Using lifestyle medicine to treat patients can reduce practitioner burnout: a conceptual model derived from healthcare staff interviews

Abstract

Background

Healthcare worker burnout is pervasive and negatively impacts practitioner and patient health. Lifestyle medicine (LM) is a burgeoning field that uses therapeutic lifestyle interventions to treat or prevent chronic diseases including obesity, type 2 diabetes, and cardiovascular disease. Greater LM practice has previously been shown to predict less burnout among LM practitioners. There is a need to further investigate the relationship between practitioner burnout and using LM to treat patients. This study examines healthcare workers’ views to develop a conceptual model to describe how employing LM to treat patients impacts practitioners.

Methods

This study is a qualitative, thematic analysis of in-depth, semi-structured interviews of forty-two staff members from five health systems in the United States that are implementing LM. Transcripts of in-depth interviews were analyzed for themes related to burnout.

Results

Staff interviewed included physicians, nurse practitioners, nurses, psychologists, health coaches, and others. Staff described a positive reaction to, and increased job satisfaction following, LM implementation in their healthcare systems. Identified factors that might reduce healthcare worker burnout include meaningful patient improvement, increased patient empowerment, enhanced patient satisfaction, providers’ heightened joy/job satisfaction, providers’ belief that LM is how medicine should be practiced, and pride and gratitude due to their organization’s support of LM. These factors are related to the three elements of burnout – exhaustion, detachment, reduced feelings of professional efficacy – in a conceptual model.

Conclusions

Implementing LM in healthcare systems can potentially reduce burnout in practitioners who believe that LM is an enjoyable and effective discipline. It may do this by creating work circumstances and patient outcomes leading providers to report greater professional joy, an improved sense of professional meaningfulness, and a strengthened conviction of being an effective healthcare worker.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13885-1.

Introduction

Healthcare practitioner burnout is a significant and prevalent problem [1–4]. The World Health Organization’s International Disease Classification handbook (ICD-11) defines burnout along three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and a sense of ineffectiveness and lack of accomplishment [5].

Burnout is associated with a lower quality of patient care [6], physicians’ and nurses’ intent to leave their job [7, 8], lower patient satisfaction [7], and a negative impact on practitioner physical and mental health [9–11]. Causes of burnout are often divided into two categories, individual and organizational. Individual factors include personal physical and emotional health, and financial stressors. Organizational factors include large caseloads [12, 13], excessive time spent using the electronic health record [14, 15], hours worked and on call [16], and insufficient support staff [17, 18].

Lifestyle medicine is recognized as a medical specialty by the American Medical Association and the Association of American Medical Colleges, and the field is growing rapidly, with now more than 15,000 members of the American College of Lifestyle Medicine (ACLM) in 2026 [19, 20]. LM physicians prescribe health behavior changes at doses adequate to produce benefits for diagnosed disease, and that are identified through collaborative goal setting with patients [21]. These health behaviors are emphasized as the foundation of treatment and include consuming a whole-food, predominantly plant-based diet; engaging in regular physical activity; optimizing sleep and social connections; managing stress; and avoiding risky substances [22]. LM practitioners emphasize these health behaviors in treatment as well as employ delivery strategies such as shared medical appointments, teaching kitchens, or behavior change strategies [23, 24]. Behavior modification is used as primary, first-line treatment, with pharmaceuticals and procedures as needed. For context about lifestyle medicine interventions, a description of programs implemented at one site is provided in Supplementary Material 1 as an example.

Research on the intersection of LM and burnout is limited, but recent data demonstrated a lower likelihood of burnout when the proportion of one’s work hours devoted to LM increased [25]. This work fills a research gap by proposing a conceptual model, based on in-depth interviews conducted with healthcare workers in 2022–2023, that describes how implementing LM to treat patients in a healthcare system may reduce practitioner burnout. By analyzing information from these interviews, our objectives were to explore: (1) how healthcare practitioners felt about practicing LM; (2) which factors of LM practice are associated with healthcare practitioner satisfaction; and (3) how these factors can lead to reduced practitioner burnout.

Methods

Research approach

The data for this study comes from the multiple case series “Lifestyle Medicine Integration in Health Systems: A Multiple Case Study”, which examined LM integration into health systems, including barriers and facilitators to its implementation. The study protocol is comprehensively detailed in another publication [26], and used semi-structured, in-depth interviews of staff at multiple healthcare systems in the United States that offer LM programming. The present study included inductive and deductive analysis approaches and applied iterative data collection, memoing, and regular study team debriefing meetings [27].

Participants, sampling, and data collection

As part of the larger study, member health systems of the American College of Lifestyle Medicine Health Systems Council were invited to self-nominate for participation. From a group of fifteen health systems, the research team selected health systems to include as cases with the goal of identifying a diverse sample, taking into consideration geographic location, LM program size, age, and patient characteristics. Once selected, each health system provided a list of staff involved in LM programming who were subsequently invited via email to participate in in-depth interviews approximately 30–60 min long. A “snowball” recruiting technique was then used to identify additional participants. Interviewees were contacted via email and included LM program practitioners, as well as administrators and some billing staff. The research team targeted 6–12 interviews per case. Number of interviews varied by case due to program size and interviewee availability.

An interview guide was developed by the research team and updated iteratively throughout the data collection period, as previously described [26]. A question on burnout was added after the topic emerged as a theme in the initial analysis. The question was “Can you talk about your experience with burnout?” Interviews were conducted via Zoom, recorded, transcribed verbatim using Microsoft 365, and analytically reviewed. Transcripts were reviewed and discussed by research team members during weekly team meetings throughout the course of the data collection period, which allowed for identification of emergent themes [26]. Transcripts were not reviewed by participants, and participants did not provide feedback on findings. A core phenomenon was identified, namely, reported effects of LM implementation on the components of burnout. Following emergent design, these topics became the foundation of this current derivative analysis [28].

Data analysis

This analysis was conducted in spring of 2023 and was restricted to five health systems for which data collection was completed prior to February 2023. All interviews for each of these five health systems were included, with interviews conducted by 6 research team members (5 female, 1 male). Interviews for an additional three health systems were conducted following completion of this analysis. Therefore, these data are not included in this analysis. However, the analyst reviewed the case narratives resulting from these interviews to confirm there were no findings that were inconsistent with the original five health systems.

Thematic analysis included both inductive and deductive approaches and engaged a constructivist perspective [29, 30]. The primary analyst (BW) reviewed transcripts and completed an inductive emergent design approach to identify burnout-related themes elucidated from the data [30]. Themes were categorized into three components of burnout based on the definition of burnout (sense of professional efficacy, exhaustion, or detachment) and the relationship (deterrents, contributors, or neither) to burnout. The analyst then followed an iterative process of reviewing and reclassifying transcript content related to burnout and identifying themes within the categories. The resulting themes were summarized in an analytical framework that presents components of LM practice and proposed mechanisms that impact clinician burnout. Study team members reviewed and discussed iterative versions of the analytical framework to achieve general agreement of the presentation.

The primary analyst also reviewed interview transcripts to determine interviewee interest in practicing LM. Interviewees were subjectively classified as positive, negative, or no preference.

Research team and reflexivity

Multiple team members are experienced in qualitative research (JG, MR, SMS, MLA, MCK, KLS) and familiar with lifestyle medicine practice (MR, SMS, MLA, MCK, KLS). Several research team members (MCK, KLS, JG) previously conducted research on healthcare clinician burnout. Familiarity with both lifestyle medicine practice and clinician burnout likely influenced how the research team interpreted the data. The research team members generally hold a positive view of LM. This manifests in their personal lifestyle behaviors, being employed by ACLM (MCK, KLS, TH), or being members of ACLM (BW). The primary analyst (BW) is a clinical psychiatrist whose experience witnessing burnout among healthcare practitioner colleagues, healthcare practitioner patients, and, to an extent, himself, informed his awareness of the significance of the data and shaped his interpretation of results.

Ethics

This study was reviewed by the University of New England Institutional Review Board and was conducted in accordance with the Declaration of Helsinki. Written informed consent of the participants was obtained.

Results

Forty-two unique individuals were interviewed and 17 were invited but either declined or did not respond. There were 6–12 interviewees for each of the five participating health systems. Table 1 includes a summary of the interviewees. Participant roles included physician (16), nurse practitioner (3), nurse (1), health coach (2), psychologist (2), dietitian (4), clinical social worker (1), exercise physiologist (1), and administrators (12). Based on interviewer assessment, there were 29 females and 13 males. Physician specialties were internal medicine (8), family medicine (2), pediatrics (2), OB/GYN (1), ENT (1), emergency medicine (1), and palliative care (1).

Table 1.

Interview participant roles

Health system	Participant role						Total
	MD*	Nurse Practitioner or Nurse or Health Coach	Psychologist or LCSW	Dietitian	Exercise physiologist	Administrator
#1	3	1	1	0	0	3	8
#2	2	2	2	2	1	3	12
#3	3	1	0	2	0	1	7
#4	1	2	0	0	0	3	6
#5	7	0	0	0	0	2	9
Total	16	6	3	4	1	12	42

*Some MDs are both physicians and administrators. These MDs with dual titles or roles are placed in the MD column

Research Question 1: How do providers feel about practicing lifestyle medicine?

All participants who expressed a reaction to the practice of lifestyle medicine (n = 18) expressed positive feelings. No participants expressed negative feelings about LM, and no participant stated preferring a non-LM approach.

Below are two examples of physician participants addressing this topic in a manner deemed positive: “Like it’s not the medicines, it’s not the tests, it’s not all of these things that I was taught that we’re supposed to have patients do. It’s none of those things, but in fact it’s about finding what…ignites the fire in a patient and finding out like what is their “why”? Why is- what’s important to them in life and using those kind of more behavioral and coaching models to help people thrive using nutrition and movement and stress management and relationships and all these things that most of us do every day. That is to me really what medicine should be about, but it’s completely not. So, for me…the eye-opening has been incredible ‘cause it’s completely changed my perspective on what it means to be a doctor.”

The second physician’s comments additionally suggest that practicing LM might reduce burnout: “There’s just a really high level [of] burnout and I think lifestyle medicine…renews for most of us that feeling that we thought we would get when we decided we were going to go into medicine…it’s also been true for me…it makes you want to keep being a doctor”.

Exploring why participants felt positive about practicing LM was the focus of the second research question.

Research Question 2: Which factors of LM practice are associated with healthcare practitioner satisfaction?

Eight relevant themes emerged when analyzing the in-depth interview transcripts. These themes are arranged in five categories: (1) staff’s perception of impact on patients; (2) impact on staff; (3) moral alignment; (4) staff’s perception of the environment; and (5) staff health. Each theme is described below and is accompanied by an exemplifying quote. The number of participants mentioning each theme is listed in parentheses.

Staff’s perception of impact on patients

1. Witnessing improved patient health (n = 13).

Numerous participants enthusiastically noted substantial patient improvement including an appropriate reduction in medication. This administrator said: “We’ve had several people that have started out with, you know, 12 point something A1C and by the end of the program it’s down to five. [Note: A level of 6.5 or above indicates diabetes. A level of 5.7 to 6.4 indicates prediabetes] And so I mean it’s been life changing. We’ve had people that were almost about to get their foot amputated because they couldn’t get a wound healed and they’re going to have to be on a wound VAC for six months and now they’re, you know, completely off their insulin. And so…it’s been great for the community”.

• 2.Facilitating Patient Empowerment (n = 8).

The importance of empowering patients to actively participate in their health journey emerged as a theme in 8 interviews. A psychologist opined about LM: “…to me it’s more patient-centered because it really is focused on the individual patient and what works in their life, which I think is really the best way to successfully support a patient making change. I think it empowers the patient. It puts the patient in the center rather than as a recipient of services. It puts them in the driver seat”.

• 3.Increased Patient Satisfaction (n = 7).

Several healthcare workers reported that patients seem happy to participate in LM programs. This physician observed regarding patients and LM: “They love it. I mean, they absolutely love it…so we use a standard of patient experience called the NRC score and ours are way above the charts when it comes to people saying they’ve enjoyed what they get in that clinic…What I love is people come back…nothing says it more than people coming back and then bringing their friends…”.

Impact on staff

• 4.Increased Job Satisfaction and/or Joy/Passion for LM (n = 21).

Healthcare workers frequently reported increased job satisfaction resulting from practicing LM, and many were passionate about using an LM approach. One physician discussed job satisfaction when noting how his clinical time is split between employing LM and a more standard type of medicine: “Lifestyle Medicine…that’s about 20% of my time. And I still do primary care 80% of my time. But I would say that if you think about where I’m getting joy and meaning, it would be the other way around, where this activity that I’m doing for just a little bit of my professional time is the…much larger source of joy and meaning for me”.

Moral alignment

• 5.Gratitude/Pride that Health System Supports LM (n = 4).

LM programming at the system level can elicit gratitude and pride among healthcare workers. This participant praised her healthcare organization: “…it’s really cool that [the health system the participant worked at] is one of the few entities out there that’s willing to start being more preventative with the risk of losing money. And so it makes me proud to be at [the health system] for that reason. It’s exciting to be at the front end and seeing that we are helping our society be more preventative…”.

• 6.Belief that LM is the Way Medicine Ought to be Practiced (n = 10).

Several interviewees felt that LM should be foundational to medical care. This physician said: “I think talking about lifestyle should always come first before we quickly pull out the prescription pad and start…putting someone on six different medicines. I think we need to really take…several moments to look at…what might be the physical, psychosocial factors that are putting them in that place in the first place”.

Staff’s perception of the environment

• 7.Supportive and Like-Minded Colleagues (n = 4).

Staff reported supporting each other when applying healthy lifestyle habits to their own lives. One clinician related: “…there’s also kind of this social support around we’re all doing this together…which has really helped. So then it feels…a little bit more like you have accountability and also you have support”. Staff also shared about focusing on the common goal of implementing an LM program for patients. This often includes creating programming. One nurse stated: “…when we come together, it’s pretty exciting…it is like an explosion of ideas…”.

Staff health

• 8.LM Wellness Initiatives for Clinicians (n = 15).

Many healthcare systems in this study are seeking to improve health and reduce burnout by implementing LM programming for their employees. Unlike the factors previously discussed, this factor regarding wellness initiatives focuses solely on healthcare system staff applying LM principles to their own lives. Even without a formal program aimed at healthcare workers in their system, one practitioner described how delivering lifestyle medicine programming, and being around other practitioners doing the same, has been personally beneficial. “…it has helped me be a better person. Hands down. We create a culture that I wanna eat better. I wanna move more…I think we definitely help each other eat better. We do a good job setting boundaries so that we’re not overworking”. Thus, applying LM professionally naturally extended to a focus on well-being and healthy behaviors in practitioners’ own lives.

In contrast to the eight identified themes, one participant expressed that implementing LM may have contributed to feeling burned out. Although this dietitian is a strong advocate for LM, they found it tiring to keep pushing the message of a whole food plant-based diet, both to other departments within their health system that were not on board with the message, and sometimes to patients. “That doesn’t feel good to be a health system offering lots of different messages…it makes patients very frustrated…I have to go up against those dietitians [who aren’t as supportive of a plant-based diet] and it creates conflict…it’s hard to meet with patients all the time. And it can be very exhausting to…say the same message…and I did get burnout like of just saying the same things. And then also the fight…you know moving that message that not everybody’s behind. And feeling like I had to like constantly kind of stake my position…it kind of gets exhausting after a while…burnout is real…you get worn down”.

Research Question 3: How can the factors associated with using lifestyle medicine to treat patients reduce practitioner burnout?

Healthcare staff identified multiple reasons why treating patients with LM can reduce practitioner burnout. The eight themes identified in Research Question 2 are linked to the three elements of burnout as depicted in Fig. 1: detachment/cynicism, emotional exhaustion, and sense of professional efficacy. For example, in the yellow portion of Fig. 1, the themes of improved patient health, increased patient empowerment, and increased patient satisfaction can lead to an increased sense of professional efficacy. Similarly, in the green portion, both LM wellness initiatives for clinicians and having supportive colleagues can be linked to decreased emotional exhaustion. Based on participants’ comments, these links demonstrate how using LM to treat patients can potentially reduce practitioner burnout.

Fig. 1.

How experience of practicing LM (outer ring) may reduce likelihood of burnout (middle ring)

Notably, one medical director described how her team providing LM for patients in a health system improves morale even for providers who are not offering LM themselves: “…it builds morale for your providers because I…feel like myself and my team, we are an extension…of the primary care providers and the sub-specialists, an extension of the care that they’re giving. I’m giving care that they don’t have time to give. We’re giving an expertise that they don’t have…So when you give a provider who really believes in this and wants to do it for their patients but doesn’t have the time, the space, the expertise, the staff to do it, and you give them these resources, there’s a big sigh of relief. And they see their patients getting better. And guess what? The patients are very thankful to their providers for sending them to these types of services. So there’s sort of this virtuous cycle there too. The providers’ morale improves, they feel like they’re giving their patients what they need and what they want…they feel relieved that…someone’s giving them this…”

Discussion

This is the first study to use in-depth interviews to explore how using LM to treat patients can reduce practitioner burnout. Participants shared many reasons for these findings including significant patient improvement, increased patient empowerment, provider passion for LM, provider gratitude that their health system supports LM, providers’ belief that LM is the way medicine ought to be practiced, and working with like-minded and supportive colleagues. Participants also discussed the benefits of applying LM to their own lives. These factors emerged repeatedly and organically throughout the interviews, even if not explored explicitly during the interview. The emergence of this topic shows the importance and impact that practicing LM had on practitioners, including its ability to buffer against burnout.

Our findings align with a survey study which demonstrated that among practitioners, greater implementation of LM is significantly associated with less practitioner burnout [25], as well as work indicating that lifestyle medicine can promote physician well-being to potentially ease the impact of burnout [31]. In addition, free-text data from this same survey revealed similar themes regarding self-reported experiences of increases in professional satisfaction, accomplishment, and meaningfulness; improved patient experience and health outcomes; and enjoyment of supportive relationships [25].

Similar findings are also reported in one physician’s description of his own and his patients’ positive experiences with an aspect of LM [32]. One meta-analysis found that interventions directed at healthcare organizations, more so than interventions targeting physicians, were associated with moderate reductions in burnout scores, particularly the burnout elements of depersonalization and personal accomplishment [33]. This is consistent with our findings in which participants working in healthcare systems implementing LM to treat patients described experiencing an increased sense of professional joy or satisfaction, and a strengthened conviction of being an effective clinician.

Two previously existing conceptual frameworks for understanding physician burnout hold relevance for understanding these findings [34]. One is Seligman’s PERMA model, which describes well-being along 5 dimensions: positive emotions, engagement, relationships, meaning, and achievement [35]. Our study finds evidence that implementing LM can foster improvement in all five areas. A revised PERMA model, PERMA+, has added optimism, nutrition, activity, and sleep [36]. All of these can be improved when providers apply LM to their own lives. A qualitative study explored how PERMA is related to the lived experience of nurses [37], with some findings paralleling ours, for example, the value of meaning and joy in the work of healthcare practitioners.

The second relevant model, Shanafelt’s, describes seven drivers of both burnout and, contrarily, engagement. Of these seven, the driver that most directly relates to our findings is “meaning in work” [38]. One study of academic physicians found that the amount of time spent working on one’s most meaningful activity was strongly related to the risk of burnout [39]. Another study found that surgeons who emphasized finding meaning in work were less likely to be burned out [40]. Additionally, a study of mostly internal medicine and family medicine physicians, which is similar to the composition of physicians in our study, concluded that meaning in work influenced their feelings about work [41].

Informed by these previous models, and by a study whose findings included an increase in a practitioner’s sense of connection to patients when practicing LM [25], we present a conceptual model (Fig. 2) based on our findings. The model presents how the implementation of LM in health systems may result in reductions in practitioner burnout. Specifically, it depicts how the trajectory of effective LM implementation can promote positive outcomes such as improved patient experience and increased practitioner well-being and, subsequently, reduced burnout as defined by decreased emotional exhaustion, decreased detachment/cynicism, and increased sense of personal accomplishment. Our hope is that this model can summarize the key dynamics influencing burnout that are present in settings of LM implementation.

Fig. 2.

Pathway to reduce burnout in organizations implementing lifestyle medicine

In contrast to the improvements in burnout components reported by most interview participants, one dietitian expressed having felt burned out when LM was implemented in their health system. This individual’s experience seemed to result from patients and co-workers who were skeptical of or resistant to whole-food, plant-predominant diets. By assessing people for readiness to change prior to entering a class, as was done in at least one health system in our study, the possibility of burnout may be reduced. Also, increased variety in the job may help to cope with burnout in some settings [42]. Another potential source of burnout could result from incongruent personal and professional practices.

The possibility that an organizational implementation of LM to treat patients may buffer against provider burnout is especially important because LM is an ascendant treatment modality, inducted into the House of Medicine only in 2024. LM is being explored as a modality that can both improve patients’ health [43, 44], which our findings touch on, and rein in health care costs [45, 46]. If it can do both, and additionally improve patient satisfaction [47] and reduce provider burnout, as our findings suggest it can, it will have achieved the quadruple aim [48, 49].

Implementing LM in a healthcare system is unlikely to buffer against provider burnout if some common institutional challenges, such as excessive caseloads, understaffing, and excessive documentation requirements, are attached to it. For example, one study found that when primary care clinicians provided behavioral counseling and education related to lifestyle factors to patients without using a team approach, there was an association with burnout [50]. It was reasonably conjectured that this might be the result of time pressure. As the authors of one study concluded, “Well-intentioned efforts promoting individual-level interventions (e.g., mindfulness training) to improve workplace wellness may be alienating if they are at odds with physician perceptions of organizational pressures as the root cause of burnout” [41]. To limit this danger, we recommend that organizational interventions, such as those highlighted by other authors [51], be pursued. One meta-analysis found that interventions directed at organizations were significantly more effective in reducing burnout than those directed at physicians [52].

Limitations

A limitation of this study is that not all participants were questioned about burnout explicitly. As with semi-structured interviews, interviewers can augment interview questions if needed. This might be the case if the question is redundant to earlier conversation or other topics seem more relevant to the interviewee. Interviewees that were not asked directly about burnout may have omitted comments they would have shared if asked. This reduces the breadth of responses. However, since many of the participants nevertheless spoke to these topics when speaking on other topics, it reveals the salience of their thoughts and experiences.

An additional limitation is that the sample may be biased to health systems with employees and practices that are favorable to lifestyle medicine. This is because all health systems were self-nominated, and all interviewees were volunteers from healthcare systems successfully implementing LM. Due to this limitation, findings from this study cannot be used to compare perspectives of LM practitioners with non-LM practitioners.

This study would have been strengthened by formally evaluating participants for burnout. Without this, definitive statements about whether implementing LM in these health systems reduced burnout cannot be made. However, the aim of our study is to gather relevant information from the participants and use it to construct a theory as to how implementing LM to treat patients may impact burnout based on these participants’ accounts of their experiences.

Future research

Future research should measure and explore the changes in participants prior to, during, and after the organizational implementation of LM. Significant potential confounders such as concomitant changes in the number of patients treated, or the number of hours worked, should be controlled for, as these factors significantly affect work-life balance, a major driver of physician stress [13, 53–55]. We also found more evidence for the benefits of LM for finding meaning in work and professional efficacy, as opposed to reduction in emotional exhaustion; therefore, changes in emotional exhaustion merit further study. Additionally, implementation science approaches would be useful in evaluating how deploying health behavior change strategies in medical practice is workable for clinicians.

Conclusion

Healthcare staff identified multiple reasons why and how treating patients with LM can reduce practitioner burnout. Given the high prevalence of practitioner burnout, organizations might wish to consider introducing and growing lifestyle medicine approaches to treatment. Doing so may benefit both patient health and the health of practitioners who believe that LM is an enjoyable and effective discipline.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

LM

Lifestyle medicine

ICD-11

International Disease Classification handbook 11

ACLM

American College of Lifestyle Medicine

Author contributions

All authors contributed to the original conception and design of the study methods under the leadership of MK and JG. BW, SS, MA, ND, and MR participated in data collection. BW led the writing and analysis with support from all other authors who offered critical feedback. All authors read and approved the final manuscript.

Funding

This study was supported by funding from the American College of Lifestyle Medicine (ACLM).

Data availability

De-identified data generated and/or analyzed during the current study are available from the corresponding author upon reasonable request and in accordance with IRB guidelines.

Declarations

Ethics approval and consent to participate

This study was reviewed by the University of New England Institutional Review Board (Project # 1221-21) and was conducted in accordance with the Declaration of Helsinki. All participants provided informed consent.

Consent for publication

Not applicable.

Competing interests

MK, KS, and TH are employed by ACLM. The other co-authors receive consulting payments from ACLM.