A new study has found that, between 2011 and 2014, the burnout rate among family physicians increased from 51 percent to 63 percent.¹ Yes, you read that right. Nearly two-thirds of us are experiencing burnout.

In previous articles in this series on physician burnout (see the “Series overview”), we learned that burnout occurs when our mental, physical, or spiritual energy accounts have a low balance over time. To prevent burnout, we have two options:

1. Decrease our energy expenditures by reducing stress (see article two in this series),

2. Increase our energy deposits by finding ways to recharge and create more balance in our lives.

In this article, we will discuss the latter, specifically, four tools for creating work-life balance.

To implement the tools effectively, it is important to understand that work-life balance is not a “problem.” Problems have solutions, but there is no simple, one-step solution to work-life balance. Instead, work-life balance is a dilemma. It is something you must attend to regularly using a multi-part strategy. If you are not paying attention to it at least twice a month, you will be out of balance very quickly. For many of us, this tendency to be out of balance began as early as our premed days.

The reason work and life seem in direct conflict so often is simple. The time and energy required for each comes out of the same pie. Each must take from the other because the pie is finite. Managing this give and take is an ongoing process, but the tools presented in this article can make it easier. We'll get to those in a minute, but first let's address a gorilla.

The 800-pound gorilla

Imagine for a moment that you live with an 800-pound, silverback lowland gorilla in your house. This is a wild gorilla. He is not a circus animal and doesn't know a single trick. Imagine how much of your house this gorilla would occupy and how much space he would leave for you and your family. You would be relegated to just the outer edges of each room, and the gorilla would make a mess wherever and whenever he wanted.

The gorilla is your career. The house is your life. Without strong boundaries and good balance habits, your career will tend to crowd out your life, leaving you just scraps and making messes at the most inopportune times. The career that was supposed to enable an extraordinary life can dominate the house, leaving little room for anyone or anything else.

But all is not lost. This gorilla can be house-trained, tamed, and shown healthy boundaries. It is your job to do this for yourself and your family. It will take a strategy to manage this balancing act. Here are four tools that I have field tested and found effective with my coaching clients.

Tool #1: The life calendar

One of the laws governing your work-life balance strategy is “the strongest structure wins.” By “structure,” I mean the calendar you are probably carrying on you right now.

If I asked you to hand me your calendar, what would I find? It would probably list your work commitments, but would it include the following:

• Your spouse or significant other's schedule?

• Your children's schedule?

• Your workout schedule?

• Your next date night?

• Your next vacation?

• Some blocked-off free time for yourself (heavens, just imagine that for a moment, will you)?

Anything not on the calendar you are carrying around with you is not likely to happen. Therefore, one of the keys to taming the gorilla is to create a life calendar and carry it with you at all times.

Creating a life calendar doesn't require you to purchase or learn any new technology, and maintaining it takes only 20 minutes a week. Here are the things you'll need:

• A simple paper calendar (you probably have one at home hanging on the side of the refrigerator),

• Some colored pens,

• Your cell phone.

Here's the three-step process:

Step one: Build your life calendar for the week ahead. Pick a time in the week when everyone in your family or household is available. A popular time is Sunday after church and before football. Pull that paper calendar off the fridge, grab the pens, and put them all on the kitchen table. Gather everyone in the household, and build your life calendar for the week ahead.

Think about not only the regular activities your family has planned but also what you personally want in your life outside of medicine in the upcoming week. Remember, if you don't put it on your life calendar right here and now, it will almost certainly not happen. Here are some things you might want to schedule:

• Workouts,

• Time for writing or journaling,

• Free time,

• Coffee with a friend or relative,

• Time to read a book,

• A class.

Whatever you want, you must put it on the calendar.

The final thing to put on the calendar is the date and time of your next life calendar session. Everyone needs to be clear on when you will meet again.

Step two: Take a picture of your life calendar with your cell phone. Yes, it really can be that easy. Your life calendar can now be in your pocket or purse at all times right there on your cell phone.

Step three: Defend your life calendar. Now you are prepared to say the magic two-letter word that is key to work-life balance: “No.”

With your life calendar in hand, if someone at work asks, “Can you cover a few extra hours on Thursday?” or if someone at your child's school asks, “Can you come to the book fair meeting next week?” you can pull out your cell phone and say, “Let me check my calendar.” If you are already booked, you can say, “I'm sorry, I have another commitment at that time. I won't be able to help.”

As you read the conversation above, did it make you feel a little uncomfortable? If you're like most doctors, it probably did because we are horrible at saying “no.” Our discomfort may stem from being completely out of practice at saying “no,” but that is fixable. Saying “no” is a skill we can practice, and “practice makes better.” We may also be afraid to say “no” because we don't want to be perceived as not being a team player or being weak, imperfect, or unable to do it all. Give that up.

Here is what will drive your discipline to say “no”: When you carry your life calendar, see a conflict, and say “yes” anyway, you will know immediately who you need to get ahold of, apologize to, and reschedule with because you just threw your plans under the bus.

This process works every time you use it. By that I mean your life will be more balanced every week you build your life calendar than if you did not take that 20 minutes to pop it into your cell phone. By proactively scheduling the items you want your family or yourself to be involved in each week, you will have less capacity for those items that aren't a priority.

Tool #2: Intentional date nights

If you think being intentional about date nights isn't a serious issue or has no relation to physician burnout, think again. A healthy relationship can recharge and strengthen you, while an unhealthy relationship can quickly deplete you, and even cause health problems.² My coaching clients have found the optimum frequency for a quality date night is twice a month, minimum. If it has been more than two months since your last date night, you are way overdue. Date nights are not the only way to strengthen your relationship, but they are critically important, so do not skip them. If you do not have a significant other, date night could be a date with someone you'd like to know better, time with a friend, or doing something nice or unexpected all by yourself. (Yes, you can take yourself out on date night, too.)

When you are really busy, figuring out what to do on your date night can seem like just another item on your task list. I encourage you to do an attitude check here. What is more important to you – the 800-pound gorilla or some love, romance, adventure, and fun? Date night is a chance to break out of survival mode and do something extraordinary.

Here are a few ideas:

• Take turns planning your date nights, but keep your plans a secret. Only reveal when to be ready and what to wear.

• Write down several date night ideas onto slips of paper, and drop them into a hat. Pick one, raffle style, and go for it.

• Make it a game, and set rules. Here is a fun one: Your date can't involve calories or money.

• Buy in bunches. In other words, if you have a shared interest and there is a season-ticket option, buy them. This will take care of multiple date nights in a single purchase.

On any date night, even before you order drinks or appetizers, your first action is to schedule the next date night. This way, you will always have a date night on your calendar. If you want to be an overachiever, as most of us do, instead of putting just the next date night on your calendar, schedule out six date nights – three months' worth.

Tool #3: The big bucket and weekly bucket lists

Bucket list (noun): The list of things you want to do before you “kick the bucket.” Bucket lists are important because they encourage you to work toward a goal that is personally meaningful. This sense of purpose and excitement can help boost your energy levels and make you more resilient.

My clients have found it useful to build two bucket lists.

1. The BIG bucket list. This is the classic list of “things I must do before I die.” A common problem with the big bucket list is putting too many things on it. This sets you up for failure. If you have too many items on your list, you will never cross any of them off and you will feel guilty.

Here is a reality check that will dramatically shorten your big bucket list:

• Make your big bucket list. Write it all down, and keep a copy in a folder somewhere.

• Give someone the list, and have them read it back to you one item at a time.

• For each item, take a moment to imagine you fail. Imagine you actually die before accomplishing this task. How does that feel?

• Note which items break your heart when you contemplate them left undone. Those are your authentic big bucket list items, and if you are like most people, your list just got much shorter.

These big bucket list items can take a significant amount of time, energy, or money to accomplish. That is why they lay dormant for so long. Here are two keys to accomplishing them.

First, schedule them. Pick your first big bucket list item. Look out on your calendar as far as you need to in order to find a time that will actually work. It could be one, two, three years out or more. Schedule it anyway. Print out a calendar for that year or month, use a brightly colored pen, and mark off the dates. Hang it in a highly visible spot at home. Go into work and block it off your schedule on the work computer as well. Put a stake in the ground now. It may be something you schedule for one specific time period (e.g., a trip), or it may be something you have to schedule regularly (e.g., writing a novel).

Next, put skin in the game. Buy the tickets. Order the resources or equipment you'll need. Book the cabin where you'll write or study or whatever it might be. Put money down immediately. If you can't make the purchase yet, open a savings account and start putting money away. Whether it is Machu Picchu, Africa, the running of the bulls in Pamplona, visiting the country of your family's origin, a Spanish immersion school in Costa Rica, or rafting the Grand Canyon, get it scheduled and paid for. Nothing will make a doctor take a trip more than putting down cold, hard cash. Afterward, it will take its rightful place in your memories as a peak experience rather than a heartbreaking regret.

2. The weekly bucket list. Is there an activity or experience that turns your whole week around every time you do it? It's the thing that makes you say, “I wish I could do that every week.” Most people know what this item is and yet only manage to squeeze it in every once in a while. Common examples are a workout or sport, play time with your children, a massage, dinner with a friend, painting, playing music, or a religious practice or meditation. Often, these items contribute to larger personal goals, such as physical fitness, healthy relationships, or artistic endeavors.

What are two to three of your weekly bucket list items?

Putting these items on your life calendar is part of carving out time and space in your busy week. Defend these items just as vigorously as you do your work schedule to show that gorilla some healthy boundaries.

Be aware that as you contemplate doing something just for yourself, guilt can surface. A little voice might say, “What makes you think you are so special?” when you are blocking off time for your own personal use. This is your programming, pure and simple. Tell that voice, “Thank you for sharing,” and then block the time anyway. As you give yourself permission to experience the pleasant things in your life, you will see what a difference this can make for you, your home life, and your work life. Taking care of yourself can give you the energy you need to take care of others.

Tool #4: The work-life boundary ritual

One of the keys to being able to recharge when you are not at work is creating a clean, solid, functioning boundary between work and home. This allows you to take the white coat off, leave work at work, and come all the way home.

Have you ever found yourself sitting at home thinking about work? It is almost a silly question. This happens when you miss the boundary. You have never been taught the “off switch” on your role as a doctor.

You can't recharge in this situation. Instead of recovering, you are still being drained by work stress even though you are not in the office or hospital.

Creating a boundary ritual is a mindfulness skill you can learn and practice. It is the energetic equivalent of an off switch on your role as a doctor. Your boundary ritual marks the transition from the environment where the patient comes first to one where you come first.

Fortunately, we have an excellent role model of a boundary ritual – Mr. Rogers. Yes, that one, from the children's television show. His personal boundary ritual had three steps:

1. He takes off his jacket and puts on a zip-up sweater,

2. He changes his shoes,

3. He sings, “It's a beautiful day in the neighborhood ….”

With his boundary ritual complete, he is the Mr. Rogers we know and love for the rest of the show.

I strongly encourage you to develop your own boundary ritual. The most effective rituals involve three things:

• An intention to let go of work,

• A releasing breath,

• An action (change clothes, walk the dog, take out your contacts and put on your glasses, make a nice dinner, etc.).

A friend of mine's father – a small-town family doc – had a very simple but effective boundary ritual. Every day after coming home from work, he would shower and change clothes. He wouldn't talk to his family until this boundary ritual was complete. Afterwards, he was just “Dad” again.

Here is a simple boundary ritual you can use if you drive home from work:

Arrive at home, and park the car. Put your hand on the keys or off button. Say to yourself, “With this breath, I am coming all the way home.” Take a deep breath. As you exhale, release all thoughts and feelings about work. Turn the car off, take the keys out, and step out of the vehicle.

With a boundary ritual, you will find yourself more relaxed at home and thinking less about work. What will your boundary ritual be, and when will you start practicing it?

Pick an idea and take action

As discussed in previous articles, it is easy to read an article like this one, with multiple suggestions, and get overwhelmed. The key is to take just one step at a time. Pick just one action from the options above and put it into action. That is all. The first step might be to call your family together and create a life calendar for next week. Once you have taken the first step, the second one will become clearer. You will know exactly what to do next. It might involve taking an afternoon off and thinking about your bucket lists. Whatever it is, just take the next step, and the next, and the next ... to put one of these tools into action in your life. With just these simple actions, you'll be on your way to a healthier, more balanced life. Constructing a strategy to build and maintain life balance is one of the keys to preventing physician burnout.