Many experts warn that physician burnout may be the single greatest threat to the foundation of our health care system. Most physicians that report burnout symptoms complain specifically of an increasing loss of autonomy and lack of enjoyment from the job. Radiologists are not immune to these feelings. Prior to the corporatization and consolidation of radiology, most radiologists functioned in small private groups. They were the captains of their ship – making all of the decisions (both clinical and business) that affected their practice. Prior to PACS, most radiologists had frequent daily interactions with referring physicians and their colleagues in the reading room. This led to a fairly strong sense of control, purpose and an overall enjoyment in their work. Imaging advances in CT, MRI, and PET made radiologists even more vital in the care of the patient.
So what happened? Reimbursement and service level pressures have forced many radiologists toward larger groups and employment models. Corporate employers, including large health systems, academic centers, or venture capital backed companies, have taken much of the business burden away from practicing radiologists. But, in doing so, they have also removed a significant amount of autonomy that radiologists once enjoyed. Financial pressures, through declining reimbursements and stipend support, have caused an increased focus on productivity in order to maintain salaries. Many groups are running leaner than before as they choose to work harder rather than backfill retiring partners. PACS and other workflow tools have allowed us to achieve these new workload levels. These same tools, however, have removed many radiologists and referring physicians from the traditional reading room interactions that facilitated relationship building, collegial consultations and a sense of direct involvement in patient care. This isolation, in combination with loss of autonomy and higher productivity demands have caused radiologists to feel more like factory workers than doctors. Not surprisingly, this has led to higher rates of burnout and overall lower levels of happiness.
Despite warnings of the alarming crisis of physician burnout throughout medical journals and mainstream media, some question whether it is a real problem or simply an issue of “softer” doctors. Having studied the principles of well-being, I believe that burnout is real but this may not be the right question. We have all heard the statistics: over half of all physicians report at least one symptom of burnout. Many are leaving medicine early and the number of physicians who would recommend medicine as a career continues to decline. Experts cite both organizational and individual approaches to mitigate burnout. Flexible work schedules, the use of scribes, and mindfulness classes are being implemented across the country. [1] These are positive steps in the right direction.
But the focus on burnout is causing us to ignore the larger truth – the absence of burnout does not equal wellness. The vast majority of physicians (and people in general) are able to function. They get to work on time, pay the bills, manage to watch some of their kids sporting events, and go out to dinner on the weekend. It is a busy life but one that we can “get through” as we look forward to our next vacation. Occasionally we will stop and reflect on how we got here. We accomplished most of the goals we set for ourselves. We became masters in delayed gratification as we waited for the next stage of our lives to finally be able to relax, to enjoy life, to be happy. The reward for all of this work should be more than just the absence of burnout. The reward should be more than simply getting through the day with mild to moderate levels of anxiety and stress. The goal for all of us should be to flourish not just function.
One definition of Flourishing is to be in a vigorous state, to thrive, to prosper. The Greeks called it eudaimonia (good spirit) which some have incorrectly translated as happiness. The problem with the word “happy” (other than its overuse) is that many think of happiness as a transient emotional state. I was happy last weekend when I was not on call or I will be happy when I make partner etc. This type of happiness is not what Aristotle was referring to when he made his famous quote:
“Happiness is the meaning and the purpose of life, the whole aim and end of human existence”.
The word that he originally used was “eudaimonia” which is better defined as a state of flourishing or optimal living over a period of time. For Aristotle and other Greek Philosophers, eudaimonia was the ultimate goal of human existence. All of our actions could be traced back to this desire to flourish.
How do we flourish?
The original goals of philosophy (before it was relegated to abstract discussions among university professors) were to teach us how to live well, how to achieve eudaimonia, how to flourish. These were the right goals 2000 years ago and remain true for all of us. Philosophy holds a wealth of guidance, but its ideas and concepts can be challenging to integrate into daily practice. What exactly does living a life of virtue mean and how can one live this way? What steps should I take to fully realize my unique potential? What philosophy lacked, in my opinion was an evidence based roadmap that tells us exactly how to live well and how to flourish.
Fortunately for us, there is a new field devoted entirely to the scientific study of flourishing – positive psychology. Positive psychology provides a functional blueprint of evidence-based techniques and principles that can guide us away from burnout, move beyond functioning, and head toward flourishing.
The History of Positive Psychology
Before WWII, psychology had 3 distinct missions: Cure mental illness, make lives of all people better, and identify/nurture high talent. – Marty Seligman
The National Institute of Mental Health changed the course of psychology after World War II. Psychologists could now earn a comfortable living by researching and treating mental illness. As a result, there were tremendous advancements in the treatment of mental illness over the past 50 years. At least 14 disorders that were previously intractable can now be cured or considerably relieved.
Unfortunately, this focus on pathology left behind the other two goals of psychology – improve lives of all people and study genius. In the 1950s, humanistic thinkers such as Carl Rogers, Erich Fromm and Abraham Maslow revived interest in these areas of psychology by creating therapeutic models that supported individual happiness and self-actualization. Many psychologists have been critical of the Humanistic movement; they asserted that it lacked scientific rigor. The field of positive psychology combined the focus of the Humanistic thinkers on individual potential with the scientific methods of traditional psychology. Positive psychology officially began as a new area of psychology in 1998 when Martin Seligman (considered by many to be the father of positive psychology) chose it as the theme for his term as president of the American Psychological Association.
What is Positive Psychology?
Positive psychology focuses on human flourishing rather than alleviating distress. Traditional psychology focused on pathology: it works on a person that is functioning at a -8 and moving them to a zero or +1 (if they are lucky). Positive psychology, on the other hand, focuses on the person who is functioning at a +1 and improving them to a +8 on a scale of human flourishing. We need both areas of focus. For too long we have been content to simply get by or exist. As long as someone is functioning and not in acute distress, we as a society feel they are ok. In reality, there is unrealized joy and potential within all of us. We need proven techniques to unlock this potential and really flourish in the short time we all have in life. This is the promise of positive psychology.
A Model of Happiness
Positive Psychology takes you through the countryside of pleasure and gratification, up into the high country of strength and virtue, and finally to the peaks of lasting fulfillment: meaning and purpose. – Marty Seligman
According to Seligman, we can experience three kinds of happiness:
- The Pleasant Life – hedonism
- The Good Life – using our unique strengths to cultivate excellent character and fulfill our potential.
- The Meaningful Life – using that potential for a purpose larger than ourselves.
Each kind of happiness is linked to positive emotion, but from his quote, there is a progression from the first type of happiness of pleasure/gratification to strengths and virtues and finally to meaning and purpose.
The pleasant life is one of pleasure where our basic bodily needs are met. This is the hedonistic stage of satisfying our cravings for food, drink, sex, and toys. As we will see from hedonic adaptation, this is a treadmill that requires more intense pleasures that never ultimately satisfy us.
The Good Life, according to Seligman, is one in which our strengths and virtues are cultivated every day as we seek to fulfill our unique potential. This was the focus of Ancient Philosophers who believed that a life of virtue and duty were key components of human flourishing.
The Meaningful Life is one in which we apply our fully developed unique potential for a purpose larger than ourselves. The principles of service to others and a feeling of connection with the Universe have been preached by several religious and philosophical texts as universal truths. When we become our best self in order to contribute to others in a meaningful way, we have entered the Meaningful Life.
There are many different models for human flourishing and happiness. Even Dr. Seligman has since updated his Three Dimensions of Happiness Model. The point is not to search for one right definition, but to understand the key components that form the basis of all models. For me, it’s the simplicity of Seligman’s model that has been critical to explain much of the discontent that many of us may feel. We search for pleasures and positive emotions but don’t realize that unless we move past this hedonistic stage, cultivate our strengths for some meaningful purpose and develop our best self to make an impact, we may keep feeling anxious and unfulfilled.
Most of us have no problem living in the Pleasant Life; in fact, much of society is firmly rooted in this stage. It’s very common for our younger years to be filled with hedonistic pursuits. We may chase money, sex and possessions. As we get older, we begin searching for the point of it all. We begin to ask ourselves if this is all there is to life. We may feel a growing sense of anxiety and discontent. If we have kids, we may look to them to provide us with meaning. Their success becomes our success. Their academic or athletic achievements are a direct reflection of us. Their popularity is our popularity. Our self-worth is based on their self-worth. We try to fill our hole of discontent with our kid’s contentment. This doesn’t work. It’s the reason we have parents screaming at their kids, coaches and umpires at sporting events. It’s why seven year olds have private coaches to get an early edge on their teammates. It’s the reason that the term “helicopter parent” – one who is constantly hovering over their child to ensure maximum output – was invented. It’s why that every parent feels their child should be in the advanced class at school. It’s the reason that many kids are urged to get in with the popular crowd, leaving a good but uncool friend behind.
If we understand the need to progress from the Pleasant Life to the Good Life, we can begin to see the source of our misguided pursuits. The reason for our discontent is a growing sense of a deep and unrealized potential. As we are stuck in the Pleasant Life, we are not fully developing our best self. We are not living in harmony with our unique strengths and virtues each day. In short, we can only enter the Good Life by focusing on our own development – our personal growth. Until we work on ourselves first, we run the risk of trying to realize our own full potential through the potential of our children. If we don’t focus on developing our own character and living in harmony with our virtues, we are in no position to teach our kids to live this way.
As physicians, we are often too busy to worry about our own happiness. Many people depend on us. We are used to living this way. We are no strangers to stress and delayed gratification. That is how most of us, myself included, made it through our academic career – waiting to reach the next level to finally be able to slow down and enjoy the fruits of our labor. The problem, however, is that this cycle never ends. The excitement of getting into medical school is quickly replaced by the stress of matching into a good residency. The promise of an attending salary is replaced by the dream of retirement. Does it have to be this way? How can we learn to fully enjoy the present while preparing our best for the next phase of life? Positive psychology has some answers for us. While it is a broad and rapidly growing field, there are a few key principles that can be very helpful to physicians.
Hedonic Adaptation: The most important principle we never learned
We are wired to adapt to stimuli in our lives that are constant. This is why we eventually take for granted the good things in our lives. The new job, car, house and relationship will all one day lose their luster. This process, hedonic adaptation, allows us to recognize and differentiate new stimuli (potential threats) from old ones that should fade into the background. While this is an evolutionary advantage, it presents a huge obstacle in our attempts to sustain or improve our well-being. Nature wanted us to survive long enough to procreate – She didn’t care how happy we were along the way. For physicians who are prone to looking ahead to brighter times in order to get through current struggles, hedonic adaptation can be especially painful. Once we achieve our goals, eager to enjoy our well-deserved reward, the fruits of our labor lose their sweetness over time.
The key to slowing or halting this adaptation process is to learn how to cultivate attention to the good in our lives. Once that new job or relationship no longer grabs our attention, we have adapted. On the other hand, anything or anyone that keeps popping into our heads will be less prone to be taken for granted.
A mentor of mine, Tal Ben-Shahar (Harvard psychologist and best-selling author) would often say “when we learn to appreciate the good, the good will appreciate”. The key for us to stop taking all of the positive things in our lives for granted is to simply learn how to pay attention to them. Because this is not how we are wired, it takes some intentional effort and strategy. One of the most effective methods to combat hedonic adaptation is gratitude. There has been a significant amount of research on the power of gratitude in the positive psychology literature. The scientific study of gratitude is perhaps the greatest contribution of positive psychology. The cultivation of gratitude has been shown to have statistically significant effects on multiple domains of well-being including decreased stress/anxiety/depression, reduced physical complaints, and self-reported measures of happiness. [2] Gratitude is an effective antidote to the hedonic adaptation process because it allows us to focus our attention on what we have in our lives. In doing so, we become far less likely to take them for granted.
There are many ways to express gratitude. One of the most effective ways is a gratitude journal where you can record 3-5 things that you are grateful for each day. It helps to go beyond the big 3 – family, health, security and delve into more detail about specific events or people. It can be as simple as being thankful for time to play catch with your son or to have an uninterrupted conversation with your daughter in the car. As radiologists at work, we can be thankful to pick up the subtle finding on the scan that led to a quicker diagnosis. We can be grateful for the biopsy that was successful without complications. Sometimes, a personal conversation with a colleague can be a very rewarding part of the day. Perhaps we can be thankful for our ability to render medical opinions by simply looking at images that most people find confusing. Either an electronic journal on our smart phones or a hand-written journal work well. The key is to do this regularly and make it part of your day (so it will become like brushing your teeth).
Mindfulness: “Wherever you go, there you are” – Jon Kabit-Zinn
The mindfulness movement has become very popular. Jon Kabit-Zinn, the founder of the widely used mindfulness based stress reduction program (MBSR) defines mindfulness as “non-judgmental awareness of the present moment.” There are several research studies outlining the positive effects of mindfulness practice on anxiety, depression, burnout, memory, clarity, focus, brain function and overall well-being. [3] At its core, mindfulness improves our ability to handle stress which many researchers feel is a common pathway to mental and physical disease states. Due to its increasing popularity, there are mindfulness meditation practices throughout our schools, military, police and health care systems. This is a growing area of research and the exciting science behind neuroplasticity (changing brain tissue and activity) through mindfulness practice is still in its infancy.
There are many ways to practice mindfulness. Even just a few minutes a day has been shown to reduce stress and increase positive emotions. There are many great apps that can provide a simple introduction to meditation (Head Space, Calm). A regular meditation practice has been transformative for many people (including myself) but what I have realized is that it may not be enough on its own. While we can think of meditation as a training session for the mind to improve focus and attention, the remainder of the day is filled with stimuli that are designed to covet our attention. It is the mental equivalent to lifting weights for an hour in the morning and then spending the rest of the day on the couch watching TV while eating junk food. Most of us would not tolerate this level of physical laziness because we know how it will make us feel at the end of the day. Yet we allow the same degree of mental laziness into our day and end up feeling tired, anxious and stressed.
It is estimated that we spend less than 20% of our time actually present in each moment. While this has always been difficult problem, the issue has become significantly worse with the advent of smart phones. Large social media conglomerates have hijacked our attention using behavioral psychology and addiction principles for their own profit. There will eventually be a backlash against these apps, ironically with more apps designed to keep us free of distraction and help us focus our attention. [4] In the meantime, we can incorporate some simple strategies that can allow us to be more intentionally present and engaged in each moment.
Over the years, I had settled into a comfortable routine of checking email whenever I felt like it which was essentially around the clock. Intellectually, I understood that this was not a good habit and certainly did not contribute to my productivity and creative work (quite the opposite). So I tried to limit the number of times I check email and other internet feeds to certain times of the day but always slipped back into my old habits. What I was missing was a trigger to enforce the rule. Recently I began to link the reward of checking my phone with another (not so pleasurable) task and a specific time of day. I can only check my email/internet once per 90 minutes and only after completing a quick 1-2 minute bodyweight workout. In this way, I can limit the times that I check email to around 8-10/day and will have done some physical activity each day. There are many other combinations of triggers – we could go for a short walk outside or read a book. While working, we could focus on reading cases for 60 minute intervals before checking our phones. The best reward from this method is the free time between sessions. This can become more focused time to read, write, work or interact with family/colleagues/friends. Constraints create freedom and attention – by limiting our choices at each moment, we are free to choose what to focus on with more intention and purpose. In this way, we can become more mindful of what we are doing throughout the day beyond our morning meditation practice.
There are many other positive psychology interventions that have been proven to increase well-being and can be very beneficial for physicians. Cultivation and daily use of unique strengths (VIA.org) is a heavily researched topic that is being used throughout schools and businesses. Research has shown that people who are aware of their strengths and have opportunities to use them regularly have lower levels of burnout and higher rates of well-being. This is an example of a low cost yet highly effective solution that our health care system desperately needs. Other areas of investigation include grit, mindset, and optimism. These have been correlated with higher academic performance, lower rates of anxiety/depression/burnout and improved physical health in business, military and education sectors. Radiology groups and departments that add positive psychology principles into their residency and faculty development curriculum will realize the same competitive advantage in terms of retention, productivity, quality and overall well-being that have been seen in these other industries.
The Promise of Positive Psychology
There is emerging research that the well-being of physicians has significant downstream effects on quality and cost of care, medical errors, and ultimately patient outcomes. Radiologists are no exception. Given the number of cases we read each day, we can have an extraordinary positive impact on a large number of patients. The health care system will only be as healthy as we are. We need to learn how to thrive not simply survive while avoiding burnout. We owe it to our families, our patients, and most of all, ourselves to prioritize our own wellness. Positive psychology can help. It can provide us with practical tools and evidence based strategies that are proven to move us closer to flourishing. With positive psychology, we can focus on character development over material accumulation, tranquility over popularity, appreciation over expectation, presence over productivity, potential over possessions, and living the Good Life over having a good life.
References:
- Physician Burnout: The Root of the Problem and the Path to Solutions. NEJM Catalyst June 2017.
- Emmons, Robert A. and McCullough, Michael E. The Psychology of Gratitude. Oxford; New York: Oxford University Press, 2004.
- Chiesa, A., Serretti, A., 2009. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. J. Altern. Complement.Med. 15 (5), 593–600.
- Thrive App: So You Can Focus On What Matters Most https://www.thriveglobal.com/stories/21184-introducing-thrive
