Balance Versus Integration

INTRODUCTION

Health care culture and attitudes have lagged behind other industries on the now highly visible topic of burnout. This topic includes conversations on the associated topics of wellness, well-being, and strategies to achieve work-life balance and/or work-life integration. Much research and data have validated why employee burnout must be addressed; the psychological and physical issues of burned-out employees cost an estimated $125 billion to $190 billion a year in US health care spending.¹ Burnout in physicians and health care professionals can have additional, and profound, impacts on society at large and health care organizations. Beyond decreased productivity and costs associated with turnover, physician wellness is vital to the delivery of highquality care. For example, burnout has been associated with increased medical errors and less compassionate care in numerous studies.² Mandates to improve care and outcomes and achieve the goal of zero harm cannot be successful if physician wellness is not simultaneously prioritized. It has been hypothesized that physician wellness is a missing quality indicator and optimization of patient-centered care cannot occur without it.³

Although burnout and achieving individual and system well-being is beyond the scope of this article and is addressed elsewhere,⁴ this article explores considerations that can support optimal work-life integration or balance. Definitions of terms commonly used when discussing physician realities of burnout, well-being, and the challenges of managing work and life are outlined next.

Burnout

A syndrome conceptualized as a result of chronic workplace stress that has not been successfully managed. It is characterized by 3 dimensions⁵:

1. Feeling of energy depletion or exhaustion

2. Increased mental distance from one’s job, or feeling of negativism or cynicismrelated to one’s job

3. Reduced professional efficacy

Of note, burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.

Wellness

The optimal state of health of individuals and groups with 2 focal concerns: (1) the realization of the fullest potential of an individual physically, psychologically, socially, spiritually, and economically; and (2) the fulfillment of one’s role expectations in the family, community, place of worship, workplace, and other settings.⁶

Well-being

The state or experience of being happy, healthy, or prosperous. This state includes good mental health, high life satisfaction, being socially connected, having a sense of meaning or purpose, and ability to manage stress.⁷

Balance

Noun: physical equilibrium; stability; aesthetically pleasing integration of elements; mental and emotional steadiness.

Verb: to poise or arrange in, or as if in, balance; to bring into harmony or proportion; to bring to a state or position of balance.⁸

Integration

Noun: the act or instance of combining into an integral whole; behavior, as of an individual that is in harmony with the environment

Verb: to bring together or incorporate parts into a whole; to unite or combine; to give, or cause to give, equal opportunity and consideration to things (eg, racial, religious, or ethnic groups).⁹

WORK-LIFE INTEGRATION VERSUS WORK-LIFE BALANCE

According to University of California Berkeley Haas School of Business, there is a difference between these 2 terms. Work-life balance evokes a binary opposition between work and life, creating a sense of competition between the 2 elements, whereas integration describes an approach that creates more synergies between all areas that define life: work, home, family, community, personal well-being, and health.¹⁰ Ideally, all these aspects are blended into a unified whole.¹¹

Throughout surgical training, the overall educational focus has been on progressive mastery in clinical decision making, surgical competence, autonomy, minimizing mistakes, and achieving independent competence to practice the subspecialty of choice. Since 2017, the Accreditation Council for Graduate Medical Education mandates that all training programs have a specific wellness program for residents and faculty, as 1 of the 6 areas of assessment to achieve accreditation.¹² The culture of well-being and how organizations function as learning environments is now a key focus for accreditation review.

After training and starting their careers, surgeons are lifelong learners and continue to master surgical procedures while acquiring additional knowledge via direct experience and required continuing medical education. For a subset of surgeons, honing teaching, research, administrative, and other educational expertise is also critical to their career development. Simultaneously, surgeons also receive day-to-day cumulative exposure to demands beyond the scheduled clinical and surgical care of patients. This exposure includes emergencies, clerical and documentation burdens, time and effort on committees, and theoretic 24–7 availability through online messaging, often with patients and their families expecting immediate responses. How to successfully navigate these demands in real time during and after clinical care and work hours is rarely taught during formal training. The consequence of these chronic imbalances lead to perpetual daily perception and experience of high degrees of stress, perception of inadequacy, physical and emotional exhaustion, lack of self-care, and psychosocial morbidity, including hopelessness, depression, and suicidality. In addition, the inner narrative for physicians and surgeons becomes one of chronic time scarcity, with no time available for anything that is not patient or medicine related. Sixty-four percent of surgeons think that their work schedule does not leave adequate time for personal and family life.¹³

The solution is not for clinicians to master more multitasking, nor is truly balancing these priorities possible. Knowing that these struggles exist, and with different frequencies and manifestations depending on the individual, how do clinicians build a healthier work-life integration? First, they must forgo the belief that there is any balance to be had. Accepting the reality of their professionally and personally integrated lives may allow them to develop new perspectives and beliefs that can create change in behavior and increase individual well-being. Focusing on self-love, self-compassion, and willingness to embrace our humanness, including limitations, is critical to holistic well-being. It is also important to note that work-life integration is often a moving target. Lack of work-life integration is not a personal failure. Physicians desire to serve their patients with energy and compassion as well as have a healthy life outside of medicine.¹⁴ As an aptly titled article notes, “Work/Life Balance: It Is Just Plain Hard.”¹⁵

COVID-19 AND PHYSICIAN WELLNESS

The COVID-19 (coronavirus disease 2019) pandemic has added additional dimensions to the immense stress chronically faced by physicians. The pandemic meets all the criteria for a traumatic event as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.¹⁶ COVID-19 is outside the range of normal human experience, markedly distressing to almost anyone, and involves a perceived intense threat to life, physical integrity, intense fear, helplessness, or horror. It is not surprising that COVID-19 has exacerbated existing and accumulated mental health issues among physicians. As in prior modern epidemics, such as the 2003 severe acute respiratory syndrome (SARS) outbreak, the long-term psychological impacts that will need to be addressed to optimize physician wellness include acute stress disorder, posttraumatic stress disorder, depression, anxiety, and substance abuse.¹⁷

Although some of the ramifications of the pandemic have been positive, such as accelerated individual and organizational adoption of technology to support collaboration and the ability to work virtually, it has also created new daily challenges, especially for women, who typically shoulder most of the burden of household labor and are more likely to head single-parent households.¹⁸ Examples of new challenges include trying to simultaneously work and facilitate virtual school; caring for young children, elderly, or at-risk family members¹⁹; and managing competing demands amid constant change and evolving public health considerations. There are also additional systems stresses that are directly experienced by individuals, such as staffing shortages.²⁰ In addition, political and social unrest has created profound individual stress on top of chronic work-related stress, particularly for health care professionals who belong to minoritized groups. Given uncertainty related to the pandemic, public health issues, and associated inherent risks to personal safety, creating awareness and helping physicians engage in authentic actions to optimize well-being is more critical than ever.

GENDER-SPECIFIC DIFFERENCES AND CHALLENGES AT WORK AND HOME

Gender differences in personality, communication, leadership, and performance have long been a subject of interest. Although gender differences in personality are a subject of debate, there is no clear consensus. Recent studies of the personality profiles of otolaryngology faculty and residents have shown that men and women otolaryngologists are more similar than they are different. Gender differences were subtle compared with the broad range of individual differences within each gender.²¹ In another study, the same 3 factors (hours worked per week, work-home conflict in the last 3 weeks, and resolving most recent work-home conflict in favor of work) were independently associated with burnout in both women and men surgeons. For both genders, work-home conflicts are rarely resolved with personal or family priorities taking precedence over work.²² As such, although there are stereotyped gender differences, treating each person as an individual is recommended rather than assuming that they will behave in accordance with gender norms.

However, there are noteworthy differences in expectations for different genders that can significantly affect both work-life integration and overall well-being, particularly in surgeons. Women are more likely to be in personal relationships where both partners are working.²² They also spend more time on domestic and parenting responsibilities. Women are also significantly more likely to report conflict between their own career and that of their spouse/partner. When these conflicts occur, it was 3-fold more likely for women surgeons that the conflict was resolved in favor of their spouse.²² It is often assumed that these gender differences are dissipating as more women enter the physician workforce. However, a 2014 study of Generation X physician-researchers found that women with children, even after controlling for professional work hours and spousal employment, spent 8.5 hours per week more on parenting or domestic activities than men.²³ Many physician-mothers report sole responsibility for most domestic tasks.²⁴ Traditionally held beliefs about women’s role in the home and workforce remain true for a large segment of the US women surgeon population. In addition, men with spouses or domestic partners who do not work full time may not appreciate challenges faced by their women colleagues, who are more likely to be in relationships where both partners work.²³ This lack of recognition hinders the ability for the culture of medicine, and its predominantly male leadership, to appropriately support women.

The culture of the medical profession has been recognized as a key factor that might deter doctors from taking care of themselves. In a study of physicians’ attitudes toward their own health, Thompson and colleagues²⁵ identified that general practitioners feel pressure from both their patients and colleagues to appear physically well, even when they are sick, because they believe their health is interpreted as an indicator of their medical competence. Similarly, McKevitt and colleagues²⁶ reported that more than 80% of the general practitioners and hospital doctors in their study worked through their illness. Their results from interviews with doctors showed that professional and organizational barriers, which reinforce one another, could contribute to reluctance to take sick leave or discuss health concerns with colleagues.²⁶ Moreover, Baldwin and colleagues²⁷ have shown that trainee doctors are adopting the same behavior that has been previously reported in older, more established doctors. When questioned about their response to hypothetical illnesses, 61% of junior doctors would go to work and wait and see if they were vomiting all night, 83% if they had blood in their urine, 76% if they had a suspected stomach ulcer, and 73% if they had severe anxiety.²⁷

It is beyond the scope of this article to discuss in detail the differences between behavior, communication, and leadership styles between men and women and how gender-based stereotypes may negatively affect professional development, especially for women. Nonetheless, it is important to note the salient ways in which the continued application of antiquated gender expectations occurs to women leaders in medicine. For example, women continue to be stereotyped as expressing and showing more emotions. This stereotype reinforces biased beliefs that women are ineffective leaders. However, the data directly oppose these outdated beliefs. For example, reviews of data from the corporate world done by the Harvard Business Review highlight corporate data that show that women score higher than men in most leadership skills.²⁸ According to an analysis of thousands of 360-degree reviews, women outscored men on 17 of 19 capabilities that differentiate excellent leaders from average or poor ones. These capabilities included metrics such as taking initiatives, resilience, practices of self-development, drives for results, and develops others.²⁸ Beginning in 2016, the Harvard Business Review (HBR) has collected data on self-reported confidence levels. The greatest difference in confidence ratings between men and women was in those younger than 25 years, with confidence ratings merging at age 40 years. After 60 years of age, male confidence declines whereas female confidence increases. The consistent observation by HBR is that women make highly competent leaders according to those who work with them, but the ceiling and barriers are multifactorial.

Primary obstacles are cultural biases and unconscious bias against women. The stereotypes, and their implications, are simply not changing fast enough. Research validates that women leaders need to be warm and nice (traditional societal expectation from women) as well as competent and tough (societal expectation from men and leaders). However, women are often judged and labeled as either being too soft or too hard. Although much of the existing literature focuses on women, most, if not all, underrepresented groups face immense pressure to conform to stereotypes and cultural expectations and face penalties if they do not. Increased awareness among individuals, senior leadership, and health systems is critical to address unconscious bias toward not only gender-based discrimination but race, age, sexual orientation, and all profiles and defining characteristics of individuals. Greater understanding, appreciation, and intentional sponsorship are needed to advance those with the ability and desire to lead. This effort must be accompanied by an awareness of bias and a true desire to create positive work environments and model positive behaviors for trainees.

The American Association of Medical Colleges (AAMC) reported in 2013 an increase of full-time women faculty from 25% to 38% over the past 2 decades. However, gender disparities in leadership positions remain striking; there is a pattern of reduced representation of women by rank consistent across most departments. The proportion of women in department chair positions remains low.²⁹ Carr and colleagues³⁰ sampled full-time faculty from 24 randomly selected US medical schools on faculty perception of gender discrimination and sexual harassment. Questionnaires from 3332 full-time faculty showed that women faculty were more than 2.5 times more likely than men to perceive gender-based discrimination in the academic environment, and that those who experienced negative gender bias had similar productivity but lower career satisfaction scores than other women. Half of women faculty, but few faculty who were men, experienced some form of sexual harassment. Publications, career satisfaction, and professional confidence were not affected by sexual harassment. Self-assessed career advancement was only marginally lower for female faculty who had experienced sexual harassment.

INFERTILITY, PART-TIME WORK, AND BIAS

Risk of infertility is much higher for women than for men. Pursuing a career in medicine often means deferring marriage and having children as young women focus on completion of medical school, residency, and additional fellowship training. Although there may be formal and informal mentorship by women faculty, counseling regarding risk factors for infertility and options to circumvent these issues is not standard. If pregnancy does occur, the focus of parental leave policies at most institutions and within most practices is on its impact on individual and group productivity and not what is best for the new parent. Many women in medical academia view pregnancy and childrearing as having a net negative impact on their productivity and career trajectory.²⁴ Policies guiding treatment of those who become parents (eg, extended tenure timelines, individualized promotion criteria) are lacking, which likely contributes to the underrepresentation of women at all levels of medical and academic leadership.

Further examples of bias against women in medicine to consider when developing policies and strategies include:

• Punitive consequences and criticism after complications are worse for women surgeons. For example, primary care physicians decrease referrals to women surgeons, but not their male counterparts, after bad outcomes.³¹

• Lack of understanding and policies that provide substantive support for those who need intermittent or temporary leave, or desire to work part-time. This lack of understanding can be in the context of raising children, caring for ailing family members, maternity leave, or personal choice for any reason.

• Societal and cultural belief that time worked is the only metric directly proportional to worth as a physician and, by extension, that those who deviate from 100%-time effort devoted to clinical practice have wasted their training and are less valuable contributors to medicine and society.

• Lack of consistent and mandatory training on conscious and unconscious bias for all.

• Violation of workplace policy, retaliation, frank and subversive attacks, or creation of hostile work environment for women and other underrepresented groups. For example, openly joking about professional support or career development activities for women, making inappropriate comments about appearance, or joking about physiologic needs related to pregnancy or breastfeeding.

Speaking to those who have experienced any or all of these problems can be very helpful for younger trainees and faculty to get guidance and perspective on how to approach or handle experiences that can create emotional trauma and/or decrease confidence.

MICROAGGRESSION

Microaggression is a subtle form of bias that includes microassaults, microinsults, microinvalidations, and environmental aggressions that are expressions of indirect, subtle, and sometimes unintentional discrimination against members of a marginalized group that serve to maintain existing power structures.³²

Originally coined in 1970 by a Harvard psychologist, the term initially referred to the minor but damaging humiliations and indignities experienced by African Americans.³³ The term has evolved in the years since to the description given earlier. The study of microaggressions is a nascent field and a detailed analysis of recent findings in medicine is beyond the scope of this article. Nonetheless, it is important to understand that they exist and are a common experience for women and individuals from minority backgrounds.³⁴ Microaggressions occur intentionally and unintentionally and can have a dramatic impact on not only their targets but the overall culture of medicine. This impact includes not only how clinicians interact with their colleagues and trainees but also the care rendered to patients. Microaggressions can generate stresses equal to or worse than overt discrimination.³⁵ Examples include addressing all physicians on an email by the title Doctor except the women, who are referred to by first name. Another common occurrence is patient disbelief that the woman or person of color who worked them up and explained a procedure and associated complications in detail is actually a surgeon because they do not look like physicians. Such microaggressions can also pathologize a person’s authentic behavior and identity expression. Individuals should not have to sacrifice their authentic selves in order to conform to biased expectations.³² Beyond sexism, other prominent microaggression themes in medicine are pregnancy and childcare related, having abilities underestimated, encountering sexually inappropriate comments, being relegated to mundane tasks, and feeling excluded/marginalized.³⁶

Several strategies have been recommended for use when a microaggression occurs. It is critical to note that it is not the victim’s responsibility to take action. Bystanders, particularly if they belong to the majority group, should also speak up. One recommended framework was described by Ganote and colleagues³⁷ and is remembered by the phrase “open the front door,” for observe, think, feel, desire. Statements are made regarding what was observed, how the comment was thought about and interpreted, how it made (or may have made) the recipient feel, and what the desired outcome may be. For example, “When you said [microaggression], it made me think [negative thing]. I feel concerned about this because [reason], and I would like us to discuss this further so we can come to an understanding. Another framework is ACTION, for ask clarifying questions; come from curiosity, not judgment; tell what you observed in a factual manner; impact exploration (ie, discuss what the impact of the statement was); own your own thoughts and feelings around the situation; and next steps.³⁸ The ACTION framework may look like the following: “I am not sure that I understood what you meant when you said [microaggression]. I want to better understand; can you please explain that to me? When I hear comments like that, it makes me feel like you think [negative thing].³⁹” Depending on the response, the discussion can close with action items for follow-up. If the person addressing the microaggression is not the intended victim, it may also be helpful to follow up with that individual to enquire about the person’s well-being and ask whether there is anything that could be done differently or better the next time.

PRACTICES TO INCREASE WELLNESS AND WORK-LIFE INTEGRATION

Micropractices are those that can be readily integrated into daily life during pauses or events that already occur (Box 1). Examples of ongoing events include hand sanitizing/washing, lag time when logging in to an electronic system, wait time for the elevator or while taking stairs, and commute time. Are you well hydrated? Hungry? Are you carrying emotional remnants of the last difficult patient encounter? Are you processing difficult news? These recurring events can serve as a cue for a valuable wellness check, especially if used to name the experienced emotions.⁴⁰ Functional MRI research has helped show the validity of this approach. Simply acknowledging and naming emotions can decrease emotional reactivity by shifting brain activity away from the amygdala to the prefrontal cortex, which can facilitate greater feelings of calm.⁴¹ Lists of feelings are readily available online to facilitate this practice.⁴²

Box 1. Factors to consider when starting a career for better work-life integration.

• Degree of flexibility in clinical responsibilities.

• Establishment of reasonable goals and timelines for professional activities, such as scholarly work, publications, research, and teaching.

• Number of partners in practice setting, which has implication on call frequency as well as less tangible factors such as availability of mentoring and peer support.

• Financial well-being/protection:

  • Organizational contributions to retirement savings

  • Years until equal partnership if private practice

  • Salary and total compensation model/formula including:

    • Benchmarks

    • Bonuses

    • Educational support

    • Malpractice coverage

    • Short-term and long-term disability

    • Legal support

    • Availability of paid time off

    • Leave policies, including parental leave

• Formal and informal mentorship availability.

• Organization/employer awareness and commitment to equity, diversity, antiracism, inclusion, and transparent policies that facilitate an equitable and just culture.

• Presence and support for use of lactation rooms in various settings and work facilities inside clinics, hospitals, and research settings.

• Attitude of the chief, chair, and immediate supervisor on burnout and well-being, as well as that of the highest-ranking senior leaders for the organization.

• Organizational, department, and division leadership; demographics of those in leadership roles; and whether they represent the diversity workforce they represent.

  • Often simply walking the hallway of the C-suite, one can see the framed glamour shots of leaders and whether diversity is present.

Gratitude has long been anecdotally linked to improved well-being and now occupies a distinct niche within the self-help industry. Depending on the context, gratitude can be an emotion, an attitude, a moral virtue, a habit, a personality trait, or a coping response.⁴³ A core theme of gratitude is the recognition of a gift. When people are asked to compare thankfulness with other emotions, it is most commonly likened to joy and contentment.⁴⁴ A gratitude practice facilitates the ability to appreciate and savor the meaningful elements of daily existence.⁴³

When health care workers were tasked with identifying 3 good things daily for 15 days, there were significant improvements from baseline in emotional exhaustion, depression symptoms, and happiness at 1, 6, and 12 months and in work-life balance at 1 and 6 months. Individuals who initially scored in the concerning range on baseline metrics experienced even greater positive effects.⁴⁵ Of note, the effect sizes of this daily gratitude practice were similar to those noted for selective serotonin reuptake inhibitors and mindfulness-based stress reduction interventions.^46,47 “Fill your tank” by recording a gratitude list, emotions and circumstances, epiphanies, and daily patient encounters or cases that brought positive experiences.

Note that gratitude is not limited to self-reflection practices. Meaningfully expressing gratitude can be therapeutic as well. Send messages of love and gratitude to your family, friends, neighbors, or anyone who has made your home or work life a better experience. For example, send surprise gifts, a card, chocolates, flowers, or other tokens to someone you care about or to a person who has made your life better in any way. Express gratitude to your leadership and colleagues, including trainees, when they have made you feel valued, respected, and heard or if they supported you during a moment of need.

Setting Realistic Expectations and Regaining Autonomy

Introspection is required for all individuals to understand and effectively communicate their priorities and goals, both in their professional and personal spheres of life. There are several baseline questions to ask. For example, what activities are engaged in most frequently? What are the most fulfilling? What is the time commitment and importance associated with each? From these questions, triage activities by order of necessity, importance, and fulfillment. Unless mowing the lawn, cleaning the house, or doing yardwork is personally fulfilling, consider engaging outside help to outsource the burden of these tasks.²³ There is much more work to be done to normalize and empower individual physicians to have autonomy to decide when, and under what circumstances, they want to adjust their schedule to make family obligations a priority.⁴⁸

Time Management

Time is the most critical indispensable asset. Developing efficiency and effective time management is crucial for success. For example, avoid wasting time driving all over town to buy supplies that can be ordered. This time could be better spent for exercise, hobbies, sleep, meditation, or other enjoyable activities. Making a schedule and adhering to it is also crucial.¹¹ Review professional commitments ahead of time. Reflect on last year: where and when did you overcommit? What did you say “Yes” to that you ended up dreading? What did you agree to that you loved doing? Consider these factors when creating schedules that are doable, avoid overcommitting, and include self-care. Self-care can include simply trying something new: Pilates, ping-pong, pickleball, yoga. When possible, schedules should be created in advance and around important activities such as birthday parties, dinners, play dates, and so forth. After committing to personal and family time, activities that you or your family really want to invest in for growth and depth can be added.

Nutrition and Exercise

Even if you do not know how, or hate, cooking, have a plan to keep your body nourished with healthy food, both at work and at home. In a 2008 survey of National Health Service physicians, nearly three-quarters of physicians indicated that hospital cafeterias did not have adequate healthy options.⁴⁹ Many meal preparation and delivery options exist. The daily work and demands of a surgical career may challenge healthy hydrating and eating habits that support blood glucose homeostasis. Because female surgeons may defer family planning and pregnancy because of length of surgical residency training and additional fellowship training, awareness of impact on blood sugar regulation as related to dietary habits and routine exercise on fertility is important.⁵⁰ Harvard researchers established relationship between fertility and diet with folic acid, vitamin B₁₂, omega-3 fatty acids, and a healthy diet having positive fertility effects, whereas antioxidants, vitamin D, dairy products, soy, caffeine, and alcohol seemed to have little or no effect on fertility.⁵¹ In addition, muscle mass decreases with age, which is especially important for women, who typically have less muscle mass than men. For this reason, developing a physical fitness routine is important for overall health and to reduce chances of musculoskeletal-related disability.

Childcare

If you have, or are considering having, children, anticipate both routine and potential unexpected childcare (eg, sick child) needs as early as possible. Parenting responsibilities contribute significantly to work-home conflicts and overall household duties. The ability to clearly plan for these needs may mitigate future frustrations. When selecting a practice, especially if a larger hospital or academic practice, on-site or flexible hour options may be available. It is also important to note that excellent childcare support occurs in many forms: spouses, nannies (live-in or otherwise), extended family, and daycare.

COUNSELING AND COACHING

Although it is possible to write the characters “I love you,” traditional Chinese culture does not include speaking these words on a daily basis, except perhaps in movies and teledrama. I lost my mother to breast cancer at age 9 years, followed immediately by immigrating to the United States, without knowing any English, and with a new stepmother. We simply did not express emotions even though experiencing deep pain from loss and grief. Despite years of what, in hindsight, was depression from unprocessed grief and challenges in adolescence, I never knew counseling existed. It was never mentioned in my culture nor did I know anyone in counseling throughout high school or college after immigrating to the United States. It was not until my third year in medical school, during my psychiatry rotation, that it was strongly suggested to me after I was outwardly expressing significant signs of depression. The immense benefit I have since experienced, not just during medical school but subsequently at intervals during residency, then as a faculty, and even now, both from individual and marital counseling, is supported by the literature.

Clough and colleagues⁵² conducted a systematic review of psychosocial interventions targeting occupational stress and burnout among medical doctors. Although only 12 of 23 articles reviewed included preintervention to postintervention effects, cognitive-behavioral interventions were promising and showed the strongest evidence, particularly for reducing stress. They also concluded that additional and more rigorous studies examining the benefits of psychosocial/behavioral interventions for occupational stress and burnout in physicians are needed.⁵² Factors associated with burnout in trainees and faculty in both surgical and nonsurgical fields have been better studied. In a review of 47 articles published between 2009 and 2014, Amoafo and colleagues⁵³ found younger age, female sex, negative marital status, long working hours, and low reported job satisfaction to be predictive of burnout syndrome across the literature. Participation in wellness programs was related to lower burnout incidence. Although causation was not established because of limited number of longitudinal studies, the use of this information to increase preventive measures and guide interventions is recommended.

Every individual has a personal story and personal journey well before entering medical school and subsequent training. Personal histories including loss, trauma, physical and/or emotional abuse, and psychological distress before entering medical school and the stress of careers in medicine and surgery all contribute to the high occupational risk of suicide in physicians. Even strong support networks do not guarantee immunity against circumstantial and unanticipated crisis. Physicians are not superhuman. It is not only expected but anticipated that periodic help from a mental health professional will be needed to help optimize work-life integration and facilitate and protect their well-being.

PEER SUPPORT

Research has shown that men and women may need different kinds of networking to succeed.¹ The researchers reviewed types of networks that helped new male and female MBAs (Master of Business Administration) land executive leadership positions. They found that men benefit from being central in the networks and by being connected to multiple hubs of people with many contacts across different groups. Women required dual networks to land top positions. In addition to centrality, they also had to have an inner circle of close female contacts, despite having similar qualifications to men, including education and work experience.

Peer support may be experienced differently between men and women. Peer support can be most constructive and insightful if it occurs across genders and includes members representing the greatest diversity in all areas of professional and personal experience. Particularly relevant in health care is for hospitals to invest and create a formal peer support/second-victim program.

The Joint Commission boldly announced in 2020 a shift in focus to emphasize worker well-being, including blogs on establishing clinician well-being as a national priority, and removing mental barriers to mental health care for clinicians.⁵⁴ A formal peer support program in which investments are made to train various team members to become peer supporters, as well as senior leaders understanding how peer support positively affects quality and patient safety, is necessary to achieve the stated goals of focus on physician well-being and achieving zero harm. Dr Susan Scott (Scott and colleagues⁵⁵) published in 2010 on “Caring for Our Own: Deploying a Systemwide Second Victim Rapid Response Team,” She is a leading researcher who has published on the impact of peer support on patient safety for the Joint Commission.

The most critical factor in creating change to ensure fair, just, equitable, and inclusive environments is the intentional creation of a culture that affirms these values. Words matter. Conversations create change and define culture. Peer support across not only small groups but entire tiers of faculty and leaders can collectively create a culture of shared advocacy, sponsorship, and bidirectional mentoring and relationships founded on trust and mutual respect.

SUMMARY

What has never been formally taught in medical school or subsequent training in a career in medicine is the fact that providing health care to others does not provide immunity against physical and/or mental illnesses or burnout. Intentional strategies at the individual, organizational, and systems levels must be used to encourage healthy work-life integration. Strategic recovery must occur on a daily basis. Normalizing use of mental health support, sharing vulnerabilities, leveraging peer support, and leveraging daily interactions to create a just and equitable health care culture are all critical components of true physician wellness.

KEY POINTS.

• Work-life integration reflects the synergy needed between professional and personal lives only achievable by creating strategies that optimize holistic self-care and efficiencies in both.

• There are gender-specific differences and various factors that increase challenges to achieve work-life integration. Awareness and intentional strategies can be used to mitigate challenges.

• Micropractices can increase work-life integration: including creating routines for gratitude, self-compassion, time management, healthy nutrition, exercise, outsourcing, finding support, and setting realistic expectations.

• Normalizing individual and relationship counseling and use of mental health support are critical to enhance work-life integration, minimize burnout, and optimize well-being.

• Formal and informal peer support are necessary to minimize second-victim effects from the cumulative impact of the acute and chronic stress inherent to the practice of medicine and surgery.