Layout 1 [Qualitative Research in Medicine & Healthcare 2017; 1:6925] [page 103] Introduction In this paper, Dr. Castelloe meditates on long-standing frustrations originating from her personal experiences in clinical medicine.1 Her exit from clinical medicine can most succinctly be attributed to burnout.2 Act at your own pace, with decisiveness.3 Time is a slippery, fickle thing: now fleeting, now interminable. Sometimes, it washes over you in waves that defy notice or quantification. Other times, a mere moment can be held up to the light and minutely examined before it finally flits away. This ever-changing nature of time is inextricable from my memories of clinical medicine: expansive forty- four-hour shifts that seemed as though they would never end, contrasting with an endless stream of brief appoint- ments, each over-and-done before I properly felt it begin. As a primary care physician in a large, multispecialty, group practice, I had no power – despite numerous at- tempts to wrest it from the administration – to change my patient appointment schedule or visit length. Fifteen- or thirty-minute appointments – with mandatory double- booking – came with the job. I could not act at my natural pace. To do so, I needed more time to listen to each of my patients; think deeply about their questions and concerns; formulate a collaborative and cohesive plan of action; document that plan, perhaps honing it as I went; and pause briefly – to reflect, breathe, recharge – before repeating the process with another patient. Instead, I worked at an unnatural, externally imposed pace, racing through and from visit to visit, day after day, week after week, month after month, year after year…until I could race no more. I left clinical medicine exhausted and overwhelmed by feelings of inadequacy; inadequacy that devolved into slow-burning shame; shame that whispered nagging ques- tions; questions that continue to haunt me. Why couldn’t I hack it? Was I less resilient than other physicians? Did I be- long in clinical medicine in the first place? If so, what more could I have done to stay? Over the years, as recognition of and concern about the prevalence of professional burnout increased, my questions evolved. Was my burnout the prod- uct of a poor fit between me – all my innate and acquired strengths and challenges – and my career choice, or simply a poor fit between me and the healthcare system in which I worked? Should I have changed practice settings before I turned away from clinical medicine? With these questions Tincture of time Erin Nissen Castelloe Pharmaceutical Medicine Consultant, San Diego, CA, USA ABSTRACT In this article (part two of a two-article piece), I, Erin Nissen Castelloe, meditate on long-standing frustrations originating from my personal experiences in clinical medicine. My exit from clinical medicine can most succinctly be attributed to burnout, burnout triggered by inadequate time to address my patients’ needs and complete the tasks mandated by the healthcare delivery system in which I worked. Self- and system-imposed pressures to meet my professional obligations led to chronic overwork, reduced personal time, sleep depri- vation, exhaustion, and ultimately, recognition that my work situation was unsustainable. For more than ten years, I have questioned my decision to leave clinical medicine, hashing and rehashing the circumstances leading up to it. I am ready to let go of the questions that have haunted me, but I want to do so deliberately, considering them carefully before I release them. Therefore, with high hopes – to understand my past, accept it, and move boldly into my future in medicine – I searched the literature, focusing on burnout in physicians and physicians-in-training; the role of time pressures in burnout; and the value of physicians spending adequate and high-quality time with patients. Correspondence: Erin Nissen Castelloe, 12594 Kestrel Street, San Diego, CA 92129, US Tel.: +1.858.354.6441. E-mail: erin@castelloe.org Key words: Burnout, therapeutic presence, visit length, time, pa- tient-physician relations. Conflict of interest: Erin Nissen Castelloe works as a paid phar- maceutical medicine consultant to several drug-development com- panies; she does not own or accept stock (or stock options) from any drug-development company for which she works. Acknowledgements: With humble thanks to the family, friends, and colleagues who reviewed drafts of this manuscript and the ideas therein. Received for publication: 8 July 2017. Accepted for publication: 8 July 2017. This work is licensed under a Creative Commons Attribution Non- Commercial 4.0 License (CC BY-NC 4.0). ©Copyright E.N. Castelloe, 2017 Licensee PAGEPress, Italy Qualitative Research in Medicine & Healthcare 2017; 1:103-108 doi:10.4081/qrmh.2017.6925 Qualitative Research in Medicine & Healthcare 2017; volume 1:103-108 No n- co mm er cia l Time is a No n- co mm er cia l Time is a slippery, fickle thing: now fleeting, now interminable. No n- co mm er cia l slippery, fickle thing: now fleeting, now interminable. Sometimes, it washes over you in waves that defy notice No n- co mm er cia l Sometimes, it washes over you in waves that defy notice or quantification. Other times, a mere moment can be held No n- co mm er cia l or quantification. Other times, a mere moment can be held four-hour shifts that seemed as though they would never No n- co mm er cia l four-hour shifts that seemed as though they would neverend, contrasting with an endless stream of brief appoint- No n- co mm er cia l end, contrasting with an endless stream of brief appoint- ments, each over-and-done before I properly felt it begin. No n- co mm er cia l ments, each over-and-done before I properly felt it begin. As a primary care physician in a large, multispecialty, No n- co mm er cia l As a primary care physician in a large, multispecialty, No n- co mm er cia l Correspondence: Erin Nissen Castelloe, 12594 Kestrel Street, San No n- co mm er cia l Correspondence: Erin Nissen Castelloe, 12594 Kestrel Street, San No n- co mm er cia l Key words: Burnout, therapeutic presence, visit length, time, pa-No n- co mm er cia l Key words: Burnout, therapeutic presence, visit length, time, pa- tient-physician relations. No n- co mm er cia l tient-physician relations. us e up to the light and minutely examined before it finally flits us e up to the light and minutely examined before it finally flitsaway. This ever-changing nature of time is inextricable us e away. This ever-changing nature of time is inextricable from my memories of clinical medicine: expansive forty-us e from my memories of clinical medicine: expansive forty- four-hour shifts that seemed as though they would neverus e four-hour shifts that seemed as though they would never on ly up to the light and minutely examined before it finally flitson ly up to the light and minutely examined before it finally flits to understand my past, accept it, and move boldly into my future in medicine – I searched the literature, focusing on burnout in physicians on ly to understand my past, accept it, and move boldly into my future in medicine – I searched the literature, focusing on burnout in physicians and physicians-in-training; the role of time pressures in burnout; and the value of physicians spending adequate and high-quality time on ly and physicians-in-training; the role of time pressures in burnout; and the value of physicians spending adequate and high-quality time on ly in mind and high hopes – to understand my past, accept it, and move decisively into my future in medicine – I re- viewed the literature. I began with broad questions. Why do physicians burn out? Do physicians recover from burnout? What aids burnout recovery? Then, I narrowed my focus toward top- ics relevant to my professional experiences. What is the role of time pressure in physician burnout? Would lifting time pressure prevent burnout and/or aid in burnout re- covery? What are the benefits of lifting time pressure for physicians? For patients? From January to July 2017, I formally searched multiple repositories of lay and aca- demic literature (e.g., online newspapers, news maga- zines, physician blog posts and/or web sites, newsletters from physician organizations, books, MEDLINE4/ PubMed,5 Google Scholar,6 a special collection published by NEJM Catalyst,7-10 Medscape11) for content related to burnout (in physicians or physicians-in-training); the ther- apeutic nature of a physician’s presence (independent of other treatment modalities); and the relationship between visit length (i.e., the amount of time that a physician spends with a patient during a discreet visit) and burnout, and/or the physician-patient relationship. My search of the burgeoning burnout literature was ex- tensive (Table 1), and I identified publications that gener- ally mention the issue of time pressures in clinical medicine, listing long duty hours, chaotic work environ- ments, lack of physician control over their schedules, and extensive administrative tasks that deprive physicians of necessary time with patients as factors impacting burnout.12 Yet, I was unable to identify a single publication that fo- cused primarily on the role of time pressures in burnout. Initially, it seemed that my search had been fruitless; this detailed process had not revealed clear or simple answers to the questions that haunted me when I began. However, by interweaving resonant passages with my reflections on burnout, I have achieved new insights and refined my goals. On May 6th, 2017, I conducted a PubMed13 search for the Medical Subject Heading (MeSH) of “burnout, profes- sional” and identified 5,407 English-language articles, 1,445 of which had been published in the last five years. I reviewed more than 500 of these 1,445 article titles and/or abstracts to distinguish studies which investigated physi- cians or physicians-in-training from those which investi- gated other professionals. Next, I created a list of more than fifty study factors – hypothesized to be correlated (posi- tively or negatively) with, impacted by, causes of, and/or interventions for burnout in physicians or physicians-in- training – and sorted the list into four broad categories; the categorized study factors are presented in Table 1. Whatever inspiration is, it’s born from a continuous I don’t know. (Wislawa Szymborska)13,14 Time is of the essence in healthcare; but what is the essence of time in healthcare? In a medical emergency, rapid-fire assess- ments and treatments by front-line providers save count- less lives and limbs. To those who regard medicine as big business,15,16 both the time it takes a physician to provide a service and the complexity of that service have a relative value unit (RVU);17 meaning, the more quickly a physi- cian can perform a procedure and the more complicated each procedure, the more valuable that physician is to the organization. Others assert that time has ethical signifi- cance, with specific implications for the patient-physician relationship, for respect of patient autonomy, for promo- tion of well-being...18 For me, the most precious part of my job as a family physician was the time I spent with each patient; that is where it all came together, where I found myself in flow,19,20 in harmony with the machina- tions of my mind and my patient. Dr. Danielle Ofri21 states: A substantial portion of healing comes from the communication and connection with the patient…the simple conversation between doctor and patient can be as potent an analgesic as many treat- ments we prescribe…Yet the conversation between doc- tors and patients is one of the least valued aspects of medical care. Insurance reimbursements for tests and medical procedures dwarf reimbursements for talking to patients or spending time thinking about what ails them.22 [page 104] [Qualitative Research in Medicine & Healthcare 2017; 1:6925] Article Table 1. Recent research topics in physician burnout. Physician characteristics A sense of calling, altruism, work passion, professionalism and/or professional commitment, perfectionism, gender, resilience, wellness or well-being, emotional intelligence, genetic factors, temperament and character, achievement goal motivation orientations, self-esteem, self-efficacy. Sources of physician stress and/or burnout Medical culture, stigma associated with help-seeking, administrative burdens, electronic health records, environmental influences, perceived quality of care, patient safety, the physical and psychological demands of medical practice, inadequate sleep, inadequate exercise, interprofessional relations, job dissatisfaction, duty hours, workload, chronic overwork, trauma, patient characteristics, stereotypes. Sequelae of physician stress and/or burnout Alcohol use, emotional pain, loneliness, depression and/or depression treatments, altered brain activity on neuroimaging, suicide, medical errors, shame, blame. Protections against and/or interventions for burnout Mentoring, mindfulness and/or mindfulness-based stress reduction, meditation, social support, coping strategies. reflective professional supervision, computer- or phone-based applications (apps), work-life balance. No n- co mm er cia l necessary time with patients as factors impacting burnout. No n- co mm er cia l necessary time with patients as factors impacting burnout.12 No n- co mm er cia l 12 Yet, I was unable to identify a single publication that fo- No n- co mm er cia l Yet, I was unable to identify a single publication that fo- cused primarily on the role of time pressures in burnout. No n- co mm er cia l cused primarily on the role of time pressures in burnout. Initially, it seemed that my search had been fruitless; this No n- co mm er cia l Initially, it seemed that my search had been fruitless; this detailed process had not revealed clear or simple answers No n- co mm er cia l detailed process had not revealed clear or simple answers to the questions that haunted me when I began. However, No n- co mm er cia l to the questions that haunted me when I began. However, by interweaving resonant passages with my reflections on No n- co mm er cia l by interweaving resonant passages with my reflections on burnout, I have achieved new insights and refined my goals. No n- co mm er cia l burnout, I have achieved new insights and refined my goals. , 2017, I conducted a PubMed No n- co mm er cia l , 2017, I conducted a PubMed the Medical Subject Heading (MeSH) of “burnout, profes-No n- co mm er cia l the Medical Subject Heading (MeSH) of “burnout, profes- relationship, for respect of patient autonomy, for promo- No n- co mm er cia l relationship, for respect of patient autonomy, for promo-tion of well-being... No n- co mm er cia l tion of well-being... my job as a family physician was the time I spent with No n- co mm er cia l my job as a family physician was the time I spent with each patient; that is where it all came together, where I No n- co mm er cia l each patient; that is where it all came together, where I found myself in flow, No n- co mm er cia l found myself in flow, tions of my mind and my patient. No n- co mm er cia l tions of my mind and my patient. us e cian can perform a procedure and the more complicated us e cian can perform a procedure and the more complicated us e each procedure, the more valuable that physician is to the us e each procedure, the more valuable that physician is to theorganization. Others us e organization. Others assert that time has ethical signifi- us e assert that time has ethical signifi- cance, with specific implications for the patient-physicianus e cance, with specific implications for the patient-physician relationship, for respect of patient autonomy, for promo-us e relationship, for respect of patient autonomy, for promo- on ly less lives and limbs. To those who regard medicine as big on ly less lives and limbs. To those who regard medicine as big both the time it takes a physician to provide on lyboth the time it takes a physician to providea service and the complexity of that service have a relative on lya service and the complexity of that service have a relative meaning, the more quickly a physi-on ly meaning, the more quickly a physi- cian can perform a procedure and the more complicatedon ly cian can perform a procedure and the more complicated each procedure, the more valuable that physician is to theon ly each procedure, the more valuable that physician is to the Stanford oncologist Lidia Schapira23 expands on these ideas, writing: …patients want to be known and respected by their professional caregivers…relationships matter… and have a healing quality, even in the face of therapeutic failure.24 The quality of communication and connection between doctor and patient are nebulous, difficult – if not impossible – to grasp, let alone measure. Yet, the Institute for Healthcare’s Triple Aim Initiative – The Best Care for the Whole Population at the Lowest Cost25 – recognizes the importance of the patient’s experience of healthcare, a key component of which is their interactions with physi- cians. Drs. Thomas Bodenheimer and Christine Sinsky assert that care of the patient requires care of the provider…[and] recommend that the Triple Aim be ex- panded to a Quadruple Aim, adding the goal of improving the work life of health care providers…26 I hope that my relationships with patients were positive parts of their ex- perience of healthcare, brought them some sense of sus- tenance, if not healing. I know those relationships buoyed me. They carried me through the sea of paperwork and the long hours. So, when my administration turned the screws, clamping down on the time I could spend with each patient, I began to sink. How might this have im- pacted my patients? Antony Broyard, in an ethereal reflection on his expe- riences as a patient with prostate cancer, wished for some- thing more in his relationship with his doctor. He wrote, I would like a doctor who is not only a talented physician but a bit of a metaphysician too, someone who can treat body and soul…I wouldn’t demand a lot of my doctor’s time; I just wish he would brood on my situation for per- haps five minutes, that he would give me his whole mind just once…I have a wistful desire for my relation to my doctor to be beautiful - but I don’t know how this can be brought about.27 What if we not only acknowledged but embraced the therapeutic and ethical essences of time in healthcare? What if we encouraged physicians to spend the time necessary to meet the needs of each patient? What if we honored patients by giving them the time they want, need, and deserve with their doctors? Might we fos- ter beautiful physician-patient relationships, enhance heal- ing, and combat burnout? Neither my burnout nor its source (i.e., inadequate time to address patient needs) are unique. A ground-break- ing national survey of physicians in the United States (US) in 2011 revealed: …the prevalence of burnout among US physicians is at an alarming level…physicians in specialties at the front line of care access (emergency medicine, general internal medicine, and family medicine) are at greatest risk…The fact that almost 1 in 2 US physi- cians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care de- livery system rather than in the personal characteristics of a few susceptible individuals. Policy makers and health care organizations must address the problem of physician burnout for the sake of physicians and their patients.28 The same team published a follow-up national survey of US physicians in 2014 – conducted in a manner compa- rable to that of 2011 – and concluded: Burnout and satis- faction with WLB [work-life balance] among US physicians are getting worse. American medicine appears to be at a tipping point with more than half of US physi- cians experiencing professional burnout…There is an ur- gent need for…addressing the drivers of burnout among physicians. These interventions must address contributing factors in the practice environment rather than focusing exclusively on helping physicians care for themselves and training them to be more resilient.29 Per my PubMed search (Table 1), most physician burnout research published in the last five years focused on physician factors or physician-mediated interventions, with much less research proposing modification of prac- tice environments and/or healthcare systems to address burnout. Yes, doctors, like everyone else, are supposed to eat right, exercise regularly, and get adequate sleep. In ad- dition, some – including the American Medical Associa- tion – assert that doctors should participate in resiliency trainings,30 mindfulness-based stress reduction (MBSR) courses, and wellness programs. Yet, if their personal and professional obligations remain unchanged, just when are they supposed to find the time to participate in these time- consuming, health- and wellness-promoting activities? The healthcare system status quo remains the same: physicians remain under tremendous pressure to deliver (and document) more complex care for more patients in less time, and we are indoctrinating new generations of physicians to the status quo. The 80-hour work week is here to stay for physicians-in-training. (Beyond residency, the 80-hour work week may be exceeded.) On March 17th, 2017, the Accreditation Council for Graduate Medical Ed- ucation (ACGME)31 released a memo in which it an- nounced that it had preserved the 80-hour work week and the maximum frequency of in-house call (every third night), while increasing the number of consecutive hours that first-year residents (i.e., interns) can work from 16 hours to 28 hours (24 hours, plus up to four hours to man- age necessary transitions) so that first-year residents will have the same maximum shift-length as residents beyond their first year. They acknowledge that the question of work hour standards appropriately provokes great emo- tion in both the graduate medical education community and among segments of the general public…recognize the significant risk of burnout and depression for physi- cians…[and are obligated to] help physicians find mean- ing and joy in their work, while also providing them with the resources necessary to care for themselves and their patients. Yet, they are assured that their decision is right because [r]esearch conducted over the past five years confirms that the cap of 80 hours worked per week (adopted by the ACGME in 2003)... provides the best bal- ance between simulating real word experiences [for] res- idents…with their ability to be properly rested.32-34 [Qualitative Research in Medicine & Healthcare 2017; 1:6925] [page 105] Article No n- co mm er cia l thing more in his relationship with his doctor. He wrote, No n- co mm er cia l thing more in his relationship with his doctor. He wrote, I would like a doctor who is not only a talented physician No n- co mm er cia l I would like a doctor who is not only a talented physician but a bit of a metaphysician too, someone who can treat No n- co mm er cia l but a bit of a metaphysician too, someone who can treat body and soul…I wouldn’t demand a lot of my doctor’s No n- co mm er cia l body and soul…I wouldn’t demand a lot of my doctor’s time; I just wish he would brood on my situation for per- No n- co mm er cia l time; I just wish he would brood on my situation for per- haps five minutes, that he would give me his whole mind No n- co mm er cia l haps five minutes, that he would give me his whole mind just once…I have a wistful desire for my relation to my No n- co mm er cia l just once…I have a wistful desire for my relation to my doctor to be beautiful - but I don’t know how this can be No n- co mm er cia l doctor to be beautiful - but I don’t know how this can be What if we not only acknowledged but No n- co mm er cia l What if we not only acknowledged but embraced the therapeutic and ethical essences of time in No n- co mm er cia l embraced the therapeutic and ethical essences of time in healthcare? What if we encouraged physicians to spend No n- co mm er cia l healthcare? What if we encouraged physicians to spend the time necessary to meet the needs of each patient? No n- co mm er cia l the time necessary to meet the needs of each patient? What if we honored patients by giving them the time theyNo n- co mm er cia l What if we honored patients by giving them the time they want, need, and deserve with their doctors? Might we fos-No n- co mm er cia l want, need, and deserve with their doctors? Might we fos- they supposed to find the time to participate in these time- No n- co mm er cia l they supposed to find the time to participate in these time-consuming, health- and wellness-promoting activities? No n- co mm er cia l consuming, health- and wellness-promoting activities?u se tion – assert that doctors should participate in resiliency us e tion – assert that doctors should participate in resiliency 30 us e 30 mindfulness-based stress reduction (MBSR) us e mindfulness-based stress reduction (MBSR)courses, and wellness programs. Yet, if their personal and us e courses, and wellness programs. Yet, if their personal and professional obligations remain unchanged, us e professional obligations remain unchanged, they supposed to find the time to participate in these time-us e they supposed to find the time to participate in these time- on ly tice environments and/or healthcare systems to address on ly tice environments and/or healthcare systems to address burnout. Yes, doctors, like everyone else, are supposed to on lyburnout. Yes, doctors, like everyone else, are supposed to on lyeat right, exercise regularly, and get adequate sleep. In ad- on lyeat right, exercise regularly, and get adequate sleep. In ad- dition, some – including the American Medical Associa-on ly dition, some – including the American Medical Associa- tion – assert that doctors should participate in resiliencyon ly tion – assert that doctors should participate in resiliency mindfulness-based stress reduction (MBSR) on ly mindfulness-based stress reduction (MBSR) In the real world, physicians are burning out at an alarming rate. They are not getting what they want and need to sustain and promote their long-term professional and/or personal health and wellbeing. Heightened aware- ness of this crisis, and its potential impact on patient care,35 has triggered numerous well-intended reactions, each designed to address hypothesized drivers of burnout. The American College of Physicians (ACP)36 has linked increasing administrative tasks to greater stress and burnout in physicians and developed the Patients Before Paperwork initiative in 2015.37,38 The same year, the NEJM Group8 launched NEJM Catalyst,9,10 a think-tank engaged in the burnout conversation which recently re- leased a publication entitled Physician Burnout: The Root of the Problem and the Path to Solutions7. Most medical schools and residency programs have launched wellness programs.39-45 Shouldn’t I feel encouraged by these ef- forts? In one sense, I am deeply encouraged. The ACP and NEJM Catalyst initiatives especially inspire hope because they recognize the importance of preserving a physician’s time for patient care18,46 and rekindling joy in medicine.7 Yet, the more I read about resiliency trainings or wellness program proposals for physician burnout, the less con- vinced I am that they will be significantly effective with- out matching reforms to the healthcare system that protect the time that doctors need to work with and for their pa- tients, that precious time which kindled and rekindled my joy in medicine. Like me, Dr. Pamela Wible47 is skeptical that wellness programs alone will save our burned-out doctors, writ- ing:…medical organizations are racing to create wellness programs as the big new innovative solution. Well that kinda seems like forward momentum. But can a wellness committee really save our doctors? Misery in medicine is at an all-time high. I get…messages…every day from mis- erable doctors like this one: Today I realized that if I be- come a dog walker and charge 25 US dollars ($)/hour and walk 5 dogs per day I would make my equivalent salary with a lot less hassles…I could be the most over-qualified dog walker out there with a bachelors, masters, doctorate and specialty certification…Maybe that would be more helpful to society than the assembly-line medicine I cur- rently participate in and I would likely be happier and healthier. What do you think? Here’s what I think. This doctor is well. She’s got normal vital signs. She exercises and eats well…[She is doing] what well-adjusted rational doctors want to do these days. Wellness is not the antidote for misery. Happiness is.48 Can the importance of happi- ness – to physicians and patients alike – be overestimated? Does happiness spring forth from health, from wellness? What is the role of a physician in supporting the happiness of her patients? Dr. Peter Aird49 eloquently jettisons the idea that physicians, by rote, champion health and wellness without any understanding of what is, to their patients, most mean- ingful: what makes life worth living, the proverbial well- spring from which their happiness bubbles up. He writes: I went to the woods because I wanted to live deliberately, I wanted to live deep and suck out all the marrow of life; to put to rout all that was not life and not, when I had come to die discover that I had not lived...[Henry David Thoreau] With apologies to Henry Thoreau: I went to the woods because I wanted to lower my BMI, I wanted to live a bit longer than I might otherwise have done and re- duce my HbA1c; to reduce my serum cholesterol below 5.0 and not, when I had come to die, discover that I really should have switched to a low fat spread…It doesn’t have the same ring to it somehow…if we are to be healthier… we…have to want to be healthier because life is worth liv- ing…[to] encourage patients to look away from health as the source of their happiness to something bigger and bet- ter – something really worth living for…50 It is the same for physicians. We will not become more resilient, mind- ful, well, and resistant to burnout – no matter how many resiliency trainings, MBSR courses, or wellness programs we participate in – if we cannot build and work within a system that recognizes, respects, and protects the aspects of medicine that kindle and rekindle our joy, lift us up, and renew our commitment to medicine day after day, week after week, month after month, and year after year. Conclusions This is your assignment. Feel all the things. Feel the hard things. The inexplicable things, the things that make you disavow humanity’s capacity for redemption. Feel all the maddening paradoxes. Feel overwhelmed, crazy. Feel uncertain. Feel angry. Feel afraid. Feel powerless. Feel frozen. And then FOCUS. Pick up your pen…Pick up your damn chin…Reveal the fierce urgency of now. Reveal how shattered we are, how capable of being repaired. But don’t lament the break. Nothing new would be built if things were never broken. A wise man51 once said: There's a crack in everything. That’s how the light gets in. Get after that light. This is your assignment. (Wendy Mac- Naughton and Courtney E. Martin)52 I think taking the time to care for patients – with em- pathy, deep consideration, and mutual respect – was my light. Indeed, it was the principal reason that I pursued medicine as a career; it was the assignment I gave myself. Those of us who have burned out have invaluable insights to share. We must not rely on policy makers and health care organizations to address burnout; we must contribute what we have learned and work to prevent and heal burnout – and its dire consequences53-55 – in ourselves and our colleagues. But how do we begin? In a blog post, an anonymous physician shares: I burned out, big and bad. I can see that now. My practice environment had become gradually untenable and every attempt I made to change it was blocked…Risk manage- ment shudders at burned-out doctors and strongly recom- mends avoidance. But we’re still here, we’re still trained [page 106] [Qualitative Research in Medicine & Healthcare 2017; 1:6925] Article No n- co mm er cia l programs alone will save our burned-out doctors, writ- No n- co mm er cia l programs alone will save our burned-out doctors, writ- …medical organizations are racing to create wellness No n- co mm er cia l …medical organizations are racing to create wellness programs as the big new innovative solution. Well that No n- co mm er cia l programs as the big new innovative solution. Well that kinda seems like forward momentum. But can a wellness No n- co mm er cia l kinda seems like forward momentum. But can a wellness committee really save our doctors? Misery in medicine is No n- co mm er cia l committee really save our doctors? Misery in medicine is at an all-time high. I get…messages…every day from mis- No n- co mm er cia l at an all-time high. I get…messages…every day from mis- erable doctors like this one: Today I realized that if I be- No n- co mm er cia l erable doctors like this one: Today I realized that if I be- come a dog walker and charge 25 US dollars ($)/hour and No n- co mm er cia l come a dog walker and charge 25 US dollars ($)/hour and walk 5 dogs per day I would make my equivalent salary No n- co mm er cia l walk 5 dogs per day I would make my equivalent salary with a lot less hassles…I could be the most over-qualifiedNo n- co mm er cia l with a lot less hassles…I could be the most over-qualified dog walker out there with a bachelors, masters, doctorateNo n- co mm er cia l dog walker out there with a bachelors, masters, doctorateNo n- co mm er cia l Conclusions No n- co mm er cia l Conclusions This is your assignment. Feel all the things. Feel the No n- co mm er cia l This is your assignment. Feel all the things. Feel the hard things. The inexplicable things, the things that make No n- co mm er cia l hard things. The inexplicable things, the things that make you disavow humanity’s capacity for redemption. Feel all No n- co mm er cia l you disavow humanity’s capacity for redemption. Feel all us e of medicine that kindle and rekindle our joy, lift us up, us e of medicine that kindle and rekindle our joy, lift us up,and renew our commitment to medicine day after day, us e and renew our commitment to medicine day after day, week after week, month after month, and year after year.us e week after week, month after month, and year after year. on ly for physicians. We will not become more resilient, mind- on ly for physicians. We will not become more resilient, mind- ful, well, and resistant to burnout – no matter how many on lyful, well, and resistant to burnout – no matter how manyresiliency trainings, MBSR courses, or wellness programs on lyresiliency trainings, MBSR courses, or wellness programs we participate in – if we cannot build and work within a on ly we participate in – if we cannot build and work within a on ly system that recognizes, respects, and protects the aspectson ly system that recognizes, respects, and protects the aspects of medicine that kindle and rekindle our joy, lift us up,on ly of medicine that kindle and rekindle our joy, lift us up, physicians, and we’d like to get back on our feet. It’s taken me a long time to get to a point where I can share this. It’s not pretty, it’s not pleasant, but it is happening more and more. Those of us who make it through burnout would like a way to rebuild. We need to start talking about what comes after physician burnout. Please.56 What will be- come of this anonymous doctor who wants to talk about what comes after burnout? She may not see a way forward because the path has not yet been trodden. Or, it has been traveled by so few that it is hard to find. In her words, I read loneliness, desperation, and an emphatic plea for a companionable hand to reach out and help her up and along the path. Though she may not realize it yet, she has, by sharing her story, taken her first step toward rebuilding her life. What comes next? This hashing and rehashing of my decision to leave clinical medicine tethers me to my past and, in some ways, hinders my forward progress. Yet, I do not consider it a waste of time to examine my unlived life, the parallel life I might have led.57 Rather, I consider it a natural stage in my grieving process. I grieve the loss of this dream I nurtured for decades and the relationships I might have cultivated and maintained with my patients. I had to ex- perience some combination of denial, isolation, anger, bargaining, and depression58 before I could reach any type of acceptance, inner peace, and resolution to act, at my own pace, with decisiveness.3 Had I been able to press a pause button on my life, I might have progressed more quickly through my stages of grief. However, I chose to mend the machine while it was in motion59, working hard to maintain a relevant presence – albeit a nonclinical presence – in medicine. According to a recent article in Harvard Business Re- view,60 the busier we are, the more critical it is to step away from the noise and cultivate silence. When we’re constantly fixated on the…agenda…it’s tough to make room for truly different perspectives or radically new ideas. It’s hard to drop into deeper modes of…attention. And it’s in those deeper modes of attention that truly novel ideas are found.61 Recently, I have been moved to heightened self-awareness by a number of circumstances and have cleared ground in my schedule.1 I have allowed myself the time, space, and silence to consider my past, truly different perspectives, and radically new ideas, holding them up to the light to determine their suitability for me, with all my strengths and challenges. Like me, medicine has its strengths and challenges. Burnout is a challenge that we both face. Therefore, both of us will need to gaze unflinchingly at our cracks – precious cracks through which the light gleams51 – to become truly self- aware, evolve, reform our best practices, become excel- lent, and achieve our full potential. This process is daunting; it will require strength, dedication, collabora- tion, truly novel ideas, and time, tincture of time. Yet, the journey of a thousand miles begins with one step.62 Let’s begin. References 1. Castelloe E. Finding myself in medicine. Qual Res Med Health 2017;1:1-5. 2. Maslach C, Schaufeli W, Leiter M. Job burnout. Ann Rev Psychol 2001;52:397-422. 3. Mindfulness. Newsweek Special Edition. 2017:18. 4. MEDLINE Fact Sheet Nlm.nih.gov. 2017 [cited 23 May 2017]. Available from: https://www.nlm.nih.gov/pubs/fact- sheets/medline.html 5. PubMed NCBI Ncbi.nlm.nih.gov. 2017 [cited 8 May 2017]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/ 6. Google Scholar. 2017 [cited 18 May 2017]. Available from: https://scholar.google.com/ 7. Shanafelt T, Swensen S, Mohta N, et al. Physician burnout: the root of the problem and the path to solutions. Boston: NEJM Catalyst; 2017 pp 1-52. 8. NEJM Group. 2017 [cited 7 June 2017]. Available from: http://nejmgroup.org/ 9. NEJM Catalyst - Home - Practical Innov Health Care Deliv NEJM Catalyst. 2017 [cited 7 June 2017]. Available from: http://catalyst.nejm.org/ 10. Lee T, Campion E, Morrissey S, Drazen J. Leading the trans- formation of health care delivery: the launch of NEJM cat- alyst. N Engl J Med 2015;373:2468-9. 11. Latest Medical News, Clinical Trials, Guidelines: today on Medscape. Medscape.com. 2017 [cited 16 July 2017]. Avail- able from: http://www.medscape.com/ 12. Linzer M, Poplau S, Babbott S, et al. Worklife and Wellness in academic general internal medicine: results from a na- tional survey. J Gen Intern Med 2016;31:1004-10. 13. Wislawa Szymborska. Nobel lecture: the poet and the world. Nobelprize.org. 2017 [cited 17 July 2017]. Available from: http://www.nobelprize.org/nobel_prizes/literature/laure- ates/1996/szymborska-lecture.html 14. Wisława Szymborska. Poetry Foundation 2017 [cited 16 July 2017]. Available from: https://www.poetryfoundation.org/ poets/wisaawa-szymborska 15. Gross T. How U.S. health care became big business. NPR.org. 2017 [cited 23 May 2017]. Available from: http://www. npr.org/sections/health-shots/2017/04/10/523005353/how-u- s-health-care-became-big-business 16. Rosenthal E. An american sickness. New York: Penguin Press; 2017. 17. RVUs: A valuable tool for aiding practice management. Med Econ 2017 18. Braddock C, Snyder L. The doctor will see you shortly. the ethical significance of time for the patient-physician rela- tionship. J Gen Intern Med 2005. 19. Csikszentmihalyi M. Flow. New York [u.a.]: Harper& Row; 2009. 20. Csikszentmihalyi M. Finding flow in everyday life. New York: BasicBooks; 1997. 21. Ofri D. Author and associate professor of medicine at NYU 2017 [cited 23 May 2017]. Available from: http://danielle- ofri.com/ 22. Ofri D. The conversation placebo. Nytimes.com. 2017 [cited 30 March 2017]. Available from: https://www.nytimes.com/ 2017/01/19/opinion/sunday/the-conversation-placebo.html? smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0 23. Schapira L, FASCO Cancer.Net. 2017 [cited 7 June 2017]. Available from: http://www.cancer.net/about-us/cancernet- editorial-board/associate-editors/lidia-schapira-md-fasco 24. Schapira L. The essential elements of a therapeutic presence. [Qualitative Research in Medicine & Healthcare 2017; 1:6925] [page 107] Article No n- co mm er cia l Had I been able to press a pause button on my life, I No n- co mm er cia l Had I been able to press a pause button on my life, I might have progressed more quickly through my stages No n- co mm er cia l might have progressed more quickly through my stages mend the machine while it No n- co mm er cia l mend the machine while it , working hard to maintain a relevant No n- co mm er cia l , working hard to maintain a relevant presence – albeit a nonclinical presence – in medicine. No n- co mm er cia l presence – albeit a nonclinical presence – in medicine. According to a recent article in Harvard Business Re- No n- co mm er cia l According to a recent article in Harvard Business Re- the busier we are, the more critical it is to step No n- co mm er cia l the busier we are, the more critical it is to step away from the noise and cultivate silence. No n- co mm er cia l away from the noise and cultivate silence. constantly fixated on the…agenda…it’s tough to make No n- co mm er cia l constantly fixated on the…agenda…it’s tough to make room for truly different perspectives or radically new No n- co mm er cia l room for truly different perspectives or radically new ideas. It’s hard to drop into deeper modes of…attention. No n- co mm er cia l ideas. It’s hard to drop into deeper modes of…attention. And it’s in those deeper modes of attention that trulyNo n- co mm er cia l And it’s in those deeper modes of attention that truly 61 No n- co mm er cia l 61 Recently, I have been moved toNo n- co mm er cia l Recently, I have been moved to 12. Linzer M, Poplau S, Babbott S, et al. Worklife and Wellness No n- co mm er cia l 12. Linzer M, Poplau S, Babbott S, et al. Worklife and Wellnessin academic general internal medicine: results from a na- No n- co mm er cia l in academic general internal medicine: results from a na-u se formation of health care delivery: the launch of NEJM cat- us e formation of health care delivery: the launch of NEJM cat- alyst. N Engl J Med 2015;373:2468-9. us e alyst. N Engl J Med 2015;373:2468-9.11. Latest Medical News, Clinical Trials, Guidelines: today on us e 11. Latest Medical News, Clinical Trials, Guidelines: today on Medscape. Medscape.com. 2017 [cited 16 July 2017]. Avail-us e Medscape. Medscape.com. 2017 [cited 16 July 2017]. Avail- able from: http://www.medscape.com/us e able from: http://www.medscape.com/ on ly http://nejmgroup.org/ on ly http://nejmgroup.org/ 9. NEJM Catalyst - Home - Practical Innov Health Care Deliv on ly9. NEJM Catalyst - Home - Practical Innov Health Care Deliv on lyNEJM Catalyst. 2017 [cited 7 June 2017]. Available from: on lyNEJM Catalyst. 2017 [cited 7 June 2017]. Available from:http://catalyst.nejm.org/ on lyhttp://catalyst.nejm.org/ 10. Lee T, Campion E, Morrissey S, Drazen J. Leading the trans-on ly 10. Lee T, Campion E, Morrissey S, Drazen J. Leading the trans- formation of health care delivery: the launch of NEJM cat-on ly formation of health care delivery: the launch of NEJM cat- alyst. N Engl J Med 2015;373:2468-9. on ly alyst. N Engl J Med 2015;373:2468-9. Cancer 2013;119:160-10. Available from: http://onlineli- brary.wiley.com/doi/10.1002/cncr.27946/pdf 25. The IHI Triple Aim. Ihi.org. 2017 [cited 17 July 2017]. Avail- able from: http://www.ihi.org/Engage/Initiatives/TripleAim/ Pages/default.aspx 26. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014;12:573-6. 27. Broyard A. Doctor talk to me. Nytimes.com. 2017 [cited 8 May 2017]. Available from: http://www.nytimes.com/1990/ 08/26/magazine/doctor-talk-to-me.html?pagewanted=all 28. Shanafelt T, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among us physicians relative to the general US population. Archiv Intern Med 2012;172:1377. 29. Shanafelt TD, Hasan O, Dyrbye LN. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015;90:1600-13. 30. Improving physician resiliency. STEPSforward.org. 2017 [cited 18 May 2017]. Available from: https://www.stepsfor- ward.org/modules/improving-physician-resilience 31. ACGME. Acgme.org. 2017 [cited 17 July 2017]. Available from: http://www.acgme.org/ 32. ACGME Common program requirements. Acgmecom- mon.org. 2017 [cited 17 July 2017]. Available from: https:// acgmecommon.org/announcement 33. Dwyer C. Rookie doctors will soon be allowed to work up to 28 hours straight. NPR.org. 2017 [cited 7 May 2017]. Available from: http://www.npr.org/sections/thetwo- way/2017/03/10/519662434/rookie-doctors-will-soon-be-al- lowed-to-work-up-to-28-hours-straight 34. Asch D, Bilimoria K, Desai S. Resident duty hours and med- ical education policy — raising the evidence bar. N Engl J Med 2017;376:1704-6. 35. Allen M, Pierce O. Medical errors are no. 3 cause of U.S deaths, researchers say. NPR.org. 2016 [cited 18 April 2017]. Available from: http://www.npr.org/sections/health- shots/2016/05/03/476636183/death-certificates-undercount- toll-of-medical-errors 36. American College of Physicians, Internal Medicine, ACP. American College of Physicians. 2017 [cited 7 June 2017]. Available from: https://www.acponline.org/ 37. Erickson S, Rockwern B, Koltov M, McLean R. Putting pa- tients first by reducing administrative tasks in health care: a position paper of the American College of Physicians. Ann Intern Med 2017 [In press]. 38. American College of Physicians. Patients before paperwork. Where we stand, ACP. 2017 [cited 18 April 2017]. Available from: https://www.acponline.org/advocacy/where-we-stand/ patients-before-paperwork 39. Hobson K. New medical school programs help students bat- tle burnout. US News World Rep 2013 [cited 9 June 2017]. Available from: https://www.usnews.com/education/best- graduate-schools/top-medical-schools/articles/2013/03/21/ new-medical-school-programs-help-students-battle-burnout 40. Daye D. Student wellness initiatives (compiled from the American Association of Medical Colleges’ Organization of Student Representatives). American Association of Medical Colleges (AAMC). 2013 [cited 9 June 2017]. Available from: https://www.aamc.org/download/351946/data/studen- twellness.pdf 41. Noori S, Blood A, Meleca J, et al. Current directions in med- ical student wellbeing: a primer for students. American As- sociation of Medical Colleges / Organization of Student Representatives. 2017 [cited 9 June 2017]. Available from: https://www.aamc.org/download/450164/data/medstuden- twellbeing.pdf 42. Vassar L. How one program achieved resident wellness, work-life balance. AMA Wire 2015 [cited 9 June 2017]. Available from: https://wire.ama-assn.org/life-career/how- one-program-achieved-resident-wellness-work-life-balance 43. Okanlawon T. Physician wellness: preventing resident and fellow burnout. STEPSforward.org 2017 [cited 9 June 2017]. Available from: https://www.stepsforward.org/mod- ules/physician-wellness 44. Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J. Changing the conversation from burnout to wellness: physi- cian well-being in residency training programs. J Grad Med Educ 2009;1:225-230. 45. Kiersz B. Promoting wellness in a family medicine resi- dency program. Society of Teachers of Family Medicine (STFM). 2016 [cited 9 June 2017]. Available from: http:// www.stfm.org/NewsJournals/EducationColumns/Septem- ber2016EducationColumn 46. Tai-Seale M, McGuire T, Zhang W. Time allocation in pri- mary care office visits. Health Serv Res 2007;42:1871-94. 47. Wible P. Ideal medical care. Idealmedicalcare.org 2017 [cited 17 July 2017]. Available from: http://www.idealmed- icalcare.org/ 48. Wible P. The weird reason why wellness programs won’t work. Available from: http://www.idealmedicalcare.org/ blog/weird-reason-wellness-programs-wont-work/ 49. Aird P, The BJGP blog. Bjgpblog.com. 2017 [cited 17 July 2017]. Available from: https://bjgpblog.com/tag/peter-aird/ 50. Aird P. Health: it’ll be the death of us: institutional arrogance in the health service? Br J Gen Pract 2012;62:317-8. 51. The official Leonard Cohen site. Leonardcohen.com 2017 [cited 17 July 2017]. Available from: http://www.leonardco- hen.com/ 52. A responsibility to light: an illustrated manifesto for creative resilience and the artist’s duty in dark times. Brain pickings 2017. Available from: https://www.brainpickings.org/ 2017/05/15/focus-wendy-macnaughton-courtney-martin- poster/ 53. Kuhn C, Flanagan E. Self-care as a professional imperative: physician burnout, depression, and suicide. Canad J Anes- thesia/J Canad Anesth 2016;64:158-68. 54. Muller DK. N Engl J Med 2017;376:1101-3. 55. Hill A. Breaking the stigma: a physician’s perspective on self-care and recovery. N Engl J Med 2017;376:1103-5. 56. We need to start talking about what comes after physician burnout. KevinMD.com. 2017 [cited 16 July 2017]. Avail- able from: http://www.kevinmd.com/blog/2017/02/need- start-talking-comes-physician-burnout.html 57. Phillips A. Missing out. New York: Farrar, Staus and Giroux; 2012. 58. Kub̈ler-Ross E, Byock I. On death & dying. 59. Tolstoy L. Anna Karenina, 1877. 60. Ideas and advice for leaders. Hbr.org. 2017 [cited 17 July 2017]. Harvard Business Rev. Available from: https://hbr.org/ 61. The busier you are, the more you need quiet time. Harvard Business Rev 2017 [cited 16 July 2017]. Available from: https://hbr.org/2017/03/the-busier-you-are-the-more-you- need-quiet-time 62. BBC World Service. Learning English. Moving words. Bbc.co.uk. 2017 [cited 17 July 2017]. Available from: http://www.bbc.co.uk/worldservice/learningenglish/moving- words/shortlist/laotzu.shtml [page 108] [Qualitative Research in Medicine & Healthcare 2017; 1:6925] Article No n- co mm er cia l 35. Allen M, Pierce O. Medical errors are no. 3 cause of U.S No n- co mm er cia l 35. Allen M, Pierce O. Medical errors are no. 3 cause of U.S deaths, researchers say. NPR.org. 2016 [cited 18 April No n- co mm er cia l deaths, researchers say. NPR.org. 2016 [cited 18 April 2017]. Available from: http://www.npr.org/sections/health- No n- co mm er cia l 2017]. Available from: http://www.npr.org/sections/health- shots/2016/05/03/476636183/death-certificates-undercount- No n- co mm er cia l shots/2016/05/03/476636183/death-certificates-undercount- 36. American College of Physicians, Internal Medicine, ACP. No n- co mm er cia l 36. American College of Physicians, Internal Medicine, ACP. American College of Physicians. 2017 [cited 7 June 2017]. No n- co mm er cia l American College of Physicians. 2017 [cited 7 June 2017]. Available from: https://www.acponline.org/ No n- co mm er cia l Available from: https://www.acponline.org/ 37. Erickson S, Rockwern B, Koltov M, McLean R. Putting pa- No n- co mm er cia l 37. Erickson S, Rockwern B, Koltov M, McLean R. Putting pa- tients first by reducing administrative tasks in health care: aNo n- co mm er cia l tients first by reducing administrative tasks in health care: a position paper of the American College of Physicians. AnnNo n- co mm er cia l position paper of the American College of Physicians. Ann blog/weird-reason-wellness-programs-wont-work/ No n- co mm er cia l blog/weird-reason-wellness-programs-wont-work/49. Aird P, The BJGP blog. Bjgpblog.com. 2017 [cited 17 July No n- co mm er cia l 49. Aird P, The BJGP blog. Bjgpblog.com. 2017 [cited 17 July2017]. Available from: https://bjgpblog.com/tag/peter-aird/ No n- co mm er cia l 2017]. Available from: https://bjgpblog.com/tag/peter-aird/ 50. Aird P. Health: it’ll be the death of us: institutional arrogance No n- co mm er cia l 50. Aird P. Health: it’ll be the death of us: institutional arrogance in the health service? Br J Gen Pract 2012;62:317-8. No n- co mm er cia l in the health service? Br J Gen Pract 2012;62:317-8. 51. The official Leonard Cohen site. Leonardcohen.com 2017 No n- co mm er cia l 51. The official Leonard Cohen site. Leonardcohen.com 2017 us e [cited 17 July 2017]. Available from: http://www.idealmed- us e [cited 17 July 2017]. Available from: http://www.idealmed- us e 48. Wible P. The weird reason why wellness programs won’t us e 48. Wible P. The weird reason why wellness programs won’t work. Available from: http://www.idealmedicalcare.org/us e work. Available from: http://www.idealmedicalcare.org/ blog/weird-reason-wellness-programs-wont-work/us e blog/weird-reason-wellness-programs-wont-work/ 49. Aird P, The BJGP blog. Bjgpblog.com. 2017 [cited 17 Julyus e 49. Aird P, The BJGP blog. Bjgpblog.com. 2017 [cited 17 July on ly www.stfm.org/NewsJournals/EducationColumns/Septem- on ly www.stfm.org/NewsJournals/EducationColumns/Septem- 46. Tai-Seale M, McGuire T, Zhang W. Time allocation in pri- on ly46. Tai-Seale M, McGuire T, Zhang W. Time allocation in pri-mary care office visits. Health Serv Res 2007;42:1871-94. on lymary care office visits. Health Serv Res 2007;42:1871-94. 47. Wible P. Ideal medical care. Idealmedicalcare.org 2017on ly 47. Wible P. Ideal medical care. Idealmedicalcare.org 2017 [cited 17 July 2017]. Available from: http://www.idealmed-on ly [cited 17 July 2017]. Available from: http://www.idealmed-