A Powerful Antidote to Physician Burnout: Intensive Healthy Lifestyle and Positive Psychology Approaches

Abstract

Burnout rates among physicians are rapidly rising. Leaders in the movement to address burnout have made the case that health care workplaces need to foster a culture of well-being, including trusting coworker interactions, collaborative and transparent leadership, work-life balance, flexibility, opportunities for meaningful work and for professional development, and effective 2-way communication. The rationale for focusing on organizational change to prevent burnout has pointed to persistent symptoms of burnout even when individual healthy lifestyle interventions are adopted. However, a case can be made that the lifestyle interventions were not implemented at the level of intensity recommended by the lifestyle medicine evidence-base to secure the desired improvement in physical and mental health when facing significant personal and environmental stressors. The lifestyle medicine community has the ethical mandate to advocate for intensive healthy lifestyle approaches to burnout prevention, in conjunction with organizational supports. By combining comprehensive and intensive lifestyle changes with organizational cultures of well-being, we can more effectively turn the tide of physician burnout.

The personal practice of healthy lifestyles at the level recommended by lifestyle medicine is a solution that complements the necessary organizational and systemic changes.

Rates of burnout among physicians are skyrocketing because of health care systemic issues and job and career demands, especially in the wake of the COVID-19 pandemic, leading to dangerous physical and mental health consequences. According to a Medscape survey of more than 12,000 physicians between August 30, 2020, and November 3, 2020, nearly 80% of physicians said they felt burned out prior to the pandemic, and 1 in 5 said that burnout emerged in the past year. Moreover, only 49% reported being happy with work life balance in 2020 versus 69% in 2019. ¹ Although studies demonstrate a greater impact from health care organization changes than individual self-care behaviors, both are needed to ensure well-being. The field of lifestyle medicine has an opportunity to lead the way on this comprehensive approach.

In a recent study, 30% of physicians who scored the highest on a resilience scale nevertheless admitted to exhibiting at least 1 symptom of burnout. ² The authors used this result to make the case that organizational changes are needed to prevent burnout and de-emphasized the role of individual health and resilience building approaches.^3,4 Indeed, workplace cultures that promote well-being are essential and include having a clearly stated mission and purpose, a balance of autonomy and support, an environment that provides the necessary tools, infrastructure, and opportunities for self-efficacy, an opportunity to engage in meaningful work at least 20% of the time, flexibility, an inherent respect and value for every employee, and opportunities for professional advancement. Moreover, health care workplaces must embrace personal wellness as foundational as well as collaboration and support from coworkers, protection of work day boundaries, collaborative leadership, transparent communication, and trusting positive interactions.^4-7

However, in recognition of the current burnout crisis, leaders and practitioners in lifestyle medicine can lend their expertise to advance a movement that will support intensive individual self-care approaches among our health care colleagues. The personal practice of healthy lifestyles at the level recommended by lifestyle medicine is a solution that complements the necessary organizational and systemic changes. Perhaps physicians who scored the highest level on the resilience scale and yet were experiencing burnout could benefit from an intensive healthy lifestyle that drives thriving and flourishing. The field of lifestyle medicine has the opportunity, and some might argue the ethical imperative, to promote comprehensive implementation of its 6 pillars—a predominantly plant-based whole food diet, physical activity, sleep, avoidance of risky substances, stress management, and social connectivity along with positive psychology-based activities—as a powerful approach to prevent burnout in the context of the workplace culture of well-being.

The Medscape survey results suggest that physicians are taking advantage of healthy lifestyle approaches. For example, 85% of respondents reported being married or living with a partner; 84% stated that their relationship was good or very good; and almost a quarter said that they were exercising 4 to 5 times a week, with 11% reporting daily exercise. ⁸ On the other hand, other signals lead us to be cautious about this positive outlook. In response to a question on whether they are spending enough time on their personal health and wellness, 46% of millennials, 43% of generation X, and 39% of boomers said that they only sometimes spend enough time on their personal health and wellness. ⁹ More alarming is the 18% response by millennials, 20% of generation X, and 15% of boomers reporting that they rarely spend enough time on their wellness.

Additionally, alcohol use, defined as having 1 or more drinks per week, was reported by approximately half of those surveyed, and about half also admitted to trying to lose weight. ⁸

From a positive psychology perspective, it is also worth noting that 33% of millennials, 27% of generation X, and 20% of boomers reported that they have no spiritual or religious beliefs. ⁹ Although further research would be needed to determine whether these respondents have other personal sources of meaning—an essential well-being element^10-12—this result may signify another reason for concern about physicians’ well-being.

According to the PERMA framework set forth by Martin Seligman—positive emotion, engagement, relationships, meaning, and achievement—these activities, and mental and emotional states represent essential underpinnings for boosting well-being. ¹³ Key positive emotions include gratitude, forgiveness, hope, and optimism. Engagement, or a state of flow, occurs when one is enjoying an activity so much that the one becomes completely engrossed in that activity and loses track of time. ¹⁴ Relationships—particularly positive social connection—are the single most important factor associated with happiness, physical health, and longevity, as concluded by the longest cohort study, the Harvard Development Adult Development Study, on well-being. ¹⁵ Meaning is associated with productivity and success at work, life fulfillment, positive mental health, lower risk of cognitive decline and disability, and longevity.^10-12 Accomplishment is associated with self-esteem, self-efficacy, and perseverance. The physiological benefits of increasing positive emotions through the PERMA elements include a boost in the parasympathetic nervous system, improved vagal tone and greater heart rate variability, increased release of positive neurotransmitters, endocrine regulation, strengthened immunity, and longer telomeres. ¹⁶

Moreover, positive emotions that are boosted by these approaches support health behavior change. According to the upward spiral theory, increased motivation and positive behaviors result from pleasant and intrinsic emotions. The latter also broaden psychological, social, and physical resources in an upward spiral toward healthy behaviors and ultimately improved health outcomes.^17,18

The literature supports this reciprocal, reinforcing link between positive emotions and healthy lifestyles. For example, physical activity improves moods ¹⁹ and increases positive emotions; in turn, those who have an increase in psychological well-being report a higher level of physical activity. ²⁰ Individuals who consume more than 7 servings of fruits or vegetables a day report feeling calmer, happier, and more energetic.^21,22 In addition this level of consumption predicted a positive mood the next day. ²² Studies suggest that the reverse is true as well; positive emotions reinforce healthy eating habits. People who conveyed being happier reported a greater amount of fruit and vegetable consumption. ²³ Individuals with low amounts of sleep—4 to 5 hours of sleep—report greater stress, anger, and sadness, whereas stress and anxiety interfere with high-quality sleep.^24,25

Along with healthy lifestyles, positive psychology interventions can boost subjective and psychological well-being. A meta-analysis of a variety of these interventions, including gratitude, use of character strengths positive goal setting, optimistic thinking, savoring, positivity reminiscence, acts of kindness, forgiveness, mindfulness, and meaningful activities, were associated with a small but significant improvement in subjective and a small to moderate increase in psychological well-being. ²⁶ Physicians with a regular mindfulness practice enjoy reduced stress, physical illness, depression, anxiety, and burnout. These physicians also experienced improvements in perceived empathy by their patients, patient adherence to their recommendations, reduced medical errors, and better patient outcomes.^27-30

In summary, to turn the tide of increasing burnout among physicians organizations need to acknowledge the inherent aspects of a health care workplace system that can trigger burnout and implement evidence-based organizational strategies to reduce burnout and increase individual and institutional well-being. Key among these strategies are support of personal wellness as foundational in a workplace, positive trusting collaborative interactions, transparent leadership, flexibility, effective 2-way communication, and healthy role modeling. However, in addition to changes at the organizational level, we need to advocate for and support our colleagues in achieving well-being at the individual level. To the extent possible, we all need to be practicing the 6 pillars of a healthy lifestyle: eating a predominantly whole food plant-based diet, being physically active, getting adequate sleep, avoiding risky substance use, managing stress, and engaging in the elements of PERMA—positive emotion, engagement, positive relationships, meaning, and accomplishment/achievement.

Although time constraints at various career stages and with job demands may not allow full implementation of intensive self-care practices, many elements of a healthy and happy lifestyle can be adopted even during busy times, such as gratitude practice. Positive emotions from such well-being habits can reinforce healthy behaviors through a reciprocal link, as shown in the upward spiral theory, leading to powerful outcomes. Together with organizational changes toward a culture of well-being, intensive individual interventions offer the greatest potential to improve physicians’ physical, mental, and emotional health and combat burnout. Now is a call to action to integrate these practices into our workplaces and personal lives.