JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 66, NO. 11, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2015.07.054
FELLOWS-IN-TRAINING & EARLY CAREER PAGE
The 3 “Rs”—Relax, Reflect, and Regroup
Avoiding Burnout During Cardiology Fellowship
Oral A. Waldo, MD
W
hether you believe that the Creator
high-volume high-acuity patients, which can result in
created the 24-h, 7-day, or 365-day cycle
increased mental and physical exhaustion. In 2014,
for a reason or that evolution selected
medical students graduated with a median debt of
cycles for a specific purpose, the fact remains that cy-
$180,000 (4). Many trainees have the added re-
cles are essential for optimal operation of any system.
sponsibility of contributing to their family’s financial
Only systems with set cycles or checkpoints for
well-being. When stress and depression skyrocket,
replenishing can endure continuous high-quality
suicide can be an end result. In fact, suicide is higher
performance. Cardiology fellows-in-training are so
among physicians than in the general population (5).
keen to increase their productivity and attain new
One retrospective study cited no significant differ-
heights in the profession that they frequently forget
ences in current mental health disorders between
to take the time to replenish themselves. Here, I will
physicians and other occupations; yet, physicians
present the cycle of 3 “Rs”—relaxation, reflection,
that committed suicide were less likely to have a
and regrouping—as a simple, stepwise method for
known alcohol or substance dependence problem (6).
fellows to use to optimize their performance and
This indicates that there are untold stories of hidden
avoid burnout.
stress and depression among physicians.
A total of 57% of internal medicine residents
There is no doubt—it is best to avoid burnout rather
experience burnout (1). Symptoms may include loss
than dealing with it. It takes at least 3 the time and
of enthusiasm for work, feelings of cynicism, and a
energy to recover from burnout than to prevent it.
low sense of personal accomplishment. One survey
This is not a new concept; we employ it in our medical
showed
experienced
practice on a daily basis. Although cardiovascular
burnout by the same criteria (2). By the end of resi-
disease is the leading cause of morbidity and mor-
dency, aspiring cardiologists are usually confident in
tality in the developed world, we are discovering that
their abilities to lead the medical team. However, the
prevention is better and can be more cost-effective.
transition to cardiology can be overwhelming, as
Sitting in the library some years ago, I made note of
that
38%
of
cardiologists
there is an increased need for evidence-based medi-
a picture that was captioned “the journey not the
cine and multiple diagnostic and therapeutic modal-
arrival matters.” Thus, it is important for one to enjoy
ities. Contrary to the joy and comfort they should
training (the journey), as this might give some indi-
bring, our routine duties as head of household,
cation of what one’s cardiology practice might
parent, or caretaker of aging loved ones; our social
be. But, how can one enjoy training when there are
commitments and our high expectations can be
so many questions to answer and so many un-
added stressors, which frequently leave very little
certainties? The answer will be unique to each indi-
room to unwind.
vidual. I have made a few suggestions for a possible
It takes an average of 10 post-secondary years in
training to become a fully licensed cardiologist (3).
Trusted with what is arguably the most critical organ,
the heart, trainees frequently devote themselves to
strategy that cardiology fellows could implement to
attempt to avoid burnout.
1. Relaxation is vital to your health. The state of
relaxation is not a passive action and requires
focused effort to be achieved. Synonymous with a
high-performance engine that needs a modified
From the Mayo Clinic, Phoenix, Arizona.
exhaustion release system, fellows need efficient
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Waldo
JACC VOL. 66, NO. 11, 2015
SEPTEMBER 15, 2015:1303–6
Fellows-in-Training & Early Career Page
ways of releasing stress. From an institutional
first-year fellow, I joined a gym and was excited to
perspective, many programs incorporate social
lose weight and gain agility. I started a strenuous
events to foster relaxed time, noting that many
exercise program and solicited the guidance of a
trainees relocate away from friends and family to
personal trainer. On the third day, the trainer
complete fellowships. Depending on the individ-
advised me to rest 1 to 2 days before continuing. I
ual, relaxation can be achieved by partaking in
responded with a puzzled look; the trainer readily
sedentary activities, such as meditation and video
stated, “When you work out that hard you really
games, whereas others prefer physical activities,
have to take time to rest, giving your muscles time
such as swimming and dancing. Although either
to repair and rebuild.” In essence, the trainer was
method is acceptable, some level of physical
saying that my muscles needed to pass through the
activity is generally recommended, as obesity is
3 Rs. They needed time to relax from the strenuous
becoming more prevalent in developed countries,
exercise, reflect on the previous week’s activities,
not absent among physicians, and also frequently
and rebuild (regroup) more muscles for improved
contributes to a depressed mood. Although anxi-
performance. Regrouping can happen in many
olytics and sleep mediations are widely prescribed
different ways. For some, it may entail reading
medications
journal
in
the
United
States,
many
of
papers,
getting
extra
equipment
for
their effects can be achieved from physical
the clinic, researching faster ways to complete
activity. Physical activity forces the body to
morning rounds, or keeping track of patients.
release endorphins and other chemicals that
Regrouping also gives us the chance to accept the
ensure relaxation and tranquility, in turn bringing
things we cannot change and to use them to create
the body to a place of contentment, in preparation
learning opportunities (7).
for reflection.
2. Reflection is a necessary and important checkpoint.
The benefit of the 3 Rs was proven to me during
Many programs have built-in checkpoints (usually
medical school. After encountering a group that
every 6 months) for fellows to meet with the chief
played recreational soccer, it became apparent to me
fellow or program director to reflect on past work
that what I termed “free time” was essential to my
and develop strategies to respond to challenges.
preservation. After a game, I would leave the field
However, transparency is often unachievable for
with a feeling of exoneration that was likened to the
the trainee due to fear of judgment. Moreover,
feeling of returning from a vacation. I achieved a
these checkpoints of scheduled meetings are usu-
more peaceful resting period, and the endorphin rush
ally too seldom to use as the sole opportunity for
was nothing short of that received from psychogenic
reflection. Reflection is a process that allows an
medications. This was my method of relaxation.
individual to sequentially dissect the events of the
Walking home and showering would be a period of
past, consider what went wrong, and determine
reflection that allowed me to retrace my activities in a
how the concerns can be prevented or changed.
constructive manner. I was completing the 3 Rs on a
Most importantly, it is a time to identify causative
regular basis by joining a pick-up game of soccer.
factors. It may be unpleasant to reflect on less than
Due to the simplicity of this method, why is it not
ideal events, and hence, it is done less frequently
more prevalent? The answer is that when it is done
than required. The method for reflection is often
correctly, it is done infrequently. As we develop
unproductive.
STAR
our medical armamentarium, we frequently fail in
(considering the complete Situation, identifying
improving our repertoire with appropriate stress
Tasks that were required to be completed, the Ac-
reduction skills. Cycling through the 3 Rs can range
tions taken by the individual, and the Results
from spending 15 min away from the crowd to an
achieved) method can help to organize thoughts in
extended beach vacation. The intensity and duration
a productive manner. It enhances the opportunity
should
to retrace and analyze the past to improve on the
Although time constraints can be limiting, the key is
skills necessary to regroup.
to find something that allows you an opportunity to
Strategies
such
as
the
3. Regrouping to form new strategies. To ensure that
be
commensurate
with
work
demands.
frequently and effectively relax, reflect, and regroup.
the process is progressive, the trainee must
regroup. During the process of regrouping, one is
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
actively engaged in acquiring the skills necessary
Oral A. Waldo, Mayo Clinic, 5777 East Mayo Boule-
to prevent recurrence of the previous nega-
vard, Phoenix, Arizona 85054. E-mail: waldo.oral@
tive outcome or to improve good outcomes. As a
mayo.edu.
Waldo
JACC VOL. 66, NO. 11, 2015
SEPTEMBER 15, 2015:1303–6
Fellows-in-Training & Early Career Page
REFERENCES
1. Ishak WW, Lederer S, Mandili C, et al. Burnout
during residency training: a literature review.
J Grad Med Educ 2009;1:236–42.
2. Medscape. Doc burnout—worse than other
workers’. Available at: http://www.medscape.com/
viewarticle/774013. Accessed February 20, 2013.
3. Baughman KL, Duffy FD, Eagle KA, et al. Task
force 1: training in clinical cardiology. J Am Coll
Cardiol 2008;51:339–48.
4. Association of American Medical Colleges.
Medical student education: debt, costs, and loan
repayment fact card. October 2014. Available
at: https://www.aamc.org/download/152968/data/
debtfactcard.pdf. Accessed February 20, 2013.
5. Schernhammer EE, Colditz GA. Suicide rates
among physicians: a quantitative and gender
assessment (meta-analysis). Am J Psychiatry
2004;161:2295–302.
6. Gold KJ, Sen A, Schwenk TL. Details on suicide
among US physicians: data from the National
Violent Death Reporting System. Gen Hosp Psychiatry 2013;35:45–9.
7. Abudiab MM, Van Woerkom RC. Inpatient
cardiology consultation: lessons learned during
fellowship. J Am Coll Cardiol 2015;66:199–201.
RESPONSE: A Prescription to Avoid Burnout
Martin E. Goldman, MD
Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
E-mail: [email protected]
Dr. Waldo has written a very thought-provoking piece on
family; financial sacrifice by delaying entering into prac-
the risk of “burnout” during cardiology training and an
tice and mounting loans; and the very nature of the
approach to deal with it. Burnout, as defined by the
intensity of the field. Certainly, the stress of life-and-
Maslach Burnout Inventory Survey, evaluates 3 metrics:
death decisions made by cardiology fellows consulting
emotional exhaustion from being overworked; depersonal-
on an unstable patient in the emergency room, during a
ization or desensitization, a lack of compassion for
coronary
patients and peers; and professional efficacy and reduced
decision making with stage D heart failure patients, and
sense of accomplishment (1).
with end-of-life decisions can take a mental and physical
or
electrophysiological
intervention,
when
Unfortunately, medicine does carry a high stress level,
toll on the trainee. This stress is compounded by the
particularly among trainees. In medicine, burnout can lead
increasing time consumption mandated by the electronic
to errors of omission or commission that deleteriously
medical records and the growing checks and balances
affect patient care. Shanafelt et al. (2) reported that burnout
and pre-certifications.
was more common among physicians than other U.S.
However, lacking in all of these burnout surveys are
workers. Physicians and specialties at the front line of care
indicators of gratification, satisfaction, and a sense of
(emergency medicine, general internal medicine, and
accomplishment experienced by trainees by their chosen
family medicine) are at the greatest risk. Physicians work a
field. Although cardiology is uniquely stressful, the field is
median of $10 h more per week than other work groups,
also distinctly gratifying in its ability to intervene and
and they are at higher risk for emotional exhaustion,
immediately reverse a patient’s terminal illness, such as
depersonalization, and overall burnout relative to popula-
with transcatheter aortic valve replacement. Medicine is
tion controls. However, there was a flaw in the sampling of
still regarded as the most admired profession in the United
this oft-cited paper. An invitation and 3 e-mails were sent to
States. A 2012 Harris poll reported that doctors have the
89,831 physicians from the American Medical Association
most prestigious jobs in America (88%), followed by mil-
Physician Masterfile, but only 7,288 physicians participated
itary officers (78%), and firefighters (76%).
in the survey (8%), which causes concern about the repre-
Dr. Waldo suggests the 3 “Rs” to prevent burnout:
sentative nature of the responders. Selective self-reporting
Relax, Reflect, and Regroup, which are powerful sugges-
to a survey may not be reflective of the general group due to
tions to avoid burnout in any chosen profession. I would
sampling errors. That survey also does not list cardiology as
include several recommendations unique to cardiology
1 of the polled specialties. However, a 2013 Medscape sur-
training that could also help increase rewards:
vey (how scientific a survey?) reported that 38% of cardiologists reported burnout (about average, 14th on the list of
specialists) (3).
1. Rely on your peers. Cardiology is a high-powered,
competitive field attracting many of the brightest,
As Dr. Waldo points out, cardiologists-in-training are
most diligent medical residents. Your peer group,
at risk for emotional strain and burnout due to their time
cofellows, and senior fellows will be your closest col-
commitment, often at the expense and exclusion of
leagues over the next few years. How have they been
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Waldo
JACC VOL. 66, NO. 11, 2015
SEPTEMBER 15, 2015:1303–6
Fellows-in-Training & Early Career Page
coping with the requirements and rigors of their pro-
backlog of orders, and police officers face stress with every
gram? What is their degree of satisfaction or stress? Will
confrontation or traffic stop. Here are several suggestions
you enjoy their collaboration and support?
to cope with stress in fellowship and life in general:
2. Fulfillment through work. Cardiology provides
many diverse career paths available to trainees,
1. Recognize intrinsic personality traits that lead
which could be customized to suit their distinct
to
personalities and desired lifestyles, including basic
procrastination
and translational research, big data, interventional
cardiology, cardiac imaging, and heart failure.
3. Mentorship. Support systems are very important in
dealing with real and perceived stress. The program
director, program administrator, chief fellows, and
cofellows are instrumental in avoiding burnout by
providing outlets for discussion, direction, and
guidance to navigate through strain and anxiety.
4. Location. The geographic location of the program
is a major part of the decision in choosing a
fellowship. Not only will patient volume, ethnic
stress:
overly
obsessive,
low
self-esteem,
2. Develop and learn better time management skills
3. Know and accept your limitations
4. Avoid confrontations and appreciate the counter
point of view
5. Express yourself: communicate with your peers
and program director
6. Seek some recreational outlet, whether sports or
relaxation
7. Develop and engage with your support system,
whether it be family, friends, or religion
8. Plan for a successful future by putting events in
diversity, and socioeconomic and educational sta-
perspective and looking toward the big picture
tus be dictated by the locale of the training site,
9. Never be afraid to ask for assistance or guidance.
but so will the cost of living, school system for
children, and relative safety.
Most importantly, take time to put your life in
perspective. You are in the most exciting field of medicine,
Importantly, stress is present in every walk of life and
and you are on the cutting edge of science and discovery.
in every profession or vocation. Teachers face stress in the
Enjoy your training; it is the most exciting and rewarding
classroom, fast food workers must respond to the growing
time in your professional career.
REFERENCES
1. Maslach C, Schaufeli WB, Leiter MP. Job
burnout. Annu Rev Psychol 2001;52:397–422.
2. Shanafelt TD, Boone S, Tan L, et al. Burnout and
satisfaction with work life balance among US
3. Peckham C. Physician lifestyles—linking to
burnout: a Medscape survey. March 28, 2013.
physicians relative to the general US population.
Arch Intern Med 2012;172:1377–85.
Available at: http://www.medscape.com/features/
slideshow/lifestyle/2013/public. Accessed July
26, 2015.