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The Western Journal of Medicine logoLink to The Western Journal of Medicine
. 2001 Jan;174(1):19–23. doi: 10.1136/ewjm.174.1.19

A qualitative study of physicians' own wellness-promotion practices

Eric L Weiner 1, Geoffrey R Swain 2, Barbara Wolf 3, Mark Gottlieb 4
PMCID: PMC1071222  PMID: 11154656

Abstract

Objective To delineate the specific practices that physicians use to promote their own well-being. Design, setting, and participants 304 members of a primary care practice-based research group responded by mail to a survey on physician well-being. From the original survey, 130 subjects responded to an open-ended survey item regarding their own wellness-promotion practices. Methods Qualitative content analysis was used to identify the common themes in the physicians' responses to the open-ended question. A validated 18-item instrument, the Scales of Psychological Well-Being (SPWB), was used for measurement. Main outcome measures Similarities and differences between the various wellness-promotion practices that respondents reported using and associations between the use of these practices and SPWB scores. Results The 5 primary wellness-promotion practices that evolved from thematic analysis of the survey responses included “relationships,” “religion or spirituality,” “self-care,” “work,” and “approaches to life.” The use of the last type of practice was significantly associated with increased psychological well-being (SPWB) scores compared with the use of any of the other wellness-promotion practice categories (P<0.01), and there was a trend toward increased well-being among users of any category of wellness-promotion practices. Comments by our respondents provide specific descriptions of how physicians attend to their emotional, spiritual, and psychological well-being. Conclusion Physicians use a variety of approaches to promote their own well-being, which sort themselves into 5 main categories and appear to correlate with improved levels of psychological well-being among users.


Why do we know so much about physician impairment and so little about positive physician functioning? Studies exploring physician functioning in the medical literature have focused on negative behavioral indices such as divorce, suicide, mental and physical illness, marital dysfunction, drug and alcohol use, and burnout.1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16 This tendency to pathologize seems to also pervade the general psychological literature.17 The presumption in the literature seems to be that the absence of impairment is an indication of health. Indeed, in a study by St Claire and colleagues, physicians defined health simply as the absence of disease.18 This stands in stark contrast to patients, who define health much more broadly, using terms such as “being able,” “taking action,” and “physical well-being.”

There is little information that delineates the specific physician practices that promote successful life adjustment. Several authors draw on personal experience or provide anecdotes of their professional work to suggest ways to prevent burnout, overcome compassion fatigue, renew the joy in practice, and create life balance.19,20,21,22 Their ideas appear to be valid, but they are generally not grounded in any specific research. Yet, many practicing physicians are able to maintain balance and meaning in their lives despite the stressors and limitations of their practices. What do they do to survive—indeed, thrive—while some of their other colleagues suffer? How is it that some are more effective at this than others? Is this something that can be promoted?

Manusov discovered that specific strategies used by 14 first-year residents to positively influence their level of happiness (an affective measure of psychological well-being) were pursuing and achieving goals, being positive, being in relationships, having a religious belief system, and receiving positive feedback.23 Quill and Williamson sorted the creative solutions used by practicing internal medicine physicians to cope with the stressors of medical practice into 5 categories: self-awareness, sharing of feelings and responsibilities, self-care, developing a personal philosophy, and setting limits.24 Their 10% response rate (out of 600 surveys) suggests that it is difficult to obtain qualitative data from busy physicians, and the low response rate may limit the generalizability of their findings.

A 1997 survey of primary care physicians found that psychological and emotional well-being among physicians was significantly associated with the ability to maintain individual identities in relationships with original family members, with the presence of strong social support, and with levels of practice stress.25 In that survey, qualitative data were requested from physician participants related to how they maintain their physical, emotional, and spiritual well-being. In this article, we report those qualitative results. Our goals are to shed additional light on the wellness-promotion activities used by practicing physicians, to assess the extent to which such practices are actually associated with increased well-being, and to promote further research in this area.

METHODS

We originally mailed an 8-page survey to all 614 members of the Wisconsin Research Network (WReN) with an MD or DO degree. Membership consists of self-selected physicians interested in conducting or supporting research in primary care practice. Their demographic characteristics are similar to those of nonmember primary care physicians in Wisconsin (Oral communication, John Beasley, October 20, 2000).

The survey consisted of a family systems assessment instrument26; a life-events checklists; single-item measures of happiness, life satisfaction, and emotional functioning; and single-item assessments of relationship support and practice stress. The survey also contained Ryff's Scales of Psychological Well-Being (SPWB),17 which measures 6 different dimensions of well-being: self-acceptance, positive relations with other people, autonomy, environmental mastery, purpose in life, and personal growth. Psychometric information on these tools has been reported elsewhere.25

The final question of the survey was the only open-ended item: “How do you solve dilemmas related to your physical, emotional, and spiritual well-being?” We report the analyses of their responses to this question.

We used a qualitative content analysis to decipher relevant themes in the data.27 The first 2 authors of this article (E L W, G R S) independently reviewed the responses to see what categories would spontaneously emerge from the data. We then compared and contrasted all of the categories until we agreed on a final list (table 1). We then went back to the original data and independently coded each response. Our level of inter-rater agreement at that point was 92%. All discrepancies were discussed until a final inter-rater agreement of 100% was reached.

Table 1.

Categories and subcategories of responses to questionnaire

Category Example or subcategory
Approaches to life General philosophical outlooks or specific strategies
Relationships* Family*: spouse, children, nuclear family,* parents, siblings, family of origin*
Friends
Colleagues (work)
Community involvement
Religion or spirituality* Religious beliefs, practices, or faith*: prayer, Bible reading, church service attendance, church activities*
Spirituality or spiritual community*
Self-care* Reading*: for enrichment, personal growth, etc; for relaxation
Activities*: aerobic exercise, learning/enrichment activities, meditation, outdoor recreation, relaxation, self-expression activities, vacations/get-aways
Good nutrition
Avoid alcohol and drugs
Treatment of depression*: antidepressant medications
Leaving unhealthy relationships
Professional counseling
Work* Satisfaction from work*: meaning from work
Choosing a certain type of practice*: stopping practice of obstetrics, working part-time, working in an academic environment
Dysfunctional strategies None
Unscorable* Described stressors, not strategies or approaches or solutions
*

Not otherwise specified.

Table 2.

Partial demographic profile* of physicians (n = 130) responding to the question “How do you solve dilemmas related to your physical, emotional, and spiritual well-being?”

Demographic Physician, no. (%)
Marital status
Married 114 (88)
Divorced 8 (6)
Separated 2 (2)
Never married 5 (4)
Income, $
<25,000 0
25,000 to 49,999 2 (1)
50,000 to 74,999 8 (6)
75,000 to 99,999 14 (11)
100,000 to 124,999 30 (23)
125,000 to 149,999 37 (29)
150,000 to 174,999 20 (15)
≥175,000 19 (15)
Religion
Protestant 54 (42)
Catholic 37 (28)
Jewish 5 (3)
Other 19 (15)
None 15 (12)
*

Includes only those not given in the text.

One subject did not respond.

As a confirmatory final step, we compared the qualitative results with the SPWB scores to confirm the strength of the associations. We thought it was essential to know whether 1 or more of the types of wellness-promotion practices reported by these physicians were significantly associated with increased levels of psychological well-being.

RESULTS

Of 304 completed surveys, 130 participants responded to the open-ended inquiry, giving a response rate of 43%. Based on a multinomial test, no statistically significant differences were found between the demographic profiles of the original and the subsample subjects (P=0.46) (table 2). Men in the subsample (n=99) outnumbered women by more than 3:1, and the mean age was 47.3 years (range, 33-77 years). Most responders (114 [88%]) were married, 119 (92%) had children, most had an income of more than $100,000, and most (125 [96%]) reported themselves to be in good or excellent health.

Responses sorted into 5 primary categories, which we termed wellness-promotion practices. Two additional categories developed around their responses: “dysfunctional strategies” and “unscorable other.” Dysfunctional strategies included responses such as “I eat too much” and “alcohol.” Other unscorable responses included those that simply described specific stressors without commenting on any coping mechanisms, strategies, solutions, or approaches to managing them.

The 5 primary wellness-promotion practice themes that evolved from thematic analysis of the survey responses included relationships, religion or spirituality, self-care, work, and approaches to life. Each primary theme had associated subcategories, as shown in table 1.

Relationships

This thematic group of wellness-promotion practices included being involved in and spending time with family, friends, or colleagues or other community involvement. Sample responses: “Time alone with my spouse. We have a weekly date for breakfast or lunch and have `getaway' weekends every 2 to 3 months.” “I discuss things with my spouse. We have weekly family meetings to work on problems.”

Religion or spirituality

This group included prayer, Bible reading, attending church services, and involvement in church activities. Sample responses: “My religious faith has been very important in my family of origin and my own family. Involvement with my church through worship, administrative responsibilities and group events (Bible camp, etc) has been very important to my emotional and spiritual well-being.”

Self-care

These wellness-promotion practices included reading, good nutrition, avoiding drugs or alcohol, getting formal treatment for depression, getting professional counseling, leaving unhealthy relationships, and various self-care activities such as taking vacations, aerobic exercise, hobbies, and meditation. Sample responses: “I try to exercise... [and] eat reasonably. Look for new projects such as learning to play the flute and improve computer skills. Modified farming and gardening. Motorcycle trips.” “I visualize positiveness at least once a day.” “I keep myself on track by reading, writing, speaking (inspirational is my favorite).” “Hockey!”

Work

Activities characterizing work-related wellness promotion included choosing a certain type of medical practice, limiting one's practice, and deriving satisfaction and/or meaning from one's work. Sample responses: “I spend lots (too much) time doing medicine, but even there I'm clear that my job is to give my clients information and options, not to mandate.” “I am very much happier in academic practice than I was in fulltime clinical work.” “I changed jobs to one that better suited my values and accommodates part-time work (and values me).”

Approaches to life

These wellness-promotion practices included general philosophical outlooks such as being positive, focusing on success, maintaining a balance in life, and specific strategies on implementing such approaches. Sample responses: “Play the hand you are dealt with to the best of your ability.” “Over the past year, I have made a large effort to simplify my life—no TV, radio, cut down on obligations.”

There was a trend toward increased psychological well-being (SPWB) scores among those who reported use of any of the 5 wellness-promotion practice categories compared with those who did not report such use. When compared against each other, the use of an “approach to life” practice was associated with significantly higher levels of psychological well-being (P<0.01) than the use of any other category of wellness-promotion practice.

Many of the approach-to-life responses seemed to emphasize the importance of balancing various aspect of one's life to be well. This could be interpreted as a “metaview” of wellness-promotion practices; the physicians who used an approach-to-life wellness-promotion practice were often, in fact, using and balancing most or all of the 5 wellness-promotion practice categories. Several additional quoted comments illustrate this point: “Balance in my life helps to alleviate stress.” “I don't take myself too seriously.” “Surviving cancer changes your perspective about what's important.” “I strive for balance with regular exercise, a healthy diet, and maximizing time with my family.” “Variety and diversity are essential parts of well-being.”

Two respondents were particularly eloquent in summarizing this point. One wrote, “It's very important to have a balance between physical, spiritual, and mental health. This involves working out, eating right, having a spiritual dimension, community volunteerism, developing the mind, setting both short- and long-term goals, etc.” The second wrote, “I usually try to reach a `balance.' I need physical, intellectual, spiritual, and relationship sustenance. When one aspect is not tended to, I do not feel as happy, peaceful, and hopeful as when all are receiving my attention.”

DISCUSSION

This group of physicians reported personal wellness-promotion practices that go beyond the traditional medical model of health as simply the absence of disease. Unlike the previously cited study by St Claire and associates,18 these physicians seem to show health beliefs and practices that reflect a wellness model. The 5 categories of wellness-promotion practices they outline show similar patterns to those described by Manusov and by Quill and Williamson,23,24 Our results also seem consistent with the core aspects of well-being described by Ryff and Keyes.17

Clearly, the use of such wellness-promotion practices by physicians is more consistent with patients' definition of health than with physicians' typical absence-of-disease model. To the extent that physicians incorporate a broader model of health behavior practices into their own lives, we might expect them to interact more functionally with their patients. Healthy healers presumably make more effective healers because they tend to give advice, interact with patients, and be role models in ways that resonate more with their patients' broader expectations regarding health.

What physicians say they do may differ from what they actually practice. Our reliance on self-report limits the reliability of the data obtained. The wellness-promotion practices of nonresponders may differ from the practices of those who did respond. Furthermore, our ability to generalize these findings is limited in that these data are the result of responses given to only 1 question. Nonetheless, 130 physicians responded, which is 1 of the largest subject pools in studies of this topic. These data offer rich initial insights but only touch the surface.

Our data show that the use of approach-to-life wellness-promotion practices—and perhaps other types of wellness promotion—is associated with increased psychological well-being among physicians. To the extent that these wellness-promotion practices are indeed effective, how can practicing physicians, residents, and medical students be encouraged and supported to incorporate these practices into their lives? Can we externally influence physicians' well-being and positive physician functioning? If we can do so, we would be adding to the calls for increased education of students and residents on physician beliefs, values, self-awareness, and reflection28,29,30 and for longitudinal courses, literature, and workshops for practicing physicians to help them reconnect with what is meaningful about the practice of medicine.31,32

Our physician respondents' descriptions of their wellness practices, using their own words, are intriguing and even compelling. However, given the paucity of data in the literature, it is clear that more data acquired by many design methods are needed to develop more depth on this issue. In particular, more study is required to determine if the use of 1 or more of these categories of wellness-promotion practices is, in fact, associated with improved levels of wellness among physicians. Finally, several important questions have arisen from our study, and further research is needed to answer them (see box).

Table 3.

Questions arising from our research
  • What are the gender differences in successful wellness-promotion practices?

  • How do these practices and activities change over time by age and sex?

  • Do cultural differences affect physician wellness-promotion practices?

  • Does developing our spirituality affect relationships with our patients?

  • Do these wellness practices actually promote well-being, or is psychological wellness in fact antecedent to these wellness practices?

Acknowledgments

We are grateful to the members and administrators of the Wisconsin Research Network, and to Alka Indurkhya for help with statistical analysis.

Competing interests: None declared

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