다섯 명 중 한 명이 번아웃된다면, 나머지 네 명은? 의사들의 회복탄력성 전략(Acad Med, 2013)

다섯 명 중 한 명이 번아웃된다면, 나머지 네 명은? 의사들의 회복탄력성 전략(Acad Med, 2013)

If Every Fifth Physician Is Affected by Burnout, What About the Other Four? Resilience Strategies of Experienced

Physicians

Julika Zwack, PhD, and Jochen Schweitzer, PhD

의사의 건강 문제는 의사뿐 아니라 환자에게도 중요합니다. 정신 건강은 전반적인 건강의 중요한 구성 요소이며 조사 결과 약 15 %에서 20 %의 의사가 직장 생활의 어느 시점에서 정신 건강에 문제가 있음을 보여줍니다.

Physicians’ health matters, not only to the physicians themselves but also to their patients. Mental health is an important component of overall health, and research shows that approximately 15% to 20% of physicians will have mental health problems at some point in their careers.1–3

코헨 (Cohen) 등의 조사에 따르면 1,999 명의 레지던트 중 3 분의 1이 자신의 삶을 '어느정도'에서 '극히'스트레스가 많은 것으로보고했다.

In a survey by Cohen and colleagues,6 one- third of 1,999 residents reported their life as “quite a bit” to “extremely” stressful.

의대생의 심리적 곤란 (우울증, 불안, 소진 및 정신 건강 문제)에 관한 40 개의 연구를 검토 한 결과, Dyrbye와 동료들은 일반 인구와 비교하여 후기의 훈련 과정에서 의대생의 우울증과 불안감을 지속적으로 확인했습니다.

In their review of 40 studies on psychological distress in medical students (depression, anxiety, burnout, and related mental health problems), Dyrbye and colleagues7 consistently identified a greater degree of depression and anxiety in medical students in the later years of training compared with the nonstudent (general) population.

비슷하게, Goebert와 동료 8)는 2,000 명의 의대생과 레지던트들에서 주요 우울증에 대한 유병율을 12 %, 경도 / 중등도 우울증에 대해서는 9.2 %를 발견했다.

Similarly, Goebert and colleagues8 found prevalence rates of 12% for major depression and 9.2% for mild/moderate depression in 2,000 medical students and residents.

의사의 distress에 관한 이러한 놀라운 데이터는 예방의 필요성에 대한 인식을 촉진 시켰습니다. 일반적인 예방 전략 중 하나는, 의사 그룹이 정기적으로 만나서 의사와 환자의 관계를 더 잘 이해할 수있는 임상 사례를 제시하는 전통적인 Balint 그룹 모델 (헝가리 정신 분석 학자 Michael Balint의 이름을 딴 것)입니다. 두 가지 추가적인 개념적 접근법이 널리 사용되는 것으로 보인다 :

• (1) mindfulness 기반 스트레스 감소: 순간 순간의 감각, 경험 및 반응에 대한 nonjudgmental한 인식을 통한 이완을 촉진하는 명상 기술에 초점을 맞춘 훈련 프로그램

• (2) 인지 행동 스트레스 예방: 스트레스 반응의 신체 및인지 구성 요소에 관한 정신-교육에 초점, 진행성 근육 이완과 같은 이완 기술 및 인지 적 개입 (예 : 비합리적이고 부정적인 생각에 도전).

• Mindfulness에 기반한 스트레스 감소는 distress, 반추 및 부정적인 감정을 줄이고 공감력을 향상시키는 데 종종 효과적이라는 것이 입증되었습니다 .11,12

• 인지 행동적 접근법은 직업 관련 고민과 전반적인 행복에 대해 유사한 유의미한 효과를보고했다 .13,14

These alarming data on physician distress have fostered awareness for the necessity of prevention. One common preventive strategy is the traditional Balint group model (named for Hungarian psychoanalyst Michael Balint) in which a group of physicians meet regularly and present clinical cases to better understand the physician– patient relationship. Two additional conceptual approaches seem to prevail: 

• (1) mindfulness-based stress reduction, a training program focusing on meditation techniques that promote relaxation through the nonjudgmental awareness of moment-to-moment sensations, experiences, and reactions, and 

• (2) cognitive behavioral stress prevention with a focus on psycho-education about physical and cognitive components of the stress reaction, relaxation techniques such as progressive muscle relaxation, and cognitive interventions (e.g., challenging irrational and negative thoughts). 

• Mindfulness-based stress reduction has frequently proved effective for reducing distress, rumination, and negative feelings and enhancing the capacity for empathy.11,12 

• Cognitive behavioral approaches reported a similarly significant effect on job-related distress and general well-being.13,14

Jensen과 동료 연구원은 의사의 회복탄력성의 네 가지 주요 측면을 확인했습니다.

• (1) 태도와 시각: 의사의 역할 평가, 관심 유지, 자기 인식 개발, 개인의 한계 수용

• (2) 균형과 우선 순위 설정: 한계 설정, 지속적인 전문 개발에 대한 효과적인 접근법 채택, 자아 존중,

• (3) 진료 관리 스타일: 건전한 경영 관리, 우수한 인력 확보, 효과적인 실천 계획 사용 등

• (4) 지지 적 관계: 긍정적 인 개인 관계, 효과적인 전문직 관계 및 좋은 의사 소통.

Jensen and colleagues,15 identified four main aspects of physician resilience: 

• (1) attitudes and perspectives, which include valuing the physician role, maintaining interest, developing self-awareness, and accepting personal limitations,

• (2) balance and prioritization, which include setting limits, taking effective approaches to continuing professional development, and honoring the self, 

• (3) practice management style, which includes sound business management, having good staff, and using effective practice arrangements, and 

• (4) supportive relations, which include positive personal relationships, effective professional relationships, and good communication.

스티븐슨 (Stevenson)과 동료들은 회복탄력적인 의사들은 작은 gain을 인식하고 축하하며 근무 시간을 통제 할 수있는 능력을 보여 준다는 것을 밝혔다. Keeton과 동료의 횡단면 조사는 후자를 확인합니다. 일정과 근무 시간에 대한 일정한 통제를 가짐으로써 일과 삶의 균형과 소진에 대한 가장 강력한 예측 인자가되었습니다.

Stevenson and colleagues17 demonstrated that resilient physicians recognize and celebrate small gains and show the ability to control their working hours.17 The cross-sectional survey of Keeton and colleagues19 confirms the latter: Having some control over schedule and hours worked was the strongest predictor of work–life balance and burnout.

방법

Method

The research team consisted of the two authors, five medical students, and one postgraduate psychologist. 

To ensure homogeneity of interviewing, 

• each member of the research team first accompanied the first author (J.Z.) for three interviews. 

• Then, each team member conducted three individual interviews, which were supervised post hoc using the audio tapes. 

• Once team members had completed this process, they conducted their remaining interviews without additional supervision. 

Altogether, the research team conducted 200 semistructured interviews with residents (employed junior physicians working on hospital wards), assistant medical directors, and registered doctors (self-employed physicians in the ambulant field).

참여자 모집

Recruitment of participants

Recruiting followed a pyramid approach. Because motivation to share personal insights and experiences represented the key precondition for participation in the study, we used a convenience sample but made sure to integrate a broad range of specialties, ages, hierarchical status, and settings. 

• We started recruiting at the University Hospital Heidelberg by contacting physicians of different disciplines and hierarchical status (residents, assistant medical directors, and registered doctors) known by members of the research team. 

• We further contacted self-employed physicians by information letters followed by phone calls. Contact information for these physicians was obtained from the telephone book. During the research process, we extended our regional focus to eight other cities all over Germany. 

• At the end of each interview, we asked for a recommendation of a colleague (“Do you know someone who could be interested in sharing his or her experiences and insights with us?”). 

Following this snowball approach, we managed to recruit a diversified pool of interview participants.

First, we conducted 83 interviews across 21 disciplines. Unexpectedly, reported resilience strategies differed little across specialties. To find out whether this was due to the low numbers of participants per specialty, we decided to focus further data collection on three specialties, whose professional day-to-day routines differed substantially. Thus, in a second phase we conducted interviews with 117 physicians working as psychiatrists, surgeons, and general practitioners. To work out potential differences, we explicitly asked for specialty-specific stressors and coping strategies within each discipline.

자료 수집

Data collection

For screening purposes, all physicians completed a German-language paper version of the Maslach Burnout Inventory (MBI) at the beginning of the qualitative interview. The MBI assesses the frequency of symptoms referring to three subdimensions (

• Emotional Exhaustion, 

• Depersonalization, 

• Personal Accomplishment) on 

a six-point scale: 1 = “never,” 2 = “seldom,” 3 = “sometimes,” 4 = “often,” 5 = “frequent,” and 6 = “very often.”20,21 

Filling in the 22 items takes about five minutes. Whereas for Emotional Exhaustion and Depersonalization, higher scores indicate higher levels of burnout, Personal Accomplishment is reverse- scored, with high scores indicating more personal efficacy.

The field manual (see Appendix 1) was developed by J.Z. and focuses on the main research question: 

• Which strategies do you apply to deal with the stressors of your professional life? 

The field manual was developed and communicatively validated through 10 trial interviews conducted between October and December 2009. 

Each interview closed with a summary by the interviewer and two questions: 

• “Are these the most important resilience strategies in your professional life?” and 

• “Is there anything else we should have asked?”

The recruiting and data collection period extended from January 2010 to March 2011. To activate a broad range of resilience strategies, interviewers framed the main research question from different perspectives (e.g., strategies found with colleagues, advice one would give to a medical student). Interviewers encouraged participants to give examples for all strategies reported. The average interview duration was 42 minutes (range = 18 minutes to 2:08 hours; standard deviation = 19 minutes). All interviews were audio-taped and transcribed in their entirety and analyzed in accordance with the Content Analysis method.22,23

자료 분석

Analysis of the data

Preliminary data analysis followed categories derived from the main research questions. To restrict distortions due to social desirability, we only coded mental as well as behavioral strategies that could be illustrated (“the way I do this …”). We differentiated between 

• “general sources of gratification,” 

• “behavioral routines and practices,” and 

• useful “attitudes and mental strategies.” 

Building on these core dimensions, we inductively educed subcategories. 

• For this purpose, we first grouped interview statements according to the three core dimensions. 

• Second, we identified and marked key themes within each dimension. 

• Building on these key themes, we developed a preliminary system of subcategories. 

• All interview statements were assigned to this category system. 

To ensure a high reliability of assignments, we conducted trials by four independent coders and worked over category definitions until we reached an average accordance of at least 80%. For 10% of the data (20 interview records), two independent coders tested category reliability with Cohen kappa ranging from 0.74 to 0.91.

결과

Results

Participant characteristics are summarized in Table 1.

직무에서 오는 만족

Job-related sources of gratification

의사와 환자의 관계에서 만족. 즉각적인 의사 - 환자 관계에서의 효능 경험은 전문적인 활동의 중요한 측면을 나타냅니다.

Gratification from the doctor–patient relationship. Experiences of efficacy in the immediate doctor–patient relationship represented a crucial aspect of professional activity.

마지막으로, 참가자들은 환자와의 만남이 자기 성찰을 위한 기회를 제공한다고 설명했다. 환자를 거울로 보았을 때, 의사의 문제는보다 명확하게 인식 될 수 있었고 동시에 관점으로 옮겨 질 수있었습니다.

Finally, participants’ comments illustrated that encounters with patients deliver occasions for self-reflection. With the patient as a mirror, the physician’s own problems could be more clearly perceived and at the same time put into perspective.

치료 효과로부터의 만족. 의미있는 전문적 활동 경험은 전형적으로 증상의 전후 비교에 의해 형성되었다. 의사들은 복잡한 진단 문제를 전문적인 능력을 향상시키는 데 도움이되는 지적 도전 과제로 간주했습니다.

Gratification from medical efficacy. The experience of meaningful professional activity was typically conditioned by symptom-related before-and-after comparisons. The responding physicians considered complex diagnostic issues as intellectual challenges that helped them to enhance their professional stature.

회복탄력적 실천

Resilience practices

스트레스를 줄이는 여가 활동. 참가자들은 일반적으로 스트레스 해소를 위해 여가 활동을 사용했으나 면밀한 조사 결과 이러한 활동이 여러 가지 기능을 수행함을 나타냅니다. 스포츠 활동은 대부분 긴장을 완화시키는 즉각적인 방법이었습니다.

Leisure-time activity to reduce stress. Participants used leisure activities in general to relieve stress, but closer inspection indicates that these activities fulfill a number of different functions. Sporting activity was mostly an immediate way of reducing tension

일부 응답자의 경우 보상 활동은 단순한 취미 이상이었다. 이 개인들은 오랜시간을 들인 비전문 분야가 "나를 서있게 하는 두 번째 다리"(부인과 의사, 53)를 제공했으며 종종 상당한 시간의 자원을 투자해야한다고 주장했습니다.

For some respondents, compensatory activity transcended the limits of a merehobby. These individuals reported that long-time nonprofessional fields of interest provided a “second leg to stand on” (gynecologist, 53) and frequently called for the investment of substantial time resources. 

보상 활동은 참여자들의 내적 자유에 대한 느낌에 많은 기여를했습니다. 응답자들은 취미를 할 시간이있을 때 단순히 취미를 추구하지 않았습니다. 오히려 그들은 자신에게 중요한 취미 생활을 하는데 필요한 시간을 찾아야했습니다.

Through the experiences of success that they enabled, compensatory activities contributed much to participants’ feelings of inner freedom. Respondents did not simply pursue hobbies when they had time to do so. Rather, they made sure to find the time they needed to pursue the hobbies that were important to them.

동료와의 접촉 및 탐구. 동료와의 견해와 경험의 교환은 professional insecurity 감소의 핵심 자원이었습니다.

Quest for and cultivation of contact with colleagues. The exchange of views and experiences with colleagues was the central resource for reduction of professional insecurity.

동료로부터의 피드백은 일상적인 수준에서 전문 지식과 전문 지식을 향상시키는 동기와 원천으로 간주되었습니다. 동료와의 교류는 어려운 환자 및 복잡한 의학 문제를 다루는 데 있어서의 자신의 잘못과 부적절함에서 유래한 감정적 압력을 감소시키는 직접적인 방법으로 사용되었습니다.

Feedback from colleagues was also seen as a source of, and an incentive for, enhanced professional knowledge and expertise at the routine level. Exchanges with colleagues served as a direct way of reducing emotional pressure caused by participants’ own fallibility and inadequacies in dealing with difficult patients and complex medical issues.

가족과 친구들과의 관계 증식. 신뢰할 수있는 가족 관계와 우정은 안정과 이해의 오아시스가되었습니다. 그들은 초점의 변화를 통해 이완을 제공했고 여러가지 것들을 하나의 관점으로 모으는데 유익했습니다.

Cultivation of relations with family and friends. Reliable family relations and friendships represented an oasis of stability and understanding. They provided relaxation through a change of focus and were beneficial for putting things in perspective.

의사는 필요할 때 자신을 현실로 돌아오게 만들어 줄 수 있는 사람들과 관계를 맺는 것이 도움이된다는 것을 발견했습니다.

Physicians also found it helpful to have relationships with people who are prepared to bring them “down to earth” when necessary.

자기 과대 평가와 자신감 부족 사이의 올바른 균형을 찾는 것이 중요합니다. 처참한 행동을 시작할 때 알려줄 환경(가족과 친구들)이 필요합니다. 제 아내는 제 가장 비판적입니다 (일반 개업의, 59).

It’s important to find the right balance between self-overestimation and a lack of self-confidence. You need an environment of family and friends who will tell you when you start behaving badly. My wife is my severest critic (general practitioner, 59).

기술, 합병증 및 치료 오류의 한계에 적극적 대처.  진행 방법에 대한 불확실성에 직면하여, 오류가 있다는 것을 숨기려하지 말 것을 권장했습니다.

Proactive engagement with the limits of skills, complications, and treatment errors. Participants recommended owning up to uncertainties about how to proceed and not trying to conceal errors one has committed.

참가자들은 의사가 불확실성과 합병증을 공개적, 적극적으로 의사소통하는 데 익숙해져야 하며, 그리함으로써 감정적, 전문적 보안emotional and professional security을 강화할 수 있다고 하였다. 또한, 그러한 문제를 솔직하게 해결함으로써 자신의 실수로부터 배운 느낌이나 환자 안전을 향상시키는 느낌은 많은 의사들이 부작용 발생 후 더 쉽게 나아갈 수 있게 만들었습니다. 또한 이러한 느낌은 자신이 부분적 또는 전적으로 책임이 있는 어떤 합병증이나 사고에 대해서 무의미할정도로 지나친 고뇌를 하지 않게 해주었다.

Participants’ comments supported that physicians accustomed to communicating uncertainties and complications openly and proactively enhance both their emotional and professional security by doing so. Also, the feeling of having learned from one’s mistakes or enhancing patient security by frankly addressing such problems made it easier for many physicians to move on after an adverse event and not to agonize fruitlessly over any complications and mishaps for which they were partly or entirely to blame.

개인적 성찰. 의식적으로 그리고 정기적으로 개인의 상황을 전체적으로 성찰하기 위해 시간을내어 다른 건강 증진 전략을 사용했다.

Personal reflection. Consciously and regularly taking time out to reflect on one’s personal situation in its entirety was another health-promoting strategy.

자기-경계 명확화. 자신과 환자 간의 명확한 경계를 유지하고 동료와 동료 간의 명확한 경계를 이끌어내는 능력은 많은 응답자들에 의해 필수적인 것으로 간주되었습니다. 이러한 분계선은 

• 전문적일 수도 (예 : "전문적으로 무엇을지지합니까? 나는 무엇을 거부합니까?"), 

• 시간적일 수도  (예 : "나는 항상 사용 가능하지 않습니다") 

• 개인적일 수도 (예: 나는 누구에게 동의하거나 동의하지 않습니까? ").  있다.

Self-demarcation. Physicians’ ability to maintain clearly defined boundaries between themselves and their patients and to draw a clear line between themselves and their colleagues/superiors was considered essential by many respondents. These lines of demarcation could be 

• professional (e.g., “What do I stand for professionally and what do I reject?”), 

• temporal (e.g., “I refuse to be available at all times”), or 

• personal (e.g., “Who do I agree to associate with and who not?”). 

환자 - 의사 관계에서 proximity and distance의 의식적인 관리는 예방적이었며, 다양한 방법으로 안도감을 주었다. 치유 전망과 도움 제공에 대한 비현실적인 기대에 공모collude하지 않음으로써 환자의 실망과 비난을 예방할 수있었습니다. 또한 individual professional standards에 대한 loyalty에 대해서도 conscious demarcation line을 이끌어 냈습니다.

The conscious management of proximity and distance in the patient– doctor relationship was prophylactic and relieving in various ways. Refusal to collude with unrealistic expectations about healing prospects and the provision of assistance prevented disappointments and accusations from the patient. Participants also drew conscious demarcation lines out of loyalty to individual professional standards.

신뢰할 수있는 경계 체계는 회복탄력적이고 장기간의 의사 - 환자 관계를위한 기본 전제 조건 중 하나로 나타났는데, 이는 "경계가 환멸보다 낫다"라는 motto와 부합한다.

reliable demarcation mechanisms emerged as one of the basic prerequisites for resilient, long-term doctor–patient relationships, in accordance with the motto “demarcation is better than disillusion.”

경계를 침범하는 환자를 다룰 때, 참가자들은 관찰자 위치를 가정하고, inner detachment가 되어 상황을 관찰 할 것을 권장했다.

When dealing with boundary-violating patients, participants recommended assuming an observer position and looking at the situation with inner detachment:

자신의 전문성을 함양. 지속적인 교육, 의학 문학 독서, 또는 품질 서클에 참석하는 것은 전문적인 효능을 보장하는 데 결정적인 역할을했습니다.

Cultivation of one’s own professionalism. Continuing education, reading medical literature, or attending quality circles played a decisive role in the assurance of professional efficacy.

자기 조직화. 자기 조직화의 주요 특징은 관료업무와 정규 잡무를 다루기위한 [개별 루틴]과 [시간 구조]의 생성이었습니다. 두 가지 방법 모두 무의미한 작업 반복과 여분 작업으로 인한 고갈감을 줄여 주관적인 효율성 경험에 긍정적 인 영향을주었습니다. 자기 조직화는 또한 활동의 ​​체계적인 위임과 우선 순위 설정 능력을 포함했다.

Self-organization. The primary features of self-organization were the creation of individual routines and of time structures for dealing with bureaucracy and regular chores. Both reduced the feeling of depletion caused by pointless repetition of tasks and extra work and had a positive effect on the subjective experience of efficiency. Self-organization also involved systematic delegation of activities and the ability to set priorities.

우선 순위의 내부 목록은 ... 나를 위해 매우 중요합니다. 그것은 필수적이며 자기 보존을위한 도구입니다. 그렇지 않으면 진정으로 시급한 일이나 다른 사람들이 긴급한 일을하도록 요청 받으면,

An internal list of priorities … is very important for me. It’s an instrument for identifying what’s essential and also for self-preservation. Otherwise, if I am asked to do things that are either genuinely urgent or are described as urgent by others,

근무 시간의 제한. 시간표 준수는 중기적으로 환자와 고용주 모두에게 이익이되는 자가 관리의 필수적인 요소로 간주되었습니다. 근무시간을 제한하는 전제 조건은 자기 자신이 꼭 있어야 한다는 생각을 극복하고 결단resolution을 의식적으로 만드는formulation 것이다.

Limitation of working hours. Adherence to a time table was regarded as an essential feature of self-care that in the medium term benefits both patients and employers. The prerequisites for limitation of this kind were overcoming the belief in one’s own indispensability and conscious formulation of resolutions.

여가 시간을 중요한 근무 시간처럼 계획하고 정리해야합니다. 그렇지 않으면 모든 것이 무너집니다.

I have to plan and organize my leisure time as if it were important working time, otherwise the whole thing collapses.

Ritualized 타임 아웃 기간. 일일, 주간, 또는 연례로 단단히 확립 된 타임 아웃 루틴은 관련 결정 및 정당화로부터의 압박감에서 해방시켜주는 기간이었다 (예 : "어떤 상황에서 환자를 기다리게해도 괜찮습니까?" 할 일이 너무 많은데 휴가를 가도 될까?")

Ritualized time-out periods. Firmly established time-out routines on a daily, weekly, or annual basis took some of the pressure out of related decisions and justifications (e.g., “Under what circumstances is it okay to keep patients waiting?” “Can I really go on vacation when there’s so much to be done?”).

영적 관행. 마지막으로, 많은 참가자 (특히 정신과 의사)는 영적인 관행이나 정기적 인 명상에서지지와 재생을 얻었 음을 지적했습니다.

Spiritual practices. Finally, many participants (particularly psychiatrists) indicated that they obtained support and regeneration from spiritual practices or regular meditation.

유용한 태도

Useful attitudes

수용과 사실주의. 회복탄력성 증진 태도 가운데서 가장 중요한 것은 희망찬 생각을 자제하고 외부 현실을 받아들이는 능력이었다.

Acceptance and realism. Chief among resilience-promoting attitudes was the ability to refrain from wishful thinking and to accept external realities.

실제로 도움이되는 것은 핵심 활동에 초점을 맞추고, [우리의 업무가 의료 솔루션을 운영하고 찾는 것과 관련]이있을뿐만 아니라 [많은 서류 작업이 필요]하다는 사실을 받아들이는 것입니다.

What really helps is to focus on your core activity and to accept the fact that our job doesn’t only have to do with operating and looking for medical solutions but also involves a great deal of paperwork.

자기 인식과 성찰. 모든 분야에서 개인의 스키마와 삶의 역사에 뿌리를 인식하고 삶의 경험을 평가할 수있는 능력이 중요한 요소였습니다. 이 의사들의 삶에서 중요한 사건들은 종종 반성과 자기 인식을 불러 일으켰습니다 (예 : "내가 어떻게 했었지?" "그렇게 하는 것이 맞았나?"). 그리고 개인적인 자기 관리에서 전환점이되었습니다.

Self-awareness and reflexivity. For all disciplines, awareness of personal schemas and their roots in one’s life history, as well as the ability to evaluate life experience, were significant factors. Frequently, crucial events in the lives of these physicians had prompted reflection and self-recognition (e.g., “How do I function?” “Does it have to be that way?”) and had become turning points in personal self-care.

의료계의 문제에 적극적 개입. 참가자들은 현실적인 문제 해결의 중요성, 특히 자신을 희생자로 삼는 것에 대한 명백한 거부를 강조했다.

Active engagement with the downside(s) of the medical profession. Participants noted the importance of addressing challenges realistically, especially the express rejection of regarding oneself as a victim.

변화가 필요한 시기를 인식. 근무지나 위치를 바꿀 수 있는 내부의 자유와 유연성은 특히 변화가 없을 때 견딜 수없는 영구적 인 스트레스에 직면했을 때 또 다른 중요한 태도였습니다. 특히 젊은 의사들은 쇠약하거나 불만족스러운 첫 번째 직업에 너무 오래 머무르면 전문적인 자신감이 생기지 않는다고 지적했습니다. 그들은 그러한 경우 적절한시기에 조치를 취함으로써 의사를 추적 할 수 있다고 언급했다.

Recognizing when change is necessary. The inner freedom and flexibility to change one’s professional location or position, especially in the face of intolerable permanent stress with no prospects of change, was another important attitude. Notably, younger physicians indicated that staying too long in a debilitating or unsatisfactory first job hinders the development of professional self-confidence. They noted that, in such cases, a move at the right time can put a physician back on track.

좋은 일들에 대한 감사. 이 전략은 일상 생활에서 일어나는 긍정적 인 사건을 인식하고 그것을 당연한 것으로 생각하지 않는 능력을 나타냅니다.

Appreciating the good things. This strategy referred to the ability to perceive positive events that occur in everyday professional life and not to take them for granted.

고찰

Discussion

간단히 말해서, 우리의 연구 결과는 문제의 스트레스 요인이 까다로운 환자든, 과도한 서류 작업이든, 시간 압박이든, 사회적 자원과 관심 분야의 well-diversified pool은 현실적인 기대와 좋은 자기 지식과 더불어 지속 가능한 대처를 지원할 것입니다.

Put briefly, our findings suggest that whether the stressor in question is a demanding patient, excessive paperwork, or time pressures, a well- diversified pool of social resources and fields of interest, together with realistic expectancies and good self-knowledge, will support sustainable coping.

자원 풀링과 스트레스 저항 사이의 순환 과정은 자원 이론 보존 (Conservation of Resources Theory) 25에 잘 설명되어있다. 이 이론에서, 번 아웃은 지속적인 (보통은 낮은 수준에 머무는) 자원의 고갈에 의해서 발생하며, 이러한 자원의 고갈은 상당한 자원을 투자한 이후, 자원의 실제 손실 또는 신선한 자원 확보 실패로 인해 생긴다. 역설적이게도 자원 손실은 에너지 절약 조치의 결과이기도합니다. 육체적 및 정신적 탈진은 종종 사회적 철수, 육체 활동 또는 정신 및 행동 습관에 집착하는 결과를 낳습니다. "배터리 충전"을 의도했지만, 오히려 예상되는 결과는 "방전"되는 기분이다.

This circular process between resource pooling and stress resistance is well described in the Conservation of Resources Theory.25 In this theory, burnout is a continuous process caused by ongoing, usually low-level, resource depletion resulting from either actual loss of resources or the failure to acquire fresh resources after significant resource investment. Paradoxically, resource loss is also a consequence of energy-saving measures. Both physical and emotional exhaustion frequently lead to social withdrawal, physical inactivity, or adherence to mental and behavioral routines. Though intended as a way of “recharging the batteries,” the likely consequence is a feeling of being drained.

프로그램은 긴장, 퇴각, 그리고 자원 풀 축소로 인한 부정적 방어나선defensive negative spirals에 대해 의사를 민감하게해야합니다 .26 휴식 기술 및 스트레스 관련 대처 전략 외에도, 의사는 어떤 사회, 신체, 정신적 자원을 실제로 사용할 수 있는지를 성찰하는 법을 배워야 한다.

Programs should sensitize physicians to defensive negative spirals resulting from strain, retreat, and a shrinking resource pool.26 In addition to relaxation techniques and stress-related coping strategies, physicians should learn to reflect on the extent to which social, physical, and mental resources are actually available.

예방의 다음 단계에서는 긍정적 자원 나선positive resource spirals의 논리를 사용할 수 있습니다. 시간이 부족하다는 것을 인식했음에도 불구하고, 방치된 자원에 재투자하는 데 시간을 할애하는 의사는 웰빙과 전문적인 효능에 긍정적인 영향을 직접 관찰하도록 격려받아야 한다. 우리의 연구에서 알 수 있듯이, 다양한 리소스 환경은 [정서 중심의 대처 전략과는 반대로] 문제 지향적 대처 전략에 대한 effective and discriminating 결정을 용이하게합니다.

In the next stage of prevention, the logic of positive resource spirals can be used: Physicians who take the time to reinvest in neglected resources in spite of perceived lack of time can be encouraged to observe the positive effects on well-being and professional efficacy. As our study demonstrates, a diversified resource landscape facilitates effective and discriminating decisions about problem- oriented, as opposed to emotion- centered, coping strategies.

Conclusions

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Acad Med. 2013 Mar;88(3):382-9. doi: 10.1097/ACM.0b013e318281696b.

If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians.

Zwack J1, Schweitzer J.

Author information

1

Organizational Psychology in Medicine Section, Department of Medical Psychology, Heidelberg University Hospital, Heidelberg, Germany. julika.zwack@med.uni-heidelberg.de

Abstract

PURPOSE:

To identify health-promoting strategies employed by experienced physicians in order to define prototypical resilience processes and key aspects of resilience-fostering preventive actions.

METHOD:

From January 2010 to March 2011, the authors conducted 200 semistructured interviews with physicians of different ages, disciplines, and hierarchical status from across Germany. The interview transcripts were analyzed according to the Content Analysis method.

RESULTS:

Analysis revealed 30 subcodes in three dimensions: (1) job-related gratifications derived from treatment interactions, (2) practices, such as leisure-time activities, self-demarcation, limitation of working hours, and continuous professional development, and (3) attitudes, such as acceptance of professional and personal boundaries, a focus on positive aspects of work, and personal reflexivity.

CONCLUSIONS:

The reported strategies and attitudes helped to develop mental, physical, and social resource pools that fostered effective decision making. Successful coping, in turn, encouraged the maintenance of resilience-promoting abilities. In relation to Conservation of Resources Theory, physician resilience emerged as the ability to invest personal resources in a way that initiates positive resource spirals in spite of stressful working conditions. Enriching traditional stress management approaches with the dynamic of positive as well as negative resource spirals would thus appear to be a promising approach.

Comment in

• Physician resilience: what it means, why it matters, and how to promote it. [Acad Med. 2013]

PMID:

 

23348093

 

DOI:

 

10.1097/ACM.0b013e318281696b