Are you happy?
This may be a question born of the pandemic. Pre-pandemic, I used to quote William Osler, MD, who simultaneously founded the Department of Medicine at the Johns Hopkins Hospital and created the modern system of medical education. He opined:
The practice of medicine will be very much as you make it—to one, a worry, a care, a perpetual annoyance; to another, a daily job and a life of as much happiness and usefulness as can well fall to the lot of man, because it is a life of self-sacrifice and of countless opportunities to comfort and help the weak-hearted, and to raise up those that fall.1
Brooklyn-born Anthony Fauci, MD, who has tirelessly led the National Institute of Allergy and Infectious Diseases (NIAID) for almost 40 years, puts it more succinctly:
You gotta [expletive] suck it up … [even when] it’s 9 o’clock at night and you really, really want to have a beer and go to sleep.2
Dr. Fauci, more than most, reflects his era. He is a member of the Silent Generation—the cohort that preceded the noisier Baby Boomers. The Silent Generation was taught the value of hard work. They learned that if they kept their heads down and followed the rules, happiness would follow. Little wonder: Coming of age during a period of prosperity, many members of this generation found this was largely true. Not surprisingly, members of the Silent Generation are often bewildered that subsequent generations have found it so hard to achieve similar levels of happiness.
Ironically, the Silent Generation also invented the midlife crisis.
A Nation in Crisis
No, not really. At the age of 35, Dante Alighieri wrote in Canto I of Inferno:
Midway upon the journey of our life I found myself within a forest dark. For the straightforward pathway had been lost.3
The concept of the midlife crisis in the U.S., however, is strongly associated with the Silent Generation. The midlife crisis joined the zeitgeist in 1976, following the publication of Passages: Predictable Crises of Adult Life by the journalist Gail Sheehy.4 In Passages, Ms. Sheehy posits that between the ages of 35 and 45, people are affected by a deep unquiet, spurred by a recognition of their mortality that forces them to relinquish the last vestiges of their carefree childhood.
In other words, they figure out that adulting sucks.
Writing for The Atlantic, journalist Jonathan Rauch describes his own midlife crisis more eloquently:
I would wake up feeling disappointed, my head buzzing with obsessive thoughts about my failures. I had accomplished too little professionally, had let life pass me by, needed some nameless kind of change or escape … . I had always thought of myself as a basically happy person, but now I seemed to be someone who dwelt on discontents, real or imaginary. I supposed I would have to reconcile myself to being a malcontent.5
I think the nation may be going through its own midlife crisis.
The Great Resignation, Revisited
It started in April 2021, when 4 million people quit their jobs. There are normal reasons that one might leave a job, but these were not normal times. The Great Resignation started in the middle of a recession when unemployment was high—not typically the time that one might leave stable employment. But leave they did.
I end as I began five years ago, by quoting my predecessor as physician editor of The Rheumatologist, Simon Helfgott, MD: “To tell the truth, when I assumed the role of physician editor, I had no idea what I was actually getting into.”
I tried explainjng the job to a colleague, and at some point, I realized it was a little like describing my internship in internal medicine to a college classmate; without any common points of reference, it’s hard to know where to begin.
Being the physician editor of The Rheumatologist has a steep learning curve, and like any good E-ticket ride, you start to enjoy yourself once you learn to lean into the dips and climbs.
I remain deeply grateful to my associate editors—Vicky Ruffing, RN-BC, Ethan Craig, MD, MHS, and Paul Monach, MD, PhD—whose guidance has graced every page that you have read over the past five years. I am equally grateful that Vicky has agreed to continue as an associate editor of The Rheumatologist for a bit longer, which will help ease the transition.
That gratitude extends to the editor, Keri Losavio, who is truly the unsung hero of The Rheumatologist. Although I am the public face of The Rheumatologist, it is Keri who ensures you have an oversized publication clogging your mailboxes once a month without fail, and she deserves much greater recognition than she receives. I am certain that Keri and Vicky will provide a soft landing for my successor as physician editor, Bharat Kumar, MD, MME, who will bring a fresh voice and a new perspective that will re-invigorate this publication.
As for me, at this point, I estimate that I’ve written approximately 145,000 words in these pages—enough to fill a novel and a sequel. I’m glad to have the opportunity to exit while I still have stories to tell.
If I did owe you one more column, I would have started by mentioning that I can’t stop thinking about the Black Death. The second plague pandemic, known as the Black Death, was responsible for killing up to 200 million people in Europe, Africa and Asia. Survivors of the Black Death were more likely to have a particular mutation that helped fight off Yersinia pestis. That mutation, now enriched in our collective genome, increases our risk of developing autoimmune diseases. In my column, I would have then segued into a discussion of our current pandemic, focusing on the enormous societal damage already wrought by COVID-19. I would have wrapped up by concluding that it may take a generation for us to fully understand what COVID-19 has cost us.
But I’m happy to leave that essay for someone else to write.
I measure my life in terms of major events. Being the physician editor of The Rheumatologist is a benchmark that will be difficult to surpass. This position has been life-altering in ways I could not possibly have anticipated. I’ve enjoyed having the opportunity to share my stories with you, and I hope I’m not leaving that part of my life behind forever.
But it’s time for a new adventure.
I am immensely grateful to each of you for your support over the past five years, and I look forward to joining you as a loyal reader of The Rheumatologist—and one of its biggest fans!
In 2021, journalist Andrea Hsu reported on the phenomenon for National Public Radio: “As pandemic life recedes in the U.S., people are leaving their jobs in search of more money, more flexibility and more happiness. Many are rethinking what work means to them, how they are valued and how they spend their time.”6
2022 has fared no better. PwC conducted a survey of over 52,000 workers in 44 countries and territories in March 2022, a year after the Great Resignation began. In its Global Workforce Hopes and Fears Survey 2022, the PwC researchers learned that one in five employees worldwide expected to walk away from their jobs sometime this year.7
This statistic includes healthcare workers. Christine A. Sinsky, MD, vice president of personal satisfaction at the American Medical Association (AMA), and colleagues at the University of Wisconsin School of Nursing, Madison and the University of Minnesota, Minneapolis conducted a survey of 206,555 healthcare workers (including more than 9,200 physicians, 2,300 nurses, and 2,100 advanced practice providers) at 124 institutions in 30 states. In the survey, they learned that 2 in 5 nurses, 1 in 5 physicians, and 1 in 3 advanced practice providers planned to leave their practice within the next two years. Overall, a third of respondents in all three groups signaled their intent to reduce their work hours.8
One common thread that appears in all of these surveys is that the Great Resignators often don’t have their next job already lined up. They don’t know where they’re going; they just know they’ve had enough.
What are they seeking? For healthcare workers, COVID-19 is enough of an excuse to hang up one’s stethoscope for good. First, there was the enormous guilt over potentially exposing one’s family to SARS-CoV-2 in the process of being a healthcare hero. Then came the unpleasant ritual of debating randomized clinical trials with patients who had absorbed some asinine spin on questionable data presented by their media outlet of choice. To this day, I am flummoxed by patients who have accepted prescriptions for biologics from me without blinking an eye, but refuse to consider coronavirus vaccination because of something that may have happened to the son of their neighbor’s sister.
The AMA survey identified other reasons for restlessness among healthcare workers—stress, workload and burnout predictably made the list. U.S. Surgeon General, Vice Admiral Vivek H. Murthy, MD, MBA, has targeted burnout as the most vexing of these issues. He notes:
Burnout manifests in individuals, but it’s fundamentally rooted in systems. … Causes include inadequate support, escalating workloads and administrative burdens, chronic underinvestment in public health infrastructure, and moral injury from being unable to provide the care that patients need. Burnout is not only about long hours. It’s about the fundamental disconnect between health workers and the mission to serve that motivates them. These systemic shortfalls have pushed millions of health workers to the brink.9
I’m sure they are all right, but I think they’re missing one more factor. I posit that this new wanderlust has been inspired by a search for happiness.
Nothing inspires deep, uncomfortable introspection like a communicable illness that forces us to isolate from family and friends for years. Without the usual distractions, one has no choice but to turn within. And not everyone liked what they saw. Under normal circumstances, we are all too busy just keeping up to ponder such existential nonsense. Also, we were imbued by a strong work ethic, laced with a heavy dose of competitiveness. We were taught to set a goal, and when that goal was achieved, to set another one. We believed that success would naturally lead to happiness, until the pandemic led us to ask if that were actually true.
And now we come to the point of this missive. Loyal readers of The Rheumatologist will know that this is the last Rheuminations column I shall ever write; with this edition, my five-year term as physician editor will come to a close. Therefore, I’ve decided to leave you with a parting gift: In this column, I shall reveal to you the secret to happiness.
Wealth & Timeshares
No, not really. I wish I could, but this secret is not mine to give. I live my life as you do yours, bumbling my way through too many tasks and obligations, hoping not to make the same mistakes twice. That said, never before have so many thought so hard about happiness as a goal, rather than a pleasant side effect of a life well lived, and somewhere among all those ruminations lie tantalizing clues, which I am happy to share.
First, let’s just get this out of the way: I know what you’re thinking. Coco Chanel purportedly said, “The best things in life are free. The second best are very, very expensive.”10 While most of us would love an opportunity to test that hypothesis, money apparently can’t buy happiness, at least not entirely.
True, happiness does require a certain basic income—enough that you’re not worried about how to pay for your next meal or a place to sleep. But the correlation between money and happiness is more complicated than that.
In 2018, Andrew T. Jebb and colleagues from Purdue University, West Lafayette, Ind., and the University of Virginia, Charlottesville, analyzed data from the Gallup World Poll, which surveyed 1.7 million adults from 164 countries. Using these data, the investigators determined that happiness correlates with income, but only up to a certain point. For college graduates, life satisfaction peaks at an annual income of $115,000. Past that satiation point, earning more doesn’t reliably bring more happiness. Ironically, it starts to bring less.11
Why should that be true? In theory, higher incomes are accompanied by higher workloads, which leave less time for leisure. Also, bigger salaries are often accompanied by bigger demands on those salaries, leaving less discretionary income. For example, New York Times reporter Allen Salkin shared the plight of the merely wealthy who struggled to afford living in Manhattan.12 Incidentally, you may be pleased to learn that in the days following publication of this article, the author claimed that he received a new piece of hate mail every 15 seconds.13
Now that we’ve gotten that out of the way, let’s set some expectations. Think about someone who, improbably, always seems happy. His secret? He’s not happy, at least not all the time. No one is.
In The Count of Monte Cristo, Alexandre Dumas wrote:
There is neither happiness nor unhappiness in this world; there is only the comparison of one state with another. Only a man who has felt ultimate despair is capable of feeling ultimate bliss. It is necessary to have wished for death in order to know how good it is to live.14
To recognize happiness, one must, on occasion, be unhappy. The pursuit of happiness is not like achieving enlightenment in Buddhism. Happiness is not a place where you live full time. It is more like a timeshare in Hawaii. You visit on occasion, but afterward, you have to return to your normal life. If you never left, you would eventually start to focus on the high cost of living, scarce housing and, of course, the volcanoes. Happiness would not exist without unhappiness. Your goal isn’t to avoid unhappiness altogether, but rather, to learn how to spend more time in your happiness timeshare.
The Science of Happiness
How does one do that? Over 4 million believe that Laurie Santos, PhD, has the answer. That’s the number of people who have registered for her course on Coursera, titled The Science of Well-Being, in addition to one out of four undergraduates at Yale, who have taken the corresponding course she offers for Yale’s Department of Psychology, making it the most popular course ever taught in the history of that august institution.15,16
Dr. Santos admits she does not know the secret to happiness, but she has identified five practices that may allow you to experience happiness on a more frequent schedule:17
- Get social: In 2002, Ed Diener from the University of Illinois and Martin Seligman from the University of Pennsylvania conducted a survey of 222 undergraduates who were screened for high happiness using multiple instruments. In their nested cohort analysis, they learned that very happy students were highly social and had stronger interpersonal relationships—both romantic and platonic—than their less happy brethren. Although many of us may believe we prefer solitude, the association they identified was so strong the investigators concluded that having others in your life is a sine qua non for happiness.18
- Give thanks: In 2003, Robert Emmons from the University of California, Davis, and Michael McCullough from the University of Miami conducted a randomized trial of 201 undergraduates. One-third of the students were instructed to keep a gratitude journal, in which, once a week, they would write down five things for which they were grateful. In other words, they were asked to count their blessings weekly. The other two groups were instructed to record five hassles or five life events, in the same fashion. At the end of the nine-week intervention, students who kept a gratitude journal felt better about their lives as a whole, had fewer physical complaints and were more optimistic about the coming week.19
- Be in the moment: Substantial research demonstrates a correlation between happiness and mindfulness, which involves remaining in the present moment, rather than allowing your mind to obsess over past mistakes or future worries. The practice of mindfulness, ideally, should include the practice of acceptance, in which you learn to approach your experiences (including thoughts, feelings and cravings) with openness rather than judgment.20
- Rest and move: Multiple studies have demonstrated the importance of good sleep hygiene and aerobic exercise to happiness. A narrative review of happiness literature concluded that as little as 10 minutes of physical activity weekly may be enough to increase your level of happiness.21
- Be kind: A meta-analysis conducted by Bryant Hui, PsyD, the Hong Kong Polytechnic University, and colleagues demonstrates a modest correlation (r=0.13) between kindness and happiness. Importantly, this includes not only organized activities, such as volunteering for a local shelter, but also random acts of kindness.22
Many of us already incorporate some of these practices in our lives, but we could all do more. Organize an outing with your long-lost college buddies. Write a thank-you note to a friend or co-worker. Meditate. Exercise. Sleep. And most importantly, be kind—to others and to yourself. By employing these practices, you may find yourself spending more time in your happiness timeshare. And I hope to see you there sometime soon!
- Osler W. Counsels and Ideals from the Writings of William Osler. Boston: Houghton Mifflin, 1905:129.
- Peele A. The pandemic is waning. Anthony Fauci has a few more lessons to share. The Washington Post. 2022 Jun 29. https://www.washingtonpost.com/magazine/2022/06/27/anthony-fauci-post-pandemic-interview.
- Alighieri Dante. The Divine Comedy, Hell (Translated by Henry Wadsworth Longfellow; Project Gutenberg eBook). https://www.gutenberg.org/files/1001/1001-h/1001-h.htm.
- Sheehy G. Passages: Predictable Crises of Adult Life. New York: Bantam, 1977. https://www.amazon.com/Passages-Predictable-Crises-Adult-Life/dp/0553271067.
- Rauch J. The real roots of midlife crisis. The Atlantic. 2014 Dec. https://www.theatlantic.com/magazine/archive/2014/12/the-real-roots-of-midlife-crisis/382235.
- Hsu A. As the pandemic recedes, millions of workers are saying ‘I quit.’ NPR. 2021 Jun 24. https://www.npr.org/2021/06/24/1007914455/as-the-pandemic-of-workers-are-saying-i-quit.
- What 52,000 people think about work today. PwC. 2022 May 24. https://www.pwc.com/gx/en/issues/workforce/hopes-and-fears-2022.html.
- Sinsky CA, Brown RL, Stillman MJ, Linzer M. COVID-related stress and work intentions in a sample of US health care workers. Mayo Clin Proc Inn Qual Out. 2021;5(6):1165–1173. https://www.mcpiqojournal.org/article/S2542-4548(21)00126-0/fulltext#%20.
- Murthy VM. Confronting health worker burnout and well-being. N Engl J Med. 2022 Aug 18;387:577–579. https://www.nejm.org/doi/full/10.1056/NEJMp2207252.
- The world according to Coco Chanel. Harper’s Bazaar. 2017 Aug 12. https://www.harpersbazaar.com/uk/fashion/fashion-news/news/a31524/the-world-according-to-coco-chanel.
- Jebb AT, Tay L, Diener E, Oishi S. Nat Hum Behav. 2018 Jan;2(1):33–38.
- Salkin A. You try to live on 500k in this town. The New York Times. 2009 Feb 9. https://www.nytimes.com/2009/02/09/style/09iht-08halfmill.20027842.html.
- Salkin A (talking to Conan N). Opinion Page: Living on half a million in NYC. NPR. 2009 Feb 9. https://www.npr.org/transcripts/100445054.
- Dumas A. The Count of Monte Cristo. London and New York: George Routledge and Sons, 1888. https://www.gutenberg.org/files/1184/1184-h/1184-h.htm#linkC2HCH0117.
- Santos L. The Science of Well-Being. Yale. https://fr.coursera.org/learn/the-science-of-well-being.
- Holt S (talking to Meraji SM). Want to be happier? Evidence-based tricks to get you there. NPR. 2020 Jun 29. https://www.npr.org/transcripts/867905101.
- Santos L. Laurie Santos, Yale happiness professor, on 5 things that will make you happier. Newsweek. 2020 Dec 20. https://www.newsweek.com/2021/01/08/laurie-santos-yale-happiness-professor-5-things-that-will-make-you-happier-1556182.html.
- Diener E, Seligman MEP. Very happy people. Psychological Science. 2002 Jan;13(1):81–84. https://doi.org/10.1111/1467-9280.00415.
- Emmons RA, McCullough ME. Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol. 2003 Feb;84(2):377–389. https://pubmed.ncbi.nlm.nih.gov/12585811.
- Greenberg M. The surprising reason mindfulness makes you happier. Psychology Today. 2020 Feb 27. https://www.psychologytoday.com/us/blog/the-mindful-self-express/202001/the-surprising-reason-mindfulness-makes-you-happier.
- Zhang Z, Chen W. A systematic review of the relationship between physical activity and happiness. J Happiness Stud. 2019;20:1305–1322.
- Hui BPH, Ng JCK, Berzaghi E, et al. Rewards of kindness? A meta-analysis of the link between prosociality and well-being. Psychological Bulletin. 2020;146(12);1084–1116. https://psycnet.apa.org/record/2020-65092-001.