Physician well-being has received growing national attention over the last 15 years, but despite these efforts, we continue to experience high rates of stress and burnout. Changing the system requires advocacy, leadership, and time — and changing the culture requires additional tools and permission. While institutional leaders and health professionals work to alleviate unnecessary system-based stressors, we must simultaneously unlearn culturally ingrained, maladaptive responses that contribute to burnout. Our focus on empowering individuals does not detract from the need for system change.

The purpose of this article is to explore the following:

• How the culture of medicine shapes our stress responses,

• How to apply the “ACE” (accept, choose, and embrace) framework to our stressors and integrate it with three evidence-based well-being strategies.

THE CULTURE OF MEDICINE

Culture is a set of rules, often unspoken, to which anyone who wishes to fit in with a certain group of people will adhere. What is the culture of medicine? Some call it the “hidden curriculum” in our training that compels us to withhold all signs of weakness, give all we have and then give more, place others’ needs ahead of our own, and model these traits religiously until we’ve proven our worth to patients, colleagues, family members, and ourselves. Medical culture is notorious for deferring basic human needs including nutrition, hydration, and sleep; and for shaming and blaming individuals for system-level inadequacies.¹ This culture begins in training and persists in the practice environment, and it greatly contributes to the deterioration of our physical and mental health. The higher we rise in the “superhero” culture, the deeper we sink in caring for ourselves.

The antidote to this damaging culture is self-valuation — prioritizing personal well-being, rather than deferring it, and adopting a growth mindset in response to errors and imperfections, rather than self-condemnation.² Yet in one study, physicians were 50% more likely than other workers to respond to their mistakes with self-condemnation and 3.5 times more likely to defer self-care.³

THREE COMMON COPING MECHANISMS

The following coping mechanisms, illustrated using three physician case examples, are often developed in training and mastered throughout our careers as physicians. We adopt them to help manage difficult emotions and situations, but they can be as detrimental to our well-being as the stressors themselves.

Dr. Imfine displays emotional numbing, professionally and personally. Her paradoxical reaction to emotional overload is to shut down her feelings, which ultimately drives her to deny the full spectrum of human emotions, from tiredness to joy. This reaction, while meant to protect her from stressors, results in a sub-human experience.

Dr. Domore exhibits a pattern of limitless agreement to do more. Their conditioned response of “yes,” designed to manage the excessive workload, results in blurred personal and professional boundaries, loss of purpose, and an overexaggerated sense of responsibility. The equating of positive self-worth with doing more creates a distorted and unattainable superhuman image.

Dr. Dontcare demonstrates apathy and a downward-spiraling negativity toward himself and those around him. His coping occurs in response to chronic stressors and continuous experiences of hopelessness, lack of control, and moral injury. His reaction results in disengagement and loss of compassion, a characteristic he previously exemplified upon entering medicine.

Maladaptive behaviors like these are modeled across generations of physicians. Intended to be adaptive, these coping mechanisms result in self-sabotage and further limit performance, decrease satisfaction, and worsen burnout. Matriculating medical students start their careers with better mental health than college graduates pursuing other fields, including lower burnout, less depression, and a higher quality of life.⁴ This is reversed by their second year, with burnout crescendoing during residency⁵ and peaking mid-career along with dissatisfaction with work-life balance.⁶

Unpacking these responses is complex but critical to physician well-being, which is part of the “quintuple aim,” along with achieving better health, better care, health equity, and lower costs for society.⁷

THE ACE FRAMEWORK

When faced with stressors, the ACE framework prompts us to accept authenticity, choose meaning, and embrace positivity in ourselves and others. This doesn’t deny the presence or impact of our very real problems, but it gives us the right mindset to deal with them. We can apply this framework by taking a moment for self-reflection and journaling responses to the following questions:

• What human aspect or authentic emotion can I accept about myself right now? Acknowledge feelings without denial, judgment, resistance, or blame. For example, “I feel exhausted,” “frustrated,” or “uncertain about how to move forward.”

• What action can I choose to do today that brings me meaning? Focus on realigning effort toward what matters most. For example, “I will rest today,” “I will focus on each patient in front of me,” or “I will talk with my administrator about my concerns.”

• What will I embrace in my life that’s going well currently? Engage the positive around me, including learning from difficult challenges. For example, “I have an upcoming vacation that will recharge me,” “I am making a difference in the lives of my patients, such as Mrs. Smith,” or “I have the support of my colleagues.”

The ACE framework integrates nicely with three evidence-based tools for well-being. Let’s explore each one using our three physician cases.

EMOTIONAL INTELLIGENCE

In response to workplace stressors, physicians like Dr. Imfine often distance themselves from their true emotions and experience emotional labor — “the act of expressing organizationally desired emotions during service transactions.”⁸ This discrepancy between how we feel and what we display is a normal human reaction to emotional overload and is well-known in organizational management.⁹ But chronically constraining one’s emotions can result in negative consequences including anxiety, depression, and precursors to burnout — emotional exhaustion, depersonalization, decreased satisfaction, and decreased sense of accomplishment.

Emotional intelligence is a strategy that involves pausing and slowing your reaction to stressors so you can understand your own and others’ emotions, and then respond more effectively. It has been shown to enhance well-being, relationships, and performance, and is critical to sustaining empathy and effective patient relationships and outcomes.^10–12 However, emotional intelligence has been shown to erode during medical training.^13,14

Here’s how Dr. Imfine applied the ACE framework to emotional intelligence:

• Accept authenticity: Facing her emotions initially felt forced and foreign. It was more comfortable to be “fine.” She processed her emotions via journaling and grieved her losses —including close relationships. With practice, she permitted herself to be tired, disappointed, and sad — and eventually content, peaceful, and joyous.

• Choose meaning: She chose to be herself around friends, family, and colleagues — not tough, just real and vulnerable — and she chose to reach out to a loved one from her past for possible reconciliation.

• Embrace positivity: She embraced time spent on self-care and self-awareness and viewed this work as a source of power and strength.

COGNITIVE REFRAMING

After years of feeling pressured to perform and say “yes” to everything, physicians like Dr. Domore eventually become burdened with an unmanageable load. Compulsiveness as a trait is glorified in medicine, especially when thoroughness and conscientiousness result in safer quality of care.¹⁵ However, with mounting system-level pressures related to the administrative burden of practicing medicine, compulsiveness fuels negative emotional responses including guilt, doubt, and an exaggerated sense of responsibility.¹⁵ Physicians can feel trapped in a life with no boundaries and no attention to self, and become susceptible to cognitive distortions such as overgeneralizations, blaming, and catastrophic thinking (e.g., “I can’t count on anyone around here to do anything right”).¹⁶ These survival-based thinking patterns fuel negative perceptions and maladaptive behaviors. They also come with an unwillingness to “let go” and a belief that these misperceptions of reality are fact.¹⁶

Cognitive reframing is a strategy to recognize and reframe distorted thinking so you can refocus your thoughts and energy more effectively. It is a component of cognitive behavioral therapy that allows one to view a situation from a different angle. It has been shown to be an effective treatment for several mental health disorders,¹⁷ and to improve quality of life and coping during the pandemic¹⁸ and while caregiving for individuals with dementia.¹⁹ It improves burnout and treatment outcomes for physicians and other providers who treat substance use disorder²⁰ and is a promising therapy for maladaptive perfectionism in medical students.²¹

Here’s how Dr. Domore applied the ACE framework to cognitive reframing:

• Accept authenticity: Accepting one’s limits was the start of healing for Dr. Domore. Challenging the belief that self-care is a sign of weakness, they reframed time devoted to personal well-being as critical to their effectiveness. Disengaging from the mindset that “a broken system is an excuse to not care for ourselves,” they accepted the mindset that “a broken system is a call to action to care for ourselves.”²²

• Choose meaning: Recognizing that robotically doing more is harmful, Dr. Domore chose to refocus their priorities and do more of what gave them meaning. They wrote their own vision (why), mission (what), and values (how) statements to use as a guide for decision making.

• Embrace positivity: One study found that those who spend less than 20% of their work time on their most meaningful activity are at highest risk of burnout.²³ So, Dr. Domore decided to embrace their unique strengths and reengage in a personal passion — preventive care. They restructured their day to include more visits related to lifestyle change and started a mindfulness program to model self-care.

APPRECIATIVE INQUIRY

Encountering relentless obstacles, physicians like Dr. Dontcare become overwhelmed and disheartened. They increasingly fixate on what isn’t working and become progressively cynical. They may even develop a “negativity bias.”²⁴ Intensely focusing on negative experiences allows a quick response to reoccurring adverse experiences, but it is detrimental to well-being. This negativity can create a toxic environment, unintentionally isolating the physician from colleagues and fueling hopelessness in making a difference.

Appreciative inquiry is a strategy to find the good in people, places, and things. It is a growth-promoting process that focuses on what’s going well even when many things aren’t. It allows us to break negative cycles by taking a moment to reflect. It has been shown to be effective in health care, improving communication, teamwork, staff morale, and financial performance.^25,26 Appreciative inquiry typically involves a series of steps focused on acknowledging positive aspects of one’s experience, envisioning a more positive future, and prioritizing strategies to achieve that vision.

Here’s how Dr. Dontcare applied the ACE framework to appreciative inquiry:

• Accept authenticity: At first, his cynicism followed him into this exercise. He felt that appreciative inquiry was pollyannaish. He refused to say something was “good” when it wasn’t. Over time, he accepted that, while obstacles are inevitable, he could alter how he reacted without personalizing them.

• Choose meaning: He chose to reconnect with what mattered and purposefully focus on his team. He learned to amplify what was going well and tap into his team to extract valuable insights about what wasn’t working and why.

• Embrace positivity: He learned to embrace his positive progress and the successes of others. In time, he even came to view challenges as opportunities to lead change. By reengaging, he became creative and solution oriented, aligning teams with grant writers to overcome budget cuts. He became an inspiration, leveraging others’ talents and ideas, amplifying their skills, and becoming the “multiplier” leader²⁷ he once was.

ACE YOUR WELL-BEING

Medicine can be extremely rewarding but presents system-level challenges and cultural pressures that limit physicians’ effectiveness and well-being. Maladaptive responses to stressors are modeled and ingrained, further contributing to burnout. Physicians deserve to thrive and experience joy in medicine. Restructuring the health care system must include transforming the culture to remedy responses that undermine our ability to accept our authentic selves, choose meaningful initiatives, and embrace the positive growth-promoting aspects of doctoring.