Keywords

Introduction

Relationships are a cornerstone of the human experience. For most people, interactions with others can have a substantial effect on mood and wellbeing. Positive and supportive interactions are an important buffer for stress, while interpersonal conflict can introduce and exacerbate stress. For physicians, the demands of medicine can be so excessive that having a supportive home or personal environment is essential to navigating the training years and successfully managing the undue stress and workload that clinical practice presents. The intersection of medical postgraduate training with early adult development makes this a challenging time for physicians in training, who are learning to take on responsibility in their new careers while also navigating the roles and responsibilities of early-to-middle adulthood. Many physician trainees in their 20s and 30s, having devoted substantial time and resources to their career development, are now honing their social-emotional skills and learning to navigate relationships and conflict. This chapter is devoted to exploration of the role relationships may play in supporting physicians, particularly during the training years, and resources available to address interpersonal conflict.

Benefits of Social Support

A career as a physician requires daily interactions with other human beings. For many aspiring physicians, serving others is a primary reason for choosing a career in medicine. Regardless of preference, most physicians will be required to interact with other human beings in their daily work. This means daily frequent communication with a variety of team members and with patients and their families, as well as challenges in communication amidst difficult clinical encounters. As with any human services profession involving person-to-person contact, the potential for burnout is high, with more than half of practicing physicians in the United States reporting at least one symptom of burnout, representing an increase in recent years (Shanafelt et al. 2015).

The social support literature for physicians as a population is small. A systematic review of studies from 1970 through 2007 (Voltmer and Spahn 2009) showed that various sources of social support had distinct effects on physicians’ health and the potential to contribute to prevention of burnout. This included social support from a variety of sources including colleagues and a professional network, a spouse, friends, and support groups. A more recent study of physicians in Israel (Russo et al. 2016) also highlighted the importance of both work and nonwork sources of support to facilitate work-life balance, which in turn augmented the likelihood of physicians having positive energy and psychological availability.

More broadly, the social support literature supports the importance of relationships for maintaining both physical and psychological health (Holt-Lunstad and Uchino 2015). Indicators of social isolation have been linked with depressive symptoms, and most researchers agree that social ties can have a significant protective effect on psychological wellbeing and depression (e.g., Kawachi and Berkman 2001; Gariépy et al. 2016). Accumulating evidence from the neurobiology literature suggests that social support confers resilience to stress, possibly through moderating genetic and environmental vulnerabilities (Ozbay et al. 2007). It is thus of value for physicians and physician trainees who are habitually confronted with excessive stress to strengthen and protect this important buffer.

Culture of Medicine

Culture can play an important role in perceived support. The culture of modern medicine has underpinnings in a military model and embodies characteristics of this culture that have persisted for decades. While some of these features, such as respect and accountability, may be beneficial to the efficiency of medical practice, others can be counterproductive and lessen a sense of perceived support for practicing physicians. For example, hierarchical structure within medical organizations and teams and a top-down approach to decision-making may discourage individuals in a more subordinate or less prestigious position to proactively engage in asserting their opinion or to engage in effective conflict resolution. Such a structural and cultural hierarchy can be oppressive and may have a deleterious effect on confidence and perhaps even on clinical decision-making (Srivastava 2013). Moreover, this aspect of medical culture may intersect with young physicians’ developmental stage to create additional vulnerability. As many young physicians in training are developmentally emerging from a delayed adolescence, they are beginning to get to know themselves in relation to the world around them. A hierarchical culture in the work setting where they have invested much of their resources may compound a developing and tenuous sense of self. A culture that discourages self-advocacy may increase risk for burnout and psychological and physical impairment and may also have implications for patient care. Chapter 5 focuses on the psychological and physical risks of burnout to the physician.

The caretaker role can be a double-edged sword. Certain common personality characteristics of physicians such as a tendency toward perfectionism are imminently useful for overcoming the hurdles it takes to have a career in medicine. These characteristics can also help physicians to be highly effective scientists and healers. Nevertheless, the push to answer every question and leave no stone unturned can also drain emotional and intellectual resources and make it difficult for physicians to delegate tasks or to do “good enough.” Over time, this intensity of caretaking increases risk for emotional exhaustion and eventually depersonalization, features of professional burnout. Medical culture promotes a myth of the strong and even invincible physician. While this illusion may be attractive to patients who want to see confidence in their healers, it can be of disservice to the physicians who are pressured to overlook their own humanity. Ultimately, physician burnout can have a multitude of negative effects on patient care and productivity (Dewa et al. 2014).

Another aspect of culture that is increasingly important is diversity on medical teams. Many institutions, including those that espouse attention to diversity and inclusion, struggle with institutional and implicit bias (Hannah and Carpenter-Song 2013). Microaggressions from those in leadership are common, and leaders are often not even aware of their own biases (Smedley et al. 2003; Staats et al. 2017). Individuals who are not members of the majority culture may find it especially challenging to navigate interpersonal dynamics in the face of implicit or unconscious bias, and this may have unfavorable effects on members of underrepresented groups in medicine (Allen and Garg 2016). For trainees and early-career physicians, bias and lack of diversity can have a profound impact on sense of community and belonging, at a time when they are just beginning their careers. Such challenges can have a negative impact on physicians’ mental health and may also negatively impact retention rates for non-majority groups in medicine (Smedley et al. 2003; Carnes et al. 2008).

Navigating Relationship Conflicts

While a supportive work environment and supportive personal relationships can be protective, unfavorable workplace factors and strain in personal relationships can contribute to physician stress and burnout. Relationship conflict will inevitably surface; how physicians deal with conflict can determine the impact on their wellbeing.

In the professional domain, medical schools widely acknowledge that physicians need strong communication skills (Ha and Longnecker 2010). Decades of research demonstrates that good clinical communication is associated with many desirable outcomes, including patient satisfaction, adherence to treatment, health behavior and health status, and even costs of care (e.g., Joosten et al. 2008). However, many trainees report feeling unprepared to manage the breadth and volume of difficult patient interactions they encounter during their residency years. Challenging patient care scenarios can lead to increased stress and over time can have a negative effect on wellbeing and mental health. Studies have documented a decline in empathy during the medical school and residency years as trainees become increasingly involved in clinical care (Newton et al. 2008; Rosenthal et al. 2011). In response, there is currently momentum to include empathy and compassion training in medical education, with some empirical support from well-designed intervention trials (Kelm et al. 2014). In addition to empathy and compassion training, institutions may consider strategies to address communication needs in patient care for their students and physicians, including interventions focused on humanism, interpersonal effectiveness skills, and conflict resolution (West et al. 2016).

Conflict in interpersonal relationships at home may also present challenges. While these issues may be different from work-related challenges, the antecedents and consequences can be similar. Excessive stress, hardship, personality differences, and differences in communication style can all complicate otherwise straightforward conversations and lead to misunderstandings, disagreements, arguments, and tension. Depending on the quality of the relationship and the ability of those involved to work together, conflicts can escalate over time, creating more intense interpersonal distress that may become disruptive to a physician’s wellbeing, creativity, or ability to engage in daily tasks. Resources for physicians vary depending on the nature of the relationship and the conflict and may range from peer or family support to self-help interventions or professional help or counseling. It is not uncommon for physicians in training to seek out couples therapy or marriage counseling for the first time during their training years. Both individual and couples therapy may be useful for addressing misunderstandings and teaching interpersonal effectiveness techniques that can be helpful in both the work and home settings.

Work-Home Integration

We hear much about “work-life balance ” in an effort to improve the practice of medicine, not just for patients but also for providers. Some older professionals may scoff at this term, and there is a pervasive myth that younger physicians are “weak” or “entitled” for wanting to work shorter hours. Despite these criticisms, there have been advances in addressing concerns associated with overwork, including reduction of duty hours, hour limits to shifts for new physicians, and dedicated nonclinical time included in some training programs (Temple 2015). Nevertheless, the global impact of such changes requires more systematic study, and the culture of medicine has a long way to go in addressing the wellness of healers. Individual physicians must achieve their own personal balance between the stressors and resources of their individual circumstances.

Cultivating Personal Wellness

Physicians have numerous options available to them to cultivate personal wellness . Many have honed a variety of coping skills to manage stress throughout their studies and training years. Some continue to use these skills, while others start to lose their connections amidst an increasing burden of stress. While physicians as a group are talented, many with significant accomplishments outside of medicine, it is not uncommon for physicians to lose touch with their prior interests and activities upon starting residency training or upon starting their practice. For many, this is a loss of an important potential buffer to work-related stress. Extracurricular and creative interests may provide a locus of self-worth and control outside of the professional domain. Some physicians are able to maintain engagement in activities by having a regular exercise or sport routine for stress management. Others stay active by engaging in music or literature groups with their peers, while many utilize travel as a means of stepping away from the demands of the workplace. For those who are starting a family, focus on the home and family activities are a way to cultivate meaning outside of the workplace.

Regardless of which, these activities are an important buffer to work-related stress and to the potential loss of meaning in the face of limited control, particularly during the training years. Diversifying one’s sense of self into multiple domains of human and social capital helps to manage and reduce the risk posed by any one individual domain, not entirely dissimilar to the strategy in financial investing. Interaction with supportive others is often an important part of these activities and also helps to create meaning and a sense of belonging. When schedules and lifestyles are aligned, cultivating personal wellness can become a shared activity. A strategic focus on self-care and quality of living through attention to exercise (see Chap. 13), nutrition (see Chap. 14), contemplation practices (see Chap. 12), and creative or extracurricular activities may thus help with both perceived support and a sense of control and balance. More detailed information on these topics is covered in other chapters.

Resources for Physicians

Hospital systems are increasingly recognizing the impact of physician wellness on patient care and are putting in place mechanisms of support for their medical professionals.

Peer Support

Peer support programs are growing as a means of supporting physicians who have experienced critical incidents, difficult patient care scenarios, and other stressful events. Some of the benefits of offering peer support include tapping into existing relationships and foregoing the need for more formal interventions that are more likely to require documentation. The literature on peer support among physicians is young, but discussion forums among physicians reveal the importance of physicians connecting with one another through peer support or supervision (Shapiro and Galowitz 2016).

Professional Support

With the increase in awareness of physician burnout, many health organizations are arranging to have on-site or easily accessible professional support available to their physicians. The variety of programs available is broad, ranging from wellness-focused resources to more intensive resources for physicians in crisis. Many programs have direct links to a mental health professional who can help direct physicians to available resources (e.g., Stanford WellConnect, https://med.stanford.edu/psychiatry/special-initiatives/wellconnect.html). There are some key barriers to utilization of professional support by physicians, such as finding time for appointments and concerns about having documentation of a mental health visit. Peer support can help circumvent some of these concerns. Nevertheless, physicians are equally if not more susceptible to mental illness than the general population and for many, access to a mental health professional will be important and necessary (See Chap. 9) (Goldman et al. 2015).

Personal Wellness

Hospital systems are increasingly offering wellbeing programs for their employees to support prevention-focused care and health maintenance. These may include access to fitness centers or classes covering a variety of topics such as contemplation, fitness, and nutrition; incentives to engage in health screenings and preventative care; coaches and trainers to support individualized wellness plans; communication coaches; and options to assist with work-life integration such as parental leave, child care assistance, and meal planning services, to name a few. Physicians are encouraged to find out what is available to them at their institutions, as many of these opportunities are underutilized.

Case Illustrations

Case 11.1 Cultural Factors

Personal wellness can be challenged when risk factors for burnout intersect and compound vulnerability for an individual physician. Shayna is a 27-year-old urology resident in her second year of training. Shayna was connected with the hospital’s Confidential Peer Support Team following a critical incident where one of the postoperative patients she was caring for coded following a medical error. Shayna reveals to her peer supporter that she has felt burned out and demoralized almost every day since starting her internship. She is concerned this is affecting her ability to focus on patient care and may have contributed to the error she made; however, she has not discussed this with anyone. On further discussion, Shayna shares that she feels quite alone in her program, and as the only person of her particular cultural background, she often feels as if she does not “fit in.” This makes it harder to develop relationships with her peers and attendings, many of whom are from the majority culture or male. She feels like a “black sheep” at times, as if everyone is waiting for her to “mess up.” The hours are particularly challenging, and Shayna does not do well with less than 6 hours of sleep per night. She also has a harder time skipping meals than some of her peers, which seems to be the norm in the surgical culture. Following the critical incident, Shayna feels even more ostracized and concerned that everyone is blaming her for the adverse outcome. She has days where she feels hopeless, sometimes to the point that she wishes she wouldn’t wake up the next day or wishes everything would just go away. She has not acted on these thoughts and feelings, nor has she shared them with anyone. The thoughts come and go and seem to be related to her level of stress and sleep deprivation.

Discussion Questions: What factors have contributed to Shayna’s vulnerability in this scenario? What resources would you recommend for Shayna?

Case 11.2 Caretaker Role

Nicholas is a 38-year-old physician recently out of training who is coping with a divorce. Nicholas and his partner were married for 9 years, during which time Nicholas came to realize he had very little control within the relationship. While Nicholas was in charge of the finances, his spouse tended to make all other decisions. When they would get into a disagreement, the outcome would be driven by his partner’s emotional state. Nicholas felt a strong need to take care of his partner and would do anything to keep his partner from getting angry. Meanwhile he tended to keep his own frustrations to himself and would cope by working out or going drinking with friends. His tolerance for alcohol has increased significantly, and he now finds himself drinking daily after work. After years of conflict with no lasting resolution, they tried to undergo marital counseling but ultimately opted for divorce. At work, Nicholas has also been dissatisfied and has many symptoms of burnout. First as a resident and now as a junior physician, he feels he is at the “bottom of the totem pole” and powerless to make meaningful change within the organization. He works late almost every day and feels he overextends himself more than his peers to try to address the complaints of dissatisfied patients. Nicholas is now dating again and finding he has a hard time expressing his needs within the relationship. He is noticing his tendency to avoid conflict and keep his frustrations to himself, as he did in his marriage. He would like to change this pattern and learn how to be more assertive about his feelings and needs.

Discussion Questions: What factors have contributed to Nicholas’ burnout, and what are some of the consequences? What resources may be helpful for him?

Case 11.3 Nonphysician Partner

Mariana is in her third year of practice after residency in a multispecialty group and is now in a role where she is supervising new attendings. She recently took on an administrative role as lead practice pediatric hospitalist, where she is tasked with overseeing the team of colleagues at her site and managing their professional development. Mariana was excited to be given the opportunity to take on a leadership role but is finding it difficult to balance this new position with her ongoing patient load, particularly since the position is taking more time than she has been allotted. She has been working late hours almost daily and when she gets home she just wants to go to sleep. There have been multiple instances where she has had to cancel plans with her partner who is a business consultant with a very different work schedule. Mariana feels her partner has limited understanding of the structure and culture of medicine and of her everyday struggles. Her partner has expressed frustration that Mariana is unavailable to spend time together at home. Her partner usually ends up either going out with friends or staying in watching television alone. When Mariana tries to approach her partner to make plans, she often gets a pessimistic response that they cannot count on her to come through. Mariana sees the truth in this but also feels frustrated that her partner does not understand her situation. She feels her friends in medicine understand her situation better and have been more supportive. She is not sure what to do as she feels this is becoming a worrisome pattern in her relationship.

Discussion Questions: What can Mariana do to relieve some of the stress at work and at home? What resources might she consider?

Conclusion

Relationships and interpersonal communication are an important aspect of physicians’ daily work. Positive relationships at work and at home can be protective for the stressors present in clinical medicine and the ever-present potential for professional burnout. Many physicians in training and in their early career are at a developmental stage in which they are learning about themselves in relationships and honing their interpersonal and conflict resolution skills. When stress becomes excessive and interpersonal communication breaks down, there are a variety of resources available for peer and professional help. Schools of medicine and hospital systems are increasingly recognizing the importance of physician wellness and burnout and are implementing novel programs to support medical staff. Physicians are encouraged to utilize these resources to help shape and maintain supportive relationships as they navigate the challenges of early career and clinical practice.