Thursday, December 1, 2011

Wellness Challenge Yields Results for Mayo Residents and Fellows

Patricia Lindholm, MD,
Immediate Past MMA President
I recently had a conversation with Noel So, M.D., (pronounced like Noelle) a resident in physical medicine and rehabilitation at Mayo, who wanted me to share information about a unique wellness activity, she and Mark Steffen, M.D., preventive medicine resident, are co-chairing-- the Mayo Fellows Association (MFA) Wellness Challenge.

The event that commences December 1 builds on the success of the previous MFA Wellness Challenge, which was a 12-week program, chaired by Christopher Weight, M.D. A total of 630 residents and fellows, or about half of those at Mayo, participated in the first Wellness Survey, and about 230 went on to enrolled in the MFA Wellness Exam at a cost of $5 per person. The exam measured fitness parameters including body mass index (BMI), percent body fat, and VO2 max. 46 teams of five people competed for the grand prize, which was a trip to the Olympics. The teams earned points for activities such as time at the gym, number of steps walked (measured by pedometers), participation in pre- and post- activity surveys and wellness exams. Another innovative activity was “Climb the Clinic” that involved walking up and down the stairs in five Mayo buildings. ID badges given to each participant were scanned at the bottom and top of each stairwell to record completion times. Dr. So tells me that the presence of the 46 competing teams fostered positive peer pressure that yielded the greatest amount of physical activity. The points earned by each team equaled the number of raffle entries each team received for the grand prize Olympics trip.

Other prizes were awarded for:
The biggest loser of fat (without being underweight)
The fittest female/fittest male (the best VO2 max)

Challenge Results
Some statistics from first wellness challenge:

Collectively the participants walked 171,008,824 steps which is equivalent to 3.4 times around the Earth at the equator;
Over 10,000 trips to the gym; and 
189 completed wellness evaluations.

After the event, a survey was sent to all Mayo residents and fellows about burnout and emotional health. The Wellness Challenge participants as a group reported less burnout, better sleep and better nutrition. The coordinating committee for the Wellness Challenge is clearly a research-oriented group.  It was noted that after the event was over there was decreased gym attendance, although it is possible that people were exercising more outdoors in milder weather, since the challenge started January 1st.  One question that was raised is how to maintain the motivation of participants to maintain fitness after the formal monitoring period.  

Social Media
The 2nd Annual Wellness Challenge will be extended to 16 weeks.  Dr. So, Dr. Steffen, and the committee will be studying the impact of social media on participation in the challenge. The challenge already has a page on Facebook, which is a social medium that I'm familiar with, but I was educated by Dr. So about Yammer, which is a workplace-based social medium using work e-mail addresses.
The MFA Athletic Committee has also introduced the concept of “walking meetings” instead of sitting around a table, so that exercise is integrated into the meeting. They are hoping to incorporate it into the Mayo culture.  

Following in their Footsteps
This challenge is a very ambitious undertaking and may seem daunting to some of us, but consider what we can do in our own workplaces and communities.  I think any of us can use the concept of monitoring with pedometers as a competitive activity, and perhaps find other parameters that are easily measured.  I am going to challenge my local partners who are fitness enthusiasts to design a fun incentivizing wellness program for our group.
If anyone is looking to do research more broadly on the effects of physical fitness on the mental, emotional and physical health of physicians, I think we can round up quite a few physician subjects across Minnesota.  I hope someone will take me up on this challenge!

Thursday, November 3, 2011

Care for the Caregivers

Patricia Lindholm, MD,
Immediate Past MMA President
I have just returned from two inspiring events in the past week.  First the MMA held a summit meeting on Sharing Solutions to Combat Burnout.  The conference was conceived as a session to share and learn from people working on physician wellness in their organizations.  There were a variety of presentations highlighting diverse and unique approaches to addressing wellness in physicians as well as studying the effectiveness of interventions or programs.  The audience was also asked to share their ideas on how the MMA can help facilitate the development of wellness strategies for physicians.  It was gratifying to see the interest in the topic and I believe we could easily have spent twice the time in order to answer audience questions and even to lengthen the presentations.  In the near future the presentations will be made available on the MMA web site with our other wellness resources.

I also attended the second biennial Canadian Conference on Physician Health.  The theme for the meeting was “Healthy Physicians = Healthy Communities”.  I have long admired the Canadian Medical Association’s international leadership in physician wellbeing.  After having an informal discussion with two Canadian family physicians at breakfast the first morning, it occurred to me why the Canadians have worked on the issue for so long.  These physicians were from different provinces and each in solo practice.  Each was in practice for about 25 years (like myself) and female (like myself).  For the most part, Canadian physicians tend to own their businesses and are facing increasing overhead expenses and decreasing payment as are the U.S. physicians.  More of their physicians are in extremely remote areas where there is little collegial or technological support.  These two physicians each shared that some years ago they had taken a two-year leave of absence from the practice of medicine due to burnout.  They do not have colleagues to cover their practices, and often cannot obtain locums coverage.  If ill or on vacation they have to close their offices.  Furthermore there is no paid vacation since they are self-employed and they continue to pay the overhead. 

I attended a breakout session regarding the stress of litigation on physicians.  There was a video scenario of a young rural physician who had been staffing an ER where she saw a patient with a painful swollen leg.  She felt it was cellulitis, but of course it turned out to be a deep vein thrombosis and the patient died of pulmonary embolus.  Of course the clinical diagnosis of DVT is not straightforward, which is why we have tests like d-dimer and ultrasounds.  This doctor would have had to send the patient fifty miles to get an ultrasound!  That is quite a decision for a remote solo doctor to make.  I reality-checked the scenario with an OB-GYN physician who had practiced in a remote area and she confirmed that lack of resources is a fact of rural practice. 

There was an interesting “debate” about the issue of limiting physicians’ work hours (or resident work hours).  Two physician leaders spoke in favor of mandatory work hour limits and two spoke against.  To my surprise both sides had compelling arguments.  I believe they were randomly assigned a position to present and of course each had data to support their arguments.  The ending plenary speaker was Dr. Roberta Bondar who was the first neurologist to take part in a space shuttle mission.  One of her themes was to maintain our curiosity and continue learning throughout our lives. 

Workshops on “music and medicine”, mindfulness meditation, nutrition, caring for physicians as patients, combating the stigma against mental illness and psychiatry, supporting medical students and residents were presented, among other topics.  Time was set aside for exercise (run/walk) or mindfulness meditation. 

Having witnessed the strong interest in addressing physician wellbeing among Minnesota physicians, I believe that we should be able to develop a more comprehensive conference in the future.  We had some visitors from the Dakotas and also several physicians who came for their own personal edification rather than from an organizational perspective.  I am very proud of the good work that is happening in Minnesota and we have much to offer to our colleagues around the country. 

I am also encouraged that the AMA President-elect, Dr. Jeremy Lazarus, plans to make physician wellbeing the emphasis of his upcoming term.  It is time to care for the caregivers.

Thursday, October 6, 2011

Welcome to Well Physician

Patricia Lindholm, MD,
Immediate Past MMA President
I am back!! No longer the MMA president, my blog has moved to a nearby address.  The work of promoting physician well-being continues to be a priority for the MMA and for me. 
For those of you who have been thinking about bringing some physician wellness resources to your community, we are here to help.  On October 27, 2011 the MMA is convening a conference to share ideas from a number of leaders in the medical community who have implemented or who are developing resources to promote an environment supportive of the health of physicians.  We will hear some great presentations and also learn from each other.  If you have ideas please come to share with the rest of us and network with like-minded colleagues throughout Minnesota and the surrounding area.  Sharing Solutions to Promote Physician Well-being Conference is free for MMA members and only $35 for nonmembers. There is CME credit (4 hours). 

Some time ago I shared that I will be attending the 2011 Canadian Conference on Physician Health.  It will be held in Toronto on October 28-29, 2011.  The title is “Healthy Doctors = Healthy Communities.”  There is still time to register. 

For those of you who have not recently checked the MMA physician well-being page we have added an excellent webinar that AMA presented on physician suicide.  Two more webinars will be presented in the near future on issues challenging medical students, residents and other physicians. 

Finally, in this new incarnation of the Well Physician Blog, I am considering inviting guest bloggers to appear from time to time.  I have some folks in mind and would also love to hear from any volunteers.  I look forward to continuing the conversation with you all.

To Err is Human

Patricia Lindholm, MD,
2010-2011 MMA President

Orginally Posted September 7, 2011

I believe that we all recognize the above title as a timeless adage, but also the title of the Institute of Medicine report that brought to public scrutiny the problem of medical errors in hospitals and the prevalence of harm that patients experience during their hospitalizations.  The report jump-started a nascent patient safety movement that now appropriately applies to outpatient care as well. 

An excellent article appeared this week in AMA News about physicians who have publicly acknowledged their medical errors.  They are using such disclosure as teaching opportunities for themselves and other health care professionals, and to highlight that systems improvement is the key to preventing errors.  The “I’m Sorry” legislation that has been discussed in various states reflects the need to provide transparency to patients and to make amends when they are harmed by medical procedures and decisions. 

The most interesting part of the article for me is a discussion of how to support physicians who have harmed patients through diagnostic or treatment errors.  I trained in the era of “shame and blame” when one person was assigned total responsibility for an error.  This led to a tendency to hide our errors from patients, hospitals and our colleagues.  Physicians judge themselves quite harshly and question their general competence or even their personal worth when faced with an error. 

In Boston at the Brigham and Women’s Hospital, a Center for Professionalism and Peer Support was created to reach out to physicians who are in the painful and lonely position of having acknowledged a medical error.  A number of physician peer advisors are available to reach out to their colleagues and ask about their wellbeing and offer support.  Similar programs have developed at medical centers around the country.  A compassionate and human approach to such colleagues can save careers as well as the lives of the physicians who are supported. 

Several years ago when I served on the board of MMIC (the professional liability company started by MMA some years back) we started the Physician Litigation Support Program.   Each physician facing a claim is personally contacted by a psychiatrist whose only purpose is to provide support and education to the insured.  We have received many thanks from recipients of this caring program.

If your training program or health care organization does not have a mechanism to support colleagues who have made errors or who face litigation, what can you do to get such a program started?  I suggest that the first step is speaking up and insisting that collegial support programs be proactive, supported and expected.  You should expect to hear from colleagues who want to work with you to make good work happen.  I suspect you will have richer friendships and happier patients as a result.   

A Common Ethical Dilemma

Originally Posted August 11, 2011

Patricia Lindholm, MD,
2010-2011 MMA President
I recently read in the Huffington Post that Dr. Lee Lipsenthal (of whom I have written earlier in this blog) has a recurrence of his cancer and has been told that is the last season of his life.  His interview is a demonstration of a remarkable ability to be fully present in life as well as fully present to others as he anticipates their grief.  His work has enriched us and will continue to do so for many years to come. 

Dr. Lipsenthal was a presenter at the inaugural program of the Osler Institute’s conference on physician wellbeing last fall in Albuquerque.  I am happy to report that the conference will be offered again in the coming year, possibly twice.  You can follow the Osler Institute on Facebook. 

Of course I am also following Dr. Kevin Pho on his site  There are many posts of interest by physicians from around the country.  One that caught my eye this week was posted by Michael Kirsch, MD and titled, “Medical ethics in the office should not be a private matter.”  It appeared the day after I attended an ethics committee meeting in our newly integrated hospital and clinic.  We discussed bringing up examples of daily ethical dilemmas faced in outpatient medicine.  Dr. Kirsch lists several such outpatient dilemmas which resonate with me.  The problem is that no sooner is the issue behind me than I forget about it and lose the opportunity to fully discuss and analyze it with colleagues.  (I suspect it is a function of middle age.)

Here is an example of an ethical dilemma I have faced many times in my practice (I paraphrase):  A patient’s family member sends a note or calls to report some private information shortly before my patient’s appointment, with instructions “not to tell” the patient about who divulged the information, but hoping I can somehow dig into the matter.  Do you tell the patient about the conversation?  I have reacted differently on different occasions.  How about you?

The Vanishing Oath

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted June 30, 2011

Recently I came across a documentary-style independent film written and directed by Ryan Flesher, M.D.  The title is “The Vanishing Oath” and is a story about Dr. Flesher’s journey through burnout and his personal examination of the causes of distress that lead physicians to leave the clinical practice of medicine.  Those of us in clinical practice know exactly what bothers him and others.  He also interviews physicians around the country who have left medicine and allows them to tell their stories.  Random people on the street are also interviewed about their take on physicians and medical care in general.  I thought this film would be depressing but it was not.  It is about an hour in length and is accessible to the general public.  It would be an excellent holiday gift to your favorite insurance company CEO, malpractice attorney or legislator.  Check it out.  I believe I ordered it from Amazon.

The Vanishing Oath (excerpt) from Lisa Molomot on Vimeo.

Another very interesting book that I am almost done reading is titled Just Like Someone Without Mental Illness, Only More So, by Mark Vonnegut, M.D.  (Yes, he is the son of Kurt Vonnegut.)  Dr. Vonnegut experienced several psychotic breaks during his young adult years and was initially diagnosed with schizophrenia.  He actually has bipolar disorder and is a practicing pediatrician who trained at Harvard Medical School and Massachusetts General Hospital.  It is fascinating to see a first person account of serious mental illness from a successful practicing physician and teacher.  He also mentions many of the same frustrations noted in “The Vanishing Oath.”  Yes, he is one of us. 

It is comforting to see that the “elephants in the room” of medicine are exposed and acknowledged publicly by two articulate and courageous doctors.  Both of these works are enlightening to anyone with an interest in the sociology of medicine.  They might also be appropriate gifts to relatives who wonder why physicians need to attend to their wellbeing now more than ever.

Promoting well-being across professional disciplines

Patricia Lindholm, MD,
2010-2011 MMA President

Originally Posted June 2, 2011

I recently was invited to Rochester to speak about physician well-being to the clinicians at the Olmsted Medical Group. The group is unveiling a new program in professional wellness, led by a committee of four physicians. The first part of the program will be working on acute problems or distress, but further plans include preventive or proactive activities to enhance or maintain well-being in the medical workplace. I look forward to hearing about their progress over the next year and beyond. From the discussions that occurred after my presentation, it was evident that professional well-being is a timely topic indeed.

Many interesting ideas were generated by the Olmsted group. Allied professionals such as physician assistants and podiatry seem to have an interest in collaborating with us to promote wellbeing across professional disciplines. What a wonderful thought! Imagine what could happen if MMA combined forces with other health professionals in Minnesota to produce cutting-edge conferences and activities to revitalize our colleagues. Think of the valuable networking and relationships that would develop! If this dream excites you, too, I would love to hear from you, particularly if you want to help make them a reality.

Finally, let me share with you a short video recommended by our colleague, Dr. Craig Chambers. On You Tube called Validation. I think it will make your day.

Becoming an Iron Doc

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted May 5, 2011

I would like to recommend a book called IRONDOC: Practical Stress Management Tools for Physicians, by Mamta Gautam, M.D., who is a psychiatrist and is known in Canada as “the Doctor’s Doctor.”  She works exclusively in the area of Physician Health and helps doctors care for themselves so they can care for their patients.

The title IRONDOC is an adaptation from Iron Man athletic competitions. For example, in the book Gautam offers 20 training tips (to deal with stress) which are like athletic drills. In addition, the book offers several chapters on the biopsychosocial factors that lead to unhealthy stress in physicians.  The reader is in the position of being “on the couch” of a skilled diagnostician.  Gautam adeptly outlines the common personality traits and defense mechanisms of physicians. 

Next she discusses the five early warning signs of stress and then the syndrome of burnout.  To overcome these obstacles, she develops the concept of the iron doc who is highly skilled in multiple areas, but not the best in every area.  So often we insist that we must be the best at all things, which is of course impossible.  If we are not the best, the thinking goes, then we are not good enough, or even worse, we are failures. 

Another aspect of this book I liked is that it is the size of one of those pocket manuals that we used to carry around in our white coat during training years (anyone remember the Harriet Lane handbook?).  The chapters are concise and the advice quite practical.  At the end of the book she recommends various resources the reader can consult for more depth in specific areas.

To see my other recommendations, visit the MMA’s new physician well-being page. We will be continually updating the site, so keep coming back!

Physician Wellness Resources

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted April 14, 2011

I am always trolling for good physician wellness resources.  I have several to share with you this time.

You may have seen an excellent article in the New York Times on physicians taking control over their work hours and lifestyle. 

What is particularly compelling about this article is that it discusses the decision process of a third-generation physician in choosing her specialty.  It also discusses the reactions of her father and grandfather who had traditional endless-hour practices.  Many of us in practice can relate to all three generations and their points of view.

Another important and exciting resource recently came to my attention.  There is a conference in May in Albuquerque by the Osler Institute that looks wonderful.  I personally will not have time to attend but want to pass along the information to you.  This is the type of conference I have dreamed about creating for Minnesota physicians, but am glad that someone is doing it!  

Speaking of conferences I will be attending the Rachel Remen workshop on “The Healing Power of Story: Opening to a Deeper Human Connection.”  Many of you have attended Dr. Remen’s programs and I have heard nothing but rave reviews.  I am excited to go to this meeting in California in early June.  The longer I practice the more I realize that practicing medicine is largely about listening to and honoring our patients’ stories.  I also have come to appreciate that all human relationships are based in stories and these are the links that often connect us to each other.  I will be happy to share with you any “pearls” that I find at the workshop.

I have another book review for you in my next blog entry.  Be well!

Reflections on Resilience

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted April 7, 2011

We have watched with awe and horror as events unfolded recently in Japan.  A massive earthquake, a devastating tsunami and then nuclear plants close to meltdown.   To a resident of Japan these events must have felt like the beginning of the end of the world.  Yet there were many acts of heroism including workers risking death by radiation poisoning to save their families and neighbors.  The Japanese are well known for their resilience.  I have no doubt that they will rebuild and work to make their country even more protected from natural disasters.
Resilience is the key to carrying on with life in spite of the pain, obstacles and other challenges that we face.  Every medical student must have resilience.  The brightest in college are now average students in medical school.  They must reframe their self-assessment and continue in a medical education.  As residents we continue to be trainees but assume more responsibility for the care and safety of our patients.  During residency a mistake can do very real harm.  The resilient resident confides in and relies on her fellow trainees as well as her faculty.   If we learn well, we discover that providing health care is indeed a team sport. 
I can recall a number of devastating experiences during residency having to do with poor outcomes for patients.  As we tend to be perfectionists, I am sure that you understand that I punished myself multiple times, feeling that I was not worthy of the profession, feeling that I had let someone down.  I felt like a fraud, an imposter.  I have had similar feelings as an attending physician.  In talking with close colleagues, I know that I am not alone in having these feelings. 
In moments of professional distress, we need each other.  We need to support and provide a reality check for a colleague who did their best and yet had a poor outcome.  The reality in the vast majority of cases is that our colleague is a good, caring physician.  We would do well to remind our colleagues of this again and again.  All of us have thought, “There but for the grace of God go I.”  The wounded healer feels alone and isolated and believes that he is constantly being judged by colleagues and other members of the health care team.  Sometimes the belief is well founded, which is an indictment of us all. 
In the 25 years in practice after residency, I have become more humble.  I have stepped off the pedestal I had built for myself over years of striving and pretending to be all-knowing, all-competent.  I remember once praying for humility some years ago, and then feeling afraid of what would logically happen if my prayer were fulfilled:  humiliation.  Well, that has happened but life did not end. 
Many things contribute to our resiliency, such as the love and support of our families, friends, and colleagues, and the appreciation of patients and their families.  Sometimes we also need professional help and therapy to get back on our feet.  I believe that reaching out for help is a sign of strength and wisdom.  Receiving care may feel unfamiliar to us but it is part of the complete human experience.  Try it sometime. 

Testing for Burnout

Patricia Lindholm, MD,
2010-2011 MMA President

Originally Posted March 25, 2011

In this blog, it has been my goal to provide useful resources to those of you who are interested in physician well-being. I hope to continue to do so in the remaining six months of my presidential term. I wish I could give you a feeling for the many connections that I have made with physicians across the country who are also interested in physician wellness. We have been sharing our work with each other in order to highlight studies and programs that exist or are being developed in the U.S. and elsewhere.

One such connection I’ve made is with Heather Fork, M.D., of Austin, Texas, who writes a blog called “Doctor’s Crossing” ( She consults with physicians who face decisions about whether to make a career change or who are battling burnout. I warned her that I would shamelessly borrow some of her material for my blog.

One of the resources Dr. Fork discovered is a simple self test for burnout. It This nonvalidated tool assesses the three dimensions of burnout:
  • Emotional exhaustion;
  • Depersonalization – viewing others as objects, developing cynicism, separating ourselves from the people we serve; and
  • Decreased personal accomplishment – less satisfaction in our work, joyless striving (what I think of as loss of a sense of purpose).

The prevalence of burnout is staggering, and it starts as early as medical school. Tait Shanafelt and Liselotte Dyrbe, two Mayo Clinic colleagues, have published an expanding volume of work documenting how burnout influences professionalism and the degree to which medical students, residents, and practicing physicians are affected by it.

If you think you might be experiencing burnout, take the self-test. If you get a high rating on the burnout scale, I encourage you to find a trusted advisor or therapist to help you refresh your spirit and your view on your work. It is possible to recover from burnout, as I can say that from my own-experience. Do yourself a favor and keep your flame alive!

Finding Balance

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted March 3, 2011

Recently I became aware of the work of Lee Lipsenthal, M.D., an internist who developed a program called “Finding Balance in a Medical Life.”  He has written a book by the same name that I suspect will be on my reference shelf and used for many years into the future.

The first half of the book summarizes what is known about the physician personality, the state of physician health and the prevalence of burnout.  My readings in the area of physician wellbeing over the last two years confirm his analysis.

The second half of the book contains a panoply of tools which can help us find our way out of burnout and back to a life of balance.  Many of these are familiar to those of us who have studied psychology and neuroscience in the last couple of decades, such as cognitive therapy and emotional shifting.  Mindfulness meditation is discussed in some detail with exercises that can easily be done over 5-10 minute periods.  There is an interesting chapter on “Psychosynthesis” which discusses how to identify our personality and sub-personalities and how to use them to respond to a variety of situations.

By serendipity, I also came across the keynote lecture that Lipsenthal delivered to the annual Scientific Assembly of the American Academy of Family Physicians in 2010 in Denver.  The AAFP shared a video of his presentation on their web site for those of us who were unable to attend the meeting.  During that talk, Lipsenthal revealed that he was undergoing treatment for metastatic adenocarcinoma of the gastroesophageal junction.  Thus far he has survived about 18 months from diagnosis and looks pretty good but is well aware of the poor five-year prognosis.  By already having established a habit of meditation and daily expressions of gratitude, he was prepared to face the illness with calm. 

The book and the talk both ended with the following words of wisdom:  Balance is knowing that today is a good day to die; that you have lived fully, lovingly and without remorse. 

May we have many good days.

MMA Moves Forward with Physician Well Being Effort

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted February 22, 2011

I wish to share with you the progress to date with the physician well-being initiatives at MMA.  At the January Board of Trustees meeting, the board approved the proposal of the Physician Well-Being Task Force.  Soon we will be discussing how to implement the recommendations of the group. 

A member survey conducted by the task force indicated strong interest in having regular articles in Minnesota Medicine on topics related to physician well-being.  I hope that by now you have read the January issue that was dedicated to the topic.  I am so proud of the contributors to the journal, many of whom were on the task force.  If you have not seen it, take a look or go to the Minnesota Medicine web site.  I truly believe this issue will be a valuable reference for us in years to come.  For those of you who are interested in member recruitment, this journal would be a good promotional piece for MMA.

It is my hope that we will offer or sponsor retreats for those of us who need to have “time out” to reflect, rejuvenate and learn new techniques to reduce stress in our lives.  It is also my hope that these and other offerings will promote the formation of “community” among us.  It occurs to me that one of the things most lacking in physicians’ lives is a sense of community with our colleagues.  I am thankful to my local colleagues who have come together for community in our small support groups.  There is a great deal of healing and soul-feeding that occurs when we can be truthful, trusting and vulnerable to each other in community.  If you would like to see a similar group in your medical community I would be happy to share our experience with you. 

I continue to be impressed with the Canadian Medical Association’s efforts in the area of physician health.  I would like you to know that the second Canadian Conference on Physician Health will be held in Toronto October 28 and 29.  I am planning to attend!  You can get information about the conference at 

I am currently reviewing a good resource on physician wellness and plan to share it with you soon as a “book review”.  Stay tuned.

Be well!

Moments of Grace

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted February 3, 2011

In January, I was a guest at the Zumbro Valley Medical Society’s annual meeting.  Because I live five hours away from Rochester I checked into a local hotel to spend the night after the meeting.  Subsequently I had two consecutive days off for travel. 
The meeting was an elegant affair with award presentations, a fine meal and an excellent talk given by Sanne Magnan, M.D., the former Minnesota Commissioner of Health.  My hosts were extremely gracious.  The awardees were all inspiring individuals which caused me to ask myself, “So what have I done with my life?” 
Don’t get me wrong.  I know as a physician my work helps people every day and is meaningful.  I am also in a leadership position in my state medical association.  These are facts.  However, internally there is often discord between fact and conviction. My own faulty wiring at work, I suppose.
During a period of socializing at the meeting I was approached by Harriett Hodgson, former president of the MMA Alliance.  She is an accomplished journalist and author.  She came to present me with her most recent book, “The Spiritual Woman.”  What a gift!  She has a beautiful introduction about the many varieties of meditation and their value and usefulness.  The book also includes a collection of inspiring quotations that can be used as the basis for a daily meditation.  I knew that this gift was a moment of grace.  Perhaps my encouragement of an open discussion of physician wellbeing has significance after all.  Indeed this gift was nourishment for the soul.
The experience also reminded me that in medical practice we are presented with moments of grace more often than we recognize: the gratitude of a patient who takes the time to write a card; the sincere “thank you” from a person who felt heard and cared for; the affection that develops when we care for patients over many years, and the hugs from children or from the elderly.  These are priceless. 
On days when we are discouraged and wonder whether we ought to have chosen a less stressful career, we are likely to have had a moment of grace somewhere, if we only had eyes to see it and the sense to appreciate it.

Professionalism, Nature or Nurture?

Patricia Lindholm, MD,
2010-2011 MMA President

Originally Posted January 6, 2011

I have been thinking about the concepts of collegiality and professionalism for a number of months. Trips to the dictionary have been unsatisfactory. After consulting a number of them, I found very limited definitions such as “belonging to a college, such as the college of cardinals in Rome” or being a member of a specific professional group.  In other words, there was no behavioral aspect to the definition of collegiality.  Perhaps like pornography, we “know it when we see it.”

Recently I read an excellent article in JAMA, “A Behavioral and Systems View of Professionalism,” by Cara Lesser et al that shed light on this issue.

The premise of the article is that professionalism is a set of competencies that can be taught and learned and that it must be practiced to be developed.  Also we are capable of improving upon professionalism as we continue in practice.

What is professionalism? According to Lesser, professionalism is not an inherent character trait or attitude.  Professionalism is defined as a set of behaviors.  It appears that collegiality - working collaboratively with other physicians and demonstrating respect for them all in the service of the patient – is one of those behaviors.

The article also demonstrated how external factors in the practice environment can affect professional behavior. Financial incentives such as pay for performance are not motivators to professional behavior.  Pride of purpose and intrinsic motivation are more important.  There are therefore two essential players in the service of professionalism: the individual interactions between doctor and patient and organizational management and governance. 

The good news of this research is that there are no hopeless cases.  All of us can learn the skills of professionalism and all of us can grow and refine our professional competencies throughout our careers.  This is one source of resiliency.  And resiliency is the preventive medicine and antidote for burnout. 
When our behaviors reflect our values we are whole people and much happier people.  We owe it to ourselves and to our patients to work to make the small and large health organizations more conducive to professional behavior and to eliminate perverse incentives in the system.

Learning to say no

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted December 2, 2010

We all have multiple roles in life, and I recently found myself filling several of them during my father’s terminal illness and death in early November. 
Several weeks ago it was apparent that my father was very ill and needed to be hospitalized.  The working diagnosis was pneumonia, but it soon became obvious that something more serious was afoot when a thoracentesis uncovered a significant lung mass.  He allowed the physicians to order scans, cytology, etc.  Later he confessed that he already knew about the cancer as it had been diagnosed in another medical facility; he confessed this to his sister, not to the physicians. (Imagine trying to diagnose and treat a patient who decided not to share such information with you!) My father liked to keep secrets.
I was the health care proxy and executor of my father’s estate.  He lived in Florida, so before getting there, I was doing long-distance work with him and the doctors/relatives/social worker, etc regarding pain management and hospice placement.  It seemed relatively easy initially to be on the “family” end of a health care crisis.  My siblings and I arrived in Florida barely in time to say farewell.  Then it was a blur of arranging cremation, cleaning up his apartment, and selling and giving away household items.   During the two weeks I was away, I carried out some media interviews for the MMA and answered e-mails and even participated in a conference call.  As physicians, we are able to go into “crisis management mode” and defer our own emotional reactions to a later time.  This state of numbness (brain-dead is what I felt at the time) continued for a little while.  Thankfully, the long drive home from Florida was a buffer between the intensity of the family loss and the return to work and life as usual.
Since returning, I have taken more time to grieve and process what has happened, and I’ve  surprised myself by saying “no” to a couple of things. Saying no is something I have spent years trying to learn, and with practice I get better at it.  As physicians, we have been trained to rise to any occasion, to get up and work in the middle of the night, to work with little sleep, and to function in spite of whatever personal issues we are facing.  We were not trained to nurture ourselves when needed.  Saying “no” was somehow shameful. I encourage us all to practice the art of saying “no.”  Obviously this must be done judiciously.  Sometimes saying “no” to more work and responsibility is actually saying “yes” to life and health.  One test that I use to decide whether to say “yes” or “no” is to ask this question: “Will this activity suck the life out of me or give me life?”  It is simplistic, but it works for me. 
Are you doing what works for you?

Chairing a physician well-being task force

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted November 11, 2010

Over the course of the last six months or so, I have been chairing the MMA Physician Well-Being Task Force.   While I was President-Elect I knew that this would be the emphasis of my presidential year and wanted to get an early start on the project.  We have a multidisciplinary group including physicians, chaplains, an attorney and a physician’s spouse.  We are in the process of generating a report and recommendations to the MMA board on how to address physician well-being. 
If you follow the MMA web site you will soon see a section on physician well being.  We have generated an extensive bibliography of articles and resources as well as web links.  We will identify opportunities such as retreats, workshops and educational sessions.  I also hope to provide information to you about how to start a physician peer support group in your local medical community.  We hope to produce some video material that can be accessed on-line. 
A great resource in Minnesota is the University of Minnesota’s Center for Spirituality and Healing.  We will soon have a link to this site.  The Center has many offerings that are valuable regarding self-care including Mindfulness Based Stress Reduction (MBSR) courses.  These are based on the pioneering work of Jon Kabat-Zinn at the University of Massachusetts.  I can enthusiastically recommend this program.  In my personal journey I have practiced MBSR for about two years.  When anxious or stressed the mindfulness meditation exercises have a wonderful calming effect on the mind and bIody. 
Another mindfulness exercise that many of us are practicing is yoga.  When we are practicing yoga asanas or another form of exercise we get out of the brain chatter that is constantly happening in our minds.  We are able to attend to what is real.  We realize where we are and are able to live in the moment.  I have not yet arrived at a continuous state of mindfulness (and likely never will) but even brief mindfulness of my breathing, emotions or bodily sensations during a stressful day can be very healing.
There are several books by Jon Kabat-Zinn that I would recommend if you would like to learn more about mindfulness.  Full Catastrophe Living, Coming to Our Senses and The Mindful Way through Depression have been very valuable resources for me.  Do you have other recommendations to share with your MMA Colleagues?  We would love to hear from you.

Take your own advice and stay home

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted November 4, 2010

A topic of interest to me is “presenteeism” among medical students, residents and physicians.  Yes, this is the opposite of “absenteeism.”  Both conditions may be problematic.  Have you ever presented for work when you were ill?  I confess that I have committed the act of presenteeism on more than a few occasions over the course of my training and career.
Most of us have received the subtle message that illness is a sign of weakness.  Doctors cannot afford to be ill, and especially cannot afford to be absent from work.  When we are absent, our colleagues usually have to pick up our workload and may let us know that they resent it.  Some patients even try to “guilt trip” us after an absence.  Most of us realize that returning to work after any type of absence means facing a mountain of charts, mail and messages that need addressing. 
Is it good practice to work when we have an infectious illness?  Of course not.  Would we advise our patients to stay home when ill?  Of course.  However, the misguided “macho” ethic of our profession has bullied us into doing the wrong thing for ourselves, our coworkers, and especially our patients. 
Is it good practice to work when we are sleep deprived, suicidal, manic, intoxicated?  Is it heroic to work immediately postoperatively or postpartum contrary to the advice of our physicians? 
Friends, let us permit ourselves to heal when sick, recover from surgery and tend to our mental health—if not for ourselves, then for our patients.   Let us also have mercy on our students and colleagues and give them the space to care for themselves.  It is odd that we even need this type of advice, isn’t it?
“Physician heal thyself” indeed!

Wellsprings of resilience

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted October 28, 2010

As physicians, we confront a host of stressful conditions and adversities, related to patient care, practice management, and just life. The challenge of a long-career in medicine is to learn how to bounce-back from these ups and downs, while still maintaining our equilibrium, openness, and wholeness. This is called resiliency by  physician-wellness experts.

I recently listened to a podcast about physician resiliency by pediatric radiologist Richard Gunderman, M.D., of Indiana University. It was part of series of podcasts I highly recommend called “Healthy Practices,” which are moderated by Dr. Mamta Gautam, who is known as “The Doctor’s Doctor.”

One of Dr. Gunderman’s thoughts is that aspiring to significance in our practices and our lives - leading lives that matter - can serve as a wellspring of resilience in ways that striving for success and prestige cannot do. In my view, medicine is a calling, not just a career or a job. I believe that burnout is more likely if we feel like cogs in a big machine, cranking out patient encounters, and racking up RVUs. If we realize that we are actually servants touching the lives of people when they are vulnerable, our work has great significance indeed.  

I would love to hear your stories of resiliency.  How have you recovered from adversity in your professional or personal life?  Can your life lessons inspire one of your colleagues? Leave a comment here or email me. 

Useful Canadian Physician Wellness Websites

Patricia Lindholm, MD,
2010-2011 MMA President
Originally Posted October 12, 2010

As I mentioned in my last post, the Canadians are doing something special when it comes to physician well-being.  I would like to share some of their resources with you since they are freely available to all of us, and it is not necessary to reinvent the wheel.

One resource that I have been following for over a year is the CMA web site  The content is excellent and includes wellness topics such as nutrition and fitness and resiliency.  There are also modules on anxiety, depression, burnout, substance abuse, disruptive behavior and so forth.  The content is updated periodically.  I was told by some Canadian physicians in Chicago that the site has drawn visitors from numerous countries around the world, with the most frequent use by Russian physicians.  Check it out!

Connected to the site is a related site called  This has good information on how to make our teams and workplaces healthier for ourselves and our coworkers.

Stay tuned for another gem from Canada!

Physician Wellness is an International Concern

Patricia Lindholm, MD,
2010-2011 MMA President

Originally Posted October 4, 2010

This week I am attending the International Conference on Physician Health in Chicago.  It is jointly sponsored by the AMA, British Medical Association and Canadian Medical Association.  There are physicians here from other countries such as Spain, Australia and Saudi Arabia.  It is clear that we in Minnesota are not alone in our concern for the well-being of physicians.  
It is interesting to see research data that shows that a physician’s self care practices are directly related to the advice that they give patients about self care.  For example, a physician who has had colorectal cancer screening is more likely to advise it for their patients.  If we have adequate exercise and a healthy diet we are more comfortable advising our patients in these areas.
There is an entire “track” at this meeting studying the correlation of physician well being and quality of patient care.  People are also starting to ask how to make the lives of medical students, residents and practicing physicians better.  This is foreign territory for a profession that feels its members should care for others at the expense of ourselves.  There was also a very powerful talk by Dr. Michael F. Meyers on the subject of physician suicide and resilience.  The abstracts for most of the presentations are available on the AMA web site. 
I also notice that the British and the Canadians are way ahead of us in the study of the prevention and treatment of distress in physicians.  However, this month the AMA has released its new toolkit:  AMA Healthier Life Steps-A Physician’s Guide to Personal Health.  It is a good start, but there is much more that we must do for our colleagues.  I am looking forward to advancing this work in Minnesota together with the MMA.