Thursday, September 29, 2016
Everyone appeared to sparkle with joy, and I felt an astonishing resentment and discontent by what they must have accomplished. This Tweet rapidly crystallized an awareness that I had not been taking care of myself. I feared my capacity to feel happiness for others had vanished for keeps. There was no denying it was a sign of burnout. I had become physically tired at the end of the work day. Time and again I was emotionally drained and needed to sit in my car for several minutes before leaving the hospital just to regain my composure. I sensed, and my palliative care team confirmed, I was periodically grouchy and irritable. I had not been taking vacations regularly throughout the year. The worst blow was intermittently missing my beloved choir rehearsals on Tuesday nights because I couldn’t catch up with notes and patient followups.
Professional burnout is real. It is a burden that does not retreat. One can feel physically, emotionally, and mentally sapped. It creeps into your ordinary thoughts leaving one feeling insecure about job performance and clouds the meaning of your work. In retrospect, it had been eroding my life. I explored the program link and hoped I could address my self neglect: Professional Training Program for Clinicians in Compassionate Care of the Seriously Ill and Dying.
I recalled seeing Dr Joan Halifax at the 2010 Boston AAHPM assembly and remember how passionately she spoke about compassion and end of life care. The psychosocial, existential, and spiritual aspects of providing end of life care are essential. Clustering these elements, learning in an intimate environment, and being fully secluded from the outside world was very appealing. I found the link to the Upaya podcast recorded from the 2015 conference by presenters Dr Tony Back and Dr Cynda Hylton Rushton. I was fascinated by their sensitivity and focus on the topic Engaged, Not Attached: Being with Dying. I could hear their wisdom with full attention. They were knowledgeable about palliative care and end of life care. They openly explored the roots of compassion and how caregivers face tremendous anguish and helplessness. They explored how the body informs us when it is stressed and how we ignore and override those signals. This presentation refocused my intention to take better care of myself. I immediately requested time off from work to attend the following year’s conference.
Fast forward to the Albuquerque airport baggage carousels where I met a group of excited and eager attendees boarding the same shuttle to Upaya’s campus, above the town of Santa Fe, NM. The campus contains what is described as a Zen Buddhist practice, service, and training center. I was entering a new terrain in the high desert, far away from my suburban Maryland hospital palliative care practice. Upon arriving, I was warmly received by the resident staff, easily recognized not only by their simple black garb but also by their mindfulness to the task at hand.
I knew setting out, this journey would travel deeply into the roots of my professional work found in AAHPM assemblies, EPEC trainings, and professional retreats at the Center for Mind Body Medicine I attended. I didn’t realize it would also repair my insight, rehabilitate my empathy, and cultivate compassion and mindfulness so effectively.
What set this program apart from formal educational training was the thoughtful pacing of work sessions that also permitted time for self-reflection. We were obligated to remain in silence outside of work sessions. This was suitable to accomplish inner work but it did push me to the edge of my comfort zone. Finding and exploring this “edge” was a theme our faculty visited and I experienced throughout the week. By the end of the program I declared these 54 CME credits to be the most demanding I’ve earned since medical school and residency training.
I, along with 60 other end of life professionals, gathered in the zendo (meditation hall) every morning for daily guided meditations with Roshi Joan. These remarkable meditations can be found in her book: Being with Dying. She led us to a space where we could reflect on loving kindness, compassion, sympathetic joy, and equanimity. We also were led to explore our own mortality or practice visualizing the taking in of suffering and giving out of comfort to those around us.
The daily 30 minute yoga practice physically challenged my body and helped to calm my mind. The daily meeting with a council strengthened connections with a wonderful group of health care providers and gave me space and time to voice feelings. We had opportunities to work in small groups throughout the week for thought provoking exercises. The late afternoon meditation gathering in the zendo gave me time to peacefully center myself after a long day of didactic and reflection sessions. The evening wrap-up helped reinforce what I had experienced during the day. The days were very long but I didn’t feel fatigued.
During the week, the neuroscience didactic sessions explored many interesting topics like neuroplasticity. I learned how my mind’s default is to aimlessly roam like a guppy and naturally hard wire the effect of distress on our body. It became apparent through scientific studies that training the mind with meditation and mindfulness can increase happiness and reduce self imposed physical distress. I caught on that my mind frequently overstimulates the parasympathetic branches of the vagus nerve and muffles my voice and breath in times of stress. After several days of meditation and reflection, our group was prepared to spend intensive time with a challenging ethical case that would touch upon moral distress, and moral outrage.
Not unexpectedly, it was a challenge to leave a supportive and nurturing retreat and to re-enter the outside world as I knew it. Throughout the week and beyond, I began to feel more comfortable in my body. I could begin to understand the benefits of a frequently repeated phrase during the week, “strong back and soft front” that rewards vulnerability with strength and support. All too often in life, I have carried a defended front and a burdened back.
After returning to work, I learned to be more mindful of physical feelings of distress that I had ignored before. I gave myself permission to pause and set my intention in the moments before entering a room to engage a patient or family. More than once in my career, I sailed into a room without a hand on the helm and managed to lose trust of a patient or family simply by not being attuned and grounded. Our ethical case presentation at Upaya helped me look at hospital based dilemmas with a different lens and focus.
I can disclose I have a restored energy, renewed passion for end of life work, and a more spacious place for inner work. Although I am still prone to the stressors of work, I now recognize the signs of burnout quickly and address them. And now looking back at the retreat Tweet, I’m filled with appreciation, gratitude, and joy!
I realize that this self-care is as essential to my professional work as the sun is to a garden. I’m trying to make these few simple changes permanent fixtures because life itself hangs by a breath.
Robert Gerard is a palliative care physician with the Mid-Atlantic Permanente Medical Group. He is the physician lead for Schwartz Center Rounds at Holy Cross Hospital, Silver Spring Maryland and can be followed on Twitter @rhgerard. He finds work/life balance and rejuvenation as a singer with the National Philharmonic Orchestra and Chorale and is looking forward to an exciting season of concerts beginning November 5th, 2016.