Wellness Review 2020, Part 1

Introduction: Welcome to Part 1 of the bi-annual Journal of Wellness review of 2020 wellness literature (January – June). In this review, JWellness editors continue the goal of bringing a cohesive awareness of recent publications within the wellness domain, encompassing wellness leaders from all disciplines in healthcare. We provide insight into unique perspectives and new science published outside of JWellness, dealing with burnout prevention and wellness initiative implementation. Methods: PubMed was searched for empirical research studies, review articles, and editorials using keywords such as “wellness,” “well-being,” “burnout” and “healthcare professionals.” We have


Studies Measuring Wellness in Healthcare Providers
In a multisite study published in the American Journal of Medicine, researchers examined interventions to enhance wellness in internal medicine residents.Interestingly, the authors found no relationship between work hours and well-being.However, individuals who exercised had lower levels of burnout, higher quality of life, and improved work-life balance.Additionally, time spent with family was associated with improved resident well-being outcomes [1].
In a study published in JAMA Surgery, 3,807 surgeons were surveyed to gain insight into the connection between career contentment, personal life factors and work-life balance by gender.The authors found similar associations between males and females related to career satisfaction and personal life factors.The study indicated the importance of team or collegial support, and that optimization of work-life balance could lead to not only decrease burnout but also improve gender equity in surgery [2].
In a survey of 1,882 providers from a large academic practice, authors sought to better understand the relationships between burnout, engagement and life satisfaction.The investigators found 30% of respondents reported high levels of burnout and low levels of engagement.Additionally, study results established that while career stage did not impact engagement, early career individuals had more burnout.The study authors suggest that promoting engagement and connectedness in the workplace may lessen burnout [3].
Howard et al. examined the impact of high stress cases on emergency medicine (EM) physicians' psychological well-being.To provide insight into this phenomenon, the authors conducted interviews with 17 EM physicians.Several interviewees vividly recalled observing young patients die, or patients dying in a distressing manner.Participants noted that witnessing the pain and grief of family and friends who had lost loved ones, carried more negative psychological impact than the overall involvement in the death.Fear of making a mistake and carrying substantial responsibility triggered distress, with some reporting trouble sleeping after adverse Wellness Review 2020, Part 1 *Correspondence To: Jacob Shreffler Email: jacob.shreffler@louisville.eduevents.The authors detail how administration could provide support to the multi-faceted concept of physician wellbeing [4].
A study published by researchers from Austria aimed to determine what was essential for well-being in a survey of hospital physicians.The study revealed that the possession of the attributes of fairness, honesty, and kindness had positive implications for well-being.The authors note that development of a culture focusing on signature strengths may improve well-being for providers, ultimately leading to better quality patient care [5].
A researcher at Yale University surveyed internal medicine physicians to better understand the association of burnout with coping, friendship and institutional support.The study revealed an association between positive coping strategies (including acceptance, grit, reframing) and lower levels of burnout and superior compassion.Furthermore, friendship was associated with lower levels of burnout and higher levels of compassion satisfaction [6].
Nassar et al. examined the three dimensions of burnout (emotional exhaustion, depersonalization, and personal accomplishment) within academic physicians.The authors found various factors associated with higher levels of emotional exhaustion and depersonalization: being younger, being a surgeon, lower academic rank, being female, living alone, and having excessive night shifts.Individuals with increased patient volumes had greater amounts of personal accomplishment [7].
Healthy lifestyle choices were highlighted in a study conducted at the University of Florida associating nutrition and lifestyle benefits with actions by physicians.While healthcare providers are more engaged in healthy lifestyle behaviors compared to the general public, they lack the education and training in these areas.The authors call for improved medical education in the areas of nutrition and physical activity [8].

Burnout and Leadership
Burnout and leadership were the principal concepts of multiple papers published in the first half of 2020.The first study, published in Academic Medicine, examined the association between residents from Mayo Clinic's viewpoints on program leadership with burnout and satisfaction [9].The authors compared a leadership survey and the two-question modified Maslach Burnout Inventory (MBI) with survey responses on resident satisfaction [9].The authors found, across a variety of training specialties and locations, that program director (and associate program director) behavior strongly correlated with burnout, as well as program and organizational satisfaction.
In JAMA Open, authors at Stanford investigated the relationship between well-being scores (including burnout, fulfillment, and sleep) and leadership.The authors, who note this is the first study of its kind, found that the leaders' scores on burnout, self-valuation, and well-being were significantly associated with the actions they displayed as leaders [10].
This theme also emerged in a viewpoint article published in JAMA Pediatrics: "Preventing Burnout Among Academic Medicine Leaders." The author focused on the idea of experiencing flow, or leadership flow.Fundamentally, flow allows individuals to be entirely focused and involved with the task(s) at hand.The author describes how once an individual has achieved flow, they have a deepened concentration on the work, which can lead to fulfillment and career satisfaction.The author further explains how leaders (and other faculty) may experience complications in reaching flow due to lack of control (e.g., time, funding, and other required tasks) [11].
In consideration of these papers on leadership and burnout, evidence suggests that individuals who lead (whether it be residents, attendings, or other personnel) should consider two things.First, leaders need to understand that their behaviors and leadership style may not only impact work satisfaction of those they supervise, but also likely mitigates the effects of burnout.Secondly, leaders must recognize the importance of their own well-being and optimize ways to enhance physical and mental wellness to both set an example for their staff to follow, as well as have greater resiliency to stress and positive interactions with those they lead.

Interventions to Improve Wellness
Multiple systematic reviews and meta-analyses published recently have summarized interventions to reduce burnout in healthcare providers.Zhang et al provide an overview of these 22 research publications from 2014 to 2019 [12].The authors provide a "bundled strategy" to reduce symptoms of burnout in healthcare providers: communication training skills, self-care workshops, debriefing sessions, teamwork, stress management training, and examination and optimization of workloads [12].
A review published in the American Journal of Health Promotion described interventions to improve well-being in physicians and nurses.Reviewing 29 studies, the authors found that mindfulness and behavioral-therapy centered methodologies are most effective in lessening psychological distress.Deep breathing exercises and harnessing the concept of gratitude may have benefits.Finally, health coaching with texting boosted activity levels [13].
A separate review piece published in Medical Education examined mindfulness interventions on physician wellness and performance.Mindfulness training fundamentals generally displayed promising outcomes on physician well-being and performance [14].
An empirical study focused on the development of peer support for hospitalists and outpatient primary care physicians.The authors found that building a sense of community by coming together in a group setting helped normalize mental challenges; individuals could discuss, share, learn from each other, and implement practices others recommended.Furthermore, the authors called for a removal of institutional barriers in optimizing wellness and noted support is needed for physician self-care [15].

Perspectives on Improving Wellness
There were several insightful and thought-provoking perspective pieces published in the first half of 2020 on wellness.In a viewpoint published in JAMA Psychiatry, the authors call for more attention on how loss of social connectedness contributes to physician burnout [16].The authors note that these human connections are vital and must be prioritized to reduce burnout and enhance the lives of working physicians.Medical professional stakeholders should revisit Abraham Maslow's "Hierarchy of Needs"-poor connections and not belonging could result in detrimental effects on well-being [16].
Gratitude was a focus of a piece in Annals of Allergy, Asthma & Immunology.The author describes how the attitude of gratitude may alleviate burnout and that we should count blessings rather than burdens.They cover how appreciative inquiry (AI) may help physicians experiencing undesirable mental health feelings find balance in their careers [17].
A commentary in The American Journal of Surgery discusses the impact of grit and optimism on burnout.The authors bring awareness to grit and resilience, its historical context including Friedrich Nietzsche's, "that which does not kill us, makes us stronger, " noting how some individuals with grit also possess disadvantageous qualities (i.e., aim too high, overly tolerant to hardships).Optimism and positive thinking correlate with overall healthy lifestyles and relationships, though optimism may have a dark side.Individuals who are too optimistic may take injurious risks or have unjustified beliefs.Ultimately, optimism should be equalized with realism [18].
An editorial piece in the American Journal of Medicine describes potential benefits of a blue zone program for physician wellness, resulting in the enhancement of one's purpose, growth, and skills.While requiring financial investment, the benefits far outweigh the costs of replacing physicians or covering for increased errors made in the setting of burnout.Institutions could track burnout data like they track clinical data, such as falls or bed sores [19].
A perspective piece proposes a health framework to advance well-being in physicians.This framework includes professional fulfillment, organizational and individual strategies to combat burnout, targeted prevention for individuals at higher risk to experience burnout, and timely mental health treatment [20].
Coaching was the focus in a supplemental piece for surgeons.The author describes how sharing wisdom and insight, having (deep) discussions, and having a commitment to learning helps manage burnout in surgeons.Engagement in coaching enhances passion for performance improvement in a variety of settings [21].
In Medical Education, authors bring up the notion that the urgency to provide interventions and resolutions towards negative wellness within physicians and trainees has led to implementation with unclear aims and consequences.The authors note that we must praise efforts to address wellness, while also recognizing how much we still do not know [22].

COVID-19 and Provider Wellness
COVID-19 has had a tremendous impact on healthcare professionals around the world.A study in Academic Emergency Medicine examined anxiety and stress among EM physicians during the acceleration phase of the 2020 pandemic.Emotional exhaustion and burnout increased during the heightened phase compared with pre-COVID-19.The majority of respondents changed their behavior with their loved ones, including decreasing levels of affection due to anxiety about transmission of the disease to loved ones.Some factors alleviated feelings of distress: access to personal protective equipment (PPE), the possibility for rapid COVID-19 testing, channels of clear communication regarding pandemic planning strategy, and the reassurance that the providers could leave if needed to care for themselves and family members [23].
A paper published in Medical Teacher describes how healthcare providers and trainees can use strategies to optimize resilience and wellbeing during a public health crisis.Some tips provided by the author include mindful awareness, focused reflection, healthy habits (nutrition and exercise), and the importance of social support [24].In The Lancet, one author focused on the impact of COVID-19 on medicine as a whole.Given the pandemic's unparalleled effects on all aspects of humankind, the author normalizes anxiety, small doses of which may be useful.The pandemic presents an opportunity to disregard potentially redundant bureaucratic work and overtreatment in medicine [25].
A piece published in American Journal of Emergency Medicine focused on the physical and psychological well-being of healthcare providers as a result of COVID-19.The authors described how despite the fear these individuals face, they continue to fight the pandemic for their patients with their fellow co-workers.Well-being plans, including accessible counseling services, are critical for individuals experiencing anguish as a result of COVID-19 [26].We must diminish the stigma related to healthcare providers seeking help for burnout or psychological distress (as a result of COVID-19 or other experiences).
Many other original research studies examined the impact of COVID-19 on healthcare provider wellness.Our review of the earliest work on this topic appears in the Western Journal of Emergency Medicine: "The Impact of COVID-19 on Healthcare Worker Wellness: A Scoping Review" in Western Journal of Emergency Medicine [27].

CONCLUSION
Wellness research continues to evolve and provide us with refreshing and actionable insight to enhance well-being for healthcare providers.As new studies emerge, we gain more awareness on relationships between wellness behaviors, burnout, leadership styles, and positive mindset.We learn more about effective interventions to alleviate both mental and physical wellness deficits: mindfulness, coaching, and training sessions.Wellness researchers continuously deliver innovative and promising visions via perspective or editorial pieces.COVID-19 has and will continue to be a focus of wellness research, specifically on healthcare providers who are positioned at the center of the pandemic.We foresee several more studies on the impact of COVID-19 on the wellness of healthcare professionals.