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The 3 “Rs”—Relax, Reflect, and Regroup: Avoiding Burnout During Cardiology FellowshipFree Access

Fellows-in-Training & Early Career Page

J Am Coll Cardiol, 66 (11) 1303–1306


Whether you believe that the Creator created the 24-h, 7-day, or 365-day cycle for a reason or that evolution selected cycles for a specific purpose, the fact remains that cycles are essential for optimal operation of any system. Only systems with set cycles or checkpoints for replenishing can endure continuous high-quality performance. Cardiology fellows-in-training are so keen to increase their productivity and attain new heights in the profession that they frequently forget to take the time to replenish themselves. Here, I will present the cycle of 3 “Rs”—relaxation, reflection, and regrouping—as a simple, stepwise method for fellows to use to optimize their performance and avoid burnout.

A total of 57% of internal medicine residents experience burnout (1). Symptoms may include loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. One survey showed that 38% of cardiologists experienced burnout by the same criteria (2). By the end of residency, aspiring cardiologists are usually confident in their abilities to lead the medical team. However, the transition to cardiology can be overwhelming, as there is an increased need for evidence-based medicine and multiple diagnostic and therapeutic modalities. Contrary to the joy and comfort they should bring, our routine duties as head of household, parent, or caretaker of aging loved ones; our social commitments and our high expectations can be added stressors, which frequently leave very little room to unwind.

It takes an average of 10 post-secondary years in training to become a fully licensed cardiologist (3). Trusted with what is arguably the most critical organ, the heart, trainees frequently devote themselves to high-volume high-acuity patients, which can result in increased mental and physical exhaustion. In 2014, medical students graduated with a median debt of $180,000 (4). Many trainees have the added responsibility of contributing to their family’s financial well-being. When stress and depression skyrocket, suicide can be an end result. In fact, suicide is higher among physicians than in the general population (5). One retrospective study cited no significant differences in current mental health disorders between physicians and other occupations; yet, physicians that committed suicide were less likely to have a known alcohol or substance dependence problem (6). This indicates that there are untold stories of hidden stress and depression among physicians.

There is no doubt—it is best to avoid burnout rather than dealing with it. It takes at least 3× the time and energy to recover from burnout than to prevent it. This is not a new concept; we employ it in our medical practice on a daily basis. Although cardiovascular disease is the leading cause of morbidity and mortality in the developed world, we are discovering that prevention is better and can be more cost-effective. Sitting in the library some years ago, I made note of a picture that was captioned “the journey not the arrival matters.” Thus, it is important for one to enjoy training (the journey), as this might give some indication of what one’s cardiology practice might be. But, how can one enjoy training when there are so many questions to answer and so many uncertainties? The answer will be unique to each individual. I have made a few suggestions for a possible strategy that cardiology fellows could implement to attempt to avoid burnout.


Relaxation is vital to your health. The state of relaxation is not a passive action and requires focused effort to be achieved. Synonymous with a high-performance engine that needs a modified exhaustion release system, fellows need efficient ways of releasing stress. From an institutional perspective, many programs incorporate social events to foster relaxed time, noting that many trainees relocate away from friends and family to complete fellowships. Depending on the individual, relaxation can be achieved by partaking in sedentary activities, such as meditation and video games, whereas others prefer physical activities, such as swimming and dancing. Although either method is acceptable, some level of physical activity is generally recommended, as obesity is becoming more prevalent in developed countries, not absent among physicians, and also frequently contributes to a depressed mood. Although anxiolytics and sleep mediations are widely prescribed medications in the United States, many of their effects can be achieved from physical activity. Physical activity forces the body to release endorphins and other chemicals that ensure relaxation and tranquility, in turn bringing the body to a place of contentment, in preparation for reflection.


Reflection is a necessary and important checkpoint. Many programs have built-in checkpoints (usually every 6 months) for fellows to meet with the chief fellow or program director to reflect on past work and develop strategies to respond to challenges. However, transparency is often unachievable for the trainee due to fear of judgment. Moreover, these checkpoints of scheduled meetings are usually too seldom to use as the sole opportunity for reflection. Reflection is a process that allows an individual to sequentially dissect the events of the past, consider what went wrong, and determine how the concerns can be prevented or changed. Most importantly, it is a time to identify causative factors. It may be unpleasant to reflect on less than ideal events, and hence, it is done less frequently than required. The method for reflection is often unproductive. Strategies such as the STAR (considering the complete Situation, identifying Tasks that were required to be completed, the Actions taken by the individual, and the Results achieved) method can help to organize thoughts in a productive manner. It enhances the opportunity to retrace and analyze the past to improve on the skills necessary to regroup.


Regrouping to form new strategies. To ensure that the process is progressive, the trainee must regroup. During the process of regrouping, one is actively engaged in acquiring the skills necessary to prevent recurrence of the previous negative outcome or to improve good outcomes. As a first-year fellow, I joined a gym and was excited to lose weight and gain agility. I started a strenuous exercise program and solicited the guidance of a personal trainer. On the third day, the trainer advised me to rest 1 to 2 days before continuing. I responded with a puzzled look; the trainer readily stated, “When you work out that hard you really have to take time to rest, giving your muscles time to repair and rebuild.” In essence, the trainer was saying that my muscles needed to pass through the 3 Rs. They needed time to relax from the strenuous exercise, reflect on the previous week’s activities, and rebuild (regroup) more muscles for improved performance. Regrouping can happen in many different ways. For some, it may entail reading journal papers, getting extra equipment for the clinic, researching faster ways to complete morning rounds, or keeping track of patients. Regrouping also gives us the chance to accept the things we cannot change and to use them to create learning opportunities (7).

The benefit of the 3 Rs was proven to me during medical school. After encountering a group that played recreational soccer, it became apparent to me that what I termed “free time” was essential to my preservation. After a game, I would leave the field with a feeling of exoneration that was likened to the feeling of returning from a vacation. I achieved a more peaceful resting period, and the endorphin rush was nothing short of that received from psychogenic medications. This was my method of relaxation. Walking home and showering would be a period of reflection that allowed me to retrace my activities in a constructive manner. I was completing the 3 Rs on a regular basis by joining a pick-up game of soccer.

Due to the simplicity of this method, why is it not more prevalent? The answer is that when it is done correctly, it is done infrequently. As we develop our medical armamentarium, we frequently fail in improving our repertoire with appropriate stress reduction skills. Cycling through the 3 Rs can range from spending 15 min away from the crowd to an extended beach vacation. The intensity and duration should be commensurate with work demands. Although time constraints can be limiting, the key is to find something that allows you an opportunity to frequently and effectively relax, reflect, and regroup.

Goldman Martin E.

Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York

RESPONSE: A Prescription to Avoid Burnout

Dr. Waldo has written a very thought-provoking piece on the risk of “burnout” during cardiology training and an approach to deal with it. Burnout, as defined by the Maslach Burnout Inventory Survey, evaluates 3 metrics: emotional exhaustion from being overworked; depersonalization or desensitization, a lack of compassion for patients and peers; and professional efficacy and reduced sense of accomplishment (1).

Unfortunately, medicine does carry a high stress level, particularly among trainees. In medicine, burnout can lead to errors of omission or commission that deleteriously affect patient care. Shanafelt et al. (2) reported that burnout was more common among physicians than other U.S. workers. Physicians and specialties at the front line of care (emergency medicine, general internal medicine, and family medicine) are at the greatest risk. Physicians work a median of ≥10 h more per week than other work groups, and they are at higher risk for emotional exhaustion, depersonalization, and overall burnout relative to population controls. However, there was a flaw in the sampling of this oft-cited paper. An invitation and 3 e-mails were sent to 89,831 physicians from the American Medical Association Physician Masterfile, but only 7,288 physicians participated in the survey (8%), which causes concern about the representative nature of the responders. Selective self-reporting to a survey may not be reflective of the general group due to sampling errors. That survey also does not list cardiology as 1 of the polled specialties. However, a 2013 Medscape survey (how scientific a survey?) reported that 38% of cardiologists reported burnout (about average, 14th on the list of specialists) (3).

As Dr. Waldo points out, cardiologists-in-training are at risk for emotional strain and burnout due to their time commitment, often at the expense and exclusion of family; financial sacrifice by delaying entering into practice and mounting loans; and the very nature of the intensity of the field. Certainly, the stress of life-and-death decisions made by cardiology fellows consulting on an unstable patient in the emergency room, during a coronary or electrophysiological intervention, when decision making with stage D heart failure patients, and with end-of-life decisions can take a mental and physical toll on the trainee. This stress is compounded by the increasing time consumption mandated by the electronic medical records and the growing checks and balances and pre-certifications.

However, lacking in all of these burnout surveys are indicators of gratification, satisfaction, and a sense of accomplishment experienced by trainees by their chosen field. Although cardiology is uniquely stressful, the field is also distinctly gratifying in its ability to intervene and immediately reverse a patient’s terminal illness, such as with transcatheter aortic valve replacement. Medicine is still regarded as the most admired profession in the United States. A 2012 Harris poll reported that doctors have the most prestigious jobs in America (88%), followed by military officers (78%), and firefighters (76%).

Dr. Waldo suggests the 3 “Rs” to prevent burnout: Relax, Reflect, and Regroup, which are powerful suggestions to avoid burnout in any chosen profession. I would include several recommendations unique to cardiology training that could also help increase rewards:


Rely on your peers. Cardiology is a high-powered, competitive field attracting many of the brightest, most diligent medical residents. Your peer group, cofellows, and senior fellows will be your closest colleagues over the next few years. How have they been coping with the requirements and rigors of their program? What is their degree of satisfaction or stress? Will you enjoy their collaboration and support?


Fulfillment through work. Cardiology provides many diverse career paths available to trainees, which could be customized to suit their distinct personalities and desired lifestyles, including basic and translational research, big data, interventional cardiology, cardiac imaging, and heart failure.


Mentorship. Support systems are very important in dealing with real and perceived stress. The program director, program administrator, chief fellows, and cofellows are instrumental in avoiding burnout by providing outlets for discussion, direction, and guidance to navigate through strain and anxiety.


Location. The geographic location of the program is a major part of the decision in choosing a fellowship. Not only will patient volume, ethnic diversity, and socioeconomic and educational status be dictated by the locale of the training site, but so will the cost of living, school system for children, and relative safety.

Importantly, stress is present in every walk of life and in every profession or vocation. Teachers face stress in the classroom, fast food workers must respond to the growing backlog of orders, and police officers face stress with every confrontation or traffic stop. Here are several suggestions to cope with stress in fellowship and life in general:


Recognize intrinsic personality traits that lead to stress: overly obsessive, low self-esteem, procrastination


Develop and learn better time management skills


Know and accept your limitations


Avoid confrontations and appreciate the counter point of view


Express yourself: communicate with your peers and program director


Seek some recreational outlet, whether sports or relaxation


Develop and engage with your support system, whether it be family, friends, or religion


Plan for a successful future by putting events in perspective and looking toward the big picture


Never be afraid to ask for assistance or guidance.

Most importantly, take time to put your life in perspective. You are in the most exciting field of medicine, and you are on the cutting edge of science and discovery. Enjoy your training; it is the most exciting and rewarding time in your professional career.