Re: Friendship as Medicine

To the Editor: We read with great interest the reflection by Dr. Silk about friendship as medicine.¹ The author provided a compelling commentary on the human need for social connection, especially its role at enhancing physician well-being. An increasingly discussed concept in leadership and medicine is the concept of belonging. Belonging is an individual’s sense that they are intentionally valued and needed in a social group or institution.² Belonging as an element of physician professional well-being is an underrecognized area for intervention. We recognize that physicians frequently prioritize work over personal and collegial relationships, often overlooking the detrimental impact this focus can have on both arenas.

The element of professional “belonging” is a key factor in physician retention, as well as reduction of burnout.² The enormous focus on physician well-being and social science literature suggests efforts to promote individual belonging to the culture or institution are key elements of well-being. Dr. Silk’s concept of prescribing social connection aligns with previous work that highlights using the power of social interactions to improve health and wellness.³ In addition, Dr. Silk mentions finding time to bond and the importance of making the effort to connect with each other. Belonging can be fostered via individual and departmental strategies such as mentoring programs, recognition of work success, group activities for social connection, and support of the physician’s personal lives (lactation rooms, exercise, personal health, accommodations for parental and caregiver burdens, etc.).

There is robust literature at the intersection of business and medicine recognizing the institutional and personal costs of attrition and burnout.⁴ While belonging benefits the physician workforce and therefore institutional health, the data are clear that patient care is also improved in the presence of a diverse population of physicians, in terms of both gender and race. All efforts should be made to address the high institutional cost of physician attrition in terms of recruitment, new employee retention, and lost revenue. Belonging is emerging as a target for professional retention interventions. Dr. Silk points out another emerging area of study: “Much like the stress of racism transforms the biology of Black women in our country to a point of higher rates of premature birth, a similar epigenetic phenomenon is occurring in the physiology of those experiencing social isolation. One study from the University of California Los Angeles (UCLA) showed increased inflammatory markers and decreased antiviral genetic activity in isolated individuals.”¹ Like social isolation, professional isolation contributes to depression, anxiety, and hopelessness.^3,5 While the impact of lack of belonging and professional isolation and their epigenetic impact have not been studied in physicians suffering from burnout, the question of the consequence of isolation still bears consideration.

In conclusion, the importance of social connections enhancing physician well-being as highlighted by Dr. Silk reflects the larger concept of belonging. We advocate for further study of professional belonging as a factor in physician well-being, which may lead to interventions to improve physician retention and reduce burnout.