Reflection, resilience, relationships, and gratitude

As a dean of a college of pharmacy, I spend most of my days considering and tending to what I perceive to be the needs or well-being of our profession’s future—that is, our student pharmacists. As academic and practice leaders, we have an obligation to prepare them to be successful in realizing their individual career goals but also to ensure they have developed the framework or strategies necessary to sustain their passion for our profession over a career of 40 or more years, while continuing to be competent practitioners and accountable to the public they serve. As Jim McAllister¹ offered in his 2003 Whitney lecture, “We need to create partnerships with our colleagues in academia and other practice settings to ensure that future generations have the optimism, commitment, and stewardship to make our profession absolutely essential and its practitioners invaluable.”

But given the accelerating rate of scientific discoveries, the increasing complexities of therapeutic decisions, the staggering costs of healthcare and the complicated healthcare system, how will the competency of these future practitioners be measured? What will patients, the public, and other healthcare professionals expect from tomorrow’s pharmacy practitioners? I like to think that we no longer judge new pharmacists’ competency on their ability to memorize volumes of facts about the top 300 drugs and regurgitate them on a written examination. However, I am absolutely certain that future practitioners will be expected to interpret complex patient-specific genetic and disease-related biomarkers and integrate these with potential risks and benefits of various therapeutic options as well as the patient’s cultural values and wishes in order to define each patient’s optimal personalized therapy in terms of efficacy, safety, and cost-effectiveness. The bar measuring expectations and competency will only continue to rise. We do know that flexibility, innovation, and collaboration will be essential for future generations of pharmacists to lead the profession through changes that we likely cannot predict today.

I vowed to myself that I would try not make this lecture a trip down memory lane or an opportunity to advocate for my own personal agenda of the requisite changes or advances that will undoubtedly influence future practice. I did, however, take the opportunity to reflect on my own career, especially the sage advice of mentors and colleagues along the way—the inspirations, the successes, the failures, and the missed opportunities. From my musings, a few themes or strategies emerged that contributed to the framework that has sustained my passion—and I hope my competency—for our profession for more than 40 years. Reflection, resilience, relationships, and gratitude have tremendously influenced my career, but I readily admit that I wish I had given more attention to some of them, especially earlier in my journey.

Reflection

Reflection is used to influence our future by defining our understanding of where we came from and the measures of our successes, failures, and near misses. “Learning from experience” is fundamental to the education and training of healthcare professionals, but frequently that phrase is used solely in the context of repetitive activities: “trial and error” or “see one, do one.” Reflection in our professional and personal lives, however, should be a structured process of critical self-evaluation. It allows us to examine, understand, and integrate assumptions, core beliefs, attitudes and behaviors, and knowledge and skills in the spirit of improvement to define our plan for the future.² In order for reflection to affect our competency, self-confidence, and career satisfaction, it must be deliberate, sincere, and honest. It should force us to confront our egos and self-interests. Reflection must be based on a core of positive attitude and with a spirit of optimism in order to evoke creativity, enthusiasm, and self-confidence. As our professional experience matures, we naturally reflect not only on our personal development but also the challenges and opportunities of the profession and how we individually and collectively may influence the future. Reflection grounds us and tempers reactive decision-making to ensure a more considerate and insightful approach.

Mentors, colleagues, students, and residents often help in stimulating our reflections through probing questions and observations, and many use structured but simple questions to stimulate reflective thinking: What, so what, and what now? Where am I now, and where do I need to be?

Faculty, mentors, preceptors, and practitioners play pivotal roles in assisting students and new practitioners in developing their reflective habits. Reflection is an important aspect of being a professional and is especially vital for healthcare professionals, whom society depends on to ensure that all drug therapy is safe, effective, and accessible, and those who are embarking on a career that will be faced with countless ethical and moral decisions.

A frequently cited quote from Peter Drucker³ is to “follow effective action with quiet reflection,” and I would add to that, “Follow ineffective action with even more quiet reflection.” Many chief executive officers and other leaders readily acknowledge that breakthroughs, imaginative disruptions, and radical game-changing strategies follow systematic, structured periods of reflection.⁴ Reflection requires scheduled, uninterrupted thinking time and the self-discipline to avoid distractions, especially information overload, which has (sadly) become our cultural norm. As professionals, our reflections form the foundation of our resolution to improve, and our reflections are the source of our inspiration to tackle the next challenge. Our reflections are often the foundation of our resilience.

Stress and burnout have become an all too common theme of management and leadership publications, including those geared toward the health professions. Burnout is typically a result of too much time in the performance zone and not enough time in the recovery zone. Burnout is characterized by emotional exhaustion, cynicism, depersonalization, and declining effectiveness.^5,6 Burnout among health professionals has been associated with detachment from responsibilities (including patient care), loss of empathy, impairment in self-care and well-being, reduced productivity, and risks to patient safety. In fact, well-being of the workforce has been cited as a critical issue in health care.^7–10

We can make the same arguments that environmentalists do in the context of sustaining natural resources such as oil and clean water: If our use of them is unlimited today, will there be sufficient resources for the future? Our individual energy, creativity, and stamina are also precious commodities, but if we continuously increase the demand for productivity without intermittent renewal, we may not be able to sustain our performance.

Resilience can be defined as the ability to recover or bounce back in a healthy, adaptive way after experiencing challenges or stress; resilience is an important “emotional competency” because resilient individuals typically grow stronger in this process of renewal.^9,11 Resilience enables us to recover from setbacks, adversities, stress, information overload, seemingly uncontrollable work and personal responsibilities, and continuous cognitive arousal. Resilience enables us to be creative, adaptable, responsive, and responsible. Ample evidence exists to confirm that pharmacy practitioners today—and even more so in the future—will need increasing resilience as healthcare becomes increasingly complex.

Resilience is a learned skill that requires work on the part of the individual but also acknowledgment and encouragement from leaders, supervisors, mentors, colleagues, family, and friends. How can we model strategies to assist our students and residents to develop and deploy the resilience to sustain their career satisfaction, optimize performance, and ensure their well-being?

We can start by examining our current expectations of their responsibilities as students, residents, and new practitioners and help them facilitate a reasonable balance in their professional and personal lives.

We can be role models by “owning up” and admitting when we are affected by stress and acknowledging the difference between our adaptive and maladaptive responses to stress. We should not hide our need for downtime and recovery.

We should encourage meaningful reflection as an important habit that promotes resiliency. Reflection gives us pause to process emotions and cognitions such as appreciating multiple perspectives, and it provides protection against stress and burnout. Similarly, we should encourage informal practices to promote self-awareness, such as slowing down when necessary and clearing one’s mind; setting boundaries regarding one’s job; and establishing enough time for sleep, exercise, relaxation, and personal relationships with family and friends.

We need to regularly reinforce that our careers are not a sprint, but rather a decades-long marathon. We should not submit to pressure to accomplish all of our professional goals in an unreasonably short time frame, and, most importantly, we should not be the preceptors, supervisors, or teachers who are encouraging or demanding such performance. Lastly, we should set recovery as an expectation for all those individuals within our organizations. Resilience is an essential characteristic of individuals and essential to our teams, workplaces, and professional organizations.

This brings me to my next theme: relationships.

Relationships

Healthcare is unequivocally a team activity. We typically think of our teams as groups defined by our employment responsibilities: our pharmacy department, the clinical service to which we are assigned, our faculty, or our leadership team. The landmark publication of To Err Is Human: Building a Safer Health System¹² brought international attention to the importance of working interprofessionally as a team in the context of patient safety, and many other reports since then have underscored the importance of team skills to optimize patient care as well as productivity and efficiency. Beyond the cohesiveness of the team, in order to achieve its responsibilities and demonstrate quality performance, it is often those interpersonal relationships with our team members who provide us with constructive feedback and moral support that have significant influence on our individual professional growth and success. I consider myself extremely fortunate to have had the opportunity and honor to work among consummate professionals throughout my career who understood and lived the mission of their organizations and epitomized team skills.

While none of us could deny the importance of the teams with whom we work in defining our professional growth and competency, I think it is equally important to recognize the value of the many other types of professional relationships that have helped us to define our professional identity, enrich our careers, and be mindful stewards of our profession. While we often emphasize the importance of networking outside of our workplace to our student pharmacists and residents, we probably do not adequately characterize the power and influence of the professional relationships we build, nourish, and sustain throughout our careers: the colleagues and friends who have been our sounding boards, our confidants, and our moral compasses—those individuals who help us to define our professional identity and inspire us to think big and to do good. Professional relationships that developed because of common professional interests or agendas, work in our professional organizations, and sometimes just serendipity that brought us together.

Of course, I cannot discuss professional relationships without acknowledging the importance of our professional membership organizations. To quote a term recently cited by Harold Godwin in his Remington Honor Medal Address earlier this year, I too am an “organizational junkie.” Throughout my career, I have been actively engaged in pharmacy and multidisciplinary health professional membership organizations and volunteer activities. These organizations are where many of my professional relationships developed and have been essential in my professional growth, motivation, and career satisfaction. But most importantly I fully realize that the collective accomplishments of our profession, our right and responsibility to ensure that every single patient has access to safe and effective medication therapy, and our ability to fulfill our societal responsibility to promote public health and welfare would not be possible without these organizations. It is the collaborative expertise and focus of our membership organizations that define our best practices and also build the framework of resources to ensure that as individual practitioners, leaders, and organizations we can each realize these best practices. Our organizations provide us a forum to discuss our ideas, share our insights, and report the outcomes of our research and experiences. It is our organizations that advocate for our profession, our practitioners, and, most importantly, advocate to ensure that the public we serve has access to high-quality medications and pharmacist care. Engagement in our organizations has enabled many of us to develop leadership skills, the privilege to engage in organized and spirited development of professional practice policies, and the ability to collaborate with professionals representing a diverse spectrum of practices. To me it is undeniable that, directly and indirectly, both dues-paying members and nonmember practitioners depend on our organizations for most of their continuing professional development throughout their careers.

Although many of our student pharmacists and residents are actively engaged in professional organizations during their education and training, many drift away after graduation. A surprisingly low percentage of licensed pharmacists belong to even 1 local, state, or national pharmacist membership organization. Why is this so? What can each of us do to change this?

There has been much suggested about the impact of technology and social media on our professional relationships and organizations. While technology applications and social media platforms have unquestionably allowed us to share information and provide feedback more easily and more quickly and to more diverse groups than most of us could have ever imagined just a few decades ago, the connections formed are often distant and diluted. Facebook friends should not replace the need for sustained and valuable professional relationships and cannot supplant the value of our professional organizations. Rather, we need to continue to optimize these applications as enhancements to our professionalization and continue to mentor our students, residents, and younger colleagues to seek out ways to build and maintain strong professional relationships.

We also have the responsibility to facilitate their engagement in organizations, providing encouragement and incentives and teaching the practical aspects of how to balance their job responsibilities and workload to ensure that they can have the time and energy to serve their organizations without sacrificing family responsibilities and social relationships. To appreciate that annual dues for 1 or several organizations is a very small investment in a practitioner’s career, given the compensation of a pharmacist and the potential return on investment. In 1976 when I was a pharmacy intern at the Fayette County Memorial Hospital in Washington Court House, Ohio, the hospital’s only pharmacist, Jerry Ragland, paid my first year’s dues to ASHP. I am pretty sure that at that time, Jerry had never attended an ASHP Midyear Clinical or Annual Meeting, but his practice was strongly influenced by the American Journal of Hospital Pharmacy and other ASHP publications, on which he regularly relied. He explained to me how being a member of ASHP would provide me with valuable resources as an aspiring hospital pharmacist. I believed him and followed his lead; 19 years later I was president of ASHP.

It is not often in our career that we have the opportunity to take the podium and address the profession, and as I continued to ruminate about this address, the significance of these professional relationships emerged as an important theme. I fully realize that it has been these collaborations and friendships that have defined me as a professional, sustained my passion for our profession, and partnered with me in every single accomplishment. Without these relationships my career would just have been a series of jobs.

This brings me to the final theme: gratitude.

Gratitude

Gratitude has been defined as the appreciation of what is valuable and meaningful to oneself and as a general state of thankfulness or appreciation.¹³ Increasingly, evidence has demonstrated the positive benefits of both expressing and experiencing gratitude, including psychological well-being, enhanced optimism, and life satisfaction.^14,15

Everyone has the innate desire to feel appreciated and valued by others, and hopefully we each work to foster a culture of value and appreciation in our organizations. Many studies have demonstrated that signs of gratitude promote prosocial behavior—that expressing gratitude to a person not only increases the likelihood that they will help you, but also that they will help someone else; they will pay it forward. Gratitude is the gift that keeps on giving. When we feel valued, our job satisfaction is higher, we are willing to work longer and harder, and we are more motivated to work collaboratively to achieve common goals.¹⁶ In fact, sincere expressions of gratitude have been associated with lower levels of burnout and increased resilience among employees.¹⁷ Likewise, regular, focused reflections of gratitude help us to define what is valuable, meaningful, and fulfilling.^18–20 Daily entries in gratitude diaries have been shown to improve mood, coping behaviors, and, possibly, symptomatology in physical health.²¹ A few minutes several times a week spent reflecting on what we are truly grateful for is time well spent and another important strategy that will serve us all throughout our careers.

It is not often that we have the opportunity to publicly express our most sincere gratitude to those who have influenced our lives and careers—those who have mentored us, critically and constructively offered advice and direction even when we did not know we needed them, inspired us to do what was right and in the best interest of our patients, our students, our colleagues, and our community, and those who consoled us when were overwhelmed or unsuccessful but then pushed us to move on.

I would like to express my sincere gratitude to the prior recipients of the Harvey A. K. Whitney Lecture Award for providing me with this opportunity to share my reflections with you.

I spoke earlier about the importance of professional relationships, and for me there have been many. It is impossible to acknowledge all of them this evening, but I am grateful for what I have learned from each of you, for your collegiality and friendship, for your inspiration and dedication to those we serve. I cannot begin to imagine what my career would have been without you. Beginning with my early mentors who influenced my career far more than they could ever know: Jerry Ragland, Harvey A. K. Whitney Jr., and Bob Williams, who I imagine still thinks of me as his most challenging resident ever.

A very special thank you to my Jefferson team—Stephen Doll, Elena Umland, Mary Hess, Cindy Sanoski, Gerry Meyer, Brian Swift, Alok Bhushan, and the faculty, staff, and students. Together this team has built something very special. Sara White, Pat Chase, Patti Kienle—very special friends brought together through ASHP—who have inspired me, mentored me, and tolerated me for more than 30 years. I also want to recognize Laura Mandos, Lisa Lawson, and Gene Gibson—my most cherished friends who have encouraged me, provided much entertainment, and been at my side during life’s happiest and most difficult moments.

In the 1970s when systemic cancer therapy was just emerging, I joined a truly exceptional team at the Baltimore Cancer Research Center. From day 1 it was apparent to me that everyone shared a common vision and mutual respect. It was truly an interprofessional team. The Baltimore Cancer Research Center (later the University of Maryland Cancer Center) is the place that I personally regard as ground zero for oncology pharmacy practice under the leadership and vision of Clarence Fortner. When I arrived in the 1970s, pharmacists were responsible for direct patient care; they were respected and held accountable as essential members of the team. They researched and published their work, and they enthusiastically networked with the handful of pharmacists across the United States who were assuming greater responsibilities in cancer care. For a new practitioner who had a lot of interest but not much experience, there could not have been a better mentor and teacher than Clarence. I am truly grateful for that career-defining opportunity but far more grateful for the time we shared together some 30 years later.

Conclusion

I now appreciate that ensuring competency and sustaining passion for our profession over the course of one’s decades-long career require much more than 30 hours of continuing-education credits every 2 years. Structured reflections, resilience strategies, building and sustaining positive professional relationships, and regular reflection and acknowledgment of gratitude bring unequivocal value to our careers. It is our inherent responsibility to demonstrate, encourage, and facilitate such life skills for our students, residents, and new practitioners so that they will have the commitment and resilience to lead the profession through unpredictable change and ensure that safe and effective medication therapy is accessible to all.

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