Abstract
Keywords
“The poor health of physicians is an elephant in the room of US healthcare.”
Introduction
A physician struggling to accept his or her own emotional and physical exhaustion might appear disheveled and fatigued, facing the ever-demanding workload. But for every unkempt physician noticeably struggling with the demand for documentation and metrics, there is a silent sufferer balancing the responsibility to both patient and self. Physicians almost habitually sacrifice self-care to satisfy the demands and complexities of patient care and home responsibilities. Though specialties report different average rates, more than 60% of all physicians will experience burnout at some point during their medical careers. 1
The complex phenomenon of burnout greatly impacts physical and mental wellbeing. Freudenberger traditionally defined burnout as three-dimensional, with emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. 2 Maslach similarly described the condition as the combination of exhaustion, cynicism, and inefficiency. 3 Burnout tends to escape the individual physician and bleed into his or her environment in the form of increased rates of medical errors, complications arising from patient turnover events, increased rates of negative patient outcomes, and decreased reports of patient satisfaction. 4
In 2009, Eckleberry-Hunt and colleagues 5 note a focus within medicine on burnout itself, rather than the arguably more important goal of wellness. They defined wellness as “a dynamic and ongoing process involving self-awareness and healthy choices resulting in a successful, balanced lifestyle” and devised a “Wellness Toolbox” for understanding, defining, and promoting a “culture of wellness.” 5 The conversation on burnout and wellness has shifted, with increasing interest in resilience, thriving, and flourishing. 6 Numerous research efforts have focused on system and personal strategies to reduce burnout prevalence. Newer efforts focus on improving physician wellbeing, but with somewhat discouraging efficacy results; many system efforts show only modest improvement in aggregate burnout/wellness. 7 Areas described in an analytic review in the American Journal of Lifestyle Medicine to guide individual interventions and improve lifestyle changes included the following: managing stress strategies, avoiding substances, eating healthy, increasing physical activity, improving sleep, and developing healthy relationships. 8 Our team sought to understand if these pillars have helped guide physicians on their path to optimal wellness.
The purpose of this study is to obtain granular data on perceptions of individual physicians approaching the concepts of “health” and “burnout,” determining which behaviors, beliefs, and system changes facilitate the transition from poor health/burnout to wellness. Although the focus continues to shift from burnout to wellness, providing some insight into how individuals and systems reduce burnout, 9 we found no publications related to the individual physician’s transition from poor health to optimal health. Through interviews with both attending and resident physicians, this work explores the individual physician’s “Path to Wellness.”
Methods
Setting and Participants
The research team recruited a convenience sample of physicians within one academic medical institution via email distribution of a campus-wide wellness newsletter. Sent to all resident and attending physicians, the email informed participants, “We are looking for doctors who have made the transition from poor health to good health. This could mean overcoming burnout, overhauling physical health, or any other interpretation of going from unhealthy to healthy. We would like to look for patterns and provide this evidence to all healthcare professionals as a potential model for improving health.” Interested physicians responded to the email and interviews were coordinated based on availability. Enrollment was also dependent on word-of-mouth. Prior to the interview, participants were informed about the research purposes, interview discontinuance, and human subject protection requirements from the university’s IRB. This study was approved by the University of Louisville (IRB # 21.0178) as exempt.
Interviews
The study utilized a qualitative approach. One-on-one, in-depth, semi-structured qualitative interviews with physicians were conducted on aspects related to respective journeys towards optimal wellness. The research team developed de novo questions (Appendix A) to understand behaviors, beliefs, and system changes that may best facilitate the transition from poor health/burnout to thriving. The study team met prior to conducting interviews to train interviewers. Interviews were conducted using virtual video conferencing with Microsoft Teams software, which provides automated transcription. The interviews contained scripted questioning but was also conversational in nature. The interviews were scheduled for 30 min, with the longest interview lasting 40 min. The team offered no incentive for interview participants. Interviews took place from April 27th, 2021 to May 25th, 2021.
Analysis
Descriptive statistics were used to provide sample characteristics. For dependability, two research team members independently coded the comments. These two team members, authors MZ and JK (a resident and medical student), met and were trained prior to analysis. These individuals utilized a codebook to provide themes to the entire research team for discussion of which facets were prevalent from both coders for reliability. Codebooks, (which detailed the code, definition, and example), were made as specific as possible in order to ensure consistency. For transferability of the qualitative themes, we have provided direct quotations with thorough descriptions of the viewpoints.
Results
Coder Results.
N = Total times code was used – multiple times within one interview; % = Percent (out of 14 interviews) theme emerged.
Wellness: Support System
Participants noted the importance of a strong support system on the path to wellness. Subjects relied on their social safety net when struggling and outlined how spouses, colleagues, or others supported their goals towards a path of superior well-being. Physicians noted importance of finding those with direct experience of burnout/poor health or who can at least provide general support. “I think I would encourage physicians to not see the recognition of depersonalization and emotional exhaustion as signs of weakness… Except that that can happen to you. It can be insidious and you need to talk to somebody, if not your spouse, somebody who can help you see it for yourself and begin to make a plan for how you going to move through that.” – Interviewee 11 “I think a very strong discipline on time management and securing enough time for your exercise, and following food recommendations, and family input and one of the strongest factors has been the entire family together doing something. So, when you want to be healthy and the rest of your family wants to eat, you know French fries and whatever it kind of doesn't work like that. So, you have to have a buy in by the entire family and I think that's been the strongest mover for me throughout this whole process.” – Interviewee 3 “the female physician communities have been great, so there's Facebook groups for like female doctors who ride peloton and they will post like workouts. And then just my own group of physician moms, because I feel like it's a really small subset and of people that kind of understand how difficult it is to have young kids and be a physician, and you gain so much weight there.” – Interviewee 1
Wellness: Exercise, Nutrition, and Sleep
Emphasis on exercise, nutrition, and sleep repeatedly surfaced for many physicians. Exercise allowed individuals to reduce stress and feel good about themselves. Physicians outlined the importance of healthy eating behaviors and sleep hygiene in wellness routines. “…the other big thing I did is I joined a CrossFit gym here in 2019 and that's something I did back in medical school that I really enjoyed. So, after you know, two years of not doing it just felt good to be able to go to schedule a class with a bunch of people who, and you know, sometimes throw some weight around doing high intensity workout. And it just it was almost like stress relief to me and it felt better being able to move again on a regular basis and, that being said, you know there were days, where I would still get calls from work while I was at the gym or I would get called back in from the gym. But those were at least fairly few and far between.” – Interviewee 6 “I’m big on yoga and mindfulness. Which are things I’ve cultivated from over the years. It’s also what I’ve learned from friends who have transitioned out of medicine and still appear to be healthy. I prefer to do yoga, mindfulness, awareness. Healthy eating is a big focus of mine. I understand nutrition is important for physical and mental wellness. Those are the things I engage in when I try to get myself out of a burnout state or try to state in a healthy state.” – Interviewee 10 Sleep feels totally out of your control in residency and having children on top of it, but as an attending I make sleep so important. I feel so much better having sleep on a regular schedule.” – Interviewee 2
Wellness: Finding a Routine that Works Well for You
Physicians discussed development of strategies to stay on track with healthy behaviors. Subjects described making lists with goals, tracking progress, being deliberate in planning and evaluation of what does or does not work. Physicians noted importance of finding individualized strategies for progress towards change in oneself. “I take a piece of paper and I take a ruler and I take a pencil and I'll make a grid Monday, Tuesday, Wednesday, Thursday, Friday. I write down who I'm working with and when we have noon conferences. I write down here where I'm working out for Orange Theory, fitness and write down a bunch of to dos. I make one of these every week… So basically, on the weekend on a on a Sunday or even maybe on a Saturday you sit down and make this list and you conceptualize your week, and, you look at the immediate prior one.” – Interviewee 8 “Well, when I'm at my best, I always like to write things down and I keep track of things. But I have goals like whether it's you know, working out, nutrition and I definitely prioritize my sleep now to the extent that I can.” – Interviewee 9 “it takes a big commitment to change. And, really, you have to be deliberate and making time for yourself.” – Interviewee 14
Wellness: Cognitive Reframing and the Importance of Reflection and Self-Awareness
Subjects described the difficult career path of a physician facing stressors, many of which fall outside of one’s control. Physicians outlined how self-reflection, awareness practices, and cognitive reframing benefit mental health. The physicians described how one’s interpretation of and response to challenges is critical in facing mental hurdles. “one of the real scary things in medicine is you know, the number of people that end up with substance abuse, higher suicide rate, etc.…And you know it requires to be in the to be in the healthcare field as a position requires a certain amount of mental toughness, but I think the other change, you need to make is you need to understand when you're vulnerable you can't assume I’m tough I can get through everything and to look for help from your friends and family when you need it.” – Interviewee 5 “…the ability to look at situations in the positive light, or when there are challenges it's not like they're sweeping them under the rug by any means, but they look at opportunities, you know they see challenges is opportunities, instead of threats. And whether they actually have a mindfulness or meditation practice I wouldn't always necessarily know. But that ability to have that sort of emotional self-regulation, so instead of spiraling downward into negativity or anger or ranting they just seem to have that ability to maintain a sort of calm demeanor in the face of stress and recover quickly…” – Interviewee 13
A major finding from interviewees related to the importance of finding purpose outside of one’s career, separating work from personal endeavors. Subjects sought to find “work-life balance” with dedicated personal time devoted to meaningful activities to maintain holistic wellness. I would say to be healthy for me is to have work life balance so not taking work home and not worrying about kids’ stuff at work. – Interviewee 1 I really think it's because as a profession, we've been geared so much to work, work, work, work, work and not do anything for ourselves… Most important thing is you have to take time for yourself. You have to schedule time for yourself and make sure you do something in that time that you like. – Interviewee 7
What is “Well” is Unclear
Finally, physicians described a lack of clarity on what it means to be well. Wellness optimization remains subjective as it continues to evolve, comprise of many dimensions that include both physical and mental well-being. “Someone with optimal wellness has many dimensions to them. The wellness I see is that people thrive at work and they show up with the passion and the energy and focus to be there, but also, the ability to leave it behind and transition to other parts of their life so they can come back refreshed. That you aren’t dependent on the need to control work, because you can’t. But if you can counter the frustration of work with other healthy practices, then you can maintain a healthy mindset. So, you’re patient, and curious, and not afraid of failure. Because if one thing falls, not everything falls. – Interviewee 2 I think healthy the term healthy, to me, is a mindset, I think it encompasses both physical and mental wellbeing, and I think it is an idea that a person has… Like I said a mindset in which somebody feels like they're healthy is what they feel like is their general wellbeing, and so I think it's a multi-faceted… I think it's evolving; I think it changes, I think that the recommendations are where they are now, but I think that's also always changing so I think that when you think about healthy it all has to encompass everything that you know, plus what might be coming down the line.” – Interviewee 4
Discussion
This study provides qualitative data on direct experiences of physicians who transitioned from poor to optimal wellness. Having reached what they defined as a low point in personal wellness (physical [weight gain, poor exercise] or mental [burnout, depression]), subjects described key strategies that directly led to improved health. Physicians lead stressful careers, spanning several decades or longer and requiring an enormous amount of investment and commitment to initiate and successfully maintain. They work closely with diverse individuals and are frequently exposed to the brightest and darkest aspects of the human experience. Most if not all regularly choose to place the health and wellness of their patients before their own while working long hours and spending time away from family and loved ones. For these reasons, many physicians struggle to nourish their own wellness and succumb to the effects of burnout and poor health. This study provides first-person experience from physicians who have successfully taken control of their own health.
The poor health of physicians is an elephant in the room of US healthcare. Would clients take advice from a financial consultant who cannot successfully manage his own money? Physicians vary in perceived barriers to personal health, with poor attention to their own preventive care 10 and scant primary care establishment, due often to long work hours and cultural norms. 11 Physicians 12 (and medical students 13 ) who practice healthy behaviors are more likely and more successful in delivering these messages to patients.
Physician burnout has been attributed to external factors affecting the wellness of the physician: decreased time spent with patients, burden of documentation and demand of the electronic medical record, increased bureaucratic oversight with loss of physician autonomy, longer work hours, poor sleep habits, educational debt, and hero mentality that remains prevalent in medical culture. Current research and commentary publications continue to highlight the system factors that lead to burnout.14,15 However, it is important to also recognize the internal factors affecting mental health and how dysregulation increases the risk for burnout.
Job demands and exposure to trauma intrinsic to the care of sick patients can deter physicians from acknowledging their suffering and asking for help. Each year over 400 physicians—nearly 2.5 times the average medical school graduation class—take their own lives. 16 Physician burnout has a negative impact on patient safety and quality of care. 17 Burnout presents medicolegal risks for physicians and hospital systems due to negative patient outcomes and potentially poor physician-patient relationships. Physicians suffering from burnout have a 17% increased risk of being named in a medical malpractice suit. 18 Physician burnout is projected to continue increasing as persistent waves of COVID-19 demand increased hospital resources due to unrealistic patient volume, overloaded intensive care units, compounded by social isolation and fear. 19
With the overproduction of research on factors contributing to physician burnout, and some optimistic work on its prevention, more research should focus on how physicians can rise out of this undesirable state. 20 Active interventions to reduce burnout amongst physicians have small but significant results. Organization-directed interventions (i.e., improving shift scheduling, reducing overall workload) were superior to physician-directed interventions such as educational interventions, mindfulness-based stress reduction techniques, exercise, and improved sleep hygiene. 21 Other research has found that workplace and individual-directed interventions both lead to small but statistically significant improvements in burnout. 22 For example, healthy exercise habits correlate with lower burnout and improved quality of life. 23
In 2011, Zwack et al described the factors that helped physicians thrive: job-related gratification from the doctor-patient relationship, medical efficacy, resilience practices, prioritization of personal and social resources, and a realistic and constructive confrontation of the limitations of the healthcare field. 24 The Path to Wellness characterizes what constitutes a “well” physician by identifying factors and lifestyle changes which allow a “burned out” physician to rise towards a state of wellness.
In the current study, coders found agreement on definitions of wellness. The top codes noted by Coder 1 (support system, exercise, cognitive reframing, nutrition, the importance of maintaining a daily routine, and developing interpersonal/familial relationships) and Coder 2 (exercise, maintaining a healthy support system, nutrition, prioritizing self-care, and maintaining a daily routine) overlapped significantly, reinforcing the intuitive importance of these interventions in developing and maintaining wellness. The predominance of physician-directed interventions suggests that the path to wellness involves personal interventions and behavior modifications more than external, organizational interventions. 21
These results suggest that physicians may benefit from resources tailored to promote wellness interventions at the level of the physician (pursuit of physical fitness and healthy dietary habits, mindfulness, pursuing wellness-promoting activities and developing and maintaining interpersonal and familial relationships). The line between individual and system/organizational interventions can be difficult to define. One paradigm sees the system as capable of removing barriers to wellness, thus reducing burnout; whereas striving for optimal health often occurs at the individual level. System level changes such as access to fitness facilities, dietary coaching, and time off work must be actualized for benefit by motivated individuals Habits to strengthen individual wellness behaviors must be instilled during medical training; Parsons et al 25 provide a review of successful individual (and systems) interventions in resident physicians (mindfulness, reframing and empathy, physical self-care, and checking in by program leadership).
Wellness should not be defined simply as the lack of burnout. Studies should continue to assess whether institutionally driven interventions such as EMR-related changes, improved shift schedules, workplace efficiency improvements, etc. can truly promote wellness and transition physicians to a thriving state, or if these modifications only assist with reducing burnout. The findings of this study suggest a greater need for promotion of physician autonomy in fostering their own path towards wellness. Physicians who can exert a sense of agency and self-efficacy can harness a stress-as-enhancing mindset and increase personal resilience.26,27
Future studies should seek to determine which individual and system strategies provide the most impact on overall wellness. 28 Research identifying removable barriers to wellness and evaluating wellness-promoting interventions must continue to make progress on the highly prevalent problem of poor health and burnout in physicians. 29 Seward et al published a study using focus groups in a large medical center in Boston, MA to inform the discussion on system and individual factors. Results highlighted the interconnected importance of top-down and bottom-up strategies. Programs such as competitions and incentives from administration can help motivate workers, but these interventions must occur with individuals who lead by example and work to form healthy interpersonal relationships. 30
Limitations
This study possesses limitations inherent to qualitative research on small non-random samples of larger cohorts. Participants from a single academic center in the state of Kentucky may not extrapolate to larger populations. Additionally, many medical specialties were not represented in this sample, most notably surgical specialties. The volunteer-based method of participant recruitment allowed for selection bias, though the intent was to interview only those physicians who had successfully transitioned from poor to good health. While this study used a consistent question list, the interview process of data acquisition is inherently subject to methodological limitations. Information provided by participants could have been limited based on willingness to share in a virtual face to face setting. In addition, given the qualitative nature of the interviews, the responses provided by subjects are susceptible to recall bias and confounding. The subjects’ recollection of what they believe were causal factors cannot be confirmed with certainty. Coded responses, measured in terms of frequency and prevalence of, do not necessarily reflect the entire spectrum of responses.
Conclusion
The results of this study of the individual physician’s path to wellness highlight the importance of individual-level factors: healthy support system, healthy lifestyle (physical exercise and nutritious eating habits, adequate sleep), time for rest and self-reflection, and developing consistent daily routines to sustain a desired work-life balance. This data underscores the influence of physician autonomy and in the transition towards a state of health and wellness. Future research should seek to determine the relative efficacy of specific physician-level strategies and system-level interventions to cultivate wellness.
Footnotes
Acknowledgments
The authors would like to thank Alyssa Thomas for her support.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Appendix A
Participant Demographics.
Gender
Attending or Resident
Specialty
# Years Practicing
F
Attending
Internal Medicine
<5
F
Attending
Child Neurology/Palliative Medicine
<5
M
Attending
Pathology/Laboratory Medicine
21–30
M
Attending
Emergency Medicine
5–10
M
Attending
Emergency Medicine
21–30
F
Resident
General Surgery/Emergency Medicine
<5
M
Resident
Family Medicine
<5
M
Resident
Radiology
<5
F
Attending
Pediatric Nephrology
5–10
F
Attending
OB/GYN
5–10
M
Attending
Pediatric Medicine
31–40
F
Attending
Gastroenterology
21–30
F
Attending
Pediatric Medicine
21–30
F
Attending
Internal Medicine
21–30
Appendix B
Interview Questions. *Of note, all interviews conducted in the study were semi-structured and conversational in nature.
Interview Questions
1
Are you an attending physician or resident physician?
2
Demographic questions (i.e., age, gender, marital status, number of children (if any), number of family members in the medical field, specialty, length of practice in years)
3
What does it mean to be healthy? Is the definition of health clear to you?
4
What does it mean to experience burnout?
5
When did you consider yourself to be in suboptimal health? When did you begin to make changes, then consider yourself to be in good health?
6
What personal or internal influences impacted your poor wellness? For example, stress
7
What external influences impacted your poor wellness? For example, personal or professional relationships, work duties.
8
Which other factors contributed to you being previously unhealthy?
9
What made you decide to want to change or become healthier?
10
What strategies were most effective for you to become healthier? Do you have any resources or categories of medium that were particularly helpful? For example, certain books, podcasts, websites? How important were consistent habits and rituals?
11
Did anyone in your life help you? For example, a coach, sponsor, friend, family member? Did you follow an example?
12
What physical changes did you make? What mental changes did you make? What relationship changes did you make? What sleep or rest changes did you make? What nutritional changes did you make? Can you expand on key changes you made?
13
Do you believe you have maintained those healthy changes to this point?
14
Do you have any routine or systematic way you currently utilize to maintain healthy mental and physical wellness?
15
What system changes do you think are most important to facilitate physician wellness?
16
Are many physicians unhealthy? If so, why?
17
Describe characteristics of a “Physician with Optimal Wellness.”
18
What recommendations would you make to other physicians who are interested in making changes to achieve ideal wellness?
19
Additional time left for open-ended comments