Balance of Life and Work - Application of SWOT Matrix
Don't Get So Busy Making A Living That You Forget To Make A Life
--- Dolly Parton
World Health Organization (WHO) defined quality of life as “the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals”. The World Health Organization Quality Of Life (WHOQOL) instruments place primary importance on the perception of the individual.
Balancing one's life and work is a serious issue in the current competitive and corporate world. With a number of studies on the incidence of burnout in the medical profession, especially the residents, must consider it seriously. There have been a number of studies on causes of burnout and its mitigation. Markets and businesses look at their problems using SWOT. The author suggests looking into the balance of work and life of individuals using the SWOT matrix.
Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis or SWOT matrix is a strategic planning technique used to help a person or organization identify strengths, weaknesses, opportunities, and threats related to business competition or project planning. The origins of the SWOT analysis technique is credited to Albert Humphrey, who led a research project at Stanford University in the 1960s and 1970s using data from many top companies. The goal was to identify why corporate planning failed., There have been few studies applying SWOT in healthcare, with reference to practices, diagnostics, and strategies.,,
There has been a paradigm shift in the careers of neurosurgeons from the early days of William Macewen (1848–1924), Victor Horsley (1857–1916) and Cushings (1869–1939)––the pre-Roentgen era to the Pre CT Scan era and to the current technology-driven era. The traditional clinical approach of diagnostic workup and principles of management itself has undergone a sea change with the modern diagnostic gadgets leading to less emphasis on clinical to the over dependence on imaging, electrophysiology, and neurochemistry. The sentences of Sir WIlliam Osler (1849–1919) “Just listen to your patient, he is telling you the diagnosis” are less practiced. They were relevant in the days of Macewens and Horsleys, Gowers (1845–1915) and Jacksons (1835–1911). With very little of an investigation, the entire process of diagnosis was lending of the ears to the patient's story and a careful clinical examination and deductive logic to interpret possible clinical localization and pathology of the disease. Trepanation was the earliest surgery to expose the contents of the cranium, which began in Greece during the fifth century BC, either for medical or mystical purposes. It was practiced widely in many ancient cultures and several parts of the world. Sharpened stones and scraping of the skull were used initially, replaced by wooden and metal trepans later.
The neurosurgery in the 50s to 70s was mostly managed by one or two persons, except in some premier institutions in India. It was very demanding with trauma, untimely calls and neuroradiology work up taking away most of the time. The strokes and subarachnoid hemorrhages were relegated to general medical units and the neurosurgeon involved in caring for only those that survived the initial crisis. Few neurosurgeons were involved in the initial care of these diseases until the late 20th century. The morbid and moribund issues of brain tumors and others had to languish in the wards and it was almost two weeks since admission for a patient with a tumor to get on to the operation table. The untimely calls for emergencies and management of disability that followed and their rehabilitation threw a variety of challenges.
The beginning of one's career often revealed how intricate the problems were. The workload and its nature demanded long hours in the hospital. The author had the fortune of doing an internship during his residency for a few weeks with the legend, Prof. Rama Murthy. Two anecdotes are worth recalling to reflect the state of the resident in Neurosurgery 1973. A resident had gone to the Chief (Prof. Rama Murthy) and invited him for tea at his house to bless his newborn child. The Chief said “what? Working in the institute of neurology how could you find time for it”. The senior Nurse in the NIMHANS (Then it was All India Institute of Mental Health and NeuroSciences) said one day “The residents in neurosurgery do not find it difficult to practice family planning - they are mostly in the wards”. The department where the author started his career in early 70 had only two doctors in the department then, whereas to this day, it has 20 faculy and residents in the department.
Burnout issue: incidence, reasons, and mitigation
Burnout is a feeling of hopelessness and inability in carrying out one's job effectively, overcoming compassion fatigue. While most reports of burnout are emanating from the west and particularly in residents, it is not confined to a particular region or specialty or age group. A few studies of its incidence are from India also. Many studies were conducted on the incidence of burnout in different specialties and healthcare scenarios and workers like residents, critical care health workers, women doctors, and nurses. Most studies used Maslach Burnout Inventory (MBI) which evaluated Emotional Exhaustion (EE) Depersonalization (DP) Personal accomplishment, Cynicism, and Professional efficacy. Some of the causes studied were quality of work, Job satisfaction, and sources of support.
Langade et al. in a detailed report observed high burnout levels uniformly among all the occupational and socio-demographic groups of medical practitioners studied. Using the MBI, the report observed participants scored high on the emotional exhaustion and depersonalization scales, low on the personal accomplishment scale and medium and low scores on the satisfaction with the medical practice scale, work overload, lack of development, and neglect, lack of satisfaction with the financial compensation. All these values indicate high levels of burnout.
Presence of depression, stress, or burnout associated with lower indulgence in recreational activities, increased verbal or physical abuse in the hands of patients/caregivers, feelings that seniors do not show empathy toward patients, and toward them. The studies also revealed a poor doctor-patient ratio in India.
A significantly higher proportion of doctors in the Indian settings were found to have experienced stress, depression, and burnout associated with long working hours and negative patient-related outcomes, adverse doctor-patient interactions, and poor interpersonal interactions among the colleagues. The Burnout is not confined to doctors alone and is seen in other healthcare workers as well, like nurses and respiratory therapists in the intensive care unit. There have been many other studies in other countries, particularly in the United States for neurosurgeons. Poor Work-Life balance, anxiety over future earnings and health care reform, inadequate operating room exposure, hostile faculty and social stressors outside of work, balance between work and home life are some of the reasons reported.,,,
Emotional intelligence and burnout
Recalling the WHO definition is burnout an issue of perception? Is burnout an issue of mismatch between expectations and reality?.,, There have been studies that show Emotional intelligence (EI) and perceived stress are related to burnout., The EI training integrated into the resident educational curriculum focused on self-awareness (being aware of one's emotions), self-management (managing emotional reactions to situations and people), social awareness and social skill. The training schedules included lectures, discussions and videos. People with high EI have more effective coping strategies, enabling them to be more resilient and better able to manage stress. Pfifferling and Gilley in their article “Putting life back into your professional life” have analyzed the issue of burn out, expectations, coping and wellness. Higher (self-rated) EI was found to be significantly associated with less burnout and higher job satisfaction. In a different study, the survey included patients.. In the recent past, there has been an increase in the violence against the doctors and other healthcare establishment for reasons beyond their control. Emotional blackmail and vandalism have also been responsible for discontent in the profession.,
To study the balance of work, life and the balance, in the context of emotional adjustment and perceived stress being responsible for burnout and wellness and resilience could be achieved with better preparation, the author suggests looking into the possible contributing factors in the SWOT matrix: resources like knowledge, skill, performance, competence, motivation, work culture, finances, support systems like professional bodies, family, etc. [Table 1].
Resources: The academic and financial resources of an individual or an organization and their role in the work need no emphasis. Our skills in meeting the demands of the profession stand good to provide a better workability. However, there are many other components of our academic resources that provide an additional cushion for comfort.
Academic: Knowledge and proficiency in the subjects concerned with one's career alone do not seem to suffice. The UNESCO's report on education for the 21st Century “Learning: The treasure within” has highlighted four pillars of Learning: Learning to Know, Learning to Do, Learning to live (together), and Learning to Be. To learn in-depth, the various opportunities available and perform with competence in different contexts, with others and teams, to live with each other, understanding the society and interdependence, management of conflicts, the spirit of pluralism, mutual understanding and finally learning to be, involving personality development, responsibility and judgment is the meaning of Learning as per this report. The report encompasses many issues that a formal education system does not include and says the education should be more inclusive. One who learns to be competent and understands the work atmosphere is less prone to feeling uncomfortable at work even in adverse conditions.
In house training: Availability of in house training facilities offers a great opportunity. While It helps upgrade one's skills, it provides an opportunity to learn the work culture, makes one appreciate the needs of the organization, interaction with peers, and higher-ups better in team building and capacity building.,
Peers: The colleagues in the departments, especially the peers in the residency programs in medical faculties, make significant contributions to the work atmosphere. The camaraderie helps sharing the work, supporting and adjusting rather than argue, to be assertive and not aggressive. One is aware of the old adage: “if you lie down with dogs, you get up with fleas” and “most peoples' lives are a reflection of their peers”.
The Professional groups offer an excellent resource by organizing seminars, guest speakers with expertise, networking, and rubbing shoulders with senior colleagues, opportunities for expressing one's opinions, experiences, and updating the skills. These also give a chance to appreciate the current issues and concerns in the profession. These bodies could be of four types: Member-benefit professional associations, eg.: Neurological Society of India, designation-granting associations, certifying bodies, and professional regulatory bodies. The first group is a significant resource. The member benefit bodies organize workshops, CME programs, and seminars that help individual professionals.
Family as resource: Missing the family when overwhelmed with work is a common feature seen in many professionals, and Neurosurgeons are no exception. Family - Partner and children offer a good cushion to a stressed person. Life Partner and children are great stress relievers when lost in thinking of work, assets and finances, and the resultant stress. One must think of the family as often as one thinks of assets and finances.
Facilities to upgrade skills, CME programs, workshops, and research are known to enhance the knowledge and skills. A White Paper on Adult Education published also stresses on lifelong learning. Lifelong learning is the “ongoing, voluntary, and self-motivated” pursuit of knowledge for either personal or professional reasons. Therefore, it not only enhances social inclusion, active citizenship, and personal development, but also self-sustainability, as well as competitiveness and employability. The need for all professionals to have highly developed learning skills in a society racing with change is evident.
Value-added courses, offer a good opportunity. Value-added courses help individuals to develop their own skills in their chosen field of the study. Most of these courses offer developing soft skills which include attitude, communication, creative thinking, work ethic, teamwork, networking, decision making, positivity, time management, motivation, flexibility, problem-solving, critical thinking, and conflict resolution and bring advanced skills into the workforce. These subjects could be chosen as per the needs of the profession or work.
Delors, reviewing the report of Learning from Within 15 years after its submission concluded lifelong learning is essential for gaining self-esteem and the ability to take control of one's own life. He also suggested emphasizing use of technology for education as well as to make people master it for living and working. The report quotes “ Getting the reform strategies right, by a broad-based dialogue, and by increasing responsibility and involvement of stakeholders at every level, will be a crucial element of educational renewal”.
The technological revolution is the Raison d'être for the paradigm shift. While the early 20th century saw a greater understanding of cerebral localization, antisepsis, anesthesia, and hemostasis leading to an era of great expansion in neurosurgical approaches and techniques, advances in digital technology, imaging, and neuro navigations, deep brain stimulation in the later part of the 20th Century has revolutionized the interventions in neurosurgery. Digital technology has become a driving force in healthcare management. Data collection, research and analysis, and a host of software have given a different perspective of healthcare management.
There has been some criticism about the Electronic Health Records (EHR). The EHR is a real-time, patient-centered record that makes information available instantly and securely to authorized users. While an EHR contains the medical and treatment histories of patients, it goes beyond the standard clinical data collected by a provider and is inclusive of a broader view of a patient's care. EHRs can contain a patient's past and current medical history, diagnosis, medications, treatment plans, immunization dates, allergies, radiological images, and laboratory and test results. They were blamed to be the cause of physician burnout.,
However, continuous revisions and newer versions of the software, scroll down menus, speech to text conversion, cloud-based EHRs, and applications of data science tools to upgrade these EHRs have contributed to the comfort of the clinician with data being available in real time at the click of a button and more importantly securely handled. In general, technological advances in the fields of diagnosis, interventions, mobile technology, and data science have made a clinicians life more comfortable, and often resulted in saving time and averting incidental mistakes that creep in.,
Stress and its relief: Lack of sleep, the pressure of work, lack of opportunities and uncertainties in profession, social pressures and inadequate family support are some of the factors of burnout as we have seen, vide supra. A number of methods are reported to resolve and overcome these stresses.
Leisure activity, hobby and creativity
George Bernard Shaw is reported to have said, “Happy is the man who can make a living by his hobby”. Hobbies show what one is inside and one's passion. These hobbies, leisure activities, or creative talents of an individual, offer an opportunity for enhancing self-esteem, confidence, creativity, and ability for multitasking, critical thinking, organizational skills. It also helps in networking with similar persons. Creativity unrelated to work affects an individual's performance. It should be encouraged in individuals., Enjoyable leisure activities are known to help psychological and physical well-being. Some leisure activities (e.g. vacations, siestas, coffee breaks) serve as breathers that provide a break, diversionary activity, and induce positive emotions and reduce stress. Enjoyable activities may also act as restorers that facilitate the individual's recovery from stress by replenishing damaged or depleted resources. Leisure is believed to play a role in benefiting overall well-being, buffering stress. The leisure activity is known to influence the negative psychological impact of stress.,, While the untimely calls and certain exigencies of the profession keep the time management difficult in a profession like that of neurosurgeon, it is known that better management, to the extent possible, of time and sleep are of help. Time management is an important issue. Dweight Eisenhover former president of USA has said, “What is important is seldom urgent and what is urgent is seldom important”. It is suggested that one asserts what is important and what is urgent and allocates and prioritizes the work and time accordingly.
To optimize the quality, costs, and work in an organization one has to consider the alignment of goals, metrics, processes, resources, knowledge, and relationships. Work culture and motivation operating in tandem with goals, metrics, processes, and resources are essential. Some organizational changes are needed for physician well-being in the hospitals. Many organizational interventions have been studied to counter worker fatigue. Troubleshooting mechanisms, along with mentoring, training in cognitive-behavioral changes, changing work schedules, Physician wellbeing programs, communication, and other soft skills, improvement of communications about end-of-life care, management of conflicts, and workshops on various stress management techniques can be included. The psychosocial work environment influences the worker significantly.,,
Mentoring: One of the organizational efforts to improve the quality of life is an institution of mentorship. A good mentor candidate should be mature, esteemed by physicians and nurses, have a strong faith, and have a strong commitment to the project. Life Centered Mentoring training helps physician-mentors develop the all-important art of medicine, which exercises skills of compassion. That means listening with the heart and not just the intellect; becoming more aware of one's own body language; identifying useful open-ended questions; and learning to sit comfortably with patients during some of the most challenging times of life.,,
Art of living and wellness concepts: A change in conceptual thinking from burnout to wellness is suggested by Eckleberry-Hunt et al. They suggested the development of a well-defined physician wellness program and plan interventional strategies to bolster it. Creation of a positive approach, better understanding of causes, and preventive strategies of burnout are to be considered.
In the current concepts of competency-based curriculum and performance, which sometimes superseded self-interests, the physician's behavior could show a greater vulnerability. A survey considering Empathy, Spirituality, and Wellness in Medicine (ESWIM) showed healthy behaviors as well as risk behaviors. The expected competencies and their expression may prevent students from maintaining healthy behaviors; they exercise less, sleep less, and spend less time in organizational activities outside of medical school. Boston University center for psychiatric rehabilitation mentions emotional, environmental, intellectual, occupational, financial, emotional, social, and spiritual factors that influence wellness. Better ways of wellness and more positive approaches are suggested by protagonists of the art of living. Studies of the role of art of living on burn out and physician wellness are limited and more studies are needed.
Quality of life is an issue of perception of an individual in the context of culture and value systems in relation to one's work as WHO states. To balance one's life and profession, various factors that need consideration could be analyzed using the SWOT matrix. While physician burnout and social violence and abuse act as threats, inadequacies in training and skills and lack of family support increase the vulnerability to such threats. One's professional knowledge and skill, inhouse training facility, peers, and financial support act as strengths. Strong support from professional bodies and family help improve one's abilities. UNESCO's four pillars of learning: learning to know, learning to do, learning to live, and learning to be seen to be very relevant. Actively looking out for available opportunities to improve one's skills such as CME programs to update one's knowledge and lifelong learning, improving the soft skills like communication and the art of living help one to face the events that cause burnout. Accepting reality, preparedness, emotional stability, family, and leisure time activity enhance resilience. Certain organizational changes, mentorship, and better time management help the individuals in coping up with stresses. SWOT matrix helps evaluate various threats and weaknesses and the strengths and opportunities available to cope with them.
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Conflicts of interest
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