Steps to Becoming a "Professional Optimist" ... And Getting Yourself Out of the Cycle of Despair

In my previous post, the discussion was around the protective aspects that approaching negative situations in your professional life with an "optimistic explanatory style" can have on physicians struggling in difficult practice environments.

We know that people who have a more optimistic style of interacting with the world tend to have a higher perception of general control over their career experience, and a greater sense of professional fulfillment. Greater fulfillment in turn supports a more optimistic view of the world – it is a self-perpetuating cycle.

But the question is: In today’s difficult practice environment, how can anyone become an “optimist”?

Let's break down the steps of how to do that.

Step #1: Changing your “explanatory style”

We know from Martin Seligman’s important research on optimism in the 1970s and 1980s, that learned helplessness is basically defined as the “perceived absence of control over the outcome of a situation” (Seligman, 1975). This is nothing new for many unhappy physicians, who don't see any options for themselves outside of the track that they are currently on. We also know however, that learned helplessness can be mitigated by how a person thinks about the world, and in fact how they express it: what Seligman called their “explanatory style”. Understanding your explanatory style is key to understanding whether you approach the world in a positive (optimistic) or negative (pessimistic) way. Your style is made up of three elements:

1. The degree of personalization you give events – i.e., do you see things as “internal” to you (a character flaw, etc.) or “external” (something more situational)?
2. The pervasiveness of an event – i.e., is it “specific” (to a situation and therefore transitory) or more “universal” (an inherent element that cannot be changed)?
3. The permanence of an event – i.e., is it “temporary” (for now), or “permanent” (for always)?

As an example, imagine yourself in an unsatisfying work environment. For many physicians this may not be hard to do! Think of the things that make you feel dissatisfied with your situation. They could include things such as:

· A lack of quantity and quality of personal time

· Challenges with the organizational climate of your medical group

· Personality conflicts and/or in-fighting with colleagues or the medical staff

· Rapid introduction of new technologies that you don’t see as adding value or that cause too much disruption in your daily work

· A lack of decision-making power in your group

How do you think of those things? Do you think of them as “internal” to you (I just don’t work well on teams) or “external” (We have some communication difficulties that need to be addressed)? Do you think of them as “universal” (This is simply what practicing medicine is like – no-one can get along, too many "lone wolves"... I don’t expect anything else) or “specific” (We have some particular personality challenges on our team right now)? What about as “permanent” (We will never be able to function on this new system, I’m not going to try) or “temporary” (We are on a learning curve with our new EMR – this too shall pass)?

For people who interpret negative events largely as “internal”, “universal” and “permanent”, this is considered a pessimistic explanatory style. It conveys a sense of discouragement, of “giving up” (hopelessness) and despair. Seligman has tied this explanatory style to a much more passive coping style, a lack of problem-solving, and a much higher incidence of depression. In physicians we tend to see this as burnout (manifesting within), or as disruptive behavior (projecting externally).

On the other hand, if you interpret negative situations as “external”, “specific”, and “temporary”, this is considered an optimistic explanatory style. This is tied to a much more resilient, active coping style, and to a person who is more likely to take steps to action than to suffer in silence.

Now, with that said – and you may be thinking this - there is a use for pessimism, particularly with certain professions. Seligman suggests that pessimism can keep people from taking risky, optimistic actions in areas where the downside risks are unacceptable. This would certainly apply to the world of patient care – and thus, many physicians must, to some extent, be “professional pessimists” since they must weigh risks that could result in devastating consequences to patients, themselves and their practices. However, this is different from having a pessimistic view of the world in their own lives – and this difference must be clearly understood. Physicians must not fall into the trap of rationalizing away any personal pessimistic views of the world, by saying that it is an occupational necessity – particularly when maintaining this view is not serving them and is inhibiting their personal or professional growth.

Think About Your Situation in New Ways – “Learned Optimism”

The good news is that since explanatory style is learned, it can be changed – what Seligman called “Learned Optimism”. We can challenge our own “knee-jerk” responses, beliefs and explanations of life’s event, and choose to change our behaviors that follow. This is the basis for many types of cognitive-behavioral therapies out there that work remarkably well with people who have become stuck in a negative or maladaptive way of thinking and behaving.

For those of you who are struggling on the more pessimistic end of the spectrum and want to figure out how to build your resilience and mobilize yourself, you can start by trying the following techniques to “retrain” yourself into thinking and behaving differently. These may seem simplistic when seen on paper, but they have been used time and time again by many different people, with good results:

1. Learn to identify the adverse/negative situations that you routinely face in your professional life: In making any kind of positive change, awareness is key. Think about what happens in your daily work that consistently “pushes your buttons” or maintains your feelings of dissatisfaction. These things may be within your control, or outside of your scope of influence – it doesn’t matter which. Just knowing what those things are is the first step to changing your reactions to them.
   
   
2. Learn to hear the beliefs about those negative events that come to your mind (the “recordings” you play in your head: You are not being asked to change them, just listen to them. See if you can figure out those “knee-jerk” responses you have to the things that frustrate you. Where have they come from? Many are very deep-seated and have been there a long time. Just listen to them when they happen.
   
   
3. Experience the consequences of those beliefs: Pay attention to what happens when you give in to those knee-jerk responses or beliefs. If possible, write the consequences down and pay attention to the emotions, energy, will to act, outcomes, etc., that surround them. Is the same old “banging your head against a wall” feeling? Don’t judge the consequences of your responses, just get to know them.
   
   
4. Once you are familiar with the components of the consequences (the effects on emotion, energy, will to act, outcomes, etc.), start disputing those knee-jerk responses: This is the tricky part, and you may need some help doing this, but it involves –

a. Challenging the usefulness of your belief (does it serve you to create a desired outcome? Like that old saying "How's that working for you?")

b. Generating alternative specific, external and temporary explanations (could there be other ways of looking at the situation that don’t involve either inherent “character flaws” that you possess, or that are more situational?)

c. Focusing on evidence that either contradicts or undermines the negative belief and supports a more positive interpretation (instead of dismissing it, can you identify and value the data that supports an external, transitory view of the problem?)

Step #2: Empowering Yourself to Behave Differently – Changing the Things You Can

Granted, we know that there are factors within medicine that are largely out of the control of individual physicians. The two cited recently by researchers at the University of Michigan Health System as causing the highest degree of dissatisfaction were lack of control over their work hours and their schedule. Unfortunately, it does not appear that these factors are going to change any time soon – it is an inherent challenge of being in medicine. However, understanding your response to those stressors, and giving yourself an opportunity to change how you think and behave around them, can dramatically change your experience of those stressors and the consequences of them. Instead of feeling like you stuck on the same treadmill of experience day-in and day-out, with no hope of changing your outcome, you now have options.

In an Australian study of general practitioners, participation in a 15-hour cognitive-behavioral training program for stress reduction (one that targeted changing explanatory styles, and creating strategies for doing things differently) was found to improve the physicians' logical analysis and problem solving and reduce emotional discharge, leading to improvement in work morale and work life. This positive effect was sustained over 3 months of follow-up.

As demonstrated by that study, if you give yourself the tools to think and act in new ways, the results can be profound. For physicians struggling with professional dissatisfaction, it can start to give them an opportunity to break the cycle of negative thinking and immobility that keeps them feeling "stuck" in their daily work. It can open a window of hope and give them the resources to begin to envision a different path for themselves – one that may or may not include staying in clinical practice - that leads to a greater overall fulfillment. It enables action and forward motion.

Step #3: Moving to Action When the Time is Right

We know that there are many unhappy physicians who feel that they have large amounts of "untapped potential" within them and want to explore their options outside of medicine or clinical practice. If you are one of these people, mastering your view and response to negative situations or events in your life is critical. Building your resilience will protect you as you navigate through sticky or stressful professional experiences. Opening yourself up and problem-solving will allow you to find more options and have a greater sense of control over your career. All of this will reinforce your confidence that there is potential for you to have the professional fulfillment you crave, and it will allow you to be ready and willing to take action when the time is right. Professional optimists see what "could be", and focus on what is achievable. They strategize to make what seems impossible a reality. They define concrete steps for themselves to get there. And they act.

Becoming optimistic is not rocket science. But it does take a significant level of self-awareness and inner work. For many it is the first step to getting themselves out of old, negative patterns in their life and into something new. If you are a physician in this position, I challenge you to try pulling yourself out of the trained and taught "learned helplessness" that seems to be permeating medicine these days. See if you can make positive change your reality.

Turning Physicians' “Learned Helplessness” Into “Learned Optimism” ... And "Learned Optimism" Into Action

From my previous discussion on why it seems that many unhappy physicians stay in unsatisfying careers, it appears that both an individual and a collective form of “learned helplessness” in the medical profession is fostering this reality. We know that this form of helplessness is defined as a “perceived absence of control over the outcome of a situation”, and it seems to be reflected in how many unhappy physicians feel resigned to stay in a career that they no longer find fulfilling. As we said before, is it possible that these docs have simply been conditioned to believe that this is all there is, and therefore stay the course and suffer in silence?

If you are one of these unhappy physicians, are you destined to stay in a situation like this simply because you feel you have no other options? Have you become “pessimistic” about your ability, skills or prospects outside the clinical world? Do you have difficulty envisioning yourself in something new, or do you feel immobilized and unable to make any steps to remedy your professional situation? Does it feel hopeless?

Breaking the patterns which create a feeling of being “stuck” in your day-to-day life is the first step in the process of making real change in your life. Long before those things become actual behavior patterns or external situations, they reside in your experience as thoughts, automatic beliefs and feelings about things in your life. Learning to “pre-empt” those patterns before they become negative behavior is the key to changing your experience.

Pessimists tend to be wary of positive experiences – thinking they’re either a “fluke” or can’t be trusted and will likely pass – and embrace the negative events in life, allowing those experiences to validate their already negative view of the world. Optimists on the other hand, tend to focus on the positive things which they hope to experience more of, and discount or diminish negative events as transitory and/or recoverable.

Typically people who view the world in an optimistic way tend to use what we call “active” coping strategies with negative events, where they create behavioral or psychological responses that are designed to change the nature of the stressor itself or how they think about it. In other words, these people don’t just experience stress, but they do something about it that mitigates the effect that it has on their lives. They are moved to action.

Pessimists on the other hand tend to use “passive” or “avoidant” coping strategies that keep them from directly addressing stressful events. These strategies may result in or include avoidant activities (such as alcohol use), or avoidant mental states (such as withdrawal or depression). While these coping strategies may protect people from stress in the short-term, they are associated with much higher levels of stress and negative outcomes in the long-term. We know that this is evident with many unhappy physicians in the medical profession, and is reflected in the degree of burnout, disruptive behavior, and substance abuse that is seen today. Avoidant coping strategies keep people stuck in a cycle of negative thinking and behaving that can foster inaction for years.

Learn New Ways to Think About / “Frame” Your Situation

The good news is that even if you have been immobilized in a pessimistic cycle in your professional life, there are ways to break free from that and begin to discover new options for yourself. We know that people who are able to frame their experiences in an optimistic way, and who look for solutions to their problems vs. avoiding the issues are the ones who are considered the most resilient and adaptive to change.

Resilience is a key factor when it comes to being able handle stress, to stay on top of the “churn” that is part of navigating healthcare these days, and to maintain a level of control of your situation. It allows you to explore and make use of the choices you have in front of you, which allows you to see situations as more manageable than they may initially seem. While pessimists tend to dismiss alternatives to a situation, optimists actively identify options and open more doors for themselves. While you may not be able to control all of the events that make up much of your professional dissatisfaction, resilience certainly allows you to control your response to them, putting you back in the “driver’s seat” when it comes to how those events affect you.

In a particular study done out of McMaster University in Canada, 17 generalist physicians in different stages of practice who had a reputation for being resilient were interviewed. Of the four things identified as “main aspects” of their resilience, their attitude and perspectives (e.g., valuing and maintaining interest in their role, developing self-awareness, and accepting both professional demands and personal limitations) lay the foundation for what was considered a “dynamic, evolving process of positive attitudes and effective strategies”.

We know that people who have a more optimistic style of interacting with the world tend to have a higher perception of general control over their professional experience, and a greater sense of professional fulfillment. Greater fulfillment in turn supports a more optimistic view of the world – it is a self-perpetuating cycle that looks something like this:

The Cycle of Optimism:

Coming Up: So How Do We Get There? In today’s practice environment, how can anyone become an “optimist”? Steps to get you on track.

What Keeps Unhappy Physicians in Their Jobs? Is It Really “Learned Helplessness”?

I’ve been thinking more about the fact that so many physicians seem unhappy these days - with the state of healthcare, I suppose the statistics I read shouldn’t surprise me. According to a report on CNNHealth.com in November 2008, it was stated that nearly half (49%) of the 12,000 respondents in a survey of U.S. primary care physicians said that they would seriously consider getting out of medicine within the next three years if they had an alternative.

It is an unfortunate thing that practicing medicine – a field to which so many have brought their energy, passion and time – has become something they now feel stuck and dissatisfied in. Something that has drained so much of their joy that they feel they are just “going through the motions”. I’m sure that this is certainly not what they envisioned when they began medical school.

What struck me the most about the above study however, was not the number of physicians thinking about leaving practice, but the quote that they would leave IF they had an alternative. We know that for every physician that actually is leaving clinical practice, there are many, many more who stay in their unsatisfying careers – either unwilling or unable to envision themselves in an different profession and/or make the move to action.

Why is this the case? Why do so many stay in what are increasingly unhappy and unfulfilling situations? Certainly the psychology of leaving medicine is complex. But is this what we mean when we talk about “learned helplessness”? Have these unhappy physicians conditioned themselves to believe that they simply have no other options?

There was a recent article on Medscape General Medicine, that suggested that physicians have developed this form of learned helplessness, and discussed reasons why: [Bond C. The training of the "helpless" physician. Medscape General Medicine 2007; 9(3):47.]

First the author details how physicians lack the ability to cope with the current health care environment, and this apparent poor coping ability is the first driver of helplessness. He believes that this is largely due to a failure of medical schools and training programs to teach them about the “competitive forces” that are shaping today’s radically changing economic climate. He states that physicians have no training in adapting to current market conditions, nor are they typically introduced to the regulatory and political environment that they will have to navigate. He feels that the lack of training in leadership or pure business survival skills leaves many physicians frustrated and unable to cope with these demands in practice.

Secondly, the author asserts that the current culture of medical training in general has created this learned helplessness that is rampant in the medical profession. He states:

"Helplessness can be trained into individuals when, regardless of repeated best efforts that should be rewarded, no reward is forthcoming; as a result, the individual eventually learns to give up and sinks into a lonely feeling of futility and malaise. It would appear that collectively the medical profession has mastered this art and is suffering the symptoms en masse."

On top of the lack of reward for time and effort, the author believes that the rigid, authoritarian, fear-based forms of medical training, with no real financial reward are continuing to help create the foundation for the profession’s helplessness, and that they in fact are training young physicians to defer gratification to such a degree that they end up “giving up” on ever getting any meaningful reward for their sacrifices. He states that,

"A dispirited acceptance of one's individual fate seems to be the dominant mood of physicians nowadays rather than a motivated mobilization toward a better lot for the individual practitioner and the profession as a whole"

It is clear why many physicians are feeling overwhelmed and underprepared for the health care environment, and that this negative experience saps them of any sense of fulfillment in their careers. But what I find most interesting is now the author highlights this “dispirited acceptance of one’s individual fate”, which would partially explain why so many physicians stay in a career that they are unhappy in. Can it be said that they simply have been taught to believe that this is all there is?

Which brings us back to the idea of learned helplessness – where people perceive that they have no control over the outcomes of a situation, and so do nothing but suffer in silence. It can drain even the most resilient of the bunch over time, and result in much of what we see in unhappy physicians: burnout, depression, substance abuse. The good news is that there are factors which can mitigate this situation. For the many unhappy physicians out there, this is great news – the idea that there are strategies they can employ to begin to change their situation, provide options (whether psychological or physical), and help to move them to action when the time is right.

It’s called “Learned Optimism”, and more on that next time.

Transitioning Out of Clinical Practice in a Tough Economy?

I'm launching my blog with a topic that has been on my mind, and I know on the minds of some of the physicians that I talk to who have been exploring the option of leaving clinical practice and expanding their professional lives into new career areas.  The topic is how does one think about making a career change and transitioning out of medicine when the economy is so bad?  Certainly leaving clinical practice is an exciting idea for some physicians - the risk, the excitement, the learning curve, the beginning of "something new".  But in today's economic climate it can seem - how do I put it - crazy?  Is one dependent on the state of the economy to determine whether or not they pursue a new profession?  Or is it something more immune to the ups and downs of the market?  I know many who are wondering this - when things are bad around you, do you still entertain those nagging thoughts of change or do you abandon your plans?

That’s what I started thinking about – I mean, it makes sense to be worried when it seems like the country is falling down around us… Unemployment is up, people are losing their homes, jobs are less secure than ever.  You hear about these realities everyday on the news, from your friends, neighbors and patients.  It is unnerving to say the least.  We know that we all must tighten our belts and reconsider our financial situations.  And at the same time, we know it is important to try and stay above this collective sense of "financial hysteria" that it seems many people are falling into, and maintain our own sense of equilibrium.  Figuring out what this equilibrium is, and how it relates to our professional needs and aspirations, is the challenge.

 So if you are one of those physicians out there who desperately want to make a professional change, where does this leave you?  What do you do when things within your professional life have simply become unmanageable, and change is required for you to keep your sanity?  How do you reconcile the desire – if not the need - to make a professional change with the inclination to just hunker down, sweep the frustrations and dissatisfactions under the rug, and stay put until things calm down?  In all honesty we know being a physician is a good career, right?  It is a high-status job and is well-respected, it pays well, is intellectually challenging, it is easy to find work and there is high job security, and there many different options for careers within clinical medicine.  All of which are good things! 

 However, the flip side of practicing medicine is what typically drives the physicians I’ve met to want to leave:  more managed care, less respect, longer hours, more paperwork, more oversight, greater regulation, a “ceiling” on income and growth potential, and a sense that one must work harder to maintain the same standard of living as in years past.  Many physicians try to counter these things by doing things like working harder, delegating some responsibilities, utilizing new technologies, trying to focus their practices on more rewarding areas, etc.  However, the feeling that they have less autonomy, less power, less time, and less control still prevails.  For many this saps them of the joy and energy that they brought into medicine, and they begin to have that nagging need to look elsewhere professionally, in order to regain that lost control and recover that sense of professional wellbeing that has somehow become elusive in their daily lives.

 However, it is a tricky proposition to consider leaving clinical practice – many don’t know where to begin, what options to pursue, where to start their research.  It is not typically a topic of conversation that they discuss with their physician colleagues, because they know that the response will most certainly be “What?  And waste all those years of time and investment?  Why??”, not to mention the sentiment of disloyalty to the profession that even approaching the idea tends to bring up in many physicians.  As such, most docs exploring this option tend to keep it to themselves, which can build into a sense of isolation as they go through the process.  The idea of leaving medicine may also bring a sense of grief and doubt around a potential loss of stability, a loss of everything that has been worked for, a loss of money, prestige, respect, and even a loss of their identity.  They may even feel like they will no longer be a “real doctor” if they are not practicing medicine. 

 A stumbling economy can make those doubts even more pronounced.  It is easy then to step back from that nagging need for professional change, and push on with what is secure, no matter how unsatisfying.  For some this may feel like the easiest thing to do at this time.

And, for many it is.  If you are a physician in this position, perhaps now is the best time to invest some serious time in doing the “footwork” it takes to make a career transition a success.  If the economy is forcing you to take a step back, perhaps now is the best time to make that step count, so that when the time comes - when things have improved to the degree that you feel comfortable starting something new - you have a head-start on your career change.  There are many ways you can do this, starting with some honest assessment of where your head is at regarding a possible career transition.  I think of it in the following ways:

1. Understand your motives:  Make sure you have really figured out what it is that is causing you to feel dissatisfied with your clinical profession – i.e., make sure that you are thoroughly exploring your feelings with your current profession before you start looking for solutions outside of your situation.  A big “aha” for many comes when they realize that the reason for dissatisfaction with their career usually comes from within.  Oftentimes physicians will list any one of the external reasons that we discussed above for being unhappy (e.g., loss of control, working too hard for too little, etc.), when in reality at this point in their lives they are just ready for a change.  Perhaps you just feel the need to experience new things and to grow as a professional and as a person – there is nothing wrong with this.  Just know why you want a career change.  If you premise a career change only on factors not truly responsible for your desire to leave clinical practice, you may find yourself in a new career with what seems like a great team, opportunity, and environment that still doesn’t satisfy you.  Take that inventory on yourself, and really spend time thinking about why you need this change, exactly what it is that is driving your biggest dissatisfaction , and the “must have” elements of a new career that would need to be in place for you (and your family) to consider it a success.  
   
   
2. Consider any new opportunities carefully:  During this “stepping back” time, ensure that you do not make the mistake of rushing into a new opportunity thinking it will solve all of your professional issues.  Do not make the mistake that so many career changers do by entering into a new profession expecting your previous frustrations to be magically resolved.  If you have not done your due diligence and clearly understood what drives your desire for a change or what your professional “must haves” are, you may find yourself in a new career experiencing many of the same frustrations as you experienced before.  What a way to feel stuck.
   
   
3. Partner with your family to ensure you’re thinking through the initial “critical success factors” for your career change:  First thing that comes to mind is your financial situation – which is top of mind for most people these days given the economy.  You need to ensure that you’ve realistically considered:
1. Your current situation – savings/investments/etc.
2. How long you could go without an income if you needed to
3. How much money you would need to make in a new position to be satisfied (and to maintain your standard/quality of living)
4. How much your spouse is willing and able to help during your transition period

To that point, the other major factor is the degree of support that you have from your spouse/significant other in making this career change.  Many spouses are rightly concerned about finances and how the family will replace the income that is earned from practicing medicine.  However, more and more spouses are starting to see the reality of declining income and longer hours in medicine, and are now starting to wonder how much money the family is losing by having the physician stay in an unsatisfying practice.

4. Know what you’re “worth”:  With the economy as uncertain as it is, knowing your worth from a market perspective is more important than ever – especially if you think you might want to make a career change.  There are online tools such as www.salary.com that can help you find out what professionals of your caliber are making outside of clinical practice, and whether or not that number has gone up or down since the recent economic downturn. Make sure you clearly understand how any potential industries you may be interested in have been impacted by the economy and what that means for the job-seeker or entrepreneur in those areas.   If you have the opportunity, speak with other physicians who have made the move into your target industries and find out how MDs are positioning themselves financially.  Do your homework during this time to ensure that when the time comes you have all of the data you need to make informed choices.

5. Deal with your “mental roadblocks”:  During the stepping back time, you have a great opportunity to identify and deal with any unresolved issues that are stopping you from moving ahead with your career transition.  Job security is a biggie, particularly since medical practice is a fairly secure profession, and other possible avenues – corporate roles, consulting, start-up ventures – are not.  Dealing with your feelings around losing the persona of “being” a practicing physician is also a hurdle for many.  And there is also of course the issue of the economy, and what that means for your prospects outside of medicine right now.  For some that is a huge, but also a somewhat “convenient” roadblock.  Arlene Hirsch, a Chicago career counselor and author of Love Your Work and Success Will Follow (John Wiley & Sons, 1996), states that "Many people rationalize to themselves that, because the economy is bad, they may not find anything else, so they stay in a job where they're unhappy… But in the end, they may become so unhappy that they sabotage themselves by not doing a good job, or even by assuming their job is safe when it really isn't.”  I love Arlene’s point because it highlights the relationship between job satisfaction and job performance.  We know that over time, no matter what the profession – physician, laborer, CEO, childcare worker – if people are not generally happy with their work and/or have an overall sense of fulfillment, their performance will slip.  Of course for physicians the consequences of that are much higher than for most other people.  And while traditional job security is generally not an issue for physicians, the ability to maintain a rewarding, empowering career is certainly something that is less than secure in today’s healthcare environment.  

Transitioning out of clinical medicine and venturing down a new career path is an extremely complex issue for the physicians who are contemplating it.  For the professionals who I speak with about it, the decision has typically has been a long process evolving over a number of years, until it finally becomes an issue of weighing the internal factors versus the external factors when determining if and when to make a change.  It is a deeply personal decision, one that is not simple nor easy.  It is, however, do-able with the right amount of introspection, planning and strategic action.