Episode 42: Who cares for the care providers? Gail Gazelle, MD, talks physician burnout, mental health, and mindfulness

"Definitively Speaking" is a definitive healthcare Podcast series recorded and produced in Framingham, Massachusetts. To learn more about healthcare commercial intelligence, please visit us at definitivehc.com. Hello and welcome to another episode of "Definitively Speaking," the Podcast where we have data-driven conversations on the current state of healthcare. I'm Justin Steinman, Chief Marketing Officer at Definitive Healthcare, and your host for this Podcast. How many times a day do you think about your health? Do you take your physical health for granted? What about your mental health? If you were burned out at work, could you give yourself permission to take some time off and recharge? Or would you view that as a failure of your strength or will? 20 years ago, mental health was something that people whispered about, or worse, didn't even talk about at all. If you were stressed, anxious, or worried, the prevailing treatment was just keep quiet and power through. If you couldn't do that, well then I guess you could go to a psychiatrist who would quote "shrink" your brain and get you back on your feet. But odds are you are most certainly not telling your friends that you're going to shrink, much less share that information with your coworkers. Thankfully, that time has passed and I think we're all healthier for it. But what about the mental health of the people who take care of our health? It's a historically stressful time to be a medical provider these days. COVID is just the tip of the proverbial iceberg, unrelenting case volumes, pressure from insurance companies to build yet evermore and ever shorter patient visits, the pressure to run your office like a small business or go be an employee of a large conglomerate. I think we all can agree that healthcare delivery just isn't as much fun as it used to be. And the data backs these statements up. Over the last two years, more than 145,000 healthcare providers have left the profession. That includes more than 71,000 physicians and more than 35,000 nurse practitioners. It seems like we're on a precipice of a mental health and healthcare crisis. Something has to be done. My guest today not only thinks something has to be done, she's actually doing something about it. Dr. Gail Gazelle is a nationally-recognized physician coach and assistant professor of medicine at Harvard Medical School. Dr. Gazelle has coached more than 500 physicians on how to take a proactive stance in their mental wellbeing. Dr. Gazelle emphasizes that seeking help isn't a sign of failure, but rather a testament to their dedication to themselves and their patients. In addition to being a coach, Dr. Gazelle is a bestselling author, her most recent book titled, "Mindful MD: 6 Ways Mindfulness Restores Your Autonomy and Cures Healthcare Burnout" provides physicians, nurses, and other healthcare workers with a real pathway toward enjoying their careers they work so hard for in spite of the dysfunction around them, and it starts with managing the most important instrument, the mind. Drawing on her experience coaching hundreds of physicians and the latest in neuroscience research, Dr. Gazelle equips readers to step out of the spiraling thoughts and emotions of burnout and into a place of autonomy and calm. And she's here today to talk with us about the impending mental health crisis facing our healthcare delivery system. Gail, welcome to "Definitively Speaking."

Oh, it's a pleasure to be here.

Thank you for joining us today to talk, to discuss such an important topic. I wanna start by asking you, what are the root causes of the mental health epidemic facing our nation's healthcare providers?

Great question, and I wanna just zoom out for a minute and not necessarily think about it as a mental health crisis, but really a burnout crisis because I don't want people to have that stigma that they're more ill than they realize they are. So let's call it the burnout crisis.

Okay.

And it's truly multifactorial. Healthcare has changed. Healthcare is run now by large corporations. Healthcare is run by large corporations that are working in competition with one another. There are scarce resources, there's understaffing, there is emphasis on productivity and the bottom line. All of those factors, what I would call system factors, make it difficult for devoted clinicians, nurses, doctors, technicians, therapists, everybody working in healthcare they makes it very difficult for them to focus on the vulnerable patients in front of them. We have to acknowledge that, there's so many pressures to get things done, and to get them done more efficiently and faster and see more patients and do more procedures, makes it very hard to do what we are morally obligated and what we signed up to do, which is to take care of vulnerable people. But that's not the whole story, and that's what I talk about in the book "Mindful MD," that what I call the roots of burnout also have to do with what we bring without even realizing that we're bringing it. So for me, as a physician who coaches other physicians, I've really come to understand a lot of our own mindset, which is not just for us as physicians, but it's also for many of us who populate healthcare providers, healthcare caregivers, we tend to be perfectionists. We tend to judge ourselves very harshly. We tend to compare ourselves to our peers, not focusing on what we're doing well, but focusing on where we perceive we're coming up short. We learn that we're not ever supposed to show weakness, never call in sick, right? And very much we learn to put patients first, which is wonderful, but we don't learn how to take care of ourselves as well. Now, these are things, again, in medical school, residency, fellowship that we learn. We actually learn this, and I know that nurses learn this as well, and we don't always realize how that makes it difficult for us to thrive in this very complex kind of corporate world that we find ourselves in. You know, makes it hard for us to focus on what we're doing well, to feel like if we can't go, and get everything done for every patient, that somehow we're some kind of failure, or that somebody's going to perceive us as a failure if we can't keep up with our charts, which is the Achilles heel of everybody in healthcare that we're gonna be found wanting. So it's a combination of all of these very real systems flaws. We're living in a very dysfunctional healthcare system, all of us. But it's a combination of that and things that we bring that make it hard for us to cope with all of those external factors.

This is a kind of a random or weird question, but how would I know if I'm burned out as a physician?

I think physicians know when they're burned out, they're feeling exhausted, even if they get a good night's sleep, it's almost like the well is dry. There's this sense of emotional exhaustion, which contributes to a sense of cynicism. Why bother? Why did I go into the practice of medicine in the first place? And that drives the third factor, which is we become very disconnected from our sense of meaning, purpose, and accomplishment. Those three are really the hallmark definition of burnout, emotional exhaustion, cynicism, and disconnection from a sense of accomplishment. But I think there's a fourth, which is that we develop a kind of tunnel vision. We can't see anything that's going well, we're kind of sucked into a vortex of negativity. So those four things really help define what burnout is. If anybody in your listening audience is wondering, I hate to say it, but those are the hallmarks, and many of us are succumbing to burnout.

Interesting. Do you think doctors have lost or are losing their sense of purpose and that healthcare has fundamentally changed the rules on them?

Oh, without a doubt. The modern healthcare system has definitely changed the rules, because just think about it, I believe the statistic is that almost 70% of physicians are employees now. And what an incredible juxtaposition that is to even 10 or 20 years ago when many physicians were in private practice or group practices that weren't owned by a large entity. And when you're an employee, by definition, you lose control over the conditions under which you work. That's part of being an employee. And so we thought that we were the boss, that we were the ones who knew how healthcare should run. We were taught in our training that we are the captain of the team, the all-knowing Paragon. And yet now we're being employed. And so many physicians say to me, "Gail, I just feel like a cog in a wheel. Nobody sees what I'm doing. Nobody sees how hard I'm working. Nobody respects how much I'm doing for each and every one of my patients." And unfortunately, the setup is such that one can feel that way, even if that isn't the intention of the employer, one can be left feeling that way when one is an employee. I don't know if that makes sense, Justin.

It does. And I actually wanna quote you back to you now. So the introduction of your book says, "The modern healthcare system leaves doctors living out of balance, spending more time on the computer than taking care of patients and struggling to turn off their busy minds and be present when home with loved ones. Long hours, endless bureaucracy and profits prioritized over patient and clinician wellbeing, strip autonomy from the healthcare workforce and induce the paralyzing anguish of self-doubt and burnout." That is one heck of a diagnosis there, Doctor. What I wanna know is who holds responsibility for this current situation? How did we wind up here?

Well, thank you for quoting me to me and to your audience. And I just wanna let your audience know that they can download a free chapter of the "Mindful MD" book at gailgazelle.com/MindfulMD so they can read this for themselves. And your question about kind of how did we get to this point and what do we do? Well, you know, that's the $64 million question I think it is, because it's really complicated. It's complicated what's going on in healthcare, and I'm not sure I'm the best one to answer. You know, how are we gonna get out of this mess?

I didn't ask how we gonna get out. I asked how we got here. Who do you think, who do you blame, if you will?

Well, we live in a complicated society. We live in a capitalist society, and it's all about profit. And so it's no surprise that healthcare is experiencing that same tension. They're human beings working in healthcare, just like there are human beings working in government, working in education, working in every sector of the economy. And yet the people kind of in power, so to speak, are all about a different motivation than those human beings might have for doing their job. It's a kind of a basic tension in a capitalist society. And healthcare is not protected from that tension.

I don't know if we knew the answer to this question, but I find myself wondering about the Canadian healthcare system where socialized medicine and the UK health system with the NHS, National Health Service, and they've really taken a lot of that profit that you've just mentioned out of the equation. Do you know if there's less burnout of physicians in those health systems or those countries?

I have coached many Canadian physicians and many of them are struggling. So it's not perfect, even in a different single payer that I think the stresses are different. You know, we are sitting here in the US as physicians haggling with insurance companies to get an MRI for our patient when that MRI is desperately needed in the care of that individual. That may not be quite the same in Canada or in the UK, but the pressures are still there. The underresourcing, the understaffing, the NHS is in a really state of distress. So the grass is not necessarily greener. And I'm not the expert on how to kind of remedy all of these large systemic problems that we're facing. What I am about is how can we help individual clinicians in a highly dysfunctional system not hand over their happiness to that dysfunction? Because unfortunately, a lot of us are doing that. We're feeling helpless. We're feeling like there's nothing we can do to regain a sense of autonomy given how much external autonomy has been taken away. It has been, what I really see is how can we restore the true autonomy that can never be taken from us? And that's the autonomy over ourselves, over how we respond to whatever difficulty comes our way. That's kind of the fundamental human challenge and the fundamental human autonomy that really cannot be taken away unless we willfully give it up. And my book is really a blueprint, a roadmap about how to restore that autonomy. Because once we have that autonomy, we see the choice points that we have. We don't feel as much like a pawn of a broken system or a cog in the wheel. And that's wonderful because when we feel that we can spend our days relating to the difficulties that we face in a very, very different way, and that's what I want for each and every one of your listeners.

You know, if it makes you feel any better, we're almost 50 episodes into this Podcast series, and nobody has figured out how to fix the healthcare system. I've had guests from all over the ecosystem and no one's got the answer yet.

Very major, large scale problems. That's right.

You know, I honestly, if we figure this out, my Podcast might be outta business, so I'm not really worried that much about it. You did say something really interesting that I want to come back to. You just said, "I don't wanna see physicians hand over their happiness." I love that phrase. How can mindfulness help them not hand over that happiness?

Well, let's go to something that you said to me before we started our conversation today. You said, "My favorite chapter, Gail, is the chapter about reducing reactivity." So I think that's an important one. Just before we started talking today, Justin, I was coaching an emergency room physician, very frustrated by what's going on in his healthcare system and feeling so frustrated that he's experiencing dread before he goes into his emergency room shifts. "How am I gonna manage the stress? We don't have enough nurses, we have traveling nurses, because we don't have beds, and particularly mental health beds, because there's a national shortage, we have to keep all these patients in our emergency room much longer than we ever would've. And you know what, Gail, it's driving me crazy. It's driving me crazy. I'm grinding my teeth. I wake up in the middle of the night feeling angry about all of this, frustrated about all of this, telling my wife, 'This is not what I signed up for.'" So as you can hear in that vignette, a lot of frustration, a lot of reactivity to everything going on around that physician. And after empathizing with how difficult this is, incredibly difficult to not have nursing staff to help you see patients in an emergency room, I mean, that is, it can be an unsafe situation. So after empathizing with that, I asked him an important question. Now, Dr. So-and-So, what parts of this are under your control and what parts aren't? There was a big pause on the phone, and he really began to realize there was a lot that was out of his control, and he was expending a lot of mental energy on things that he had absolutely no control over and no hope of having control over. He can't change the staffing situation. He couldn't change the bed situation, the mental health crisis that we're in in this country, and what that means for emergency rooms. And that helped him shift a little bit to being less reactive. So the mindfulness piece there is awareness. Mindfulness is all about awareness. What's going on in our mind? What are our emotions? What are our patterns of reactivity? We can't treat or intervene with those patterns until we diagnose them, until we are aware of them and understand them. That's where mindfulness comes in. I think when people hear that word, they think about monks on the mountainside or aging hippies and Woodstock or whatever image or kind of selfish naval gazing, but that's not what mindfulness is. Mindfulness is about the awareness that we gain when we pay attention to what's going on in this most important instrument, the one between the two human ears. Once we pay attention, we realize we can redirect ourselves. So for this emergency room physician, he realized he was wasting a lot of his reactivity, a lot of his emotional energy, sleepless nights, coming home and complaining to his family, which was beginning to erode his marriage. He began to see that he had a choice. Sure, the working conditions are difficult, of course, that's not a question, but he began to see that he had a choice of how he responded to them. And that helped him be less reactive. That's autonomy. That's autonomy over himself. He felt better about himself. He began to have less dread. You know, when he was using some of these things that we were working on, he felt more of a sense of healthy command over the one thing that we could ever hope to have command over, which is ourselves. So that's what I'm talking about here. That's where mindfulness is not this abstract concept like, oh, go meditate for hours that you don't have. None of my six ways are meditation. They're not, they're skills that we can use to develop mastery over our mind rather than being captive to it.

You know, I have to be honest, when I read your book, I actually felt like portions of it apply to me. I'm not a doctor, I don't play one on TV or the radio or podcast, right? I'm just a good old business guy who's made a career in marketing. But I really felt like a lot of it did apply to me, and there were lessons that I could take out and apply to my professional and personal lives. Do you find that you kind of, you're also working or find yourself applicable to non-physician people?

Without a doubt. And many people who've read the book have said exactly that. If you look at reviews on Amazon, there are people who say, "I'm not even in healthcare myself and yet it really helped me, helped me show up in a better way so I can feel good about myself, so I can be the role model that I wanna be in my workplace, with my kids, in my community." And that's what autonomy can do, and that's how it can, mindfulness can really mitigate burnout. As a coach and as a physician, I wanna find solutions. This is not about just kind of mental whatever, it's really about what we can each do differently that's not gonna add hours to our busy days that help us show up and see the choice points that we have. That's really what mindfulness is about. We realize as we become more aware that we do have choice, we do have autonomy. It's powerful when we really hone in on that.

So another one of the chapters in your book is titled "Lean into Compassion, Connection, and Purpose." Why is that combination so important?

Well, most of us who go into healthcare go in because of compassion, right? We see the suffering of others and we're moved to do anything that we can to alleviate it. That's what healthcare is really all about about physical and mental and emotional suffering and caring about our fellow citizenry. But in the challenges that we see in healthcare now, we can lose that compassion. That's part of burnout. With that cynicism that I mentioned, we start to depersonalize. We don't see patients as the whole human being that they are, that they need us to see them in, right? We've all had that experience as a patient that the doctor doesn't really take the time to listen and understand our unique difficulties, right? Doctor maybe just wants to hand us a prescription because they're burnt out and they're also under pressures to see so many patients. They don't have time to be with us. That's the moral injury that many healthcare clinicians are experiencing. So we have to remember why we did this in the first place. And it was about compassion, connection, and purpose. So part of what I do as a coach is help busy, overworked, burnt out physicians get back to their sense of purpose, their why, because we can lose touch with it, right? I think that's part of the human condition. We get so kind of downtrodden and in that very narrow lens that we forget the bigger purpose. So I try to help my clients reconnect with that purpose. I do that in the book.

So I feel like this might be a bit of a stereotype, but you talk about it in your book, and you even mentioned earlier in the Podcast, and maybe it's not, right. How do you get a physician to embrace coaching? I mean, these are people who've usually been at the very top of their academic class. These people are hyper-competitive, uber successful. They might view using a coach as an admission of failure or weakness. How do you get 'em to overcome that?

Interesting question. And the good news about coaching is that it doesn't carry the stigma that perhaps going to therapy or seeing a psychiatrist or trained mental health professional might carry. I think the other thing is there's that interesting phrase, what got you here won't get you there. And I think a lot of physicians are beginning to understand that that they're very successful. Of course, they have a life of so many accomplishments and achievements, but they reach a point in their career where it just feels like things are coming apart at the seams. They're not sure how they're going to go on. They may have huge educational debt and mortgages and kids that they wanna put through college, and they have to stay in the profession, but they're not sure that they can. So what coaching is about is giving them the tools so that what got them here can continue to get them there. They just need a bigger toolkit. That's all it is. And in training, we don't get that toolkit. We don't learn how to work with our own mind. We don't learn how to work with self-sabotaging and limiting thoughts and self-criticism. We don't learn how to work with the fact that we all will have vulnerabilities at some point. 'Cause again, we are taught no vulnerability, never show weakness. And that's particularly true for surgeons and surgical specialists. So I help busy physicians understand that they just need a bigger toolkit. It's not some kind of deficit. It's not that there's something wrong with them, they just didn't have enough tools. Coaching is going to provide those tools.

Do you work with a certain specialty or a subspecialty more? Do you see more surgeons or more PCPs or ER docs? How does that break down?

It breaks down to a pretty broad view of physicians, pathologists, radiologists, interventional radiologists, internists, family docs, pediatricians, pediatric emergency room docs, neurosurgeons, deans of medical schools, department chairs. You know, everybody because so many people in medicine are struggling.

Fascinating. So your book ends with an epilogue titled "A New Healthcare," and I wanna explore that a bit. I think we've established throughout this conversation that healthcare is absolutely broken. It's beyond the ability of any one party to kind of fix. But I'd love to know your thoughts on who has responsibility to take a leadership role in fixing it. Is it the patient? Is it the doctor? Is it the hospital executive, the government, the insurance company, or someone else entirely? Somebody's gotta take a leadership role here. From your vantage point, who do you think that should be?

Well, I think it should be all of us, actually, because healthcare is all about the human endeavor and the human condition. And I can be burnt out and pissed off about all the changes, and I can show up angry, irritated, not fully respectful of those I work with, not fully listening to the patient who's sitting in front of me. In other words, I can show up mindlessly and many of us do. Or I can show up acknowledging all the problems, not sweeping them under the carpet. Not saying, oh, just put on a smile and everything will be great. But I can show up realizing that if I lean into compassion and connection and purpose, I'm gonna be happier. And you know what? I'm gonna smile more. And guess what? People will smile back at me as opposed to if I walk down the hall furrowed, in just like a total grump, I can have an impact there. And when I do that, I actually bring my best, I feel better about myself. I come home and I actually can tell my family at the dinner table about something good that happened rather than all the miseries and everything that went wrong. I can sleep better because I'm not in that state of reactivity and negativity and I can show up differently because when I show up differently, there's a ripple effect. And that's what's in it for each and every one of us in healthcare to notice our own patterns, be mindful, be aware of our own patterns, and realize we have a choice. That's, to me, really the only hope for healthcare is that we all band together. Because oftentimes that vortex of negativity just we kind of become almost like in our survival brain, very narrow. We don't show up as our best. We show up angry, bitter, annoyed, frustrated, et cetera. Me, me, me, me, me. So to me that is the answer that we all make the right choices. We all are mindful and pay attention.

So I must say you have a way with words, vortex of negativity. I'm gonna steal that phrase and start using that regularly. I love it. So before I let you go, we've covered a lot of ground, but I want to try to wrap it up in kinda one big question here. You're a physician listening to today's conversation, we have quite a few physicians who listen to "Definitively Speaking" hopefully on their drive to and from work. And you're intrigued by mindfulness, but you don't think you have time in your very crazy, busy day to try it out. What do you recommend this physician do to break the cycle?

Well, there's a lot that I outline in the "Mindful MD" book, but at the end of the day, if we can realize that our mind is a busy place, our mind is busy producing thoughts, some of those thoughts incredibly helpful, many of them not. And when we can pause and observe our own mind and realize that we are not our thoughts, which is my first way that mindfulness restores autonomy and cures healthcare burnout, it's really powerful to separate us from the tangle of fears, worries, preoccupations, annoyances, frustrations, catastrophic thinking that populates the human mind. One physician said to me the other day, "My mind is just full of irrelevant thoughts, Gail." And when we pay attention and notice our thoughts, we realize that's the truth. It's messy up there. And in realizing that, we begin to see that we have a choice. We don't have to attach to all those negative thoughts that are just dragging us down. There's plenty that's wrong, not just in healthcare, but in the broader American society, right? We can get caught in a lot of unhelpful thoughts. So to me, at the end of the day, that's probably the biggest takeaway. Become the observer of your thoughts. Don't get caught in all of them. Realize that a lot of those unhelpful ones, you can just imagine them being like clouds in the sky. They arise, they pass through your mind. And then they are no more, there's no thought that any human being has had that has lasted. All of our thoughts are transient mental events. So if your listeners take away nothing else, take away the idea that you are not your thoughts. You don't have to get as caught in all of your difficult and challenging thoughts. That alone can restore your autonomy and help you stay out of burnout.

That's a really good advice there, Gail. Thanks for your time today on a very important topic.

Pleasure talking with you.

And for all our listeners out there, thank you for listening to "Definitively Speaking," a Definitive Healthcare Podcast. Please join me next time as we go from one doctor to another. On our next episode, I'll be joined by Dr. Matthew MacEwan, Co-Founder and Chief Science Officer at Acera Surgical. Acera focuses on the field of soft tissue repair. Their electrospun fiber matrix technology is now available in surgical matrices, providing relief to patients who suffer from surgical wounds, trauma, burns, and chronic wounds. If I've got you intrigued or you're just wondering what in the world electrospun nano fibers are, then you should definitely tune into this episode. If you like what you've heard today, please remember to rate, review, and subscribe to the show on Apple Podcasts, Google Podcasts, Spotify, or wherever you get your Podcasts. To learn more about how healthcare commercial intelligence can support your business, please follow us on Twitter or X @DefiniteHC, or visit us at definitivehc.com. Until next time, take care. Please stay healthy and remember to one, avoid that vortex of negativity, two, become an observer of your own thoughts, and three, remember that a smile can have a very big impact.