The practice of psychiatry endeavors to lessen suffering and to enhance life satisfaction and wellbeing among people living with mental illness. For many healthcare providers, great professional and personal fulfillment is derived from the act of caring for others. Indeed, many clinicians would consider the privilege of caring for others to be worthy of great personal sacrifice. But, as we have observed in recent years, caring for the self is also necessary for clinicians to sustain meaningful care for others. Sustained self-sacrifice may lead to emotional exhaustion, diminished professional engagement, and what is referred to as “burnout.”

Thankfully, the scientific merit of studying physician wellness is now well accepted, and a strong literature base is emerging to bring the insights of psychology, psychiatry, and medicine to bear on the wellness of practicing healthcare professionals. We see these developments as important not only for clinicians, but also for patients and society. What could be more important for the public good than a workforce of professionally engaged, effective, and personally fulfilled healthcare workers?

Psychiatrists have many tools at their disposal for promoting patient wellness in the face of adversity and life stress, from psychotherapy treatments and mindfulness practices to daily habits known to boost happiness, like regular exercise and connection with loved ones. Given staggering rates of burnout and depression among trainees and practicing physicians alike, the time has come to apply what psychiatrists already know so well to enhance the wellbeing of our own colleagues and selves.

The unique hazards in the practice of mental healthcare are well recognized, and include challenging patient characteristics and organizational demands [1]. The phenomenon of burnout cannot be ignored, as it places at risk both the professional’s quality of life and quality of work, with potential for grave individual outcomes for health professionals, as well as adverse consequences for patients.

Positive Psychology Perspective

In psychiatry, self-care has been long viewed as a fundamental component of professionalism; stated differently, poor self-care has been known to lead in some cases to impairment, boundary transgressions, and the “lovesick” physician [2,3,4]. Similarly, the psychological literature has clearly framed burnout and its prevention as an ethical imperative related to competence [1, 5], given that psychologists must “engage in ongoing efforts to develop and maintain competence” and “be aware of personal problems that may negatively impact competence and take appropriate action” [6].

With its emphasis on studying positive emotion, positive character, and positive institutions, the positive psychology movement (e.g., [7, 8]) has also paved the way for greater focus on wellness in psychiatry. Regardless of life circumstances, there is increasing evidence that wellbeing can be actively cultivated through intentional happiness-inducing practices and actions aimed at strengthening positive emotionality [8, 9]. Importantly, we know that potentially stressful life events do not inevitably lead to individual impairment and adverse outcomes, but rather sometimes lead to resilience and great fulfillment. If both personal and system-level supports were readily available, professionals could be better equipped to tackle challenging job responsibilities with resilience and achieve great fulfillment [5, 10].

In alignment with positive psychology, psychiatric researchers are moving beyond the important goal of reducing burnout toward defining an even more ambitious and positive goal—to improve professional engagement. This construct is defined, in direct opposition to burnout, as consisting of high energy, strong involvement, and increased sense of personal accomplishment [11]. The goal is that professionals do not just survive their work lives, but flourish [5].

The February 2018 issue of Academic Psychiatry features a very special collection of articles, all of which deal with the important topic of wellness and its unique relevance to healthcare providers. Many important papers on the topic of wellness have previously been published in the journal and it is exciting to see continued progress toward a culture of greater wellness for physicians.

Urgent Imperative for Attention to Physician Burnout

In the April 2017 issue of Academic Psychiatry, we highlighted six papers related to the problem of physician burnout. Important contributions continue to expand this strong literature base, showing that while burnout and depression affect people of all professions, the problem particularly plagues physicians for reasons highlighted in this current issue, such as high levels of perfectionism [11] or the unique emotional stress of caring for psychiatric patients, as discussed in Zhang’s perspective essay [12]. Serious scientific attention is still urgently needed to understand and address this complex problem.

Burnout has historically been defined as a syndrome including emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment [13]. The problem is pervasive among medical students, residents, and practicing professionals. Several papers in the February 2018 issue identify burnout as a global problem that affects trainees from a diverse set of professional cultures, though in somewhat unique ways [14,15,16]. Evidence from psychology training programs has indicated that effort to build a “culture” that explicitly values self-care appears necessary to help graduate students engage in higher self-care levels [17]. Similar efforts in medical school and residency programs are emerging and warrant further study. For instance, Chaukos, Chad-Friedman and colleagues [18] describe their well-accepted resilience curriculum pilot program which still cited high levels of resident burnout at post-intervention (77% met burnout criteria).

Innovative Interventions

One important area of contribution is in interventions to improve professional engagement for physicians. As this literature base grows, proposals for promising intervention models and scientific evaluations of real-world effects are both critically needed. Taking a public health approach, Chaukos, Vestal and colleagues [19] organize the diverse goals of (1) fostering resilience, (2) identifying those at-risk for burnout before it is too late, and (3) improving access to treatment as primary, secondary, and tertiary health interventions. The model these authors propose is a helpful way of conceptualizing the diverse and important objectives related to prevention, screening, and treatment of professional burnout, both at individual and system levels.

Individual Treatment

Given the evidence that there may be personal benefits when providers focus on patient wellness, application of treatment strategies known to enhance patient wellness is one promising approach for boosting physician wellbeing. In the paper introducing “Hope modules,” Griffith [20] identifies that “demoralized” patients may place a particular strain on treatment providers. Griffith proposes a treatment approach which aims to activate hope by mobilizing successful coping resources from past experiences and to directly enhance realistic optimism and resilience. This deliberate focus on resilience in the face of adversity can have a powerful effect on the optimism of both patient and provider. The approach fits well within an existing literature supporting that resilience can be enhanced deliberately through self-care acts like adequate rest and exercise [21] and through social support and use of cognitive coping skills [1].

Direct application of evidence-based treatment approaches to help professionals in training is also explored, for instance, in a study of cognitive behavior therapy for maladaptive perfectionism in four medical students [22] and mindfulness training for psychiatry post-graduate students [23]. These studies add to the body of literature showing that clinicians who rate themselves as more mindful have more satisfied patients, engage in more patient-centered communication, and use more positive emotional tone when discussing patient concerns [24]. A letter to the editor even highlights the innovative idea of integrating wellness-themed games into the resident training experience [25].

Systems Supports

While core healthcare system goals typically involve enhancing patient experience, improving population health, and reducing costs, there is increasing support for a fourth goal of enhancing provider wellbeing [26]. Insights from the discipline of organizational psychology are now helping to frame system-level solutions for enhancing workforce engagement. While high job demands and low resources are typically associated with provider burnout, recent models have also emphasized the resources that can be enhanced to reduce burnout (e.g., opportunities for professional development, supervision, feedback [1]).

MacKinnon and Murray [11] argue that at the system level, organizations may be slow to adopt practices supporting physician wellness until the problem is seen as affecting the entire organization and proper organizational incentives, including clear understanding of financial repercussions, are in place. While more data are needed, it is already clear that physician burnout results in lower productivity and jeopardizes consumer satisfaction and quality of care.

Given the growing literature on factors contributing to both burnout and its opposite, engagement, MacKinnon and Murray [11] advocate for changes that can be made right away to enhance engagement. The authors acknowledge that while emotional distress is likely endemic in the practice of medicine and psychiatry, organizational level interventions can be made to reduce overload and enhance autonomy and social support. Hours worked and administrative paperwork seem greater contributors to burnout than number of patients [1], suggesting that system-level supports could be quite effective without reducing capacity for care. Underappreciation, which is a major contributor to burnout, can also be targeted by healthcare systems [1], as also suggested in Chabra’s letter to the editor [27] discussing resiliency training by chief wellbeing officers.

MacKinnon and Murray [11] also highlight an intriguing paradox. When workers perceive job demands to be excessive, emotional exhaustion often results; however, this relationship is mitigated when work is perceived as a challenge. It seems that a sense of control and autonomy can reduce the feelings of helplessness that fuel burnout. In addition, the strong sense of meaning and purpose that many providers feel about their work can be harnessed as a buffer against burnout. Such insights strike us as important—the intrinsic work of understanding the suffering of patients and providing care in the context of such suffering is hard. The nature of the work itself does not change and will not ever become “easy.” The aim of self-care in this context is to foster clinicians’ strengths so that they may turn to this inherently difficult work with resilience and compassion, bringing their expertise to fulfill their role in society.

The inevitable conclusion from this is that providers must be involved in the design of programs to enhance their own wellness, an idea tested in a “by residents—for residents” resilience curriculum [18]. Similarly, Robledo-Gil and colleagues [28] report on a peer advocate program for medical students which 77% reported to be extremely or very helpful in coping, primarily with relationship and mental health concerns. While leadership and cultural support are certainly necessary, a grass-roots component is also warranted in the design of programs to enhance wellness in practicing physicians and psychiatrists. Providers must be empowered to solve the problem of their own wellness in an individually meaningful manner. Nothing an administrator or executive can mandate will enhance control and autonomy in the same way.

Together, these papers form a base of support for interventions that can support individual and system-level professional engagement. Many of the most meaningful future contributions may come from studying engaged physicians and from studying model systems with high physician engagement to better understand factors that can support this critical organizational goal.

Methodological Challenges

For the science of physician wellness to advance, standard measurements must be developed. Several important papers in this issue tackle the challenge of measuring this critical subjective construct. In a systematic review, Brady and colleagues [29] examine the inconsistencies in the literature base related to physician wellness, propose a holistic definition, and make a strong argument about the need for greater consistency in definition and measurement of this construct across studies. Trockel and colleagues [30] evaluated the reliability and validity of a new scale that measures both burnout and professional fulfillment. The introduction of this scale is a promising step toward more systematic study of positive factors associated with physician wellbeing. Chaukos, Chad-Friedman, and colleagues [18] discuss harnessing newly available technologies to track wellness behaviors and also highlight a number of methodological challenges in their innovative use of wearables. While important scientific questions are often difficult to study in a truly scientific way, these papers make clear how the science of physician wellness is an intriguing and potentially rewarding topic for future inquiry.

We hope you will find these articles focused on self-care and well-being to be thought provoking and inspiring. The field is ready for major advances in wellness interventions across the professional spectrum from undergraduates to practicing professionals and faculty. Academic Psychiatry is delighted to be a forum for scientific and conceptual advances on the topic of physician wellness, a topic literally central to our health as a discipline.