Previously, we talked about the importance of myths in the societies and cultures in which we live, and how they are important in medicine, from concepts of Do No Harm to people like Galen to Osler. We also talked about how the Health Architect embodies a new myth, incorporating knowledge and skills to aspire to a state of health and wellness and conquer the demon of burnout that lives within us. We then differentiated burnout from moral injury, showing how burnout has a longer history, is multidimensional, and is a dynamic phenomenon that impels us into the future rather than the past, especially when we use the Health Architect myth in our favor.
Let’s continue our discussion here by talking about another erroneous myth.
Myth #3: Burnout is synonymous with stress.
Fact: False
It is easy to think of stress as all bad. We hear about it all the time – stress isn’t good for you! Heart attacks, high blood pressure, and even cancers are now linked to increased stress and inflammation in a process called “inflammaging.” Recently, the messaging has kicked into overdrive: Look for ways to de-stress, they tell us! Think about the countless ads on TV or social media bombarding us with wellness measures from scented oils to supplements to spa packages – all designed to extirpate stress out of our lives. The claim goes that life would be perfect if we could just get to the phantasmagorical island of wellness, where no hint of stress can touch us.
But all this ignores the simple truth that stress is actually part of our natural state. As living beings, we constantly interact with our environment, and our environment interacts back with us. One simple manifestation of this natural push-pull between our bodies and our world is our circadian rhythm, marked by undulations of steroid and other hormone levels throughout the day and night in a cadence that morphs throughout our lifetimes. Another is how our sympathetic nervous system (known for its “fight or flight” reflexes) and parasympathetic nervous system (known for its automatic functions like gut peristalsis) are in a constant and delicate dance to maintain internal balance. The milieu of cellular and metabolic processes that defines our physiology sees stress as a feature, not a bug, when it comes to maintaining homeostasis.
Of course, stress can hurt us too, whether it’s from sepsis (a life-threatening infection), suffering a panic attack, or having an asthma exacerbation. Most of these negative stress events, which are often involuntary, can lead to detrimental consequences that not only can be difficult to recover from now but also may affect our ability to face the next challenge in the future. In this way, certain types of stress can be disruptive and traumatic.
On the other hand, we need stress not just to survive but to excel. Our bones need stress from weight-bearing postures and activities to stay healthy. Our muscles need stress to strengthen, not only to prevent injury to joints but also for basic life-sustaining actions like eating or urinating and volitional tasks like running to the bus when we’re late. Much of this is voluntary stress, but some is not. Our immune system needs stress from viruses, vaccines, and allergen exposures, especially in childhood, to ward off future threats of illness. Either way, without stress impelling us forward, the inexorable force of entropy leads us to atrophy and age quicker.
Add to this that certain types of stress can even be psychologically rewarding. Think about exercise, fasting, meditation, breathing techniques, even cold water plunges for some – all these activities involve physiologic stress that have potential not only to build our endurance and strength but also be pleasurable. In fact, certain stresses can be fun and exciting – just think of skydiving, rollercoaster rides, or watching a horror movie or thriller. (Note: I include meditation as a stress only because if you’re anything like me, meditation can be frustrating in the beginning)
In short, the wrong stress may hurt us, but the right stress can help us.
Stress and burnout
In our discussion about burnout, when should I start to worry about stress? Essentially, stress leads to burnout when the following factors are present:
1. There are too few positive stress experiences
2. There are too many negative stress experiences
3. The magnitude of experienced stress is too high.
Let’s address each individually.
Why We Need More Positive Stress
First, we need more positive stress experiences to protect us against burnout. Why? Because they afford multiple synergistic benefits:
Positive stress activities build our physical and emotional stamina. This helps us face the inevitable involuntary stresses that come our way, whether it’s getting sick, standing all day doing surgery in the OR, or missing meals during a frantic day in the ICU.
Positive stress activities narrow the gap between our intrinsic demand and supply, whether it’s physical, psychological, or both. This optimizes the conditions under which the “flow state” is possible (a concept I will discuss below)
Positive stress activities often actually feel good in the moment (e.g. who doesn’t like the runner’s high?)
So, how do we do this? When burnout sets in, the idea of committing to positive stress activities can feel overwhelming or even unnecessary. Yet this is precisely when we need to act—gently, but deliberately. The goal isn't to overhaul everything at once, but to take small, manageable steps that create stability and lay the groundwork for recovery. For example, my own meditation practice began with just a few minutes a day before hitting my steady state of 20-30 minutes months later. By gradually conditioning our bodies and minds through consistent practice, we become better equipped to handle future stress and avoid the downward spiral that points us to burnout.
In other words, long hours alone in the clinic or operating room aren’t always the culprit. When we’re unprepared, they can feel brutal. But when we’re physically and mentally primed, those same hours can be purposeful—even fulfilling. I’ve left many ICU shifts feeling physically drained but emotionally grounded, knowing I did meaningful work. The key lies in understanding your personal limits—both physical and emotional—and building and respecting them. Unfortunately, this is a skill we’re rarely taught during our training, as I shared in Episode 10.
How to Protect Against Negative Stress
On the other hand, we need to minimize negative (involuntary) stresses as much as possible. This can be tricky, because they often appear in unexpected or unpredictable ways. So how do we navigate this? By making choices to avoid situations that lead to these stresses. This requires deep self-awareness and situational awareness – topics we will discuss in a later post. For now, just know that our personality (e.g. if we are perfectionistic or people-pleasing), our psychological tendencies (e.g. feeling FOMO or have a need to feel technologically “connected”), and our physical limitations may set us up for failure in workplaces that have high demands in these areas. Knowing who we are and what we are getting into is crucial. Again, more about finding a “best fit” in a later post.
We Need Stress to Enter the Flow State
Finally, whether it be a positive or negative stress experience, we must examine the magnitude of the stress itself. Stress is often described as an imbalance between demand and supply. Mihaly Csikszentmihalyi, a Hungarian-American psychologist, described the relationship between demand and supply and stress. He said that problems occur when there is a gross mismatch between our intrinsic supply and required demand. This can happen in either direction: when we have too much supply with not enough demand, we feel bored. On the other hand, when we have too much demand and not enough supply, we may feel anxiety, or in extreme cases, trauma. Both situations drive burnout.
The key is to get in the middle. And when we do, an interesting phenomenon appears. This is what Csikszentmihalyi called “flow” – an immersive state in which high performance and a sense of calm and even joy happen all at the same time. This is what professional athletes call being “in the zone” and their abilities are often lifted as a result. Studies have shown that humans find flow states deeply enjoyable, and it’s one reason that professional sports, video games, martial arts, and jazz are highly addictive to those who participate in them. Meanwhile, the pursuit of the flow state is nothing new and dates back to even shamanic times when “soul flight” was achieved through ritualized practices and medicinal therapies like ayahuasca.
So what are the conditions to achieve flow? First, the activity must be immersive, intensely coupling the person and the activity itself – think video games or martial arts. Second, the activity must afford immediate feedback to gauge success or failure of actions taken. Think of the rock climber who misses the finger hold and falls. Third, the difference between a positive and negative result must be clear (think again about the rock climber who misses the mark).
What about stress? Achieving the flow state requires that stress is present – that is a prerequisite – but it must not be excessive. In general, the demand just exceeds the supply. Note that I said that the demand is more than – not equal to, or less than – the supply. In other words, we need to raise our game to meet the challenge. Said differently, we need to feel stress to achieve a flow state.
Is a Flow State Possible in Medicine? Yes!
In the practice of medicine, these states of flow may seem rare, even elusive—but they do exist. During my sub-internship, when I was planning to become an ENT surgeon, I witnessed it firsthand. My attending physician was fully immersed in the intricate microsurgery of a radial free flap, crafting a new tongue for patients who had undergone total glossectomy for cancer. The delicate anastomosis between the radial and lingual arteries demanded extraordinary precision; even the slightest error would be instantly evident in a gush or slow ooze of blood. But he didn’t make any. More surprising still, my attending made every movement with a preternatural calmness – without a word, as if in a trance. When the operation was done, he seemed energized, even as the clock pushed toward midnight and the rest of the OR staff was long gone. It was no surprise to me that he did several of these arduous cases each day. He was clearly consumed by this work. In retrospect, I see that during his surgeries, he was in the flow state.
At other times, I experience flow myself— like when I’m leading resuscitative efforts when patients suffer a cardiac arrest, when I address crashing oxygen levels on the ventilator, or when I conduct family meetings in the ICU to navigate end-of-life decisions. While these situations are often emotionally taxing for many, I’ve trained myself—as a Health Architect—to approach them with both expertise and emotional readiness. All the elements required for flow are in place: full immersion, immediate feedback for actions taken, and clear results. In the case of family meetings, I’m fully engaged, attuned to every shift in posture and tone—both mine and theirs—and able to sense immediately when a word or movement sends the conversation off course so I can adjust in real time (like a rock climber or jazz musician). The result is profound. More often than not, I feel a strong sense of connection, trust, and competence. Sometimes, there's even a quiet euphoria—right there in the moment. I feel calm, clear, and capable. In other words, I’m in flow. And it feels really good.
The Health Architect Approach to Stress and the Flow State
Health Architects understand that overcoming burnout isn’t just avoiding or eliminating stress. It requires critical understanding of the types and degree of stress. It requires seeing stress as something that can actually be harnessed for our benefit and transformed into flow, a state that is both energizing and deeply rewarding. The myth of the Health Architect offers a path toward this transformation by helping us grasp both the destructive and generative sides of stress. It invites us to channel our creative energy toward restoring agency and human connection in medicine. As I discussed in Episode 10, physicians—like professional athletes—must cultivate both mental and physical readiness. Health Architects know that part of the answer to burnout lies in understanding stress and not rejecting it when it comes to enhancing our sense of agency and human connection.
Take-home point:
Stress isn’t the enemy—it’s a natural, essential part of life. When understood and strategically harnessed, it becomes the raw material for growth, resilience, and even joy. Burnout arises not from stress alone, but from an imbalance of positive and negative stresses and the excessive nature of certain stress when we encounter it unprepared. Health Architects understand that by conditioning our bodies and minds—like athletes—we can weather unwanted and harmful stress, engage in purposeful stress, and even enter flow states that restore meaning, agency, and connection in medicine. This is the mindset of a Health Architect using stress to overcome burnout.
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