending upon your audience.
• Don’t be afraid to talk to your colleagues about the grant that was not scored or did not score well enough to be funded, even if they are not in your field!
• Rejection happens to everyone, no matter your reputation in your field. Even Nobel laureates experience it. Ideas, new and old, are rejected all the time. What matters is how you respond to criticism and reshape your ideas!
• Even though you may have the most cutting-edge idea, your proposal may lack widespread approval in the study section and require tweaking. Sometimes you have not exactly read between the lines in the summary statement, and you keep resubmitting the same idea while expecting different results. This is when you really need to get out of your comfort zone and reimagine—consider a chemist/biochemist collaborating with an immunologist, a vaccine researcher (perhaps, an extreme example)!

A great example of reimagining - Katalin Karikó, PhD

Katalin Karikó, PhD, a Hungarian-born biochemist, first laid the foundation for the messenger RNA (mRNA) therapeutics that have been used to develop the COVID-19 vaccine. Messenger RNA transfers the information from DNA to ribosomes to make specific proteins in cells. Karikó hypothesized that if a genetically coded synthetic mRNA was injected into mice, the cells in the body would make the specific protein instructed by the synthetic mRNA. In the 1990s, when she was faculty at the University of Pennsylvania, Karikó submitted several grant proposals on this idea. The proposals were repeatedly rejected, as the reviewers’ thought this concept would not work because of the potential degradation of the synthetic mRNA in the body and the potentially dangerous inflammatory immune reaction.

Despite professional setbacks, Karikó believed in her idea and continued the work with little money. Karikó began collaborating with immunologist/mRNA vaccine researcher Drew Weissman, MD; together they came up with the idea to modify the structure of uridine, one of the four nucleosides of the building blocks of RNA. As they predicted, the modified mRNA encapsulated in a lipid nanoparticle was taken up by cells; Karikó and Weissman then extended this technology to deliver the synthetic mRNA in mice.

They published a paper in 2005 and obtained NIH funding, and this new technology was patented by the University of Pennsylvania. BioNTech, a German company known for developing vaccines, licensed this technology, as did Moderna, a biotech company in Boston.

Karikó is now the senior vice president of BioNTech RNA Pharmaceuticals. The Pfizer-BioNTech partnership developed an mRNA vaccine designed to induce neutralizing antibodies against a portion of the SARS-CoV-2 “spike” protein that the virus uses to gain access into human cells. The antibodies against the “spike” protein recognize and neutralize SARS-CoV-2, thus preventing the infection.

Although Karikó encountered early setbacks in her research, she never gave up and always “imagined how the synthetic mRNA approach could treat so many diseases.”


Reimagining a work-life balance

Ideally, having a good work-life balance would give one satisfaction, fulfillment, a sense of purpose, and empathy.

During this pandemic, a barrier to optimal work-life balance exists for parents (more often mothers), particularly single parents, as they juggle work with childcare and home schooling.

People in the workforce are on different trajectories. Some just starting, some climbing up and trying to reach cruising altitude, some pushing the “reset” button, and some pushing the “rest” button. All too often, people (myself included) are too carried away in their work and give little attention to their life outside of work. Organizations conduct workshops to teach us ways to restructure our lives, which may not seem like rocket science, but it may be nearly as difficult. In what ways can we strike a good work-life balance?

I leave this to the experts to ponder. If we take the time to pause and contemplate it, we will be off to a great start.



Reimagining relationships

Professional advice on improving relationships is available everywhere, in workshops, talk shows, magazine articles. This is all well and good and may work for some people, but often we just need to reimagine the little things that are forgotten. Yes, I understand, “Physician, heal thyself,” and I think it goes well with “better late than never.” In his article, 10 Ways To Reimagine Your Relationship, Barton Goldsmith, PhD, says “doing new things together, and old things in new ways, makes your love stronger.” He proposes a number of ideas to reimagine relationships:

• Let go of the past. Learn to forgive and forget, and focus on the positives. Be grateful for each other and treat each day as a blessing. Write down at least one thing (daily or weekly) that you appreciate about your partner.
• Create your fantasy vacation. Daydreaming about your ideal vacation can be fun! During the pandemic, this may be hard to fathom, but things will get back to normal. And when you are able to take a vacation, you will be ready.
• Take a class together. Or do other activities with your partner: Take a virtual cooking class, learn CPR, learn a new language, take a walk through the park.
• Have lunch together once a week. This will help break the monotony.
• Ask your partner 20 questions. Show curiosity in your partner’s interests. What are some things you’ve always wanted to know about your partner but never took the time to ask?

To this list, I’ll add: Never be afraid to poke fun of yourself. Self-deprecating humor can ease those tense moments.

I am sure you can find many more fun things to add to this list.

Reimagining stress reduction through mindfulness

Emerging science convincingly shows that routine exercise, yoga, meditation, and mindful meditation can alleviate stress, anxiety, and depression. Herbert Benson, MD (Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital) pioneered the beneficial effects of meditation (e.g., lowering blood pressure and heart rate, and increasing brain activity). Functional MRI studies support the beneficial aspects of meditation to combat depression and anxiety.

Suzanne Westbrook, MD, a retired doctor of internal medicine, says, “our mind wanders all the time, either reviewing the past or planning for the future.” Mindfulness teaches the skill of paying attention to the present, and that life is in the moment. Mindfulness is not about trying to empty the mind; rather, it is about remaining present. It is a practice designed to improve brain health. Taking a slow deep breath through the nostrils (i.e., inhaling) and then slowly breathing out through the mouth (i.e., exhaling) will help you relax, reenergize, and reconnect. Repeat this inhalation/exhalation technique about 10 times. Use it as a “balance break” as needed during tense times (e.g., grant preparation). Mindfulness will improve your focus on the task at hand and face challenges with a healthy attitude, reduced stress, and increased energy. Mindfulness could be incorporated into many things—eating, conversation, listening. Some people practice 20–30 minutes of meditation that involves “mindful body scan,” during which one notices the sensations one is feeling without judgement. Indeed, mindfulness is presently at the top of the wellness universe as a stress reduction technique!


Let us imagine and then reimagine 2021! But not without first learning from 2020. Yes, hindsight is 20/20.



Balaraman Kalyanaraman, PhD, is Professor and former Chair of the Department of Biophysics at MCW.

MCW's Student Assistance Program: Build It, and They Shall Come

From the September 15, 2023 issue of the Transformational Times - Student Mental Health 

Take 3 with Dr. David Cipriano - MCW's Student Assistance Program: Build It, and They Shall Come

Dr. Himanshu Agrawal, co-editor-in-chief of the Transformational Times, converses with Dr. David Cipriano, Director of Student and Resident Behavioral Health at Medical College of Wisconsin, about student mental health services. 

 

As the director of student and resident behavioral health at MCW, what would you say has been the greatest accomplishment that MCW has made in the last five years? 

 

David Cipriano, PhD: I would say that one of the greatest successes we have achieved has been improved accessibility. We accomplished this through increasing the number of sessions that are available to each MCW student at no cost to them (from five sessions to ten sessions per academic year) and through bringing ComPsych, a Student Assistance Program onboard (to increase choices, flexible scheduling and out-of-network care options). This has coincided with an increase in utilization of mental health services by MCW students. Please be on the lookout for a detailed description of these results in an upcoming paper to be published in the Wisconsin Medical Journal. 

 

Our second biggest accomplishment is that we have seen a significant decrease in stigma around mental health in survey data that we have been collecting for several years now. This also undoubtedly contributes to increased utilization of our services.  

 

As the director of student and resident behavioral health at MCW, what will be your top priority for the next five years? 

 

David Cipriano, PhD: We have two top priorities: first, to ensure our clinical services are inclusive and welcoming for all students, including those underrepresented in medicine; secondly, we aspire to increase and improve group offerings. This will include general groups as well as specialty groups.  

 

 

As the director of student and resident behavioral health at MCW, what is the one thing that you wish to say to each student at MCW? 

David Cipriano, PhD: I've said this before and I will say it again — there does not need to be a major crisis or a major diagnosis for you to come to us, to seek help.

The stress of training, moving to a new city, leaving behind your old support system, or any of the myriad of personal situations is reason enough to talk to a therapist for a new perspective, more tools and better coping strategies.

David J. Cipriano, PhD, is a psychologist and an associate professor in the Department of Psychiatry and Behavioral Medicine at MCW. He also serves as the Director of Student and Resident Behavioral Health.