The Burnout Crisis

Doctor burn-out can result in emotional exhaustion, an inability to show or feel empathy, and a sense that you aren’t accomplishing enough—or anything at all. In this podcast, Gail Gazelle, MD, and Mount Sinai’s Lauren Peccoralo, MD, discuss how to deal with burnout and how coaching can help.

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Road to Resilience brings you stories and insights to help you thrive in a challenging world. From fighting burnout and trauma to building resilient families, we explore what’s possible when science meets the human spirit.

Transcript

[00:00:00] Stephen Calabria: From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria, Mount Sinai's Director of podcasting. 

[00:00:12] On today's special edition of Road to Resilience, we welcome Gail Gazelle, MD. Dr. Gazelle got her start in palliative care and geriatrics, ultimately moving into physician coaching. She's currently an Assistant Professor of Medicine at Harvard Medical School and Associate Scientist at the Brigham and Women's Hospital in Boston, Massachusetts. 

[00:00:30] Dr. Gazelle is an expert in treating and diagnosing physician burnout, which he covers in her new book, Mindful MD: 6 Ways Mindfulness Restores Your Autonomy and Cures Healthcare Burnout.

[00:00:41] Dr. Gazelle is interviewed on this episode by Dr. Lauren Peccoralo, M. D., a professor of medicine in the Division of Internal Medicine at the Icahn School of Medicine at Mount Sinai. Dr. Peccarello is also the Senior Associate Dean for Faculty Well Being and Development at the Icahn School, where she's helped combat burnout among Mount Sinai's own ranks.

[00:01:00] Together, the two discuss why burnout occurs among both those who work in medicine and those who don't, and how burnout may be overcome. We're honored to have Drs. Gail Gazelle and Lauren Peccorallo on the show. 

[00:01:12] Lauren Peccoralo: Hi everyone, I'm Dr. Lauren Peccarello. I'm the guest host today of Road to Resilience at Mount Sinai.

[00:01:20] I'm very excited to welcome Dr. Gail Gazelle, a hospice physician, a master certified coach, and an assistant professor at Harvard Medical School, who is globally recognized for her work in mindfulness and resilience. Welcome, Dr. Gazelle. It's so great to have you. 

[00:01:38] Gail Gazelle: Oh, such a pleasure. Thank you so much. 

[00:01:41] Lauren Peccoralo: So, I was wondering, to get us started, could you briefly tell us about your background in medicine and in coaching? 

[00:01:47] Gail Gazelle: Yes. So, I trained in internal medicine back in the 1980s, when end of life care was not really a specialty, palliative care was not a specialty, but my main interest was working with individuals who were terminally ill.

[00:02:04] That's actually why I went to medical school. So, started working as an internist. I wasn't sure how to get involved in end of life care, so I signed up for a medical ethics fellowship here at Harvard Medical School.

[00:02:17] And then I was working as an internist at a large HMO here in Boston, and lo and behold, they decided to start a palliative care program. And they looked around, and they thought, well, who knows something about end of life care? 

[00:02:29] Well, she did a fellowship in medical ethics. Let's pick her, even though I'd, you know, barely written a script for opioid in my head. So that really took me to my main love, which was end of life care. So that's what I practiced in for the duration of my clinical career.

[00:02:46] Along the way, I experienced burnout, as many physicians do. I felt like I was never good enough. I felt like I wasn't doing enough for my academic and my clinical career. When I was home with my son, I felt guilty that I wasn't doing more for patients. 

[00:03:02] When I was at work, I felt guilty that I wasn't doing enough for my son. And I constantly felt this sense that I wasn't good enough. I stumbled into coaching. I saw a flyer here at Harvard Medical School hanging on a bulletin board. 

[00:03:16] And coaching really changed my life, not just my career, but my life. I was able to let go of a lot of self limiting beliefs about myself and about my efficacy. I was able to right size guilt. I was able to stop that ever present having to prove myself and focusing on where I was coming up short. 

[00:03:36] So I pivoted in my career in 2011 and became a pioneer in the field of physician coaching. Since that time, I've had the pleasure of coaching over 700 physicians and physician leaders. So this is what I do full time. 

[00:03:51] And it gives me as much joy to help physicians who, many of whom have kind of lost their way in the modern, complex healthcare system. And it gives me just as much joy and pleasure as I enjoyed when I was taking care of individuals who were facing the final chapter of their life. 

[00:04:09] Lauren Peccoralo: Well, thank you so much for sharing. You have given us a lot of things to dive into. So let's start with burnout. 

[00:04:16] When I think about burnout and what we've discovered from a lot of the work that we do, we think about symptoms that result from chronic workplace stress, such as emotional exhaustion, lack of ability to feel or show empathy, and the inability to experience a sense of accomplishment.

[00:04:35] Are there other specific symptoms or signs that we should consider or look for when we're thinking about, am I burned out? What should I be thinking about? 

[00:04:45] Gail Gazelle: Well, what you've stated is what we think about the clinical triad of burnout. And the only thing I would add to that is that we develop a real sense of cynicism. Why bother? I'm not having any effect anyway. Why did I go into the practice of medicine in the first place? 

[00:05:02] And along with that cynicism, we begin to depersonalize. We see patients and even loved ones as objects that we have to navigate through in our day. Independent of that clinical triad, there's a fourth factor that sometimes gets less attention, which I see, and that's that we develop a kind of tunnel vision.

[00:05:21] We only see what is going wrong within ourselves, in the environment around us, certainly in the healthcare system, and we have a hard time latching onto the positives, particularly the good that we're doing, what we are accomplishing. 

[00:05:36] We're very focused on what we're not able to accomplish. And I think that's an important distinction, because for so many of us in healthcare, we're there to help people, we're there to have an impact. 

[00:05:47] That's what got us into our professions in the first place. That's what fuels us. And yet we lose that. We don't just lose our sense of meaning and purpose. We lose our very sense of accomplishment.

[00:05:58] Lauren Peccoralo: I think that's so poignant. We just recently completed our faculty survey. And for the first time this year, we asked faculty, what is the thing that they're most passionate about that they're doing in their work? 

[00:06:10] And hands down, it was taking care of patients and, and having that direct connection to patients. That certainly makes sense, but it was reassuring that people still feel connected to that. And I can imagine that making sure that sort of on a day to day, minute to minute basis, that if you're continuing to connect with that, that you'll maybe decrease that sense of burnout. 

[00:06:34] Right? Because we know sort of globally that that's so important to us. But, when we're working in our tunnel vision and we're not seeing all the good work that we're doing, we may disconnect from that, feeling of passion. 

[00:06:47] Gail Gazelle: I think it's critically important not just to come back to our why, our sense of purpose, why did we don the white coat in the first place, but also really to be able to see the good we're doing. So many times physicians call me severely burnt out and they say, I'm not accomplishing anything. 

[00:07:05] And what a painful place to be as a clinician, right? To not be able to see the good that you're doing So I typically empathize with that because it's a very painful place. It's like crossing the desert without a drop of water. And then I challenge them.

[00:07:19] I say, well doctor so and so, go and go back over the last week think about the patients that you saw and i'm just curious about any high points. 

[00:07:28] Often there's a big pause because the negativity bias and that tunnel vision makes it hard for us to see those and typically the mind is flooded with all the things that didn't go well. But then typically physicians warm up a little bit. 

[00:07:41] Well, I was with Mrs. Jones and yes, she has very advanced CHF. We've maximized her medical therapy. There's not much that we can do. But you know, Mrs. Jones said to me just how much it means to her that I've been on this journey and that I haven't given up on her.

[00:07:57] Then, you see the physician's face soften. You see their eyes brightened, and all of a sudden the floodgates open, and they start telling you about other positives, and yet, perhaps they've been going home at the end of a busy day, telling their spouse everything that went wrong, all the things that they weren't able to accomplish, all the difficulties that they experience in this very complicated, and many would argue highly dysfunctional American healthcare system. 

[00:08:22] So we have to help people not be Pollyanna, not like, Oh, everything's so great, but actually to have a realistic sense of the stimuli that are coming in, many of which are highly positive. Our interactions with trainees, with colleagues, with coworkers, and very definitely with patients.

[00:08:40] Lauren Peccoralo: I mean, that brings to mind a very close example for myself where I recently had a patient pass away, actually just last weekend.

[00:08:51] And I had just seen her the week before with her daughter. We knew that things weren't going well. She's very old and had end stage dementia. And that day we talked about it. We talked about, we made her DNI that day in DNR. We were sad together. 

[00:09:10] And when I called her just a few hours after her, Mom passed away, she just thanked me so deeply for the care that I had given her.

[00:09:21] And even though it was a sad moment, it was a very reassuring and humbling and also, good feeling moment that I had done something to potentially make this time a little bit easier for the patient's daughter. 

[00:09:38] And we don't reflect on those things, right? It's like, okay, done, done, done. Now I got to move on to be with my family. So, having moments like that to reflect on the fulfilling parts of what we do I think is really critical, as you said. 

[00:09:52] Gail Gazelle: It's absolutely essential, because there's so much that we can't control. The corporatization of medicine. There's a lot there that you and I and most of our health cannot control, and yet we can find ourselves railing against the system, being angry at those people, those administrators.

[00:10:09] We hear a lot of that. And if we can exert control there, that's wonderful. But if we can't exert control, that energy is so precious for all of us working so hard in the field of medicine. So, we have to be able to focus on the good that we're doing for so many reasons. 

[00:10:29] It helps really have a ripple effect. There's almost a vortex of negativity in healthcare that many of us get pulled into. And yet, we don't feel good when we're walking around negative, and we don't feel like we're helping others. 

[00:10:43] We feel downtrodden, and yet if we can focus on those very realistic bright spots, it's a bit of a lifeline.

[00:10:51] Lauren Peccoralo: Something else that you just mentioned made me think about this other concept that's in your book, which is this idea of autonomy and control, right? So there are, there are things we can control and things we cannot control. 

[00:11:04] Certainly our office works diligently, the Office of Well being and Resilience, to try to make changes in the system, right, to change efficiency challenges, to work on the electronic health record, to make it more user friendly, and to decrease some of the challenges with respect to patient messages.

[00:11:25] But ultimately, there are a lot of things that we have only limited amounts of control over. So how do you kind of see that push and pull, that yin and yang between the system, what the system's responsible for, and what we ourselves are responsible for in terms of what we have in our locus of control with respect to our own well being and resilience?

[00:11:48] Gail Gazelle: Well, it's certainly multifactorial. There's never been a harder time to be a physician than in the complex matrices that we find ourselves in. 

[00:11:56] So these are tough times in healthcare. Certainly they were tough before the pandemic, but with the under resourcing and the great resignation and the silent quitting and all of the factors, it's a complicated time.

[00:12:09] So, many people, including the AMA, say that 80 percent of burnout is due to systems problems. That's a big chunk, and hopefully, and luckily, there are people like yourself working on the systems level. What changes can we make? 

[00:12:26] How can we reduce all the below grade tasks that physicians and others in healthcare are just smothered by, the never ending inbox demands so critically important to work on the problems in the systems which are pervasive throughout the healthcare industry in the U. S. and in other countries as well. 

[00:12:46] But what interests me and where I work is in that 20 to 40 percent, because that is also a big chunk. And if we can take responsibility and learn how to apply our natural resilience that we have as healthcare providers, we are a very resilient lot, and we have the evidence to support that.

[00:13:06] If we can apply that resilience to help ourselves even 20%, let alone 40, that can actually add a lot of ease to our days. So in the book, MindfulMD, which your listeners can download a free chapter at gailgazelle.com/MindfulMD, 

[00:13:25] what I talk about is what I've seen in the hundreds of physicians and physician leaders I've had the pleasure and privilege coaching over the last decade and a half.

[00:13:34] Of course, so much external autonomy has been wrested. There's no question about that. But what about the other part of autonomy, the autonomy over ourselves, the autonomy about how we respond to the difficulties we face, the autonomy over our own mind? 

[00:13:52] Which is expert at producing thoughts, worries, fears, ruminations, stories, etc. that I have seen greatly contribute to our misery. And we learn a lot of wonderful things in our training. We don't learn how to manage this instrument that we're all using in all our waking hours. 

[00:14:12] And furthermore, as I outline in the, in part one of the book, which is really the short part that I call the Roots of Burnout, what I see is that we learn a lot of things in our training that actually contribute to burnout.

[00:14:25] We learn that we're supposed to be the invulnerable, all knowing captain of the healthcare team. 

[00:14:31] Well, that's great, but what happens, let's say, in the early parts of a pandemic when there isn't an answer and we've been trained that we must have the answer and we must have the perfect answer? 

[00:14:40] Right? We learn in our training to be very harsh with ourselves, to say things to ourselves we would never say to anybody else. We learn to compare ourselves to others, not to focus on where we're doing well, but to focus on where we're coming up short.

[00:14:53] Something that, what I see as plants the seeds for feeling like an imposter later on. So we learn a lot of things in our training that I think create what I call the fixed medical mindset.

[00:15:06] Which is a fear based way of thinking. We feel like we have to prove ourselves. It's not the whole story, but it's an important part of the story. And it's the part that we can have autonomy over. How we work with our own mind, how we process our own experience, where we focus. 

[00:15:24] And mindfulness is fundamentally about training the mind to focus where we want it to focus. It's not so much on all the thoughts and stories and, you know, all the perturbations that go on in the human mind, a lot of catastrophic thinking, et cetera, but to actually focus on what it is that's actually in front of us. 

[00:15:41] And I, I see over and over and over that that's a game changer in minimizing physician burnout.

[00:15:50] Lauren Peccoralo: So much amazing stuff in what you just said. I wanted to sort of circle back to a few of the things. So you talked a little bit about this idea that mindfulness. It's not really about meditation, right? It's something very different. So can you explain the difference between the two? 

[00:16:07] Gail Gazelle: I think when people hear the word mindfulness, they think about monks meditating on the mountaintop or maybe aging hippies coming out of Woodstock. 

[00:16:15] They think it's all about meditation, and in particular, for busy, overworked clinicians, there can be a sense of, oh yeah, mindfulness, yeah, like that's going to change anything. You know, you just want me to go meditate and, you know, keep a gratitude journal and like that's going to make it all better.

[00:16:33] There's a lot of cynicism about the M word, and I really try to address that head on in the book. What we're doing with mindfulness is we're paying attention. And we're mainly paying attention to what is going on in our own minds.

[00:16:50] So, I talk about, in the first way that I have seen mindfulness restore autonomy and cure healthcare burnout, a very busy thoracic surgeon, who I coached for a number of years, who was sent to coaching, did not come voluntarily, but was sent to coaching because people found him really rude. Nurses, in particular, found him condescending.

[00:17:12] And when he got that feedback, it didn't make any sense to him. He thought he was doing great, he was a real asset to his hospital, and he thought, you know, what does their opinion matter anyway? 

[00:17:23] And when we began to talk about recognizing the thoughts that he was having, I charged him with keeping an eye on his own thoughts and noticing what his mind was up to. His task was to do that for two weeks. He called me three days later. He said, Gail, what is going on in my mind? 

[00:17:43] It's like a crazy town up there. He was shocked at how busy his own mind was. And what he began to see too, is that his mind was very focused on the negative. It wasn't focusing on what the nurses were doing well, how the patients were doing, contributing to their good care, what was going well in his hospital. 

[00:18:01] In fact, because he'd been trained as an expert surgeon, his job was to fix problems. So his job was to spot those problems in the first place. And he just hadn't realized what was going on in his own mind. 

[00:18:12] Once he did, he loved to learn, just like almost every physician and really everybody in healthcare. We love learning, but he'd never focused that lens of learning on his own mind. 

[00:18:21] So, what we're doing with mindfulness is, in a way, we're becoming the observer of our own mind. We're finding out, well, what is my mind up to? These thoughts that I have all day long, which ones are helpful to me? Which ones are unhelpful to me?

[00:18:36] And furthermore, how can I train my mind to focus on the ones that are helpful and let the ones that are unhelpful go by? You know, just to take this a little bit further, it's a rare physician that doesn't suffer from the imposter syndrome, which is very surprising to the general public, right? 

[00:18:53] For those listening who are maybe patients or loved ones of doctors, you could think to yourself, well, why would all these physicians feel like an imposter? They're so smart. They went to these elite medical schools. You know, they, they're the pillar of our society. 

[00:19:07] And yet, many of us walk around feeling like an imposter. We don't always realize that these are unhelpful thoughts that we have. These thoughts of accusing ourselves of, you know, being some kind of phony.

[00:19:18] With often very limited data to support these thoughts, this assessment that the mind is making. So that's just one example, and I do go into that in the book Mindful MD. How do we learn, how do we train the mind to not be as wedded to these thoughts that are actually not doing us any good? 

[00:19:39] Lauren Peccoralo: I think that's a really wonderful way to put it, and I wanted just to also mention that our system has a mindfulness based stress reduction program, which is really, I think, unique. We have some wonderful folks that lead that program, and we're hoping to actually expand it a bit. 

[00:19:57] So, that is something we have available to physicians and actually anybody who's really interested in learning more about it. I did want to ask you, so you talked a little bit about your thoughts, right, that first step is to recognize your thoughts. What's next? How do we move on from our thoughts? 

[00:20:16] Gail Gazelle: Well, there are quite a few things we can do. We can begin to train the mind. To be less attached to the unhelpful thoughts and I, I just want to say that that is where meditation comes in because in meditation we're not banishing thoughts, we're just getting to know what's going on in our own busy mind.

[00:20:34] So that's a key part of training the mind. We have to almost diagnose what the mind is up to before we can intervene. So that's critically important. 

[00:20:45] When we begin to recognize that we are not our thoughts, we begin to see that there's almost an inner narrator inside of us that's talking to us all day long, that's telling us all kinds of things, you know, your nose is too big, move here, take care of this patient, why are you thinking that, you're a phony, on and on and on.

[00:21:05] So we need to get to know that narrator, so that we can work with it more effectively. All of these thoughts come together into stories that we tell ourselves. And some of those stories are great. For many of us, those stories, like I talked about with my own burnout, are ones of inefficacy. 

[00:21:23] Ones of not measuring up. Not being as good as our peers, for example. So, we have to unpack those stories. And I provide some tools in the book for doing that. Once we get to know our mind a little bit more, we can also gain much greater autonomy over our patterns of emotional reactivity.

[00:21:42] There's a lot of frustration in healthcare these days. As we discussed, a lot of autonomy over the conditions of our work have changed, and most of us are employees now, and by definition, employees have much less control over the conditions of their workplace. 

[00:21:58] And that's a hard pill to swallow for us because we were taught that we controlled everything and we know how everything should work.

[00:22:06] And we can be very reactive about it. So many physicians sit down to chart, which is really the Achilles heel of the modern physician, having to spend all this time on the care and feeding of the electronic health record. 

[00:22:18] So many physicians tell me they sit down to chart and they feel so angry. They feel like it's so unfair to have to spend all of this time when this isn't what they signed up for. They signed up to take care of vulnerable patients in their time of need.

[00:22:31] If we don't learn how to manage those emotions, they really derail us. It makes it very hard to get the job done, to get the charts done, for example, because we're, it's almost like we have smoke coming out of our ears.

[00:22:42] We're so distraught. So that's another way that we can restore autonomy, autonomy over our own emotions. And how we work with them. So those are a few, Lauren. I'll pause there and then we can get into a few more. 

[00:22:56] Lauren Peccoralo: I mean, it was just making me think because one of the things I hate most is writing notes. It's definitely my Achilles heel. And because of that, even though I always get it done within my 24 hours, I often wait till that very end of that 24 hour mark to get it done.

[00:23:14] And I've found that there are some strategies that can help me. I typically don't listen to music when I do any other work, but when I listen to music and chart, it kind of calms me down. So I can see how that, sort of reduced reactivity, right?

[00:23:28] That calming music can help me focus in on a task that might not be my favorite task to do. And it also maybe is bringing some additional joy through the music that I'm not getting from the actual task at hand. 

[00:23:42] So, I can see how even pairing some not fun tasks with, you know, more enjoyable tasks or more enjoyable background can be helpful. That was one thing that I was thinking of. 

[00:23:56] Gail Gazelle: Active, mindful awareness, being aware of what is, what are the conditions that help me be at my best for the difficult tasks that, you know, every job involves difficult tasks. So how can I really diagnose what it is that works for me and what doesn't.

[00:24:09] It's so important to take the time to do that so that these odious tasks can be more manageable. 

[00:24:16] Lauren Peccoralo: Yeah, that makes a lot of sense. And the other thing that, I was thinking about as you were talking was, a lot of the concepts you're mentioning make me think about things like cognitive behavioral therapy and dialectical behavioral therapy.

[00:24:30] They have these elements, right, that you're bringing in into these mindfulness and coaching strategies. Am I right about that? You know, some of them are similar. 

[00:24:39] Gail Gazelle: Without a doubt, some of them are similar. There's a lot of overlap between some of the psychological techniques that can be used, like CBT. Fantastic to be able to notice when our thoughts are bringing us down and gaining agency over reframing those thoughts. 

[00:24:55] That's a lot of what CBT is about. DBT, that you mentioned, is very much based on mindfulness. Marsha Linehan talks a lot about mindfulness and she uses it very heavily in what she formed in DBT.

[00:25:08] So mindfulness is not the only way, but it is a way that we can restore our autonomy, that fragile sense. And if we think about the Viktor Frankl quote, that very famous quote that everything can be taken from a man, and obviously a woman as well, except that one freedom, that one freedom to choose how we respond to whatever it is that we face.

[00:25:31] So for me, that's where the money is in mindfulness. There's so many choice points that we have in the course of our busy days. Sometimes we're not aware of those choice points. We think we don't have a choice. 

[00:25:42] How can I be happy given the difficulties that I'm facing? Well, the difficulties are there and you have a choice in each of those moments about not necessarily, you know, happiness with a big H.

[00:25:54] But at least contentment, and at least a sense of fulfillment. And if your listeners get nothing else from this session, and from the MindfulMD book, it's that we don't have to hand over our happiness to broken systems. We don't. 

[00:26:11] That's a choice that we have. We can. We can hand over our happiness, and we don't have to.

[00:26:17] And so my hope is that the book provides a roadmap, not just for individual physicians, but for medical schools, for residencies. It's being used in a lot of programs now to help restore that autonomy so that you don't hand over your happiness. That's the key here. 

[00:26:35] Lauren Peccoralo: That makes me think about a couple of things. And I want to also ask about the other three strategies. But what I was thinking there is this idea that there are broken systems. We can't get away from them. 

[00:26:46] We don't even necessarily need to leave them to be happy. Right? There's this idea that, oh, if I just do X, Y, and Z, then I'll be happy. But really, we can be happy and content even in the moment where we might not have already accomplished X, Y, and Z or sort of the next step. 

[00:27:05] But I was wondering if you can talk a little bit, and we talked about this earlier, about this idea of leaning back into that connection and purpose, right? That's the next strategy. So how do we think about reconnecting with our sense of purpose and meaning? 

[00:27:19] Gail Gazelle: Well, that is what I articulate as the fourth way that mindfulness can restore autonomy and cure healthcare burnout. And I'll just give another vignette of a young emergency physician who reached out to me.

[00:27:32] Very burned out, just a couple of years out of her training, not sure if she could continue.

[00:27:38] And she said to me, you know, I really dread going into my emergency room shifts. And I dread it because everybody's miserable. Everybody's walking around, not smiling, head down, not helping one another out. And she said to me, what choice do I have but to feel miserable? 

[00:27:58] And it really struck me in that moment, one, the contagion of the negativity. What I think about is that vortex of negativity that's almost nipping at the heels of all of us working in the healthcare endeavor. 

[00:28:12] But more importantly, what I really thought about is the importance of connection, the importance of compassion. If we're all walking around so focused on the miseries, we're losing our sense of connection.

[00:28:27] She felt so disconnected that she wanted to leave emergency medicine just a couple years out of her training, so tragic. And yet, if she was able to go in and smile herself and offer to help somebody out, of course that's hard, but maybe there'd be a ripple effect. 

[00:28:46] Maybe others would lean into connection and sense of purpose, helping one another.

[00:28:50] What could be more at the heart, really, the fabric of what we're doing in healthcare, is helping fellow human beings in their time of need. So, she was talking from a place of lost autonomy. I have no choice but to be miserable and there's nothing I can do anyway. 

[00:29:07] And yet, when we can lean into connection, compassion, why did we do this in the first place, we can all be a little less downtrodden and we can begin to work together, well, what are the parts of this that we can control?

[00:29:20] We can control how we relate to one another. And we feel a lot better about ourselves when we're open and when we're kind to others and when we are working as a team toward the common good. 

[00:29:33] And that's what I'm deeply committed to, helping individuals and teams of clinicians feel better about their work. Because it's there, it's possible. Again, not Pollyanna. Not like, oh, it's all wonderful, because it isn't. 

[00:29:46] But how can we lean into these important factors so that we can help one another and lift one another up?

[00:29:54] Lauren Peccoralo: So I love that idea and it's, it's thinking about that this doesn't always have to be top down, right?

[00:30:00] Certainly it's great if your leader is embodying these characteristics that you want, you know, to show- the connectedness, the caring, the compassion for the team and for everyone working together. 

[00:30:12] And we know our data shows that folks tend to report less burnout when they feel connected to their leader and that their leader is valuing them. But it sounds like there's also some ability, for folks who may not be the leaders to change the culture in a way, right? 

[00:30:31] To be able to try to bring out the connectedness, maybe not with their leader, but with everyone else working on their team, so they can still feel connected and like they have relationships that are worth it at work. 

[00:30:46] Gail Gazelle: It has a tremendously positive impact on the individual and on those around them. The ripple effect of it. It takes me to the final way, and we missed one that I can't get back to you, but the final way that mindfulness restores autonomy and cures burnout, which is cultivating upward rather than downward spirals.

[00:31:04] And we know a lot from the modern field of psychology, the subfield positive psychology, thousands of studies now on the incredible impact of positive emotions.

[00:31:15] Which, again, doesn't mean just walk around and just put a happy face on and everything will be great. It's far from that. It's having a balance of what we might think about as up emotions to down emotions. 

[00:31:26] And I do an exercise sometimes. I give a lot of keynotes and workshops and grand rounds. And I do an exercise sometimes. I call it Magic Monday. And I asked the audience members, usually downtrodden physicians, to imagine that they go to work on Monday, and everything is the same. 

[00:31:43] Same patients, same co workers, same difficult EMR, same haggling with insurance companies, but the only thing that's different is that they are able to see the positives- in themselves, in their colleagues, in their patients, in the environment. 

[00:31:57] And I have people do a little visualization, a Magic Monday visualization. It is amazing what people say. People say, well, I would smile more. And you know what? 

[00:32:06] People would smile back at me and that would feel good. I would feel lighter in my day. At the end of my day, I'd go home and I'd tell my wife about what went well during the day. I'd be more efficient at getting my charts done. I'd be better with patience.

[00:32:23] It's absolutely incredible. So again, we're not trying to be unrealistic here, but with mindfulness, we gain clarity, clarity about what is truly going on, and often It's a lot better than our mind is telling us.

[00:32:37] The negativity bias on the human mind is a force to be reckoned with. It focuses all of us on what we're not doing well. So that's, that's to mean where the rubber meets the road. It's not top down, far from it. 

[00:32:53] Lauren Peccoralo: So that makes a lot of sense. And I know it sort of brings me back to the book that Dean Charney, Stephen Southwick, and John DePierro wrote, which really talks about all of the elements of resilience.

[00:33:03] And in fact, I think a lot of them sort of match up with what you've written in your book, but the idea of realistic optimism, right? This idea that we're not expecting everything to be perfect, but, all in all, when all the chips fall at the end of the day, we're expecting to be better off tomorrow than we are today, right?

[00:33:21] There's something that's positive that's going to happen that's moving forward. Not, you know, everyone's going to win the lottery, but realistically, you know, there's something good to come out of almost everything that happens, and I think that also fits with the growth mindset.

[00:33:34] The idea that I'm going to learn from these challenges and struggles and mistakes that I'm making and come out of this better, come out of this having more knowledge and potentially feeling better about where I'm at.

[00:33:49] Gail Gazelle: It's really true and that's a sense of autonomy that we can regain. Most of us in medicine have a lot of strengths. We've shown our ability to persevere, right? And how do we apply those strengths to help ourselves and help our peers cope in with the challenges that we face? That's a lot of what this comes down to.

[00:34:12] Lauren Peccoralo: So, why don't we wrap up and tell me what the last one that we missed was.

[00:34:17] Gail Gazelle: Yes, we missed a way that I call, work with what is. And what I mean by that is, the mind is very good at creating stories. And one of the storylines that many of us have, has to do with, I can't be happy because, and I'll be happy when. 

[00:34:37] Okay, so here's, here's what I like to do around that. So, you're. in high school, and you think you might want to go into the field of medicine and become a physician. So you want to get into a good college. So you think to yourself, well, I'll be happy when I get into a good college. 

[00:34:52] Then you get into that college, you want to go to med school, it's very competitive to get into medical school. Oh, I will be so happy when I get accepted to medical school. Then you get into medical school, which is not exactly a walk in the park for many of us.

[00:35:05] It's not necessarily a happy time, although there are good parts. And you think to yourself, well, I'll be happy when I match into the right residency. Okay, then you get into residence, and here's the kicker, I'll be happy when I'm an attending. 

[00:35:19] And for those of you listening who are attendings, you kind of get that that's a complicated punchline because there's so much unhappiness. And we walk around as attendings thinking, well, I'll be happy when I retire. 

[00:35:31] And of course, there are kernels of truth in there, and yet it keeps us from being happy and fulfilled and content and satisfied today. Again, we're forestalling our happiness and we're saying something outside of me needs to change.

[00:35:47] And I can't be happy until that happens. And how predictable is the world around us? Not very. The weather, our spouses, our kids, our health care systems, the politics, the planet. There's a lot that's unpredictable and highly beyond our control. 

[00:36:05] So why not focus on what is under our control and get to know these mental stories that again, are only serving to decrease our sense of meaning, fulfillment, and joy?

[00:36:17] Lauren Peccoralo: I think that is a perfect way to sort of move on to the next idea that I wanted to talk about, which is, all of these techniques and strategies sound really good, but I wanted to know what the role is of the coach and helping physicians and healthcare workers really work through the process.

[00:36:37] I know a lot of people hear about that concept of coaching, but don't really understand what it is. And I also will just mention that our institution through our office has just started a coaching program. Right now we're just doing group coaching for faculty and it's been going really well.

[00:36:52] We've had some great feedback. Some faculty are able to access executive coaching. But I'm wondering if you could give us a little bit of a sense of what coaching is as you see it, and how you see a coach's role in sort of working through this process of building resilience. 

[00:37:09] Gail Gazelle: Well, in many ways, coaching is mindfulness in action. 

[00:37:13] Coaching is all about facilitated change. And the coach's job is to motivate change, to inspire change. to help the client, in this case the busy physician, harness their strengths and apply those strengths to areas where they may not be quite as strong, and to break out of so many self limiting thoughts and stories that we can have, everything from I've never been as good as, or I'm a phony, or I'll never be as good as, or they only let me into medical school because, and fill out the blank, all kinds of very self limiting beliefs that make it hard for us to fill ourselves and to be at the best that we can be professionally, but even more importantly, on a personal level. 

[00:37:56] So a good coach is not telling you things, not teaching you things, not talking at you, but asking the right questions, making the right reflections, really understanding the physician mindset, the things that we learn in our training.

[00:38:12] That if we're not perfect, we're some kind of failure. Again, invulnerability, always having to have the right answer. There are things that we learn that make it very difficult for us to thrive. So a really good physician coach understands those things, has walked in the path of a physician. 

[00:38:29] I'm very involved in the Harvard Institute of Coaching. I spearheaded a two year project where we developed standardized competencies for those who coach physicians, and that was just published in the May 1st edition of the Mayo Clinic Proceedings, because there are a lot of people just hanging out a shingle now. Oh, I can coach physicians.

[00:38:48] And yet there are a lot of competencies that physicians require to get good coaching. So I encourage people who are listening and maybe shopping around for a coach to take a look at that May 1st issue of the Mayo Clinic Proceedings because we did a very scientific process, that made it worthy of being published.

[00:39:05] So, coaching is all about results. It's not about standing still and it's about figuring out what, what are the roots for me of why I'm burned out or why I'm not moving into leadership or all the things, all the ways that we can be stuck in our lives. 

[00:39:19] And it's about getting the tools and the support and the validation to move forward. What I coach, I coach one on one and I also include group coaching so that we can break the isolation that so many physicians are feeling. 

[00:39:32] So, My clients get both the one on one coaching as well as the group coaching because it's an another ingredient in moving forward and really reaching your potential in this one precious life that each of us get to live.

[00:39:47] Lauren Peccoralo: That's super helpful. And I'm hopeful that more and more of our physicians and non physicians alike can access that type of resource because I think can be really helpful in terms of growth and development and reducing burnout. 

[00:40:03] To sort of close this out, I have a couple of last questions for you. What do you think in the long term, burnout and well being looks like for physicians? Do you see this getting better? And if so, what are the things that you kind of see as the major drivers of improving burnout in healthcare?

[00:40:24] Gail Gazelle: Well, as we've discussed, it's multifactorial. If systems are causing 60 to 80 percent of burnout, that really tells us something and, that nobody's really questioning those numbers. Many are even saying 80 to 90 percent. 

[00:40:37] So, we need systems that support clinicians and that support clinician well being, in terms of the expectations around productivity, around managing the inbox, all the below grade tasks. There's no question that we need that. 

[00:40:52] At the same time, that 20 to 40 percent is the area where we can each take responsibility for how we show up. I provide some questions in what I think about as an epilogue to the book, you know, A New Healthcare, where we ask ourselves, well, how did I show up today?

[00:41:09] What can I do to lift up myself and my peers? What am I going to feel best about when I go home at the end of the day to my loved ones? They should, you know, how can I contribute to the healthcare system that I want? 

[00:41:20] So that's the personal part of it in addition to the all important systems part of it.

[00:41:26] It's about the end. It's not an either or, because a lot of physicians roll their eyes to the M word, mindfulness, and then when I say to them and they kind of roll their eyes and say, well, don't ask me to do anything, you know, it's all the system. 

[00:41:39] And then when I say to them, so when do you think the system's going to be fixed? Next week, next month, next year, and then the eye rolling about mindfulness is replaced by eye rolling about the system. 

[00:41:50] So what do we do? All this time and effort and financial input that we've made, this incredible investment in these wonderful careers, what do we do? And that's really where MindfulMD comes in.

[00:42:05] Lauren Peccoralo: I think that makes a lot of sense. And what I'll remind our audience is that, institutions like Mount Sinai and certainly Mount Sinai in particular, there are efforts that are happening, as we talked about before, that are system level. 

[00:42:19] We offer a grant program to pilot innovations that can decrease the clerical burden and increase well being for physicians. We work very closely with our digital technology partners and our faculty practice to make sure that we are looking at things like the in basket. 

[00:42:39] We're looking at things like results management to try to minimize some of those clerical burdens for physicians. And we're offering coaching programs and we have mindfulness based stress reduction and we offer leadership training.

[00:42:54] And many of the leadership training, material is very similar to some of the things that you're talking about in terms of creating psychological safety, learning how to have a coaching mindset as a leader. 

[00:43:05] So those things are offerings that we're trying to encourage folks, faculty, and other leaders alike to attend. 

[00:43:12] In the final minutes, I wondered if you could share a little bit of advice for a new physician or a young APP or a young nurse just starting out in their healthcare career. What should they be doing right out of the gate to maintain their resilience and try to avoid and minimize burnout?

[00:43:33] Gail Gazelle: There's a lot. But I'll pare it down to one thing. Get to know the workings of your own mind. That's what mindfulness is about. You can read that as a free chapter, MindfulMD, www. gailgazelle. com/MindfulMD. Get to know your own thoughts. 

[00:43:53] Figure out which ones are helping you and which ones aren't and follow some of the techniques in the book for detaching from the ones that aren't helpful.

[00:44:01] It's going to be a game changer for you. At this point in your career, in the rest of your life, in the longevity of your career. I've seen it over and over and over completely change the ability to withstand the difficulties that you will invariably face in your career in healthcare. 

[00:44:18] Lauren Peccoralo: Well, I want to thank you so much, Dr. Gail Gazelle, for this fabulous discussion. I think it was so helpful for me and I hope it will be very helpful for those listening to hear all about the suggestions you have and \ the hope that we both have that there are ways to make this better that include both ourselves and system changes. So thank you so much. 

[00:44:41] Gail Gazelle: Thank you. Such a pleasure. 

[00:44:44] Stephen Calabria: Thanks to Drs. Gazelle and Peccoralo for their time and expertise. Dr. Gazelle's book, Mindful MD: 6 Ways Mindfulness Restores Your Autonomy and Cures Healthcare Burnout, may be found on Amazon and wherever books are sold.

[00:44:57] That's all for this episode of Road to Resilience. If you enjoyed it, please rate, review, and subscribe to our podcast on your favorite podcast platform. Road to Resilience is a production of the Mount Sinai Health System. It's produced by me, Stephen Calabria, and our executive producer, Lucia Lee.

[00:45:12] From all of us here at Mount Sinai, thanks for listening, and we'll catch you next time.