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Stoicism Defeats Burnout

2020; Wiley; Volume: 27; Issue: 12 Linguagem: Inglês

10.1111/acem.13967

1553-2712

Martin Huecker,

Medical Malpractice and Liability Issues

The isolation that a burned out physician experiences resembles the archaic punishment of exile. Emergency physicians face adversity: more than half of our time spent on the EMR, administrative challenges such as boarding and billing, a lost sense of meaning, expectation to do more with less resources, autonomy slipping away. Patients have unpredictable, unfortunate outcomes and may rate their care without understanding our intentions. Some of these obstacles are unavoidable, intrinsic to medicine, out of our control. They become less troublesome to a doctor equipped with Stoic principles and practices that curiously match the categories of burnout. Stoicism originated in third century B.C. Greece, flourished in the Roman Empire (particularly under the Stoic philosopher-king Marcus Aurelius), and then declined as Christianity became the state religion in the fourth century A.D. In modern times, the word "stoic" brings images of cold, emotionless Mr. Spock from Star Trek. This misleading caricature steers individuals away from an effective tool for personal wellness. The confusion stems from a misunderstanding of the Stoic emphasis on apatheia (Greek). Rather than what we now conceptualize as apathy, the ancient meaning was closer to "equanimity" than "indifference." Stoics also work to attain ataraxia, which refers to a "lucid state of robust equanimity characterized by ongoing freedom from distress and worry."1 This makes Atarax one of the coolest (and perhaps misleading) trade names for a drug. The tranquil (not apathetic) stoic prioritizes three core principles, covered in sources from a few years old to thousands.2 One of the most practical but profound volumes is the personal diary of Marcus Aurelius (Meditations).3 Conveniently, surprisingly, covertly, the three principles fit as key-in-lock remedies to modern categories of burnout. When Seneca the Younger was banished to the island of Corsica, he foresaw the phenomena Freudenberger and Maslach would describe thousands of years later. Stoic Principle #1: Virtue Treatment for: Lack of Personal Accomplishment "Just that you do the right thing. The rest doesn't matter."—Marcus Aurelius Stoic Principle #2: Control of Emotions Treatment for: Emotional Exhaustion "You don't have to turn this into something. It doesn't have to upset you."—Marcus Aurelius Stoic Principle #3: Nature and Community Treatment for: Depersonalization "It's silly to try to escape other people's faults. They are inescapable. Just try to escape your own."—Marcus Aurelius Stoicism is more than a pleasant, abstract idea; it was developed as a philosophy of life before philosophers argued about meanings of words. As ER docs, we embrace the wide breadth of knowledge in medicine, curious about pathogenesis and mechanisms of treatment. But we are foremost pragmatists, stabilizing acute components of ill health with limited data and therefore may appreciate stoic practices more than principles. This creative tool superficially appears pessimistic or even morbid. Stoics visualize losing parts of life they hold dear: car keys, career, even a person. Like a near death experience, this reflection will teach you to not take good fortune and loved ones for granted. Negative visualization allows you to exit the hedonic treadmill. Remember that at one time in the past, the thing you wanted most was to become a doctor. What if you became disabled and could not practice medicine? The Trichotomy of Control, William Irvine's adaptation of Stoic philosopher Epictetus's Dichotomy, divides life circumstances into those of which we have full control, partial control, or no control.2 They recommend to not spend time worrying, or becoming angry, about factors you cannot change. Research supports the focus on autonomy for higher job satisfaction (and a virtuous, happy life). When you face a challenge at home or work, focus only on the aspects that are within your locus of control, your own thoughts and behaviors. The serenity invocation puts this concisely: Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. Stoicism advises a mild form of fatalism—accept the fate of events that have already happened and focus efforts on the present. Nietzsche lived by the Latin phrase Amor Fati, love of fate: Enthusiastically welcome what the world throws at you. Jocko Willink used a shorter version of this phrase in his military leadership career.5 When something undesirable happened, rather than lament his poor fate, he said "Good!" and conceived a positive spin. The ED is busy, Good! I can learn from all of these patients. My patient has cancer, Good! I can use my compassion and expertise to break the news. Dropped my pizza on the floor, Good! I can continue my fast (or test my immune system). Stoics were known for a hyperbolic acceptance of discomfort, practicing living without amenities solely to tolerate nuisances. Cato the Stoic would "trigger the disdain" of other people so he could practice ignoring it.2 Embracing voluntary discomfort hardens the self, removes anxiety about future hardships, and ensures that you will appreciate the comforts of modern life. Stoics recommend not to simply remain calm in the face of your suffering, but to experience a setback without actually suffering. Irvine comments on meta-delight, the pleasure derived from achieving pleasure even with minimal comfort. Go a day without food, abandon your coat to walk the dog in the winter, run the stairs in your hospital … you will become stronger. Literature on physician burnout invariably includes data on mindfulness. If you find difficulty clearing your mind of all thoughts, attempt the stoic technique of rational reflection. In the morning, plan what fate might permit you to accomplish; throughout day, approach setbacks and good fortune in a mindful manner; at night, reflect on what went well and how to improve your own virtue.6 Surprisingly few published essays link the practice of Stoicism to the practice of medicine. Stoics like Chrissypus built on Hippocratic philosophy, but very few modern medical historians highlight these timeless concepts. Let us revive this surgically precise antidote for burnout. Start today. Overcome harmful, negative emotions by recognizing them as judgments. Strive to be "free from passions and yet full of love."3 Notice and appreciate the connection you have with other people, even the difficult ones. And focus your attention on what you can control.