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Recovering Joy in the Workplace Requires P.R.A.C.T.I.C.E.

      INTRODUCTION

      Physician burnout is a global healthcare crisis which has been compounded by the recent coronavirus disease 2019 (COVID-19) pandemic. Drivers of physician burnout include excessive workloads, inefficient work environments, lack of autonomy, work-home conflicts, and lack of organizational support. The consequences of physician burnout are great, with impact on patient care, physician health and engagement, and healthcare systems and organizations (
      • West CP
      • Dyrbye LN
      • Shanafelt TD
      Physician burnout: contributors, consequences and solutions.
      ). Radiologists report higher levels of burnout than physicians in many other specialties (
      • Giess CS
      • Ip IK
      • Gupte A
      • et al.
      Self-reported burnout: comparison of radiologists to nonradiologist peers at a Large Academic Medical Center.
      ,
      • Shanafelt TD
      • West CP
      • Sinsky C
      • et al.
      Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.
      ). Burnout among radiologists is seen at all career levels, from trainees to department chairs (
      • Perry H
      • Naud S
      • Fishman MDC
      • et al.
      Longitudinal resilience and burnout in radiology Residents.
      ,
      • Chetlen AL
      • Chan TL
      • Ballard DH
      • et al.
      Addressing Burnout in Radiologists.
      ,
      • Ganeshan D
      • Wei W
      • Yang W
      Burnout in chairs of academic radiology departments in the United States.
      ). In a study conducted by the Association of American Medical Colleges between 2016 and 2018, only 28% of all clinical faculty, and 31% of radiologists reported that they enjoyed their work (
      • Ganeshan D
      • Wei W
      • Yang W
      Burnout in chairs of academic radiology departments in the United States.
      ). By early 2020, when COVID-19 cases reached hospitals and clinics in the US, physician burnout rates were already at epidemic levels with nearly 50% of those surveyed reporting symptoms of burnout (

      AAMC Burnout among US medical school faculty. February 2019 analysis in brief V19 N1. Available at: https://www.aamc.org/data-reports/analysis-brief/report/burnout-among-us-medical-school-faculty. Accessed March 2022.

      ). The pandemic brought unprecedented challenges to an already stressed and burned-out healthcare workforce (
      • Yates SW
      Physician stress and burnout.
      ,
      • Smallwood N
      • Pascoe A
      • Karimi L
      • et al.
      Moral distress and perceived community views are associated with mental health symptoms in frontline health workers during the COVID-19 pandemic.
      ). The cost of this pandemic to our healthcare system and to our communities has been tremendous. In addition to the lives lost to this virus, we have realized many other losses throughout this crisis. We have experienced loss of jobs, loss of opportunities, loss of connection with loved ones, loss of hope, and for many, loss of joy in our work as healthcare providers. Recovering joy in our work during the greatest health care crisis many of us have ever seen is critical to our ability to weather this storm and those that follow. It is going to require collective action and it is going to take P.R.A.C.T.I.C.E. We are going to examine how Purpose, Reflection, Appreciation, Connection, Time, Inclusion, Choosing Wisely, and Embracing change can help us recover and maintain joy in our work.
      PURPOSE: Meaningful work“May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” — excerpt from the Hippocratic Oath (
      • Preti E
      • Di Mattei V
      • Perego G
      • et al.
      The psychological impact of epidemic and pandemic outbreaks on healthcare workers: rapid review of the evidence.
      ).
      For many of us, one of the earliest memories we have of our medical career involved the donning of our white coats and recitation of the Hippocratic Oath alongside our new classmates and future colleagues. The enthusiasm and eagerness we felt in those early moments, mirrored the sentiments of our personal statements filled with excitement and determination to answer the call to medicine. As we travel down our career path and face the inevitable challenges, setbacks, and crises, these early sentiments are easily forgotten (
      • Miles SH
      The hippocratic oath and the ethics of medicine.
      ). Recent studies have shown that physicians who experience a greater degree of burnout are less likely to identify with medicine as a calling (
      • Grimes PE
      Physician burnout or joy: rediscovering the rewards of a life in medicine.
      ). Revisiting the intrinsic factors that motivated us to become physicians can help us become more resilient and reclaim the joy in our practice. Finding meaning in our daily work is a key element to physician engagement and a protective strategy to mitigate burnout (
      • Jager AJ
      • Tutty MA
      • Kao AC
      Association between physician burnout and identification with medicine as a calling.
      ). Shanafelt et al have placed meaningful work at the center of their driver dimensions model for physician burnout and organizational change (Fig 1) (
      • Restauri N
      • Nyberg E
      • Clark T
      Cultivating meaningful work in healthcare: a paradigm and practice.
      ). Improving our connection to the value and meaning in our work requires examination of our daily practice. Physicians who spend <20% of their time at work on activities that they found personally meaningful were almost three times more likely to experience burnout. We must prioritize work that aligns with our passions and values throughout our careers (
      • Shanafelt TD
      • Noseworthy JH
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      ,
      • Serwint JR
      • Stewart MT
      Cultivating the joy of medicine: a focus on intrinsic factors and the meaning of our work.
      ). We must take an active approach to defining and re-defining what meaningful work looks like and encourage and support others in doing the same. It is through identifying and prioritizing that which drives us and gives us purpose, that we may discover more joy in medicine.
      Figure 1
      Figure 1Shanafelt's driver dimensions of burnout and organizational change.
      REFLECTION: Looking back
      Reflective practices have been defined as “those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation” (
      • Shanafelt TD
      • West CP
      • Sloan JA
      • et al.
      Career fit and burnout among academic faculty.
      ,
      • Lutz G
      • Scheffer C
      • Edelhaeuser F
      • et al.
      A reflective practice intervention for professional development, reduced stress and improved patient care–a qualitative developmental evaluation.
      ). Interventions focused on reflective practice have shown to improve physician well-being (
      • Koshy K
      • Limb C
      • Gundogan B
      • et al.
      Reflective practice in health care and how to reflect effectively.
      ,
      • Rabow MW
      • McPhee SJ
      Doctoring to Heal: fostering well-being among physicians through personal reflection.
      ). Reflecting on what we have been through collectively and as individuals is crucial to our ability to learn from what we have endured and celebrate what we have accomplished. Moments of reflection aide in examining a microlevel environment, such as one's immediate work unit (i.e., reading room or division) or macrolevel environment, such as an organization or institution or even a larger world view. It is important that we welcome and honor all feelings that arise from difficult experiences without judgement, including grief, anger, frustration, loss, hopelessness, relief, and gratitude. Mindfulness practices, such as meditation, breathing exercises, or journaling allow the space and time to reflect on what we have experienced. Reflecting on the struggles that we faced in the past offers us a chance to learn from how we responded and to better understand and appreciate the unique qualities that we possess.
      APPRECIATION: Appreciative inquiry and gratitude practice
      Appreciative inquiry is a “strengths-based approach to identify “what is going well” with a situation” and use this information to envision positive change (
      • Hunt SL
      Reflective debrief and the social space: offload, refuel, and stay on course.
      ). Instead of asking or dwelling on “what is going wrong,” ask and focus on “what is going well.” These questions seek to identify strengths that individuals or organizations can build upon to achieve intended goals (Table 1). Additionally, perceived weaknesses can be reframed as strengths to be developed (
      • Hunt SL
      Reflective debrief and the social space: offload, refuel, and stay on course.
      ). This small change in mindset can have a notable impact on internal motivation. In the context of perceived weaknesses, a key word to consider is “yet.” Contrast the statement “I can't engage my audience effectively” with “I can't engage my audience effectively yet.” The former portrays a fixed mindset, whereas the latter portrays a growth mindset with a desire to achieve the goal of how to engage an audience more effectively.
      Table 1The “5-D model” of Appreciative Inquiry and Building on Current Strengths to Achieve Goals Includes the Following Phases (
      • Shanafelt TD
      • West CP
      • Sloan JA
      • et al.
      Career fit and burnout among academic faculty.
      )
      1. Definition – “is this worth doing?”
      2. Discovery – “what is working well?”
      3. Dream – “what would the ideal future situation be like?”
      4. Design – “what do we need to do to realize that future?”
      5. Destiny or Deliver – “what needs to be done to ensure that the changes continue?”
      Appreciative inquiry, including reflecting on “what is going well,” cultivates gratitude. Positive life experiences, such as receiving an award or recognition, also cultivate gratitude. It can be difficult to cultivate a sense of gratitude during negative or challenging life experiences. Noticing and appreciating things we might otherwise take for granted, such as having a job, good health, food on the table, our family, and/or the beauty of nature, cultivate not only gratitude, but also well-being and joy. Gratitude practices take this one step further and include intentional actions that express gratitude toward ourselves or others (
      • Sandars J
      • Murdoch-Eaton D
      Appreciative inquiry in medical education.
      ). In a study, investigating gratitude and subjective well-being, the participants who practiced gratitude exercises showed higher levels of positive affect and well-being (
      • Lutz G
      • Scheffer C
      • Edelhaeuser F
      • et al.
      A reflective practice intervention for professional development, reduced stress and improved patient care–a qualitative developmental evaluation.
      ). Examples include saying thank you, writing 1-3 things we are grateful for in a daily gratitude journal, paying it forward with acts of kindness or volunteerism, and/or sending thank you cards, emails, or texts.
      CONNECTION: The value of social connection
      “Social connection is an umbrella term that refers to the ways in which one can connect to others physically, behaviorally, cognitively, and emotionally” (
      • Emmons RA
      • McCullough ME
      Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life.
      ). This connection can provide structural support (via presence of relationships in our lives), functional support (via the resources or functions these relationships do or could potentially provide) and quality support (encompassing the positive and negative emotional part of our relationships.)
      The science of human connection has been well studied. Our need to connect with others has been described as “fundamental as our need for food and water” (
      • Holt-Lunstad J
      Fostering social connection in the workplace.
      ). Shanafelt et al includes lack of social support and community as one of the key drivers of physician burnout (

      Dinnen M (2020) The importance of human connection in remote work. Workhuman. Available at: https://www.workhuman.com/resources/globoforce-blog/the-importance-of-human-connection-in-remote-work Accessed March 2022.

      ). Cultivating a sense of belonging is an important intrinsic motivator and key component of our well-being. Fishman et al propose three categories of activities that have the potential to enrich the radiology workplace community through connection: socializing, radiologist volunteer work, and radiologist participation in workplace operations (
      • Shanafelt TD
      • Noseworthy JH
      executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      ). Connection builds community, combats feelings of isolation and depression, and mitigates burnout.
      TIME: Integrating work and life
      In modern medicine, there is increasing time pressure on both academic and private practice physicians, making it more difficult for physicians to accomplish all that they want in both their professional and personal lives. The 24/7 nature of clerical and administrative tasks, coupled with the ubiquity of the electronic health record, has further blurred the boundary between “work” and “life” (
      • Fishman MDC
      • Mehta TS
      • Siewert B
      • et al.
      The road to wellness: engagement strategies to help radiologists achieve joy at work.
      ,
      • Overhage JM
      • McCallie Jr., D
      Physician time spent using the electronic health record during outpatient encounters: a descriptive study.
      ,
      • Peccoralo LA
      • Kaplan CA
      • Pietrzak RH
      • et al.
      The impact of time spent on the electronic health record after work and of clerical work on burnout among clinical faculty.
      ). Previously, this was conceptualized as work-life balance suggesting that there was a tradeoff between the demands of work and life which could be balanced. More recently, however, given the ubiquity of work in people's lives, the concept has shifted towards achieving a harmonious integration of work and life, a concept known as work-life integration (
      • Melnick ER
      • Sinsky CA
      • Dyrbye LN
      • et al.
      Association of perceived electronic health record usability with patient interactions and work-life integration among US physicians.
      ).
      Making time for leisure or recreational activities is a critical component of work-life integration and is a learned skill that takes practice and dedication to perfect. This critical act of self-care and has been likened to “securing our own oxygen mask” before helping others (
      • West CP
      • Dyrbye LN
      • Shanafelt TD
      Physician burnout: contributors, consequences and solutions.
      ). Strategies to achieve better work-life integration are multifactorial and require individual and systemic changes (
      • Karakash S
      • Solone M
      • Chavez J
      • et al.
      Physician work-life integration: challenges and strategies for improvement.
      ). Potential ways individuals can move toward better integration include outsourcing and delegating tasks and replacing perfectionism in all areas of life with an acceptance of being “good enough.” In addition, setting healthier boundaries for designated work time, such as not working during vacation days or limiting off-hours work is an important aspect maintaining better work-life integration (
      • Tawfik DS
      • Shanafelt TD
      • Dyrbye LN
      • et al.
      Personal and professional factors associated with work-life integration among US physicians.
      ).
      INCLUSION: A place for everyone
      We spend many hours at work and may even spend more of our waking hours with our work colleagues than our family members. Thus, having collegial and inclusive work relationships is important for our day-to-day well-being and mental health. Relationships based on mutual respect and trust are important not only for the daily micro-environment, such as with members of your division, but also important with leaders at a departmental level and even an institutional level. As human beings, we need to feel a sense of belonging that is all encompassing and includes feeling seen, accepted, valued, appreciated, and supported (

      Zucker R Help your team achieve work-life balance- even when you can't. Harvard business review. 2017. Available at: https://hbr.org/2017/08/help-your-team-achieve-work-life-balance-even-when-you-cant Accessed March 2022.

      ). We feel joy and deep satisfaction in our work when there is alignment of our goals with the mission of our institution and the work environment is positive. However, this feeling of belonging in academic medicine is often a privilege that is not universally experienced, particularly for individuals in nondominant groups (
      • Baumeister RF
      • Leary MR
      The need to belong: desire for interpersonal attachments as a fundamental human motivation.
      ).
      It is well established that having a diverse workforce is imperative to the success of organizations because diversity in thought, perspectives and experiences leads to more creative ideas and innovative solutions (

      Roberts LW Belonging, respectful inclusion, and diversity in medical education, Acad Med: 2020;95 (5) 661-664 doi: 10.1097/ACM.0000000000003215

      ). In the Diversity 3.0 Framework from the Association of American Medical Colleges, creating a culture and climate of inclusion begins with making diversity a core value (
      • Bourke J
      • Smith C
      • Stockton H
      • Wakefield N
      From diversity to inclusion: move from compliance to diversity as a business strategy.
      ). The framework calls on the engagement from all levels of “human capital” within the organization, from administrators to faculty to students to learn, practice and create policies that encourage mutual respect and belonging (
      • Bourke J
      • Smith C
      • Stockton H
      • Wakefield N
      From diversity to inclusion: move from compliance to diversity as a business strategy.
      ).
      At the institutional level, policies are a testament to the institution's culture of inclusion, such as nongendered bathrooms to prevent discrimination against transgender or nonbinary individuals (
      • Nivet MA
      • Castillo-Page L
      • Schoolcraft Conrad S
      A diversity and inclusion framework for medical education.
      ). Creating policies that promote diversity and inclusion creates a safe space for employees to present their authentic selves at work without fear of discrimination (
      • Nivet MA
      • Castillo-Page L
      • Schoolcraft Conrad S
      A diversity and inclusion framework for medical education.
      ). The sense of belonging occurs when people feel connected to others because they have meaningful relationships with their colleagues. We as individuals must examine our own biases and unintended microaggressions to become aware of how our words and actions are preventing others from feeling included (

      Fallon N A culture of inclusion: promoting workplace diversity and belonging. 2021. Available at: https://www.businessnewsdaily.com/10055-create-inclusive-workplace-culture.html Accessed March 2022.

      ).
      CHOOSING CAREFULLY: Setting your intention
      Choices are ubiquitous in our personal and professional lives. The ability to make choices with intention and purpose is a skill that we need throughout our careers, not only for personal success, but also for sustainability. Personal agency, autonomy, and control are considered drivers of well-being (

      Volini E Belonging. From comfort to connection to contribution. 2020. Deloitte Development LLC. New York, NY. Available at: https://www2.deloitte.com/us/en/insights/focus/human-capital-trends/2020/creating-a-culture-of-belonging.html Accessed March 2022.

      ). For instance, a survey of nearly 250 academic radiologists revealed that lack of autonomy was associated with high rates of burnout (
      • Lomas T
      Positive work: a multidimensional overview and analysis of work-related drivers of wellbeing.
      ). We must make our choices carefully and with intention.
      Making choices can be difficult, particularly if a radiologist is trying to cultivate a scholarly niche or foster administrative duties while attending to clinical work. Prioritizing activities means being strategic about what one says “yes” and “no” to since time is a limited resource. A mentor may give advice to a mentee about which choices might be beneficial to their career. A coach may help a radiologist develop insight and self-reflection to guide personal and professions decision making (

      Gowda V, Jordan SG, Oliveria A et al. Support from within: coaching to enhance radiologist well-being and practice. Acad Rad. Published online Dec 16, 2021.

      ).
      At an organizational level, businesses and institutions use mission statements to focus and guide their efforts. A personal mission statement can be the foundation upon which one optimizes their approach to their personal strategic planning. An effective personal mission statement should inspire its creator and affirm their intrinsic motivation; in essence, a personal mission statement can serve as our internal compass reminding us of our true north, our core values, helping to inform the choices we make. Li et al describe an effective seven-step framework for crafting a personal mission statement aligned with the acronym INSPIRE (
      • Li STT
      • Frohna JG
      • Bostwick SB
      Using your personal mission statement to INSPIRE and achieve success.
      ). In short, the process includes identifying our core values; setting our vision, planning how we will achieve our vision and identifying specific activities that align with our mission. It is important to recognize that our personal goals and visions will evolve over time, and we must revise our personal missions accordingly.
      EMBRACING CHANGE: Crisis as a catalyst for change
      The response of educators and scholars to the COVID pandemic has been summarized by three emerging themes, caring, courage and curiosity (
      • Howard-Grenville J
      Caring, courage and curiosity: reflections on our roles as scholars in organizing for a sustainable future.
      ). It requires courage to discontinue familiar methods and theories and to challenge the status quo. As physicians we used our curiosity and creativity to rethink how we care for our patients and design new ways of teaching our students and trainees. The innovative solutions we have created, have served in many instances as a catalyst for positive change. This is especially true regarding medical education. The logistical changes in radiologist staffing under COVID-19 social distancing policies resulted in new opportunities for remote work and concurrently, remote teaching. Radiology trainees adapted to remote lecturing and video conferencing formats, and radiology curricula and teaching activities had to be revised, updated, and reimagined into online or hybrid formats. The positive side of these changes was increased learner and faculty participation in many of these sessions. The ability to attend or host lectures and inter-disciplinary conferences virtually, made participation by faculty and learners at different locations possible. Virtual “visiting” professorships further enhanced remote learning and students on virtual rotations were able to experience radiology at distant locations without travel and relocation costs (
      • Larocque N
      • Shenoy-Bhangle A
      • Brook A
      • et al.
      Resident experiences with virtual radiology learning during the COVID-19 pandemic.
      ,
      • Belfi LM
      • Dean KE
      • Bartolotta RJ
      • et al.
      Medical student education in the time of COVID-19: a virtual solution to the introductory radiology elective.
      ,
      • Belfi LM
      • Dean KE
      • Sailer DS
      • et al.
      Virtual journal club beyond the pandemic: an enduring and fluid educational forum.
      ). As we continue to navigate our way out of this crisis, we need to ask ourselves which of our adaptive solutions we would like to take with us. Many of the solutions like expanded teleradiology practices, virtual teaching abilities, and greater collaborative efforts in the workplace served to help us survive during the crisis and may help us thrive going forward.

      CONCLUSION

      Recapturing joy in medicine has been described as the “antidote” to burnout (
      • Miles SH
      The hippocratic oath and the ethics of medicine.
      ,
      • Manion J
      Joy at work! creating a positive workplace.
      ). Nurturing the intrinsic factors that drew us to medicine and rediscovering purpose and meaning in our work, combined with reflection, appreciation, and connection to and inclusion of others helps us realign with the humanism that is at the core of medicine. Taking time for ourselves outside of work and making careful choices with intention create space for more effective integration of work and personal life. These elements help build resilience and enhance our ability to embrace change and see the challenges we face as opportunities for growth. It will take P.R.A.C.T.I.C.E, but we will be able to recover and sustain joy in our practice of medicine.

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