9. The Master Skill of Taking Breaks

The thought of taking a break during a busy work day can sound impossible if not contrary to the ethos of our job. The reality, however, is that taking a break is not only possible, but will likely make you clinically sharper, more efficient, and possibly even happier. In this episode, Dr. Joshua Russell walks us through how to take a break within the constraints of our clinical responsibilities as well as pitfalls to avoid when taking a pause from patient care.

The importance of breaks.

• For those who feel depleted during their workday, taking a break can positively impact your affective state and ability to care for patients.

• By taking breaks, nourishing your body, being with co-workers, and talking about non work-related things, you will return to work feeling less drained and with renewed vigor.

• When you work in an environment where there is a paucity of natural break opportunities or an ethos and cultural expectation that you should just power through, you need to make a habit to ensure that the break happens.

There is abundant evidence that says that breaks are helpful.

• When you take an effective break, work tends to be more fun, you’re more efficient, and you often feel like you’ve taken better care of patients. While some might feel that it’s a sign of weakness to take a break, the truth is that it’s really a sign of maturity and an understanding our limitations as human beings.

• Medicine is a cognitively demanding job with no mandate or labor law requiring that we take breaks during our shift. Yet there is data supporting that doing so is cognitively beneficial.  

Cognitive psychologists have demonstrated that mental vigilance naturally wanes and decision fatigue sets in as the day progresses; nobody functions with the same efficiency throughout an entire day. 

• Data shows that towards the end of the day, clinicians behave differently and patient outcomes may be adversely affected.

  • One study of primary care clinics examined the rate of antibiotic prescriptions for cough in the afternoon versus in the morning. The rate of antibiotic prescribing was significantly higher among clinicians at the end of the workday. This is presumably due to decision fatigue and efficiency compromise that happens as our mental energy wanes.

  • Colonoscopists find fewer polyps later vs. earlier in the day.

  • There are more anesthesiology complications later in the day.

When we’re in a negative affective state (ie. a “bad mood”), our ability to be deliberate in our decision-making is compromised. Daniel Kahneman outlined 2 ways of decision-making and thinking:  System 1 and System 2. 

• System 1 thinking is fast thinking.  It is intuitive and takes very little energy.  This type of thinking is most appropriate for simple decisions or for patients with basic presentations. It is also the type of thinking we tend to use as our mood worsens.

• System 2 thinking is slow thinking.  This thinking is necessary for complex situations, where we need to deliberate the pros and cons of a case in order to avoid bias or falling into cognitive traps. System 2 thinking requires a lot of cognitive energy, and this energy may not be available to us at the end of the shift or when we’re in a sour mental place.

What does a healthy break look like?

• Don’t engage with your phone.  During your break, your mind should be in an unfocused state, in the “default mode network”.  In order to recharge the focus capacity of your brain so you function at your best when you return to work, you really need to not be focusing on anything when on your break -- in particular, you should not be on your phone.

• Listening to naturalistic sounds can activate the default mode network and parasympathetic activity in the brain.

• Get outside. The location of your break matters.  Whenever possible, get out of the care environment. The most regenerative location usually involves nature. If you can’t go outside, find a window to look out of or listen to nature sounds on a white noise app.

• Interact socially.  Social interaction can be beneficial, but avoid taking work discussions out of the care environment and into the break room.

• Meditate and breathe.  Sitting quietly with your eyes closed and meditating for a few minutes can help clear the mind.  Another exercise for calming the excited state is doing a series of breath cycles where you inhale for a count of 4, hold for a count of 7, and exhale for a count of 8.

• Try brief physical activity.  Exercise (such as pull-ups, push-ups, or jumping jacks) can be a great stress-reliever during a break.

Finding the time for a break takes intention.  Anytime you start a new habit, it’s important to make it achievable.  

• If you work in the emergency department, the goal may be a micro-break which should not meaningfully affect the tasks that you have to do.  It can be as short as 1-2 minutes taken every couple of hours.  Josh sets an alarm on his phone to remind him that it’s time to break.

• By taking breaks, you can experience the “fresh start effect” many times throughout your day. The motivation and vigor that you feel at the beginning of your shift can happen repeatedly.

Shownotes by Melissa Orman, MD

References:

Gould van Praag CD, et al. Mind-wandering and alterations to default mode network connectivity when listening to naturalistic versus artificial sounds. Sci Rep. 2017 Mar 27;7:45273.PMID: 28345604.