Ann Allergy Asthma Immunol xxx (2020) 1e2
Contents lists available at ScienceDirect
Perspective
Preventing burnout through wellness and an attitude of gratitude
Marcus Shaker, MD, MSc
Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
Department of Pediatrics, Medicine, and Community and Family Medicine, Dartmouth Geisel School of Medicine, Hanover, New Hampshire
A R T I C L E I N F O
Article history:
Received for publication May 23, 2020.
Accepted for publication June 6, 2020.
Burnout can hit like a hammer, but more often builds gradually.
It is a condition with various definitions, but perhaps the best is “an
erosion of the soul caused by a deterioration of one’s values, dignity,
and spirit.”1,2 The 3 classic features of burnout are exhaustion, lack
of personal accomplishment, and depersonalization.1,3 Overall,
burnout is not infrequent among US physicians, with estimated
rates between 45% and 54%.1 A recent survey by the American
Academy of Allergy, Asthma, and Immunology (AAAAI) of a random
sample of 1035 fellows and members evaluated burnout rates
within the specialty.1 Of the 138 respondents (13% response rate),
35% reported burnout.1 Although it is encouraging that allergists
and immunologists seem to have a lower rate of reported burnout
than nonselected physicians, the impact of burnout remains large
because it is associated with underproductivity, depression, a lack
of fulfillment, and even suicide.1,3 It is important that every clinician
realize the warning signs of burnout. In short, if one begins to feel
exhaustion and depersonalization as if they are watching their life
and not living it, then it is time to feed the soul to prevent burnout.
Medical practice continues to become increasingly complex and
the ability to stay current with an evolving standard of care, com-
bined with keeping up with the electronic medical record, new
paradigms of care delivery, continuing medical education, coding
and billing, regulatory and licensure issues, institutional mandates,
and practice improvement can be substantial challenges.1 It can be
difficult to leave daily frustrations at work and unplug. Finding
balance can be elusive.1,4 As clinicians, we may feel trepidation at
multiple levels: (1) for our patients with difficult and refractory
conditions; (2) for our practices navigating new and unprecedented
financial challenges in the face of a recent global pandemic; (3) for
Reprint: Marcus Shaker, MD, MSc, FACAAI, Section of Allergy and Immunology,
Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, 1
Medical Center Drive, Lebanon, NH 03756; E-mail: marcus.s.shaker@hitchcock.org.
Disclosures: Dr Shaker is a member and co-chair of the Joint Task Force on Allergy
Practice Parameters; has a family member who is the cheif executive officer of
Altrix Medical, LLC; and serves on the editorial board of the Annals of Allergy,
Asthma, and Immunology, The Journal of Allergy and Clinical Immunology: In Practice,
and the Journal of Food Allergy.
Funding: The author has no funding sources to report.
https://doi.org/10.1016/j.anai.2020.06.019
1081-1206/Ó 2020 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
ourselves, as we work to find a balance to provide the right care at
the right time; and (4) for our families who we feel may deserve
more.3 Our fears can be pervasive; although some may be obvious,
more often they are subtle and unrecognized.1,4 A helpful strategy
can be to take a brief moment at the beginning or end of each day to
simply make an inventory of our fears and recognize them, because
fears may lead to resentments and anger that can negatively impact
wellness. A habit of reviewing, acknowledging, and releasing fears,
anger, and resentments, and practicing forgiveness (of ourselves
and others) each day can lead to an improvement in the dimensions
of wellness.3,4
Table 1 reviews the domains of wellness, which include
emotional, spiritual, intellectual, social, physical, environmental,
financial, and occupational dimensions, with helpful strategies to
promote healthy habits. Of note, in the AAAAI survey, only 31% of
respondents had a personal hobby, 14% performed meditation, and
7% performed yoga.1 Although individual behaviors were not pro-
tective against burnout, job-related stress and job dissatisfaction
were highly significant burnout predictors.1 This finding empha-
sizes the need to appreciate the domains of wellness as an inter-
connected network that can support a holistic approach to health.
Although it is important to address negative feelings, it is critical to
maintain perspective and count blessings (rather than burdens) as
well. The positive influence of incorporating a daily gratitude practice
cannot be underestimated. Appreciative inquiry (AI), which seeks to
lead decision-making through the lens of gratitude and optimism, can
help define a path that informs important priorities. AI can help cli-
nicians find a balance to enable serenity, feed the soul, and prevent
burnout. A simple mindfulness practice that acknowledges the levers
of anger vs gratitude can greatly improve spiritual and emotional
well-being.1,3,4 Several wellness resources are available from the
American Academy of Allergy, Asthma, and Immunology, American
Medical Association, Institute for Healthcare Improvement, and
others.3 Additional mindfulness applications can also be utilized to
encourage wellness.3 Another useful technique, the Strength-Focused
and Meaning-Oriented Approach to Resilience and Transformation, is
an approach that reinforces the 8 dimensions of wellness to foster
resilience and gratitude.3 This approach encourages awareness and
2 M. Shaker / Ann Allergy Asthma Immunol xxx (2020) 1e2

Table 1 acceptance to cope with the challenges within the domains of mind,
Eight Dimensions of Wellness and Associated Strategies body, and spirit, then develops strengths within each of these areas to
Dimensions of wellness Strategies create a broader understanding of how individual experiences can
Emotional Develop resilience promote growth and understanding.3
Foster healthy relationships Addressing and preventing burnout is paramount for effective
Inventory fears, insecurities, anger, and practice, and is a cost-effective endeavor.1,3 The consequences of
resentments burnout can include loss of employment, decreased productivity,
Acknowledge mistakes and missteps, correct
when possible
substance abuse, family stress, and suicide. A health and economic
Practice forgiveness model of clinician burnout indicated that wellness is a cost-
Maintain an attitude of gratitude effective investment.3 Even if reduced compensation was consid-
ered as a trade-off for wellness, at a 20% disutility of burnout, a 5%
Spiritual Engage in volunteer service
reduction in compensation presented an incremental cost-
Use self-reflection
Develop a mindfulness practice effectiveness ratio of $68,735 per quality-adjusted life-year.3 In
Practice meditation or prayer reality, the cost-effectiveness of wellness is likely dominated by its
Participate in community associated increased productivity and avoidance of adverse con-
Incorporate spiritual practices consistent with
sequences of burnout, leading to a win-win scenario. It is not a
personal values and traditions
Intellectual Maintain curiosity question of whether we can afford wellness, but more accurately
Work with colleagues whether we can afford to live without it.
Pursue patient-focused learning The demands of medical practice are significant and stressful.
Attend conferences and engage with learners
However, one needs to appreciate that in giving all of themselves
Play games and solve puzzles such as Sudoku
and crosswords and holding nothing back, clinicians can find themselves feeling
Social Maintain friendships within and outside of empty, lonely, and lost. The reality is quite the opposite. We are
medicine fortunate to practice within a specialty at the leading edge of
Collaborate with colleagues medicine, with grateful patients and a community of colleagues
Incorporate group activities into other wellness
domains
with a shared vision to provide effective treatments to our patients
Adopt routines such as family game nights across the country and around the world. As the recent pandemic
other group activities guidance for clinician wellness suggested, “if we don’t realize it in
Explore new hobbies such as golf, line dancing, the beginning, we will certainly realize it in the end that without
or scuba diving
self-care, we will have nothing left to offer anyone.”3 The impact of
Physical Dedicate time for personal exercise
Consider yoga burnout is significant on multiple levels, and there is no doubt our
Engage in outdoor walks and activities specialty and society have endured challenging times. However, by
Avoid tobacco use realizing how much we have been given, and how much we can still
Do not use alcohol excessively or to cope with
serve our patients, families, and communities, there is a great op-
stress
Seek confidential help if struggling with mental portunity for each of us to stand by the good and make it better.5
health, alcohol misuse, or substance abuse
through the Federation of State Physician
Health Programs Acknowledgments
Environmental Maintain a clean and attractive environment
Reduce clutter The author thanks Robert A. Greene, MD (Lebanon, New Hamp-
Promptly address safety concerns at work and shire) for his critical review of this manuscript.
home
Practice environmental stewardship and
gratitude
Take time to care for your pet References
Financial Have a household budget 1. Bingemann T, Sharma H, Nanda A, et al. AAAAI Work Group Report. Physician
Live within your means to reduce stress wellness in allergy and immunology. J Allergy Clin Immunol Pract. 2020;8(4):
Avoid credit card debt 1224e1229.
Contribute to charity 2. Maslach C, Leiter M, eds. The truth about burnout: how organizations cause per-
Appreciate stages of practice and wealth sonal stress and what to do about it. San Francisco, CA: Jossey-Bass; 1997.
management 3. Bansal P, Bingemann TA, Greenhawt M, et al. Clinician wellness during the
Participate in financial planning COVID-19 pandemic: extraordinary times and unusual challenges for the aller-
Address savings needs gist/immunologist. J Allergy Clin Immunol Pract. 2020;8(6):1781e1790.e3.
Occupational Balance work and leisure time 4. Indiana University School of Medicine Wellness Services. Eight dimensions of
Support colleagues wellness. Available at: https://md.mednet.iu.edu/support-services/wellness-
Develop a positive office culture services. Accessed May 23, 2020.
Engage in appreciative inquiry 5. Emory Unversity History and Traditions. Atticus Greene Haygood: Emory college
Value the importance of your work President 1875-1884 Class of 1859. Available at: http://emoryhistory.emory.edu/
facts-figures/people/presidents/profiles/haygood.html. Accessed May 23, 2020.