Physicians Don't Have A Resilience Problem

This week's podcast episode is taking a dive into two papers studying Self-Valuation behaviors in Physicians.  Listen for more on why resilience may not be the panacea for preventing burnout, because physicians already are high in resilience. What we ARE lacking is self-valuation.

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Transcript

season 2 ep1

[00:00:00] So we are made to feel, that the problem with burnout is our resilience. And that we just need to build more. I don't think that you can really make a valid case for that based on this data. And this isn't the only data like this. Um, but when you're talking about a population with higher resilience than average,

 And you know, that the people with the highest resilience scores still have significant burnout rates? I don't think that telling the group of people with high resilience scores that they need to be more resilient Is a valid suggestion. I think that someone who does that is victim blaming.

[00:01:00]

Hello! Oh, I've missed you. I'm so glad to be with you today. I have, um, that was what, a couple months ago that I told you I was going to have some new episodes out soon. Sorry about that. Life happened to me. And everything is okay, but lots of things and Uh, for those of you who I don't know, maybe I've talked to or posted about my mom is doing well.

She is in the middle of chemo right now for breast [00:02:00] cancer and She had a port infection and that was not fun, but all is much better now. So, thank you for your graciousness in being patient with me and for coming back and listening to more after I seemingly abandoned you don't have any intentions of doing that again, but.

I I have been turning over so many ideas, so many things I've been having conversations in my head with you. And the topic today is something that I've been so excited about. Ever since January, I went to the health care burnout symposium in San Francisco and. I had a chance to meet Christina Maslach of the Maslach Burnout Inventory that Dr. Christina Maslach uh, she just happened to sit down next to me at my table. And I felt it was like a rock star sat down [00:03:00] and was I just, I had to talk to myself for a minute and say, It's going to be okay. I'm sure she's a really nice, you can't let this opportunity get away just because you feel nervous.

And don't be creepy, but also let her know how much her work has meant. And so I did, I introduced myself and just briefly told her that I had experienced burnout years ago and that her work had meant a lot to me. There wasn't a lot about burnout in physicians at the time. And her work talked about occupational stress and I was able to recognize what was happening to me and understand that it was a universal phenomenon. It wasn't something, there was this, something wrong with me inherently because of it. And she was so kind and she, she seemed to kind of surprise. That I was, uh, had been so impacted by her work, but she was so kind and gave a wonderful talk, but her talk is not what I'm going to talk [00:04:00] about today.

I, I, I'm going to talk about a couple papers that were published, uh, 20, 19 and 2021 about physicians. And self-evaluation so the, the behaviors and mindset. With respect to the way that we care for ourselves as physicians. And I found out about these papers. I don't know how I missed them and I haven't seen anybody else talking about it. So it, it slipped under my radar for sure. But Tait, Shanafelt the great Tait Shanafelt you'll recognize his name. If you know much about the world of research on physician wellbeing and burnout. He was the first person to be named as a chief wellness officer at an academic center. So he's at Stanford.

He was at Mayo and works with a lot of physicians who do research in that area. And he gave a talk about the newest information about burnout, [00:05:00] particularly how things went during the pandemic and then toward the end of his talk, he mentioned these two papers as a way to take a step forward in the right direction.

And really making a difference in burnout rates and improving wellbeing of physicians. And when he rented this data, I just felt I was so excited by it. And I also felt so validated because it, it tells the story of how important it is for us to care for ourselves. And. To treat ourselves in a way that recognizes our humanity, just as much as the patients that we serve.

So I'm going to start with I've got the papers right here in front of me. So you might hear some rustling. I apologize for that. Or maybe you might like it. I was inspired to have the papers in front of me by listening to Kelly Casperson on her [00:06:00] podcast. You are not broken. You may know her already.

She has a fabulous wildly popular podcast. She's a urologist who specializes in sexual medicine and she has done some episodes where she did like a journal club and she goes through the paper with her highlighter and everything in front of her. And this sort of inspired me to do that, but I'm not going to get in that much of a detail.

I'm not going to read the paper to you because I've really got three papers to talk about. So, first of all when a point this first nugget of information from a study from July, 2020 in the JAMA Network Open titled resilience and burnout among physicians and the general us working population.

This was authored by Colin West Liselotte Derby, Christine Sinsky, Mickey Trockel Michael tody, uh, Lawrence Netta, lik. Lindsey Carlasare and Tait Shanafelt so some really heavy hitter names there in this, in this field. And basically what they did was they did a cross-sectional [00:07:00] national survey of 5,400 physicians and a probability based sample of 5,100 individuals in just the general us working population.

This was in late 2017, early 2018. So this is pre pandemic. And what they found was that physicians had higher levels of resilience than the general working population substantially higher, which we're not suprised by. Also that resilience was inversely associated with burnout symptoms, but burnout rates were substantial even among the most resilient physicians.

So we are made to feel, I think a lot of times that the problem with burnout is our resilience. And that we just need to build more of it. I don't think that you can really make a valid case for that based on this data. And this isn't the only data [00:08:00] like this. But when you're talking about a population with higher resilience than average, who also has higher burnout rates than average, 

and you know that the two are inversely related. And you know, that the people with the highest resilience scores still have significant burnout rates? I don't think that telling the group of people with high resilience scores that they need to be more resilient Is a valid suggestion. I think that someone who does that is victim blaming. And, and I, I see it a lot and you've probably seen this too, especially in corporate medicine where there's some lip service given to wellness programs and they're really just programs to teach you. That you're not sleeping enough or you're not, you aren't doing these things that you should be doing, ignoring the elephant in the room. The fact that it is the occupation [00:09:00] and the occupational environment that created the burnout, burnout is always occupationally induced. So with that bit of information setting the stage the first of the self evaluation papers it was published in let's say 2019. Yes. October, 2019 Mayo clinic proceedings.

So this is. Many of the same authors, but not exactly the same. The title of the paper is self-valuation attending to the most important instrument in the practice of medicine. That is a bold claim, but I love it. It's very exciting. And I think that they're onto something. I think you'll agree.

Let's talk about it later. So. their objective with this first study . So there were four items in the self valuation scale on a five-point Likert scale. So that's very unlike me neutral, like [00:10:00] me or very like me, that, that sort of thing. Okay. So there were four questions and, they pilot tested it with 250 physicians first. And then they did a multi-site wellness survey and they also included validated burnout measures . So they ended up sending surveys out to 6,100 physicians and 38 99 responded. So pretty good response rate for surveys. What they found was very interesting. So for each one point increase in the self-valuation score there was a 1.1 point decrease in their burnout score. When they adjusted for gender, they found that women had lower self-valuation scores and higher burnout scores, which we know from multiple other surveys and sources.

If you corrected for the self-valuation score, differences, it accounted for most, [00:11:00] all of the sex-based differences in burnout scores. Does that ring true? It does for me.

So then they moved on another year later with a follow-up to that study involving comparing physicians with people in the general us working population. So they wanted to see how. This effect between self-valuation and burnout held up against the general population and whether there were differences. So they took a random sample of physicians from the AMA master file. So the other group was a group of academic physicians. This is a group of anybody, any physicians. And then they took a probability sample from the general us population.

So I didn't talk about this. With the other paper, but some more details [00:12:00] about what self-valuation means. What is this self-valuation score? The questions were items pertaining to

how likely you are to self condemn versus encourage yourself after a challenge or after making a mistake, or how likely are you to put off taking care of your own health needs due to time pressure? So there were questions like that. Do you care for your physical needs and how do you treat yourself?

So what they found which is, it's just so fascinating and it rings so true that self-valuation is lower in physicians than the general population. We have higher resilience, but we have lower self-valuation .They also found that if you adjusted for the difference in self-valuation between [00:13:00] physicians and the general population, that it completely eliminated the difference in burnout and actually made the physician burnout rates lower than the general population.

So I, I found this to just be so validating and. Fascinating at the same time. I think it was accepting my self as I am and learning to be who I am unapologetically and learning to. Have boundaries that are in line with my real capacities and desires that that made me able to recover from burnout and I can, if I feel it starting to come on, I always know there's perfectionism, that's crept in, I haven't held my boundaries like I should, and I know how to adjust. I think that. [00:14:00] This gives us some ways that we can move forward that are different than simply telling people that they need to be more resilient.

Because again like that is just disingenuous. It is ridiculous to tell a group of people with high resilience who still have burnout, that they just need more resilience. It's also important to talk about what resilience means and how it's measured and how it was measured in these studies. So resilience at its most essential is the ability to withstand stress.

You could also say ability to meet a challenge or to withstand a challenge without breaking, without it harming you coming out as well as you were on the other side and maybe better. So. There are a couple of different ways that you can measure resilience. So one is through a uh, a questionnaire based approach, which is what was done in these surveys.[00:15:00]

And asking questions about, how you respond to stress and your ability to withstand challenge and meet a challenge. And then there are studies that look at endpoints, there are practically no studies that are longitudinal reading and preparing for this was really interesting.

And I, I. I kind of thought we knew we had more data than we really do. But, but there really aren't longitudinal studies of resilience with interventions, you know, and of course some of that would be unethical, but the opportunity to to measure resilience comes up in times where there has been, disaster or trauma.

One of the papers that stands out the most to me, that I read was a study of children and teens after hurricane Katrina in new Orleans. And there's, was an end point study. So they tracked a group of kids. And they [00:16:00] measured, which ones got PTSD, which ones didn't which ones who did get PTSD, got better after a period of a few months and who didn't and then they studied the experiences and the differences among those different groups of children and made conclusions of what made the difference, what led one group of children and teens to do better than the others. And in that study, interestingly enough, it was peer support. It was not even violence in their home. It was peer support.

Did they have peers? That supported them. And this is children and teenagers. That seems like that's probably true for us too, huh. But so anyway, these measures of resilience that we're talking about here are not the most perfect. Okay. So they're they're questions that people are answering.

There's much more room for bias there than in an endpoint driven [00:17:00] study, like the one about hurricane Katrina. I mentioned. Um, there are aspects of resilience that have to do with endurance and endurance certainly is tied to how we talk to ourselves. But you can imagine that there is a type of resilience that is formed on the back of a very unhealthy mindset, right? Grinding the, pushing, the hustle, the, the fear of being not enough. And then there's the resilience that is built on a foundation of self-trust trusting others. Confidence in yourself and your ability to withstand stress alongside the people that are part of your team confidence in your ability to take care of yourself[00:18:00] in the long run and the short run.

So those are different kinds of resilience. And I don't know that we really know. And if you know of studies here, if you'd know of things, please let me know. This is fascinating to me, but I didn't really find, where, where those things are compared in academic papers. Um, I hope that this has been helpful to you.

When I when. Uh, Dr. Shanafelt finished his talk. After he had mentioned these papers on self valuation there was a Q and A session. And I asked him what he thought that meant for us as far as interventions. What do we do with that as a culture in medicine. He suggested that we be more purposeful with sharing our stories that those of us who are further along in our careers, those of us who have tenure, those of us who have higher positions in our organizations that we talk about our mistakes. We talk about how we grew. When we [00:19:00] talk about not being perfect and sharing with each other, the the struggles that we have.

And I think there are lot of other ways that we could put this information to use. And in particular, because this is a group of primarily women and focused for women. I think that this data that a big portion of the difference in burnout, Is related to lower self valuation scores that, that rings true.

It rings true for me and for a lot of other women that I know we have difficulty setting boundaries. We have difficulty accepting that we're worth the trouble that, that it's worth us sitting down and hiring help. That we're worth that money, that our wellbeing is worth, that, that our families deserve that.

And it can be difficult for us to, put our foot down when we gotta put our foot [00:20:00] down when someone's violating our boundaries. And one way I think that we can begin to move forward or continue to move forward. We've been moving forward a long time. is to talk to each other and support each other and share our stories with each other.

I hope that you will reach out if you loved this as much as I did, or if you have questions or if you, if you contest it, if you do not believe what I'm saying, I love to have those kinds of talks. So you can easily find me on social media. And I would love to talk with you and I'm gonna, I'm going to bring some more information like this.

Soon I've got more content, super interesting stuff coming very soon, much, much closer together than last time. But as always much, much love to you and, um, go, go flourish.

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