I have confessions to make about self-care and avoiding burnout that will surprise and may even shock you. As it happens, much of (but not, as you’ll discover, the most important part) my own self care routine was installed over the seven weeks from March 25th until May 13th of New Zealand’s Level 4 Alert response to COVID-19. Before we get to the specifics, I’d like to start with my story of how life seemed to change in New Zealand during our ‘lockdown’. After all, what better year to be pontificating on the importance of looking after ourselves than 2020?

When NZ entered Alert Level 4 we were asked to stay home, stay local, only be in near physical contact with those we were already living with, wash our hands, and to be kind. All businesses except those providing essential services were to remain closed, with travel only permitted for people providing those services. The centre of Wellington where I live fell near silent, the perpetual weekday hum of vehicles and commerce replaced by birdsong. The streets emptied of traffic, and my bicycle commute to work became quicker, more enjoyable, and felt infinitely safer. A few weeks in, I noticed entire families out biking together. When I walked, the air was clearer and people I’d never met smiled and said hello (while keeping their distance). I felt inspired to go out running daily, and I noticed hundreds of other fellow runners and walkers out too, spilling out onto the roads whenever we pleased. A usually near deserted local park came alive: people worked out in the sun, kicked about balls, threw frisbees, or exercised pets in their ‘bubbles’. And it really did feel like we all shared a common purpose as part of a ‘team of 5 million’.

For my part, despite continuing working, I slept well, exercised, ate healthier than ever, enjoyed the end of summer sun, and read a lot of books. While I know many people’s experience of lockdown was one of stress and uncertainty, I suspect I was not the only one making the most of some of its positives. On May 13th we started ‘reopening’. Cars returned to the roads en masse. Promised temporary bike lanes were largely forgotten and then vociferously opposed by business owners. Our air quality reduced back to ‘normal’. One of the most eagerly anticipated and celebrated changes here was the reopening of fast food restaurants: New Zealanders queued for hours (usually in their cars) to pay for highly processed, low quality food. Noise returned to the centre of our cities, and the birds disappeared. The local park fell back into disuse, people went back to minding their own business, and fewer ran or walked when I did. Now, even though we are still not 100% open for business, life for the most part feels 100% where it was prior to March – with a few exceptions, we are back to ‘normal’. I would hazard a guess this is similar in most parts of Australia too.

This begs the question of what ‘normal’ means when it comes to the lifestyles and self care of New Zealanders and Australians in 2020? Well, it is normal for about 2 in 3 of us to be overweight or obese, and it is normal for about 1 in 3 of our children to also be overweight or obese^1,2. It’s also normal for over two thirds of Australians and close to half of New Zealanders not to manage to eat even 2 servings of fruit a day^3,4. It is normal for less than 4% of Australians and less than 1% of Australian children to manage to eat the minimum recommended amount of vegetables, beans and legumes³. In New Zealand, it’s normal for over a third of us to consume less than three servings of vegetables a day⁴. In New Zealand and Australia it is normal for about half of us not to meet the recommended minimum physical activity levels (30 minutes a day, 5 days a week)^5,1. It’s normal in New Zealand and Australia for over a third of us to sleep less than 7 hours a night^6,7. It is also normal for stress to affect the mental health of almost two thirds of Australians, and for almost two thirds of New Zealanders to report being stressed weekly^8,9.

However, I’m writing for a specific audience here. We health practitioners spend years training and a career learning not only to understand the importance of health, but also that nutrition, physical activity, sleep, relaxation, and connection are all important to achieving and maintaining it. This intensive, ongoing education should be reflected by a group of professionals role modelling healthy behaviours and presumably demonstrating better health outcomes than the general population. The reality is that health practitioners do not fare much (if at all) better. In the United States, 53% of primary health care physicians are overweight or obese, and in England almost 86% of nurses and 63% of other health professionals are too^10,11. In Scotland, two thirds of nurses and over half of other health professionals do not meet the government guidelines for fruit and vegetable intake¹². Almost a quarter of hospital doctors in Ireland are physically inactive, and in Scotland, almost half of nurses and other health professionals failed to meet physical activity guidelines^13,12. In the US, physicians average 6.5 hours sleep a night, and a study of California physicians found over a third reported getting six or fewer hours of sleep^14,15. In this same study over 53% of physicians reported experiencing moderate to severe stress, and the findings of a number of other studies show almost half of physicians reports symptoms of clinical burnout^14,15.

Therefore, somewhat staggeringly, what is normal for the general population is more or less normal for health practitioners too. Presumably then, a factor that is largely shared with the general population contributes to our lack of self care and high levels of burnout. What is it that stops us from regularly engaging in the very lifestyle habits we know are essential to health and that we ourselves recommend to our patients? A clue is that medical students are universally recognised as also faring pretty poorly. Nearly 7 out of 10 New Zealand medical students can be classified as disengaged, and almost 8 out of 10 suffer from exhaustion¹⁶. Over a fifth of them report currently seeing a health provider for mental ill-health. Australian medical students also report higher mean depression, anxiety and stress scores than the general population¹⁷. We also know that medical students are more likely to report depressive symptoms than are other students¹⁸. The remedy, of course, appears no different than what we would expect: Australian research has demonstrated that higher levels of self-care among medical students are associated with lower levels of psychological distress¹⁹.

Most of us can probably hazard a guess as to the cause of medical students’ woes. I vividly remember the heart-sink moment during my interview for medical school when one of the interviewers explained that many first year students study 60 or more hours a week. Obviously I managed to recover from this untimely revelation well enough to pass the interview, but sadly this turned out to be a fairly accurate representation of the workload and required time commitment.

Could it be then that the reason most of us aren’t as healthy as we should be, and that we are stressed and burned out, is simply that we are all working too hard and too much? I believe so. It would be hard for our ancestors to fathom that despite the panoply of labour saving devices now deployed in the workplace and the majority of women (rightfully) entering and remaining in the workforce the ’40 hour’ work week that was established in New Zealand 180 years ago this year has remained exactly that for most of us (and an aspirational luxury for others). Without even considering the time spent preparing for, travelling to and from, and unwinding from work, almost all of us spend the vast majority of our daylight hours and at least half of our waking hours working. And we expect to do this five out of every seven days for all of the best years of our lives. It should come as no surprise then that the things that we need to do in order to be healthy become an afterthought for most, including, as we have seen, even the group of workers who arguably should be the most highly informed and motivated to engage in these.

Level 4 gave us a tiny glimpse of what our society might look like if we had more ‘spare’ time. New Zealanders apparently decided to increase their activity levels en masse. Old hobbies were returned to, and, where possible, new ones embarked upon. People had time to spend with their families, pets, and even to communicate more intentionally with their friends using the various technologies available to us. A cynic might contend that we were just choosing to do so because there was little else that could be done, but regardless of motivations there are surely benefits for our health and happiness in having more sovereignty over how we choose to spend our time (which after all is our most important and finite resource). Some will contend that our current hours of work maintain our expected levels of wealth and productivity, but the relationship between income, happiness, and life satisfaction is complicated: the American Time Use Survey suggests that happiness peaks among those earning between $50,000-$75,000, with people earning $100000 less happy and in fact no happier than those earning $25000²⁰. There’s also been plenty written about the importance of comparative wealth – we actually seem to be happier when we are similarly well off to everyone else around us. The same American Time Use Survey also reveals, consistent with our earlier hypothesis, that happiness and sense of purpose are at their highest among people working between 21 and 30 hours a week²⁰.

Even when it comes to productivity, it’s far from clear that there is a linear relationship between hours worked and productivity achieved. Inspired by an article citing studies of office workers in Canada and the UK that revealed they were productive for 1.5-2.5 hours of a typical work day, New Zealander Andrew Barnes of Perpetual Guardian began trialling a 4 day work week for his staff in 2018. Productivity, engagement, job satisfaction, work-life balance and employee wellbeing all improved (you can watch him tell this story in this TedX talk). It is also ‘normal’ for most of us not to be particularly enjoying work: Gallup has been tracking employee engagement in the US since 2000, which has reached a new ‘high’ this year of 40%²¹. Their often cited (but comparatively dated) worldwide analysis suggested the number was a mere 15%, with Australia and New Zealand faring slightly worse with 14% of our workers being engaged in their jobs²². Finally, it is worth mentioning that the pandemic has also provided a visually striking insight into the effects of our current work at all costs model on our environment – the many before and after pictures illustrating rapid improvements in air and water quality truly are worth a thousand words.

So this leads on quite nicely to my confessions. Firstly, one of the main self-care measures I take is working only 3 days a week. The fact that this may shock or unsettle, that I feel somewhat guilty about this, and also that I am adding the caveat that I use the extra two ‘work’ days largely volunteering my time to organisations (and occasionally doing private consultations) demonstrates the pervasiveness and power of the concept that we each have a societal responsibility to work away most of our lifetimes (see David Frayne’s rather excellent book The Refusal of Work for a very interesting discussion and critique of this²³). I do appreciate that I’m privileged to be in this position, but I also believe that finding ways to spend less of our time on or at work, when we are able to, can be something very positive for both our own and our society’s health and wellbeing. At the very least, enabling people to pursue more flexible work arrangements, such as working from home when feasible and preferred would be a step in the right direction for business and policymakers to consider. Ultimately what is needed is a cultural shift away from only considering and recognising time spent in paid employment as of value, and it is likely that adoption of a guaranteed or universal basic income would go a long way towards this.

My second confession is that I think I could still do a lot better at self-care, and despite the activities that I am currently regularly engaging in to improve my physical and psychological wellbeing (daily bike rides, bodyweight training and running 4 days a week, whole foods plant-based diet, occasional meditation) I still find myself becoming burned out. This may further irritate or even enrage many of you who are needing to work a lot more hours than I am, but I do suspect that when it comes to self-care things are inevitably and unfortunately a little more complicated than just working fewer hours. Furthermore, from a practical perspective for most people it doesn’t seem that the reduction of work hours is on the current agenda, even though there has probably never been a better year for this discussion than 2020.

Fortunately, behaviour change experts like BJ Fogg, PhD and UK GP Rangan Chatterjee may have a solution in the meantime, at least when it comes to helping us to adopt new health promoting habits. In his 2019 book Tiny Habits, Fogg explains that starting with small changes can prove very effective in generating new habits, and in fact in most cases may be the only way these are likely to be maintained in the longterm. Chatterjee argues convincingly that in fact significant time investment is not required for activities to generate noticeable improvements in health and wellbeing. He has written an entire book on this subject providing numerous examples of 5 minute ‘health snacks’ that we can choose from to engage in at times convenient to us²⁴. I’m planning to start following some of their guidance for improving my own self-care, and their ideas and prescriptions should be especially helpful for people on a tighter schedule.

More time for all of us to spend on health promoting activities, and less time to be spent on work should be a goal for our society. Clearly, simply educating people about what they should be doing, and preaching the doctrine of personal responsibility is not working – even for the health professionals who we could expect to be a shining example of doing all the right things. I still have some hope that ideas like the 4 day week may become part of the conversation for the public and our leaders and policymakers as we look to how to respond to the social, economic and environmental challenges currently facing us. I hope also that some of you who may be able to reduce your time spent on or at work feel more empowered and less guilty about doing so. In the meantime, there’s certainly comfort in knowing that even small changes are worthwhile when it comes to improving our own health and wellbeing, and by extension those of our patients.