Abstract
Background:
Balancing the personal and the professional is an ongoing struggle for most professionals, and palliative care clinicians are no exception. A sustained lack of balance can lead to feelings of frustration, inadequacy, and guilt. Palliative care physicians may find this balance particularly difficult due to the nature of their work: caring for patients and families who are often suffering and in crisis.
Discussion:
In this article, we describe challenges to work-life balancing and strategies that may promote balance, including “timeshifting,” goal setting, cognitive reframing, and self-care. We argue that the search for balance is a lifelong endeavor that entails self-reflection and continuing examination of one's values and goals.
I do know how to pay attention, how to fall down into the grass, how to kneel down in the grass, how to be idle and blessed, how to stroll through the fields, which is what I have been doing all day. Tell me, what else should I have done? Doesn't everything die at last, and too soon? Tell me, what is it you plan to do with your one wild and precious life?
Introduction
Challenges to Work-Life Balancing
Finding a good definition of work-life balance is challenging. Hill and colleagues define work-family balance, one type of work-life balance, as “the degree to which an individual is able to simultaneously balance the temporal, emotional, and behavioral demands of both paid work and family responsibilities.” 1 Work-life balance can be defined more broadly as maintaining an overall sense of harmony in life. 2
Work-life balance is an issue for the majority of Americans. However, the issue seems to be particularly pressing for parents. A recent report from the Center for American Progress and the UC Hastings College of the Law found that 90% of U.S. mothers and 95% of U.S. fathers report work-family conflict. Seventy percent of American children live in households where all adults are employed and nearly 25% of Americans care for elders. Federal policy does not provide specific supports for working parents; the United States lags behind the 30 industrialized democracies in the Organization for Economic Co-operation and Development in its support of working families. 3
As women have entered the professional workforce in greater numbers, many clinicians are members of two-earner families; some are single parents. Working men and women with children often feel caught between work and family demands, especially when children are young. Women physicians often train and enter practice or academia during their peak reproductive years. Men and women are combining early career with parenting, a combination with potentially significant effects on the health and stress level of parents and the family unit.3,4 Negative consequences for working parents can involve withdrawal from family interaction, increased conflict in relationships, less knowledge of children's experiences, shorter periods of breastfeeding for full-time mothers, depression, greater likelihood to misuse alcohol, and overall decrease in quality of life. Negative consequences at work may include psychological stress from distressed family units, decreased job satisfaction, greater likelihood of leaving the organization, and increased absenteeism. 3
There are many challenges to work-life balance particular to physicians' lives. In medicine, people's lives and well-being hang in the balance. Patients need to be seen in real time in the office or hospital and hospitalized patients need to be cared for around the clock. Palliative care providers are often hospital-based and need to consider issues of patient continuity in the often short periods they are working with patients and families, where relationship building and rapport are crucial. Physicians, like many other professionals, are often expected to work 50 or more hours per week. Clinicians in academic medicine and private practice have particularly long work weeks. Although part-time work is an option, clinicians rightly worry that a reduction in hours could affect short-term career success.5,6 Linzer at al. write that departments of internal medicine have been reluctant to “embrace part-time careers.” 7 Barriers to part-time work include “negative perceptions about part-time individuals' work ethic and commitment to medicine, lower rates of promotion and tenure, less effective mentoring, and less research support compared with full-time physicians.” 8
The structure of academic medicine makes part-time work difficult. Not all institutions offer slowed down tenure clocks for part-time faculty. For those on the research track, most career development awards do not allow less than 50% effort and require special permission for less than 75% effort. The Association of Specialty Professors task force has produced a consensus statement and a series of recommendations, including allowing flexible time as well as part-time work; countering negative perceptions about part-time faculty; developing policies to allow flexibility in academic advancement; considering part-time faculty as candidates for leadership positions; and encouraging granting agencies to consider part-time faculty eligible for career development awards. 9
The emotional valence of palliative care may heighten challenges to work-life balancing. Working with patients and families facing serious illness is emotionally charged. Although those of us practicing palliative medicine must learn to maintain personal-professional boundaries and attempt to leave work behind when we go home, this is not always easy. We get involved in peoples' lives at times that are deeply personal and emotional; we become witnesses and participants in intense life dramas that do not end when we leave the office. It is hard to let go of suffering as we walk out of the hospital doors. For each family member we talk to about an impending death, it is for that person—whether a moment of crisis or peace—a unique moment that they will live only once. The loss we face when our patients die can be cumulative. If we cannot find healthy outlets for our emotions, we may become less emotionally available to our families and friends, and less likely to take care of ourselves. On the other hand, the emotional intensity of palliative care can make us more thankful for what we have, bringing into sharper focus the importance of family, friends, good health, and a fulfilled life, all of which we might otherwise take for granted.
Strategies That Can Assist with Work-Life Balancing
The work environment
Flexibility in the timing and location of work, whether full-time or part-time, has been shown to promote work-life balance in the business world. 3 For clinicians, job flexibility may be difficult to achieve, as patients need to be seen in the clinic or hospital, often during business hours. For clinician-educators or researchers, there may be opportunity for flexibility in the timing and location of their academic work. Teleconferencing technology could allow participation in meetings from home, and mobile technology offers more flexibility in addressing urgent issues that arise over the day. Academic work can also be done in the evening hours, giving people the flexibility, if one's employer allows, to pick up children at daycare or to care for an ailing parent during the day.
Part-time work can give physicians the opportunity to shape careers in ways that meet individualized personal and professional needs. 10 Data show that part-time physicians in outpatient internal medicine clinics have higher productivity and provide equal quality care. 9 10 Women or men who choose part-time work at one point in their career will likely become full-time employees again at a later date. Recruitment of new employees to replace part-time ones is extremely expensive and leads to a loss of talented, dedicated individuals. For part-time clinicians, dedication to work can be demonstrated by objectively measured outcomes, rather than by working a certain number of hours. 9 With part-time or flexible work, there will likely be trade-offs. Decreased “face time” with employers or colleagues may mean missing spontaneous project or leadership opportunities, or not being thought of when new opportunities arise. In academic medicine, researchers and clinician-educators may need to renegotiate expectations regarding productivity temporarily. Although career goals such as promotion may take longer to achieve, other values-congruent life experiences may be more achievable and lead to greater overall work fulfillment. Institutions can support part-time faculty by extending the time limit for promotion, appreciating and rewarding collaborative work, and providing family-friendly supports, such as onsite child and elder day care. 11
A recent report from the Center for American Progress and the UC Hastings College of the Law called for four areas of focus to make the work place more family- and personal life-friendly. These include: promoting workplace flexibility; legislating short-term and extended time off; providing good quality, subsidized child and adult care; and addressing discrimination against employees with family responsibilities. These environmental changes would likely contribute to improved morale and retention. 5
Personal approaches
Timeshifting and mindfulness
We live in a high-paced society, and feel pressure to make good use of our time. We rarely allow ourselves the luxury of slowing down or if we do, we may feel guilty that we are wasting time. This way of living is in stark contrast to our ancestors. Earlier societies, especially agricultural ones dominated by the seasons, had rhythms that imposed both hard work and rest. In our society, work has taken on a larger and ever increasing percentage of our time. Despite a myriad of technologies to make our lives easier and more efficient, we feel a sense of “time poverty.” We can easily feel that we are at the mercy of time, rather than in control of, our time. In Timeshifting Stephan Rechtschaffen describes a group of highly successful professionals who have significant trouble relaxing during their vacations; slowing down has become foreign and uncomfortable to them. He argues that we need to develop the ability to “downshift” as well as move fast in order to be refreshed and productive. To “downshift,” we must first develop an awareness of our bodies that we have lost in our high-speed world. Timeshifting requires mindfulness, or cultivating awareness of our thoughts and sensations in the present moment. Wherever we are, waiting for the elevator or walking outside to our car or public transportation, we can train ourselves to notice the sights, smells, and sounds around us. For this brief period, we may feel that time slows down and even feel less stress. Alternating between periods of intense activity and relaxation, even briefly, can be incredibly renewing. In the end, Rechtschaffen argues, this ability to timeshift will allow us to feel happier and be more efficient. 12
Setting goals
In order to achieve our goals, we must plan. Our goals should be guided by our values, which should be made explicit in the process of goal setting. There are many books that describe strategies to define and achieve our goals. One strategy is to write down 10 long-term goals every day for a week. At the end of the period, one identifies the 10 goals that are most consistently represented in the daily lists. Next, one writes down steps to make each major goal possible, breaking down the steps into yearly, monthly, weekly, and even daily tasks. A complementary approach to goal setting is to write a personal vision or mission statement. 13 Although tedious, this process may challenge the fantasy that we can “do it all,” and force us to set clear priorities both professionally and personally. This process can give us permission to let go of certain things, which could include an orderly and neat household, cooking for one's family regularly, or keeping up with everyone's birthdays. It allows us to focus on those things which are most important to us.
Regularly monitoring whether one is meeting one's goals is important. Self-reflection about failure to meet goals can lead to clarification about the goals (“Are they unrealistic?”), about oneself (“Am I getting in my way somehow?”) or about one's values (“Have I truly aligned my values and goals?”). Reflecting on one's answers to these questions can get one back on track.
Remembering that life has many seasons can help us set priorities sequentially and help us refrain from trying to do too much at one time. Goals and expectations at work may need to be adjusted during times of life when caregiving requirements are high. Clinicians with young children may decide, if financially possible, to work part-time, recognizing that when childcare demands decrease, they can again work full-time.
Many physicians are perfectionists. One important survival tactic at work and at home is to know when one can get away with “good enough” and alternately, when we need to use our perfectionist tendencies to their full advantage. It is important to realize, for example, that writing beautiful, eloquent patient notes is not time-effective. Communicating clearly and succinctly is. Making a memo or e-mail perfect may not be a good use of time. Figuring out when we can cut corners appropriately and when we should not is an important academic and life skill.
Cognitive reframing and building resilience
It is important to be aware of common cognitive distortions that get in our way at work, at home, and in our attempts to find good work-life balancing. It is easy to let our negative internal messages derail our momentum and discourage us from reaching for our goals. When we have “failed” in some way at home, we may say to ourselves, “I'm a bad parent, spouse, partner, or friend” or “I'm a loser; I'll never get this balance right.” It might appear that our colleagues are thriving in their balancing act. We might say, “What's wrong with me? I should be able to do more like my colleagues.” These critical voices are unhelpful. Identifying these negative messages is the first step in moving forward. Learning how to counter these distortions with more balanced thoughts, on our own or with the help of a trusted friend or therapist, can be a powerful tool in problem solving and making positive changes. These negative thoughts, when analyzed, might be rightly identified as overgeneralizations, black and white thinking, or catastrophizing. Dwelling on what we “should” be able to do often leads to insecurity and guilt. Instead of saying to ourselves, “I really should have gotten this work-life balance figured out by now,” we could say, “How can I do this better?” The latter approach leads to curiosity and a problem-solving mentality, rather than to feelings of self-defeat. There are many cognitive techniques that can enable us to accept ourselves as we are, and help us to find better balance. 14
Research in adults shows that our ability to cope with stress, and maintain health during stressful times, correlates with three personality traits: commitment or having a sense of purpose, taking stress as a challenge, and having an internal locus of control. 15 Most palliative care professionals are committed and have a strong sense of purpose. The extent to which we can learn to view stress as a challenge and cultivate a sense of self-efficacy can lead to happier, more fulfilled lives.
Taking care of ourselves
Our physical health is often a low priority, leading to lack of exercise, poor eating habits, and the risk of poor health. Using the stages of change model, we are often in the “Pre-contemplative” or “Contemplative” stage of behavior change. We need to change our paradigm such that we view exercise, adequate sleep, and healthy eating as obligatory. A plethora of literature describes the overall and psychological benefits of regular physical activity and adequate sleep. 16 17 18 The costs of putting aside time for ourselves may seem high, thereby preventing us from moving toward “Contemplative” and on to “Action.” We tell ourselves that we will live healthier lives in the future. However, because health habits have a cumulative impact on health outcomes, we cannot defer them without risking personal harm. Finding modest ways to exercise, such as walking up stairs at work, or walking to a local restaurant, make a difference in our health. Getting preventative medical care, including dentistry and important screening tests, is another important health behavior. 19 The more we make these healthy behaviors into habits, the more successful we will become. Moving from “Pre-contemplation” through “Contemplation” and then to “Action” requires exploring our values and making a commitment to our loved ones and ourselves. 20
Beyond the physical, we need to find ways to nurture ourselves emotionally and spiritually. Nurturing our relationships with our spouse or significant other, children, friends, and other family is a vital part of self-care. For some, engagement in the larger community can enhance well-being. Engaging in self-reflection, including sharing our stories and struggles with partners or friends, can legitimize our challenges and help us gather the strength to persevere or change. A number of studies describe the overall benefit of regular prayer, meditation, and reflective journaling. 21
To take care of ourselves, we also need to set boundaries at work. This is difficult in our medical culture. We feel we must always put our patients first, even if this leads to personal neglect. This is unsustainable over the long run and can lead to burnout, compassion fatigue, or illness. Setting boundaries can take a number of forms, some of which may not be possible in our specific situations. Examples include committing to leaving work at a certain time, learning to say no to nonessential projects and requests, or not working in the evenings, on weekends, and during holidays except in exceptional situations. Taking all of our vacation time and “unplugging” from our computers and cell phones are important strategies.
Asking for help
We all need help when we have such incredible demands on our time. Finding ways to protect our time for our families and ourselves is crucial. If our finances allow, we should consider hiring household help for laundry, cleaning, or cooking. Living near parents or other relatives can provide critical support. Investing in excellent childcare can be essential to our emotional well-being at work. Getting help with emotional or spiritual issues is also important. The stigma of counseling is receding and is particularly encouraged in the palliative care community, which encourages both patients and providers to explore their feelings and values. Finally, we should seek help from colleagues or mentors at work when we feel overwhelmed and at risk for burnout.
Conclusion
Balancing our work and personal lives is difficult but incredibly important. It is critical to avoid a pattern of delaying what we value most and prioritizing those things that are ultimately of less value to us. Examining and living by our values, while hard, is a vital step to achieving balance and happiness in our lives.
We must all find a variety of strategies, both personal and professional, to assist us in negotiating this balancing act. First, we can aim to maximize the fit between ourselves and our jobs by looking for employers that offer the flexibility we need. We can also advocate for increased flexibility in our current jobs, understanding that we may or may not be successful. In the personal realm, we recommend a variety of techniques, including consciously slowing down and cultivating mindfulness, which can help us become aware of our thoughts and our physical sensations in the moment. This awareness allows us to hold on to what is important and to lower our stress levels. In addition, we recommend making ones values explicit and setting concordant personal and professional goals. If our values conflict, we need to wrestle with this discrepancy and make hard decisions. Lastly, we need to take care of ourselves physically, emotionally, and spiritually, and learn to ask for and accept help. We need to identify sources of support, both emotional and practical, in our families, friends, and communities.
Ultimately, as we grow older, we may feel a sense of regret if we have not lived our lives in concert with our values. During goals of care discussions, we work hard to help our patients understand this. We owe ourselves the same respect and care.