Mitigating Physician Burnout and Enhancing Wellness by Modeling a Gratitude Practice

The “differential diagnosis” of physician burnout is broad, ranging from simple job dissatisfaction to major depressive disorder. The syndrome develops over time, specifically in response to work-related issues.(1) Maslach identified the three essential domains of burnout: emotional exhaustion, cynicism or depersonalization, and a lack of self-efficacy or sense of personal accomplishment at work.(2)

After reaching a record high of 62.8% at the height of the COVID-19 pandemic in late 2021, physician burnout rates have dipped below 50% for the first time since 2020. The American Medical Association’s latest figures show that 48.2% of physicians reported at least one burnout symptom in 2023.(3)

The cost of physician burnout is steep for the individual provider and the organization as a whole. Burned-out doctors are leaving their jobs, retiring early, or moving to non-clinical positions, leaving sites short-staffed.

The Medical Group Management Agency found that in 2023, nearly one-third of physician group practice leaders reported that at least one physician left the organization or retired early because of burnout.(4) Replacing one physician can cost from $500,000 to $1 million, given the high cost of recruitment and onboarding.(5)

Even if physicians stay in their jobs, burnout is associated with a higher rate of medical errors and overall poorer patient satisfaction, which makes addressing staff burnout a paramount priority for those of us in healthcare leadership.(6)

The Role of Individuals and Leadership

For many years, burnout mitigation measures have focused on the individual healthcare workers themselves. Interventions that promote wellness and reduce stress such as mindfulness sessions, gratitude practices, and individual professional coaching certainly have their place in addressing burnout.(7,8) But given that burnout, by definition, develops in response to the work environment, those in leadership positions within that environment have a responsibility to be part of the solution.

Leadership qualities that translate into the highest rates of satisfaction in the physicians under their governance include highlighting individuals’ talents and contributions, recognizing physicians’ accomplishments, and discussing organization values and purpose in a way that allows doctors to align their own individual morals with the group’s ideals.(9) Expressing appreciation for an employee’s hard work not only fulfills a basic human need, it also can cultivate a culture of teamwork and mutual respect.(7)

Gratitude as a Positive Psychology Intervention

For the past several years, the field of positive psychology has been turning its attention to the idea of using gratitude interventions to enhance our physical and psychological well-being.

Gratitude can be defined broadly as an appreciation of what is valuable or meaningful to us. We can express this emotion specifically when someone gives us something or does something for us. Gratitude can also be considered a character trait, as when we simply express the overall sentiment of thankfulness.

Whether gratitude is studied as a specific intervention such as journaling or as an emotional state, research findings generally link greater degrees of gratitude with higher levels of well-being.(10)

Gratitude Broadens and Builds

Psychologist Barbara Frederickson studied gratitude in the context of other positive emotions, such as joy, pride, and curiosity. She coined the phrase “broaden and build” to describe how the actions inspired by positive emotions are expansive.(11)

Negative emotions tend to narrow our repertoires of response (anger creates the urge to lash out; fear triggers the urge to flee) but positive emotions lead to wider reactions. Joy broadens by encouraging play and being creative. Pride broadens by engendering an impulse to accomplish bigger and better things.

Gratitude broadens by inspiring us to “pay it forward”—returning favors or looking for ways to be a positive force for good in the world. All these broadening actions build personal capital, extending the life of the original positive emotion and allowing us to “bank” these resources to be drawn upon in the future as needed.(11)

Gratitude Practice in Healthcare

Gratitude interventions have been studied specifically in healthcare professionals and found to positively influence mental health. After journaling about work-related events and experiences for which they were grateful, study participants reported lower levels of perceived stress as well as reduced depressive symptoms compared to non-journaling controls.(2)

Individuals who practice gratitude interventions build and maintain personal resilience which contributes to physician well-being.(12)

Gratitude and Burnout

Beyond contributing to resilience and feelings of well-being, gratitude and gratitude practices can specifically mitigate the burnout that is epidemic in our ranks as healthcare professionals. Following completion of a 21-day gratitude journaling intervention, nurses and other healthcare professionals reported significantly higher levels of gratitude than non-journalers.(13)

More importantly, perceived stress scales and burnout scores were significantly decreased in the group of participants who completed the gratitude intervention. These reductions persisted at the three-month follow-up and the effect sizes were medium to greater than large.(13)

Gratitude as Leadership Practice

How can an individual wellness intervention such as a gratitude practice be utilized by physician leadership to benefit their entire medical community?

In addition to making such a practice available and easy to access for healthcare workers, physician leaders can model the intervention themselves in observable ways.

When leading meetings and working together with staff on joint projects, leaders can express appreciation for jobs well-done. As Carrau and Janis point out, “Recognition of accomplishments, appreciation of hard work, and alignment of individual talents to specific needs can cultivate a culture of mutual respect, appreciation, and teamwork.”(7)

In a process Frederickson calls “elevation,” simply witnessing helpfulness prompts others to stretch themselves in searching for ways to repay kindnesses themselves. Observing leaders in the field display gratitude inspires staff and colleagues to seek their own people or things to show gratitude to or for.(11)

Gratitude transforms individuals and creates opportunities for growth, creativity, and resilience in what Frederickson refers to as a continuous “upward spiral.” Modeling the intervention ourselves, as leaders, can prompt our colleagues and staff to explore or invent ways to help their team members, benefiting the entire community.(11)

A Model of Leadership Gratitude Practice in Action

What can a gratitude practice at the leadership level look like and how exactly would it help medical staff in their day-to-day jobs?

1. Physician leaders can begin meetings with a gratitude chain. Each team member can share one thing they are grateful for in that moment in their work. This sets the tone for the meeting.
   
   A potentially contentious or challenging agenda can be re-framed as an opportunity to problem-solve if team members feel appreciated and their opinions and solutions are eagerly sought.

2. Physician leaders can follow up with team members after meetings to communicate gratitude for their ideas. Sending individual messages by phone, email, or a personal visit to the employee’s office or clinic demonstrates a leader’s willingness to invest time and energy in their team and their appreciation for everyone’s involvement.
   
   If an idea was particularly helpful or will be incorporated into future policies and procedures, this can be explicitly stated. But conveying gratitude for an idea that met with resistance or was dismissed by some team members can be even more inspiring or satisfying to that attendee.
   
   This isn’t a mere “everyone gets a trophy” move. Leaders are communicating not only their gratitude, but also a belief in each person’s worth and value to the team. It shows that leadership is listening.

3. A strategy that pediatricians often use in helping parents deal with challenging behaviors in their children is one of “catching them being good.” It is a way of having parents acknowledge and show appreciation for the behaviors they want to see more of in their kids rather than just focusing on the negative ones they wish to extinguish.
   
   This is not to say that we should treat our colleagues like children, but rather that being appreciated feels good at any age. If an employee known for negative attitudes or unhelpful comments can be shown gratitude when there is even a glimmer of optimism, kindness, or good will, more of that kind of participation will likely follow.

4. Gratitude doesn’t come easily for some. We need to be mindful of our colleagues’ varying backgrounds, experiences, and emotional range or capacity and not force participation from a reluctant team member.
   
   Creating an open and welcoming environment for sharing is critical for gaining trust and building team connections. An explicitly stated “what happens in this room stays in this room” policy can go a long way toward inviting input and encouraging participation in these gratitude exercises.

5. To be sure, every team will have its cynic who will call efforts to introduce a gratitude practice just so much Kumbaya. After all, cynicism is one of the three main dimensions of physician burnout Maslach identified.(2)
   
   But as these gratitude practices become commonplace, the workplace culture will gradually shift. With practice as well as observation of the growing esprit de corps and mutual support of an effective team, most team members will ultimately join in.

Toward an Attitude of Gratitude

Gratitude interventions have been found to support the wellbeing and resilience of healthcare professionals and, more recently, to reduce burnout scores. Physician leaders have a role to play in this “attitude of gratitude” and in mitigating burnout in their staff. Some simple gratitude interventions, sincerely deployed, can begin the process of healing from moral injury and finding cohesion in their healthcare team.

This article provides some examples of ways gratitude could be incorporated into the workdays of physician leaders. Future research could focus on the effect such gratitude interventions by leadership have on the well-being of their healthcare professional teams.

References

1. Hu JS, Pangaro LN, Andrada G, Ceasar RC, Phillps IL. Physician Leadership and Burnout: The Need for Agency; A Qualitative Study of an Academic Institution. J Healthc Leadersh. 2024;16:121–130. https://doi.org/10.2147/JHL.S419203

2. Maslach C, Leiter MP. Understanding the Burnout Experience: Recent Research and Its Implications for Psychiatry. World Psychiatry. 2016 Jun;15(2):103–11. https://doi.org/10.1002/wps.20311

3. Berg S. Physician Burnout Rates Drop Below 50% for First Time in Four Years. American Medical Association. July 2, 2024. https://www.ama-assn.org/practice-management/physician-health/physician-burnout-rate-drops-below-50-first-time-4-years .

4. Harrop C. Staying Vigilant Against Physician Burnout: Is Progress Being Made? MGMA Stat. October 4, 2023. https://www.mgma.com/mgma-stat/staying-vigilant-against-physician-burnout .

5. Rosenfeld J. Calculating the Financials Cost of Physician Burnout. Medical Economics. February 15, 2018. https://www.medicaleconomics.com/view/calculating-financial-costs-physician-burnout .

6. Yates SW. Physician Stress and Burnout. Am J Med. 2020;133:160–164. https://doi.org/10.1016/j.amjmed.2019.08.034

7. Carrau D, Janis JE. Physician Burnout: Solutions for Individuals and Organizations. Plast Reconstr Surg Glob Open. 2021;9(2):e3418. https://doi.org/10.1097/GOX.0000000000003418

8. Cheng St, Tsui PK, Lam JHM. Improving Mental Health in Health Care Practitioners: Randomized Controlled Trial of a Gratitude Intervention. J Consult Clin Psychol. 2015;83(1):177–186. https://doi.org/10.1037/a0037895 .

9. Shanafelt TD, Gorringe G, Menaker R, Storz KA, et al. Impact of Organizational Leadership on Physician Burnout and Satisfaction. Mayo Clin Proc. 2015;90:430–440. https://doi.org/10.1016/j.mayocp.2015.01.012 .

10. Sansone RA, Sansone LA. Gratitude and Well Being: The Benefits of Appreciation. Psychiatry (Edgmont). 2010;7(11):18–22.

11. Frederickson BL. Gratitude, Like Other Positive Emotions, Broadens and Builds. In: Emmons RA and McCullough ME, eds. The Psychology of Gratitude. Oxford, UK: Oxford University Press; 2004. https://doi.org/10.1093/acprof:oso/9780195150100.003.0008 .

12. Gogo A, Osta A, McClafferty H, Rana DT. Cultivating a Way of Being and Doing: individual Strategies for Physician Well-being and Resilience. Curr Probl Pediatr Adolesce Health Care. 2019;49:12. https://doi.org/10.1016/j.cppeds.2019.100663 .

13. Tully S, Tao H, Johnson M, Lebron M, Land T, Armendariz L. Gratitude Practice to Decrease Stress and Burnout in Acute-Care Health Professionals. OJIN: The Online Journal of Issues in Nursing. 2023;28(3). https://doi.org/10.3912/OJIN.Vol28No03PPT75b