1. Debra A. Gould MD, MPH Michael J. Aquilino MS, LMHC Patricia Robinson PhD Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # A3 in Period 3 Friday, October 16, 2015 Transforming Burnout Using ACT

2. Faculty Disclosure The presenters of this session currently have the following relevant financial relationships during the past 12 months: New Harbinger Publishing Inc. Authors:Debra A. Gould MD, MPH Patricia J. Robinson PhD Springer Publishing Inc. Authors:Patricia J. Robinson PhD Guilford Publishing Inc. Authors:Patricia J. Robinson PhD Mountainview Consulting Inc. - Patricia J. Robinson PhD

3. Learning Objectives At the conclusion of this session, the participant will be able to: Understand current research on burnout and impact on healthcare workforce. Define mindfulness and the ACT specific psychological processes associated with mindfulness. Learn how to use specific ACT-based exercises and tools focused on the processes of acceptance, present moment awareness, defusion and perspective-taking.

4. Learning Assessment 1.What is the potential impact of burnout on the primary care workforce? 2.Name 2 of 4 specific ACT processes that cultivate mindfulness? 3. Name 1 ACT-Based Mindfulness exercise you will use at your practice/teaching site for cultivating Resiliency?

5. Quadruple Aim From triple to quadruple aim: care of the patient requires care of the provider.From triple to quadruple aim: care of the patient requires care of the provider. Bodenheimer T, Sinsky C. Ann Fam Med. 2014 Nov- Dec;12(6):573-6. doi: 10.1370/afm.1713. PMID: 25384822 “Improving the Work Life of Clinicians and Staff”

6. Burnout Adverse workflowLow MD satisfaction Low control High Stress/Burnout Unfavorable culture Intent to leave (Linzer et.al, Working Conditions in Primary Care: Physician Reactions and Care Quality. Ann Inter Med 2009;151:28-36.) 6 ConditionsCosts $236,383

7. Psychological Toolbox Be Present Defuse Acceptance Observer Self ACT Psychological Flexibility ACT Values Action

8. Psychological flexibility Acceptance and Commitment Training (ACT) Be Present Connect with Values Accept Defuse Observer Self Act on Values Mindfulness Values

9. Evidence The value of psychological flexibility: Examining psychological mechanisms underpinning a cognitive behavioural therapy intervention for burnout. Lloyd J, Bond FW, Flaxman PE. Work & Stress, 2013, 27(2):181-199, http://dx.doi.org/10.1080/02678373.2013.782157http://dx.doi.org/10.1080/02678373.2013.782157 Population: Employees UK govn’t Department Intervention: 3 ½ day sessions of ACT to increase psychological flexibility. Comparison: Wait list Outcomes: ACT arm - Emotional Exhaustion Depersonalization

10. Neuroscience of Mindfulness  Resonance Circuits  Executive Function  Plasticity The Mindful Brain, Reflection and Attunement in the Cultivation of Well-Being Siegal, D. W W Norton & Company, New York, 2007.

11. Mindfulness Observing one’s private experience: Present moment awareness Accepting of unwanted thoughts and feelings Openness toward self Goal: Self-Regulate Respond not React Act according to your Values

12. TEAMS Skill Training: Think about a difficult situation with a your clinic administration or a patient TEAMS ElementWhat comes up? Thoughts Emotions Associations Memories Sensations (Exercise)

13. Case - Difficult Situation – New EMR You are a clinician and you have been working at a federally qualified health center for the past 10 years. Your organization has used a locally produced electronic medical record (EMR) for the past 5 years; it is relatively user friendly and you use it well. Some of the functions actually work pretty well - sending prescriptions (safer patient care), inserting your dictations (patient’s narrative), and it has a sort function that you can use to find key information (efficient). However, it cannot produce reports for meaningful use measures. Your clinic administration makes a decision to implement a new EMR. The new EMR requires you to click boxes for data entry. It does not have a sort function for quick retrieval of information. It has no dictation component so you now have to type your notes. Bottom line: You’re spending up to 2 hours after clinic getting your notes done.

14. TEAMS Skill Training: Think about a difficult situation with your clinic administration or a patient TEAMS ElementWhat comes up? Thoughts Emotions Associations Memories Sensations De-brief – Observer Self, Defuse, Be Present, Acceptance

15. MindfulnessThought Reminds me of…. I’m going to fail…… Anxious Anger De-brief – Defusion, Observer Self, Acceptance Observer Self Racing heart beat! Feeling (Exercise)

16. Breath deeply and slow down Observe your TEAMS Listen to your values Decide on action & do it Mindful Warrior Struggling (Tool) (get out of your mind & into your life for teens, Ciarrochi JV, Hayes L, Bailey A. New Harbinger Publications, 2012.)

17. Summary Psychological Flexibility builds Resilience… Acceptance and Commitment Training Accept Defuse Present Observer Self Values Action

18. 1.From triple to quadruple aim: care of the patient requires care of the provider. Bodenheimer T, Sinsky C. Ann Fam Med. 2014 Nov-Dec;12(6):573-6. doi: 10.1370/afm.1713. PMID: 25384822From triple to quadruple aim: care of the patient requires care of the provider. 2.Estimates of costs of primary care physician turnover. Buchbinder SB, Wilson M, Melick CF, Powe NR. Am J Manag Care. 1999 Nov;5(11):1431-8. PMID:10662416Estimates of costs of primary care physician turnover. 3.Effectiveness of a mindfulness education program in primary health care professionals: a pragmatic controlled trial. Asuero AM, Queraltó JM, Pujol-Ribera E, Berenguera A, Rodriguez-Blanco T, Epstein RM. J Contin Educ Health Prof. 2014 Winter;34(1):4-12. doi: 10.1002/chp.21211. PMID: 24648359Effectiveness of a mindfulness education program in primary health care professionals: a pragmatic controlled trial. 4.The value of psychological flexibility: Examining psychological mechanisms underpinning a cognitive behavioural therapy intervention for burnout. Lloyd J, Bond FW, Flaxman PE. Work & Stress, 2013, 27(2):181-199, http://dx.doi.org/10.1080/02678373.2013.782157 http://dx.doi.org/10.1080/02678373.2013.782157 5.To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice. Lamothe M, Boujut E, Zenasni F, Sultan S. BMC Fam Pract. 2014 Jan 23;15:15. doi: 10.1186/1471-2296-15-15. PMID:24456299To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice. References

19. Learning Assessment 1.What is the potential impact of burnout on the primary care workforce? 2.Name 2 of 4 specific ACT processes that cultivate mindfulness? 3. Name 1 ACT-Based Mindfulness exercise you will use at your practice/teaching site for cultivating Resiliency?

20. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!