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    Thanks, a lot

    Students and doctors learn to practice gratitude to ward off burnout and rekindle their love of medicine.

    journal with writing

    Seven years into his career as a urologist at National Naval Medical Center, Hal Frazier, MD, “went through this really dark time.” The hours, the stress, and the despondency over patients who declined despite his best efforts had pushed him to the brink of burnout – “feeling like, why am I doing this?"

    A colleague observed that Frazier had caught a common malady of practicing medicine: obsessing over every negative aspect of work while ignoring all the good in his life. The colleague suggested that Frazier keep a gratitude journal to write 10 things he’s grateful for each day. Frazier laughed.

    On the way home, he bought a journal: “lime-green, nasty-looking.” That night he mustered three items. Within a week he reached 10 a day — including some that were personal (wife, family, home), professional (supportive colleagues, nursing staff, and patients who express thanks), and general (safe drinking water) — and a habit was born. “It totally changed my life perspective,” says Frazier, now associate dean for graduate medical education at the George Washington (GW) University School of Medicine and Health Sciences. “If I didn’t do this, I probably would’ve been one of those people who dropped out” of medicine.  

    Frazier discovered the power of gratitude — a discovery that is spreading among medical schools and hospitals. Gratitude manifests in both informal practices, like sticking apple-shaped thank you notes on paper trees, and formal gatherings where students and clinicians review what they did well or learn ways to express gratitude every day.

    “There are so many pressures to perform and do well for the sake of my future career opportunities … it's easy to burn out,” says Lillian T. Peng, a second-year medical student at the Mayo Clinic Alix School of Medicine. There, she helps to organize wellness activities as a member of the Student Life and Wellness Committee. “Gratitude reminds me of the reasons I was drawn to medicine in the first place.”

    It also might produce tangible, long-lasting benefits through repeated practice. In Designing Positive Psychology, contributing authors Robert A. Emmons, PhD, and Anjali Mishra, PhD, cite “the emerging strong association between gratitude and well-being,” including enhancements in self-esteem and coping with stress as well as reductions in “toxic emotions from social comparisons.” Seeking to address burnout among health care workers, Duke University researchers conducted a pilot study in 2014 in which physicians, nurses, and others practiced the Three Good Things intervention, recording three things they are grateful for each day. The study found that the practice decreased burnout and depression, and increased work-life balance and happiness.

    “Gratitude is a performance-enhancing drug,” says Kelli Harding, assistant clinical professor of psychiatry at the Columbia University Vagelos College of Physicians and Surgeons and author of The Rabbit Effect: Live Longer, Happier, and Healthier with the Groundbreaking Science of Kindness. “To take good care of people we need to take good care of ourselves.”

    An antidote to burnout

    The growth of strategies to enhance gratitude are part of a national movement to enhance the well-being of clinicians across medical education and clinical practice.

    “I tell residents and fellows there is a secret to happiness,” says Heidi Allespach, PhD, director of behavioral medicine at the University of Miami Miller School of Medicine. “That secret is called cognitive restructuring — changing our perceptions about people, places, and things.” While people might not be able to change those realities, she says, “we can learn to change the way we look at those situations.”

    Gratitude contributes to that change by guiding people to notice and celebrate the good in their lives. Emmons, a professor of psychology at the University of California, Davis, and the founding editor of The Journal of Positive Psychology, identifies two key components: “an affirmation of goodness” and a recognition that “the sources of this goodness are outside of ourselves,” and therefore are gifts.

    Finding ways to routinely recognize those gifts in the high-pressure environment of medical school or a hospital might require the intervention of a colleague or teacher — like what Frazier got at GW, which he now pays forward. He makes a mission of holding one-on-one sessions in his office with residents to draw out such feelings as loneliness, overload, and inadequacy.

    “I say, ‘Have you ever asked, “Why me?” or “What’s wrong with me?”’ I’ve never had one resident say, ‘I don’t know what you’re talking about.’”

    “You’ve got to figure out how to control that internal dialogue,” Frazier tells them. His suggestions include journaling; he shows them one of his journals.

    “I just did it an hour ago,” he says.

    You don’t have to buy a notebook. Catherine Pipas, MD, a professor of community and family medicine at the Geisel School of Medicine at Dartmouth, encourages medical students and physicians to practice gratitude by building quiet time into their daily routines, regularly calling out people at meetings for things they did well, forming coffee groups with colleagues to share appreciations, and looking for opportunities to practice kindness to others.  

    Institutionalizing gratitude

    For wellness practices to create widespread impact among students and staff, Pipas says, institutions must infuse those practices into the routine of their culture.

    “We need to have the time, the tools, and the permission to use these,” says Pipas, who directs Dartmouth’s Leadership and Culture of Wellness curriculum and last year published A Doctor’s Dozen: 12 Strategies for Personal Health and a Culture of Wellness.

    Some schools and hospitals are carving out time and providing tools. A few notable examples:

    Reviewing success: At the University of Miami, some residents convene in groups called Vitality Rounds, where they build discussions around what went right in specific cases — balancing out the somber tone of traditional morbidity and mortality conferences.

    “It’s a way to showcase what you did well,” Allespach says. “It’s a way to show, ‘The team and I really did make a difference for that patient.’”

    Story-sharing: The Mayo Clinic’s Student Life and Wellness Committee organizes a series of talks called My Story, in which a student, resident, or staff member tells a story of challenges and growth.

    Alexandra Wolanskyj-Spinner, MD, senior associate dean for student affairs at Mayo, once shared her own story of struggle with physical challenges. “When you’re able to see someone who’s an upperclassman, or a peer, or a resident, or a staff or faculty member, who’s able to make themselves vulnerable and share a time they’ve experienced failure and how they overcame it – that is extremely empowering,” she says.

    “A common theme is that while a lot of things are hard, students are grateful for their experiences as growing opportunities and grateful for their support systems,” says Peng.

    Trainings: Columbia provides a four-year Foundations of Clinical Medicine course that includes wellness practices such as gratitude and reflection. Students journal about their challenges and accomplishments.

    Harding, a preceptor for the course, acknowledges that some students scoff at attending a class not focused on the science of medical care and wouldn’t attend if it wasn’t required. It’s required.

    “One of my students told me that initially he had thought the course was not going to be that important compared to his other courses,” Harding says. “Then he realized it was his most important course.”

    In a similar vein, Mayo mandates that first-year students take mindfulness training, which includes gratitude practices, Wolanskyj-Spinner says. She says students may continue the trainings through all four years.

    “We teach them things such as, ‘Think of three grateful thoughts in the morning,’” Wolanskyj-Spinner says. “Think of three people you’re grateful for. Or it can be broader: a patient you saw, maybe a mentor you haven’t seen in a while.”

    Dedicated staff: At the University of Miami, Allespach’s position illustrates a broad institutional dedication to the cause: A psychologist, she works with residents and interns on their wellness, including through lectures, support groups, one-on-one sessions, and shadowing. She coaches them to develop the habit of finding reasons for gratitude and expressing it to colleagues, patients, teachers, family, and friends.

    “Frequently at the end of a support group, I will say, ‘I would like everyone to think about three things you’re grateful for today,’” Allespach says. Then everyone shares those thoughts. “This always seems to make their day better.”

    Easy thank yous: Several schools and hospitals have set up ways for patients and staff to post notes of gratitude to each other in public places. Kaiser Permanente guided its hospitals and medical centers to adorn their walls with Gratitude Trees: large paper trees on which staff and patients place leaf- and apple-shaped sticky notes expressing their thanks for anything, including each other.

    The trees stem from an overall wellness strategy that Kaiser carries out in partnership with the Greater Good Science Center at the University of California, Berkeley. The center runs an initiative, Expanding the Science and Practice of Gratitude, that provides examples of institutionalized gratitude practices and tools for instituting strategies.

    In addition, the National Academy of Medicine’s Clinician Well-Being Knowledge Hub includes organizational and individual strategies to address burnout.

    More often than not, however, most people in medicine learn about gratitude through the counseling of a caring colleague – as Frazier did. He has since replaced journaling with other daily routines, including long, meditative walks during which he recounts what he’s grateful for. Yet his journal maintains a meaningful life: Referring to the student with whom he shared it an hour earlier, Frazier says, “The guy came back a few minutes ago to show me that he’d gone out and bought a journal.”