Simple Tool Shows Lasting Reduction in Burnout

Rabiya S. Tuma, PhD

October 23, 2017

SAN FRANCISCO — Physicians and other healthcare workers who use a simple tool for 2 weeks show reduced burnout within a few days of starting the intervention and retain most of the benefit a year later, researchers reported here at the American Conference on Physician Health.

The intervention, called Three Good Things, revolves around strengthening a person's ability to perceive and savor positive emotions, said J. Bryan Sexton, PhD, director of the Duke University Health System Patient Safety Center at Duke Medicine in Durham, North Carolina.

The standard measure of burnout, the Maslach Burnout Inventory, includes three pillars: emotional exhaustion, depersonalization, and diminished sense of personal efficacy. Yet when researchers look at what interventions appear effective in reducing burnout, they all seem to have something in common, Dr Sexton said: They all seem to improve a person's ability to perceive positive emotions.

Noting that he is trained in psychology, Dr Sexton said, "Your focus determines your reality." To illustrate the point, he showed a lung computed tomography scan with substantial white nodules. In the black background, there was an outline of a gorilla. "If you show a scan like this to a room full of radiologists, 83% will not notice the gorilla: a radiologist's job is to look for the white nodules in the [computed tomography] lung scan. If you are trained to look for the white, you are not going to notice the darkness."

Similarly, he continued, "Your perceptions are influenced by how you feel. A lot of times when we are burned out, we forget that it changes what we notice and don't notice about the world around us."

For example, if you show people who are stressed or burned out a series of positive, neutral, and negative images, they recall "in stunning detail all that was happening in the negative images, but they don't recall factual information from the positive or neutral images," he said. Yet, gaze-tracking software shows that the volunteers looked at positive and negative images; they just did not take in the positive or neutral content.

From an evolutionary perspective, that makes sense, Dr Sexton said. "If you're running from a saber-tooth tiger, you focus on what else might eat you or get in your way. But you wouldn't be stopping to look at a rainbow.

"That is great for survival of our species, but terrible for your individual well-being and happiness."

With that psychological view as a starting point, Dr Sexton said he would like to propose a simpler working definition for burnout. "Burnout, at its core, is the impaired ability to experience positive emotion."

Burnout, at its core, is the impaired ability to experience positive emotion. Dr J. Bryan Sexton

To counter that, Dr Sexton and colleagues have been testing a simple program called Three Good Things to reduce burnout. For the studies, researchers ask each volunteer to write down, just before going to bed, three good things that happened that day and label them with one of the 10 positive emotions that have been most closely tied to burnout: joy, gratitude, serenity, interest, hope, pride, amusement, inspiration, awe, and love. They can be minor things such as watching a funny television show or spending time with friends.

"As silly as that sounds, what you are doing is flexing your muscle to notice the good, and you actually counteract a lot of the other demands that are put on your brain that force you to focus on the negative."

In a trial with 148 internal medicine residents at Duke Medicine, researchers saw a 15% decrease in burnout in just 2 weeks, declining from 65% at baseline to 50% after the intervention. A year after the intervention ended, 48% remained resilient, suggesting the intervention has a lasting effect on risk for burnout, Dr Sexton reported.

The residents also reported significantly less depression in the postintervention measures, fewer delays, less conflict, and better work-life balance.

The team found similar results in other groups of healthcare workers. Among patient safety officers at Duke, the intervention was associated with a 19% reduction in burnout, dropping from 57% at baseline to 38% after the intervention. Similarly, burnout decreased from 64% to 53% among personnel in the neonatal intensive care unit at Stanford University hospital in Palo Alto.

"The key here is the ability to accurately evaluate your situation, and not hold onto an old emotion that is no longer relevant. In order to do that you have to have access to the positive emotions," he said.

Dr Sexton and colleagues have tested different lengths of intervention, but typically they run 7 to 14 days, with 10 days appearing to be a key duration.

"This is not a high-resource or big time commitment, and it is mildly addictive. Are you supposed to do this every day for the rest of your life? No. One or 2 weeks a year, and then the other 50 or 51 weeks you do something else," he said.

Incorporating the Positive

Dr Sexton notes there are other ways to incorporate this kind of positive attention into the work schedule in healthcare. For example, in some settings, participants have been able to share their three good things with other team members, either online or by writing on a piece of butcher paper hung on the wall in a work area. The sharing appears to extend the positive benefits.

Also, even if individuals are not ready to participate specifically in a Three Good Things project, healthcare leaders can cultivate some of the benefits in other ways, such as ensuring that teams talk about what is going well in their work and not just focus on what needs to get better. During safety walkarounds at Duke Medicine, for example, leaders are supposed to ask what is going well and make a point of celebrating the successes and individuals contributing to them.

In an interview after the session, Beth Averbeck, MD, senior medical director in primary care at HealthPartners in Bloomington, Minnesota, said that bringing about this sort of positive attention is important. "At our [ambulatory] clinics, what the medical directors are doing is starting their team meetings with somebody sharing something positive," she told Medscape Medical News. "We have introduced the Three Good Things concept to our medical director leaders to have them be able to cascade it."

She said that although they do not have specific data yet on the Three Good Things model, there are hints that emphasizing what is going well improves team morale and reduces individual burnout. For example, survey results showed that one of the teams was particularly happy at work. When the team leader was queried about what might be contributing to that, Dr Averbeck and others found that the team regularly reviews case reports, which supports a stronger sense of purpose and satisfaction, and they celebrate the holiday that is most important to each person on the team, which promotes a feeling of inclusion and personal connections.

Dr Sexton is clear that building individual reliance is not the whole answer to burnout in healthcare, but it can be beneficial while institutions are attending to the structural issues that contribute to burnout. In the meantime, however, he and his colleagues are continuing to work on the Three Good Things model and are currently enrolling healthcare workers, including physicians, nurses, and support staff, in a large study. Anyone interested in enrolling can find the documents on the Duke website.

American Conference on Physician Health. Presented October 13, 2017.

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