Physician Well-being.

Abstract

Clinicians and trainee physicians should be aware of the components of wellness and how to foster them in their daily practice. Interventions have been aimed at the individual and organizational levels.After completing this article, readers should be able to:Physician well-being has become a national priority in recent years. Many physicians pursue a career in medicine because of their desire to serve others and the reward of the reciprocal relationships they develop with patients, (1) which are deeply tied to easing patients’ suffering and contributing to something larger than just oneself. (2) Despite the rewards found in this work, at times inevitable challenges, different perspectives, and emotions can lead to frustration, fatigue, burnout, and depression. There is an increasing gap between what society and employers expect and what physicians can provide with the resources and time physicians have available. (3) This growing dissonance for physicians between the need to find meaning in their work (4) and constraints in time, limited resources, and increased administrative tasks have contributed to a decline in physician wellness. Wellness is the “complex and multifaceted nature of physicians’ physical, mental, and emotional health and well-being.” (5) Wellness “goes beyond merely the absence of distress and includes being challenged, thriving and achieving success in various aspects of personal and professional life”. (5)(6) Physician wellness is affected by personal health, fatigue, stressors at home or on the job, and burnout. (5)(7)Unfortunately, burnout in physicians has reached epidemic proportions, reportedly up to 54% in 2014. (8) Burnout affects physicians across the entire educational continuum, starting in medical school (9)(10) and continuing through residency (7)(11)(12)(13)(14) and fellowship training to practicing clinicians in academic (15)(16) and nonacademic (17) positions. (18) Although the importance of physician well-being and mitigating burnout have been “on the radar” for several decades, a critical turning point seemed to be when 2 interns committed suicide within 1 week of each other in New York City in 2014. (19) This major loss was immediately noted by the Accreditation Council for Graduate Medical Education, which organized the first Symposium on Physician Well-being in November 2015. (20)In the past decade, multiple other national organizations, including the National Academy of Medicine, the Association of American Medical Colleges, (21) and the American Medical Association, have promoted physician well-being. (22) Pediatric-specific national organizations have also contributed support and resources, including the American Academy of Pediatrics (7)(23) and the Association of Pediatric Program Directors. (24)(25) The involvement of these national organizations highlights the importance of physician well-being, and they provide resources, national guidelines, initiatives, and research science to work to mitigate burnout and develop a healthy workforce (Table 1). (26)(27)Interventions must be considered at the national, organizational, institutional, and individual levels to maintain the high integrity of the medical profession and physicians’ ability to provide humanistic care to patients and to themselves. To take the necessary action, pediatric providers need to better understand the science of burnout and strategies to cultivate a culture of physician well-being.In 1982, Christina Maslach published a book titled Burnout: The Cost of Caring (28) describing the concept of burnout and the effect on people who pursued a career in the service of others. Maslach defined burnout as a “psychological syndrome in response to chronic emotional and interpersonal stressors on the job” (29) that affects the following 3 domains: emotional exhaustion—being emotionally overextended and exhausted by one’s work; depersonalization—unfeeling and impersonal responses toward recipients of one’s service; and personal accomplishment—lack of feelings of competence and successful achievement in one’s work. (30) The Maslach Burnout Inventory, a 22-item questionnaire that is widely considered to be the criterion standard for measuring burnout, has been used as the defining outcome measure among health professionals in numerous studies. (8)(31) Although Maslach defined burnout as a continuum across these 3 domains, operationally, investigators have adopted a dichotomous outcome measure as well. (31) By convention, high scores in depersonalization or emotional exhaustion are considered burned out in most studies of the prevalence of burnout in physicians across the professional continuum. (8)(16)(31)(32)Shanafelt and colleagues (8) published comprehensive national assessments of physician burnout in 2011 and 2014. They conducted periodic surveys of a national sample of physicians from the American Medical Association’s Masterfile database simultaneously with a probability-based sample from the US general population. (8) As previously stated, the overall prevalence of burnout in US physicians was 45.5% in 2011, which increased to 54.5% in 2014. In contrast, the prevalence of burnout in the general population sample was stable during that period and nearly half that of physicians (28.4% and 28.6%, respectively). These surveys represented nearly every medical specialty and noted an increase in the prevalence of burnout across all specialties. Among physicians who self-identified as general pediatricians and pediatric subspecialists, the prevalence of burnout was less than the overall mean for physicians, reported to be 35.3% in 2011 and 46.3% in 2014. (8)In this same study, the authors evaluated physician satisfaction with work-life balance and suicidality. Satisfaction with work-life balance declined in physicians from 48.5% to 40.9% compared with an improvement in the general population from 55.1% to 61.3% between 2011 and 2014. (8) Finally, physicians reported nearly twice the prevalence of suicidal ideation in the previous 12 months compared with the general population (7.2% vs 4.0%; P < .001). (8)In a national cross-sectional study that included medical students, residents, and early-career physicians, the prevalence of burnout was highest in residents/fellows at 60.3% (55.9% for medical students and 51.4% for early-career physicians), all significantly greater than a probability-based sample of age-matched college graduates. (16) In practicing physicians, burnout seems to peak during middle career, from 11 to 20 years in practice. Dyrbye et al (15) reported the prevalence of burnout by career stage and type of practice (private practice, academic medical center, and veterans hospital) and showed that for all 3 practice types, burnout is highest in those in middle career, with those in private practice reporting the highest prevalence across each career stage. Middle-career physicians reported “working more hours, taking more overnight calls, having lower satisfaction with their specialty choice and their work-life balance, and were most likely to plan to leave the practice of medicine for reasons other than retirement.” (15)Indeed, time pressures in medical practice across the professional continuum mirror the observations of increasing rates of physician burnout. One small but well-designed study evaluating physician time was conducted among 4 specialties in 4 states in which investigators directly observed physicians in their practices and asked them to complete diaries of their work activities. This study found that during the office day, 27% of time was spent on direct patient contact and 49% was spent on the electronic health record (EHR) and desk work. While caring for patients in the examination rooms, 53% of physician time was spent on direct patient contact and 37% on the EHR. Of the 1 to 2 hours per day they worked at home, most were spent on desk work. The authors estimated that for every 1 hour of patient contact, physicians worked an additional 2 hours completing administrative tasks and EHRs. (33) A single-institution study that explored physicians’ perception of meaningful professional activities conducted among 556 academic internal medicine physicians found that 68% reported that patient care was their most meaningful professional activity. In this study, proportion of time spent on the most meaningful activity was correlated with decreasing prevalence of burnout: those spending less than 20% of time on meaningful activities had an increased rate of burnout (odds ratio [OR] = 2.75; 95% confidence interval = 1.49–5.40). (34)Professional factors that have been associated with burnout include unrealistic expectations of endurance, time pressures, excessive work hours, challenging interactions with patients and colleagues, coping with death, unprocessed grief, sleep deprivation, and clerical burdens. (7)(35)(36)(37)(38) Unsupportive work environments that lack monitoring for discrimination and sexual harassment (39) and the persistence of inequity in salary and career advancement continue to perpetuate the problem of burnout. (40) Personal factors associated with burnout include financial concerns (eg, debt), personality traits (pessimistic, disengaged, unorganized), limited free time, perceived inadequate social support networks, disconnection with purpose, culture of silence, and depression. (7)(13)(37)(41) Longitudinal studies that could provide insight into factors specific to pediatrics are currently underway. (25)(42)(43) Unfortunately, most studies aimed at exploring prevalence and associations of burnout have used a cross-sectional design and/or small sample sizes. Therefore, knowledge gaps remain in understanding the national prevalence, distribution, natural history, and individual and institutional protective/risk factors to guide intervention development.Increasingly emphasis has been shifting not only to understanding burnout but also to understanding and conceptualizing the factors that affect physician wellness (Table 2). There is significant overlap in these frameworks, but the approach of promoting endeavors to maximize physician well-being can be useful in maintaining appropriate focus on individual, unit, and systems opportunities and efforts.Given the prevalence of burnout in physicians it is important to review the impact of burnout on these individuals and on their patients. Not surprisingly, burnout has a major effect on the mental health of all health-care providers. Burned-out individuals are at higher risk for suicidal ideation as well as major depressive disorder. (10)(44) Resident physicians have been shown to have twice the rate of suicidal ideation compared with age-matched peers. (45) More prevalent among burned-out individuals are symptoms of decreased mood, poor concentration, insomnia, appetite changes, and fatigue that can disrupt functioning in an intense, fast-paced medical workplace. (46) Burnout is also associated with increased alcohol and drug use. (47)(48)There is additional evidence that the ongoing stress of the burnout state interacts with physical health. In the short-term, burned-out individuals are more likely to develop viral infections such as gastrointestinal illnesses. (49) They are also more likely to have long-term health consequences from greater consumption of fast food and alcohol and less frequent exercise, (50) leading to increased cardiovascular risk factors and elevated inflammatory biomarkers. (51)(52) In a 2018 paper by McClafferty et al (53) surveying more than 200 pediatric residents enrolled in an integrative medicine curriculum, there was an inverse correlation between rate of burnout and engaging in healthy eating, socializing regularly, and sleeping adequately.Burnout in the medical profession starts to affect performance as early as medical school. Dyrbye et al, (32) in a survey of 4,400 medical students (61% response rate) from 7 medical schools, reported a burnout rate of 53%. Those with burnout were more likely to report having behaved unprofessionally, to hold less altruistic views, and to have a lower desire to care for the underserved. (32)Furthermore, the effects of burnout are not limited to the individual. Increasing evidence has demonstrated that patient care is also affected when physicians are burned-out. For example, West et al (54) demonstrated that residents with burnout had lower in-training examination scores than residents without burnout, correlating burnout with lower medical knowledge. Burned-out physicians are more likely to leave their clinical practices, which affects access to care and is very costly to the health-care system. (55)(56) In 2000, the cost of replacing 1 physician at an academic institution was estimated to be $250,000 to $500,000, which encompasses the time required to search and screen new staff, interview candidates, and pay locum physicians. (57)(58)(59)(60)Panagioti et al (61) published a meta-analysis of studies that demonstrated an association between physician burnout and poor patient satisfaction, risk of patient safety incidents, and poor patient care due to professionalism issues. This meta-analysis included a review of 5,234 records, 47 studies, and 42,473 physicians. Poor patient care associated with professionalism issues included lack of adherence to guidelines (not following standard treatment practices, issues with test-ordering practices, poor referral practices, and abnormal discharge practices), professionalism-associated malpractice litigation, poor communication, or low empathy. Patient satisfaction data were gathered by patient report. Strikingly, burnout was associated with a 2-fold increased OR of an adverse patient safety event, a 2-fold increased OR of a negative patient care issue related to poor professionalism, and a 2-fold increased OR of decreased patient satisfaction. Moreover, a higher score in the depersonalization component of the Maslach Burnout Inventory led to a 3-fold increased OR of an issue with professionalism and a 4.5-fold increased OR of having a low patient satisfaction score. The effect of burnout on patient care related to professionalism had a particularly strong relationship in residents and early-stage physicians compared with later-stage physicians. (61)This meta-analysis is a valuable summation across specialties of findings noted in several smaller studies: patients suffer from physician burnout. Pediatricians are not immune to this phenomenon. Baer et al 62 surveyed 258 residents in 11 pediatric programs. Residents who experienced burnout reported that they were significantly more likely to discharge patients to make their service manageable, to limit discussion of treatment options, and to make medication errors. Hence, in this cohort both patient safety and patient care issues were identified. 62 Halbesleben and Rathert 63 completed another important study in adult patients that examined the relationship between hospitalized patients and their primary inpatient physician. In this study, patients of burned-out providers had lower patient satisfaction scores and longer postdischarge recovery times despite controlling for illness severity. 63 Physician well-being matters. It matters to the health of the physician, and it matters to the health of their patients.Given the severe consequences of burnout on physicians personally and professionally, it is imperative that health-care organizations recognize key drivers of burnout and potential strategies to promote resilience in physicians. With burnout rates as high as 50%, the burden should not be placed only on the individual physician to address her or his burnout; organizational systems must also own the concerns and pursue effective interventions that address multiple factors that affect physician well-being (Table 2). (30)64 Engaging individuals in designing and implementing systems improvements can help deliver encouraging results. (37) Interventions should focus on the development of a positive state of self and not only the absence of burnout. 65 Personal interventions focused on improving individual physician self-care, mindfulness, resilience, and other personal skills now have accumulated evidence demonstrating effectiveness. (38)6667 Two meta-analyses of controlled trials and observational studies aimed at reducing physician burnout noted that organization-directed interventions had greater effects on improving burnout than did individual-based physician interventions. (38)66 These efforts included modifications to work schedules, increasing physician participation in decision making, and meetings to enhance teamwork and leadership. 66 Institutions can also effectively address burnout through providing individual-focused content and support that complements structural and organizational interventions that focus on reducing system-derived stress on physicians. 38686970 There may be real value in combinations of individual and organizational efforts. 38 Evidence for the value of both organizational and individual interventions is accumulating.Trainee work hours have been debated in the past 10 years, even more so after the recognition that poor work habits and inefficiency in residency can lead to downstream effects on physician well-being. In 2003 and again in 2011, the Accreditation Council for Graduate Medical Education implemented duty-hour restrictions secondary to concerns about sleep deprivation and fatigue affecting clinical performance and patient safety. 7172 Improvements in rates of resident burnout have been noted through duty-hour restrictions, 73(74) but improvements have not been noted in rates of medication errors, resident depression, (75) patient care, or overall resident well-being. (76) Unfortunately, attending physicians in academic settings, who bear the burden of full responsibility for their patients and tend to be older, continue to lack limits on shift durations and total work hours. (77) There is concern that these attending physicians may deliver suboptimal care due to excessive work demands. 71(78)(79)(80)Organizational emphasis on productivity-based pay has had detrimental effects on physician well-being and patient care because increased productivity is typically fostered through longer hours at work, less time spent with individual patients, and/or ordering more tests with little effect on patient outcomes. (81)(82) The inherent nature of being professional and the motivating impact of achieving autonomy and mastery in their work explains the demotivating and depersonalizing effects of excessive pressure on productivity and output. (6) Physicians are not salesmen and do not run assembly lines, so organizations that are aligned with modern motivational forces are more likely to develop and retain a productive, engaged physician workforce. (83) Shanafelt et al (37)68(84)(85) describe the dimensions that can prevent and/or mitigate physician burnout and limit engagement, including alignment of individual and organizational values, workload, efficiency, control over work, work-life integration, social support from the community, and the degree of meaning derived from work.First, organizations must acknowledge the problem and assess its effect on their trainees and practicing physicians by measuring domains of wellness in their physicians. (86) Modalities to engage physicians in these discussions include town halls, video interviews, and face-to-face meetings with clinical leaders/chief executive officers. (37) Institutions should perform annual performance metrics of physician well-being in the same manner as routine safety/quality metric assessments. (5)(87) Measurement of an organization’s health should include measures of staff wellness domains. (88) Awareness of early signs of physician burnout and development of measures to mitigate burnout are integral in preventing these problems from overwhelming providers and undermining the ability to accomplish the mission of the health-care organizations. (89) Potential dimensions of well-being to assess in individual physicians include job satisfaction, burnout, resilience, work engagement, fatigue, sleepiness, perceived stress, and quality of life. (37) Partnerships between organizations and physicians using repeated quality improvement cycles can mitigate burnout by meeting physicians’ personal and psychological needs. (90)Second, recognition of the unique talents of individual physicians and what motivates them (37) is necessary to improve well-being. Shanafelt et al (34) found that “physicians who spend at least 20% of their professional effort on dimensions of work they find meaningful are at a decreased risk of burnout.” These professional activities can include medical education, community outreach, mentorship, research and scholarship, or administrative roles and should be fostered in individuals by organizations as a means of enhancing professional skills, professional well-being, and meaning derived from work. Specific to pediatrics are the unique challenges of caring for vulnerable youth within the limits of our social health system and management of children who are critically ill. Organizations must foster a sense of community and aid pediatricians in navigating these professional challenges through the development of avenues for peer support, including formal spaces to interact and support for physicians. (91)(92) Organization-sponsored gatherings of physicians to discuss their experiences in today’s work environments have been shown to improve meaning in work and decrease burnout. (93)(94) Balint groups are small groups of clinicians who meet to discuss interactions among patients and physicians to improve physician communication; these groups have demonstrated positive effects on burnout rates. (95)(96) Adoption of Schwartz Center Rounds, a gathering of physicians to “discuss the psychological, emotional, and social challenges associated with their work,” have also been shown to be beneficial to staff well-being. (97)Last, organizational willingness to modify the work structure of individuals at various stages of their career is necessary for improved work-life integration. The challenges of work-life integration are most problematic for female physicians, the predominant workforce in pediatrics, given societal expectations and childbearing that occurs early in their careers. (8)(98)(99) American physicians work longer hours and have greater struggles than other workers. (100) Reducing professional work hours has been shown to help physicians recover from and/or mitigate burnout. (36)70 Moreover, judicious attention to diminishing work burden is likely to minimize and/or prevent burnout. Not surprisingly, decreasing the burden of EHRs and other administrative tasks by the use of scribes and physician extenders results in better physician satisfaction, productivity, and efficiency. (101) In addition, providing resources and protected time to promote self-care, resilience, mindfulness, and financial health can improve not only the health of physicians but also the care they provide their patients. (89)(102)(103)(104)(105)In both health-care and professional well-being, the foundation for personal interventions is based on healthy habits in a healthy habitat. Establishing healthy personal habits includes regular physical activity, adequate sleep, healthy eating, forgiveness, gratitude, nurturing social relationships, a balance of personal and professional activity, a sense of meaning, purpose, connection with something larger than one’s individual self, and optimal social-emotional-mental self-regulation. (106) Healthy habits alone are insufficient for overall well-being; they must be imbedded in a healthy environment at the sociocultural, unit, and institutional levels. The components of the well-being interventions currently being offered by residency programs have not been studied well. In a 2012 survey of family medicine residencies, 83% reported offering stress management lectures or workshops; 79% reported residency retreats; more than 90% reported access to counselors, social workers, or mental health professionals; and more than 90% reported offering support or Balint groups, but no data were provided on program effectiveness. (107) In a 2016 survey of pediatric residency program directors, the most common activities aimed at improving well-being were organized social events (91%), access to mental health specialists (90%), retreats (72%), and didactic lectures about well-being and burnout (67%), but less than half of the programs assessed trainee wellness or burnout, so little is known about the benefits of these activities. (24) Interventions that have been studied and have accumulated evidence of effectiveness include mindfulness-based stress reduction (108)(109)(110)(111)(112) and interventions to enhance communication skills, (113)(114) self-care, (115) and physical health (116) and decrease stress 3866(117)(118)(119)“Resilience is the adaptive capacity to respond to stress in a healthy way such that goals are achieved at minimal psychological and physical cost. Resilient individuals bounce back after challenges while also growing stronger in the process.” (120) Factors associated with better personal resilience include a healthy perspective in the individual, presence of family support, and integration into a strong social system. (121) Firth-Cozens (122) defined personal and organizational factors that can lead to poor outcomes after stressful events in physicians, highlighting the interplay of personal factors (personality, previous adversities, and coping strategies), organizational factors (workload and overall hours), and sociocultural factors (the culture within Medicine itself as well as the broader society’s efforts).Resilience can be developed before stressful events occur to mitigate the burden on the individual. (123) Promoting stronger personal functions is frequently cited as the target of resilience training. (124) Individual elements associated with resilience include the capacity for mindfulness, self-monitoring, limit setting, (120) persistence, knowing when to seek help, and attitudes that promote constructive and healthy engagement during challenging situations at work. (105)(125)(126) Cultivating these skills and attitudes to promote resilience is possible in trainees and practitioners and includes methods that promote community among physicians and other members of the health-care workforce. (120)(127)(128)Rogers (127) recently summarized the evidence for effectiveness of resilience interventions in physicians, and Fox and colleagues (129) reviewed published interventions designed to improve resilience in physicians. The results, summarized in Table 3, include cognitive behavioral approaches (eg, Stress Management and Resilience Training [SMART] program), (133) workshops (eg, Aware Compassionate Communication: An Experiential Provider Training Series), (131) small group work, meditation/relaxation training, and mentoring programs. Resilience-enhancing workshops with varying lengths of engagement (ranging from 4 hours across 4 weeks [134] to ten 2-hour sessions across 10 weeks [124]) have demonstrated useful benefits based on participant self-assessment scores.It is clear that well-designed courses that enhance individual resilience can decrease personal burnout and distress in physicians. One downside of many traditional resilience cognitive behavioral training programs is the considerable time commitment involved. (120) Sood et al (135) demonstrated the effectiveness of a short resilience training program, based on cognitive behavioral principles, called the SMART program that involved less than 2 hours of training. In Sood et al’s randomized study of 40 faculty comparing the 90-minute SMART intervention with a wait-list control group for 8 weeks, participants demonstrated significant improvements in “resiliency, perceived stress, anxiety, and overall quality of life 8 weeks after the intervention.” (135) He subsequently demonstrated the effectiveness of a SMART intervention that consisted of a 90-minute workshop in radiology physicians. (133) A SMART program can be accessed online at https://resilience.mayoclinic.org for a nominal cost, or provided at an institution in person by specially trained personnel. A certified resilience training program that trains professionals in teaching SMART is available at https://www.resiliencetrainer.com/certified-resilience-trainer. Resident-led resilience training programs have been detailed in psychiatry residents and pediatrics, which may be an approach worth considering during residency retreats. (136)(137) Longer effective courses for health-care (138) and non–health-care (139) workers have also been reported. Efforts that use these principles to promote physician wellness and resilience through online modules have been launched. (140) Responding to a need from the Section on Medical Students, Residents, and Fellows, the American Academy of Pediatrics has also created a Curriculum on Resilience in the Face of Grief and Loss, which teaches learners how to adapt/integrate the inevitable challenges and losses that come in caring for patients (Table 1). (141)Among the intervention studies, group work devoted to problem and resource sharing can be effective in promoting physician resilience. (142) Mentoring programs can augment other approaches to develop individual physician resilience and are another method that deserves additional study and development. (143) Three barriers exist for resilience training in physicians. (128) First, physicians tend to not want to learn about resilience because it is not “on their final examination.” Many see resilience training as not as valuable as time spent improving medical knowledge. A second barrier is that many physicians do not believe that resilience can, in fact, be learned. The third is uncertainty about effective methods to develop and teach resilience. Lovell (128) aptly termed this the resilience paradox.One of the most popular ways to enhance social-emotional-cognitive self-regulation is through mindfulness and other types of meditation. Mindfulness has been defined as “paying attention in a particular way, on purpose, in the present moment and nonjudgmentally.” (144) Paying attention in the moment assists the individual in developing better awareness of the present and modulating one’s reaction to respond rather than react. (145) In cross-sectional studies, higher mindfulness levels are associated with lower risks of burnout. (146)(147) In a prospective trial of pediatric residents conducted over 2 years, higher levels of mindfulness in year 1 were associated with lower risk of burnout in year 2. (148)Meditation practice has been associated with physiologic changes in the brain, such as increased functional connectivity, particularly in areas dealing with executive function and emotional self-regulation. (149)(150)(151)(152)(153) There is growing evidence that meditation training and practice can improve physician well-being and reduce burnout. A 2016 meta-analysis showed that meditation training was associated with significant improvements in emotional exhaustion, personal accomplishment, and life satisfaction. (154) Although early studies relied on costly weekly or biweekly in-person mindfulness training across 8 to 19 weeks with monthly booster sessions, (89)(93)(109)(155) subsequent studies have shown that even brief training (90 minutes or 1 weekend) can also have significant benefits on burnout and well-being. (133)(156) More recent studies have shown significant immediate and long-term benefits of video-module and online training in mind-body skills, including mindfulness. (157)(158)(159)(160)(161) Hybrid models combining brief in-person experiential training with online modules or use of smartphone applications (Table 4) have also proved effective. (137)(162)(163) Mindfulness training not only decreases burnout and improves well-being but also decreases medical care use and health-care costs while improving health, productivity, and clinicians’ engagement with work. (164)(165) It is important to note that almost all of the positive effects associated with mindfulness training have been noted during elective training, with less benefits noted from mandated training. (166) Additional research is necessary to determine the optimal delivery system and dose of mindfulness training on the well-being of pediatricians at different stages of clinical practice, and how to encourage staff to incorporate mindfulness into their daily routines.Mindfulness may be the most well-known but it is not the only type of mind-body practice that can improve pediatricians’ well-being; practices that foster positive cognitive and affective states, such as self-compassion and gratitude, may also promote well-being. Physicians who have high personal standards and perfectionism often experience self-criticism. Self-compassion is a way to minimize the self-criticism and judgement and replace both with compassion during times of personal suffering or challenges. (167)(168) The components of self-compassion include “1) self-kindness to be gentle and understanding of ourselves 2) recognition of our common humanity and connecting with others through our suffering and 3) mindfulness by holding our experiences in balanced awareness; not ignoring but also not exaggerating our pain.” (169)The benefits of increasing self-compassion have been demonstrated in multiple studies. Greater self-compassion in medical students was associated with more engagement with their studies and lower levels of exhaustion. (170) Within pediatric residents and other health professionals, self-compassion was significantly associated with clinician resilience (147) and fewer sleep problems. (171) In a prospective national study of pediatric residents, higher levels of self-compassion in year 1 were associated with lower levels of burnout and stress in year 2. (148) Online training for health professionals in attention that focus on positive states such as gratitude and compassion have been associated with significant increases in gratitude, well-being, self-compassion, and confidence in providing compassionate care. (172) In a 2017 study of NICU staff, an online program reminding participants to reflect on “three things that went well today” promoted a sense of gratitude for colleagues and a greater sense of well-being. (173) Additional research is needed to identify the optimal type and dose of training in promoting self-compassion, gratitude, and other attitudes that stimulate well-being across the spectrum from medical students to pediatricians in practice.Physician well-being is encompassed by one’s personal and professional health, burnout state, mindfulness, resilience, and self-compassion. Burnout, the most well-studied component of well-being, has detrimental effects on physicians, patients, and the health-care systems as a whole. (37) The time has come to prevent this negative state of health. (7) To date, organizational values have focused on patients and safety, but happy satisfied physicians lead to happy and well-served patients. The evidence is clear that the triple aim of “improving the health of populations, enhancing the patient experience of care and reducing the per capita cost of health care” (174) can be accomplished only by including a fourth aim, which is “improving the work life of health care providers, including clinicians and staff.” (3)