Managing burnout with lifestyle medicine principles

“I am so burnt out!” This statement has become common in the face of the COVID-19 pandemic. Though recognized by the medical profession earlier, the pandemic pressed us to accept it.

An urgent national problem, burnout among health professionals is reported at 66% in 2022, up from 44% in 2017. The projected physician shortage due to burnout ranges between 37,800 and 124,000 by 2034 [1].

The concept of burnout has been defined since the 1960 s. Recognized at the time of the Vietnam War, it came to the forefront when the idealistic young clashed with the barriers and circumstances existing around them [2]. Burnout occurs due to clash between human ideals, e.g., in medicine, a clash between “a calling” to enter medicine and frustration due to the actual experience. Burnout is a combination of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment. A combination of individual approaches and changes in external environments can be solutions to address burnout [3].

Recognized dimensions of burnout are compassion fatigue, decreased resilience, depression, anxiety, and stress [4]. Health care delivery systems and complex supporting processes trigger hurdles to quality care rather than improvements. Factors contributing to system-level issues are navigating several electronic platforms, spending less time with patients, rotating schedules, experiencing staffing shortages, and meeting challenging quality metrics beyond the physician’s capacity to influence, for example, inadequate public health infrastructure and workplace culture. This impacts all healthcare personnel including nurses, pharmacists, social workers, respiratory therapists, hospital security officers, and administrative support across the health care spectrum. About 52% of nurses (according to the American Nurses Foundation) and 20% of doctors say they are planning to leave their clinical practice [5]. See Table 1 for further relevant statistics.

Cumulative stress with continual challenges of navigating obstacles in complex caregiving roles causes an allostatic load, which, when persistent, drives burnout [5].

According to Shanafelt et al., 60% of physicians felt that increased bureaucratic demands, redundant inefficient processes, and long hours contributed to burnout, and about one-third felt that burnout was due to lifestyle and coping skills [6]. Burnout has also been reported in medical students at the time of graduation from medical school [7].

Burnout subtly implies a lack of resilience due to individual frailty. Moral injury, on the other hand, refers to the inability to meet patient needs despite knowing their needs due to limits enacted by the medical framework [8]. Healthcare systems, including but not limited to the use of electronic medical records, quality metrics, and productivity tracking (i.e., the need to meet relative value units), contribute to burnout. Burnout causes increased medical errors, lowers patient satisfaction, leads to higher health care costs, and decreases the quality of patient care. It contributes to chronic diseases due to stress, social isolation, lack of self-care, poor diet, lack of exercise, and physician suicide, to name a few situations.

Lifestyle Medicine (LM) is a medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions like cardiovascular disease, type 2 diabetes, and obesity [9]. It is an emerging field of medicine in which practitioners treat chronic conditions by using evidence-based lifestyle interventions that incorporate the six pillars/domains of LM: 1) a whole-food, plant-predominant eating pattern, 2) physical activity, 3) restorative sleep, 4) stress management, 5) risky substance avoidance, and 6) positive social connections [10].

The focus in LM is to empower the patient and enable them to participate in their wellbeing by incorporating the six pillars of LM as opposed to being a passive recipient of care as provided by conventional medicine.

Practices like sustained gratitude and mindfulness and activities promoting life purpose are associated with a wide range of health-related behavioral and physiological effects, including fewer strokes and myocardial infarctions [11]; lower body mass index, lipids, hemoglobin A1c, and insulin resistance; better heart rate variability among other risk factors [12, 13]; decreased health care use [14]; increased use of preventive services [15]; engagement in healthy eating and physical activity [16]; and longevity [17, 18].

Positive emotions help with promoting behavior change and physiological benefits like wound healing, inflammation, telomere length, and endocrine regulation [19].

Various entities collaborate to improve physician lifestyles and help with burnout. These include health organizations, government, the fitness industry, community organizations, providers, and individuals [19]. Different strategies can be implemented targeting either health systems or health teams, for example, onsite meditation, retreats, evidence-based interventions for wellness, self-development, and cultures of meaningful interactions with patients and team members [19].

Improving shift scheduling and reducing overall workload have been noted to be better than physician-directed interventions (e.g., mindfulness, mindfulness-based stress reduction, exercise, improved sleep hygiene) in addressing burnout [3]. A study found that exercise, maintaining a healthy support system, nutrition, prioritizing self-care and maintaining a daily routine are helpful in developing and maintaining wellness. Wellness is not just lack of burnout. More studies are needed to follow up on lifestyle interventions and their outcomes [20].

While it is important to address burnout, implementation of LM principles has proven successful in this task, be it incorporating exercise, eating a whole-food plant-based diet, focusing on self-care with the addition of mindfulness to daily routines, or seeking out like-minded friends who focus on maintaining positivity. Adopting and integrating the principles of LM has been proven to improve wellness, which in turn can help with mitigating burnout. While burnout exists in varying shades, use of LM with the principles of positive psychology can provide a ray of hope at the end of the tunnel of moral injury-induced burnout [19, 21].