Addressing Clinician Burnout: A Unifying Systems Medicine Model with Meditation as a Heart-mind Intervention.

More than 50% of US physicians report at least one symptom of burnout, and 28% of cardiologists report mental health conditions. Burnout is a risk factor for cardiovascular disease (CVD) through mechanisms like sympathetic nervous system activation and inflammation. The Transcendental Meditation (TM) technique has been studied in four recent trials among healthcare providers, showing reductions in burnout, stress, anxiety, and depression, and improvements in resilience. TM is also associated with reduced blood pressure and CVD risk. The authors propose a systems medicine model called the Square of Health, integrating spiritual, mental, physical, and environmental domains, with a unified field of consciousness as the foundation, to address burnout and CVD.

Study at a glance

Abstract

BURNOUT IN CARDIOLOGISTS AND OTHER PHYSICIANS Physicians Are More Burned Out Than Ever – Here’s What Can Be Done About It was a Journal of the American Medical Association (JAMA) headline in 2023 highlighting the alarming rates of burnout among physicians and health care professionals.[1] Among all physician specialties in the United States (US), more than 50% report at least one symptom of burnout. This is twice the general population’s rate. Less than half of the physicians were satisfied with their work–life balance.[R2-R4] At least 50% of the US cardiologists are stressed.[5] Cardiologists around the globe suffer from high rates of mental health conditions that put them at risk for burnout. According to a 2023 study in the Journal of the American College of Cardiology (JACC), 28% of cardiologists reported mental health conditions – psychological distress, substance abuse disorder, suicidal ideation, or clinical psychiatric disorder.[6,7] These mental health conditions exacerbate burnout.[7] These conditions existed before COVID-19; however, the pandemic intensified rates and recognition of burnout and mental health conditions of anxiety, depression, and stress disorders in health-care providers.[8,9] Besides the costs to physician and patient health, the economic cost of physician burnout is estimated at $4.6 billion annually in the US health-care system alone.[10] Burnout in medicine knows no national boundaries. After reviewing international reports, a Lancet editorial declared physician burnout is a global crisis.[11] In its International Classification of Diseases-11, the World Health Organization (WHO) defines burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed and is characterized by three dimensions: (1) feelings of energy depletion or exhaustion, (2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job, and (3) reduced professional efficacy.[12] This echoes the US Surgeon General’s Advisory on clinician burnout.[10] Summing up the evidence in JAMA Health Forum in March 2023, Khular concluded that, Physician burnout is a major threat to health care quality, patient outcomes, and the vitality of the medical workforce.[13] BURNOUT, MENTAL HEALTH CONDITIONS, AND CARDIOVASCULAR DISEASE In addition to impacting the quality of life of physicians and healthcare providers, quality of patient care, and health-care costs, burnout is recognized as a risk factor for cardiovascular disease (CVD).[14] Vital exhaustion is closely related to burnout and has been recognized for many years in risk for CVD. Burnout adds to other mental health conditions associated with CVD, namely depression, anxiety, hostility, anger, pessimism, stress and low social support, and loneliness.[15] Pathophysiological mechanisms for the CVD risk conferred by burnout and other mental health conditions have been well described. They include sympathetic nervous system activation, parasympathetic nervous system deactivation, hypothalamic–pituitary–adrenal dysregulation, amygdala hyperactivation, endothelial dysfunction, inflammation, microcirculatory dysfunction, platelet aggregation, and thrombosis.[R16-R18] In Heart and Mind, Theorell reviewed psychosocial stressors in CVD and Jiang considered the history of neuropsychocardiology.[19,20] While in JACC, Kubzansky et al. evaluated the role of positive psychosocial factors in CVD that may ameliorate burnout and related mental health conditions.[21] In terms of practice guidelines, the 2021 European Society of Cardiology Guidelines for CVD Prevention in Clinical Practice acknowledged the role of psychosocial stress in CVD as do the American College of Cardiology recommendations for prevention of CVD in women.[22,23] While the latter guidelines addressed women’s health, there is no evidence that men are immune from the cardiovascular effects of stress. CARDIOLOGY ASSOCIATIONS CALL TO ENHANCE CLINICIAN RESILIENCE AND PREVENT BURNOUT Despite the profound consequences of burnout among physicians and other healthcare providers, few steps have been taken to address the problem, in terms of policies and programs.[24] Recognizing the seriousness of burnout and mental health conditions in cardiology clinicians, the World Heart Federation, European Society of Cardiology, American College of Cardiology, and American Heart Association (AHA) jointly called for efforts to augment clinician resilience and well-being, in addition to structural changes in health care.[5] The US National Academy of Medicine issued its plan for health workforce well-being for strategies to improve well-being and resilience.[25] This culminated in the enactment of the Dr. Lorna Breen, Health Care Provider Protection Act as groundbreaking legislation to establish and share evidence-based strategies to improve mental health of clinicians and prevent its untoward health and health-care sequelae.[24] The present editorial advance the spirit of this initiative. SPIRITUALITY IN BURNOUT AND CARDIOVASCULAR DISEASE One potentially powerful dimension that is often overlooked in clinician burnout is spirituality.[26] Dalle Ave and Sulmasy in JAMA point out that the WHO declared spirituality an element of overall health in 1995, yet nearly 20 years later, it is still neglected. An international and national consensus defined the spiritual dimension of whole person health as a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred.[27] These authors advocate incorporating the spiritual dimension for healthcare providers (as well as healthcare consumers) to cope with stressful demands and prevent burnout.[26] As VanderWeele et al. in JAMA observe, Clinicians regularly overlook dimensions of spirituality when considering the health of others – or even themselves.[28] A multidisciplinary expert panel conducted a systematic review of the highest quality evidence on spirituality in illness and health reported in JAMA 2022. The panel concluded that incorporating spirituality into health care would enhance the mental health and well-being of healthcare providers, patients, and population health.[29] To provide a framework for these initiatives, the National Competencies in Spirituality and Health were developed for medical education.[27] Spirituality is not only relevant to burnout and mental health. This dimension predicts hard CVD outcomes. An integrative review entitled Heart, Mind, and Soul found that spiritual experiences and practices affected cardiovascular outcomes, namely major adverse cardiovascular events (MACE), and CVD risk factors – hypertension, metabolic syndrome, and inflammatory markers. Plausible neurologic, neuroendocrine, and neuroimmune mechanisms were proposed.[30] ENVIRONMENTAL STRESS LEADS TO BURNOUT AND CARDIOVASCULAR DISEASE Another emerging level of risk to the heart and mind is environmental stress. Several potentially modifiable environmental factors contribute to clinician burnout. Occupational stressors include workload, work hours, lack of control over work environment and resources, administrative burdens, and circadian rhythm sleep disorders.[31] Theorell elegantly described how environmental stressors, such as work conditions, family conflicts, life changes, and psychophysiological reactions contribute to CVD.[19] In response to the demands of the time, the American Medical Association highlighted time constraints, technology, and regulations as factors causing and fueling physician burnout.[32] The emerging field of environmental cardiology identifies stressors in the geophysical, built, and social environments that increase the risk for CVD.[33] Among these are exposure to air pollution, noise pollution, light pollution, climate change, poor urban planning, and social stressors such as violent crime in the community and war, all of which have been associated with excess risk of CVD.[33,34] These findings suggest that either modifying the environment, reducing exposure to environmental stressors, or modifying reactivity to these stressors may reduce the burden of both burnout and CVD in healthcare providers, their patients, and communities. Cardiologists of the future will likely consider environmental stress routinely.[35] EVIDENCE FOR MEDITATION IN ENHANCING CLINICIAN RESILIENCE AND PREVENTING BURNOUT The Transcendental Meditation (TM) technique is a standardized, validated, and widely practiced mind–body technique reported to reduce stress, related mental health conditions and physical disorders, and promote positive health and well-being.[36,37] In Transcendence, psychiatrist and researcher, Rosenthal describes the experience of TM practice as one’s mind easily settling inward, through quieter levels of thought, until one experiences the most silent and peaceful level of awareness, characterized by a sense of unity, peace, and transcendence of time and space.[36] It is the physiological and psychological correlates of this transcendental experience that are proposed to counter the effects of stress.[36] Over the past 2 years, four studies evaluated the efficacy of TM programs on stress, burnout, and mental health conditions in physicians and health-care providers. The first study, in the Journal of the American College of Emergency Physicians in 2021 by Azizoddin et al., evaluated the feasibility, acceptability, and efficacy of a TM program in emergency clinicians during the COVID-19 pandemic. The study found that TM was feasible and acceptable among emergency clinicians and associated with reductions in stress, burnout, and anxiety symptoms. The authors concluded that TM may be a valuable tool for emergency clinicians during times of crisis.[38] The second study, published in JAMA Network Open in 2022 by Joshi et al., was a randomized controlled trial to evaluate the effects of TM among 80 healthcare providers. While there was a nonsignificant between-group difference in the primary outcome of acute stress, the TM group showed significant improvements in chronic stress, burnout, and insomnia after 3 months of intervention.[39] The third study, in Journal for Continuing Education in the Health Professions 2023 by Loiselle et al., was a randomized controlled trial in 40 physicians to investigate the effects of TM on burnout and mental health in an academic medical center. The trial found that the TM technique was efficacious in reducing symptoms of total burnout, emotional exhaustion, depression, and personal accomplishment.[40] The fourth study, published in PLoS ONE in 2023 by Nestor et al., investigated the effects of TM on mental health and well-being in 65 healthcare providers during the COVID-19 pandemic using a parallel group design. The study found that the TM program was associated with reduced symptoms of stress, anxiety, and depression, with greater resilience and overall mental well-being.[41] When considered together, these studies in contemporary medical settings suggest that the practice of the TM technique is acceptable and feasible for physicians and healthcare providers and may be an effective tool for ameliorating symptoms of burnout, stress, anxiety, and depression while promoting mental health and resilience.[R38-R42] NEURAL MECHANISMS OF TRANSCENDENTAL MEDITATION IN BURNOUT Neural mechanisms of TM practice contrast with neural correlates of burnout. Notably, greater frontal alpha electroencephalogram coherence, blood flow, and activity in the anterior cingulate cortex (ACC) are reported during the TM technique compared to decreased activity in these same regions during burnout.[R43-R45] Lower activity in the ACC is tied to disrupted emotional regulation.[46] In a controlled prospective study, Orme-Johnson et al. tested the response to a laboratory stressor and found that TM practice was associated with reduced reactivity in the prefrontal cortex (PFC), ACC, and thalamus. These neural changes are consistent with reduced neural reactivity to stress and potential prevention of burnout in practitioners.[47] Furthermore, these and related neural correlates differentiate TM from other common meditation practices.[48,49] EVIDENCE FOR MEDITATION IN CARDIOVASCULAR DISEASE – PRIMARY AND SECONDARY PREVENTION Given these connections between the heart and mind, it is relevant that a series of randomized controlled trials demonstrated that TM practice was associated with reductions in traditional CVD risk factors such as hypertension,[R50-R53] metabolic syndrome,[54] smoking and substance abuse,[55] surrogate markers of CVD including carotid intima-media thickness,[56] left ventricular hypertrophy,[57] and stress-induced myocardial ischemia[58] as well as long-term mortality and morbidity.[59,60] These findings suggest that TM may be a valuable tool for cardiologists, healthcare providers, and their patients in the primary and secondary prevention of CVD.[53] The mechanisms for these clinical effects likely involve a combination of physiological and behavioral consequences. Chronic stress has been linked to the development of CVD through sympathetic nervous system activation, adrenocortical hormones, inflammation, endothelial dysfunction, and oxidative stress, all which can lead to atherosclerosis and other CVD-related pathologies. By reducing stress and improving mental and physical health, the TM technique may help to mitigate these risk factors and prevent the development of CVD.[16] The AHA reviewed this literature and issued three scientific statements on alternative methods, including meditation to lower blood pressure and cardiovascular risk. In 2013, the AHA issued a scientific statement on using alternative approaches, including meditation, to lower blood pressure, which concluded that TM may be considered in clinical practice to lower blood pressure in those with hypertension.[51] In 2017, the AHA issued a scientific statement on meditation to reduce cardiovascular risk, which stated that there is a potentially significant reduction in blood pressure and CVD risk with TM.[61] The third AHA scientific statement in 2021 synthesized relationships between the mind and heart and included a section on the role of meditation in improving cardiovascular health.[62] These scientific statements developed by consensus of AHA expert panels suggested that the TM technique may be a useful mind–body approach in the primary and secondary prevention of CVD. SYSTEMS MEDICINE OF BURNOUT AND CARDIOVASCULAR DISEASE In 2021, Listopad et al. systematically reviewed factors related to burnout. They identified relevant biological, psychological, spiritual, and socio-environmental factors.[63] In essence, Listopad and team anticipated a systems medicine model of burnout and health. Systems medicine is an application of systems science to health and disease.[64] It is an interdisciplinary field of study that views the systems of the human body as part of an integrated whole, incorporating networks of biochemical, physiological, psychosocial, and environmental interactions. In their New England Journal of Medicine article, Greene and Loscalzo “put the patient back together” as they advocated replacing molecular reductionism, which began in 18th century science, with postgenomic holism of the 21st century. They argue that biomedical reductionism misses crucial aspects of human disease and that a systems approach recognizes the complex interplay between genes, behavior, and environment in all their levels.[65] Lets say, Federoff and colleagues echoed this proposition in their article, Systems healthcare: A holistic paradigm for tomorrow, where information from molecules, cells, organs, the individual, families, and communities, to man-made and natural environments, are integrated into a whole dynamic portrait.[66] Similarly, the National Institute of Mental Health Research Domain Criteria (RDoC) is a systems-oriented framework of interconnected domains affecting mental health, comprising emotional, cognitive, biological, behavioral, and environmental influences. Importantly, not explicit in other models, the RDoC framework expressed the influence of the dynamics of time. That is, changes may occur in each of the domains over the individual’s lifespan and life course development.[67] In their Whole Person Health strategic initiative, the National Institutes of Health (NIH) National Center for Complementary and Integrative Health calls for exploring how an individual’s physical, mental, emotional, and spiritual dimensions together form a whole health system.[68] Considering these developments in postmodern system-oriented medicine, McKinsey Health Institute, recommends to its government, corporate and organizational clients a modernized understanding of health that comprises four dimensions: physical, mental, spiritual and social. 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