Guest Commentary

Cultivating Serenity While Working in Broken Health Care Systems

Dean Gianakos, MD

Centra Health, Lynchburg, Virginia

Gianakos D. Cultivating serenity while working in broken health care systems. Consultant. 2020;60(5):e1. doi:10.25270/con.2020.05.00001

The author reports no relevant financial relationships.

Dean Gianakos, MD, Director of Medical Education, Centra Health, 1901 Thomson Dr, Lynchburg, VA 24501 (


We can’t wait for the storm to blow over, we’ve got to learn to work in the rain.

Pete Silas, Former Chairman, Phillips Petroleum


In a recent study published in the Mayo Clinic Proceedings, physicians rated the usability of electronic health records (EHRs) as “not acceptable,” which translates to an F grade.1 As the authors note, this grade may reflect not only poor usability, but also frustration with increased regulatory, administrative, and documentation requirements. Either way, the results are no surprise to physicians. The EHR is a major contributor to burnout and is now an obstacle to providing excellent care—as well as a metaphor for a lot that is wrong with health care.

To extend the metaphor, it may not be an exaggeration to say clinicians are being asked to drive an EHR car that has a flat tire, with no spare, on a lonely road, with no service station in site. Most are highly motivated to drive for excellent patient outcomes, but the flat tire slows them down. The puttering and sputtering car eventually exhausts, annoys, and angers them to the point that many lose their way and purpose. They become deflated like their tires, with often dire consequences for patients—and themselves.

As early as 2002, Shanafelt wrote that burnout erodes professionalism, diminishes quality, contributes to medical errors, and impacts the health of resident physicians.2 More than 18 years later, he and others are still writing about the lack of evidence-based solutions to physician burnout. The National Academy of Medicine recently published a 320-page document by leaders and experts in clinician burnout, highlighting the need to take a systems approach to professional well-being, including the need to enable technology solutions, reduce administrative burden, create positive work environments, create positive learning environments, provide emotional support to clinicians and learners, and invest in research.3

The academy’s call to action is ambitious, admirable, and necessary to improve the health of our physicians—and our patients. No one doubts physician leaders must work to change health care organizations and systems. However, after scanning this lengthy document and noting the magnitude of changes required to improve the system, Reinhold Niebuhr’s Serenity Prayer comes to mind: “God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.”4 Considering the enormity of the changes required, it is unlikely that significant corrections will occur soon.

So, what do physicians and leaders do while they wait for and engage in widespread, systemic changes at the frontline, organizational, and regulatory levels? How can they stay positive, energized, and committed to a profession that gives (or once gave) significant meaning and satisfaction to their lives?

I cannot generalize; physicians must answer for themselves. Here are a few suggestions to consider:


Self-awareness starts with asking questions. How do I move toward higher levels of physical, social, emotional, mental, spiritual, financial, and creative performance? For example, why do I feel so sluggish today? Is it more than sluggishness? Could it be depression? Am I exhausted because I was on call last night, or because I missed a diagnosis of pulmonary embolus yesterday? Or was it the argument with my spouse? No exercise in 2 weeks? Neglected my Bible study that sustains my faith? Credit card debt? My tendency to see the glass half empty? Is it more than frustration with an inefficient EHR?

Do I need a colleague, friend, coach, pastor, or counselor to help me sort this out? Do I have the humility and courage to ask for help?

What are my values? How do they conflict or conform with the prevailing culture of medicine? Do others feel like I do: guilty, indecisive, and sacrificial, leaving little time for reflection and recreation?


Cultivating positive emotions also starts with asking questions: What are positive emotions? What is preventing me from experiencing them? What would it be like to feel more joyful, grateful, faithful, and loving? What is the foundation for these emotions? Faith? Family? Friends? Colleagues? How do I take more responsibility for my emotions?

Do I know my strengths? Am I grateful for them? How do I express gratitude? To whom do I express it? Do I write down blessings and examples of good fortune, so I don’t forget them? Do I meditate or pray about them? Do I share good news and joy with others?

Do I obsess about my weaknesses instead of focusing on my strengths? If so, how does that affect me? Do I believe everything I think about myself and others? What positive stories are there to tell? How can I develop more positive and healthy habits of thought, feeling, speech, and behavior?

Who can help me to change my mindset?6,7


Susan Scott writes, “Our work, our relationships, and our lives succeed or fail one conversation at a time.”8

What conversations do I need to hold in order to advance my personal and professional well-being? What relationships do I value? Why? How can I develop and strengthen them? What keeps me from sharing more with my colleagues and friends? Do I have the communication skills to start a tough conversation with my boss, colleague, or significant other? Can I stay in dialogue when I’m feeling frustrated, hurt, irritated or angry, or when I’m the target of strong feelings?9

Do I have the courage, humility, and skills to hold hard conversations? If I don’t, how can I acquire these virtues and skills?


A few examples:

Physical action. Walk 30 minutes a day. Hire a personal fitness trainer. Get a medical checkup. Develop new habits: Eat less sugar, drink less coffee.

Emotional action. Keep a daily gratitude journal. Learn to meditate, pray, or practice mindfulness. Learn to challenge your thoughts and beliefs: Don’t believe everything you think about yourself or others.10

Social action. Ask a colleague to join you for coffee. Take a daily walk with a friend. Smile more. Share positive news with colleagues and friends. Volunteer.

Intellectual action. Recommit to reading a favorite medical journal once a week. Enter a leadership program.11 Teach medical students and residents. Don’t procrastinate, make decisions. Join an information technology committee to optimize EHR usability.

Spiritual action. Read the Bible or other sacred texts, or poetry, or meditations. Attend religious services or a faith study.

Financial action. Review your financial situation. Get a financial checkup with a financial advisor.

Creative action. Start a new hobby. Draw, write, or pick up the violin again.

Political action. Join a medical advocacy group. Write to your member of Congress.

As Alex Korb writes in his remarkable book, The Upward Spiral, small actions can work together to create an “upward spiral,” characterized by improved mood, performance, and well-being:

“Everything is interconnected. Gratitude improves sleep. Sleep reduces pain. Reduced pain improves your mood. Improved mood reduces anxiety, which improves focus and planning. Focus and planning help with decision making. Decision making further reduces anxiety and improves enjoyment. Enjoyment gives you more to be grateful for, which keeps the loop of the upward spiral going. Enjoyment also makes it more likely you’ll exercise and be social, which in turn will make you happier.”12

The rapid changes in health care in the past 20 years challenge physician leaders and clinicians to take stock of their lives by asking themselves important questions: How should I live my life? What’s really important to me? What’s preventing me from flourishing as a leader and human being?

In the next decade, it is unlikely that EHRs will be optimized. Health care changes will accelerate. In the meantime, while system and organizational improvements are under way, it behooves physicians to engage in self-examination and to determine for themselves how to personally and professionally flourish. The suggestions and questions in this article are the beginning of a conversation, a conversation that physicians ought to have with themselves first, and then with trusted friends, coaches, and mentors—and counselors, if needed. As leaders, they can encourage and inspire their colleagues to hold similar conversations to achieve higher levels of personal, professional, and spiritual well-being.

When physicians and leaders flourish, so do our patients, organizations, and communities.


  1. Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc. 2020;95(3):476-487. doi:10.1016/j.mayocp.2019.09.024
  2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358-367. doi:10.7326/0003-4819-136-5-200203050-00008
  3. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies Press; 2019. doi:10.17226/25521
  4. Shapiro FR. Who wrote the Serenity Prayer? Chronicle Review. April 28, 2014. Accessed April 13, 2020.
  5. Jeste DV, Palmer BW, eds. Positive Psychiatry: A Clinical Handbook. American Psychiatric Publishing; 2015.
  6. Dweck CS. Mindset: The New Psychology of Success. Ballantine Books; 2006.
  7. Menon NK, Trockel MT, Hamidi MS, Shanafelt TD. Developing a portfolio to support physicians’ efforts to promote well-being: one piece of the puzzle. Mayo Clin Proc. 2019;94(11):2171-2177. doi:10.1016/j.mayocp.2019.09.010
  8. Scott S. Fierce Conversations: Achieving Success at Work and in Life One Conversation at a Time. New American Library; 2017.
  9. Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations. 2nd ed. McGraw-Hill; 2012.
  10. Gianakos D. Rethinking burnout: 3 suggestions to reduce the stress of practicing medicine. Consultant. 2017;57(2):126-127.
  11. Rosenthal SL, Landers SE, Gamble C, Mauro C, Grigsby RK. Leadership training and risk of burnout. Physician Leadership J. 2019;6(6):43-49.
  12. Korb A. The Upward Spiral: Using Neuroscience to Reverse the Course of Depression One Small Change at a Time. New Harbinger Publications; 2015.