“There’s no place like home for the holidays.” Only you’re not at home. Instead, you are holding down the fort while others are soaking in the holiday cheer. As the world around you lapses into a happy fugue of food, song, gift giving, and celebration, you are putting in extended hours, taking more call, and wading through compressed schedules. And during this “most wonderful time of the year,” the tragedy and the pathos you face seems all the more pointed and intense.

Yes, the holidays seem like a most opportune time to sag, to slump into some good ol’ fashioned self-pity, maybe even to succumb to burnout. The plight of your patients feels all the more piercing; the sacrifices you make for them, your partners, and your career are never more in your face. What’s more, with nary an administrator or c-suite executive anywhere in sight, there is never a time where you feel less appreciated.

Of course, you’re not solely at risk during the holidays. Psychological distress is a year-round risk. Industry-wide, an estimated 54.4 percent of providers are affected by burnout (Shanafelt). Studies of medical oncologists find anywhere from 52 percent to 78 percent are affected (Hlubocky). Studies of oncological nurses and trainees report similar rates.

Now come on, you might be thinking, these reported prevalences of burnout have to be overestimates, don’t they?

We would say yes…and no.

Profound, paralyzing, destabilizing burnout is probably not nearly this prevalent, even in fields as emotionally challenging as oncology. On the other hand, most caregivers likely experience some or all of the components of burnout many times during their careers, perhaps many times in their work weeks. And during periods of burnout symptomatology, the typical caregiver is at risk of retreating to maladaptive coping responses such as acting out, drinking excessively, withdrawing, participating in high-risk or exceedingly expensive activities—and is at risk of performing their duties sub-optimally (Shanafelt). Unattended and unsoothed burnout can lead to profound emotional and psychiatric disturbances.

Burnout occurs when an individual is subjected to stressors that, due to their frequency and/or intensity, overwhelm his or her coping mechanisms. It manifests itself in affected individuals as variable degrees of emotional exhaustion (lack of sufficient energy to deal with day-to-day challenges), depersonalization (going numb), sense of inefficacy (what an individual is doing has no impact on the overall progress of things). The very nature of oncology guarantees for all its providers a high-frequency exposure to high-intensity stressors—some might argue, an unprecedented exposure to profound stressors. Almost no one in today’s society is exposed to as much human fear, pain, tragedy, ethical quandaries, and mortality.

What is more, the medical administrations of the discipline are often highly morbid and of considerable risk, outcomes are far from guaranteed and complications are expected, and no one relishes a visit to their oncologist.

Add to this the stress cauldron of practicing in what feels like a colder, more calculating, intransigent, mechanized, commoditized, and administratively over-burdened delivery of care environment than we’ve ever experienced before, and one should not be surprised at even higher rates of burnout amongst those in the discipline. Now throw in the resentment, the sense of lost youth, the loneliness, the nostalgia, and the sense of passage of time that are all part and parcel of the holidays. No wonder those in oncology working this time of year are primed for severe emotional distress.

Is there anything we can do about it? Good news (finally!)—the answer is yes. In our books The Thriving Physician and Thriving in Healthcare, we offer up dozens of strategies and exercises to help the individual provider build psychological and emotional resilience (Simonds, Sotile). Resilience refers to an individual’s ability to come through a stressful experience and flourish and grow rather than wilt and contract. Studies have demonstrated that resilience training can be an effective tool in preventing and ameliorating burnout (West).

We will sketch a few critical resilience-building strategies and concepts for you here in a moment. First, though, there’s a caveat we feel we must get out of the way.

Discourse on the subjects of burnout and resilience has reached a fevered pitch of late. While we consider the attention on these critical entities very welcome, it does carry some intrinsic risk. First, all the discourse concerning what many consider a “soft” science has bred a significant level of cynicism and generated slews of sarcastic rejoinders deriding the “snowflakes” of the new generation of caregivers. Please, don’t fall in with this. Burnout is a very real entity, and it is a miserable state of being. Furthermore, it compromises patient care. Enough said.

Another fallout of the current landslide of interest in the subject is what we term “burnout-aversive work ambivalence.” In other words, some practitioners are interpreting the discourse as a dire warning about the perils of working in healthcare—do it too much and you will collapse into a burned-out husk of a human being. The point we are trying to drive is that with resilience training, the medical workplace could and should act in the opposite way. It should enliven, thrill, strengthen, and embolden its participants. It should help them get more out of life.

Finally, with all the ongoing dialogue, the “big boys” have gotten into the mix. By this we mean the national organizations, educational foundations, and governmental healthcare entities. Their involvement brings an assumption, or perhaps a prayer, that outside forces will swoop in and correct all the ills of modern healthcare delivery and eliminate the risk of burnout for one and all. Our thought? Don’t hold your breath. Healthcare will never be a Shangri-La. It will always be high-intensity, high-volume, annoying, and stressful. Think again about the field of oncology; you can create a sensational work environment, but the discipline, by definition, will always deal with horrible tragedies on a daily basis.

Thus, we advocate that burnout and resilience-building can be and should be, at least in part, tackled from the ground up, out of the trenches where all the delivery is actually taking place, by individual practitioners and groups of colleagues. Whatever systems, organizations, and the government add can be icing on the cake.

So what to do? To follow are a few suggestions. They can be undertaken during the holiday season, of course, but realistically you may not be able to tackle some of them until the new year has arrived. That’s fine. Rome wasn’t built in a day and neither will resilience be.

First, grant yourself permission for self-compassion and self-care. This means do something that comes very unnaturally to most healthcare workers: Keep an eye on your own well-being. When it is flagging, address it. Note when you are down, feeling overwhelmed, overworked, and stressed-out and what may have brought you to said state. Work on your coping skills. Adjust your work schedule. Ask for help. Discuss with trusted family members, friends, and colleagues. Note also what makes you feel good, what excites you, and what brings you joy, peace, wonder, and a sense of meaning. Give yourself permission to do these things.

Organize a resilience group. Gather a collection of colleagues and specifically focus upon, with some regularity, the concept of building resilience amongst the members of the group. Recognize that it will take multiple sessions for members to truly open up. Be patient and lead by example. Share. Identify principal shared stressors and address them as a group. When the stressors relate to systemic dysfunction, there will be more chance of correction if they are raised by a collection of well-meaning coworkers. (Remember, what is discussed in the groups should stay in the groups.)

Debrief stressors. With your resilience groups or trusted friends, discuss stressors that affect you the most. Simply airing stressful situations begins to dissipate them. Stay away from blow-by-blow minute descriptions of trying events, and focus more on your responses to them. Were your responses optimal? Did they help alleviate your stress? Are there better responses? Who handles such situations the best and how do they do it?

Harvest uplifts. Amazing things are going on around you all the time. Wonderful things, happy things, joyful things, miraculous things. We in medicine, however, are problem-focused and thus tend to blow by them in favor of fixating on the latest disaster. Take some time daily to consider the positive things that are going on around you: a smile from a coworker, the discharge of a once very sick patient, a thank you from a patient’s family member. Harvest these uplifts. Write them down. Reflect on them when you have a moment and just before you go to bed at night. This is not just a smarmy, new-age, feel-good ploy; multiple studies support the concept that “collecting” uplifts can significantly boost well-being and counter psychological distress.

Change your work environment. So often in healthcare, we simply accept Dickensian work conditions. Often, they are vestiges of practices of the past that are no longer applicable or efficient in today’s healthcare delivery world. Often, not much thought has been given to workflow and work demands for decades. If the demands of your work are untenable, seek to improve them. Be constructive. Offer alternatives. Engage your colleagues and/or your resilience group in the effort. Focus on the welfare of the patient and the providers.

Celebrate who you are and what you do—especially during the holidays. There is no better time of year to be a doctor or a nurse. You are truly the heroes of the holidays. You are sacrificing your precious time and energy so the holidays can shine that much brighter for others; so that they can enjoy some moments with their loved ones, be shielded from fear, be offered hope, be soothed and comforted. There are few more noble human undertakings. Involve your family. Rather than portray work as a burden, celebrate it with them for what it is, a near-sacred endeavor. Have the kids make cards and decorations for your patients stuck in the hospital. Discuss with them the strength, bravery, and grace exhibited by patients on a daily level. Remind your family that they are all part of the effort, part of the fight against cancer.

Nourish and cherish your relationships. We are social creatures, but in high-intensity fields such as oncology, we tend to shrink our contact with those we love and whose company we enjoy. Every group of oncologists we have ever surveyed admit to a progressive contraction of their true social networks (face-to-face contact with friends and family). This is the antithesis of what needs to be done. Stop this cycle and fully commit to nourishing your relationships. The holidays give us the perfect excuse to give small tokens of love and friendship, to write heartfelt notes, to make that long-overdue phone call. Take full advantage of this. Don’t let gifts, holiday cards, or calls be surface or obligatory. Really think about how to express your gratitude and love for the people in your life, whether they’re your family, your friends, or your coworkers.

A final note about working during the holidays: Ask yourself, What nobler, more meaningful thing could I be doing right now? Realize that you are protecting vulnerable people. And in oncology, we are talking about some of society’s most vulnerable, most desperate people. Consider the incredible contribution you get to make, and how it’s far better to work during Hanukkah or Christmas or New Year’s Eve than to be hospitalized during this time.

The practice of medicine offers so much opportunity for wonderment, humanity, awe, discovery, fascination, and acts of kindness and compassion. These are all key features to building a most robust resilience and fending off burnout and other forms of psychological distress. This does not change over the holidays. In fact, it is only brought into sharper focus.

Accept that you are truly a hero for so many during the season, that you play the role of an earthly angel. Be proud of your efforts. Soak in the positivity of it all. Again, we can think of no better time to be a healthcare worker.

References
[1] Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al.  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
[2] Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al.  Burnout and medical errors among American surgeons. Ann Surg 2010; 251: 995– 1000.
[3] Addressing Burnout in Oncology: Why Cancer Care Clinicians Are At Risk, What Individuals Can Do, and How Organizations Can Respond. Fay J. Hlubocky, PhD, MA, Anthony L. Back, MD, and Tait D. Shanafelt, MD DOI: 10.1200/EDBK_156120 American Society of Clinical Oncology Educational Book – published online before print October 29, 2018. PMID: 27249706
[4] West CP, Dyrbye LN, Erwin PJ, Shanafelt TD.  Interventions to prevent and reduce physician burnout: a systematic review and meta‐analysis. Lancet 2016; 388: 2272– 81.


Gary R. Simonds, MD, MHCDS, and Wayne M. Sotile, PhD, are coauthors of Thriving in Healthcare: A Positive Approach to Reclaim Balance and Avoid Burnout in Your Busy Life (Huron|Studer Group Publishing, 2019, ISBN: 978-1-62218-108-7, $32.00), The Thriving Physician: How to Avoid Burnout by Choosing Resilience Throughout Your Medical Career (Huron|Studer Group Publishing, 2018, ISBN: 978-1-62218-101-8, $32.00), and Building Resilience in Neurosurgical Residents (B Wright Publishing, 2015, ISBN: 978-0-69244-951-6, $24.95

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Gary R. Simonds, MD, MHCDS is a highly experienced clinical and academic neurosurgeon. He trained at Walter Reed National Military Medical Center and completed a medical research fellowship at the Walter Reed Army Institute of Research. He also holds a master’s degree in health care delivery science from Dartmouth College. He is a professor at the Virginia Tech Carilion School of Medicine, the Virginia Tech School of Neuroscience, and the Edward Via College of Osteopathic Medicine.Known for his compassion and broad neurosurgical expertise, Dr. Simonds has personally performed over 13,500 operations, adult and pediatric. His interests have included socioeconomic issues affecting patient care, medical ethics, education of all levels of learners, and the promotion of wellness in medical practitioners and trainees. He recently retired from his position as chief of neurosurgery and residency program director at Carilion Clinic-Virginia Tech Carilion School of Medicine.
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Wayne M. Sotile, PhD is the founder of the Sotile Center for Resilience and the Center for Physician Resilience, in Davidson, North Carolina. Of the 45,000 people they have coached or counseled, more than 70 percent have worked in healthcare, including 12,000 physicians. Dr. Sotile is an international thought leader on resilience and work/life balance for busy professionals. He has published widely in the peer-reviewed medical literature and has authored nine books. His work is featured frequently in the national print and television media, and he has appeared on Good Morning America, CBS This Morning, Dateline NBC, and other broadcast programs.As one of the most sought-after keynote speakers today, Dr. Sotile has delivered more than 9,000 invited addresses and workshops to audiences of high-performing professionals across disciplines. He consults nationally with organizations interested in deepening workforce resilience and leadership passion and effectiveness.