Loneliness and Leadership

Former US Surgeon General Vivek Murthy frames loneliness in the starkest of terms, “At work, loneliness reduces task performance, limits creativity, and impairs other aspects of executive function such as reasoning and decision making.¹

One in two adults report experiencing loneliness.² It is associated with poor physical and mental health and a mortality impact equivalent to smoking 15 cigarettes a day.² Lack of social connection is associated with increased Medicare spending, lower individual academic achievement, and worse performance at work.² Loneliness has been linked to increasing burnout, declining productivity, and rising attrition costing US companies up to 154 billion dollars annually.³

Loneliness is defined as “A subjective distressing experience that results from perceived isolation or inadequate meaningful connections, where inadequate refers to the discrepancy or unmet need between an individual’s preferred and actual experience”.² The causes of loneliness are many and complex. Research is limited by the difficulty of separating loneliness from social connection as a cause or effect and lack of consideration of antecedents such as personality type. Social connection varies by structure (the number and type of relationships), function (the reliability of the relationship), and quality (the nature of the relationship).²

Measuring loneliness is imperfect. The UCLA Loneliness Scale is a 20-item instrument that is considered the gold standard scale in loneliness research. Most studies use only three items: (1) “How often do you feel that you lack companionship?”, (2) “How often do you feel left out?”, and (3) “How often do you feel isolated from others?”, answered with (1) “hardly ever”, (2) “some of the time”, or (3) “often”.

These are scored 1–3 and summed so that a total greater than six indicates loneliness. This abridgement is valid for measuring overall loneliness, but not social connections.⁴ Some individuals meeting criteria for loneliness do not perceive it as problematic.⁵

Using the three-item UCLA loneliness scale, Dr Ofei-Dodoo found a 43% prevalence of loneliness in physicians which was associated with depression and burnout.⁶ A study of family physicians found a prevalence of 44.9% (38.08% in older physicians) and an association with being divorced/separated, widowed or single, having a chronic health condition, and/or a disability.⁷ A 2024 CERA survey of 1,004 academic family physicians (20.7% response rate) found a 27.8% prevalence of loneliness.⁵

Medical literature contains virtually no studies of loneliness in leaders, and although business literature discusses this topic with more frequency, there is little empiric evidence. For example, leader loneliness has been shown to be associated with undesirable team behavior and inhibited decision making, but no causality has been established.

Studying loneliness in leaders is challenging. A 2024 review identified conceptual and methodologic limitations of studies including (1) overlap of loneliness and social disconnection; (2) empiric findings based on differing research paradigms that led to inconsistent conclusions; (3) lack of, or differing definitions of leader loneliness; and (4) quantitative studies limited by endogeneity (poor team function may be both the cause and effect of leader loneliness) and qualitative studies limited by both design concerns (sampling) and lack of considerations of context.⁸ Leaders may be uniquely susceptible to loneliness because of singular responsibilities and role isolation, boundary issues and confidentiality, reduced peer group, and time constraints.^9,10

In this issue of Family Medicine, Wilson et al explored loneliness in department chairs with a CERA survey using the UCLA -3 Loneliness Scale.¹¹ Of the 227 chairs responding (50.2% response rate), 35.8% scored in the loneliness range. Loneliness was associated with the number of trusted colleagues within their institution. There were no significant differences found for age, gender, underrepresented status, or external professional relationships. Almost one-third reported increasing feelings of loneliness since becoming a chair. Unfortunately, while this study adds to the sparse literature on loneliness in medical leaders, it was unable to investigate factors of social connectedness that may be associated with loneliness such as the chair’s prior experience or duration as a chair or other leadership positions. The study was also unable to explore the chair’s longevity in their current medical community, characteristics of the department, or personal or professional supports or challenges, as well as any information about their support system, residential longevity, or personal resiliency behaviors.

There are suggestions in both the medical and business literature for establishing social connections and decreasing loneliness—both in general and for leaders specifically—but all lack empiric evidence of effectiveness. General suggestions include attention to work-life balance, fostering a culture of inclusion, building team relationships, increasing awareness and measuring loneliness, destigmatizing mental health needs, and supporting prosocial behavior.¹² Frey advocates restoring the doctors’ lounge for relationship building rather than the structure of “soulless efficiency.” He recommends asking ourselves the three UCLA loneliness questions, and then “creating safe spaces and time for conversations”.¹³ Ameling describes discussing “sacred moments” with patients as a vehicle for clinician connection.¹⁴ The Society of General Internal Medicine published a report describing systems and infrastructure to restore connection and empathy using a three-part approach of values alignment, communication, and positive organizational design.¹⁵

Core discussion networks are circles of people who have conversations about difficult topics that foster social connections across differing experiences. Facilitating cross-disciplinary challenges in a work setting could build social connections and improve work relationships, resulting in increasing well-being, trust, and decreased loneliness.² Making social connection a strategic priority will prompt medical educators to enhance connection within our work communities.² Tracking this sense of belonging can be included with other quality metrics.²

The Surgeon General’s report calls for the establishment of six pillars to build a culture of connection for communities, including strengthening social infrastructure within communities, enacting proconnection public policies, mobilizing the health sector, reforming digital environments, and establishing a research agenda to further build a culture of connection.² A robust research agenda would include longitudinal studies, intervention trials, organizational outcomes, and a consideration of intersectionality, equity, and context.²

Loneliness and lack of social connection in our leaders, ourselves, our staff, and our patients, is destructive and calls for ongoing attention.