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Balancing Unbalanced Lives

A Practical Framework for Personal and Organizational Change
      Rising rates of physician burnout have led to efforts to decrease stress in clinical environments. Although mild to moderate stress can improve productivity, prolonged or sustained stress becomes “distress,” as revealed by national statistics on physician burnout.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      Burnout can affect personal relationships and disrupt family life. Professionally, burnout can harm patient care, relationships with patients and colleagues, a person's integrity, and, eventually, the viability of our health care system, as providers exit prematurely and patients lose confidence in their care.
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? Results from the Healthy Work Place Study.
      “Work-life balance” is a suggested remedy for physician burnout. This term implies that it is up to physicians to maintain a healthy personal–professional equilibrium among their multiple roles over time; imbalance, in turn, can increase stress. The demands clinicians have at home and work are additive: rearing children, maintaining important relationships, caring for patients, and meeting productivity targets. In a job-stress model validated in physicians, countering these demands are the control physicians have over working conditions such as schedules, and the support they receive at work.
      • Linzer M.
      • Gerrity M.
      • Douglas J.A.
      • McMurray J.E.
      • Williams E.S.
      • Konrad T.R.
      Physician stress: results from the Physician Worklife Study.
      Similarly, practices at home can help equalize physicians' multiple demands, such as arranging personal time and family schedules, and nurturing relationships with family and friends. Others have suggested that resilience—the ability of individuals and medical teams to manage change in healthy ways—can counteract the burden of too many demands.
      • Epstein R.
      • Krasner M.
      Physician resilience: what it means, why it matters, and how to promote it.
      • Miller W.L.
      • Crabtree B.
      • Nutting P.A.
      • Stange K.C.
      • Jaén C.
      Primary care practice development: a relationship-centered approach.
      Many physicians find that work-life balance and their own well being are elusive because of working conditions. Productivity expectations may be unrealistic in the face of insufficient time, staff, and resources. Workplace cultures may promote competition, backbiting, and fear of retribution. The need to complete electronic medical record documentation after hours can impinge upon personal time, creating a “work-anywhere” environment. However, the medical workplace can either mitigate or contribute to physicians' ability to reduce stress.
      Organizational leaders can begin to help by modeling respectful and supportive behaviors that set expectations for a healthy work culture and by promoting realistic work expectations, well-functioning teams, and mindful practices for all employees.
      In this article, we describe an updated conceptual model of physician stress useful for organizational leaders and physicians to analyze causes of stress. Building upon the “demand-control” model of job stress, this updated model includes both work and home perspectives and adds resilience and well being into the structure of the model. The model can guide both individual and workplace strategies to decrease physician stress and improve work-family balance. We believe that use of this model will lead to better care and a more sustainable, effective health care system for providers and patients.

      Current Conceptual Model

      The current model of job stress underscores the importance of labor demands and workers' ability to exert personal control. This “demand-control” model conceptualizes a “seesaw” in which stress fluctuates as work demands on one side are kept in check by control over conditions on the other side. A lack of control without a decrease in work demands can lead to the seesaw tipping up and stress rising. This model has been well known and validated for close to 40 years. In large studies of Swedish workers, Karasek showed that workers balance their work demands with control of the work environment. Without that control, workers are at risk for stress and ultimately cardiovascular events.
      • Karasek R.
      • Baker D.
      • Marxer F.
      • Ahlbom A.
      • Theorell T.
      Job decision latitude, job demands, and cardiovascular disease: a prospective study of Swedish men.
      Johnson and Hall updated the study in 1988 by demonstrating that social support is also able to balance work demands, creating the “demand-control-support” model of job stress (Figure 1).
      • Johnson J.V.
      • Hall E.M.
      Job strain, work place social support, and cardiovascular disease: a cross-sectional study of a random sample of the Swedish working population.
      In this expanded model, improving either control or support can rebalance the system and the individual worker. This model was validated in physicians in 2002.
      • Linzer M.
      • Gerrity M.
      • Douglas J.A.
      • McMurray J.E.
      • Williams E.S.
      • Konrad T.R.
      Physician stress: results from the Physician Worklife Study.
      Figure thumbnail gr1
      Figure 1The demand control support model of physician stress

      Updated Model

      We propose to further expand the model of physician stress in 2 ways: by anchoring the stress scale with physician well being as the ultimate aim and by adding resilience as a third stabilizing force to the right of the seesaw (Figure 2). With well being opposing stress on our scale, we clarify that balance is more than stress reduction; it is optimal health and development.
      Figure thumbnail gr2
      Figure 2The expanded model of physician stress
      We also suggest a practical way to integrate both personal and professional aspects of physicians' lives into the demand-control-support-resilience model. We have summarized the moderators of physician stress (Table). Although some of them are intuitive, many have supporting evidence.
      • Linzer M.
      • Gerrity M.
      • Douglas J.A.
      • McMurray J.E.
      • Williams E.S.
      • Konrad T.R.
      Physician stress: results from the Physician Worklife Study.
      • Epstein R.
      • Krasner M.
      Physician resilience: what it means, why it matters, and how to promote it.
      • Linzer M.
      • Manwell L.B.
      • Williams E.S.
      • et al.
      Working conditions in primary care: physician reactions and care quality.
      • Rodriguez H.
      • Giannitrapani K.
      • Stockdale S.
      • Hamilton A.
      • Yano E.
      • Rubenstein L.
      Teamlet structure and early experiences of medical home implementation for veterans.
      • Mitchell P.
      • Wynia R.
      • Golden B.
      • et al.
      Core Principles & Values of Effective Team-Based Health Care.
      • Emmons R.A.
      • McCullough M.E.
      Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life.
      • Klimecki O.M.
      • Leiberg S.
      • Ricard M.
      • Singer T.
      Differential pattern of functional brain plasticity after compassion and empathy training.
      • Lanham H.J.
      • McDaniel R.R.
      • Crabtree B.F.
      • et al.
      How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.
      • Benzer J.
      • Mohr D.
      • Evans L.
      • et al.
      Team process variation across diabetes quality of care trajectories.
      • Yoon J.D.
      • Rasinski K.A.
      • Curlin F.A.
      Conflict and emotional exhaustion in obstetrician-gynaecologists: a national survey.
      • Gordon E.K.
      • Baranov D.Y.
      • Fleisher L.
      The role of feedback in ameliorating burnout.
      • Edmondson A.C.
      Making it safe to team.
      For demands, the typical set of roles that physicians play are listed, although these will vary for each person. Having control over one's home and work schedule, and the availability of resources allows for better organization and delegation of duties. Support at home and work comes in the form of positive relationships and shared values with family, friends, colleagues, and leaders.
      • Linzer M.
      • Gerrity M.
      • Douglas J.A.
      • McMurray J.E.
      • Williams E.S.
      • Konrad T.R.
      Physician stress: results from the Physician Worklife Study.
      • Linzer M.
      • Manwell L.B.
      • Williams E.S.
      • et al.
      Working conditions in primary care: physician reactions and care quality.
      • Rodriguez H.
      • Giannitrapani K.
      • Stockdale S.
      • Hamilton A.
      • Yano E.
      • Rubenstein L.
      Teamlet structure and early experiences of medical home implementation for veterans.
      Personal resilience is “the capacity to respond to stress in a healthy way so that goals are achieved at minimal psychological cost.”
      • Epstein R.
      • Krasner M.
      Physician resilience: what it means, why it matters, and how to promote it.
      Workplace resilience can be described as “adaptive reserve” or a work team's ability to adjust mindset and actions as they coordinate care, address quality improvement, and streamline workflows.
      • Miller W.L.
      • Crabtree B.
      • Nutting P.A.
      • Stange K.C.
      • Jaén C.
      Primary care practice development: a relationship-centered approach.
      Resilience of both individuals and workplace teams can be influenced by relationship-centered communication and other practices that enhance insight and mindfulness.
      • Epstein R.
      • Krasner M.
      Physician resilience: what it means, why it matters, and how to promote it.
      • Miller W.L.
      • Crabtree B.
      • Nutting P.A.
      • Stange K.C.
      • Jaén C.
      Primary care practice development: a relationship-centered approach.
      • Mitchell P.
      • Wynia R.
      • Golden B.
      • et al.
      Core Principles & Values of Effective Team-Based Health Care.
      • Emmons R.A.
      • McCullough M.E.
      Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life.
      • Klimecki O.M.
      • Leiberg S.
      • Ricard M.
      • Singer T.
      Differential pattern of functional brain plasticity after compassion and empathy training.
      • Lanham H.J.
      • McDaniel R.R.
      • Crabtree B.F.
      • et al.
      How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.
      • Benzer J.
      • Mohr D.
      • Evans L.
      • et al.
      Team process variation across diabetes quality of care trajectories.
      • Yoon J.D.
      • Rasinski K.A.
      • Curlin F.A.
      Conflict and emotional exhaustion in obstetrician-gynaecologists: a national survey.
      • Gordon E.K.
      • Baranov D.Y.
      • Fleisher L.
      The role of feedback in ameliorating burnout.
      • Edmondson A.C.
      Making it safe to team.
      TablePersonal and Workplace Moderators of Physician Stress
      DemandsControlSupportResilience
      Personal Factors
       • Caretaker role

       • Income needs

       • Partner's work
      • Dependents' schedules

      • Commute time

      • Home help
      • Relationships

      • Partner support

      • Family support

      • Community support
      • Mindfulness
      • Epstein R.
      • Krasner M.
      Physician resilience: what it means, why it matters, and how to promote it.
      • Miller W.L.
      • Crabtree B.
      • Nutting P.A.
      • Stange K.C.
      • Jaén C.
      Primary care practice development: a relationship-centered approach.


      • Self-care (healthy diet, sleep, exercise)

      • Gratitude
      • Emmons R.A.
      • McCullough M.E.
      Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life.


      • Compassion for self and others
      • Klimecki O.M.
      • Leiberg S.
      • Ricard M.
      • Singer T.
      Differential pattern of functional brain plasticity after compassion and empathy training.
      Workplace Factors
       • Work role

       • Work hours

       • Panel size

       • Time pressure
      • Linzer M.
      • Gerrity M.
      • Douglas J.A.
      • McMurray J.E.
      • Williams E.S.
      • Konrad T.R.
      Physician stress: results from the Physician Worklife Study.


       • Case mix
      • Linzer M.
      • Gerrity M.
      • Douglas J.A.
      • McMurray J.E.
      • Williams E.S.
      • Konrad T.R.
      Physician stress: results from the Physician Worklife Study.


       • Team staffing
      • Rodriguez H.
      • Giannitrapani K.
      • Stockdale S.
      • Hamilton A.
      • Yano E.
      • Rubenstein L.
      Teamlet structure and early experiences of medical home implementation for veterans.


       • Documentation
      • Mitchell P.
      • Wynia R.
      • Golden B.
      • et al.
      Core Principles & Values of Effective Team-Based Health Care.
      • Work schedule

      • Work responsibility
      • Mitchell P.
      • Wynia R.
      • Golden B.
      • et al.
      Core Principles & Values of Effective Team-Based Health Care.


      • Productivity
      • Linzer M.
      • Gerrity M.
      • Douglas J.A.
      • McMurray J.E.
      • Williams E.S.
      • Konrad T.R.
      Physician stress: results from the Physician Worklife Study.


      • Team members' responsibilities
      • Rodriguez H.
      • Giannitrapani K.
      • Stockdale S.
      • Hamilton A.
      • Yano E.
      • Rubenstein L.
      Teamlet structure and early experiences of medical home implementation for veterans.


      • Work resources
      • Leadership style
      • Linzer M.
      • Manwell L.B.
      • Williams E.S.
      • et al.
      Working conditions in primary care: physician reactions and care quality.


      • Work culture
      • Linzer M.
      • Manwell L.B.
      • Williams E.S.
      • et al.
      Working conditions in primary care: physician reactions and care quality.


      • Values alignment

      • Supportive colleagues
      • Linzer M.
      • Gerrity M.
      • Douglas J.A.
      • McMurray J.E.
      • Williams E.S.
      • Konrad T.R.
      Physician stress: results from the Physician Worklife Study.


      • Team function
      • Miller W.L.
      • Crabtree B.
      • Nutting P.A.
      • Stange K.C.
      • Jaén C.
      Primary care practice development: a relationship-centered approach.


      • Supportive relationships
      • Team relationships
      • Mitchell P.
      • Wynia R.
      • Golden B.
      • et al.
      Core Principles & Values of Effective Team-Based Health Care.
      • Lanham H.J.
      • McDaniel R.R.
      • Crabtree B.F.
      • et al.
      How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.


      • Communication
      • Mitchell P.
      • Wynia R.
      • Golden B.
      • et al.
      Core Principles & Values of Effective Team-Based Health Care.
      • Lanham H.J.
      • McDaniel R.R.
      • Crabtree B.F.
      • et al.
      How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.


      • Managing conflict
      • Miller W.L.
      • Crabtree B.
      • Nutting P.A.
      • Stange K.C.
      • Jaén C.
      Primary care practice development: a relationship-centered approach.
      • Yoon J.D.
      • Rasinski K.A.
      • Curlin F.A.
      Conflict and emotional exhaustion in obstetrician-gynaecologists: a national survey.


      • Feedback
      • Miller W.L.
      • Crabtree B.
      • Nutting P.A.
      • Stange K.C.
      • Jaén C.
      Primary care practice development: a relationship-centered approach.
      • Yoon J.D.
      • Rasinski K.A.
      • Curlin F.A.
      Conflict and emotional exhaustion in obstetrician-gynaecologists: a national survey.


      • Psychological safety
      • Edmondson A.C.
      Making it safe to team.
      This framework can guide physicians and their organizational leaders to specific remediable factors to reduce stress and burnout. It is important to highlight workplace-based approaches to reduce stress through this model. Many physician burnout initiatives employ wellness interventions intended for personal use such as mindfulness, nutrition, and exercise. Although it is important that physicians be empowered to influence their own well being, it is disingenuous to ask physicians to respond to mounting organizational pressures on their own.

      Conclusion

      There have been several recent calls to address physician burnout. This new model of physician stress is a framework to guide personal and institutional change. Both administrators and clinicians can identify contributing factors to physician stress in the context of work and home environments. This model can help guide adjustments in workplace conditions as well as balance promoting practices to help physicians achieve resilience and adjust to change. Changes on personal and organizational levels are important to attain balance and should not be viewed as mutually exclusive or dichotomous but as part of a holistic approach to a healthy workplace.
      Those concerned with sustainable medical careers must cultivate resilience to be able to adapt to necessary changes and reject those that are existential threats to the profession. To relieve the distress physicians are experiencing, leaders of medical practices and front-line physicians must have collaborative conversations about healthy work environments and individual well being. With respect, trust, concern, and active listening, support will be manifest and change more likely to occur. Only then will we be on our way to addressing the epidemic of physician burnout.

      Acknowledgment

      We would like to thank our graphic designer, Nancy Pinckert, for understanding the thoughts in our minds and for her creativity to transform them visually.

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