By SANJ KATYAL

The absence of burnout does not equal wellness. While the focus on physician burnout as an epidemic is finally gaining more attention, we may be missing a larger issue. Most physicians are not burned out. We are able to function. We get through our days, make it to some of our kids’ activities and even manage to go out to dinner on the weekends. We survive the work week as we look forward to our next vacation. We do this because that is what we have always done. We put our heads down and do our work. We often project ourselves past the next exam or to the next stage of our lives to help us get through the stress. We become masters of delayed gratification. We develop the mindset of “I’ll be happy when…” I get into medical school or match into a good residency spot or make partner or have enough money to retire etc…Along the way, we may have some bright spots – falling in love, having kids, taking great vacations. We may even reward ourselves for our hard work with a new car or nicer house. We deserve it. But deep inside, “something is missing”. We have achieved most, if not all of the goals we have set for ourselves. Yet despite our hard work, many of us remain unfulfilled with our careers and often with our lives. What is it that we need? A better job with more money? A different car? A different title? Better vacations?

I have struggled with these questions and many more. How do I stop wanting what I don’t have and start wanting what I do have? How can I fully enjoy the present while also preparing for a better future? How can I spend quality time with my kids while they are still around? How can I have a career that uses all of my potentials? Of all the questions that I’ve asked myself, the most important one was this – How can I learn to flourish and not just function?

Fortunately, I found answers in the relatively new field of Positive Psychology which is the scientific study of human flourishing. Unlike traditional psychology which alleviates distress and moves a patient from a -8 to a 0 or +1 (if they are lucky), positive psychology focuses on a patient that is functioning at a +1 and tries to move them to a +8 on the flourishing scale. We need both areas of focus. There are many people that are functioning well by most standards but are nowhere near their potential level of fulfillment.

So how can we reach our highest potential by applying Positive Psychology? There are a few principles that are especially helpful for physicians. The first principle is a model of happiness that was described by Martin Seligman, considered the father of positive psychology. He stated that there were three levels of happiness on a continuum: the pleasant life, the good life, and the meaningful life. The Pleasant Life involves hedonistic pursuits where we chase money, sex, and possessions. Most of society is stuck in this stage. The Good Life is where we use our unique strengths to develop our best self. This is the stage of personal character development and virtue that Aristotle and others preached as the path to happiness. Finally, when we use our fully realized potential and best self in the service of a cause larger than ourselves, we have entered the Meaningful Life. There are many other models of happiness and even Seligman has updated this original model. The exact terminology does not matter. The simplicity of this model is what is important and can explain much of the discontent that many of us feel. We keep searching for the bigger house or nicer car but don’t realize that until we work on ourselves and our own potential and then use that potential in the service of others, we will likely remain unfulfilled. Many of us try to fulfill our unrealized potential by focusing on our kids. We try to replace our discontent with their contentment and achievement. It doesn’t work. This is why we have parents yelling at coaches and umpires at sporting events and why 8-year-olds have private hitting instructors to get an early edge over others. It is why every parent thinks their kids should be in the advanced classes. Think about the people that you know. Think about yourself. What stage are you in?

The reason for the first stage, the Pleasant Life, is so alluring and dangerous is because of another key principle that positive psychology has elucidated – Hedonic Adaptation. We adapt to all positive things in our lives which are constant. Think about the initial thrill of getting into medical school or landing that first attending job. While exciting at first, we quickly adapted. Although hedonic adaptation is a huge obstacle in improving and sustaining our well-being, it did provide us an evolutionary advantage. If we didn’t get used to old stimuli that were constant, we would not be able to recognize new potential stimuli (threats) from old ones that should have faded into the background. Nature just wanted us around long enough to procreate but didn’t care how happy we were along the way. This is a critical principle to understand and should be taught in schools. How do we stop taking all the good things in our life for granted? How do we move past the Pleasant Life into the Good Life? The key is attention. What we focus on becomes our reality. Appreciating the good will make the good appreciate. How do we do this? The simplest way is through the cultivation of a gratitude habit. This has been heavily studied in positive psychology and is perhaps the field’s greatest contribution. Grateful people are happier, healthier, and have greater life satisfaction. Writing down 3 things that you are thankful for every day can be transformative. It helps to go beyond the usual health, family, and food. Look for moments or experiences throughout the day that you will write about in your journal. It can be as simple as playing catch with your daughter, having an uninterrupted conversation with your son in the car on the way to practice, or a glass of wine on the deck with your spouse. Another effective antidote against hedonic adaptation that has worked well for me is negative visualization. Rather than write about the positive aspects of my life, I mentally subtract one and imagine what life would be like without it. This takes less than a minute and is easily done on the ride home from work. Long day at work? Imagine if your job was eliminated and you had to find another one. Kids arguing with each other? Imagine if they were no longer living with you and how much you would miss them. Bad is stronger than good – which means that we are wired to respond to potential loss more than we are to possible gain. This is the power of negative visualization.

Attention to the positive aspects of our lives can make us less likely to take them for granted. But what about attention to the present moment? Do we take this for granted? I know that I often do. The non-judgmental awareness of the present is referred to as mindfulness. Like the word happiness, mindfulness is increasingly overused. We see it on the cover of major magazines. There are classes given in schools, businesses, the military, and hospitals. Mindfulness, while not a panacea, does deserve considerable enthusiasm and attention (no pun intended). The cultivation of mindfulness has been associated with improvements in multiple domains of well-being including decreased stress, lower blood pressure, and cortisol levels, lower rates of anxiety/depression, and increased life satisfaction. The most widely studied program is the MSBR or Mindfulness-Based Stress Reduction eight-week course developed by Jon Kabat-Zinn. The most effective method to cultivate mindfulness is through meditation. There are many forms of meditation and some great apps (calm, headspace) that are designed for beginners. Even a few minutes of following one’s breath can be incredibly powerful if done consistently. The habit of meditation has been transformative for many, including myself. It can make one less reactive, less stressed, more appreciative, healthier and of course, more present. It is estimated that we spend less than 20% of our time actually engaged in the present moment. By learning to become more present, we can effectively increase the amount of time we have to live.

These habits of gratitude, negative visualization, and meditation have worked well for me. They can be done in less than 10 minutes per day. They are backed by science and have been preached for thousands of years by religions and ancient philosophers. As physicians, we are often too busy to worry about our own happiness. Many people depend on us. We are used to dealing with stress. But the healthcare system will only be as healthy as we are. There is considerable evidence linking physician wellness/burnout, medical errors, and patient satisfaction. We owe it to our patients, families and most of all ourselves to prioritize our own well-being. Positive psychology can help. It can move us away from burnout, beyond functioning and straight toward flourishing.

Sanj Katyal is a practicing radiologist and the founder of the Positive Psychology Program for Physicians.