Restoring Well-Being for Physicians Through Lifestyle Medicine

Abstract

In the wake of the COVID-19 pandemic, physician burnout is a more relevant concern than ever. Pre-existing stressors in health care, such as poor work-life balance, perfectionism, and inadequate social support, have been exacerbated by uncertainty, increased risk exposure, and general anxiety. Burnout places not only physicians, but also patients, systems, and communities at risk. The promotion of physician well-being is critical to sustaining the health care system. Actions to reduce burnout and increase well-being can and should occur on multiple levels. Organizations and leaders must take steps to create a culture of support and respect for health care providers. Such steps may include improved time-off policies, destigmatizing the use of mental health services, and reducing administrative burden. Physician well-being may benefit from action on an individual level as well. The pillars of Lifestyle Medicine provide a framework for engaging in behaviors compatible with overall well-being, such as physical activity, social connection, and sleep. Lifestyle Medicine plays a key role in mitigating the impact of physician burnout, and will be essential to the success of the health care system moving forward.

“By raising awareness of the value found in the pillars of lifestyle medicine, we can protect and preserve the health care workforce and the individuals who compose it.”

Introduction

In the wake of the COVID-19 pandemic, physician burnout is a more relevant concern than ever. Pre-existing stressors in health care, such as poor work-life balance, perfectionism, and inadequate social support, have been exacerbated by uncertainty, increased risk exposure, and general anxiety. ¹ In addition, the electronic medical record has created an increased administrative burden. Physician burnout poses a multitude of risks; physicians may become depressed or experience suicidality, patients may receive a lower quality of care, and organizations may experience increased rates of physician turnover and related costs. ² When a health care system loses a physician from its workforce, it costs the system double the physician’s salary to replace them. ³ All of this adds up, emotionally and financially. Addressing these concerns and finding sustainable and accessible solutions is critical to the health care system’s success.

Ultimately, burnout is an issue at a systemic and organizational level. Disparities in resources and demands within the workplace cause physicians to feel drained and overwhelmed. ⁴ Consequently, changes at this high level are required to mitigate current physician burnout rates. Feedback from physicians experiencing burnout suggests that organizational changes like a decreased administrative burden, improved work-life balance, and increased access to support are largely desired and have the potential to alleviate signs of burnout. ⁵ Without changing the context in which physicians develop burnout, rate reduction may not be feasible or possible.

While organizational change is truly needed, lifestyle medicine can be beneficial for addressing signs of burnout on an individual level and promote physician well-being. Lifestyle medicine emphasizes using evidence-based tools focused on six key pillars, to include: getting adequate sleep, engaging in regular physical activity, fostering social connections, managing stress, focusing on a healthy diet, and avoiding risky substances. Research reveals that poor sleep quality, ⁶ low levels of physical activity, ⁷ social isolation, ⁸ and risky alcohol consumption ⁹ are correlated with higher levels of physician burnout. An intervention to mitigate these risk factors could protect physicians from burnout, even if the underlying causes cannot be eliminated.

To address the challenges faced by physicians in pursuit of well-being amidst a storm of burnout, we highlight potential remedies on institutional and individual levels. The purpose of examining physician burnout through the lens of lifestyle medicine is to identify opportunities for personal growth, as organizational change can be a time-consuming process over which individuals exert limited control. Additionally, in working to mitigate burnout, organizations may consider implementing programs that are conducive to a healthy lifestyle for all employees.

Well-Being

In recent years, the importance of focusing on physician well-being has garnered increasing attention. ¹⁰ The onset of the COVID-19 pandemic highlighted the burdens placed on clinicians and the importance of their well-being. Well-being, though a broad concept, can roughly be described as judging life positively and feeling good; in public health, physical health is also viewed as a critical component. ¹¹

In 2020, Shanafelt and Swensen presented a model in which wellness, contentment, and resilience overlap to facilitate well-being. ¹² The model explores how these states can be nurtured to increase overall well-being. Practices for wellness, for example, may include high-quality sleep, physical activity, and movement. Resilience practices include cognitive flexibility, mindfulness, and spirituality. Relationships, hobbies, and work-life integration may improve contentment over time. Wellness, contentment, and resilience are posited to be antithetical to depleting factors in life, and without all three, depletion can dominate and result in an overall lack of well-being.

Another factor in well-being discussed by Shanafelt and Swensen is fulfillment, with high fulfillment correlated with improved well-being. ¹² When values and work are aligned, and that work is meaningful, the result is fulfillment and happiness. A sense of purpose is emerging as a critical factor for providers and patients' well-being. In 1985, Bellah et al described three ways individuals relate to their work: a job, a career, or a calling. ¹³ Per Bellah, a job is a means to an end, and a career is a chance for advancement, but a calling connotes a sense of purpose and intrinsic motivation. Indeed, research has found that physicians who view their profession as a calling generally demonstrate higher levels of satisfaction and resilience when compared to peers who do not. ¹³ Some of the drivers found to be correlated with professional satisfaction and in turn well-being in physicians, have been relationships with patients, relationships with colleagues, intellectual stimulation, a sense of mission, and work-life balance. ¹⁴ Research has elucidated that increased time spent engaging in these meaningful aspects of work can be protective against physician burnout and support well-being. ¹⁵

Physician Burnout

In contrast to well-being, burnout can be defined as an incongruity between what a person is and what they have to do. ¹⁶ To illustrate this point, Shanafelt found that medical teaching faculty who spent less than 20% of their working hours on meaningful activities had significantly higher rates of burning out. In this study, the self-reported most meaningful aspects of work varied among physicians. Some found teaching most meaningful, while others took the most meaning from research or from providing direct patient care. Regardless of what an individual physician found most meaningful, less time to dedicate to that activity was associated with higher rates of burning out. In other words, these physicians feel a conflict between their calling and reality. Several experiences can lead to this conflict. Erosion of engagement occurs when work one used to enjoy becomes meaningless and unpleasant. Over time, enthusiasm and dedication for one’s vocation can become anxiety and depression, a process referred to as erosion of emotion. For many, this experience feels isolating, leading to a perceived failure to fit in. When these factors are present, the individual is at risk for burnout, and feel that their chosen career is no longer suitable.

Burnout can manifest in several ways. One dimension of burnout is emotional exhaustion, in which the individual feels drained emotionally and physically and does not have the energy to face a project or person. ¹⁷ Perhaps as a consequence of emotional exhaustion, cynicism or depersonalization are also indicative of burnout. Embodying cynicism may involve abandoning one’s ideals and approaching work with a cold, distant attitude; this kind of depersonalization may be used as an attempt to avoid disappointment and exhaustion. Finally, personal ineffectiveness is often present in burnt out professionals. Projects seem overwhelming, and obstacles seem insurmountable, which may make the individual feel inadequate and lose confidence in their abilities.

In the health care profession specifically, the rates of these manifestations have been rising. In 2021, the average rate of self-reported physician exhaustion was 38.6% higher than in 2020. ¹⁸ Self-reported career satisfaction, work-life integration, and professional fulfillment in physicians saw notable declines between 2020 and 2021. Additionally, research has shown that female physicians are more likely to experience burnout than male counterparts, with emotional exhaustion particularly impacted. ¹⁹

Physician burnout can have numerous consequences. As mentioned above, female physicians are more likely to experience burnout than males. A 2019 study found that statistically, female physicians are significantly more likely to reduce working hours, especially among physicians with children. ²⁰ Across the board, physicians are leaving the profession, retiring early, or reducing hours due to burnout. ²¹

The United States already has disparities in provider availability relative to demand, and burnout-induced attrition is projected to exacerbate the issue. The combination of fewer available physicians and an overburdened workforce results in poorer outcomes and higher rates of safety incidents for patients. ²² These may be related to patients having less time with their providers, purposeful emotional distancing from patients, and general overload.

Burnout also impacts the physician on a personal level. High levels of self-reported physician burnout have been correlated with insomnia, ²³ cardiovascular risk, ²⁴ substance abuse, and suicidal ideation. ²⁵ Additionally, physicians experiencing burnout are at an increased risk of failed interpersonal relationships and anxiety and depression. ²⁶ The combination of these factors may lead providers to leave the profession, further broadening the gap between physician supply and demand, and posing a risk to patients and organizations.

Lifestyle Medicine and Individual Change

Although physician burnout is often a consequence of organizational-level concerns, aspects of lifestyle medicine can improve well-being and therefore protect a physician’s health. Attitudes that promote resilience include positivity, ²⁷ a growth mindset, ²⁸ and gratitude. ²⁹ Aside from managing their attitude, physicians can look to the tenets of lifestyle medicine to maintain well-being in situations of burnout. Important behaviors include physical activity, a whole food plant predominant diet, improved sleep, forming and maintaining relationships, and stress management. ³⁰ Managing lifestyle factors is a potent way physicians can manage their stress levels and, in turn, moderate burnout.

Recent research has shown the impact of a positive attitude on not only physicians but the public in general. According to Dr Barbara Fredrickson, ²⁷ different forms of positivity include joy, serenity, hope, amusement, awe, gratitude, interest, a sense of pride, inspiration, and love. In line with a positive attitude, a growth mindset can lead to greater resilience as it urges people to view their mistakes as learning opportunities rather than downfalls. A study that surveyed 832 physicians and 5182 participants in other fields found that 30% of physicians were more likely to condemn themselves rather than learn from their mistakes. ³¹ It was also found that the culture within a physician’s typical workplace tends to defer self-care and responds to errors with shame and blame. With healthy mindset practices in place, this is a statistic that physicians can work to reduce. Further, it is recommended that physicians work with coaches or therapists to reframe mistakes as opportunities to learn and grow. A simple exercise that can be implemented to improve mindset is a gratitude practice. Seligman et al conducted a study that found writing three good things down at the end of the day increased happiness and decreased depressive symptoms for six months. ²⁹

Supporting mental health using nutrition can be difficult for those working in a fast-paced environment, as many physicians are. However, focusing on a whole food plant predominant diet can reduce symptoms of burnout and support mental health. In a recent study, researchers found that consumption of “unhealthy” foods, such as sweets or fast food, was significantly positively correlated with perceived stress in females and depressive symptoms in both males and females. ³² In contrast, consuming “healthy” foods, such as fresh fruits or cooked vegetables, was significantly negatively correlated with perceived stress and depressive symptoms scores for both sexes. Foods found to improve mood include bananas, dark chocolate, fermented foods, oats, berries, nuts, seeds, coffee, beans, and lentils. ³³ Instead of having a bowl of candy on the desk, a bowl of fruit could help nourish and satiate with its added fiber and water content.

An often-overlooked tenet of lifestyle medicine is the importance of restorative sleep. Insufficient sleep has been found to cause industrial accidents, medical errors, increase risk-taking behaviors, and even cause depression. ³⁴ In a study reported in the Journal of Occupational and Environmental Medicine, researchers found that being awake for 18 hours is the same as a blood alcohol level (BAC) of .05 and being awake for 24 hours is equal to a BAC of .10. ³⁵ With a BAC of .08 being considered legally intoxicated, it is clear how dangerous it is to be sleep deprived. Physicians often have to work long hours on little sleep; however, there are methods to increase focus throughout the workday. When feeling focus decline, taking a walk, sitting quietly, or taking deep breaths can bring rejuvenation. ³⁶ An effective method to support this concept of “taking a break” might involve setting an alarm to go off every hour with a reminder, to take a few minutes to regroup and increase focus.

Maintaining a sense of purpose and a supportive community can increase a physician’s mental welfare and thus prevent burnout. Richard Davidson, the founder of the Center for Healthy Minds, emphasized that purpose has emerged as one of the most important predictors of well-being. Having a higher sense of purpose has been shown to contribute to greater life satisfaction, high-quality connections, improved brain function, and longer lifespan. ³⁷ A survey of 13 770 adults compared the top vs lowest quartile of purpose to find that a higher sense of purpose at baseline was associated with a lower likelihood of developing unhealthy behaviors over time. ³⁸ Evaluating where free time is spent can help practitioners regain their sense of purpose and notice where they want to put their energy. Aside from perpetuating a sense of purpose, keeping strong social connections can also help physicians maintain a healthy mental state. High-quality connections can create feelings of vitality and aliveness, a higher sense of positive regard, and felt mutuality. ³⁹ This can create a greater emotional carrying capacity, which can be necessary for those working in a health care environment.

According to the U.S. Surgeon General Dr Vivek Murthy, it is important for health care workers and health care leaders to identify key signs of burnout, such as recognizing the signs of distress, mental health challenges, and burnout in oneself and in one’s colleagues. Further, health care workers should stay connected, reach out for help, prioritize moments of joy and connection, get back to basics with good health habits, and use their voices to advocate for positive changes in the workplace, learning environment, or communities. ⁴⁰ The World Health Organization defines stress as any type of change that causes physical, emotional, or psychological strain. ⁴¹ Focusing on stress reduction techniques outside of work hours can help to reduce the strain that can be placed on workers throughout the day. Effective methods include forest bathing, ⁴² exercise, ⁴³ mindfulness, ⁴⁴ listening to music, ⁴⁵ and expressive writing. ⁴⁶

Organizational Factors

As stated above, ultimately, burnout is an issue at a systemic and organizational level, rather than a fault of the individual. Workplace factors that can increase rates of burnout include workload, perceived lack of control, lack of intrinsic and extrinsic rewards, unsupportive community, lack of fairness, and values mismatches. ¹⁸ All of these factors can potentially cause physicians to feel exhausted, unfulfilled, inadequate, or hopeless. On the other end of the spectrum, workplaces can support employee well-being with factors like protection from harm, connection and community, work-life harmony, mattering at work, and opportunity for growth, all of which should be centered on the worker’s voice. Making workplaces conducive to physician well-being is essential to recovering from the epidemic of burnout. Indeed, United States Surgeon General Vivek Murthy has identified health worker burnout prevention as a key priority and has shared outlines of actions organizations and institutions can take to further this pursuit. ⁴⁷

One critical need at an organizational and systemic level is decreased mental health stigma. Research has found that many physicians are reluctant to seek help for mental illness out of fear they would let colleagues and patients down, that their concerns would not be kept confidential, and that career progression would be negatively impacted. ⁴⁸ Beyond internalized fears, in the workplace, physicians with mental illnesses may be perceived as incompetent, unsafe, and poorly suited for the profession. ⁴⁹ Because of the culture surrounding mental illness among health care workers, struggling physicians may not seek help when needed.

In addition to the stigma around mental health, organizations may perpetuate burnout by not listening to feedback from health care workers. In one study, every physician who reported burnout reported that electronic health records contributed to their current state, with aggravating factors being poor usability and intuitiveness of the system. ⁵⁰ When an organization-implemented software causes such universal distress, physicians who see no change after sharing their perspective may become disenfranchised or overwhelmed. Health care leaders should also listen to physicians’ concerns regarding safety. Frontline health care workers regularly face inadequate personal protective equipment, ⁵¹ patient-perpetrated violence, ⁵² and peer- and superior-perpetrated discrimination. ⁵³ One study found that 23.4% of physicians reported experiencing workplace mistreatment in a 12-month period. ⁵⁴ Physicians who reported working in systems that adequately protect providers reported lower levels of occupational distress than those who did not work in systems that protect providers. While not all violence and discrimination can be prevented, organizations that seek to prevent distress and burnout should listen to the needs of physicians and build systems to protect them accordingly.

Per Shapiro et al, wellness needs of health care workers can be placed in a hierarchy. ⁵⁵ At the bottom are basic needs, such as food, sleep, absence of depression and anxiety, and access to bathrooms. The next level is safety, both in the sense of physical safety and job security. The third level is respect, which can be regarding work-life balance, having a reasonable administrative load, and being met with cultural sensitivity. Fourth is appreciation from the institution, colleagues, and patients, and at the top is the autonomy to care for patients. When these needs are progressively met, physicians are able to approach well-being.

Poor work-life balance is an additional factor leading to burnout among physicians at an organizational level. Since the onset of the COVID-19 pandemic, physicians have reported decreased satisfaction with their work-life integration. ¹⁸ Lack of control over one’s schedule and little flexibility to change it are significant contributors to physician burnout. ⁵⁶ Additionally, many physicians work extra hours, conduct work-related activities outside of work, and are reluctant to take time off. ¹⁰ Until organizations develop a culture that supports breaks and leave and discourages working on vacation, physician burnout will continue to be prevalent throughout the system.

Organizational Change

Change at the level of health care organizations may not only decrease rates of physician burnout but empower providers to engage more freely in the healthy lifestyle behaviors previously discussed. In a study of hospital workers, Tawfik et al found that positive impressions of local leadership were correlated with lower levels of burnout, better safety and teamwork climates, lower perceptions of workload, and reduced intentions to leave. ⁵⁷ By taking concrete steps, organizational leadership can significantly improve provider conditions and foster a healthier and more engaged workforce.

On a high level, giving health care providers more control over their professional life has repeatedly been found to reduce rates of burnout. Policies surrounding scheduling and time may be one area in which organizations can cede control. Organizations may offer flexible scheduling, provide childcare during irregular work hours, reduce the burden of documentation, and allow health care providers more control over the structure of their workday.^58,59 Reduced administrative burden and control over structure may allow physicians to spend more time doing work they find meaningful, reducing the likelihood they will experience burnout, Additionally, physicians should receive, and be encouraged to use, benefits like paid leave, sick leave, and rest breaks. ⁴⁰ Employees should be encouraged not to send non-urgent emails outside of working hours. These changes can make physicians feel heard and respected and decrease rates of burnout accordingly. Such changes also inherently promote improved work-life balance. Increased time away from work may allow physicians to get more sleep, prepare healthy meals, pursue stress relieving hobbies, and conduct other healthy lifestyle behaviors to further reduce the impact of burnout.

Organizations may give further control to health care providers by actively listening to and incorporating feedback from the frontline. Listening can and should occur at the level of the unit, department, full organization, and any other distinct groups. Provider feedback on safety conditions must be acknowledged and addressed. When physicians report inadequate personal protective equipment, violence, or workplace discrimination or racism, leadership should take concrete steps to develop and enforce relevant policies and should do so with the input of the affected provider or providers. Furthermore, organizations should listen to what work is most meaningful to physicians and strive to increase the time physicians can spend on these activities. ¹⁶ For example, implementation of speech recognition software during surgical encounters may reduce the burden of documentation and enable surgeons to spend more time providing clinical care. ⁶⁰ Without taking steps to protect the workforce, organizations may be unable to retain high-level employees. While not all changes are possible, simply feeling heard can reduce symptoms of burnout in health care providers. ⁵⁷ This can be achieved by appointing a well-being leader on a team level, or by hosting town-hall style forums or listening sessions for groups. ⁶¹ For example, the American Medical Association’s “Get Rid of Stupid Stuff” program encourages physicians to appoint representatives to meet with hospital leadership from various departments. ⁶² By implementing meaningful listening, organizations can support individuals in decreasing levels of stress and improving attitude, both of which may alleviate symptoms of burnout on an individual level.

In decreasing rates of physician burnout, organizations must create a culture of well-being in the workplace. In addition to providing benefits like paid leave, creating such a culture necessitates destigmatizing treatment for mental health. To do so, organizations must make mental health care a standard benefit and ensure it is readily available and accessible to all employees. Mental health interventions may be viewed with cynicism, fear, or hostility by various providers. ⁶³ To combat this trend, workplaces can initiate open discussions about mental wellness and normalize challenges and accommodations; supporting colleagues in sharing stories about burnout and mental illness can be positive. ⁶⁴ Ensuring physicians have easy access to confidential professional mental health support is essential, and additional measures like peer support or support groups have been found to be successful. ⁶⁵

In addition to support groups, organizations should encourage and facilitate a collegial work environment. ⁵⁹ Medical workers who feel like part of a team have been found to make fewer medical errors, experience fewer workplace injuries, display higher retention rates, and increased job satisfaction. ⁶⁶ Through action, organizations can bolster feelings of community. Hosting or funding social gatherings for departments provides an opportunity for physicians to connect in a non-clinical environment; a valuable investment as social connection is a lifestyle factor which can protect against burnout. Organizations may also encourage social support through leadership and educational practices. Leaders and mentors should be trained on management techniques to ensure relationships are helpful and supportive rather than patronizing and dismissive. ⁶⁷ Team leaders should encourage social connection among physicians through modeling collegiality, facilitating positive group interactions, and forming relationships with individual employees. These steps can make physicians feel like part of a welcoming community, thereby reducing feelings of isolation and burnout. ⁶⁸

How Can Organizations Introduce Lifestyle Medicine in the Health Care Setting?

A concrete step organizations can take now to help physicians and health care providers is to offer Well-being Rounds in place of Grand Rounds at least six times a year. These Well-being Rounds can provide CME credit just as Grand Rounds does. However, these Well-being Rounds will also provide the opportunity to learn about the six pillars of lifestyle medicine and hold discussions about them within individual communities and hospital systems. This is already being done successfully at Spaulding Rehabilitation Hospital, a Harvard Medical School affiliate. In 2022, the Wellness Committee began Well-being Rounds. Health care providers in the Spaulding Rehabilitation Network have learned the science behind the power of social connection and experienced it themselves through breakout rooms during the Well-being Rounds.

There are other concrete steps that leaders can take in order to improve well-being among health care workers. Some examples include, (1) shifting the way people move each day to incorporate more walking meetings, (2) providing standing workstations or exercise balls as chairs, (3) ensuring access to quiet meditation rooms, (4) normalizing “email free” times of the day, especially on the weekends, (5) encouraging individuals to take vacation time, (6) cultivating social connections by including breakout sessions in meetings, such as during Well-being Rounds, (7) providing healthy snacks for health care providers instead of candy in a bowl, donuts for breakfast or pizza for lunch, and (8) setting boundaries for work-related meetings to occur during work hours leaving time for home life and activities. Such interventions will help to enhance a sense of well-being for health care providers.

Conclusion

Physicians today face many stressors, including administrative burdens and workplace hazards, and these stressors have been exacerbated by the COVID-19 pandemic. In such a climate, physician burnout is nearly inevitable. Without sweeping change on systemic and institutional levels, rates of burnout will continue to increase, and the health care system as a whole will bear the consequences. Because such reform may take time, on an individual level, physicians can implement skills from lifestyle medicine to optimize well-being and minimize the health risks associated with burnout. By raising awareness of the value found in the pillars of lifestyle medicine, we can protect and preserve the health care workforce and the individuals who compose it.

While organizational change is truly needed to address the immense challenge of burnout among health care workers, lifestyle medicine can play an important role in promoting physician well-being on an individual level. With creativity, leaders in health care can use the pillars of lifestyle medicine to improve provider health and happiness while the organization works to restructure itself to ease the administrative burden of practicing medicine.