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One CE Credit

Assessing Wellness in Psychology: Examples from Medicine  by Jodie Eckleberry-Hunt, PhD, ABPP and Heather Kirkpatrick, PhD, ABPP, MSCP

Instructional Level: Intermediate

Learning Objectives

  • Compare findings from research on physician wellness to psychologists.
  • Use the three scales of the Physician Wellness Inventory to better understand psychologist wellness.
  • Describe activities and strategies that can boost feelings of wellness.

Wellness is increasingly becoming an area of research and clinical focus among health care professionals. At the same time, it is not entirely clear what constitutes attainable wellness goals, particularly among individuals in demanding professions. The focus of this paper is to review recent research on physician wellness and draw comparisons to psychologists. We discuss our research findings that physician wellness encompasses three factors, Career Purpose, (lack of) Distress, and Cognitive Flexibility. The hope is that psychologists, who are increasingly moving into medical practice settings, will be able to benefit from this different perspective.

Assessing Wellness in Psychology: Examples from Medicine

The practice of psychology can be stressful (Hannigan, Edwards, & Burnard, 2004). Commonly reported stressors include excessive work, concerns about poor management, excessive, competing responsibilities, a lack of resources, self-doubt (Hannigan, Edwards, & Burnard, 2004), long hours, compassion fatigue, and secondary traumatization around working with patients who have chronic problems and in difficult life circumstances (Barnett, Baker, Elman & Schoener, 2007; Lawson, 2007). To complicate matters, the last 10 years in health care have ushered in vast changes in documentation, reimbursement, and organizational structure. These changes have been associated with a "do more with less" philosophy that has left health care professionals at all levels feeling strained. Perhaps not coincidentally, there has been an increase in research that examines burnout and stress among health care providers. We now know a great deal about factors that contribute to burnout and impairment. On the other hand, we know much less about factors that contribute to wellness and resilience among health care providers. The focus of this article is to highlight the importance of wellness promotion as a method of thriving in health care practice as opposed to merely ameliorating stress. We focus on our research findings related to physicians and draw comparisons with psychologists who may benefit from this different perspective.

Historically, literature in both psychology and medicine has focused on awareness and treatment of burnout and impairment so that clinical practice is not compromised. Both fields share the common feature that much initial attention was paid to distress, burnout and impairment, while attention to wellness came later. Barnett, Baker, Elman, & Schoener (2007) argued that psychologists have an ethical mandate to engage in self-care in order to allow them to practice psychology competently. There seems to be general acknowledgment that impaired psychologists are more likely to harm clients, and well psychologists are more likely to help their clients improve (Lawson, Venart, Hazler & Kottler, 2007; Smith & Moss, 2009.) We agree that self-care is extremely important in order to provide quality patient care, but we also believe that an equally important goal of wellness promotion is more aspirational - to assist the psychologist in optimal overall functioning. Arguably only by working toward becoming our fullest selves can we achieve high levels of performance, connection, and authenticity in our work as psychologists. We espouse the position of Keyes (2002) who argues that in order to achieve mental health, we should focus on flourishing or being filled with positive emotion. Survival alone (akin to, perhaps, amelioration of burnout) gives undue emphasis to a "good enough" philosophy (Wise, Hersh, & Gibson, 2012).

Even the most vigilant psychologists will find themselves in circumstances where wellness is challenged due to the very nature of the work. Compounding this is the observation that, mental health professionals don't do well at self-care (Dattilio, 2015). Psychologists are not alone in this regard; physicians work in very similar circumstances. Psychologists and physicians are well-trained in wellness strategies for patients, and they teach these to patients in daily work. At the same time, both professionals are noted to be low utilizers of self-care in their personal lives. Does a health care professional have to exercise, eat well, and meditate to be well? In addition, what does it mean to be well?

Physician Wellness

Our research has focused on wellness for physicians. Although these ideas are untested among psychologists, we think there may be some important parallels that extend to psychology as a profession. We began by considering what wellness may be for a physician. Historically, wellness has been conceptualized as finding life balance (Eckleberry-Hunt et al., 2009), but Federico (2015) suggested that the general goal of balance isn't often reasonable for physicians (and perhaps psychologists). Depending on the demand experienced at any particular time, either work or home may be more heavily weighted, making the concept of "balance" illusory. While this is true, it is important to acknowledge that physicians and psychologists cannot be all things to all people and remain well. There is a tradition in medicine of long work hours and self-denial of needs in order to meet the needs of patients - just as the demands of clinical training and practice place similar demands on psychologists. Younger generations (e.g., the Millennial Generation) are more vocal about stronger expectations of having home-life balance, but the culture of medicine is slow to change.

In our research, we avoided the concept of "balance", because we worried that if wellness were defined as balance, physicians would appear perpetually deficient. "Balance" infers that it is possible to achieve a state of total satisfaction in work and home at the same time, and this may be a damaging inference. The culture of psychology has historically been more focused on the need for balance in order to remain effective in our work (at least compared to the medical culture), but it appears that psychologists, too, are facing increasing work demands (particularly administrative tasks) in workplaces that emphasize doing more with less.

It may be that all health care providers are finding it difficult to lead balanced lives. Just as physicians are being asked to become schedulers, coders, and billers, so to do psychologists face these increased burdens. As psychologists increasingly work in settings where they are aligned more with physicians versus other mid-level providers, we, too, may experience the impossibility of fully balanced work-home life ratios. Although some evidence exists to posit that "satisfied" psychologists are better able to maintain a sense of balance between work and home lives, this is hardly the only factor driving career satisfaction (Rupert & Kent, 2007) nor does it imply that such balance is readily attainable.

As previously noted, our research was performed with physicians. While they will serve as the primary reference point in discussing our work, we believe that these concepts can easily be extended to the profession of psychology. In an attempt to move beyond a discussion of balance, we sought to conceptualize physician wellness by specifically addressing their complex job demands. Previous attempts to measure wellness among physicians focused on distress and burnout, for example as measured by instruments like the Maslach Burnout Inventory or the Physician Well-Being Index. Our work, however, was predicated on the belief that wellness is more than just the absence of distress and burnout, just as health is more than the lack of active disease. We strongly felt that by identifying an evidenced-based definition of physician wellness that incorporated job stress we could more accurately define the concept of physician wellness. When "wellness" is expressed in measurable terms, it can be accurately assessed and tracked to determine what strategies may improve it within the physician population. Of course, even the act of measurement of wellness can be an intervention itself.

We reviewed the literature, conducted physician interviews, and utilized expert opinion to develop a broad range of characteristics that might be associated with physician wellness. We conducted a pilot study and developed an instrument to test further among practicing physicians. We distributed the Physician Wellness Inventory to a random sample of full members of the American Academy of Family Physicians and performed a factor analysis to determine the best conceptual structure from the responses. We utilized the Maslach Burnout Inventory and the Subjective Happiness Scale to serve as validity comparisons. The final instrument, The Physician Wellness Inventory (See Appendix A) has three scales: Career Purpose, Distress, and Cognitive Flexibility. Interestingly, items on social support, exercise, and nutrition did not significantly load onto a scale. We cannot say that these factors are not valuable, but they were not salient to our study sample of family physicians. While it is possible that exercise, nutrition, and social support are necessary factors for wellness, it seems our sample of physicians did not perceive them as critical in predicting burnout or happiness. It is possible that our sample was over-identifying with aspects of work, or perhaps as medical professionals, there was little variance in reported exercise, nutrition, and social patterns. For the general population, Keyes (2002) argues that total wellness encompasses emotional and psychological wellness and social and relational wellness, including warm interpersonal relationships. These elements, too, were not factors related to wellness identified by our sample. This supports our initial idea that wellness may look differently for different professionals depending on the demands of their career. We describe our findings below, but more technical data are published elsewhere (Eckleberry-Hunt, Kirkpatrick, Taku, Hunt, & Vasappa, in press)

Career Purpose

The first and most robust scale, Career Purpose, involves getting satisfaction out of working with patients, having work-related joy, and having a good balance of positive vs. negative patient relationships. This finding is consistent with a literature review on resilience and wellness by McCann et al. (2013) who found that positive patient interactions were the most strongly associated with wellness among physicians in qualitative studies. Given the strong relational work necessary for assessment and treatment of clients, psychologists' wellness may even more strongly value or require positive patient interactions--or at least a greater proportion of positive vs. negative patient reactions. Among physicians, ways to increase Career Purpose include reflection groups where physicians can discuss the joys of practice and remind themselves and each other why they chose medicine. Psychologists have long engaged in consultative groups with colleagues; if appropriately directed, such groups might provide a similar opportunity. There is support within the psychology literature that work satisfaction is related in part to maintaining professional identity/values and participating in continuing education programs (Rupert & Kent, 2007). This is a good reminder to continue this practice in a work environment that is full of time constraints and limited resources. Ways to remain attached to one's original calling are likely powerful strategies to maintain wellness in physicians and psychologists.

Some authors (Hannigan, Edwards, & Burnard, 2004; Leiter, 2015) suggested that workplace engagement and finding work that aligns with personal/professional values will increase wellness and Career Purpose. Psychologists are taught to self-reflect in order to connect empathically with clients, and the very nature of empathic connection with others can provide a meaningful experience. By attending to one's ability to connect on a daily basis, one may develop a shared set of meaning with one's patients. By contrast, physicians have been taught objectivity without attention to connection, to "cure" rather than "heal" or "care" and to view themselves, their knowledge, or their procedural skills as the curative agent. This is slowly changing, particularly within primary care specialties.

Traditionally, wellness work among psychologists has focused on internal factors related to wellness and how those internal factors relate to the external environment (Stevanovic & Rupert, 2004). It is also important to recognize that external factors can also influence the degree of meaningful work one perceives. Within the literature on physician wellness, a trend is emerging that highlights how the work environment affects wellness. McCann et al. (2013) supports that we need to begin looking at resilient environments, particularly work environments, as they relate to wellness. Workplace environments that allow physicians or psychologists the ability to focus more on meaningful work may improve wellness. Thompson, Ametea, and Thompson (2014) found that workplace factors had a major role in the development of counselor burnout and compassion fatigue, and Lawson and Myers (2011) noted that the most meaningful contribution to wellness was the work setting. As such, increasing Career Purpose may involve environmental shifts within the health care environment. For example, physicians who work in team-based environments are more well (Sinsky et al., 2013). Team-based care decreases the burden associated with complex and chronic patient situations so that one person does not feel solely responsible. As team based care increases in primary care via the integrated primary care movement, psychologists and physicians may benefit. Another example of a workplace factor associated with Career Purpose is that physicians are increasingly dissatisfied with paperwork and administrative demands that take away from the joy of patient care. Physicians complain that doing paperwork or billing isn't what they planned or what they are trained to do. It may be that work redistribution is another environmental way to increase Career Purpose.


The second scale, Distress, involves symptoms of depression and anxiety, distress from competitive administrative and clinical demands, distress from patient encounters, and difficulty controlling the distress. It is important to note that this scale of distress reflects situations specific to patient care, as well as competing demands upon one's role, versus generalized psychological distress. When the work that a physician is doing is perceived to be pointless or is related to difficult patient situations, distress results. Although we don't have solid data on how well interventions work to prevent distress among physicians or psychologists, internal strategies such as gratitude expression, prayer, self-reflective journaling, mindfulness, relaxation and challenging negative self-talk are thought to be important (Dattilio, 2015; Wise, Hersh, & Gibson, 2012). The challenge may be finding ways to increase practitioners' use of these strategies. Meditation, for example, can work but only for those who are willing to commit to a regular practice of meditation. More research needs to be completed regarding brief interventions that can be delivered in more settings. One thought is that health care organizations should offer workplace based interventions to encourage utilization and underscore self-care as a core value. The location would be convenient to practice and may increase support amongst colleagues. The possibility for professional organizations to offer virtual interventions is another area ripe with possibility (c.f., "Virtual Hope Box" app created to address distress in brain-injured military personnel, National Center for Telehealth & Technology, 2015).

Elevated scores on the Distress scale indicate that physicians may need assistance in dealing with secondary traumatization associated with bad outcomes and negative patient encounters. Again, professional support and reflection groups may be good forums to process traumatic encounters. Physicians remain reluctant to seek personal counseling, and a top barrier is fear of compromised confidentiality and fear of negative consequences for licensure and practice. While fear of negative consequences for practice or licensure may be less of a barrier for psychologists, practical barriers to psychologists seeking personal counseling may be present. Dual-role relationships may be one barrier, particularly in smaller, more rural settings. Perceived lack of time may be another. One potential solution may be for health care organizations to provide on-site, confidential counseling for physicians and psychologists. These encounters would not be billed to insurance companies, limiting any paper trail. This approach is be consistent with the internal management of police occupational stress and trauma where debriefing and support is provided on the job. Indeed, if the distress that physicians experience is related to work, as our scale suggests, on-the-job supportive counseling would be a logical tool. Other studies show that there is a role for workplace interventions that decrease chaos, unnecessary administrative tasks, and improve flow (Sinsky et al., 2013).

Cognitive Flexibility

The Cognitive Flexibility scale assesses openness to new ideas, being self-reflective, seeing multiple perspectives, and feeling compassion for others. This finding is new to the physician wellness literature but fits with the idea that being able to shift set and let go is important to being well. Dattilio (2015) suggested that to flourish, one needs to demonstrate flexibility and ability to shrug off unrealistic expectations. Cognitive Flexibility interventions might include reflective/mindfulness and/or cognitive-behavioral therapy type interventions to improve wellness. Wise, Hersh, & Gibson (2012) suggested that mindfulness based approaches can increase cognitive flexibility, as well as improve quality of life and joy. Sirgy and Jackson (2015) suggest that differential mindfulness strategies may be beneficial for therapists and possibly physicians. Other research has demonstrated that mindfulness has benefits, including enhanced attention, expanded affect tolerance and acceptance, greater self-awareness and empathy and greater wellbeing (Cashwell et al, 2007; Goodman & Schorling, 2012).

Finally, we examined the relationship of hours worked per week and perceptions of workload manageability. Among physicians, the number of hours worked per week is significantly related to Cognitive Flexibility, while the ability to manage workload is significantly related to Career Purpose and Distress. It appears that physicians need to consider both how much they work and how able they feel to manage the volume of work that they have. The implication of these findings is that for physicians (and perhaps psychologists), wellness involves more than self-care of breaks, exercise, and stress management.

Wellness on a Budget

One of the approaches we recommend for work with physicians "wellness on a budget." Commonly, physicians insist that there is no time for self-care, but this may be a cognitive distortion. We routinely work with physicians to improve wellness by employing creativity and negotiating discrete bits of time to demonstrate that even five minutes can boost feelings of wellness. We can tailor our wellness strategies to the time available. Please see Table 1 for suggestions regarding wellness activities.

Table 1. Wellness Strategies.

Time required Activity
  • Communicate to trainees that wellness is important, even if it can't be ultimately achieved right now
  • Set quarterly wellness goals for oneself with a supervisor or colleague
  • Put wellness on the agenda for faculty meetings and staff meetings
  • Schedule fun outings or events after hours
  • Set up sports teams or spectator outings
  • Create a fun work environment - playfulness
  • Send out a weekly email reflection
  • Demonstrate appreciation
  • Develop a list of PCPs in the area who are known to be good and who accept the insurance provided by the institution
  • Develop a list of psychologists, psychiatrists, social workers, and counselors who know how to work with physicians or psychologists and who accept insurance provided by the institution
  • Emphasize this upon orientation and post it where openly accessible
  • Send "Piece of My Mind" from JAMA
30 - 60 minutes
  • Conduct a meditation, guided imagery, or visualization
  • Have a mini-consultation or reflection group
  • Watch a TED talk together and discuss how it is relevant to your work
  • Journaling with specific prompts relevant to your work setting
  • Gratitude is renewing to our souls. Provide cards, stamps, and 15 minutes. Have psychologists write a thank you letter to someone. Mail the letters for them.
  • Watch a powerful video: Struggling in Silence: Physician Depression and Suicide (American Foundation for Suicide Prevention)
  • Do a values auction (Create a long list of values, particularly career related ones such as "autonomy", "flexible work hours", and "high salary." Write values one at a time on index cards. Give each participant a set amount of money. Auction off the values one at a time. People will not know what values are for sale ahead of time, and there is no additional money. Discuss the results at the end.)
  • Create a list of positive comments about a group of people and give it to them
  • Do something fun (jokes)
  • Have the program director or faculty member take trainees out to lunch, and discuss stresses specific to your specialty, as well as "lessons learned" for coping with stresses
  • Conduct the gratitude reframing exercise with a tennis ball (ask a participant to identify a stressful situation, then throw the tennis ball to another participant who must reframe the situation. Example: "flat tire = maybe missed an accident on the way." Continue until no other reframes are identified, then start a new stressful situation).
  • Ask a nutritionist to come and speak about healthy ways to eat on the run. Specifically ask for nutrition information about energy drinks.
  • Provide trainees with their personal statement from their application. Ask them to read it with reverence. Some portion of that self is still with them.
  • Have a monthly support group
  • Administer a measurement tool (Physicians Wellness Inventory; Maslach Burnout Inventory), give feedback, monitor in a safe way
  • Engage in a group goal--Biggest Loser, or training for a marathon, or fundraising for something specific
  • Have exercise breaks
A half or whole day
  • Go off site if possible; arrange coverage by offering to hold pagers for another program's wellness day if they will hold yours
  • Wellness conference with breakout sessions
  • Team building with ropes course
  • Reflective writing
  • Service Learning project: clean up a river, serve at homeless shelter, contact organizations marketing department to see about possibilities

Back to Psychology

We believe that psychologists have something to learn from how physicians have addressed various aspects of occupational distress and work satisfaction. Psychologists should aspire to flourish and not just survive. In order to achieve this goal, both internal and workplace factors should be considered. Psychologists may consider working in team-based care and in organizations whose values align and that minimize unnecessary administrative tasks. Health care organizations may do well to provide in-house stress management and mindfulness skills, as well as confidential, free counseling.

One area that we consistently draw attention to is the need to incorporate strategies for wellness within training settings. New physicians and psychologists are inheriting our flawed work environments and should be coached on realistic strategies to work toward wellness. Barnett and Cooper (2009) argued that the profession of psychology needs to do a better job of educating graduate students about self-care and burnout. We would add that graduate programs also need to educate students on wellness and resilience. Bamonti et al. (2014) reported that only a minority of graduate school handbooks have any sort of statement on self-care. These statements do not address wellness promotion or flourishing. We agree that education regarding burnout is necessary and important, but graduate programs in psychology need to help future professionals to reflect and find purpose in work as a long-term aspirational strategy for fulfillment. Programs should assist students to consider work with organizations with similar values. As well, students need to learn more about research on positive work environments that will perhaps decrease distress.

Opportunities to learn advocacy skills would be helpful to empower future psychologists to ask for workplace interventions that decrease distress. In conclusion, we believe that psychologists can learn from our conceptualization of physician wellness. Career Meaning, Lack of Distress, and Cognitive Flexibility are facets that resonate with psychologists given our educational and experiential backgrounds. As psychologists continue to move into medical practice settings, there is a risk of over-identifying with some of the negative aspects of the culture of medicine, particularly its history of self-denial in service of others. Further research into realistic strategies that enhance wellness of both physicians and psychologists is needed. We suggest that the Physician's Wellness Inventory might provide one avenue of research illuminating how changes in workplace demands for psychologists affect various aspects of functioning and psychological health.

The Scale

We recently completed development of the Physician Wellness Inventory, but we have not yet had the opportunity to explore the application of the scales among physicians other than family doctors. We are beginning to examine the usefulness of the PWI among physician trainees of all specialties but are in the data collection phase. From an intervention perspective, we have routinely used it as a way to begin the conversation with individual physicians about one's wellness. Having a conceptual definition of wellness specific to physicians (high Career Purpose, low Distress, and high Cognitive Flexibility) has led to fruitful discussion of wellness strategies for individuals and training programs. This work can be more supported in the future with research to examine what strategies lead to improvements in which subscales as well as improvement overall. We have also not examined the applicability among other health care professionals. On the face, the PWI appears relevant to other providers, such as psychologists. At the same time, we suspect that different health care professionals may have differing values. As we mentioned previously, although we asked physicians about diet and exercise, these factors did not significantly load onto a PWI scale. These may be stronger factors among psychologists. The PWI is available in the public domain for others to use. We encourage researchers to examine its validity and utility among psychologists, and we give permission to alter the items to better fit psychologists' unique workplace demands. Our findings emphasize that physicians and should begin to consider how the work that they do relates to wellness. Given the similarities in the professional roles, psychologists may wish to do the same.

References available at

Appendix 1. The Physician Wellness Inventory.

Circle the number in the appropriate column Strongly Disagree  Disagree  Neutral  Agree Strongly Agree

1. Working with patients brings me satisfaction.

1 2 3 4 5

2. I often see more than one side to an issue.

1 2 3 4 5

3. Over the last month, I have been bothered by feeling nervous, anxious or on edge.

1 2 3 4 5

4. During the last month, I have been bothered by little interest or pleasure in doing things.

1 2 3 4 5

5. I feel a spiritual purpose or connection in my life's work.

1 2 3 4 5

6. I am open to new ideas and ways of doing things in the workplace.

1 2 3 4 5

7. During the past month, my inability to control my distress has negatively affected the care I give patients.

1 2 3 4 5

8. I spend time reflecting on things I can improve about myself, my life, and my professional role.

1 2 3 4 5

9. Over the past month, there has been a patient encounter that distresses me.

1 2 3 4 5

10. My work brings joy to my life.

1 2 3 4 5

11. I am generally satisfied with my career choice.

1 2 3 4 5

12. During the past month, I have often been distressed by administrative demands that compete with clinical duties.

1 2 3 4 5

13. Positive patient relationships outweigh negative patient relationships.

1 2 3 4 5

14. Feeling compassion for others is a regular part of how I work.

1 2 3 4 5

CP: Career Purpose assesses the meaning of your work.

Total items 1, 5, 10, 11, and 13 and divide total by 5.

Mean: 4.12  SD: 0.66

Your score __________________/5=_____________

D: Distress assesses emotional distress and stress specific to physician responsibilities.

Total items 3, 4, 7, 9, and 12 and divide total by 5.

Mean: 2.85  SD: 0.83

Your score __________________/5=_____________

CF: Cognitive Flexibility assesses open minded-ness and the ability to see different perspectives.

Total items 2, 6, 8, 14 and divide total by 4.

Mean: 4.25 SD: 0.46

Your score __________________/4=_____________

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