by M. Victoroff, MD
Featured in the July-August 2019 Colorado Medicine Colorado Medicine.
Occupations expose their practitioners to intrinsic and extrinsic stresses. For health care, some intrinsic stresses are taking call, emergencies, night shifts, interruptions, coping with fatigue, sorrow, people in distress, errors and falling short of your own expectations. You knew these when you signed up.
Extrinsic stresses are things you didn’t necessarily foresee and aren’t inherent to the job. These are things like difficult bosses, colleagues or subordinates, unrealistic schedules, administrative burdens, balky technology, nonsensical regulations and dysfunctional organizations. They can also be political or social conditions completely extraneous to medical practice.
There is a well-intentioned trend to address stress from both sources with programs for individual “wellness” or “resilience.” This can be a mistake. For intrinsic demands of the profession, individual measures like lifestyle hygiene, pacing and self-care are valid. But, organizational problems usually need organizational solutions. Yet, despite more of us spending more time in more organizations, we are not as well served by them as we should be. Being offered self-improvement remedies for extrinsic stresses can feel condescending or victim-blaming.
“They” could be sure the problem is you. You could wonder if “they” are right. Your defense could be to disengage (“I just mind my own business and go home”) or to enroll in the bubble of a protection-group. Both tactics are counterproductive in organizational terms. The evidence-based solution is elevating awareness of group process to the same level of attention other important business matters receive. Of course, this is annoying, intrusive and time consuming. But, it’s hard to see solving group interaction problems without group interactions. And, these may need to be externally facilitated to avoid making things worse.
Distinguishing between “it’s me” and “it’s them” means overcoming guilt, resentment and doubt. This is where peers are vital, when given a chance. Mythology stereotypes doctors as “loners” and “fixers.” If you are a self-sufficient type, you will often be exposed to trolling in today’s hypercritical culture, but less often offered help. Objectively working the me/them problem on your own is pretty much impossible. You need a trusted network for reality testing. But, networks demand care and feeding. Not everybody has them. Medical professionals are more isolated these days than ever before, and bona fide social networks – in contrast to synthetic counterfeits – are a threatened species.
It’s unavoidable to reflect on your own temperament, unless you are a narcissist or sociopath. A lot of times, it turns out the problem comes from interactions between the environment and your personal constitution. Don’t necessarily accept the broad whitewash, “you see, it’s all of us!” That’s a lazy analysis. All of us don’t have equal roles in creating working conditions. But, the fact that a lot of stress is from external causes doesn’t mean they are necessarily malicious. That’s paranoid (usually). A constructive starting point is to assume, “all of us are trying imperfectly to do our best.”
One tactic is to name the stress and treat it as if it were a person in the room. Not an enemy to be destroyed but a colleague to be invited in, worked with, listened to empathically and coached. Might the stress be open to change?
Many of us reach a point when we think, “why do I always have to be the mature professional? Why can’t I be the cranky person once in a while?” But, unconstructive behavior creates a negative spiral. The solution to exasperation is not to hit your boiling point and ventilate. It’s to take turns being the adult in the room so that no one gets imprisoned in that role.
Role shifting is an indispensable skill in effective groups. One is a helper; another asks for help; one calls attention to a problem; another is attached to the problem. If you’re depleted from patient care, you’ll have a hard time summoning energy to help a peer. But, you could still recognize the need. Professionalism is not the ability to eliminate conflicts of interest. Professionalism is the ability – and the obligation – to manage conflicts of interest. Healthy organizations monitor the energy needed for group hygiene and make sure it’s well spent.
It’s possible to find yourself in a fix that isn’t fixable. That’s when you pull the ripcord and get out. Doubt is one of the stages. “Am I a quitter?” “Should I just try harder?” Again, answering this calls for help from your network. Well-functioning organizations understand the importance of professional networking. If the doctors’ lounge is empty at lunchtime, chances are the organization is under stress.
Human networks are the root and the remedy for a lot of stress. Research shows the best groups are diverse and inclusive. They tolerate disagreement, conflict and discomfort. They push through these to create solutions that a homogeneous group could never achieve. “Comfort groups,” where everybody is compatible, are objectively less creative, productive and successful than groups where sincere disagreements are constructively resolved. If you are in a setting where you are content and happy all the time, you can be sure someone else isn’t.
High performance teams are populated by imperfect people who manage boundaries well and compensate for each other’s blind spots. Members rapidly identify needed changes and adjust to them. This kind of organization is the most rewarding to work in, and the sort we want to cultivate for health care.