1. From Burnout to Burning Down the House: When the Physician Becomes the Therapy Patient Jodie Eckleberry-Hunt, Ph.D., A.B.P.P. Anne Van Dyke, Ph.D., A.B.P.P. Oakland University William Beaumont School of Medicine

2. Objectives Understand scope of the physician burnout and psychological problems Understand consequences of untreated psychological disorders Understand treatment considerations for psychological disorders

3. What is Physician Burnout? High Emotional Exhaustion High Depersonalization Low Personal Accomplishment Irritability Apathy Pessimism/Negativity Substance Abuse Mood Symptoms (energy, sleep, affect)

4. Why Physicians are at Risk? Compassion Fatigue Perfectionism Desire to Control Lack of Control Imposition of Regulations Difficult Patients Grief Lack of Sleep Fear of asking for help

5. Burnout: A Risk for Other Disorders Substance Abuse Depressive Disorders Anxiety Disorders Suicide Violence

6. What are the Costs? Relationship Break-ups Medical Errors Doctor-Patient Relationship Disruptions Lower Quality Medical Care Physician Deaths Job Turnover Missed Work

7. Prevalence of Psychological Disorders Among Physicians Limited and at times contradictory data with methodological issues Studies address the prevalence of burn- out showing 30-60% rate in primary care physicians and specialists Common in academic faculty (37-47%) Significantly prevalent in private practice (55-67%) Younger docs experience 2x more than seasoned docs, with onset as early as residency training

8. Characteristics of Difficult Physicians Perfectionism; denial Unwillingness &/or inability to admit to impact of stress Lack of receptivity White knight syndrome; self-sacrificing Autonomy and self-reliance Egocentricity Feelings of invincibility Self-treaters

9. Physicians and Depression Depression common during training; 27- 30% among interns Studied more in practicing females vs males 51% female physicians (and 32% female PhDs) admitted to depression Another study found same prevalence rate of depression in females whether physicians or in general population

10. Physicians and Divorce Rates 10% - 20% higher than general population More unhappiness in marriages for those who stay married “Psychology of postponement” may result in more difficulty connecting due to hx of postponing pleasure and simply “getting through” Work can be placed above all else

11. Physicians and Substance Abuse Received more attention as problem in medicine than depression or suicide Similar etoh and illicit drug use as general population However, physicians at increased risk for prescription drug abuse due to availability and self-medicating tendencies Strong association between suicide and substance abuse (40%) and drug abuse (20%)

12. Physicians and Violence More than twice the risk for suicide than general population Higher suicide risk than other professions Female docs > 4xs higher rate than females in general population for completed suicide Completed suicide rates for female docs similar to male docs Hx of drug problems not unusual at some point in lives Prevalence of domestic violence

13. Treatment Approaches and Recommendations Culture Change Physician Wellness Committee/Program Physician-focused EAP Integrated Care/Private Care Understand the Culture of Medicine Intellectual vs. Emotional Focus Treat them Differently/Don’t Treat Them Differently Paradox

14. Treatment Considerations and Recommendations http://www.ishiprograms.org/ (Remembering the Heart of Medicine)http://www.ishiprograms.org/ Kitchen Table Wisdom; My Grandfather’s Blessing (Rachel Naomi Remen, M.D.) Healing environment Anecdotal experiences

15. Case Examples 40 year old physician behaving erratically Learners report inappropriate jokes Public drinking when on call Angry confrontations with nursing staff Denies problems

16. Case Examples 35 year old physician with two small children. Feeling hopeless about patients and learners Feeling hopeless about life balance History of depression Adult child of an alcoholic Reluctant to take medication

17. Case Examples 33 yo female physician whose spouse is a research physician and an alcoholic Two young children Grew up in home with bipolar father and critical mother Spouse is emotionally and verbally abusive Has reached out to close female physician friend when in crisis Left multiple times, recently called off divorce just before finalized

18. Case Examples Early forties family physician with large and devoted continuity of care practice Married twenty plus years Three teen aged children Took life by use of firearm Shock-waves through the community including family and close friends Hidden and untreated major depression

19. References Miller MN, Ramsey McGowen K. The painful truth: physicians are not invincible. Southern Medical Jo. 2010; 93; 966-973. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. American Jo of Medicine. 114(6); 513-519. Cicala R. Substance abuse among physicians: what you need to know. Hospital Physician. July; 39-46. Rosenstein A. Physicians under stress: recognition & support. Med Board of Calif Newsletter. July 2011. 8-9.

20. References Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T. et al. Suicidal ideation among American surgeons. Arch Surg. 2011;146;54-62. Stanton J, Caan W. How many doctors are sick? BMJ 2003:326; S97a. Halbesleben JR, Rathert C. Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev. 2008;33:29-39.

21. References Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA. 2001;286:3007-14. Arnetz, BB. Psychosocial challenges facing physicians of today. Social Science and Medicine. 2001;52:203-13. Riley G. On being a doctor. MJA. 2004;181:350-353. Lemaire JB, Wallace, JE. Not all coping strategies are created equal: a mixed methods study exploring physicians’ self reported coping strategies. BMC Health Services Research. 2010;10:208.

22. References Wallace JE, Lemaire J. On physician well being – you’ll get by with a little help from your friends. Social Science and Medicine. 2007;64:2565-77.6. Wallace JE, 3. Wallace JE, Lemaire J, Ghali W. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-21. Wallace JE, Lemaire J. Physician well being and quality of patient care: An exploratory study of the missing link. Psychology, Health and Medicine. 2009:14;545-552.

23. References Schernhammer, E (2005). Taking their own lives – the high rate of physician suicide. NEJM;352(24), 2473-2476. Eckleberry-Hunt, J. et al. (2009). Resident physician burnout: who needs help and why won’t they get it? Annals of Behavioral Science and Medical Education, 15(2), 6- 10. Eckleberry-Hunt, J. et al. (2009). An exploratory study of resident burnout and wellness. Academic Medicine, 84(2), 269- 277 Association of Professors of Medicine. The well-being of physicians. Am J Med. 2003;114:513-519.