I received an automated nastygram that I was delinquent on my wellness modules. The irony made me spit out a snarky laugh and clench my teeth. I forced myself to log in to the program, and with every brightly colored suggestion to take a deep breath or feel grateful I became more and more annoyed.

Wellness and physician burnout are all the rage. As an integrative palliative medicine physician, you would think that I’d be waving the wellness module flag. I have been trained by the Stanford Medicine WellMD Center and co-run a physician wellness committee. I’m all in on team physician wellness.

Yet the infantilizing and superficial approach that some institutions adopt, is tone deaf, counter-productive, and insulting.

“Come to yoga Fridays at 7:30pm”

“We offer meditation class before work every Tuesday.”

“Just be sure to increase your RVUs, empty your patient portal inbox, and get your pre-authorizations done. Sorry, we don’t have the budget for more support staff.”

I’m being a little harsh. I do appreciate that there is increasing awareness of physician burnout and that efforts are being made to address it. Yet physicians who are stretched so thin that you can see through them, can’t simply add tai chi to their overflowing to do list and suddenly feel well.

Depression in physicians-in-training is associated with suicidal ideation, motor vehicle accidents, and medical errors; an increase in work hours is associated with higher levels of depression (Pereira-Lima et al 2019). The level of resident depression is consistent within certain programs, suggesting that it is not simply the work, but also the working environment, that impacts mood (Pereira-Lima et al 2019). Therefore, programs that aim to improve physician burnout must also assess the working environment when constructing a wellness plan.

Interestingly, high patient satisfaction scores were associated with higher levels of emotional exhaustion in attending physicians (Windover et al 2018). This is perhaps not surprising because patients may appreciate physicians who give of themselves without limits, but this approach can leave the clinician feeling depleted over time.

Some of the language that is commonly used when discussing burnout can be problematic. For example, when we talk about resilience, and efforts to increase it, it implies that physicians are burned out because they are not sufficiently resilient. That it is somehow their intrinsic lack of grit or fortitude that leads to their burnout, rather than insufficient staffing or ever-increasing RVU requirements.

That said, some people do seem to suffer more than others, and there are interventions that can make tough situations feel less oppressive. So, should exhausted physicians be doing hospital-provided yoga after all? Does the system need to change or do physicians need to change?

The answer, of course, is nuanced and complex. Both the system and the physicians have a role in preventing burnout and facilitating physician wellbeing.

The model that I find the most useful is to assess and address the “fullness of your cup.” I use a cup because I like the image of a steaming cup of coffee or tea, but you could use the image of a gas tank if you prefer.

If your gas tank is empty, your car won’t move. Even if you’re resilient, or tough, or grateful. Where you stopped is where you’re staying until somebody puts the right oily fluid into that tank. Your gas tank might be empty because it has a hole and the precious gas is leaking onto the road, or it could be empty because you’ve been using it up and have neglected to fill the tank from the top. If both conditions are present, and you have a leaky tank that is never topped off, the tank will be bone dry in no time.

Cup emptiers and cup fillers are highly individual. For some people, running five miles fills their cup while for others that would be an uncomfortable and exhausting cup emptier. Some people find that yoga, meditation, guided imagery, or qi gong effectively fills their cup, while others lean more towards listening to classical music, cooking, or snuggling with their dog.

There are some fairly universal cup emptiers, such as fighting with a loved one, worrying, and not getting sufficient sleep. Yet otherb are individualized. For extroverts, spending hours in a group of boisterous friends is a cup filler, while for the introvert that same event can be a powerful cup emptier. Work can be a cup emptier or filler, depending on the day. Often it is both.

The key is for each of us to keep an eye on the fullness of our cup and take steps to both plug the leaks and actively pour into the vessel from the top.

What empties your cup?

Spend a few moments writing down the things that empty your cup. They could be physical experiences, such as pain or constipation. They could be states of mind, such as worry or grief. They could be habits such as staying up too late, not moving enough, or eating a lot of junk food. They could be things at work such as patient portal messages, charting, or working late. They could be things at home such as fighting with a spouse or kids not going to bed on time. Perhaps you’re overscheduled or your dog pees in the house. Write down as many cup emptiers as you can think of. What you’ll notice is that some of them are within your control, while others are not. This is an important distinction. Spending time agonizing about cup emptiers that are not within your control, such as a loved one’s illness or advancing age, only empties your cup further.

What fills your cup?

Now write down things that fill your cup. They could be people or pets, or small moments in your day such as the first sip of coffee. Your cup fillers might include yoga or meditation and if they do, that’s terrific. But if yoga and meditation don’t fill you up, that’s OK too. If that’s you, don’t get up early for Tuesday morning hospital-based yoga class. Maybe your favorite cup filler is dancing to upbeat music in your kitchen. Maybe it’s playing the violin or digging in the garden. Maybe it’s knitting or drawing or practicing Italian verb conjugations. It isn’t about the thing, it’s about what the thing does to the fullness of your cup.

When you are contemplating an activity, ask yourself “is this a cup filler or a cup emptier?” Circle three of the cup emptiers and fillers from your list, focusing on the ones that are within your control. Choose options that you are motivated to work on. Perhaps you want to work on: not staying late at work, getting more sleep, and being less cranky with your kids. What will help you do that? How about a timer during your patient visits, a decision to be in bed by 10:30pm, and listening to a relaxation tape after dinner. Try to structure your day to do more cup fillers and fewer cup emptiers. This is the best path to wellbeing and burnout prevention.

What is easy to say is often challenging to implement. For example, you may have written down that seeing 28 patients a day is a cup emptier. If you’re employed and you’ve chosen that cup emptier to work on, you may need to request a lighter schedule. That will result in a smaller paycheck so you might need to talk to your spouse. Your request might be denied, so you might need to consider seeking another job. The point here is to focus your interventions on the cup emptiers and fillers that are within your control and will have the most impact on your wellbeing.

Life can be hard.

Practicing medicine can be hard. Yet when we are depleted, when our cup is empty, hard things are even harder. Each of us drains and fills our cup in unique and individualized ways; this is why ‘one size fits all’ wellness programs simply don’t work.

Keep an eye on the fullness of your cup and make it a priority to keep it more than half full. This may require that you stop some cup emptiers and add in some fillers. Your plan will look different than mine and that’s just fine.

So, the next time you get an email from your hospital about a new wellness program, your question to yourself should be “will this fill or empty my cup?”

Imagine if we had been taught this in medical school. If instead of simply sucking it up as more work got piled onto us, we were able to construct a life where our cup stays mostly full. What if we had a shared language and supportive culture so that a colleague would feel safe to say, “you know, my cup is bone dry right now I just can’t take on another committee,” and we would fully understand and applaud their self-awareness.

We can create this shared language and culture if we do it together. We don’t need to accept the culture of rigid self-sacrifice that many of us were trained into. Let’s work on ourselves so we can be there for each other.

This is the kind of burnout prevention that I can get behind.