1. Faculty Development Committee Department of Obstetrics and Gynecology Professional Development Series October 16 th, 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

2. Avoiding Burnout: Recovering the Joy of Medical Practice Our Aims today are: 1.Understand contribution of physician personal well- being 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)

3. “In a culture where work can be a religion, burnout is its crisis of faith.” Jennifer Senior, November 26, 2006, New Yorker Magazine Norm Jensen MD MS Professor (CHS) Emeritus Department of Medicine nmj@medicine.wisc.edu Burnout “The cost of caring”

4. Personal Bio l Rural Wisconsin, public schools l UW college and med school l Harvard - Boston City residency l Drafted Navy doctor, Viet Nam Years l UW Grad school - social psychology l Fellowship - clinical communication l Teacher - Clinician 44+ years l Academic focus: clinical skills l No conflict of interest with this talk

5. Intended Learning Outcomes l Cognitive l What’s burnout l How am I doing? l What helps? l What hurts? l Attitudinal: just a touch of l Self awareness

6. The Story Begins  What is Professional Burnout?  Why is it important?

7. Burnout, professional (MH) l An excessive stress reaction to work. l manifest by feelings of – emotional and physical exhaustion – & sense of frustration and failure. l (NLM-MESH)

8. Burnout defined l Work-related distress that combines – Emotional exhaustion – Depersonalization l treating people in an unfeeling, impersonal way – Sense of low personal accomplishment Ramirez. Lancet 1996;347:724-28. Ramirez. Lancet 1996;347:724-28. l ICD-10: "Problems related to life- management difficulty". ICD-10

9. Research concept l 1970 Maslach & Jackson – Maslach Burnout Inventory l exhaustion, cynicism inefficacy l exhaustion, cynicism, inefficacy l Maslach & Leiter – Burnout antithesis = “engagement” l energy, involvement, efficacy

10. 7395 Medline Publications Burnout, professional (MH) Updated September 29, 2014 MESH: STRESS, PSYCHOLOGICAL 1983-89, STRESS, PSYCHOLOGIC 1969-72

11. 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

12. 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? Physician’s Well-Being Index Dyrbye LN, et. al. J Gen Intern Med 2012;28:421-27. DURING THE PAST MONTH

13. 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?

14. 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

15. 1. Have you felt burned out from work? DURING THE PAST MONTH Clickers: press A = yes press B = no

16. 2. Have you worried that your work is hardening you emotionally? DURING THE PAST MONTH Clickers: press A = yes press B = no

17. 3. Have you often been bothered by feeling down, depressed, or hopeless? DURING THE PAST MONTH Clickers: press A = yes press B = no

18. DURING THE PAST MONTH 4. Have you fallen asleep while stopped in traffic or driving? Clickers: press A = yes press B = no

19. 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

20. 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

21. 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

22. If you responded “YES” to four or more, click “Yes” now Clickers: press A = yes press B = no

23. Physician’s Well-Being Index Dyrbye LN, et. al. J Gen Intern Med 2012;28:421-27. l => 4 “yes” – Likelihood ratio 3.85 – Specificity 86% l < 4 “yes” – Likelihood ratio.033 Likelihood of Low Physician Well Being

24. The Story Develops  Prevalence  Profession  By specialty  Life cycle  Consequences  Personal  Healthcare  Risk Correlates  Personal  Work conditions  Moral Injury concept

25. Physician Burnout Prevalence l Practicing physicians – 30 – 65% l Lancet 2009, JAMA 2009, Mayo Clin Proc 2013, JAMA Intern Med 2012 l Hospitalists 30% l JGIM 2011 l Pediatric residents 74% l 2008 Mar 1;336(7642):488-91. l BMJ. 2008 Mar 1;336(7642):488-91. l Med Students 50%, > 6% suicide thoughts l Ann Intern Med 2008 l Highest mid-career l Mayo Clinic Proceedings 2013 l Difference among specialties …

26. USA Physician Burnout Survey, Arch Intern Med 2012;172;1381 Burn out %

27. USA Physician Burnout Survey, Arch Intern Med 2012;172;1381 Work-Life Balance

28. Mayo Clinic Proceedings 2013;88:1363

29. Personal correlates l Personal suffering l 1996;347:724-8 (Hospital consultants) l Lancet 1996;347:724-8 (Hospital consultants) l Stress Hormone excess l l YALE J BIOL MED 2002;75:199-205. l Coronary artery disease + l l Psych Bulletin 2006;132:327–353 l + metabolic syndrome, HPA dysreg, sympathetic activation, sleep disturbance, systemic inflammation, and impaired immunity, blood coagulation, and fibrinolysis, and poor health behaviors. l Mental health l Anxiety, mood, adjustment, AODA, Suicide l ICD-10: "Problems related to life-management difficulty" ICD-10

30. HealthcareCorrelates l On the job error l l Ann Surg 2010 Jun;251(6):995-1000 (surgeons) l 2008 Mar 1;336(7642):488-91. (Peds res) l BMJ. 2008 Mar 1;336(7642):488-91. (Peds res) l Clinician empathy – compassion fatigue l Career & job dissatisfaction - disability – Sick leave, early retirement, job turnover l Patient dissatisfaction / adherence l € 20 Billion economic loss (Awa 2010) – $115 - 587,000 to replace a physician l Threat to & from healthcare reform?

31. Correlating factors l Work load l Meaning in work l Work conditions l Feeling poorly managed and resourced – Effort : reward – Work demands : skills – Low autonomy & control l Patient suffering – “moral injury” l Intellectual stimulation l Work variety l “Work place bullying”

32. Correlating factors l Work-life balance l Life style l Lack of life partner l Personal l Woman l Personal management skill l Communication skills l Self care – resiliency l Mid-career

33. 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

34. 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.

35. What helps? Work Focused l How days are organized – Modulate pace of work – Minimize hassles, interruptions & paperwork – Support staff share tasks requiring little / no professional judgment

36. What helps? l 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

37. What helps? Person focused l Right job for the right person l Sabbaticals, vacations, breaks l Work-home-life balance l Self care – AMA book, The Resilient Physician

38. What helps? Personal & professional learning l Mindfullness training l Advanced communication skills – JAMA 2009;302:1284-92. l Stress Management skills – CBT vs Yoga (RCT) – Cog Behav Therapy – Physical Exercise l Conflict management skills l Personal Management, life coach

39. Concept of Resilience “The long-term ability to survive in and thrive on adversity.” Med Ed 2012;46:349-356. l Self – efficacy l Self – control – Cognitive: plan and act – Emotional intelligence l Self aware & modulation – Learn from difficulty – Persistence l Social intelligence – Engage help & support

40. What helps? Work - Person Interaction l Employers / supervisors must – Understand sources of work-home interference & help manage l Cross coverage l Child care l Part-time practice l Flexible work hours l Advocacy

41. c. 1970s

42. The Story Continues ACTIONABLES

43. 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”

44. 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?

45. Enhancing Mindfulness Skills Reading Reading Jon Kabat-Zinn, Wherever You Go, There You Are. Hyperion, New York, 1994 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 Zinn J-K, Davidson RJ, The Mind’s Own Physician. New Harbinger Publications, Oakland, CA, 2011 Training classes, UWHealth Training classes, UWHealth http://www.psychiatry.wisc.edu/uwpMindfulness.html http://www.psychiatry.wisc.edu/uwpMindfulness.html http://www.psychiatry.wisc.edu/uwpMindfulness.html https://www.uwhealth.org/onlineservices/classes/class/viewClass/21 https://www.uwhealth.org/onlineservices/classes/class/viewClass/21 CME courses CME courses http://www.urmc.rochester.edu/family-medicine/mindful- practice/presentations-workshops.aspx http://www.urmc.rochester.edu/family-medicine/mindful- practice/presentations-workshops.aspx Personal practice Personal practice

46. Revise Priorities Annually Personal Personal Family Family Professional Professional Keep dynamic record Keep dynamic record Revise New Year’s Day Revise New Year’s Day Share with significant others Share with significant others

47. Personal Maintenance l Social life l Personal physician / clinician l Optimize personal health – Emotional intelligence – Food intelligence – Weight control – Physical activity – Sleep, R, R, & R – Disease screening

48. Continue learning l Assess your risk at http://www.mind tools.com/stress/B rn/BurnoutSelfTes t.htm http://www.mind tools.com/stress/B rn/BurnoutSelfTes t.htm http://www.mind tools.com/stress/B rn/BurnoutSelfTes t.htm l AMA book store, $35, $30 for members.

49. 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 CHAPTERS

50. 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

51. 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

52. Clinical Skills CME l MINDFUL PRACTICE: l MINDFUL PRACTICE: Enhancing Quality of Care, Quality of Caring, and Resilience April 27 - May 1, 2015 l Hosted by: The Center for Experiential Learning, University of Rochester Medical Center l http://www.urmc.rochester.edu/family- medicine/mindful-practice/presentations- workshops.aspx

53. Clinical Skills CME l American Academy on Communication in Healthcare –www.aachonline.org/ l 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/www.aachonline.org/

54. N Y Times, July 8, 2003 ERICA GOODE Doctors' Toughest Diagnosis: Own Mental Health N Y Times, July 8, 2003 ERICA GOODE Doctors' Toughest Diagnosis: Own Mental Health

55. Intended Learning Outcomes l Cognitive l What’s burnout l How am I doing? l What helps? l What hurts? l Attitudinal: just a touch of l Self awareness

56. I have enjoyed being with you. References available on request References available on request nmj@medicine.wisc.edu nmj@medicine.wisc.edu If you wish to share a story please contact me by email and we’ll arrange a time to talk. If you wish to share a story please contact me by email and we’ll arrange a time to talk.

57. The lecture ends here! Questions? Answers $0.25 Answers requiring thought $1.00 Correct answers $2.50 Comments?