Speak up or burn out.

A little over 50 years ago, the experience of some U.S. Forest Service smokejumpers showed that in certain circumstances, the best way to save their lives was to do something outrageously contrary to their natural tendencies.

In August of 1949, 15 men parachuted into a mountainous area of Montana to put out a growing fire. Within minutes the fire exploded out of control spreading at 660 feet per minute and threatening to consume the firefighters. They started running pell-mell toward a ridge, but when the crew foreman realized they couldn't outrun the blaze, he turned toward the approaching inferno and set the grass in front of him on fire.

As the grass finished burning he yelled for his comrades to drop onto the ashes to save their lives, but they kept running. In the end, the foreman threw himself into the burned out area and survived as the fire skipped over and around it, but 10 of his crew were killed before they could reach the safety of the ridge.

Unfortunately, like the Montana smokejumpers who were overcome, when people are placed in overwhelmingly stressful circumstances they frequently "run for the ridge." In other words, they tend to do things that actually put them at risk of greater harm.

Doctors are no different. The 2006 Physician Morale Survey by the American College of Physician Executives points to a growing combination of stressors that are overwhelming a disturbingly high number of doctors and physician leaders.

Challenges like patient overload, loss of autonomy, loss of respect, lower reimbursements, and bureaucratic red tape create a hostile environment for medical professionals that is so intense that three-fourths of doctors report having experienced stress-related problems.

Symptoms like fatigue, emotional burnout, marital and family discord, and even clinical depression regularly afflict more than half of doctors. The problems are so pervasive that 60 percent of doctors report having considered leaving the medical profession.

According to Christina Maslach, a professor of psychology at University of California Berkeley, and the leading researcher in the area of burnout, people cross the line from simple exhaustion to burnout when two things happen:

* Their relationships become increasingly depersonalized.

* They become chronically pessimistic.

When people withdraw from their relationships and become increasingly convinced of their own powerlessness, they enter a downward spiral of pessimism that can feel impossible to escape.

Like the smokejumpers facing fire, people become convinced that running away is the only available option. However, when physicians under stress take this route, they retreat from the only options that enable them to master their complex and stressful environment.

Stress becomes burnout

According to Maslach, when physicians' stress turns into burnout they experience depleted energy, lowered resistance to illness, increased absenteeism and decreased effectiveness on the job. Everyone suffers when doctors are trapped in this cycle of stress, withdrawal and burnout.

But not all doctors who experience stress are consumed in this cycle. Some cope well and remain resilient in the same environments that overwhelm others. Our research suggests that one significant key to coping with stress is akin to running toward the fire rather than running away.

Specifically, the best way to fight the creeping depersonalization and pessimism that underlie burnout is to take active steps to strengthen our relationships and increase our circle of influence. And the path toward both begins with investing time and effort in six "crucial conversations."

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It turns out that physicians who handle stress better engage more consistently and more effectively in six kinds of conversations that strengthen their social support systems and give them a greater sense of efficacy.

Here's a look at the six conversations that provide both inoculation and remediation against burnout.

1. Ask for support from your physician team.

Doctors who avoid burnout take the time to discuss creative ways of supporting and assisting each other so that the team deals with stress together rather than asking each to handle it alone. Often, they are able to find small adjustments that make big differences in lightening each others' burdens.

For example, one doctor reported that just getting a Friday off to attend an important family gathering was enormously helpful--even though her regular long workdays continued unabated afterward.

As doctors invest time in understanding the needs and concerns of their physician team, they develop creative solutions that help them cope better with unrelenting demands. Equally important, they build connections with others that reduce stress while avoiding the isolation that turns stress into burnout.

2. Step up to peer performance problems.

It isn't just unreasonable patient workloads that create stress. When peers fail to do their share--or are incompetent to do their share--it can pile resentment on top of stress. Too many physicians fail to confront and resolve concerns they have with their partners and peers.

Our research shows that most doctors allow their resentment to simmer for years before broaching these crucial conversations. The irony is that these doctors think they're avoiding stress by avoiding these conversations when in fact they are magnifying their stress many times over.

In our Silence Kills study (see www.silencekills.com), we found that doctors who more quickly and effectively confront performance problems with peers experience improved quality of work life. One of the best ways to avoid burnout is to address stressors over which you have some influence.

3. Influence nursing and other staff.

There are many actions nurses, ancillary departments, or other staff can take to lighten the loads of physicians. But many doctors fail to draw on this vital resource--to their own detriment. Instead, when under stress, some doctors actively burn these bridges either through neglect or through emotional outbursts.

Doctors who take the time to coach and develop support staff build a reserve of goodwill and competence that can ease their burdens. In addition, a few minutes regularly invested in improving the functioning of the team on which a physician depends is the key to substantially reducing the added stress that comes from mistakes, rework and disappointments when they fail to anticipate his or her needs.

4. Create optimism by exerting influence.

In an environment where bureaucracy is increasing and personal discretion is decreasing, it's easy to feel a loss of respect and control. Yet optimism and confidence in our own personal effectiveness are the most important bulwarks against burnout.

Most stressed physicians do the opposite. Resentment toward intrusive management and regulations makes them withdraw from dialogue with the administration and focus exclusively on their patients. As a result, their influence decreases. They then become increasingly resentful of their isolation and powerlessness.

Physicians who are able to succeed despite mounting bureaucracy do so by strategically selecting a small number of issues in which to invest themselves. They make time for the crucial conversations that increase their influence and maintain their optimism.

5. Above all else, maintain primary relationships.

When all else fails, physicians have got to have a nourishing place to renew themselves. The most insidious thing about burnout is that it is frequently taken out on those who are the last line of defense against it.

Never allow family or other significant relationships to deteriorate to the point that they become a source of stress rather than comfort. Wise physicians protect time with these primary relationships. There are inevitable periods when that time is not available, so they proactively prepare for those times by holding crucial conversations to prepare for them.

For example, when long hours or heavy responsibilities compete with family time, effective doctors don't wait for resentment to build and communication to deteriorate. Instead they discuss present relationship challenges with loved ones to ensure they maintain a sense of shared purpose through it all. They likewise discuss future challenges to determine how they and their loved ones will mutually cope with it.

Equally important, they make commitments in these crucial conversations to how and when they will return to some semblance of balance.

6. Ask for help.

For a variety of reasons, doctors are notoriously bad at asking for help. Even when they've held the previous crucial conversations consistently and well, they can still find themselves sinking into the abyss.

At these times, it's critical to fight the natural tendency to run all alone for the ridge. Instead, run toward those who can help. Ask for it. Acknowledge your needs and your problems. When a third of doctors report having been depressed and 1 in 20 acknowledge having had thoughts of suicide, it's time that we create a climate where it's okay to cry "uncle"--to raise your hand and say you need a break, you need to talk or you need counseling.

While it might feel like a taboo thing to say, it will save your health, it will protect your patients, and it may even save your life.

Our research suggests that far fewer doctors would suffer from burnout if they would engage regularly in the first five crucial conversations above. But even if the first five are held well, there will be times when asking for help is all that's left. Doctors must learn to speak up before they burn out.

Tips to get started

Some of these six crucial conversations can be tricky to navigate. For example, solving relationship problems at home or confronting a poorly performing colleague requires skill.

We've spent thousands of hours watching what doctors and other professionals do to succeed in these dicey moments. Here are a few steps that will reduce your stress and increase your chance of a good outcome.

* Don't wait until you're angry.

Less skillful people put off handling crucial issues until they can't hold it in any longer, and then they explode. For example, your spouse has been snipping at you about missing important family events for weeks. Your patience is diminishing. You feel unappreciated, blamed and defensive. Now is not the time to talk.

Despite the fact that this is when most people tend to finally speak up, the time to talk is when you see the problem emerging and have not yet become emotionally consumed with it. Stop making excuses for not dealing with things and you'll start dealing with them when they're emotionally manageable.

* Ask the humanizing question.

When confronting a colleague who's not pulling his or her own weight, don't open your mouth until you've opened your mind. When others let us down, we make matters worse by casting them as villains in our minds. We tell ourselves that they are selfish, egotistical, lazy, etc.

Sometimes these judgments happen so quickly that we aren't even conscious of them. If you find yourself losing patience with the person with whom you need to have a crucial conversation, this is a sign you need to change your view of him or her before opening your mouth.

Turn the person from a villain into a human by asking yourself, "Why would a reasonable, rational, and decent person do what this person's doing?" When you see your colleague as a person with a flaw rather than a villain with no soul, you'll approach him or her far more effectively.

* Start with safety.

Begin your crucial conversation by finding common ground. Demonstrate respect for the other person. Point out goals and interests the two of you share. When you do this before diving into a deep discussion of the problems, you create a condition of safety that enables healthy dialogue.

When you fail to do this, you commonly provoke defensiveness. Creating safety is the key skill for succeeding at crucial conversations. Doctors who do it best build the healthiest relationships and maintain substantial relationship reserves to draw on when under stress.

* Eliminate excuses.

In our Silence Kills study, we found that the most common reason doctors don't hold crucial conversations is that they tell themselves, "It's not my job."

For example, a nurse appears incompetent at her duties. A doctor who sees the nurses' problem most clearly is in the best position to give her helpful feedback. But he doesn't. Why? Because "It's not his job."

Interestingly, it wasn't just doctors who tended to make this excuse for not speaking up--administrators, nurse managers, and just about everyone found a way to rationalize away their responsibility to speak up.

Those who are best at holding crucial conversations don't consider whether it's in their job description to speak up, they consider whether it's in their interest to. So they tend to do so far more frequently.

* Dialogue not monologue.

Finally, the most skillful doctors we studied have a different goal in their crucial conversations. The less skillful come at the conversation as though it is a monologue. Their goal is to speak their minds and their hope is that the other person is committed to hearing them.

This egocentric approach to crucial conversations inevitably provokes defensiveness, convincing the doctor that it was a waste of time to even try. Doctors who seek out dialogue experience the reverse. When they come to the conversation willing to share their views but also sincerely interested in the perspective of others--in fact, intensely curious about others' realities--their openness invites openness in others. Their willingness to be wrong makes it safe for others to admit to shortcomings.

When your goal is dialogue rather than monologue, your crucial conversations tend to lead to mutual learning rather than dueling defenses.

The health care environment is likely to become more rather than less stressful in the future. The good news is that doctors who fight the natural human tendency to respond to stress by retreating from action and relationships can do a lot to keep stress from building into burnout.

Regularly engaging in healthy crucial conversations that strengthen relationships, improve teamwork and influence positive change can be enormously helpful in not only avoiding being consumed, but also in restoring much of the meaning and joy that attracted doctors to health care in the first place.

Joseph Grenny is the coauthor of the New York Times bestsellers Crucial Conversations and Crucial Confrontations. He is the president of VitalSmarts, where he leads a series of consulting and research projects on the role crucial conversations play in medical errors, employee retention, and patient satisfaction. He has also consulted with more than 300 of the Fortune 500 on corporate change initiatives over the past 30 years. Grenny can be reached through his company's Web site at www.vitalsmarts.com

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