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Bouncing Back: Reverse the Victimization Trend and Make Institutional Change

Barringer, Kelly, MD; Buller, Dave; Cienki, John, MD; Deluca, Lawrence, EdD, MD; Freeman, Matt, DNP, MPH; Grall, Kristi, MD; Johnson, Rick; Lam, Robert, MD; Staggs, Kira; Stoneking, Lisa, MD; Vermilyea, Elizabeth, PhD

doi: 10.1097/01.EEM.0000547702.34226.40
Bouncing Back

Resilience isn't just that grit you can use to promote wellness, it's also an idea that provides hope that you can recover from burnout. No matter what you call it—grit, determination, or resolve—resilience is a synonym for toughness. One hundred patients in the lobby? No problem; I'm resilient! The EMR elevates my heart rate? Nope, I'm resilient! Ten discharges by 10 a.m.? See if I care. I'm resilient!

Perhaps this definition of resilience as resistance has been so widely adopted because it is code for not being bothered by high-stress environments. We profess that we are resilient without addressing the underlying stressors.

The repeated exposure to chronic stress results in wear and tear to the body, the allostatic load. The result: Our new normal is an elevated stress level, and we keep taking care of business. Like other deficit disorders, high-stress situations take a toll. Even if we get used to it, it still creates cognitive, emotional, and physical damage. And when our high stress continues, our psychological and physiological adaptive systems become overwhelmed and resilience is disabled.

High-stress environments like EDs can create stress fractures, as Nisha Mehta, MD, described. (MedPageToday April 26, 2018; http://bit.ly/2Qpr5My.) Allostatic loads are destructive to good medical care. Resilience has nothing to do with toughing it out; it means recognizing dangerous stress and doing something about it.

Physicians should incorporate resilience into their wellness programs through activities and by setting limits. Such practices may include setting professional boundaries around things like taking lunch and then using that time to talk to others, exercise, or set up lunchtime basketball games.

EPs can also embrace “resilience as recovery” as a catalyst for changing the workplace. This requires a radical departure from the professional socialization physicians undergo. We must transition away from the torturous residency model of sleeplessness and competition to one that places a high value on personal wellness and mutual support. Institutions also need to recognize that wellness breeds wellness, that resilience needs support, that healthy healers have the best outcomes.

We must admit that burnout exists and confront the shame in admitting it. A 2015 article by Pamela Wible, MD, about the abuse experienced by medical students is accompanied by videos, and two physicians describing their experience are pixelated out. Nothing could provide a better depiction of the shame we must overcome than that. (Idealmedicalcare.org; Dec. 16, 2015; http://bit.ly/2COxGxf.)

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Reconnecting

The next step is reaching out. Family and friends can be helpful, but connecting with other physicians who understand the job stresses better than anyone might ease the stigma of admitting to depression or burnout. As long as physicians isolate themselves from their community, associate burnout with weakness, and equate resiliency with grit, we will perpetuate damaging behaviors and attitudes and disempower the physician community.

We must reconnect with our jobs and workplace. The Medscape burnout survey makes it clear that some causes of burnout—EMRs, the lack of respect and collegiality among colleagues and from patients, and an overwhelming number of bureaucratic tasks—are systematic issues. (Medscape National Physician Burnout & Depression Report 2018, Jan. 17, 2018; http://wb.md/2E58ouW.) Many of our wellness strategies are individual ones—meditation, mindfulness, the insidious “can-do” attitude. The final connection we must make is back to the workplace. We must re-engage and re-empower ourselves to make changes. We must demand changes in the workplace and show their value to the whole organization.

How many of us know the names of all the nurses? Do we thank the physical therapist for the important work she does? Take it to an institutional level: Our hospital just launched a “Know Your Name” campaign to make knowing someone's name meaningful.

If we are upset by lack of respect, one of the easiest things to do is model better behavior. Saying something nice to someone can lift our spirits as well. My favorite question to people in distress is “How can I help?” It is remarkably disarming to be asked that.

We may not be able to change the EMR completely, but perhaps we can form a committee to identify the top five issues that would improve it. Physicians working together can find common ground to make the institutional change needed. Our institution's reconsideration of the flow for signing resident charts reduced the number of clicks by nearly half and cut attending charting time significantly. It also led to a physician committee working on other recommendations.

EPs frequently express feelings of victimization about a system over which they have significant responsibility but little control. We can reverse this trend and take control of the system. Institutional change is within our grasp: We participate in hospital committees, have professional organizations, do research, and produce guidelines.

It's time for us to manage our resiliency and longevity. The notion of resilience gives us comfort that we can recover, and it reminds us that we must reshape ourselves and our environment to do so.

The authors wrote this article on behalf of the American Academy of Emergency Medicine's Wellness Committee.

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