Abstract
Recognition of how physicians contemplate and approach their activities, positive or negative, may shed light into a more holistic depiction of physician well-being. The purpose of this work was to develop items to measure wise cognitive exertion, constructed with Stoic thought, and determine its association with physician stress, well-being, and life satisfaction. A survey was sent to physicians and university staff members. This pilot investigation found a relationship among focusing on a purposeful life, acknowledging locus of control, avoiding wasteful cognition, and taking (good or bad) life experiences for personal growth and superior life satisfaction, well-being and lower stress. A 13-Item Wise Exertion Scale was developed and had significant associations with stress, well-being, and life satisfaction. Each of the four factors from the 13-Item Wise Exertion Scale were significantly associated with each measure with the exception of Control Consciousness and life satisfaction. Within physicians (N = 59), the 13-Item Wise Exertion Scale was a significant predictor, after adjusting for demographics with stress, well-being, and life satisfaction. Physicians had significantly lower 13-Item Wise Exertion Scale scores compared to non-physicians (N = 126). Future inquiries are required to determine if physicians with a mindset assembled with these beliefs have superior well-being.
Keywords: wellness, physician, stress, wise exertion
“Practitioners of the Stoic branch of philosophy took particular interest in how we approach inevitable life stressors.”
Introduction
Physicians under stress may experience burnout which encompasses emotional exhaustion, depersonalization, and inferior feelings of personal accomplishment. 1 Affecting half of physicians, burnout is a systemic problem that leads to healthcare errors, higher costs, and lower quality of care. 2 Physicians with burnout experience substance abuse, relationship concerns, depression, and death. 3 While root causes of burnout vary within each provider and specialty, most cases involve work stress. 4 Despite research efforts to understand acute and chronic stress, as well as interventions to alleviate stress, the issue remains a serious problem made worse by the COVID-19 pandemic. 5
In addition to measuring burnout and stress, investigators have studied positive aspects of physician wellness. Markers of physician well-being focus on thriving or life satisfaction rather than on distress. 6 Researchers should seek constructs to assess negative (stress) as well as positive (e.g., life satisfaction) factors to augment physician well-being.
A variety of interventions has been implemented to combat distress and improve physician wellness. Mindfulness and cognitive behavioral therapy (CBT) can formally or informally cultivate equanimity, compassion, and clear thinking. 7 When done properly, reflection on one’s actions and life may reduce stress. Family medicine program directors who were more cognizant of what makes one’s life meaningful reported lower levels of burnout and superior quality of life. 8 Additionally, a 2017 systematic review found interventions for cognitive or behavioral change showed promise as psychosocial interventions for physician stress and burnout. 9 Physicians can incorporate self-awareness, mindfulness, coping skills, and self-care in their routine work as a protective factor against burnout. 10
In consideration of strategies to reduce stress, physicians could consider how they exert mental capacity. Practitioners of the Stoic branch of philosophy took particular interest in how we approach inevitable life stressors. Epictetus first described a “dichotomy of control,” separating stressors into those we can control, and those we cannot. (William Irvine added a third category, things over which we have some control). 11 The Stoics prized personal virtue as the ultimate goal in life, thus focusing on one’s own thoughts and actions and recognizing the importance of agency. Concentration camp survivor Victor Frankl famously stated that our response to stimuli or stressors lies within our own power. 12 Like Frankl, physicians can utilize adversity to grow as people. Finding intrinsic motivation and seeking purpose with a clear mindset will benefit physician well-being.
While arguably valuable for any human, these practices may be especially important to physicians and other individuals in high stress environments. In the U.S., Stoic practices are embraced by the armed forces to combat stress. 13 Despite potential benefits, no known study has examined the relationship between a Stoic mindset and physician wellness. The purpose of this work was to develop a tool to measure “wise cognitive exertion” based on Stoic thought, and determine its association with stress, well-being, and life satisfaction. Additionally, scores between physicians and non-physician respondents were compared to determine differences between groups.
Methods
Sample and Instrument
The sample consisted of employees working at one urban university. A survey was sent via email through university email contacts to physicians (residents and attendings) and university staff members for a comparison group. The respondents were asked a set of demographic questions regarding the following: gender identity, race/ethnicity, age group, parental status, and work role (e.g., physician, university staff member).
To quantify wise exertion, the authors developed 30 items associated with Stoic teachings for this project (Appendix A). The respondents completed these items by responding to each statement from strongly disagree to strongly agree. In addition to the wise exertion questions, the respondents were asked to complete the validated World-Health Organization (WHO-5) Well-Being Index to measure well-being. 14 This questionnaire consists of five questions in which respondents describe how they have felt over the past two weeks. 15 The participants were tasked with completing the validated Cohen’s Perceived Stress Scale by responding to statements regarding their feelings toward stress over the last month from never to very often. Finally, respondents answered five questions from the validated Life Satisfaction Scale, rating five items on a 7-point scale. 16
Data Collection and Analysis
Data were collected in REDCap™, a secure and encrypted online database. Sample demographics are reported with frequencies and percentages. Cronbach’s α and item statistics were used to evaluate the scales. Principal components analysis was utilized to examine the wise exertion scale with Promax rotation. Factors were retained if eigenvalues were greater than 1. Factor loadings (and cross loadings) were examined and classified based on data and underlying meaning of the items grouped. We report findings for the full 30-item scale as well as a shortened 13-item scale to measure wise exertion.
Pearson correlations were conducted among wise exertion, stress, well-being, and life satisfaction. Linear regressions were conducted to determine which of the following were predictors of stress, well-being, and life satisfaction in physicians: gender identity, age group, parental status, and wise exertion score. Independent samples t-tests were conducted to determine differences in scores between physicians and non-physicians. Additionally, a regression analysis was conducted to determine if wise exertion scores were significantly related to whether or not a respondent was a physician after controlling for gender identity, age group, and parental status. Statistical significance was set at p < .05 and we report 95% confidence intervals (CIs). IBM SPSS Version 27 Statistics was used for data analysis.
Results
Sample Characteristics
One-hundred and eighty-five subjects ultimately responded to the survey. Fifty-nine (31.9%) respondents were physicians. The majority of respondents were white (87%), female (72.4%), and parents (66.5%). Age groups included 18–29 (11.4%), 30–39 (25.9%), 40–49 (23.2%), 50–59 (19.5%), 60+ (19.5%), and unknown (.5%).
Measuring Wise Exertion
For the entire sample, the Cronbach’s α for the full 30-item scale was .896. Within physicians only, it was slightly higher, Cronbach’s α = .902. Due to many cross-loading concerns with the 30 items and length, a shortened measure was identified. The modified instrument consisted of 13 items (Table 1). The 13-Item Wise Exertion Scale Cronbach’s α was .822 (Cronbach’s α = .800 in physicians only). Principal component analysis revealed Bartlett’s tests of sphericity was significant (p < .001) indicating adequate correlation among the variables. An inspection of eigenvalues and the scree plot revealed a four-factor solution accounted for 64.6% of the total variance. Factor 1, which we describe as Control Consciousness, consisted of four items and accounted for 32.8% of the variance. Factor 2, which we describe as Wasteful Cognition, consisted of three items and accounted for 12.4% of the variance. Factor 3, which we describe as Growth Mentality, consisted of three items and accounted for 10.9% of the variance. The final factor we describe as Purposeful Being, consisted of three items and accounted for 8.5% of the variance. Table 1 provides item loadings for each factor.
Table 1.
13-Item Wise Exertion Pattern Matrix.
| Item | Control Consciousness | Wasteful Cognition | Growth Mentality | Purposeful Being |
|---|---|---|---|---|
| I recognize that I am in command of my actions. | .848 | |||
| I recognize that I am in command of my feelings. | .761 | |||
| I accept that I cannot control feelings of others. | .663 | |||
| I accept that I cannot control actions of others. | .661 | |||
| I tend to dwell on negative things that have happened to me in the past. | .840 | |||
| I think of my problems as bigger than they actually are in the grand scheme of life. | .836 | |||
| I spend too much time thinking about matters that are not useful. | .806 | |||
| When something negative happens to me, I consider it as an opportunity to grow as a person. | .957 | |||
| I take each life lesson, good or bad, and apply it to my mindset for personal growth. | .690 | |||
| I recognize that what happens to me in life is for me and not to me. | .671 | |||
| I spend energy on the things that matter most in life. | .822 | |||
| I focus my engagements on what is most important in life. | .796 | |||
| I recognize that we as humans are fragile and that time on earth is precious. | .624 |
Principal component analysis. Promax Rotation.
Wise Exertion Relationship to Stress, Well-Being, and Life Satisfaction
Significant associations were found between the full 30-items measuring wise exertion and each measure, (all p < .001). Additionally, the 13-Item Wise Exertion Scale had significant associations with each measure. Each four factors, from the 13-Item Wise Exertion Scale, were significantly associated with each measure with the exception of Control Consciousness and life satisfaction (p = .117). Table 2 provides all scale correlation findings.
Table 2.
Scale Correlations.
| Wise Exertion 30 | Wise Exertion 13 | Control Consciousness | Wasteful Cognition | Growth Mentality | Purposeful Being | |
|---|---|---|---|---|---|---|
| Stress | −.661* | −.588* | −.350* | −.572* | −.389* | −.328* |
| Well-being | .432* | .420* | .240* | .324* | .333* | .349* |
| Life satisfaction | .417* | .380* | .117 | .362* | .295* | .297* |
*P < .001.
Physician Wise Exertion
Results revealed, after controlling for gender identity, parental status and age group, the 13-Item Wise Exertion Scale was a significant predictor of stress (p = .002), well-being (p = .001), and life satisfaction (p < .001) in physicians (Table 3).
Table 3.
Physician Wise Exertion with Stress, Well-Being, and Life Satisfaction.
| B | SE | Beta | t | P | 95% CI | |||
|---|---|---|---|---|---|---|---|---|
| Stress | Female | .939 | 1.424 | .078 | .66 | .513 | −1.925 | 3.804 |
| Parent | 1.086 | 2.363 | .086 | .46 | .648 | −3.667 | 5.84 | |
| Under 40 | 2.818 | 2.468 | .233 | 1.142 | .259 | −2.146 | 7.783 | |
| Fifty and older | −1.368 | 2.073 | −.098 | −.66 | .513 | −5.537 | 2.802 | |
| 13-Item Wise Exertion Scale | −.461 | .138 | −.463 | −3.355 | .002 | −.738 | −.185 | |
| Well-being | Female | −5.46 | 4.077 | −.167 | −1.339 | .187 | −13.662 | 2.742 |
| Parent | −10.295 | 6.768 | −.307 | −1.521 | .135 | −23.911 | 3.32 | |
| Under 40 | −10.629 | 7.143 | −.327 | −1.488 | .143 | −24.999 | 3.74 | |
| Fifty and older | −4.425 | 6.198 | −.114 | −.714 | .479 | −16.895 | 8.044 | |
| 13-Item Wise Exertion Scale | 1.411 | .409 | .525 | 3.451 | .001 | .589 | 2.234 | |
| Life satisfaction | Female | −.953 | 1.519 | −.073 | −.627 | .534 | −4.009 | 2.104 |
| Parent | 0.7 | 2.519 | .052 | .278 | .782 | −4.367 | 5.767 | |
| Under 40 | −1.837 | 2.626 | −.141 | −0.7 | .488 | −7.12 | 3.446 | |
| Fifty and older | −3.107 | 2.216 | −.206 | −1.402 | .168 | −7.565 | 1.352 | |
| 13-Item Wise Exertion Scale | .676 | .149 | .631 | 4.549 | .001 | .377 | .975 | |
After controlling for gender identity, parental status, age group, well-being scores, and life satisfaction scores, the 13-Item Wise Exertion Scale was not significantly associated with stress (p = .296). Similarly, after controlling for gender identity, parental status, age group, life satisfaction and stress scores, the 13-Item Wise Exertion Scale was not significantly associated with well-being (p = .455). However, after controlling for gender identity, parental status, age group, stress scores, and well-being scores, the 13-Item Wise Exertion Scale was a statistically significant predictor of life satisfaction (p = .015), B = .430 (95% CI: .09, .77). In this model, stress (p = .762) and well-being (p = .059) were not significantly associated with life satisfaction after adjusting for other variables.
Differences in Wise Exertion
T-test results revealed there were statistically significant differences between physician and non-physician scores on the 13-Item Wise Exertion Scale. There were also significant differences on Growth Mentality and Purposeful Being between the two groups (Table 4).
Table 4.
Score Differences between Physicians and Non-Physicians.
| Physician | Non-Physician | Difference | (95% CI) | P Value | |||
|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | ||||
| Wise exertion 30 items | 105.9 | 14.1 | 110.1 | 13.2 | −4.2 | (−8.7, .3) | .064 |
| 13-Item Wise Exertion Scale | 47.7 | 6.1 | 50.2 | 6.4 | −2.5 | (−4.5, −.5) | .017 |
| Control distinguishing | 16.6 | 2.1 | 17.2 | 2.3 | −0.6 | (−1.3, .1) | .085 |
| Wasteful cognition | 9.4 | 2.7 | 9.9 | 2.8 | −0.4 | (−1.3, .4) | .320 |
| Growth mentality | 10.3 | 1.8 | 11.1 | 2.1 | −0.7 | (−1.4, −.1) | .022 |
| Purposeful being | 11.2 | 1.7 | 12.0 | 1.8 | −0.8 | (−1.4, −.2) | .005 |
| Stress | 17.1 | 5.9 | 16.3 | 5.2 | 0.8 | (−.9, 2.5) | .350 |
| Well-being | 54.7 | 17.1 | 55.3 | 18 | −0.6 | (−6.2, 5.0) | .830 |
| Life satisfaction | 25.7 | 6.9 | 24.7 | 6.7 | 1.0 | (−1.2, 3.1) | .368 |
Regression results revealed, after adjusting for gender identity, age group, and parental status, there was a statistically significant association between physician status (yes/no) and the 13-Item Wise Exertion Scale (Exp B = −2.33, 95% CI: −4.45, −0.20), p = .032, with physicians having lower scores.
Discussion
This pilot investigation found a relationship among focusing on a purposeful life, acknowledging locus of control, avoiding wasteful cognition, and taking (good or bad) life experiences for personal growth and superior life satisfaction, well-being, and lower stress. Within physicians, the 13-Item Wise Exertion Scale constructed in this study was a significant predictor for stress, well-being, and life satisfaction, after adjusting for age group, gender identity, and parental status. Physicians had significantly lower 13-Item Wise Exertion Scale scores compared to non-physicians. This study provides pilot results for future investigations into Stoic thought and well-being in physicians.
Though the survey items do not cover all Stoic principles (e.g., negative visualization) and may not align to all teachings, they were created with understanding of both Stoic thought and modern positive psychology ideas. Future work can examine the psychometric properties of the items and the 13-Item Wise Exertion Scale with four factors focusing on: Control Consciousness, Wasteful Cognition, Growth Mentality, and Purposeful Pursuits. It is important to note that while individuals embracing a mindset aligned to the items included in the 13-Item Wise Exertion Scale may improve their well-being, this mentality is not a system change. System changes are critical to address physician burnout and distress; steps must be made at the organizational level to alleviate barriers to optimal physician wellness by developing solutions to combat the sources (e.g., EMRs, reimbursement pressure, increased work duties, etc.). 2 The items and factors associated with wise exertion in this study can be applied to the individual physician wellness context and be potentially helpful in strategic planning of studies assessing physician well-being.
Control Consciousness
Focusing on what is within one’s control (agency) may be an area necessitating further exploration by physicians. For example, long hours and night shifts may disrupt sleep schedules and circadian rhythms in physicians. Depending on specialty and autonomy, the long hours and shift changes lie largely out of the physician’s control. However, physicians can optimize sleep hygiene (understand the benefits of light therapy, sleeping in a dark, temperature-appropriate room, taking strategic naps) and structure non-work obligations around optimal sleep, among other strategies.17,18 Other factors potentially out of the physician’s control include patient volume, patient behavior, and work inefficiencies such as electronic health records (EHRs). Physicians can exercise agency cooperating with nurses, other physicians, and administration to address patient volume, interacting with patients in a professional and respectful manner, and bringing up concerns regarding work inadequacies. Distinguishing and accepting what is in the physician’s control may reduce stress and improve happiness. Physicians concerned with facets outside of their control are by definition wasting cognition.
Wasteful Cognition
Wasted cognition involves expending valuable cognitive resources on issues of small significance, dwelling on past events, or overestimating the magnitude of problems without placing them in larger context. Physicians face numerous challenges throughout their training and careers. One adversity impacting physicians and leading to burnout relates to lack of control/autonomy at work. 19 Staying true to one’s values, voicing one’s concerns in a respectful manner, and participating in healthcare leadership may mitigate stress. Ruminating on negative reactions to leadership or lack of control may affect one’s work-life balance.
Physicians facing common stressors at work should attempt to minimize negative mental effects from adverse work events to avoid impact on their home lives. This spillover affects individual mental health, relationships, and correlates with physical health setbacks such as cardiovascular disease, type II diabetes, and poor immune function. 20 Physicians should spend little time dwelling on current or former problems and instead receive instruction on benefits of emotional regulation. 21 When one does face adversity or problems in their work or home lives, they should not waste cognition but instead strive for personal growth.
Growth Mentality
Physicians can utilize both good and bad life experiences for personal growth. A 2018 study of 6586 US physicians found 10.5% of participants reported a self-perceived major medical error that occurred in the previous three months. 22 While physicians should avoid medical errors and work mistakes, when they inevitably occur, they can be used constructively. While accepting some degree of regret or remorse, physicians in these situations can focus on benefits such as education, improved quality processes in their hospital, and improvements in personal practice. Stoics do not necessarily deny individuals’ human feelings; however, they believe individuals should anticipate grief as well as joy and respond appropriately. 23 Aiming for personal growth, or a positive and proactive journey towards self-improvement, helps individuals cope with a variety of complex, unavoidable obstacles. 24 A mentality of personal growth improves coping, self-efficacy, self-compassion, optimism, and happiness. 25 This change needs to be intentional, not accidental, with individuals viewing stressors as opportunities towards self-improvement. 26 One may be better equipped to flourish if trusting the concept that life happens for you and not to you. This cosmic thread may allow humans to live at one with nature, 27 prioritizing purposeful pursuits.
Purposeful Pursuits
Physicians should focus on what matters most in life, what provides meaning. Using reason to formulate a life philosophy, in contrast to a vague, unexamined outlook on the good, helps one lead a virtuous life. 28 Calibrating one’s sense of purpose with life experiences is fundamental to human fulfillment and correlates with thriving and well-being. 29 It is critical that physicians assess their personal values and target goals to achieve work-life integration and overall happiness. 30 Physicians should look for pursuits they find intrinsically meaningful, through an alignment with their personal values. 29 In addition to focusing work efforts, physicians should align their thoughts and pursuits with what they personally value in order to live the good life.
Limitations
A major limitation of this work is sample size. This study encompasses data from only one large urban university thus limiting generalizability. This was a pilot and exploratory inquiry aiming to provide baseline insight to guide future work; any study findings should be further investigated and corroborated. The psychometric work was for the total sample, due to low subgroup numbers, thus future work should validate items in specific populations (physicians, non-physicians) in different contexts. While our study focused on stress, well-being, and life satisfaction, we did not measure burnout, which future work could examine. While study outcomes focused on physicians, items were written as inclusive for all, allowing future work to focus on different groups. On this same note, comparing physicians to non-physicians may not be practical due to different work requirements and environments. Furthermore, utilizing an optional survey, we may have missed distinct perceptions from non-responders.
Conclusion
This work sheds light on mindset factors that could predict overall happiness, grounded in Stoic belief. This work used an exploratory lens to determine associations among physician locus of control, wasteful cognition, growth mentality, and purposeful pursuits with stress, well-being and life satisfaction. Data indicated relationships among variables of interest. Future inquiries could determine if physicians practicing Stoic thought have superior well-being.
Appendix A.
Appendix.
Please indicate the extent to which each item describes you on a 5-point Likert-type scale ranging from 1 = Strongly Disagree; 2 = Disagree; 3 = Neutral; 4 = Agree; 5 = Strongly Agree.
| 1 | I spend time thinking about aspects of my life that I have no control over. |
| 2 | I set goals that can be accomplished with the skills and qualities I possess. |
| 3 | When setting goals, I recognize my limits. |
| 4 | I spend too much time thinking about matters that are not useful. |
| 5 | When reflecting on my life, I worry about how others' actions have impacted me. |
| 6 | I do not let other persons' (countering) viewpoints bother me. |
| 7 | I let other persons' actions hinder my own path to fulfillment. |
| 8 | I recognize that I am in command of my feelings. |
| 9 | I recognize that I am in command of my actions. |
| 10 | I accept that I cannot control feelings of others. |
| 11 | I accept that I cannot control actions of others. |
| 12 | I approach each day focusing on things I can accomplish. |
| 13 | I spend efforts attempting to change things outside of my control. |
| 14 | When I face adversity, I acknowledge that it is part of life. |
| 15 | When I face adversity, I let it negatively influence my well-being more than it should. |
| 16 | I think of my problems as bigger than they actually are in the grand scheme of life. |
| 17 | I focus my engagements on what is most important in life. |
| 18 | When something outside of my control (e.g., traffic) negatively impacts my day I let it affect me more than it should. |
| 19 | I recognize when I am feeling extremes of emotions (e.g., too excited or too sad) and aim to rebalance myself. |
| 20 | I recognize that what happens to me in life is for me and not to me. |
| 21 | I recognize that we as humans are fragile and that time on earth is precious. |
| 22 | When something negative happens to me, I consider it as an opportunity to grow as a person. |
| 23 | I take each life lesson, good or bad, and apply it to my mindset for personal growth. |
| 24 | I spend energy on the things that matter most in life. |
| 25 | I spend energy on trivial aspects of life. |
| 26 | I reflect on how I can be a good human. |
| 27 | I acknowledge that my problems impact one human in a world of billions. |
| 28 | I pay minimal consideration to things outside of my own control. |
| 29 | I focus my energy on the current time and place. |
| 30 | I tend to dwell on negative things that have happened to me in the past. |
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Jacob Shreffler https://orcid.org/0000-0001-6023-0594
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