Health behavior was my emphasis in my MPH. Add a faculty development fellowship, time as residency faculty, work in a private practice, and increasing interaction with medical students now as faculty at a medical school; the outcome is not just an emphasis, but a mindset. A mindset of health behavior that is not just for patients, but for physicians, as well.

I must have company in this concept as ten invitations to various conferences on physician wellness are in my inbox, and multiple workshops at an upcoming annual conference for many of my fellow family physicians in Seattle are dedicated to these topics. Rather than continuing to “TED talk” the problem of physician stress, though, the following article will use health behavior theory to consider an intervention that could begin to change the specific behavior of physician stress.

Stress is defined in multiple ways by Merriam Webster. Here are two of them: “A physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation,” and “a state resulting from a stress; especially one of bodily or mental tension resulting from factors that tend to alter an existent equilibrium.”

The factor may not be changeable, but the state is.  Let’s hypothesize that an intervention that targets a state resulting from stress will, in fact, reduce the exposure related to the factors leading to a primary outcome of “healthier” physicians. From a research design perspective, I acknowledge that this is a terrible primary outcome due to its vagueness. The determination of “healthy” is subjective, therefore ripe for a qualitative research design to be best defined.

Within health behavior theory, a transactional model of stress and coping does exist, but let’s instead apply the health behavior transtheoretical model to the physician state of stress. This model includes the familiar stages of change construct, as well as the less familiar processes of change.

The first four processes of change are consciousness raising, dramatic relief, self-reevaluation, and environmental reevaluation. All are fairly self-explanatory with the exception of dramatic relief, defined as the “experience of the negative emotions that go along with unhealthy behavior.” This definition is referenced from Karen Glanz, Barbara Rimer, and K. Viswanath’s text, Health Behavior and Health Education, Theory, Research, and Practice. In applying the transtheoretical model, health behavior change in human beings, including physicians, begins with four processes of self-reflection.

Self-reflection is a key process in medical and graduate medical education reflective practice writing, a strategy which helped many of us analyze the impact we have on our practice of medicine.  Self-reflection can continue to help us understand how the practice impacts us, can get personal, and so would happen ideally through personal and consistent journaling.

This theoretical lead-in is important as many humans, including physicians, are resistant to self-reflection and change. According to our construct, all change requires self-reflection and may actually happen as a result of it.  From this analysis, I have concluded that all physicians (including medical students) should journal as a strategy for beginning the process of any change they might wish to see in their health behavior and life. Business literature presents this as well. Specifically, Greg McKeown’s book, Essentialism: The Disciplined Pursuit of Less,  describes the discipline of journaling as primary among many successful leaders who have also revealed themselves as “essentialists.”

A study published in 2015 and presented on NPR that same year reported a simple intervention of consistent journaling in a cohort of college freshmen that led to significant increases in overall success (through a variety of outcome measures) especially among gender and ethnic minorities. Journaling won’t be the only intervention in the process of health behavior change, but it seems to be an imperative first one.

Whether any of us make changes as a result of resolutions on the first of January is debatable, but motivation for health in my family and I (or wellness or balance or happiness or whatever you call it) has actually moved me through the stages of change from pre-contemplation to action. I’ve never been so motivated to make a change to a habit in my life than when I’ve felt at my worst. Specifically, in an effort to simplify things at home, I took time to clean out my office. I found a stack of journals representing my life that ended up filling three storage containers. In 41 years, I could see that I’ve been at my healthiest when I was consistently self-reflecting and journaling as a daily discipline.

My husband (a pediatric urologist) and I will join an amazing group of couples as we facilitate a workshop at an upcoming conference called Families in Family Medicine. Perhaps habits are present in you or your families’ lives that you’d like to change. Perhaps you have habits that have preserved your health and the health of your family. In this workshop, we will spend the morning in self-reflection, journaling, and literature review followed by an afternoon of group discussion, strategy sharing, and peer support (all additional processes of change in the transtheoretical model).

Self-reflection through journaling is a start, but shared strategies through community is another intervention that will keep all of us well or healthy or balanced or happy or whatever you want to call it.

Amanda S. Cuda is a family physician.

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