“Breaking Bread” to Combat Burnout

Article · March 14, 2019

We were into our dessert course when a physician in her early 40s stood up to summon the attention of the dozen guests around the table.

“I’ve been practicing for 15 years and I’ve never felt more connected to my colleagues than I do at this moment,” she told those gathered. “I came here tonight ready to leave medicine. And I’m leaving here tonight feeling like I’ve finally found my tribe.”

Her colleagues in the room clinked glasses, wiped tears, and nodded in agreement. Within a few minutes, as plates were cleared, plans were made for book clubs, storytelling nights, and workplace incubators. Three hours and four courses later, community was beginning to form.

In early 2018, Primary Care Progress — an organization working to strengthen the health care community — embarked on an initiative to better understand the community of care in the trenches of American medicine. We wanted to go beyond the well-documented drivers for the rising rates of burnout and professional dissatisfaction; instead, we were curious if there were consistencies in drivers of fulfillment. Our study took us to 34 states to interview hundreds of primary care clinicians, host more than 50 dinners with health care providers, speak at dozens of gatherings, and facilitate 15 focus groups.

In our pursuit of clinician fulfillment, we indeed discovered a powerful and prevailing theme — connection. But where we found the greatest spaces for connection — the presence of connection and the opportunity to cultivate greater connection — was perhaps the bigger surprise: dinner.

The Power of Breaking Bread

There’s little doubt that the experience of sharing a meal can be transformative. It’s part of our collective experience — even our history, what Winston Churchill coined “dining diplomacy.” In June 1790, over boeuf à la mode, Thomas Jefferson, Alexander Hamilton, and James Madison negotiated a deal for the federal government to assume state debts. One hundred and seventy years later in New Orleans, over spicy gumbo at Dooky Chase’s, Rudy Lombard, Cecil Carter Jr., Lanny Goldfinch, and Oretha Castle planned a sit-in down the street at McCrory’s whites-only lunch counter, a key moment in the fight against segregation. And then there are the examples in Biblical tradition — from the bite of an apple to 5,000 fish to the Last Supper.

Again and again, food has been a vehicle for connection, community, and social change. In the medical world, the connection is even more direct, with Hippocrates saying, “Let food be thy medicine and medicine be thy food.” Which begs the question: Could this simple act of breaking bread be a tool in the fight against burnout?

So far, the answer is a resounding “yes.”

The Decline of Community

In a recent article in the Annals of Family Medicine, Dr. John Frey bemoans professional loneliness and the loss of the doctors’ dining room. Frey notes of his early days in medicine, “On the second floor was the . . . cafeteria. At 11 pm, the cafeteria was opened. Probably 60 house staff and almost equal numbers of medical students showed up every night to talk about admissions and stories from the day and drink coffee. We were exhausted, but life was vivid and memorable and collegial . . . . When I started practice at a community health center in a new family medicine residency program, the four faculty members at the clinic would have lunch most Wednesdays at the corner booth at a local Chinese restaurant . . . . We talked, as Lewis Carrol put it, ‘. . . of many things: Of shoes — and ships — and sealing-wax — Of cabbages — and kings.’”

In many ways, Dr. Frey is describing the bygone era of salons. With their roots in 16th-century Europe, salons were gathering places to quite literally feed a person’s quest for connection, inspiration, and insight. They were a blending of the emotional intimacy of the family meal with the drive for professional engagement and social change.

Fast forward to modern America, and along with salons, we’ve lost so many vehicles for connection and social change: the closure of churches, fraternal societies, and bowling leagues, as well as the loss of both colleague lunches and family dinners.

Many point fingers at technology, beginning with the advent of air conditioning that moved people from fanning themselves on front porches with their neighbors to closing windows and doors to keep the cold air in. And then there’s the mobile phone that has diverted eyes from people to screens and hands from pats on backs to taps on keyboards. For clinicians, the electronic health record (EHR) is routinely and justifiably blamed as accelerating the demise of the patient-provider relationship.

But whatever the culprit, community is the victim. And when we lose community, we lose so much more than the soul enrichment and physical benefits of connection; we also lose a kind of fellowship that breeds insights and innovation. We no longer make the time nor have the space for people to come together to think, connect, and be restored.

The Rise of a Disconnected Workforce

This loss of community is painfully evident among America’s burned out health care workforce. A September 2018 report from the Physicians Foundation found that 78% of doctors report the symptoms of burnout. Physicians have the highest rates of suicide in the nation. Interns experience a tenfold increase in depression in the first year alone.

This comes at a time when we’re seeing increasing attention paid to the epidemic of isolation nationwide (the objective measure of how large a person’s social network is) and loneliness (a subjective perception of how a person feels). The former is a risk factor for the latter, and the latter touches one in three older Americans. Former Surgeon General Vivek Murthy, MD, calls loneliness the greatest epidemic of our generation. In fact, loneliness is nearly as prevalent as obesity and even more deadly — as risky to health as smoking 15 cigarettes a day, shortening our lifespan by 8 years. Doctors understand better than anyone how our solitary existences impact health, with health systems leaders like Sachin Jain, MD, exploring ways to push for the prescription of friendship through interventions like weekly “phone calls, home visits, encouragement, and connection to community-based programs” for patients who report being lonely or who have limited social ties.

Most interesting for these epicurious researchers is that according to the U.K. Campaign to End Loneliness, 35% of individuals experiencing loneliness report that sharing a meal is the activity they miss the most.

The Factors Driving Fulfillment

As Primary Care Progress listened to stories of burnout and fulfillment, it was clear that the themes playing out nationally — crises of community and feelings of loneliness — were especially felt in health care. It was like the space of the clinic was a distilled amalgam of America’s ills.

As we engaged in conversation after conversation, a pattern emerged. Like Tolstoy, who posited that, “All happy families are alike; each unhappy family is unhappy in its own way,” we discovered that across specialty, geography, career stage, and job type, the drivers behind burnout were varied. The driver behind fulfillment, however, was the same: connection — to patients, to purpose, and to peers.

Health care leaders, to their credit, are jumping on any shovel-ready project with a modicum of promise and some element of “togetherness” — from mandatory mindfulness sessions to group yoga. We also understand the power of a phenomenon known as positive contagion — that is, the organic spread of positivity. Just take the findings of a report in the American Psychology Association: People with happy partners are significantly more likely to report better health, experience less physical impairment, and exercise more frequently than participants with unhappy partners.

The question, then, becomes: How we can create community among health care providers that has the power to spread?

The Birth of a Movement

David Brooks argues in a piece in the New York Times that a renaissance is occuring in American communities across the country. Citing James and Deborah Fallows’ book, Our Towns, he finds that “as the national political climate has deteriorated, small cities have revived. As the national scene has polarized, people in local communities are working effectively to get things done.”

Could that be true of the increasingly polarized and dysfunctional health care system? Could hundreds of nationwide, local gatherings over dinner salve the healer’s soul and ignite a kind of revival of connection and purpose in health care? The jury is still out, but the early wins are compelling.

Just take one dinner we hosted in the fall of 2018. As we were enjoying barbecue and beer with a dozen residents and faculty in rural Arizona — strangers to each other despite having worked in the same area for years — it took clinicians only a few appetizers before they began connecting around the things they have in common: shared experiences, similar backgrounds, what they love about their work, how they deal with their frustrations. The stories kept coming and coming. It was remarkable how buoyed they became when they discovered that they weren’t alone — when their ideas were listened to and their values and aspirations welcomed with curiosity and exploration.

It was intended to be an hour and a half; they stayed for nearly three. They moved from the complaints of the present to the possibilities of collective action. And in that experience, a community of peers and change agents was born.

Dozens of gatherings later, and the examples abound. In late August, we hosted a dinner for physicians of color in Atlanta. As we approached the topic of race in the clinic, one clinician offered an incident that had occurred just days prior, when a patient refused treatment, insisting he be seen by a white doctor. It was a sensitive dialogue. After listening empathetically to the experience, a colleague piped up, “Are you looking for support or a second opinion?” The women spoke of actions and reactions — shared traumas and the impact of bias. It was powerful in a way I didn’t understand until several days later when one of the doctors reached out. She had just experienced the very same episode in her own clinic. But rather than being stunned into inaction, she was able to respond in a way that felt authentic and empowering. More importantly, she didn’t have to push down those feelings; she slipped into her office and sent her colleague a note.

She had found her tribe — and with it, her voice.

Experiences like these confirm both our beliefs and our research. Will a shared meal with a colleague eradicate burnout and revolutionize care? Maybe not (fixing the EHR and abandoning prior authorization would go a long way). But our army of providers in the trenches of care need to eat. Let’s see if we can feed their bodies and their souls, and in doing so, bring community back into care.

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