REVAMP: Taking Physicians from Burnout to Flourishing

I vividly remember the moment when I was struck by my dream of becoming a doctor. It was my sophomore year of high school, and Miss Provost, an inspiring educator was eating her daily first-period bagel with cream cheese. While she ate, she taught us how the various organs in the human digestive tract would differentially digest the carbohydrates, fats, and proteins in her bagel. One long tube with specialized functions and accessory organs working together to strip a delicious breakfast meal into fuel. Compelling!

Fast forward to my years as a Penn undergraduate where I immediately pursued the premed path, taking more biology, chemistry, calculus, physics, and organic chemistry…. A wise professor recently joked with my medical school class that the premed requirements are really just a ruse to pay chemists! I was steadfast on my premed path, when sometime during my freshman year, my mother, a preschool director always up on the latest literature in early childhood education, told me that I simply HAD to study with Dr. Martin Seligman. He had founded a field called positive psychology that she said sounded so aligned with the way I lived my life. I scoffed at her, “You think a big shot professor is really going to meet with me, a freshman? Okay mom….” Even though I ignored her urgency to set up that meeting, I purchased Learned Optimism at the Penn bookstore. I didn’t have much time to read as a college freshman, but I kept the book next to my bed to read a few pages before bed after long days of class and a cappella rehearsals.

My mom is [almost] always right. My a cappella group was hired to run a vocal workshop for the culminating session of the 2012 Master of Applied Positive Psychology cohort. I recall feeling a tangible energy simply being inside the room filled with MAPP students, their eyes filled with tears as my group stood in our formation and sang the words, “Let’s set the world on fire, we can burn brighter than the sun.” Never before had I been in a place so absolutely positive! I was deeply moved to find myself in the presence of 40 students of all ages from all parts of the world studying and living positive psychology.

Making a Decision

Simultaneously I was struggling with a question. If positive psychology is about helping people and institutions to be their best and flourish, what is medicine all about?

The more experience I accumulated working with physicians and taking my premedical courses, the more I realized that medicine was still in the same state that psychology was before the advent of positive psychology in 1998: largely focused on ridding people of disease and affliction, rather than promoting health and thriving. So rather than applying to medical school my senior year, I applied to MAPP. I felt called to immerse myself in positive psychology in order to reconcile this gap within the medical field and perhaps help foster in medicine the paradigm shift that occurred within psychology two decades ago.

Where to Start?

I spent my year in MAPP and my two years since as a medical student working toward fostering positive medicine. I had to decide where to start because the opportunities to make medicine a more positive discipline are vast. After interviewing many physicians and medical students, it became obvious to me that the place to start was with the healers themselves. Principles of self-care and positive psychology could be embedded in medical training starting as early as Day 1 of medical school.

How can we possibly promote a more positive, health-focused healthcare system, if our physicians themselves are not thriving? Physician burnout has been a well-documented problem for decades, and sadly, burnout and suicide among physicians are on the rise. I believe, that tackling this pervasive problem requires our medical education institutions, from medical school through continuing medical education, to embrace and support positive medical training for practitioners as a new norm, treating it as a clinical skill for optimal patient care.

Inspired by Martin Seligman’s PERMA model and other conceptions of well-being by researchers such as Ryff, Huppert, and Prilleltensky, I developed REVAMP: an acronym that serves as a call to action for medical practitioners. The letters stand for familiar aspects of positive psychology adapted for medical professionals:

Building strong relationships

• Relationships include physicians’ sacred relationships with their patients, relationships with others on the healthcare team, and importantly, the relationship with the self. As mistakes are inevitable in medicine and can put lives on the line, self-compassion is an essential skill for physicians and those in training.
   
• Engagement is about finding flow in the work environment, practicing mindfulness as a means of stress reduction, and employing the best of ourselves in our work through the use of character strengths.
   
• Vitality, perhaps the element most obvious to physicians, is all about physical health: sleep, nutrition, exercise, moderating alcohol use, avoiding substance abuse, tobacco cessation, and energy management. It centers on the fact that physicians who employ healthy practices are more likely to counsel their patients effectively in these behaviors. It also positions physical activity as a means of combating psychological stress. Exercise promotes resilience.
   
  Readers may already be familiar with Vitality as crucial component of well-being. Emiliya Zhivotovskaya started teaching the PERMA-V model as part of the Certificate of Applied Positive Psychology (CAPP) program in 2012, adding the V for Vitality to Seligman’s PERMA model. Elaine O’Brien described the CAPP program in 2014 in PERMA-V: Training with rigor and vigor.
   


Getting and giving help

• Accomplishment in the REVAMP model is about recognizing that success in medicine is NOT a zero-sum game. Instead it is about finding and sustaining generative ways to help others. It is important to collaborate with others including peers, colleagues, and patients. It is about being comfortable asking for help. I’d like to think that physicians and medical students are driven to help others. However, competitive medical training can promote isolationism and individualism over collaboration.
   
• Meaning is about connecting with the great privilege of healing others. This is an opportunity to call on the humanities including literature, music, and art to enhance our understanding of human nature, suffering, healing, and transcendence.
   
• Positive emotions, the daily experience of the positive, involves carefully shifting our focus within medicine, which is notoriously negative, toward the beauty, gratitude, joy, serenity, and love we have in our work and lives. Focusing on the positive even in the midst of hardship, death, and pain, is the crux of resilience, a skill that is absolutely necessary for a sustainable career in medicine.

Putting REVAMP into Action

My master’s capstone and subsequent work has focused on expanding these six elements as a path to enhanced well-being for healthcare providers, the healthcare environment, and ultimately, for patients.

Over the past two years, I have had the great privilege of teaching a positive medicine curriculum involving the REVAMP model at the Icahn School of Medicine to medical students, residents, and faculty. I’ve been able to study the effects of the training and continue to evolve the ideas as I move forward in my own medical education and practice. I am now a second year medical student. I find myself living by the principles I espouse every day, especially now that I am gearing up for my first medical boards in June! I am counting my blessings, exercising daily, cooking healthy meals with my roommates, and reveling in the sacred privilege of being a trusted confidant to my patients, even while I am still in the short white coat of a medical student.
 

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References

Feingold, J. (2016). Toward a positive medicine: Healing our healers, from burnout to flourishing. MAPP Capstone, University of Pennsylvania.

Cornuz, J., Ghali, W., Di Calantionio, D., Pecoud, A., & Paccaud, F. (2001). Physicians’ attitudes towards prevention: Importance of intervention-specific barriers and physicians’ health habits. Family Practice, 17, 535-540.

Frank, E., Elon, L., Naimi, T., & Brewer, R. (2008). Alcohol consumption and alcohol counseling behavior among US medical students: Cohort study. British Medical Journal, 337, 1-10.

Huppert, F. A., & So, T. T. C. (2013). Flourishing across Europe: Application of a new conceptual framework for defining well-being. Social Indicators Research, 110(3), 837-861. Abstract, references, and figures.

O’Brien, E. (2014). PERMA-V: Training with rigor and vigor. Positive Psychology News.

Prilleltensky, I., Dietz, S., Prilleltensky, O., Myers, N. D., Rubenstein, C. L., Jin, Y., et al. (2015). Assessing multidimensional well-being: Development and validation of the I COPPE scale. Journal of Community Psychology, 43(2), 199-226. Abstract.

Ramirez, A. J., Graham, J., Richards, M.A., Cull, A., Gregory, W. M., Leaning, M. S., Snashall, D. C., & Timothy, A. R. (1995). Burnout and psychiatric disorder among cancer clinicians. British Journal of Cancer, 71, 1263-1269.

Rebele, R. W. (2015). Being “otherish”: Resolving the false choice between personal and prosocial goals. In R. J. Burke, K. M. Page, & C. L. Cooper (Eds.), Flourishing in Life, Work and Careers: Individual Wellbeing and Career Experiences (New Horizons in Management series), (pp. 26-44). Cheltenham, UK: Edward Elgar Publishing.

Ryff, C. D. (1989). Happiness is everything, or is it? Exploring the meaning of psychological well-being. Journal of Personality and Social Psychology, 57(6), 1069-1081.

Snyder, M. (2014). Positive Health: Flourishing Lives, Well-Being in Doctors (pp. 47-74). Bloomington, IN: Balboa Press.

Seligman, M. E. P. (2006). Learned Optimism: How to Change Your Mind and Your Life. 2nd Edition. New York: Vintage.

Seligman, M. E. P. (2011). Flourish: A Visionary New Understanding of Happiness and Well-being. New York: Free Press.

Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P. (2015). Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings, 90 (12): 1600 – 1613. Abstract.

Photo Credit: Flickr via Compfight with Creative Commons licenses
Digestive tract courtesy of Remko Tanis
Tied up in paperwork courtesy of wintersoul1
Doctor Smiling courtesy of CIFOR
White coat medical students courtesy of Jordyn Feingold
Getting and giving help courtesy of ReSurge International
Jordyn in her short white coat courtesy of Jordyn Feingold