Gratitude as a Healthcare Leader:
How Reflection Builds Resilience, Self-Compassion, and Joy

Transforming Healthcare Coaching Podcast — Episode 103: Gratitude as a Healthcare Leader with Dr. Carolyn Roy-Bornstein. An author interview. Host: Lillian Liang Emlet, MD MS CHSE CPC ELI-MP. Guest: Carolyn Roy-Bornstein, MD FAAP — board-certified pediatrician, writer-in-residence at the Lawrence Family Medicine Residency, and author.

Carolyn Roy-Bornstein: We've become good at sitting with these stories and taking in these sufferings, but no one's ever taught us how to let it go. The most painful times where we're really with our patients as they're suffering are also the times that have the capacity to create the most joy and meaning for us. Everybody just wants to be seen.

Lillian Emlet: So you went to healthcare to help people, but somewhere between the charting, the overnight calls, and the weight of it all, did you forget to help yourself. Our guest today, Dr. Carolyn Roy Bornstein, is a physician, pediatrician, author who has spent years exploring what it actually looks like to flourish in medicine, not just survive it. We're talking about gratitude that isn't toxic positivity, resilience that isn't just tough it up. And the kind of self-compassion that honestly, most of us were never taught in training. And so if you've ever felt like an imposter in your own career, wrestling with who you are outside the white coat, or wondered when medicine stopped feeling like a calling, this episode is for you. Welcome to the Transforming Healthcare Coaching Podcast. So I'm super honored today to have Dr. Carolyn Roy Bornstein. You are a pediatrician, you are a writer in residence, you're author, you are at the Lawrence Family Medicine Residency Program and you're author of multiple books, about your own personal journeys stories, and you're so relatable in all of the different things that you've been working on. Thank you so much for coming on our podcast today.

Carolyn Roy-Bornstein: Thanks for having me, Lillian.

Lillian Emlet: So before we dive in, can you take us back to the moment or in the season of your career, way back when, when you first realized that thriving in medicine was something you had to actually consciously work towards?

Carolyn Roy-Bornstein: So I think actually something that you may not know about me yet, but you're about to, is that I was a nurse for 10 years before I was a physician and I worked side by side with residents. I worked in a teaching hospital as a nurse and in fact, I worked, my first two years of medical school, I was still working as a nurse.

Lillian Emlet: No way.

Carolyn Roy-Bornstein: I would say I knew, I always knew from that experience that it takes work to thrive, to flourish, to remain optimistic. There's an author Suzanne Segerstrom, who wrote a book about optimism about I think it was Breaking Murphy's Law, how optimists can have what they want in life and pessimists can too. And she says the difference between optimism and wishful thinking is elbow grease. You just have to work at it. And the director of the program for human flourishing at Harvard Tyler VanderWeele. He has a lot of great activities for promoting, flourishing, and thriving in medicine, including some of the things we'll probably talk about, gratitude interventions, and so forth. We'll get into.

Lillian Emlet: I love that. You know as when you think about, when you look at all the healthcare professionals that you've been working with for so many years and who you write with, what are the things you wish they knew earlier in their career? You're lucky because you get to work with people who are in training and so you do make an impact. but I'm curious what you wish they knew earlier.

Carolyn Roy-Bornstein: Well, I think it's easy to feel that we have no control, that it's other people out there who are controlling our destiny and our everyday work. and to a large extent they do. They can dictate how many patients we see and how much time we spend and so forth. But, I think that I want people to understand that they do have and can have some agency, whether that is in claiming their voice, in claiming small moments of joy, in their day and meaning, there was an article in the New England Journal of Medicine that Lisa Rosenbaum wrote about Beyond Moral Injury. Talking about an incident that happened with a resident she was working with, and this resident had gone to see a patient and tried to get a history and the patient didn't have her Milk Duds, she was just obsessed. She couldn't focus on what the resident wanted her to participate in. So the resident did her best with the history and went on about her day. And that evening as she was in the cafeteria, she went by the vending machine and she saw

Lillian Emlet: Milk

Carolyn Roy-Bornstein: Duds, and she bought the Milk Duds and went back to the patient and gave them to her. And the patient was just overjoyed and she said. was the most meaningful thing I did all day, and it's a little bit sad when you think about it. I mean, it's joyful and wonderful, but in all the opportunities that we have to make connections and feel joy and create meaning that it was this extra, that she stayed extra, stayed late, went above and beyond the call of duty, and Dr. Rosenbaum goes on in the essay to ask: "what do we have to do to create that space for more meaning, for more agency in our jobs? Is it staying late, going the extra mile, working extra?" and I don't think so, but I think we do need to conscientiously consciously make space for reflection, and that is where the magic happens to me. That's where I see the magic happening with the residents is creating meaning or recognizing those joyful moments and interactions with patients and colleagues and each other.

Lillian Emlet: Spoken like a true educator. And the reality is, you know, we, we act and we do, and there has to be that closed loop to be able to reflect and add it to the scaffold of your prior experiences. In order for the sensemaking, I mean, really to some degree, if AI is just data translated into a pattern recognition, humans, you know, what we thrive in is storymaking and sensemaking, and relations with each other. So, I do wonder whether a lot of this is related to the narrative that we often see that's very widespread and sort of regurgitated about how it's always the system's fault and how much is the system's fault versus the individual's fault. and this is no shade on the chief wellness officers we've had on the podcast and also who are doing very important work at the policy level and the systems level, but that's one half of the story. The other half of the story for us as educators for the next generation is really increasing the awareness and like you're saying, slowing down to be able to reflect and have individual skills. We often, I mean, society really hasn't focused much on what are the individual skills that we have to be resilient and grateful. And, and I think, again, like we'll get into a lot of these things, but, but it's a two way street.

Carolyn Roy-Bornstein: Right. I mean,

Carolyn Roy-Bornstein: you mentioned skills and inner strengths, and I think that's one thing that reflective writing can do, narrative medicine can do, and that I see with the residents. our most recent session, I usually pick a theme that we talk about, and we were talking about silence in the doctor, patient relationship, and the discomfort of it, or the usefulness of it. And we had read a poem with regard that reflected silence, and then we were writing to try to connect our own clinical and personal experience to the poem that we had just read. And one of the residents was describing an experience where she sat quietly and silently with a patient and was just focusing on how it was really uncomfortable. It was really hard for her, and she really wanted to fill in and busyness of the day was weighing on her, but also just the discomfort of the silence. And, you know, at the end her colleague said, "You know, look what came out of that though. Look what your patient was able to reveal." And she was like, "wow! Yeah, I did that, I facilitated that." And just sometimes it takes a village to see our own inner strengths, but I think that that initial activity of reflecting and writing can help us identify those inner strengths.

Lillian Emlet: The gratitude gets a really complicated reputation in healthcare. Some people here be grateful and if they feel like leadership is trying to gaslight them about the system being broken, and you've really thought very differently about this. and as we think about how can we understand how gratitude really looks like as a leadership practice, what does it look like in the clinical environment that is objectively hard to name or to do for a leader?

Carolyn Roy-Bornstein: Yeah. I wrote about this in the Physician Leadership Journal last year. and I think what helps leaders understand is looking at the science of it, where evidence-based people we want to "show me the proof that this is working." and there is evidence, there's a Hong Kong research study looking at a gratitude intervention that showed, objectively, fewer burnout symptoms in physicians who did a very brief one thing about this Hong Kong study. It was a very brief, it was portable, it was private, and it was integrated easily into a busy day. So that was point that the researchers made in that there was a gratitude intervention using Martin Seligman's three good things you're grateful for each day. And nurses reported improved work-life balance they felt like, and improved resilience using these gratitude intervention. So I think the first thing is just, acknowledging that it is helpful and we know that physician wellbeing improving is helpful in terms of lowering medical errors, for example. So I think those kinds of things help leadership get on board, with it. And you know, in the article I talk about, you can start a meeting with a gratitude chain, just saying what everyone is grateful for. if it's the meeting is going to be a particularly contentious or a particularly challenging agenda, that can sometimes set the tone for it, but also just individually recognizing ideas and contributions, whether that's in a follow up email or whether it's quick drop in to the team member's office it goes a long way. everyone wants to be acknowledged or seen as Oprah famously said. Everybody just wants to be seen. and I think that goes a long way. And there might feel sort of performative at first, and it is if you're not that type of person who might look at something like that as more too touchy feely for me. So it can feel that way initially, but I think it takes time for the culture change. But with time and with objective, outcomes being followed, you can expect the culture to change. And, there might always be still some, a naysayer who again, is not quite on board. But even with naysayers, if we call out those ideas and contributions and name them and just believe in everyone's, contribution and, being part of the team, I think that can really go a long way.

Lillian Emlet: I love those. Those are just really simple meta awareness and making the what's already present and already people know it. so you're just sort of restating it so that people can pay attention to it and do the same to point out. For others and to pay it forward, I think, whenever, like it's just like in the Starbucks line, if someone pays it forward to you, you get a little glimpse of joy. of feel like, "wow, that was really cool. how else can I do it?" And so it is a little bit contagions. The fact that if you name and praise, then maybe somebody else might name and praise in your group.

Carolyn Roy-Bornstein: Well, there's actually in my research about gratitude, Barbara Fredrickson, who works out of the University of North Carolina Chapel Hill has a theory called "Broaden and Build" with regard to positive emotions and gratitude specifically. And as a young researcher, she was trying to fit her findings for positive emotion into the structures that existed for negative emotions where there's an emotion and action that is very narrow. If you're angry, you have the urge to lash out. If you're fearful, you have the urge to flee. Whereas positive emotions have a much broader repertoire of actions that come about after the emotion. For example, joy creates the urge to play, to be creative. and gratitude has probably the broadest actions of all like you said it creates the urge to pay it forward, either do a kindness, pay a kindness to the person who is kind to you, or just to seek out, she calls it 'elevation', just watching, others be kind ask us to stretch ourselves a little bit and be kind to others. it has legs, the gift that keeps on giving.

Lillian Emlet: Yeah, that's a challenge to everyone who's listening. You know, when you go to work today on your next shift, what's one thing you can just sort of notice and like actually not keep it in? I think a lot of us do notice things in others and are appreciative, but it's really just naming it outside so that everyone can see like, thank you for doing that, that really helped the family x, Y, Z. I see you doing the invisible work that other people may not recognize and it takes one second because the more you can just do one little one per day, or even notice. So again, just with noticing, so in the beginning, if you can't even notice that that's step number one, keep it to yourself and then when you're like, "Hey, I actually notice something every day." You won't be able to keep it inside to be able to like say something to somebody, even if it's just a colleague, even if you don't say it to the person. Because I think that's the next step, is you can like tell another colleague that this other particular human in your team was great or did something really wonderful. and then the very last is, be able to say it to the person themselves, but thank you for all of those tips. I'm wondering, you know, whenever we talk about these things with gratitude, it really is a skill for resilience. And 'resilience' is probably the most complicated word for me right now because I really do believe that the fact that resilience in terms of bouncing back better, even from the things that happen to us. what do you think, what do you think people get wrong about the word resilience in healthcare?

Carolyn Roy-Bornstein: Yeah, I don't see it so much as bouncing back. I think we think of resilience as, like you said it earlier in the podcast is taking it like how much can we take and still stand up? Whereas, I think resilience is so much more than that. It's looking at the big picture, it's taking perspective, it's creativity, it's flexibility, it's cultivating openness. Openness to novelty, to new situations. And you know, I think, I have two foster daughters and we wish we didn't have to be resilient. "I wish they didn't lose their dad. I wish they weren't in foster care." But they did. And they are, and they're beautifully resilient. and I think, also being asked to be resilient, if that's part of your institutions' wellness program is putting you in a resilience workshop. I think that can feel like, "why should I be the one working on my resilience when, I have an inhumane schedule? I have no flexibility. I can't pick up my kids." there are all these institutional system-wide issues that need to be solved. Why am I being asked to Be resilient and that's not wrong. The systems should look at, all those other things. But I think we're coming a partnership approach. Tait Shanafelt, who I'm sure you're familiar with at Stanford, has done a lot of work with physician wellbeing and he had great piece in the Mayo Clinic proceedings a few years ago talking about physician wellbeing 2.0, where we were and where we're going. And he talks about the, where we were as the era of distress. when, especially where it was just the goal seemed to be humiliate the medical student and resident and ask the questions until they don't know the answer or are in tears or whatever. you know, residency was rite of passage and you're on every other night, and that is slowly beginning to change, we're addressing workplace hours. Your institution at your critical care fellowship with its wellness or wellbeing curriculum is addressing it with fellows, which I applaud. so I think it's joint and I think, well, resilience is, even in an ideal practice environment, even if you have the perfect hours that you want and the all the time you need to see patients and do your work, we're still going to face adversity in our jobs, Because we sit with patients as they suffer and undergo traumatic events and pain and grief and loss, and we're still going to carry that with us. So, I think to develop a little resilience is still a positive thing on a personal level, and I think reflective writing can help with that in that we do have to absorb these stories. If you're familiar with Rita Charon, who named Narrative Medicine and who directs the program at Columbia. She describes a porousness that physicians have to have a permeability to take in these stories of suffering. And I think maybe we've become good at that, sitting with these stories and taking in these sufferings, but no one's ever taught us how to let it go. And I think writing can be that filter where we let go of this suffering, that it doesn't belong to us, It belongs to our patient. Yes. We have to hear it. Yes, we have to absorb it in order to understand the patient, get the diagnosis right. institute a treatment plan, but ultimately we have to let it go. And writing can help us do that while still holding on to those lessons that we learn from our patients. That wisdom that we gain from that relationship.

Lillian Emlet: So well spoken in terms of, you know, the realities. How do you hold both? And the realities, no matter what ends up happening in life, the reality is all of us have to be more resilient because life happens to us too. Like in terms of we become the caregiver, we become the patient, and things happen, and it becomes our story of our own suffering. And also how can we not allow others to be when we're the container to hold and to be the Sherpa to help people along to that not let that overwhelm us. And that is that really aggressive attention I would say, to self-care. Things like gratitude, things like what helps you process, what helps you regain your own professional self and identity. And you know, a lot of different educators have thought a lot about professional identity formation, like you said, culturally, generationally, you know, we have come from a different time compared to currently all the different generations in the workplace. and then we hear a lot of times our coaching clients, the reality is healthcare professionals are very compassionate with others. Everyone else hold everyone for everyone else, and then they often forget about themselves along the way. And so I'm curious, do you think the self-compassion actually makes us better leaders, better educators, better clinicians, not just happier people?

Carolyn Roy-Bornstein: I do, and that's been shown that Self-compassionate doctors manage stress better. Self-compassionate physician leaders, specifically, are able to pivot more easily when circumstances change so that that has been shown to be the case. But you're right, I think we're just traditionally really hard on ourselves and maybe we think we've had to be, to get where we are and hold ourselves to this super high standard, but it's not sustainable. And you're right, I think we show kindness and compassion to others in a way that we don't necessarily to ourselves. There's also Kristin Neff out of, UT Austin has done a lot of work with self-compassion, and she talks about self-kindness and also common humanity as a component of self-compassion, which is just understanding that you're not alone. That every person on the planet has come up short, made mistakes, it's not the ideal person that we have set ourselves to be at every moment. and that we need to recognize that or else we just become isolated and, isolation and shame is kind of that other end of that self-kindness.

Lillian Emlet: Yeah. that's a whole nother week again to a whole nother episode. We should have you back and talk about just connection and how do we find that connection. But I actually wanted to end our conversation about where you've said before, where you love to spend the most of your time, which is about joy, meaning, and flourishing. And you know, that's actually why we got into healthcare. Taking care of people. We can't help it. People who are in the healthcare industry, whether you're a nurse, physician, APP, we just love to help people. And so, I just want to talk about what it might look like for sustainability. And I think the route can sustain us for the long haul may be the thing about sacred moments in medicine. And can you describe what is a sacred moment? And maybe just share one that's either stayed with you or with one of the people that you've taught.

Carolyn Roy-Bornstein: Yeah, I'm not sure if this is what you're referring to, but there was just a recent article on Sacred Moments out of University of Michigan. They looked at over 600 internists and asked whether and how frequently they Experience sacred moments with their patients, and they describe it as 'brief moment of deep connection with a patient,' very simple definition, and over two thirds of the practitioners said, 'yes' they did. And when they were asked, "did you share it with anybody, did you talk about it with a colleague?" It was overwhelmingly 'no.' Which gets back to the point you made earlier about having these conversations out in the open, naming it, Christine Sinsky, who I think she was Vice President of Physician Wellbeing for the AMA. She wrote a commentary on this article and she made that very point that you made called it naming and norming. If we have these conversations to be able to talk about sacred moments. I think for me, we talked a little bit about agency, about taking control and one of the things, I talk about in the book is 'job crafting' and Shanafelt says, "he showed that if physicians are given 20% of their time to do what they're either passionate about or just like, whether it's teaching, whether it's administration, it's starting a book group literature and medicine group, whatever it is, I started doing home visits on newborns First time parents, I would go to the home." So one of the sacred moments that sticks with me is going to the home of a newborn whose mom, I took care of when she was born. we call them in my practice, I was in a two person practice and we called them "grand patients." So I was doing a home visit on one of our grand patients. and there was nothing remarkable the newborn was perfect. I did an exam. We talked about the usual anticipatory guidance. The mom made me coffee and we sat and had coffee and looked at this lovely newborn. But every time I did feel a deep connection, at that moment. and every time the mother came in after that, she'd say, "Dr. Bornstein, remember when you came to my apartment and we had coffee together?" And I said, "yes, I do remember." And so it wasn't about end of life or I guess it was beginning of life, but it was just this special connection that we had just from being outside of our typical. she had other children. Actually, she was new to my practice, but that was one sacred moment that that comes to me. But I think reflection, I wonder if the next step to that study would be looking at reflective writing and saying, "will that make us open to these open to recognize them or open to create them ourselves just by giving ourselves permission?

Lillian Emlet: Really wonderful. There's so many things in there. Obviously the reality is it's just really need to sort of think about the idea, like, having the flexibility as so as leaders as we are more creative to give people a little bit of wiggle room and not be overly prescriptive on what makes a excellent person in the group, gave you the freedom to be able to do something that in the end has long-term good ripple effects, In terms of a way early pioneer of what we now consider home care, And home-based primary care and so many other things now that, in terms of shifting things that are more patient centered, I mean, what you're describing was, I'm assuming, pretty early on in your career, in your practice, somewhere along the way. And just having the permission from a leader to be able to do something later on builds the the data, To show that you can deliver care in a different way. That's very human-centered and actually meets the needs of the community and provides you as the clinician the moments that you, you still talk about so many years later. And we have to now, by just sharing the story, you've now impacted many more other people to think about. "Huh? I actually do have these moments and maybe I could be a writer or maybe I should write just for myself. That's also completely okay. Not everybody wants to write for other people. Often writing is just for yourself. And most writers, good writers will tell you, "eh, it might get popular, it might not. I wrote this really just to be." and so I guess I'm wondering, you know, as we come to a close, if there's anything I've missed, what's one thing you hope for every listener to take away from this conversation we've had today?

Carolyn Roy-Bornstein: I would say just to not wait for someone else to give you permission, but to take your own permission to be imperfect, to be messy, to be creative, to claim joy, to look for those moments and claim those small moments of joy because that can feel like real agency when maybe nothing else is.

Lillian Emlet: And so I do want to mention that you have a new book that's coming out, "a prescription for burnout." It's restorative writing for healthcare professionals. It is literally a compendium of all different things, that people can do. And so almost like a work at home on your own kind of guide. And also for people who are listening who are in directors of wellbeing programs, narrative medicine programs, it literally is a guidebook that you can use with your programs. Can you tell us a little bit more about the new book you have coming out and how can people find you, follow along with what you're doing, book you to come to their organization?

Carolyn Roy-Bornstein: So the best way to do all of those things is probably through my website, which is, I'm sure you'll have in the show notes, but www.carolynroybornstein.com. and the book is coming out April 28th through Johns Hopkins University Press, and it's available for pre-order now. and I used Christina Maslach's, three dimensions of burnout as the structure of the book. I want readers to be on a transformative journey where they start out maybe, if not burned out, at least maybe disillusioned. but in the end, by the ending chapters. So the beginning chapters, we talk about stress and what it does to the body. We talk about suffering, we talk about bearing witness, we talk about trauma narratives, and secondary trauma. And towards the end we're talking about joy and creativity and mindfulness and all these more positive things, thriving and flourishing. So that's what I hope for your listeners and for my readers, is to not just manage stress, but to actually thrive and flourish in our work. Because I think what can be the most painful times where we're really with our patients as they're suffering are also the times that have the capacity to create the most joy and meaning for us.

Lillian Emlet: Totally true. Carolyn, this conversation has been such a gift. You've given us a language for things that so many of us feel that we, we struggle to name it. And that is really hard for many of us. and that is really important and thank you for sharing those glimpses in into your own personal story. because I think we also, when we see people who are before us role model that for us, it gives us permission as the younger generations to be like, "it's okay to talk about these things." And so thank you for talking about gratitude and resilience and you know, why we get into this work. You know, as a physician, a nurse practitioner, a PA, pharmacist, you know, we all have something to contribute, in the healthcare space. And so everyone, thank you so much for listening here To the end, if you'd like to find out more about Transforming Healthcare Coaching and our programs, please feel free to contact us at hello@transforminghealthcarecoaching.com If this episode resonated, please share with someone on your team who needs to hear it. Give it to your boss who wants to inform their Chief Wellness Officer, your local wellbeing lead. We really want the message to get out as there's different ways to participate and give resources to each other and begin to all change our narrative in terms of what we do together to be able to make healthcare a better place. Carolyn, any final concluding words or thoughts?

Carolyn Roy-Bornstein: stay present, stay in the moment, and stay joyful.

Lillian Emlet: Awesome. Thank you so much. Thank you everyone for listening and catch you next time.