Faculty Development Committee Department of Obstetrics and Gynecology Professional Development Series October 16th, 2014 Avoiding Burnout: Recovering the Joy of Medical Practice Professor Emeritus Norman M Jensen, MD, Department of Medicine American Academy on Communication in Healthcare President, 2007-2009 Board Chair, 2011-2013 Faculty Guide for Distance Fellows Faculty for Clinical Skills Enhancement Courses: - Philadelphia, PA in June, 2015 Avoiding Burnout: Recovering the Joy of Medical Practice Our Aims today are: 1. Understand contribution of physician personal wellbeing to good clinical practice 2. What is burnout? 3. Score our own Ob/Gyn Well-Being Index (clicker questions) 4. What are the best counter measures for physicians? 5. Resolve to undertake one measure to ward off or diminish burnout (will be mailed to you in 2 months) “In a culture where work can be a religion, burnout is its crisis of faith.” Jennifer Senior, November 26, 2006, New Yorker Magazine Burnout “The cost of caring” Norm Jensen MD MS Professor (CHS) Emeritus Department of Medicine [email protected] Personal Bio Rural Wisconsin, public schools UW college and med school Harvard - Boston City residency Drafted Navy doctor, Viet Nam Years UW Grad school - social psychology Fellowship - clinical communication Teacher - Clinician 44+ years Academic focus: clinical skills No conflict of interest with this talk Intended Learning Outcomes Cognitive What’s burnout How am I doing? What helps? What hurts? Attitudinal: just a touch of Self awareness The Story Begins What is Professional Burnout? Why is it important? Burnout, professional (MH) An excessive stress reaction to work. manifest by feelings of – emotional and physical exhaustion – & sense of frustration and failure. (NLM-MESH) Burnout defined Work-related distress that combines – Emotional exhaustion – Depersonalization treating people in an unfeeling, impersonal way – Sense of low personal accomplishment • Ramirez. Lancet 1996;347:724-28. ICD-10: "Problems related to lifemanagement difficulty". Research concept 1970 Maslach & Jackson – Maslach Burnout Inventory exhaustion, Maslach cynicism, inefficacy & Leiter – Burnout antithesis = “engagement” energy, involvement, efficacy 7395 Medline Publications Burnout, professional (MH) 600 500 400 300 # Pub 200 100 0 1977 1982 1987 1992 1997 2002 2007 2012 2017 Updated September 29, 2014 MESH: STRESS, PSYCHOLOGICAL 1983-89, STRESS, PSYCHOLOGIC 1969-72 Burnout: What’s the big deal? It’s prevalent It harms the clinician personally It harms the clinician’s clinical skill It risks harm to patients It is costly to the healthcare system Inefficiency and waste Professional workforce attrition Physician’s Well-Being Index Dyrbye LN, et. al. J Gen Intern Med 2012;28:421-27. DURING THE PAST MONTH 1. Have you felt burned out from work? 2. Have you worried that your work is hardening you emotionally? 3. Have you often been bothered by feeling down, depressed, or hopeless? 4. Have you fallen asleep while stopped in traffic or driving? 5. Have you felt that all the things you had to do were pilling up so high that you could not overcome them? 6. Have you been bothered by emotional problems, such as feeling anxious, depressed, or irritable? 7. Has your physical health interfered with your ability to do your daily work at home or away from home? A Personal Inventory • Each of the next 7 slides has one personal question. • Please answer “yes” or “no”, quickly, the first response that comes to mind. • Keep a personal count of the number of “yes” answers. • Use your “clicker” for anonymous group prevalence. Clickers: press A = yes press B = no DURING THE PAST MONTH 1. Have you felt burned out from work? Clickers: press A = yes press B = no DURING THE PAST MONTH 2. Have you worried that your work is hardening you emotionally? Clickers: press A = yes press B = no DURING THE PAST MONTH 3. Have you often been bothered by feeling down, depressed, or hopeless? Clickers: press A = yes press B = no DURING THE PAST MONTH 4. Have you fallen asleep while stopped in traffic or driving? Clickers: press A = yes press B = no DURING THE PAST MONTH 5. Have you felt that all the things you had to do were pilling up so high that you could not overcome them? Clickers: press A = yes press B = no DURING THE PAST MONTH 6. Have you been bothered by emotional problems, such as feeling anxious, depressed, or irritable? Clickers: press A = yes press B = no DURING THE PAST MONTH 7. Has your physical health interfered with your ability to do your daily work at home or away from home? Clickers: press A = yes press B = no If you responded “YES” to four or more, click “Yes” now Clickers: press A = yes press B = no Physician’s Well-Being Index Dyrbye LN, et. al. J Gen Intern Med 2012;28:421-27. Likelihood of Low Physician Well Being => 4 “yes” – Likelihood ratio 3.85 – Specificity 86% < 4 “yes” – Likelihood ratio .033 The Story Develops Prevalence Profession By specialty Life cycle Consequences Personal Healthcare Risk Correlates Personal Work conditions Moral Injury concept Physician Burnout Prevalence Practicing physicians – 30 – 65% Hospitalists 30% Ann Intern Med 2008 Highest mid-career BMJ. 2008 Mar 1;336(7642):488-91. Med Students 50%, > 6% suicide thoughts JGIM 2011 Pediatric residents 74% Lancet 2009, JAMA 2009, Mayo Clin Proc 2013, JAMA Intern Med 2012 Mayo Clinic Proceedings 2013 Difference among specialties … USA Physician Burnout Survey, Arch Intern Med 2012;172;1381 Burn out % USA Physician Burnout Survey, Arch Intern Med 2012;172;1381 Work-Life Balance Mayo Clinic Proceedings 2013;88:1363 Personal correlates Personal suffering Stress Hormone excess YALE J BIOL MED 2002;75:199-205. Coronary artery disease + Lancet 1996;347:724-8 (Hospital consultants) Psych Bulletin 2006;132:327–353 + metabolic syndrome, HPA dysreg, sympathetic activation, sleep disturbance, systemic inflammation, and impaired immunity, blood coagulation, and fibrinolysis, and poor health behaviors. Mental health Anxiety, mood, adjustment, AODA, Suicide ICD-10: "Problems related to life-management difficulty" Healthcare Correlates On the job error Ann Surg 2010 Jun;251(6):995-1000 (surgeons) BMJ. 2008 Mar 1;336(7642):488-91. (Peds res) Clinician empathy – compassion fatigue Career & job dissatisfaction - disability – Sick leave, early retirement, job turnover Patient dissatisfaction / adherence € 20 Billion economic loss (Awa 2010) – $115 - 587,000 to replace a physician Threat to & from healthcare reform? Correlating factors Work load Meaning in work Work conditions Feeling poorly managed and resourced – Effort : reward – Work demands : skills – Low autonomy & control Patient suffering – “moral injury” Intellectual stimulation Work variety “Work place bullying” Correlating factors Work-life Life balance style Lack of life partner Personal Woman Personal management skill Communication skills Self care – resiliency Mid-career Multivariate Analysis Mayo Clinic Proc 2013;88:1364 Factor Odds Ratio Work hours / week 1.02 / hour Call nights / week 1.03 / night Recent home & work conflict 2.47 Resolution favored work 2.13 Have children 0.63 Academic practice 0.63 The Story Develops What helps? Work focused Person focused (resilience) Work - Person Interaction State of the art review of evidence Burnout prevention: A review of intervention programs. Patient Education and Counseling 2010;78:184-190. What helps? Work Focused How days are organized – Modulate pace of work – Minimize hassles, interruptions & paperwork – Support staff share tasks requiring little / no professional judgment What helps? Work control improvements – ↑ clinician participation in management – decentralize control – Monitoring work load – Promoting teamwork – Orientation of the new to set reasonable job expectations – Management by goal setting & feedback What helps? Person focused Right job for the right person Sabbaticals, vacations, breaks Work-home-life balance Self care – AMA book, The Resilient Physician What helps? Personal & professional learning Mindfullness training Advanced communication skills – JAMA 2009;302:1284-92. Stress Management skills – CBT vs Yoga (RCT) – Cog Behav Therapy – Physical Exercise Conflict management skills Personal Management, life coach Concept of Resilience “The long-term ability to survive in and thrive on adversity.” Med Ed 2012;46:349-356. Self – efficacy Self – control – Cognitive: plan and act – Emotional intelligence Self aware & modulation – Learn from difficulty – Persistence Social intelligence – Engage help & support What helps? Work - Person Interaction Employers / supervisors must – Understand sources of work-home interference & help manage Cross coverage Child care Part-time practice Flexible work hours Advocacy c. 1970s The Story Continues ACTIONABLES Resilience Plan • Burnout meter awareness • How’s the energy supply? • Mindfulness skills • Awareness of me • Revise priorities regularly • Really, is this what you want? • Personal maintenance • “Keep the saw sharp” Check Burnout Meter Monthly 1. burned out from work? 2. emotionally hardened? 3. mood down, hopeless? 4. daytime sleepiness? 5. overwhelmed by work? 6. emotional problems? 7. physical symptoms? Enhancing Mindfulness Skills • Reading • • • Training classes, UWHealth • • • http://www.psychiatry.wisc.edu/uwpMindfulness.html https://www.uwhealth.org/onlineservices/classes/class/viewClass/21 CME courses • • Jon Kabat-Zinn, Wherever You Go, There You Are. Hyperion, New York, 1994 Zinn J-K, Davidson RJ, The Mind’s Own Physician. New Harbinger Publications, Oakland, CA, 2011 http://www.urmc.rochester.edu/family-medicine/mindfulpractice/presentations-workshops.aspx Personal practice Revise Priorities Annually • • • • • Personal Family Professional Keep dynamic record Revise New Year’s Day • Share with significant others Personal Maintenance Social life Personal physician / clinician Optimize personal health – – – – – – Emotional intelligence Food intelligence Weight control Physical activity Sleep, R, R, & R Disease screening Continue learning Assess your risk at http://www.mind tools.com/stress/B rn/BurnoutSelfTes t.htm AMA book store, $35, $30 for members. CHAPTERS • Defining & Exploring Personal Assessment & Management Strategies • What really stresses physicians? • Self-Assessment: How are you doing? • The psychology of physicians • Stress resilience • The balancing act • Understanding & Managing Relationships in the Medical Workplace • Conflict self-assessment • Anger management • Negotiating conflict • The disruptive physician • Listening & communication skills • Coping with change • Understanding & managing the stress of medical training • Making your workplace a positive interpersonal culture Continue learning • • • • • Chapters Beyond Expertise • The New Yardstick • Competencies of the Stars • Hard case for soft skills Self Mastery • The Inner Rudder • Self Control • What moves us People Skills • Social Radar • The Arts of Influence • Collaboration, teams, group IQ A New Learning Model • The Billion-Dollar Mistake • Best Practices Emotionally Intelligent Organization • Taking Organizational Pulse • The Heart of Performance Continued learning A great first read on mindfulness, especially for one who wants learn it on their own, or at least begin that way. 3 Parts -270 pages 1. In the bloom of the present moment 1. 31 chapters 2. The Heart of Practice 1. 18 chapters 3. In the Spirit of Mindfulness 1. 24 chapters 4. Practice MP3s available Clinical Skills CME MINDFUL PRACTICE: Enhancing Quality of Care, Quality of Caring, and Resilience April 27 - May 1, 2015 Hosted by: The Center for Experiential Learning, University of Rochester Medical Center http://www.urmc.rochester.edu/familymedicine/mindful-practice/presentationsworkshops.aspx Clinical Skills CME ENRICH: Communicating in highly effective healthcare systems June 18-21, 2015 at Drexel University College of Medicine in Philadelphia. American Academy on Communication in Healthcare –www.aachonline.org/ N Y Times, July 8, 2003 ERICA GOODE Doctors' Toughest Diagnosis: Own Mental Health Intended Learning Outcomes Cognitive What’s burnout How am I doing? What helps? What hurts? Attitudinal: just a touch of Self awareness I have enjoyed being with you. •References available on request [email protected] •If you wish to share a story please contact me by email and we’ll arrange a time to talk. The lecture ends here! Questions? Answers $0.25 Answers requiring thought $1.00 Correct answers $2.50 Comments?