I'm going to switch gears and talk more about psychology, your mental health going through your future career. And I really have no disclosures except for the fact that I think I've been burned out a couple times in my career, which has probably forced some of my career changes in the past. Anyway, I think that burnout and recognizing and understanding it has led me to be able to share, I think, some pearls of wisdom with you today that I hope you can take home and use in your future. So I was asked to talk about work-life integration and wellness, and there are too numerous to count books and articles and things out there about this. It's really been kind of the buzz phrase for maybe 10 years. I know my inbox is cluttered with things from Medscape, Doximity, my own hospital, articles about these topics. But I asked myself, okay, I think I know what work-life integration is, but what is wellness? I mean, what is physician wellness? Does that mean like my BMI, my blood sugar, my blood pressure, and my cholesterol are all normal and so I'm healthy? And I wasn't sure. So I decided to ask CHAT-GPT, all right, what is physician wellness? And they told me that it's an overall sense of well-being and quality of life such that you are happy at home and you're happy at work and life is all good, and that physicians who have this sort of wellness provide better care to their patients. And so there is some data on this. It's estimated that over 50 percent of physicians at some point during their career are going to experience burnout, and that has a definite negative impact on your overall sense of well-being and happiness, but also has been statistically shown to have a negative impact on patient care. Burned-out physicians make more medical errors. They have reduced patient satisfaction, and that's bad. You know, I don't know if you guys know about Press Ganey surveys yet, but they will become a part of your life, and I mean, they suck, you know, because it's like a popularity contest, in my opinion. The patients, they like you or they don't like you. It has really nothing to do with the quality of your medical care, but they're out there and your employer looks at them and the public looks at them, and so it is important. So burned-out physicians tend to have reduced satisfaction, and they have higher mortality rates, surprisingly. So all of this is sort of related to what I call work-life imbalance, right? Things are just not in sync with you. You have difficulty maintaining your home relationships. You have difficulty engaging in outside activities, like I know friends who've been burned out or even myself at times, I just didn't want to go out and do anything. I didn't want to be social. I didn't want to talk to anybody in the hallway. I just was working. I'm the only one who's working really hard, and I need to get out of here. They also have a higher risk of depression, anxiety, substance abuse, and sadly, even though we're well aware that these problems exist, there's still kind of a little bit of a stigma around seeking help. Help is out there. What causes it? You guys can make this list yourselves, I'm sure. We're overworked. We work long hours, and when you're in practice, there's no rules about how long you can work. You work until the work is done, right? We tend to be in situations where there's no escape, call nights, weekends. That pager or phone is ringing. It could be constant or it might not be. It's unpredictable. You don't know if you're going to get six hours of sleep or two hours of sleep or whether you'll see your children or not. The administrative burdens are constant and chronic. The EMR, it's a never-ending thing, and upgrades happen. You think you got all your smart phrases, everything's good, and then all of a sudden they upgrade and it changes. You have to kind of learn things all over again. It's very frustrating. There's the constant medical-legal worries, right? That patient didn't like me or didn't have a good outcome. Are they going to sue me or not? And then we have this overall culture that out of one side of the mouth talks about wellness and work-life balance, and out of the other side of their mouth, they prioritize productivity over your well-being. So, you know, I know people, my hospital has all these things for wellness and whatnot, but I have friends being called in and talked to because they didn't make enough RVUs last quarter or last year, so, you know, that's difficult, that's stressful. It all kind of boils down to having, really feeling like there's a lack of control over your work. And so what you have to learn to do is manage your environment, and it's not that easy, but it's doable. I mean, the first thing is talk to your peers. You know, most of us have been through things, and just share the story. It feels good to unburden yourself, and frequently you'll have somebody who's experienced the same thing or an older colleague who can give you some advice on how to handle that difficult patient or difficult situation. There is, as I said, a lot of organizational support. If you go to work for a hospital system or a business entity of some sort, an academic institution, they have support systems in place that you can access. There's mindfulness and resilience training. That's kind of the other buzz phrase that's been around the last few years. I get a lot of emails from my system about it, and I always thought, wow, that seems cool. I'd like to do that, but I don't have time to do it. But then COVID came, and I said, well, you know, I have time to do this. So in March of 2020, I did a little mini course that the hospital had, and, you know, I liked it. I felt like it was helpful, and it doesn't take very long. I only do things related to it when I'm really stressed, and I do it just for a few minutes. I get in the elevator and go up 12 floors, and I close my eyes and take three deep breaths, and it helps, you know, just kind of clear my head and bring me back to the moment. So I think those kind of things can be helpful. Self-care, really important that you maintain your own health so that you can help others. Exercise, nutrition, sleep. But you know what? Those are the first three things that go out the door when you're busy and you're overworked and you're stressed. I don't have time to exercise today. I'm too tired. I have a headache. Oh, I didn't get time for lunch. The drug rep brought warm brownies and cookies, and, you know, that's my lunch. And then you get home for dinner, and it's fast food because you're too tired to cook. And sleep, you know? I mean, that just has to happen when it can, you know? You might not get to bed till midnight after you finish with your kids and everything, and you've got to be back to work at 7. And when that happens repeatedly, you know, you get exhausted, and you really can't take good care of people. So what you need to do, sounds easy, is set boundaries to achieve your balance. So I'm going to give you some practical pearls because I always read these articles, and I'm like, well, okay, that sounds good, but how do I do it? You know, what do I really do to make this happen? And you know, so getting there requires that you set boundaries, all right? You cannot have work-life balance without having boundaries in your life. So as you're moving forward, take stock of your future job opportunities, but go into it with a thought of how you want your life to look. It's never going to be perfect, but if you have children, you know you want to be there for them. You don't want a job that keeps you at work every night till 8 o'clock and that you have call every other weekend. It's not compatible with that sort of a lifestyle. So look for a job match that fits your life needs. And I'm telling you, your employer won't fix this for you. They're not out there looking to make you have good work-life balance. You have to make it happen and try to get the right job fit to start with. I won't go over this list of things to ask, you know, to help you figure this out because we've had a lot of good talks on this already. The only thing I would pull forward a little bit here is hospital work, consults in the hospital. That is the biggest disruptor, I think, in your day because you think about it, most doctors have clinic and clinic and maybe hospital rounds, you know, half a day clinic, little bit of a few hours hospital rounds, they're done, right? But we have three parts to our day. We have clinic, we have endoscopy, and we have hospital rounds. And those rounds tend to come real early in the morning before your endo schedule starts or in the middle of the day when you're supposed to be taking a little break and having lunch or after your clinic is over and you're going back at night and doing those consults that came in. So if you can find a job where they have coverage for hospital consults, maybe you'll be lucky enough to have a GI hospital, that's not very common, but it would be nice, or you just have your partners share so that somebody's on for the week for the hospital consults and then you can plan your schedule much more easily. So I think that's something that really is something that led to a lot of burnout for me was that never-ending unpredictability of my schedule. I like predictability, and that wasn't happening when I was doing a lot of that work. So let's talk about boundaries. There's three types of boundaries. There's the physical ones, those are easy, you close the door, you turn off your phone. But the really important ones are psychological and emotional. Psychological boundaries are cognitively leaving work behind so that when you go home you're in the moment, you're focusing on your family and your children, you're not just constantly thinking about what happened or what you're going to do tomorrow. And that emotional boundaries are being able to leave your mood at work. You know, you had a bad day, you don't want to go home and take it out on your spouse. You know, leave it at work if you can. And that's a little bit where some mindfulness or other techniques you might find that work for you can help you through that. So those boundaries are also important because people who have strong boundaries tend to have a better sense of identity and self-respect. They're able to say no more easily when an unreasonable request comes up. And they feel more confident sharing their ideas and don't have their feelings heard if someone disagrees with you. So there's a little science behind this. I'm going to share this with you. There's a woman named Ellen Kossak, she's a PhD at Purdue University whose life's work has centered around executive wellness, DEI issues, women's equality in the workplace. And she has studied boundaries. And she feels like everybody sort of has their own style of boundary management that consists of five different things. Where you are with your current level of control. How you handle cross-role interruption. Work interfering with home life and home life interfering with work. How do you prioritize your identity? Do you identify primarily as a physician or do you identify primarily as a father or a mother or a family person? What's your level of dependence on technology? And how much time do you need for yourself just to relax and be sane? And she's created a little mini self-assessment. And I'm sharing this with you mainly so you can organize your thoughts about what type of person you are, which will then help you decide what sort of boundaries you need to set in your life. So those five things, there's a strongly disagree to strongly agree scale. First question on I control whether I'm able to keep my work and personal life separate. Cross-role interruptions. I take care of personal or family needs during work. I work during my personal or family time. The work career family identity. Work centric. I invest a large portion of my time in my work or I invest a large portion of my time in my family. I find time for myself is important to my overall quality of life. And I check my computer or handheld device as soon as I see or hear a new message that has arrived. I'm that person. I don't like that about myself but I am. So you kind of score yourself and there's no right or wrong to any of these. The only one in which a high score is actually important is boundary control. People with good boundary controls feel like they're in control of their work and their life and those who have low boundary controls usually feel overwhelmed, burned out, overworked. Their work and personal life are constantly at odds with each other. They feel their job is inflexible. So she says there's three types of boundary styles. There's the integrator, the one who does have work and life overlap with each other. The separator who needs division between those things and not be interrupted when they're in each section of their day. And there's a kind of combination of the two. So just as an example, the integrator, this is the person who lets, you know, get phone calls from home during the day and when you're at work or when you're at home you're taking some business home with you. If you're an integrator like that and you have high boundary controls, she says you're a fusion lover. You actually enjoy it. You're happy. That sort of stuff doesn't really bother you. But if you have low boundary controls and you're an integrator, she says you're more of a reactor. You feel like you're constantly reacting to things, putting out fires, juggling work and home, and you really wish it were different. That's the person who's going to get burned out and unhappy with their job. And that person would actually prefer to be a separator because that lack of control diminishes their happiness. And then take the opposite. Let's say you are a separator and you have high boundary control. Again, you're probably pretty happy with the way things are going. But if you're a low controller, she says you're captive, that you're rigid. You feel like you can't adapt. You just don't have good crossover enrichment in your family life and your work life. So if you kind of figure out which one of those you think you are, which boundary controller you are and what type of person you are, a separator, a divider, an integrator, it can help you sort of see now where things might not be right in your life. So it can help you decide whether your style is working and do you want to make some changes? Do you want to actually be more of an integrator or do you want to be more of a separator? That sort of thing. And so figure that out if you can. And then how do you set the boundaries? This is kind of those practical pieces of advice I think that we lack sometimes. Understand that it's okay to say no if it doesn't align with your priorities or it doesn't fit in your schedule. Say no. That could mean added on patient care. It could mean committee work, administrative work. Somebody wants to assign you. Now, you know, I will say if you're in clinical practice, you really don't want to say no, you know, to the console. They won't call you again. But you can say things like, oh, wonderful, I'd love to see that patient. I'm going to my kid's soccer game this evening. Would it be okay if I see them tomorrow? And most everybody understands that. They'll say, yeah, yeah, sure, no problem. But that's how you sort of take a little bit of control of that interfering with your life and still manage to separate it out from your home life. So do a boundary audit, okay? This is important. Pay attention to things, to people, situations, or your actions or reactions to things that cause distress. And those things signal you have a crossed boundary and they need to be reset. Maybe it's an employee. You've been assigned a medical assistant who just doesn't sync with you. Maybe they're rude. You're stressed all the time about it. You know, that's a crossed boundary, right? You know, you need to just get a different person. It could be something simpler than that. But if you're feeling stressed about it, that's an area you probably should look at resetting things. So figure out where you want those limits and set boundaries that are reasonable, you know, not too rigid. And little things matter. Like, I remember when my first child, she was young and in grade school, and I was really jealous that I wasn't one of those moms who got to drive carpool and be there at 3 o'clock and go do play dates. I was always working, and I just, I felt resentful. And I had Tuesdays, and my schedule were a little bit light in the afternoons, and I told my office manager, you know, I want to go pick Kelsey up at 3 o'clock on Tuesdays. I'm going to be in that carpool with those moms. And so, she helped me set that boundary, and every time I wanted to break it, she said, Dr. Woods, this is Kelsey's time. You can't do that. I'm going to make that move to whatever extra day. And she held me to it, and it was great. I felt good about it. My daughter enjoyed it, but I think I felt better about it than she did just because I had a boundary, you know. I had taken control of something that was related to my home life, and it made me feel good. So do a time management assessment and track how you're spending your time. You'll find you're probably wasting a lot of time on little things you don't really need to do. So put boundaries on those things. If you can eliminate them, do it. That's, you know, like a committee or something that you're on that you don't find pleasurable. It doesn't have to be something that is going to help you get promoted, but if it's something that you really like, stay with that. But if it's something you don't enjoy and it's not going to get to your end goals, then get rid of it. And then look at the rest of the things. If they can be delegated, delegate, delegate, delegate. Right? You're going to have expendable income when you get into your job, so you can afford to have somebody come and help clean the house, vacuum the carpet, clean the bathrooms. Our deal was, yes, we had somebody come and do that. We were a dual working household. But homework tutor, you know, my first child, she's the one who I learned everything from. She was hard-headed, you know. My day would end and I would come home. We'd have dinner together and then it was homework time. And oh my gosh, it was always a fight with her and me. And one of us inevitably a couple times a week ended up crying or yelling. And we told her teacher and she said, oh that's easy, get a homework tutor. I said, what's a homework tutor? She said, oh, you know, there's these college kids out there. So we found somebody who came twice a week and oh my gosh, our life was so different. She got more responsible about her homework. She didn't really need a tutor. She just needed an adult that was not me, right. And so she was happy and I was happy and the rest of the time we spent at home those evenings was not, you know, being angry at each other. So that was money well spent, we thought. Try to make yourself more efficient. You know, the people that I see staying late at night at their desk are finishing their clinic notes, right. I don't do that. I finish my clinic note in clinic before I see the next patient. I figure out a way, I walk in and I look at the patient and I'm typing what they're saying. I'm looking at them but I'm typing it. And then I walk out and I sit down with the dictaphone and I finish the note, close it and move on to the next patient. So when I'm done with clinic, I am really done. I'm not going back and I may go back and make some phone calls or whatever but I'm not working in that nasty EMR finishing my notes. So figure out a way to make yourself efficient with that. The hospital consults I've already mentioned, find a way if you can so that you're not responsible for those all the time. It's already been talked about getting block time and endoscopy that makes you so much more efficient if you know, you know, you've got four hours every day or three days a week that that's your endo time and you don't let it get interrupted and you're much more efficient doing it that way. So use physical boundaries, you know, turn off your phone or email notifications. If that person who, you know, you hear it go off, you've got to look at it. Our, my employer offers to pay for a cell phone so that a lot of people have their work phone and they have their personal phone and they turn that work phone off when they're home. You know, if you're gonna take work home, that is inevitable. There's times you need to do work at home. Have a separate space if you can so that, you know, you can close the door and say, I'm gonna be in here for two hours, set your time and then come out, close the door, don't look at it again. It's not in the middle of your living space where you're looking at that and feeling guilty about leaving those papers over there. I like checklists. I'm a list maker anyway. When I got ready to leave my two jobs that I left, I made lists about what was the pros and what was the cons. But you do that daily or weekly with your things that you need to do and then delegate again as much as you can and then prioritize that list and it's so easy to do the things that you think are easier on that list first, but if the harder things are the most important things, you've got to force yourself to do those first and get them off the list. So, my boundaries. This is telling you now a little bit about myself. I have moderate boundary controls. I'm a separator. I'm work-centric, tech-dependent, and I need time for myself. You know, I didn't really like myself very much when I read this and I'm like, well, you know, it is what it is. So I also know, and I knew this before I did this little quiz, I know what makes me stressed out. I cannot stand running late. I'm the kind of person, I'm late if I'm not early, right? When I feel trapped, oh, I'm very angry. It could be a bad meeting that's wasting my time and I can't get out. It could be traffic or it could be that patient who's droning on and I'm like, you know, I gotta get out of here and I need to control this conversation and I can't. Those things really irritate me. And then I blame, number one and number two, for number three, not having enough time for my family and myself. So I've tried to structure my day to minimize. You can't avoid them, but I try to minimize them. So I put time buffers into my schedule. So I have blocked time every day for endoscopy. And it's generally from seven in the morning until, it goes till noon, but I try to make my last case at 11 and I start my clinic at one. You know, endo never finishes on time. It may finish at 12.30. But I have 30 minutes in there before clinic starts. I can run up to my office, I can have lunch. Lunch, right, what's lunch? All your employees get lunch. It's mandatory, it's labor laws. They get an hour for lunch. We don't get lunch. If you get it, you get it. If you don't, you don't. And usually when you do get it, it's brownies or cookies or an unhealthy lunch that the drug company brought and you feel kind of lucky that you got something. So I made this pact, and my husband's supportive of this. He packs my lunch at night. I have leftovers from whatever we had for dinner. And it's there. And I run in there and I get it and I have something, whether I have time to eat it all or not, I have something. And it's way healthier than what I might have gotten had I gone into the room where all the drug company food was. In my clinic, I hate to run late for patients. Their time is as valuable as mine. And I don't like to be that doctor that they waited an hour for. So I have a 15 minute cushion between every three patients. So I book every patient new or follow up in 15 minute blocks. So I have 15 minutes at the end of the hour. If I'm running late, I usually catch up. So by the second hour, I'm on time again. That really made a big difference for me. When I was doing hospital work, I had to get out of it. I got a PA. And I told her, your job is to get me home to have dinner with my children by 6 PM. If you make me a profit, great. But if you don't, I need quality of life. I need to be home and I need to be with my kids. And she did that for me. And it was wonderful. And it was an expense that was good for me to use. And she didn't really make me much of a profit. I could have managed her differently. But that's not what I really wanted. I don't take charts home. In the old days, paper charts, I'd wheel a little bag of 10 charts home and wheel it back. And I never opened it. And it was a guilt trip. Every time I walked past it in the kitchen, I'm like, oh, I need to do that. And I never did. So I just stopped doing it. I put a hard stop several days a week to my day. And I do that by scheduling. I love to exercise. That's a big stress reliever for me. And I schedule this class that if I cancel within eight hours of the time of the class, I pay them $15. I'm cheap. I don't want to waste $15. So I say, I'm out of here. Done. There's very few things that really can't wait till tomorrow. A true medical emergency, yeah, that's different. But other stuff, phone calls and things, you can usually get to them the next day. So that's worked well for me. And my family, we always made Sunday sort of our sacred family day. And that was a nice way to kind of recover and get ready for the week. And we all had our meals together and whatnot. And that was really nice for us. So I've mentioned a few of my career choices along the way. I've been practicing for 33 years. I was academic for 10 years. Seven years, I knew I wasn't happy anymore. I didn't like research. I didn't like writing papers. I figured that out. You know, I wanted to be like my attendings when I finished fellowship, right? I really admired them. I'm like, yeah, I want to do what you do. I didn't really like doing what they did. But I love taking care of patients and teaching. So I finally took three more years to make the cut and make the decision. And I moved into private practice where I was very happy for a long time, continued to teach, continued to do society work. But it became too difficult financially to maintain that practice and all the things that happened. And so a group of us went to our hospital where I've been practicing for 30 years, same place. And they wanted to hire us. So we went to work for them seven years ago. We were able to negotiate a pretty good deal. And I made a list of what I needed to keep me happy. And I got it. And it wasn't an extreme list. It was like keeping my employees and having the same number of people working for me, those sorts of things. And I like it. I'm very happy. Grass is always greener on the other side. There's things that I'm not that happy about. But I'm pretty good with where I am right now. So other pearls I've learned in closing out, you can't make everybody happy. And not everyone is going to like you. And that's particularly as it relates to patients. Now, if nobody likes you, that's your problem. But if only a few patients are unhappy, you can't make everybody happy. There's just unhappy people out there. And they don't like anybody. And you may be the fifth gastroenterologist they've seen. And you're probably not. One of my senior partners a long time ago, she told me, when I see that patient and they're complaining about their other doctors as him and him, and they were terrible, she said, I just look at them. And I go, in my experience, it's only a matter of time before you're talking that way about me. And I said, man, that's bold. But it's true. There's just people you can't make happy. So learn to accept it. Don't fester about it and move on. Workplace interactions and reactions are not necessarily related to you, often related to what's going on in that other person's life. So a crabby tech or nurse, it's probably not really you. I mean, maybe it is. But it's probably not. And you just kind of accept it. If you know them well enough, maybe you talk to them about it. Otherwise, don't engage. Scheduled vacations, so nice. You have something to look forward to. I kind of, in the early days, maybe twice a year now, I try to go way more often. But it's really nice to know I have something to look forward to. Exercise or hobbies, something that you can be passionate about, that takes your mind off work, very important to have those just to kind of keep you sane. So closing with my life rules, you always have choices. I said that yesterday. You're a doctor. You can go anywhere you want. No career decision is final. You could be in academics. You could be private practice. You could be private practice and go to academics. It's all happened before. And so no decision on the career is final. And neither is a relationship or a marriage. If you're really, really unhappy, you can make changes. But you have to make that decision and be bold enough to do it. Patience and job demands will take as much time as you give them. And they will ask for more. So no one will make boundaries for you except you. And you get what you tolerate. If you let it happen, it's kind of your fault. So you need to make some boundaries to make that controllable for you. Your kids are only young once. Let them remember that you were there for them and set reasonable boundaries that you can follow and that they understand. Once you set boundaries, it's amazing. The world will still go on. Patients will still love you. And you will feel more in control and happier. I remember the first time I decided to take two weeks off. Whoa, I've never done this. And I went away to the Maldives on a dive boat. No internet, no Wi-Fi, nothing. It was the best vacation ever. And I came back, and I was so worried about my practice. And I walked in, and it was all the same. Nobody died. Everybody was still happy. And I was happier. So I realized things still go on. It's not all about you all the time. So I like that. So if something is making you unhappy, analyze it. Find out what you can fix and try to do that. Accept what you can't. And move on and just tolerate it if you can, or delete it from your life. And I mean delete it. I mean quit that job or do something totally different. Take the opposite direction. I try not to fester, because I'm a festerer. If I can't solve the problem, I'm constantly thinking about it. So I figured out that I just need to cut the cord if I need to. So life is good. Make the most of it. Enjoy your family. Remember to cut the world off when you go home and focus on them. Focus on your relationship. Love your partner. Tell them you love them. It's all, it makes life so much better. And have a hobby or exercise or do things that really make you happy. So closing, Stephen Covey's quote. I really like this. The key is not to prioritize what's on your schedule, although you do need to do that somewhat, but to schedule your priorities. So thank you. I hope that helps you at some point in the future. Thank you.

work-life integration

wellness

burnout

physician wellness

work hours

time management