by Nikhil Agrawal, MD, and Luke Grome, MD
A cheerful heart is good medicine, but a crushed spirit dries up the bone.
The conversation on burnout in residency focuses on ways to avoid getting down. We need to focus not only on ways to make life less bad, but also on ways to make our lives better. There is a growing and exciting field of psychiatry centered around this very problem. “Positive psychology” was developed by Martin Seligman who defines it as the “scientific study of optimal human functioning that aims to discover and promote the factors that allow individuals and communities to thrive.” He has discovered that to be happy we need to have contentment with the past, happiness in the present, and hope for the future. Three ingredients are essential to accomplishing this: 1. positive experiences, 2. positive individual traits that make life fulfilling, and 3. institutions that create positive environments.1
In this post we will focus on a few easily applicable strategies that residents can integrate into their daily life: gratitude, mindfulness, and vitality.
This is the greatest contribution and best studied concept that positive psychology has given residents. It is why keeping a diary can be such a positive experience even if you never go back and read it. Gratitude helps you to reflect on an experience and frame it in a positive light. This powerful tool has been shown to increase outlook and improve happiness and satisfaction.
Interestingly, a practice of gratitude may positively affect both mental and physical wellbeing. A study examined three groups of individuals. Each group was required to reflect on experiences and write three of them down daily. The group that wrote down three positive experiences, versus those that wrote negative experiences, and those that wrote experiences without an emphasis, exercised more and had fewer doctor’s visits.2
Gratefulness can also use it to make lives better for the people around you while making your own life better. Thanking someone who truly deserves it can increase your own happiness in a lasting way. This has the added benefit of making those around you happier as well as inspiring them work harder.
There are two easy ways to integrate this into your life. The first is to think of three good things that happened to you during the day either on your drive home or before you go to bed. The second is to ask the question when you finish a case, talk, or clinic, “What went well?” This practice can be difficult because we are trained to focus on the negative and what we did wrong. While critical assessment is important, you will also improve by being aware of what went well and how to continue to use those same maneuvers in your next endeavor.1
Distractions disconnect you from the world around you and make you unhappy. Constantly focusing on the present is surprisingly difficult and tiring to do for anyone. It can be even harder for goal-oriented individuals who feel like every unproductive moment is a moment wasted. The constant stream of emails, texts, and beeping pagers keep your mind distracted from enjoying the now. We see amazing and fascinating things every day but hardly have the time to appreciate it. Being able to focus on the sights, sounds, smells, and environment while in the operating room or in conference will help you value those moments much more.
There is debate within the field on whether or not this ability can be learned or if it is innate. It seems clear that there is at least some learning that can be done. Furthermore, it is important to understand because it has been shown to increase positivity, reduce stress, and improve quality of life.3
While we cannot eliminate all distractions and our mind will always wander, we can practice this skill. Meditation is the traditional way to practice this but you can also practice when you sit down to eat dinner and incorporate it throughout your day.
The best way to quickly understand the goal mindset is to focus on drinking your daily coffee or tea. Sit or stand still and feel for a minute the cup in your hand, the smell of drink, the heat on your face, and then slowly take a sip. Let it roll around in your mouth and think about how it tastes; does it have fruit flavors or chocolate flavors? If your mind wanders, even if it is to wonder what use this exercise is, acknowledge the thought and re-direct yourself to the task at hand. Once you do this you are practicing mindfulness.
Then, the next time you are in conference, do your best to go through the same though process about the lecture being given. You will have a new appreciation for what is happening and with time your focus will improve and you will enjoy the experience a little bit more.
It is hard to exercise or eat well while in residency, but any discussion on ways to improve happiness is incomplete without this topic. Probably the most interesting study on the topic pitted three groups of patients with depression against each other. One group was prescribed antidepressants, the 2nd exercise, and the 3rdboth. All three improved with the treatment, but at 10 months, 31 and 38 percent of the antidepressant only and combination group respectively had relapsed. This is compared to 9 percent in the exercise only group.4 I imagine exercise has a similar effect on burnout. It has even been shown that self-control and self-discipline when making a workout routine and sticking to it can strengthen these traits in other aspects of your life as well.
Even small steps like taking the stairs instead of the elevator can give you a sense of accomplishment. This combined with five minutes of brisk low impact exercises is enough to improve your mood.1 If you want to get into a workout routine, here are a few tips to make it easier.
Change into workout clothes and go straight to your gym or studio immediately from work. The minute you get home it becomes that much harder to leave. This may require packing a protein bar to eat along the way. It has been shown that your mood at the beginning of the workout will help determine if you end up enjoying it. Therefor you should listen to your favorite song right when you start. If you get bored easily put on a podcast. The PRS Journal Club podcast is a great way to hear some perspectives on the latest articles while working out.
Gratitude, mindfulness, and vitality are powerful tools against the battle with burnout. Small changes each day yield large rewards. It’s low hanging fruit like this too often is overlooked. As a profession we commit everything to helping others. I encourage you to make a small effort to help yourself.
For those that are interested in learning more, I encourage you to read a book by Bridget Grenville-Cleave titled A Practical Guide to Positive Psychology.
1. Grenville-Cleave, Bridget. Positive Psychology: A Practical Guide. MJF Books, 2016.
2. Emmons, Robert A., and Michael E. Mccullough. “Counting Blessings versus Burdens: An Experimental Investigation of Gratitude and Subjective Well-Being in Daily Life.” Journal of Personality and Social Psychology, vol. 84, no. 2, 2003, pp. 377–389., doi:10.1037/0022-35126.96.36.1997.
3. Carlson, Linda E., et al. “Randomized Controlled Trial of Mindfulness-Based Cancer Recovery Versus Supportive Expressive Group Therapy for Distressed Survivors of Breast Cancer (MINDSET).” Journal of Clinical Oncology, vol. 31, no. 25, 2013, pp. 3119–3126., doi:10.1200/jco.2012.47.5210.
4. Blumenthal, James A., et al. “Effects of Exercise Training on Older Patients With Major Depression.” Archives of Internal Medicine, vol. 159, no. 19, 25 Oct. 1999, doi:10.1001/archinte.159.19.2349.