The Role of Positive Psychology in the Modern Medical Practice

In daily conversations with colleagues, and in regular conversations with physician clients and friends, we hear a constant refrain of pessimism about today’s healthcare profession. Many of these doctors unabashedly share with us that if they had to do it again, they wouldn’t become doctors—nor would they recommend to their children that they enter the healthcare profession. This pessimism trickles down and infects professional colleagues, administrative staff, and, ultimately, our patients and the care we provide to them.

What has happened to this once-prized career path? And how is the climate of today’s typical medical practice not only deleterious to our practice of medicine but also to our health and well-being? And most importantly, what can we do to improve the quality of healthcare, our practices, and our lives? This article offers answers to this question based on new research from the fields of social neuroscience and positive psychology. To appreciate these insights, however, it is first helpful to step back and revisit the pathophysiology of stress.

The Pathophysiology of Stress

To understand how stress impacts our practices, our health, and our interpersonal relationships, including those with our staff and our patients, we need to appreciate a little bit of evolutionary psychology and biology. Thousands of years ago, our ancestors faced true threats to their continued existence, encountering predatory animals (e.g., saber-tooth tigers) on a regular basis. To enhance their prospects of surviving, primitive humans developed a virtually instantaneous response that prepared them to fight or run from the danger. The “fight-or-flight” response became so finely developed that our ancestors, and now we, often are able to anticipate danger even before it exists. This prompts most of us, for example, to avoid dark alleys at night—although often we wind up anticipating (and worrying about) dangers that don’t exist. Winston Churchill is credited with recognizing this byproduct of our evolutionary heritage when he observed that “I am an old man and have known a great many troubles, but most of them never happened.”(1) (Think “overprotective parent” or hypochondriacal patient.)

Although most physicians practicing in the United States today no longer need to fear encounters with predatory animals, our brains remain “hardwired” to react in fight-or-flight mode to modern day threats—threats that are more accurately and fairly characterized as petty nuisances and annoyances, such as, for example, when supplies are unavailable, having to wait a few extra minutes for an operating room to become available, or needing to complete extra paperwork for (declining) reimbursement. Beyond mere petty annoyances, we are prone to experience stress in any number of critical care circumstances, such as when a patient’s condition is inexplicably deteriorating or when dealing with a patient (or that patient’s family members) who feel that they are not receiving sufficient attention. Finally, of course, come all the other stresses we might face in our personal lives, including those that relate to our spouses and children.

Whenever our primitive fight-or-flight response kicks in—and for whatever reason—the physiological events that we experience today are the same as those our ancestors experienced when facing true physical threats. Nerve cells release chemicals such as adrenaline, noradrenalin, and cortisol into the bloodstream. These chemicals, in turn, trigger enhanced blood flow into the muscles of our limbs (and away from the digestive tract and the pelvis), making it easier to run away from the danger. Simultaneously, there is also an increase in the heart rate and the respiratory rate to increase the oxygen evolutionarily necessary to help make legs run faster when trying to flee a charging tiger. Other physiological changes include dilation of the pupils, improved (sharpened) eyesight, and increased awareness, all of which enhance a human’s ability to focus on getting out of harm’s way.

These automatic stress responses are our body’s way of protecting us from danger. When they work appropriately, they help us stay focused, energetic, and alert. In an emergency, these stress responses are lifesaving, giving us extra strength to protect our loved ones and ourselves. It is this very reaction that allows a soccer mom to pick up a car off of a trapped child—something she wouldn’t normally be able to accomplish under nonstressed conditions.

Repeated negative events, multiple times each day, lead to a build-up of stress hormones.

Unfortunately, our bodies and our neuroendocrine responses cannot differentiate between the threat posed by a saber-toothed tiger at the cave entrance and that posed by an irate patient complaining about not being seen on time. As a result, the reactions that occur in our bodies for nonexistential threats—including such things as an increase in cortisol and adrenaline into the bloodstream, and increased heart and respiratory rate—often are overreactions.

Worse, particularly in today’s medical milieu, the nonstop action and responsibilities healthcare workers face every day can result in a lifestyle where one’s fight-or-flight alarm system is constantly “on.” Medical science has discovered that repeated negative events, multiple times each day, lead to a build-up of stress hormones that, in turn, can have unhealthy consequences on a number of areas, including mood (e.g., increased anxiety, depression, irritability), behavior (e.g., drug or alcohol abuse, smoking), and, of course, on one’s health (e.g., high blood pressure, heart disease, obesity).

A variety of strategies are available to help manage these fight-or-flight reactions.

Fortunately, a variety of strategies are available to help manage these fight-or-flight reactions and, in so doing, enhance one’s personal and professional quality of life and job performance. In this article we share some of these strategies that have been scientifically validated by researchers in the burgeoning fields of positive psychology and social neuroscience for physicians and other healthcare workers to draw upon.

Positive Psychology in the Modern Medical Practice

Positive psychology is the scientific study of happiness and human potential. The Positive Psychology Center at the University of Pennsylvania describes the field as “the scientific study of the strengths that enable individuals and communities to thrive...[Positive psychology] is founded on the belief that people want to lead meaningful and fulfilling lives, to cultivate what is best within them, and to enhance their experiences of love, work, and play.”(2) The field is focused on understanding, and helping to apply, new tools for optimal living—for individuals, families, and organizations. Unlike pop psychology’s often unsubstantiated conclusions and recommendations, positive psychology is a science, and, therefore, the insights, conclusions, and recommendations it offers are based on empirical data generated from research conducted pursuant to the scientific method. This research has demonstrated that small shifts in how we communicate and behave not only make us happier and healthier, but also can enhance an organization’s bottom line, including “31 percent higher productivity, 25 percent greater performance ratings, 37 percent higher sales, and 23 percent lower levels of stress.”(3) Of particular relevance is research that shows that physicians who are in a good mood—feeling positive and optimistic—come up with the correct diagnosis 19% faster than doctors who report feeling “neutral.”(4)

We offer the following 10 key recommendations that we believe will be of interest to physicians.

1. Use Words that Prime Positivity

Physicians depend on team work, including with partners, other healthcare professionals, administrative staff, and others. Researchers at Stanford University have found that simply including the word “together” helps motivate people to work longer hours and produce better quality work.(5) Consider beginning a conversation or meeting with positive news or observations that emphasize the importance of teamwork and collaboration. In her book The Morning Meeting Book, Roxanne Kriete asserts that related research demonstrates that emotions, whether positive or negative, are highly contagious, and, so, beginning positively—“positive priming”—enhances cooperation, empathy, and a sense of shared responsibility.”(3) Of special note, consider beginning an e-mail with a positive comment to help reduce the risk of being misunderstood, as so often happens with this form of communication because of the absence of nonverbal cues such as body language, facial expressions, and tone of voice.

2. Adjust Your Positivity Ratio

Barbara Frederickson, the Kenan Distinguished Professor of Psychology at the University of North Carolina, is well known for her work on the importance of positivity ratios—the ratio of positive comments to negative comments. Decades of work by Frederickson and others has amassed considerable empirical data on the correlation of a higher positivity ratio with happiness and success.(6,7)

Too many physicians and healthcare workers suffer from low positivity ratios.

Informal observation over the years suggests that too many physicians and healthcare workers suffer from low positivity ratios. Catch people doing things right! There are so many instances when staff members do something above and beyond the job description and their efforts go unnoticed. One of us (NHB) remembers a time when a staff member took sample medication to a patient’s home when the prescription she received caused her to have side effects that precluded her using the expensive medication. When this kind of “extra mile” behavior is observed, compliment or reward the staff member for going above and beyond what was “required.” Strive to be as positive as possible, but, at least, to have four or five positive comments for every negative one. Having a higher positive-to-negative ratio is likely to lead to a more productive team or practice.

3. Avoid Negative People

Scientists are identifying biologic evidence that validates the existence of positive and negative people.(8) Being around negative people can bring us down. Doctors going to hospital lounges and cafeterias often find themselves surrounded by swirling pessimism. Avoid those encounters and seek out others who don’t participate in “pity parties.” Avoid “negative” staff meetings by starting with something positive, perhaps even asking each staff member to tell something positive that happened to them in the practice since the previous meeting. This simple idea gets everyone thinking positively and, as a result, the staff meeting becomes more meaningful and more productive.

4. Dealing with Bad News

Physicians often find themselves in the position of having to deliver bad news, such as to a patient who has just been diagnosed with a terminal illness. Michelle Gielan(3) describes how physicians at the Children’s Hospital of Philadelphia seek to shift their conversations with patients and their families to “something positive,” such as “Given what your family is up against, what are you hoping for?” Describing Dr. Chris Feudtner’s approach, Gielan writes:

Dr. Feudtner says that families usually have a list of seven or eight wishes, including to make happy memories before the end of the child’s life, to manage the child’s pain well, and to let the child spend the remainder of his or her days at home rather than in the hospital. [His approach moves the conversation from no cure] to modest success in achieving some of those wishes.

Related research suggests how physicians would benefit by using “plain English” rather than medical jargon when delivering news, particularly bad news, expressing compassion through words, tone of voice, or even a hug.

5. Express Compassion

Compassion, a major tenet of the world’s major religions, has been increasingly studied by researchers, revealing amazing results that physicians would be wise to pay attention to. (Unlike empathy, where one experiences another person’s emotions, compassion is generally defined as experiencing another person’s suffering and involves an authentic desire to help.) Research conducted at the Lexington Veterans Affairs Medical Center in Kentucky found that a hospital’s policy of permitting doctors to say “I’m sorry” in the event of suspected medical malpractice resulted in a 627% lower payment per claim than hospitals that didn’t have such a policy.(3) Learn to say “I’m sorry!”

6. Offer Constructive Feedback

Notwithstanding its emphasis on “positivity,” positive psychology does not ignore the reality that we encounter disappointments and adversity in our lives. Researchers help us understand that the most constructive way to manage such situations caused by others is to be encouraging and provide constructive feedback, similar to what a great coach might offer.(9) Constructive feedback will help others bounce back faster and help create energy for renewed efforts. Next time one of your colleagues makes a mistake, try taking a moment to create a learning opportunity rather than yelling, griping, or expressing some negative emotion.

A pat on the back is better than a kick in the pants. It is so much nicer to compliment someone, patient or staff member, when they do something well as opposed to giving them a kick in the pants when they don’t do what is expected. For example, if a patient is overweight and the obesity is contributing to his or her poor health, even a modest weight loss should be celebrated. This motivates the patient to continue with the process and not “let the doctor down” by not being a compliant patient.

7. Offer a Helping Hand

We depend on others to help us do our jobs and accomplish our goals in countless ways. Research reveals that when we help others, even if we do no more than lend a listening ear, we boost our own happiness and that of others. So-called “work altruists” have been found to be 10 times more engaged at work than those who do not offer help to their colleagues and are 40% more likely to be promoted.(6) Find the time to help a colleague. Volunteer to take an extra day of call to give an obviously overworked colleague a much-needed break. Scrub-in to assist with a difficult surgery. Or help a colleague with an administrative matter that he or she is uncertain about how to best handle.

8. Find Time to Socialize

We suspect that most physicians’ days are filled with too much to do and too little time to do it—seeing patients, talking to family, paperwork, etc. The hectic and harried pace often leaves little time for colleagues to socialize. A by-product of this harried pace and modern forms of technology is that communication today too often takes place through impersonal e-mails and text messages, rather than in face-to-face conversations. With little or no socializing, relationships become more distant and, in turn, more stressed. Research suggests that finding some time to socialize—such as over a cup of coffee at the start of the day, a quick bite to eat during the day, or a cocktail or dinner at the end of the day—improves social bonds and the quality of interpersonal relationships.

9. Express Appreciation and Gratitude

Write a thank you note every day. One of us (NHB) met Lou Holtz when he was the head football coach of Notre Dame, and learned that he was famous for writing at least one thank you note every day. He also encouraged his staff and his football players to do the same. After seeing how successful Coach Holtz was, I adopted the same letter writing approach and make every effort to say thank you to someone every day. I also encourage my staff to write notes of appreciation (Figure 1).

Figure 1. Thank you note from Dr. Baum.

Write a thank you note every day.

10. Smile!

Finally, researchers are finding out some interesting facts about smiling that we urge physicians to consider. Aside from making us feel better, researchers who tracked the lives of women who had the best smiles in yearbook photos found that they reported living happier lives, having happier marriages, and having fewer setbacks than their classmates whose smiles weren’t as big.(10) In another study, researchers found baseball players who had big smiles on their baseball card photos lived, on average, seven years longer than those whose smiles weren’t as big.(11)

Beyond these personal benefits, saying “hello” and smiling has been proven to have “bottom line benefits” to healthcare systems. Consider Ochsner Health System, a large Louisiana healthcare provider, that has garnered widespread attention for implementing what it calls the “10/5 way.” Ochsner employees are encouraged to make eye contact if they’re within 10 feet of someone, and say hello if they’re within 5 feet. Ochsner reports improvements in patient satisfaction scores and patient referrals—and its bottom line!(12)

Summary

Is it any wonder that modern day forms of stress lead to problems with our staff, our patients, and even our health? In today’s society, it is neither socially acceptable nor generally helpful to come to blows with someone who is annoying us, nor can we always run away from (avoid) the stressful situation. Instead, we need to learn how to avoid the stress whenever possible (“self management”), or when that isn’t possible, to control the stress (“stress management”) and dissipate all those chemicals, cortisol, and adrenaline, as quickly as possible so that they don’t create unhealthy and counterproductive reactions that can wreak havoc on our practices and our personal lives as well.

Without the right tools to handle these events, we are prone to overreacting or reacting inappropriately, reactions that often backfire and can exacerbate the situation—often, for the physician, negatively impacting the quality of our relationships with our colleagues, our staff, our patients, and even our families and friends. The consequences of too much negativity in our lives include impaired bodily functions, reduced productivity, and negative effects on the quality of relationships with others and, ultimately, our quality of life. Fortunately, ongoing scientific research suggests a number of easy-to-adapt strategies that can help all of us live more productive, satisfying and healthy lives. We hope you explore some of this exciting research and test some of the suggestions described above!

References

1. Langworth R. Churchill by Himself: The Definitive Collection of Quotations. New York: PublicAffairs; 2008:531.

2. Positive Psychology Center. Our mission. http://ppc.sas.upenn.edu/our-mission . Accessed August 1, 2015.

3. Gielan M. Broadcasting Happiness: The Science of Igniting and Sustaining Positive Change. Dallas, TX: BenBella Books; 2015.

4. Estrada CA, Isen AM, Young MJ. Positive affect facilitates integration of information and decreases anchoring in reasoning among physicians. Organ Behav Hum Decis Process. 1997;72:117-135.

5. Carr PB, Walton GM. Cues of working together fuel intrinsic motivation. J Exp Soc Psychol. 2014;53:169-184.

6. Fredrickson B, Losada M. Positive affect and the complex dynamics of human flourishing. Am Psychol. 2005; 60: 678-686.

7. Fredrickson BL. Updated thinking on positivity ratios. Am Psychol. 2013;68:814-822.

8. Michigan State University. Biological evidence of positive and negative people in the world. ScienceDaily. April 2, 2014; www.sciencedaily.com/releases/2014/04/140402100052.htm . Accessed August 1, 2015.

9. Black SJ, Weiss MR. The relationship among perceived coaching behaviors, perceptions of ability, and motivation in competitive age-group swimmers. J Sport Exerc Psychol. 1992;14:309-325.

10. Harker LA, Keltner D. Expressions of positive emotions in women’s college yearbook pictures and their relationships to personality and life outcomes across adulthood. Journal of Personality and Social Psychology. 2001;80(1):112-124.

11. Abel EL, Kruger ML. Smile intensity in photographs predicts longevity. Psychological Science. 2010;21:542-544.

12. Porath C. No time to be nice at work. The New York Times. June 19, 2015; www.nytimes.com/2015/06/21/opinion/sunday/is-your-boss-mean.html?_r=0 . Accessed June 21, 2015.