Physicians, nurses, and other healthcare professionals currently live and work in a culture with more stress, isolation, moral injury, and burnout than any of us might have imagined at the beginnings of our careers. Whereas burnout implies deficient resilience on the part of the provider, a better description is moral injury, which identifies health-system factors that add tasks and time to providers' workloads but without the needed resources, such that providers cannot meet their professional expectations. Physicians, nurses, and other medical providers are increasingly challenged to take on excessive, granular electronic health record documentation; navigate the multiplying administrative barriers to care; and address the growing complexities of our patients' circumstances but find themselves trapped in a working environment that hinders their success. Doing more with less in medicine is like trying to place a square peg in a round hole. Emotional exhaustion, depersonalization, and a low sense of accomplishment inevitably follow.

Corporate changes in the practice of medicine and the COVID pandemic have further exacerbated this moral injury and degraded the provider experience. Nevertheless, each of us seeks a way to live in the current environment, carry out our professional commitments, find meaning in our work, and maintain balance in our lives. Expert groups, our professional organizations, and our health systems have attempted to provide support to their clinicians and employees. They have offered well-meaning suggestions and tried to improve work system factors. The medical work environment, however, remains challenging, and there are no breakthrough solutions close at hand, or even on the horizon.

In this article, we articulate three professional themes that we have found useful to help ourselves and colleagues navigate these difficult professional times, enjoy meaning in our work, and resist burnout: building connection with patients, conscious empathy, and intentional professionalism.

BUILDING CONNECTION WITH PATIENTS

We physicians, nurses, and healthcare professionals have a unique role in society of affirming to our patients their value as human beings and our high regard for them. Regardless of the challenging work environment, each patient encounter is an occasion to lift the heart and soul of the person in front of us and to ease mental and emotional burdens as well as physical symptoms. We providers may have all too little control over the schedule and requirements of our workplace, but we can control our own response to each patient during a visit. Although circumstances may conspire to indicate otherwise, we can treat our patients not as a diagnosis code, a level of care documentation, or a chart note to be completed, but rather as a person with whom we connect and about whom we care.

How do we make this caring connection with each patient in each encounter? One strategy that has helped the authors and many others over the years is mindfulness practiced consciously and consistently. The essence of mindfulness in the patient encounter is intently focusing our attention on the patient in front of us in the present moment, avoiding distraction from other thoughts or needs. When providers are particularly mindful, the patient experiences the provider's complete attention, and the provider vividly experiences the patient's emotions and viewpoint. Mindfulness occurs naturally to some degree, but it can be improved and developed by any healthcare professional.

We cultivate mindfulness for our own benefit as well as for our patients. One can build reminders into the office encounter routine to help with focus on the patient during the encounter. There are many books and courses available on mindfulness-based stress reduction and smartphone applications, such as Headspace and Calm, that guide an individual to learn and practice mindfulness. There are also heart rate variability smartphone applications that use paced breathing and biofeedback to develop mindfulness. An excellent example is HeartMath (http://www.heartmath.com). Regardless of the approach, the tone of the encounter is set by the provider, and we can choose to make the most of the moment.

CONSCIOUS EMPATHY

Empathy is the ability to understand and share other people's feelings. It enables us to perceive the emotions of others, resonate with them emotionally and cognitively, understand their perspectives, and distinguish between our own and others' emotions.1 When providers are particularly empathetic, they pick up on the patient's emotional cues. As a result, patients are more comfortable sharing their concerns, and providers can better ally themselves with patients in therapeutic partnership. Empathy in healthcare professionals has been extensively studied, can be measured, and can be improved by training.2-5 Provider empathy correlates positively with patient satisfaction, patient outcomes, and provider satisfaction.3,6-8

However, physician empathy decreases during medical training.9,10 Like mindfulness, empathy occurs naturally but can be further developed and enhanced by any healthcare professional. We recommend The Empathy Effect by Dr. Helen Riess and Empathetics (http://www.empathetics.com).11 Activities to develop our empathy help us grow professionally and foster our own personal gratitude for the professional experience and opportunities we enjoy.

INTENTIONAL PROFESSIONALISM

Intentional professionalism can also be called a culture of vulnerability and self-compassion, or "well-being 2.0."12 The adverse changes in the medical provider experience that have evolved in the 21st century and worsened in the COVID pandemic years will not disappear anytime soon. The time constraints, financial pressures, and tedious documentation will continue. Efforts to improve provider resilience will do little good and may backfire. Health system efforts to improve work system factors will continue to be modest and incremental.

Intentional professionalism recognizes these difficult realities but encourages the medical provider to move forward with adjusted expectations, a renewed sense of changing what one can and accepting what one cannot, a focus on one's professional excellence within the limits of a reasonable work-life balance, and a commitment to support one's professional community and patients. Intentional professionals know the value that they bring to healthcare, appreciate their opportunities to bring a caring interaction to the sometimes-indifferent world of healthcare, and cheerfully share their purpose and hope with colleagues and patients. Intentional professionalism is not created by a health system training module or a continuing medical education course. It is up to each provider.

A PERSONAL EXPERIENCE

As an author of this article and a doctor for the past 50 years, I have treated thousands of patients, but 8 years ago I became a patient myself and underwent surgery for renal cell cancer in my left kidney. All went well with the surgery, and I was referred to an oncologist for follow up. As I sat in the waiting room, my mind wandered and provided images of "what if!" Finally, I was led to an examination room and again waited for the oncologist to come in to discuss next steps. As the doctor entered, a calm came over the room as he proceeded to introduce himself and ask questions regarding the status of my health issues. Everything seemed to disappear and the only awareness I had was being in the moment with only the doctor, my wife, and myself with no outside interference. We became the only people in his world! The doctor was there to inform and educate. It really did not matter how many patients were in other examination rooms or the waiting room. This atmosphere continues with each follow up visit to this day.

The lesson learned is that we doctors can build a connection with our patients by understanding and sharing feelings. All the outside pressures will remain around us but focusing on the patient during the encounter can help us both.

CONCLUSIONS

In the authors' experience, the mindfulness, empathy, and strong motivation that bring people to medicine in the first place serve us well as we adjust to these extraordinary changes in the healthcare workplace, seek meaning and value in our work, care for ourselves, and resist burnout. Our professionalism is our best protection against burnout. It is ours to preserve and we need not surrender it.

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