Physician Burnout: A Lifestyle Medicine Perspective

Abstract

Physician burnout, as described in North America, is a multidimensional work-related syndrome that includes emotional exhaustion, depersonalization, and a low sense of accomplishment from work. More than 50% of physicians were reporting symptoms of burnout prior to the COVID-19 pandemic. This silent epidemic of burnout is bound to become less silent as the pandemic continues. Lifestyle medicine is an evidence-based discipline that describes how daily habits and health practices can affect overall health and well-being of individuals. Lifestyle Medicine can potentially play a significant role in preventing and ameliorating physician burnout. This article explores the burnout process, including the historical context, international definitions, symptoms, and imprecision of the clinical diagnosis. The systemic etiological issues are discussed, and the psychological underpinnings are explored, including physicians’ personal vulnerabilities contributing to burnout. The stress response and lifestyle medicine’s role in healthy coping are described. A prevention model for risk factor reduction is proposed, focusing on primordial, primary, secondary, and tertiary prevention. Lifestyle medicine clinicians’ role in prevention, treatment, and advocacy to ameliorate the potential for burnout is discussed along with specific recommendations.

‘Health care providers are experiencing all the adverse life impacts of COVID-19 that plague the general population, including stress, depression, grief, and isolation.’

Introduction

In recent years, there has been much focus in the medical literature on physician burnout, wellness, and self-care. The core principles in the practice of lifestyle medicine can potentially play a significant role in preventing or ameliorating physician burnout. Lifestyle medicine is an evidence-based discipline that describes how daily habits and health practices can affect the overall health and well-being of an individual. Lifestyle medicine provides strategies based on 6 pillars that can support physician wellness and thereby provide a compelling model to approach the reduction of the individual risk factors in burnout.

Physician burnout is described in the North American academic literature as a multidimensional work-related syndrome characterized by emotional exhaustion, depersonalization, and a low sense of accomplishment from work.¹ Prior to the coronavirus disease 2019 (COVID-19) pandemic, health care workers were already working in stressful circumstances, with more than 50% reporting burnout. Health care providers are experiencing all the adverse life impacts of COVID-19 that plague the general population, including stress, depression, grief, and isolation. In addition, they are also taking care of an increased number of critically ill patients, often at times without appropriate training, thereby often feeling helplessness in the process.² Additionally, there are concerns that the COVID-19 pandemic has stopped the conversation around physician burnout and physician wellness.³ Now, more than ever, addressing physicians’ well-being is vital because the silent epidemic of physicians’ burnout is bound to become less silent as the pandemic resolves.

In 2018, the World Health Organization (WHO) announced that the International Classification of Diseases, 11th Revision (ICD-11), which is scheduled to come into effect in January 2022, will include burnout as an occupational syndrome.⁴ Furthermore, in the ICD-11, burnout will be considered as a problem associated with employment rather than as an individual mental health diagnosis and will be considered distinct from mood disorders, adjustment disorders, anxiety disorders, or disorders specifically associated with stress.¹

As we continue to understand more about burnout, physician wellness and self-care will be paramount in the discussion. According to the WHO, self-care is the “ability of individuals, families, and communities to promote health, prevent disease, and maintain health and to cope with illness and disability with or without the support of a health-care provider.”⁵

In 2014, it was suggested that the Triple Aim approach to optimize health system performance (enhancing patient experience, improving population health, and reducing cost) ought to be expanded to include a fourth aim. The Quadruple Aim includes an aim to improve the work life of health care clinicians and staff.⁶ In 2017, the modern successor to the Hippocratic Oath added a clause that physicians should also attend to their own wellness as part of their professional responsibilities to their patients.^7,8 In the same year, the National Academy of Medicine launched an initiative to study the wellness of physicians as a national priority.¹

In this review, we will first describe the historical complexity of the construct of burnout and illustrate the current understandings of the physician burnout pandemic. Although it is clear that mitigating burnout will require organizational interventions such as work system redesign, we will focus our discussion on lifestyle medicine strategies that may help individuals with burnout symptoms. Lifestyle medicine can potentially play a part in minimizing the individual symptoms and risk factors before, during, and after the appearance of the burnout syndrome. We will limit our discussion to burnout among physicians while noting that nurses, physician assistants, and other health care providers may also suffer from burnout.

Historical Context

The term burnout was first mentioned in passing in a medical academic publication by H. Bradley in 1969 when proposing a thoughtful work schedule for staff in an attempt to avoid staff overwork and subsequent experience of “burnout” in a community-based youth treatment program.⁹ The first formal definition in the literature of burnout was provided by a practicing clinical psychologist, Herbert Freudenberger in 1974, who is often given credit for coining the term. Freudenberger, a trained psychoanalyst, volunteered his time to provide consultations at St Mark’s free clinic in New York’s East Village. The free clinic often included chronic drug abusers who often used the term burnout to describe the disabling effects seen in illicit drug abusers. Freudenberger borrowed the commonly used term in his clinic population and described the gradual emotional depletion, loss of motivation, and reduced commitment among the staff volunteers at the clinic as staff burnout.¹⁰ In his earlier articles, he often focused on the autobiographical aspects through self-analysis in his writing as he reported experiencing burnout twice in his career.¹¹ Simultaneously, in the 1970s, social psychologist Christina Maslach and her colleagues were studying emotional arousal on the job and noted “detached concern” and theorized that the arousal and strategies to cope had important implications for their professional identity and subsequent behaviors on the job.

What about the 1970s was so unique that we had an emergence of burnout? Some social psychologists believe that the economic, cultural, and social movements of the 1960s in the United States precipitated the emergence of the burnout crisis.⁹ In the 1960s, many young people began working in the service industries with an idealistic motivation and desire to change systems. After a period of time, many of these young workers became frustrated with their jobs. This phenomenon is consistent with the literature that physicians who are motivated view the profession as “a calling,” with a very high desire to heal others, and are the most likely to have stress reactions and burnout. Those people who have jobs with less motivation to fulfill a calling appear to struggle less.

Lack of Consistent International Definition of Burnout

Inconsistencies exist with the definitions of burnout among countries, which lead to difficulties in studying and understanding the phenomenon. In North America, burnout has typically been defined as an occupational phenomenon—a “work-related syndrome”—rather than a medical condition.

The psychiatric community in North America publishes the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) at varying intervals. The current version, DSM-5, does not include burnout as a diagnosis category. In 1997, Sweden recognized burnout as a disease after ICD-10 added burnout as a syndrome needing further investigation as problems associated with difficulties in coping with life.¹¹ In 2005, Sweden further revised their country’s burnout diagnosis to include difficulty in life management called “vital exhaustion.” Vital exhaustion bears a striking resemblance to symptoms of clinical depression, including 2 weeks of low energy, difficulty concentrating, irritability, emotional lability, dizziness, and sleep difficulties. These symptoms must interfere with the performance of work responsibilities to qualify as vital exhaustion. Sweden’s citizens have access to care and services based on this diagnosis, including sick days, disability, and treatment. The other country that has recognized burnout as a diagnosis is the Netherlands, where they use the term overstrain, and the diagnosis spans various occupations with prevalence rate of 3% to 7%.¹²

Clinical Diagnostic Imprecision

Is burnout a distinct psychiatric illness or part of a depressive disorder? What is the overlap in the symptoms seen in job-related physician burnout and psychiatric disorders? Debate exists in the academic literature on the clarity versus imprecision of the construct of burnout. It has been argued that there is a lack of consistency in nosology and overlap in the symptoms with established diagnoses, including adjustment disorder, depression, anxiety disorders, and others. This overlap can make the process of identifying the individual with burnout complicated, and clinicians may potentially overlook other serious conditions for which we have identifiable treatments.

The clinical and theoretical foundation for burnout has been questioned as a discrete, unified pathological phenomenon. Some investigators have described it as tenuous at best because some of the core symptoms of burnout are more strongly associated with depressive disorders.¹³ Schonfeld and Bianchi¹⁴ examined the overlap of burnout and depression and concluded that burnout is a form of depression. They further argue that job-related burnout is, in fact, depression and that the Maslach Burnout Inventory (MBI) does not allow for the assessment of emotional exhaustion, depersonalization, and personal accomplishment in other situations outside the job.

To add to the confusion, burnout in the North American literature has been typically described as a dichotomous variable. Maslach, however, has suggested that burnout is better described as a continuous variable with degrees of severity in each of the 3 domains.¹⁵ As a continuous variable, the clinical presentation of burnout is better understood as a process that evolves over time: the burnout process. Maslach argues that research on testing the discriminant validity of burnout by assessing if it could be differentiated from job stress and depression has established that burnout is a distinct construct.^16,17

Given the lack of consensus on burnout, for the purpose of this review, we will assume that burnout is a distinct entity and refer to the burnout process with the commonly used term burnout.

Symptoms of Burnout

The categories of symptoms associated with burnout include physical, affective, cognitive, behavioral, and motivational.¹⁶

Physical Symptoms

Physical symptoms often seen with burnout include anxiety symptoms associated with a sympathetic nervous system activated stress response, including increased heart rate, increased blood pressure, headache, restlessness, and nausea.¹⁸ In addition, burnout has been linked to metabolic syndrome, increased musculoskeletal pain, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, impaired immune function, systemic inflammation, and cardiovascular disease.¹⁹ Burnout has been demonstrated to be a significant predictor for hypercholesterolemia and type 2 diabetes in some studies.

Affective Symptoms

Many affective symptoms of depression and anxiety are seen, including depressed mood, changing mood, increased tension, anxious feelings, irritability, hypersensitivity, blunted empathy, anger, and fear. Of note, evidence supports that burnout, depression, and anxiety are associated with the inflammatory marker C-reactive protein (hs-CRP) and fibrinogen that is gender dependent.²⁰

Cognitive Symptoms

Helplessness and a cynical perception of others coupled with pessimism are observed on the cognitive level. In addition, long-term burnout is known to be associated with a decrease in subjective memory, executive functions, and impaired attention.²¹

Behavioral Symptoms

Behavioral symptoms include emotional outbursts, medical errors, declined productivity, and increased turnover in jobs. Physicians are also more likely to retire earlier or change their specialty if they experience burnout.²²

Motivational Symptoms

Often physicians who have experienced burnout show decreased motivation and overall loss of interest and low morale. Physicians experiencing burnout often start questioning their decision to enter the profession in the first place.

Overlapping Symptoms

The symptoms of burnout have significant overlap with psychiatric conditions such as adjustment disorder and major depressive disorder. This overlap makes it difficult to clearly understand the symptoms when they are present in an individual patient. Psychiatrists have a unique psychological knowledge and clinical diagnostic experience to contribute to further assessment and interventions at both the individual and systemic levels.²³ Early assessment and treatment of a psychiatric disorder could help reduce the course and severity if treated early and adequately. Chronic fatigue and burnout also share some common symptoms. Chronic fatigue’s severity, however, does not depend on the situation. Similarly, people with exhaustion tend to feel refreshed after resting, whereas burnout-associated depleted energy tends to be protracted.

Extent of the Problem, Epidemiology

Alarmingly, in numerous, recent large studies in the United States, 40% to 54% of physicians have reported at least 1 symptom of burnout as assessed by the MBI.^24-27 Evidence suggests that significant variation occurs by physician practice specialty and setting. Private practice physicians have been reported to experience about 30% higher risk for burnout than physicians in academic settings.^25-28 Only 40.9% of the physicians felt that their work schedule left enough time for personal/family life, with 14.6% neutral and 44.5% disagreeing with this assertion. In all the surveys, a notable variation exists in burnout by physician specialty, with the highest in the physicians on the frontlines, including emergency medicine and primary care. Early career physicians experience higher reported burnout, which is purported to be related to the increased burden of balancing personal family obligations and professional responsibilities.^29-31 In addition, women also are at increased risk for burnout after accounting for adjustments for personal and professional factors.

When in the Path to Becoming a Physician Was Burnout First Observed?

Studies have shown that premedical students have higher occurrence of burnout than their peers upon entering medical school but appear to utilize better coping strategies than their peers. This has translated in the literature to support the argument that medical students have higher psychological well-being than their peers when they enter medical school.³² Studies, however, have shown that once in medical school, medical students suffer a high prevalence of burnout compared with their peers. Numerous studies have reported that 45% to 56% of medical students have at least 1 symptom of burnout.³³ These high rates continue during residency, with more than 60% of resident physicians reporting at least 1 symptom of burnout.^33-36 International medical graduates appear to be less vulnerable to burnout than their domestic counterparts. Limited data exist on self-identified lesbian, gay, bisexual, transgender students and physicians and the effects of race on the risk for burnout.

Numerous consequences of physician burnout may be exhibited, including the quality of care, job performance, adherence of patients to prescribed treatments, patient satisfaction, mental health issues for physicians, physicians abandoning the field of medicine, litigation risk, and many others. An unhealthy work environment can create enormous human as well as financial costs. In 2018, studies estimated that $4.6 billion in annual costs are directly related to physician turnover and reduced clinical hours.³⁷

Etiology and Psychological Underpinnings

How did we get here and what are the developmental underpinnings? The developmental vulnerabilities can be described as both systemic issues and personal contributing vulnerabilities.

Systemic Etiological Issues of Burnout

Systemic etiological issues for developing burnout in the workplace include the day-to-day stressors in the work environment. It has been asserted that organizations cause personal stress for physicians.³⁸ In 1997, Maslach and Leiter described physicians as experiencing a decreased sense of intrinsic worth. They suggested that work had often become an obligation rather than a resource for satisfaction that provided community and support. In addition, health care institutions have significantly redistributed power. Leading many to question health care institutions’ citizenship practices.

As medical schools continue to seek potential medical trainees with an altruistic calling for service in medicine, a widening mismatch has developed between the nature of the job and the nature of the person attracted to the profession. This concept is exacerbated by physicians reporting lack of control in the workplace and productivity goals misaligned with physicians’ internal drives. Physicians are left feeling overworked and unrewarded and at odds with management resulting in an overall breakdown in the sense of a healthy community. Increases in administrative and clerical burdens (including electronic health records) have become commonplace in medicine, which contribute significantly to stress. Insurance mandates pose additional added stress as does the continuing corporatization of health care institutions, contributing to decreased flexibility in the workplace. Physicians report continuous stress from unpaid work time, including the often cited “pajama charting” time at home in the evenings. This has contributed to erosion of the professional versus personal boundaries for physicians and has been attributed as a risk for burnout.³⁹

Physicians’ Personal Vulnerabilities Contributing to Burnout

Many personality traits are inherent to those that practice medicine that may lead to problems in the current health care environment. There is a cultural expectation that physicians serve selflessly, caring for those in medical need and as “heroes” when needed. Physicians’ health and personal desires typically assume secondary status. Indeed, physicians have agreed to the altruist calling and fiduciary responsibility of medicine often at the cost of their own health.

The medical school selection process selectively filters and selects future physicians with inordinate focus on attention to detail, those students who display perfectionistic qualities, and who are mission driven. The physician pipeline consists of students who exhibit a history of excellence and have little experience with failure (personally or academically). Indeed, future physicians are proud of their intellectual capacity and pursuit of excellence. Throughout their primary and secondary schooling, future physicians are often the smartest kids in the room, serve as mentors of their peers, and are identified early for their intellect, drive, and study skills. All these would seem to be positive, even admirable traits. How is the current state of medicine eroding this strong, healthy personal and professional identity?

On entering medical training, the trainee is confronted with the many systemic issues at an organizational level buttressed by a culture that often does not respect or function to acknowledge a physician’s humanity.

Lifestyle medicine must stress the need for physician self-care as a necessary part of patient care. How can physicians take care of others with a full mind and heart if they are constantly running on empty? Furthermore, senior physician supervisors often lack empathy or support for medical students and residents during their training. Maltreatment of medical students and trainees is, unfortunately, commonplace within the informal curriculum.⁴⁰ What happens when these experientially failure-naive students experience reprimands, are constantly criticized, and are told about every mistake they make while in training? The risk is high for these students to feel shame, hurt, and self-blame and be emotionally unable to deal with the harshness of these blows.

Often, medical students have been successful and excelled at every task that they have approached and are ill-equipped with the psychological mechanisms to cope and feel “good enough” after being told that they are inadequate or just above-average in their performance. Trainees overburdened with studies and patient care may go through training psychologically compartmentalizing their personal disappointments with themselves. As the work load increases with every year of training, they often lack time to process their negative feelings towards themselves and to process the sickness and death that they witness all around them. Tragically, these same students and residents who struggle to use healthy coping strategies during their own training, may adopt harshness towards the next generation of trainees once they are out of their own training, and the aversive culture of medicine is thereby perpetuated.

Self-acceptance frameworks suggest that we accept “you are good enough” as a guiding principle for ultimate happiness. However accepting less than perfect performance is not a part of the culture of medicine. Indeed, perfection is the professional goal for physicians because medical errors are costly to patients and society. So how do physicians learn to take care of themselves and develop healthy coping strategies if their environment does not support it? What happens to physicians as they encounter novel and stressful situations in the workplace or in their daily lives?

The Stress Response

Physicians adapt to the stressors of the health care environment in diverse ways, which can either be positive or negative. If the stressor is overwhelming, persistent, unyielding, or otherwise unpleasant, physicians may have maladaptive responses to the occupational stress, thereby putting themselves at greater risk for burnout.

Stress can also lead to physiological responses, including increased cortisol. This stress response can manifest as blood sugar imbalances, high blood pressure, loss of muscle tissue, changes in bone density, lower immunity, inflammatory responses, and structural changes in the brain.⁴¹ Chronic stress has been shown to affect the HPA axis and to result in decreased gray matter volume in the hippocampus.⁴²

The stress response is mediated by prefrontal cortex inhibition of the brain and limbic system structures and is improved by the perception of control over a stressor.⁴³ Resilience research shows that the most effective ways to deal with stress are active or proactive coping mechanisms such as the ones stressed in lifestyle medicine.

Using healthy coping mechanisms has been shown to help return the body to a state of homeostasis. It is increasingly evident that the neural processes underlying stress and stress resilience are complex and involve the interaction of neurobiological, genetic, epigenetic, and environmental components.⁴⁴ Lifestyle medicine interventions that address the inflammatory responses by exercise, food choices, stress reduction, and adequate sleep all play a part in helping preventing or slow down the progression of a stress response to burnout.

Burnout Assessment

Multiple tools are available for the assessment of burnout of physicians.

• MBI-Human Services Survey for Medical Personnel. This is a 22-item survey that covers 3 areas: emotional exhaustion, depersonalization, and low sense of personal accomplishment. This instrument is proprietary and available for a modest cost.

• Oldenburg Burnout Inventory. This is a 16-item survey with positively and negatively framed items that cover 2 areas: exhaustion and disengagement from work. It is freely available with no cost.

• Copenhagen Burnout Inventory. This is a 19-item survey with positively and negatively framed items that covers 3 areas: personal, work, and client-related burnout. It is freely available with no cost.

• Stanford Professional Fulfillment Index. This is a 16-item survey that covers burnout (work exhaustion and interpersonal disengagement) and professional fulfillment. There are no costs for nonprofit use with permission.

• Well-being Index. The purpose is to identify distress in a variety of dimensions. This is a 7- or 9-item instrument with yes/no responses. Free for research and nonprofit use with permission.

Risk Factor Reduction Using a Prevention Model

Because physician burnout is a systemic problem, it will require a concerted effort by all invested parties to modify the systems of health care and address the roots of the problem. Efforts are underway at a national level to improve the structure, organization, and culture of health care. Specific interventions for burnout may be conceptualized as risk factor reduction using an occupational health prevention model. Individual risk factors associated with burnout can be approached through the lens of lifestyle medicine, which provides an evidence-based approach to address many of them. These are best described by the 6 pillars of lifestyle medicine and include the following:

1. Strategies to manage stress

2. Avoiding risky substances

3. Healthful eating

4. Increased physical activities

5. Improved sleep

6. Formation and maintenance of healthy relationships

These 6 pillars can guide interventions at multiple levels for an individual. Ideally, addressing improved and positive lifestyle changes ought to be done before symptoms of burnout are present. When physicians practice healthy lifestyles, it not only affects their quality of life, but also results in improved patient care.

The occupational health prevention model describes the process of risk reduction as consisting of 3 levels, including primary, secondary, and tertiary levels of risk reduction. We believe that this approach is relevant to the discussion of burnout risk reduction but suggest adding a fourth category: primordial prevention. The 4 levels of prevention are described in detail next. Lifestyle medicine interventions can be effective for the prevention of burnout at each of these stages as depicted in Figure 1.

Figure 1.

Individual-focused burnout risk reduction strategies can target primordial, primary, secondary, and tertiary prevention.

Primordial Prevention

Primordial prevention is defined as a strategy to avoid risk factors before they begin to affect the individual instead of attempting to reduce the risk factors once they are already present. The concept of “primordial” prevention was prominently featured in 2010 in a strategic plan by the American Heart Association as a mechanism to reduce the impact of heart disease.

Lifestyle medicine specifically addresses embracing healthy habits that would decrease personal risk factors before burnout onset. Interventions in all 6 of the pillars of lifestyle medicine effectively improve overall physical and mental health, thereby serving as a buffer to the development of burnout. For example, engaging in social support by forming and maintaining healthy relationships can decrease social isolation and loneliness.⁴⁵ Building social support networks in the workplace, seeking to reduce stigma about burnout, and working to increase or maintain job control are all ways to prevent and reduce the risk factors of burnout before it begins.⁴⁶ Maintaining physical well-being through exercise and adequate sleep and avoiding tobacco and other risky substances all represent personal factors that can prevent burnout. Other individually focused interventions include strategies that involve self-care, wellness, building coping strategies, meditation, mindfulness, social connection, and focus on a healthy diet.

Systems-Based Primary Prevention

Primary prevention interventions seek to identify and reduce the source of burnout and are likely to be systems-based, promoting organizational change. This vision focuses on the human aspects of care, promoting empathy and compassion as core values of the profession. In doing so, physicians may be able to derive enhanced meaning from their work. The National Academy of Medicine Clinician Burnout committee provides 6 major goals¹:

• Create positive work environments: Transform health care work systems by creating positive work environments that prevent and reduce burnout, foster professional well-being, and support quality care. Human-centered designs should be followed, with co-creation of the infrastructure and organization with physicians.

• Create positive learning environments: Transform health professions’ education and training to optimize learning environments that prevent and reduce burnout and foster professional well-being.

• Reduce administrative burden: Prevent and reduce the negative consequences on clinicians’ professional well-being that result from laws, regulations, policies, and standards promulgated by health care policy, and regulatory and standards-setting entities, including government agencies (federal, state, and local), professional organizations, and accreditors.

• Enable technology solutions: Optimize the use of health information technologies to support clinicians in providing high-quality patient care.

• Provide support to clinicians and learners: Reduce the stigma and eliminate the barriers associated with obtaining the support and services needed to prevent and alleviate burnout symptoms, facilitate recovery from burnout, and foster professional well-being among learners and practicing clinicians.

• Invest in research: Provide dedicated funding for research on clinician professional well-being.

Individual-Focused Primary Prevention

Systems-based primary prevention measures that we described in the primordial prevention section may also be utilized as individual-focused lifestyle medicine interventions that we described in primordial prevention. Although the interventions may be similar, primary prevention is focused on reducing the effects of burnout after it already has been noted in a physician. Many of the individual-focused primary prevention strategies will be in the workplace. For example, one recent study investigated a 9-month facilitated peer group support for physicians meeting twice a month. This support group was based on the Balint approach to support groups and was found to reduce burnout symptoms.⁴⁶ Primary prevention measures also included attempting to address physicians’ unmet needs, including decreasing isolation, normalizing struggle, organizational issues, workload and pace, community, need for processing emotional dimensions of work, moral distress, institutional infrastructure, and individual issues.

Enhancing professional self-efficacy represents one of the ways in which we can decrease stress and potentially prevent burnout. How is that done? Bandura discusses ways to improve self-efficacy by experiences that help in performance mastery either directly or vicariously. An example is a physician decreasing their stress after watching the positive changes in another physician (role modeling). Another example is that health care organizations adopt a distributive leadership model and have physicians actively design and lead the organization thereby giving them more control.⁴³

More recent ideas in the literature have included professional coaching interventions.⁴⁷ In one study, institutional paid 3.5 hours of coaching showed improvement in burnout as measured by the MBI. As expected, the coaching did not address the multiple complex systems issues contributing to the burnout.

Secondary Prevention Interventions

Secondary and tertiary prevention interventions are often reactive and do not seek to address the root of the problem. Secondary prevention interventions aim to reduce the severity of burnout symptoms once they have been identified. One of the goals of secondary prevention of burnout is early detection before the symptoms negatively affect the individual and the people around him/her. Developing an ongoing screening program using validated approaches standardizes the secondary prevention process. In addition, developing resources for physicians who screen positive for burnout should promote a more open and healthy culture of professional well-being. Stress management programs that incorporate coping strategies to mitigate the effects of stress are also examples of lifestyle medicine secondary prevention interventions. For example, mindfulness techniques can help physicians reduce rumination about factors they cannot control.

Tertiary Prevention

Tertiary prevention seeks to minimize the adverse consequences of an established, ongoing condition. Unfortunately, it is inevitable that some physicians will slip through the cracks of primordial, primary, and secondary prevention. Ensuring that physicians who suffer from burnout have the proper resources to deal with it, and to prevent their burnout from further deteriorating their physical and psychological well-being, tertiary prevention involves employee assistance programs and potentially other referrals. Psychiatric disorders may occur as an adverse consequence of burnout, especially clinical depressive disorders or anxiety disorders.

Nutrition in Depression and Anxiety

Studies indicate that a healthy diet is associated with a lower incidence of depression.⁴⁸ In addition, one meta-analysis showed that adherence to a Mediterranean diet, which is based primarily on plant-based whole foods reduced the risk of depression by 27% to 32%.⁴⁹ Numerous lifestyle factors may also influence the gut microbiome, including stress, dietary intake, and dietary inflammatory index. The link between the gut microbiome and depression and anxiety has been reported in studies that also show improvement with the use of probiotics.^50,51

Exercise in Depression and Anxiety

Many studies have shown the benefit of exercise to ameliorate depression and anxiety.^52-54 Exercise provides effects on mood states and feelings of sadness, stress, and anxiety. The effects are mediated through multiple pathways, including increased gray and white matter volume with aerobic exercise, effects on neurogenesis in the hippocampus, increased production of vascular endothelial growth factor, and formation of new synapses between neurons.^55-57

Tobacco Use and Psychiatric Disorders

Tobacco use is associated with an increased risk of depression and anxiety disorders.^58,59 In a recently published large meta-analysis, smoking tobacco significantly increased the prospective risk of depression.⁶⁰

Next Steps

Lifestyle medicine can play a central role in informing health care providers about healthy lifestyle to help protect against and decrease the effects of burnout. A vast amount of literature confirms that positive lifestyle factors offer dramatic improvement to health and lower risk factors for chronic disease.

Lifestyle medicine offers an opportunity for physicians to find joy and meaning in their profession again. Physicians are busy working, but there may be severe misalignment between caregivers’ values and the current health care system. We continue to have problems in reconciling the difference between the extrinsic and intrinsic motivators in a physician’s life.

Helping patients find ways to improve their healthy life span, enjoy their lives, and decrease the impact of chronic disease in their day-to-day life would not only help the patient, but also professionally gratify the physician. There are several, specific ways that we would advocate lifestyle medicine physicians’ work to ameliorate the potential of burnout. First, as already elucidated in this review, multiple components of lifestyle medicine can reduce the risk of burnout among lifestyle medicine practitioners. It is important that lifestyle medicine physicians engage in those behaviors as part of their overall approach to a healthy lifestyle and also lowering the risk of burnout.

Second, we believe that lifestyle medicine clinicians should play a more active role in helping individuals who are entering the field of lifestyle medicine either as medical students or residents or are in the early stages of training. This involves recognizing that in addition to education in the components of lifestyle medicine, an emphasis should occur on adopting the pillars of lifestyle medicine as a way of reducing the risk of burnout. Third, we believe that lifestyle medicine practitioners are uniquely positioned to offer their services to hospitals, large medical groups, and other health care providers as a way of helping these organizations create environments that systematically reduce the likelihood of physician burnout.

There is no question that the challenge of physician burnout is significant. We believe that lifestyle medicine practices can play an important, and even unique, role in helping reduce this rapidly emerging problem.