BB: It is well recognized that medicine is a high stress profession. Some stress, for example during training, is beneficial and expands resiliency and strength. Stress becomes problematic and traumatic, however, when it overwhelms and is accompanied by shame, guilt, and fear. What is less well known is that chronic stress may be punctuated by episodes of terror, even acute stress reaction and post traumatic stress disorder when a mistake is discovered or a lawsuit ensues. We live in a culture and profession that tends to deny psychological trauma and when we deny trauma in ourselves, we tend to deny trauma in others such as patients, and valuable opportunities for healing are lost. Do you know that a significant percentage of medical students have suffered major trauma prior to entering medical school and that they are primed to having their traumas retriggered when they enter training – described by one author as resembling "an abusive and dysfunctional family system?" When they encounter patients with psychological trauma they may try to rescue those individuals or avoid exposure to them. Unfortunately, rather than finding themselves in a healing profession, they find one that is soul-denying and soul-destroying. I would like to see serious attention being paid to the topic of psychological trauma in the practice of medicine. For sure we must shift the culture so that those physicians who feel traumatized can reclaim their spirit and well-being in an environment of safety. Perhaps then the high suicide rate in physicians (a sorely neglected topic) will fall. So, I would not be surprised if much that is labeled stress is something much more serious.

Returning to the issue of stress, one pervasive cause is "too much to do, too little time." Conventional approaches result in us spinning our wheels, multi-tasking as we try harder, and life becomes a blur of activity and exhaustion. In a landmark study in Canada in 1998 they found that two-thirds of physicians reported feeling overworked and in another study they found something like 48 percent of physicians suffered from advanced burnout. And numerous studies in the United States demonstrate a high degree of physician dissatisfaction and burnout. Other important causes of stress are lack of autonomy and control in the face of a constantly changing, challenging and hostile business environment. Personal relationships suffer and this aggravates the situation with secondary stress.

We desperately need fresh, out-of-the-box approaches that support time expansion, total quality improvement and efficiency, self-care and above all collaboration and support. Many effective solutions are counterintuitive, for example expanding one’s time by slowing down, creating speed bumps in one’s day, investing time in order to save time, super-standardizing routine procedures in order to create space for the patients that need listening, etc. The average physician has hundreds of thousands of patient encounters in the course of a typical career – many involving suffering – and is seriously disempowered by a lack of professional counseling and communication training. We are infamous for not knowing how to respond in a brief and meaningful way to suffering. Physicians frequently ignore effective communication as a way of saving time, then pay a heavy price for this neglect when we encounter divorce, dissatisfied patients, disgruntled employees, and litigation.

Above all, we need to think in terms of collaborative, supportive systems. As human beings we were not designed to function in isolation. We need others to help us ventilate, innovate, develop proactive solutions, and be there for us when we hurt.

One of my clients is an obstetrician who is suffering from litigation stress and is in a partnership with three others. They meet regularly with their accountant to discuss the figures, yet in 17 years of practice have never once met to discuss their weekends on call that he describes as "hell." Isolation is a huge theme and adds to physician suffering.

Burnout has been described as "an erosion of the soul." My wife, who is a Rabbi, uses the metaphor of soulstream. Just as you need nutrients for your bloodstream, you need nutrients for your soulstream. You need rest, time to chill out and integrate, friends, community, meaning, joy, a sense of control over your life. And when this is deficient, when you’re putting out more than you’re putting in, your soulstream becomes depleted. The result is what we call burnout with irritability, aggression, lethargy, inefficiency, and a sense of disempowerment to go and do anything other than just cope with the situation. Sir William Osler described medicine as a lifelong learning adventure. It should not be a drudge; a commitment to a lifetime of slavery.

BB: We know that medical mistakes are common. It’s estimated that up to 100,000 people a year die from errors in the USA. Sympathy is appropriately directed towards the patient and his or her loved ones. And yet little sympathy is given to the person who made the mistake. Often this individual is a victim as well, since the event is often due to system failure rather than simply one person’s lapse of judgment. A system that imposes hours of record keeping a day cannot be held blameless when it causes the professional to rush through an examination. A mistake can be particularly devastating to a perfectionistic, caring, well-intentioned physician. Our response to a colleague who made a mistake or is being sued is often one of reassurance. This isn’t particularly helpful.

BB: It minimizes the trauma. The individual may feel isolated, carrying feelings of shame and guilt and a dismissive comment such as: "don’t worry, this is a normal part of practice" serves to further isolate. For example, when a psychiatrist loses a patient to suicide, this has been reported to be as devastating to some as the death of a parent. A physician might experience an acute stress disorder and even post traumatic stress disorder.

Shortly after working as a volunteer chaplain for the American Red Cross following 9/11, I attended a workshop on medical mistakes. One doctor shared his experience on discovering a post-operative complication in a young patient. Participants responded with empathy and with reassurance for example: "You used your best judgment. You couldn’t know." These comments only seemed to make the physician more agitated. His eyes seemed teary, his face flushed and he seemed genuinely distressed. Recalling trauma victims from the World Trade Center in Manhattan, I suddenly had an ah-hah! moment. Then I said, "Let’s pause. I’d like you to tell me what you noticed in your body, the moment you realized that you had made a terrible mistake." And the physician responded, "Time stood still, a sense of unreality came over me, everything became slow motion. My breathing became heavy, my heart was beating through my chest, I had an image of myself on a witness stand. I felt weird for days." I then said, "You describe symptoms of an acute stress reaction as if you were a victim of major trauma. This had to be so painful for you." The relief on this physician’s face was quite dramatic as I labeled and validated his trauma and suffering. I labeled it and validated it.

Other clients for whom I provide support during the litigation process describe the same phenomenon. Their trauma is retriggered during the lengthy litigation process and some have had multiple lawsuits. One of my clients, an excellent physician by the way, had had five. We need to study this issue of mistake, litigation and trauma and see whether the definition of PTSD needs to be broadened. In any event, what I do is in my telephone sessions is to create an environment that is safe, confidential, non judgmental. I validate the trauma, the losses and the suffering. I encourage the retelling of the story very slowly, like playing a video tape. Then, because trauma isolates, I develop a solid supportive connection with the person – the first step in his/her reconnection with society. They become curious: "How can I apply this in my work with my patients?" I give homework assignments so that my clients learn more about the nature of trauma, suffering and healing. I role-model and teach communication skills that heal. Instead of becoming withdrawn, traumatized loners, fearful of making a mistake and perhaps burying their pain in work or substance abuse, these physicians learn to become better communicators and healers. Work becomes more meaningful as they recognize the trauma in patients with life threatening illness and know how to support their patients and their families. The end result is that the lawsuit can actually be a blessing in disguise as trauma is transformed into empowerment and growth.

BB: If you do a literature search on the use of ritual in medicine you’ll find ritual denigrated as thoughtless, meaningless, routinized repetitive tasks that date back to the Florence Nightingale era. Yet "meaningless" rituals help create structure and relieve anxiety. We all have ritualized behavior from the moment we wake up, read the newspaper while listening to NPR and have coffee.

Other rituals are intentional, such as with life-cycle events, wedding, funerals, etc. Mostly, however, our rituals are unconscious. I was at a lecture in which the speaker was a person who had written a thick tome on medical ritual. As is customary, we signed in, took our seats, the speaker was introduced, the lights went off, he cracked a joke, then began to talk about his book. One by one participants began nodding off as he droned on and on. The lights went on. He was thanked. One or two questions were asked and evaluation reports were filled out and we left. The point of his talk was that we should discard meaningless ritual in our hospitals and offices and create new more useful ones. Halfway through this lecture, I began to giggle uncontrollably as I looked at the sleeping bodies around me and realized that we were immersed in the ritual of the medical lecture, one centered on the PowerPoint. He seemed oblivious that this was one ritual that could be discarded in favor of something more interactive that would draw on the wisdom of the group.

What I have been innovating and teaching is the use of conscious, designed rituals, ones that assist us in our self-care and patients in their healing. For example, rather than rushing into the office straight into work, pause, notice what emotions and pressures you feel, acknowledge your concerns, breathing deeply as you do so, then transition into the office being much more fully present to those around you. On returning home at the end of the day, instead of barging in and spilling negative energy from work, creating a conscious ritual allows one to detoxify and refresh. For one it might be a long shower, for another listening to soothing music on the commute home. Patients can be encouraged to conduct conscious rituals before major surgery or courses of treatment – or upon recovery. I have a chapter on the conscious use of ritual in my book Communication Skills that Heal.

Two years ago, my wife and I were invited to do a conscious ritual related to medical mistakes at the annual conference of the American Psychiatric Association at the Jacob Javits Convention Center in New York City. This was based on one originally done at the AMA/CMA conference on physician health in Canada. We based the ritual on a passage in Deuteronomy where it says if a leader of the tribe of Israel makes an unintentional mistake, he will come before the high priest and conduct a sacrifice, then all will be forgiven. Well we weren’t going to do an animal sacrifice, however, we did take a slide projector cart, draped it with a black cloth, set a large rock on it, then placed the cart in the center of the room. The tradition of the medical lecture with its frontal learning style was still very strong and despite clear instructions that the room was to be set up with chairs in a u-shaped formation, we encountered rows of seats like a 747 jumbo jet. Fortunately we had arrived early and immediately set upon changing the structure.

We made it a very safe environment. We spoke about confidentiality and then created a ritual within a ritual. We asked participants to think of the teacher that they most revered and why. And one by one they came up with the name and the quality of the teacher on an individual Post-it note that they placed on bulletin boards. Then we made the point that learning is a lifelong experience, that risk and mistakes are inherent to it, and that we have the capacity to learn from these mistakes and become in ourselves like the teachers that we revere – and we certainly are teachers to our patients and to our students.