Health of the Health Professional Conference Auckland, New Zealand, November 2011 Jane Lemaire MD and Jean Wallace PhD William Ghali MD

* To increase awareness of the link between physician wellness and effective health care systems

“Wellness goes beyond merely the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life” (Shanafelt et al 2003)

“I think quality of life is being happy both in your work and your home, ….being allowed to do what you enjoy to do in both places, to the quality and standards to which you want to do them.” Lemaire JB, Wallace JE. Well Doc? What constitutes quality of life for physicians? Can J of Gen Int Med 2009;4:

* Physicians are at risk for being unwell * Physicians pay suboptimal attention to self-wellness * Unwell physicians negatively affect health-care systems * Physician wellness as an indicator of health-system quality? Wallace JE, Lemaire JB, Ghali WA. Physician Wellness: A Missing Quality Indicator. Lancet. 2009;374:

* Workload * Long hours * Emotional and cognitive demands * Frequent systems change

* Emotional exhaustion * Reduced sense of accomplishment * Cynicism * Inefficacy

* Individual factors * Profession–related factors * Workplace factors

All physicians within the Calgary Health Region Stage One: Physician interviews (N=42) Physician job observations (N=44) Spouse interviews (N=32) Stage Two: Survey to all physicians in the CHR Received 1178 surveys (40% RR) Jean E Wallace, Jane Lemaire, William Ghali, Dave Megran, Todd Watkins, Maeve Obeirne, Alyssa Borkosky Determinants of Physician Well Being

Source: 2009 Determinants of Physician Well Being: Stage Two Report (n=1178) Individual barrier

Source: 2009 Determinants of Physician Well Being: Stage Two Report (n=1178) Individual barrier

Coping strategies while at workCoping strategies outside of work Deal with stress/work through itExercise Talk with co-workersHave some quiet time Take a time outTalk with spouse Use humorSpend time with family Ignore or deny the stressLeave work at work Source: 2008 Determinants of Physician Well Being: Stage One Report Coping strategies: Major themes extracted from the interviews (n=42)

“Usually denial. I just put it on the back burner and just go on ‘cause you know, if you get too stressed out then you can’t function and so I usually just suppress it. That’s my coping mechanism at work.” Source: 2008 Determinants of Physician Well Being: Stage One Report

Frequency of use of coping strategies Lemaire JB, Wallace JE. Not all coping strategies are created equal: a mixed methods study exploring physicians’ self reported coping strategies. BMC Health Serv Res. 2010;10:208.

* Culture of medicine * Conspiracy of silence

Profession-related barrier

Source: 2009 Determinants of Physician Well Being: Stage Two Report (n=1178) Profession-related barrier

“But I’m not sure that the link between their own health and patient care is probably very clear. Because you can’t believe that right? You can’t believe if you’re having a bad day that you’re going to provide poor patient care ‘cause that’s just not what you do.” Wallace JE, Lemaire JB. Physician well being and quality of patient care: an exploratory study of the missing link. Psychol Health Med ;14:

“I‘ve been running since 7 o’clock this morning. I have not had a break for lunch. I’m happy if I get time to go to the bathroom during a busy day… if I’m lucky I’m eating on the run, like literally, like going up the elevators, going down the stairs eating something… which is not healthy, but that’s the nature of my day.”

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bookcase tractor fork kitten towel letter computer stapler

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appointment novel pig glass portrait light bulb eraser church

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table cloud intersection blood mask banana bed prairie

*Indicates a statistically significant difference by specialty (p<.05) Source: 2009 Determinants of Physician Well-Being: Stage Two Report (n=1178) Frequency of stressful work environment characteristics

Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:

* How do we move forward and develop a more contemporary and holistic measure of physician health and well-being as it relates to individual doctors, the medical profession and health care systems?

Well Doc? Module 1 Physician nutrition and cognition during work hours: Effect of a nutrition based intervention Adriane M. Lewin MSc William A. Ghali MD MPH Delia Roberts PhD Jane Lemaire MD Jean E. Wallace PhD Kelly Dinsmore MSc Department of Medicine

Lack of timeN=15 Limited access to nutrition and water and/or convenience N=14 Limited food choicesN=10 Work ethic N=7 Professionalism and doctors’ attitudes N=5 Cost N=3 Barriers to nutrition during the work day Lemaire JB, Wallace JE, Dinsmore K, Roberts D. Food for thought: an exploratory study of how physicians experience poor workplace nutrition. Nutr J. 2011;10:18.

Emotional symptoms (irritable, frustrated) N=18 Physical symptoms (tired, hungry, nauseated) N=17 Cognitive symptoms (can’t focus or think clearly) N=13 Negative impact on ability to complete work N=9 Negative impact on interactions with colleagues N=7 Inadequate nutrition: Impact on physicians Lemaire JB, Wallace JE, Dinsmore K, Roberts D. Food for thought: an exploratory study of how physicians experience poor workplace nutrition. Nutr J. 2011;10:18.

Nutrition and cognition Lemaire JB, Wallace JE, Dinsmore Kelly, Lewin Adriane, Ghali WA, Roberts Delia. Physician nutrition and cognition during work hours: effect of a nutrition based intervention. BMC Health Serv Res. 2010;10:241..

Mean Glucose On intervention day… Glucose was lower and less variable Less hypoglycemic symptoms were reported

Cognition BaselineInterventionp-value Simple reaction time test Mean Tput score (SD)210 (32)220 (32)0.003 Mean reaction time in msec (SD) 293 (52)279 (55)0.03 Complex reaction time test Mean Tput score (SD)85 (17)92 (20)<0.001 Mean reaction time in msec (SD) 630 (82)609 (95)<0.001 On intervention day… Cognition was superior

Knowledge translation Practical ideas Make work place nutrition a requirement! Role model nutrition breaks Raise awareness about the warning signs and symptoms of lack of nutrition Educate your colleagues Lemaire JB, Wallace JE, Dinsmore K, Roberts D; Nutrition: In A practical handbook for physician health and well-being: The Royal College of Physicians and Surgeons of Canada CanMEDS physician health guide. ed Puddester D, Flynn L, Cohen J. Ottawa 2009.

Well Doc? Module 2 The effect of a portable biofeedback tool on physician stress Jane B Lemaire MD Jean E Wallace PhD Adriane M Lewin MSc Jill de Grood MA Jeffrey P Schaefer MD Department of Medicine

Study flow chart Interview

Measures Stress: Physicians’ perceptions of how unpredictable, uncontrollable and overloaded they find their lives Response Set: Never (0), Almost Never (1), Sometimes (2), Often (3), Very often (4), Always (5) Maximum score 200 (40 items)

Heart rate variability Lemaire JB, Wallace JE, Lewin AM, de Grood J, Schaefer JP. The effect of a biofeedback-based stress management tool on physician stress: a randomized controlled clinical trial. Open Med. 2011;5(4):e154–e163.

Mean stress score and stress score change over days 0-28 by group (RCT) ControlIntervention Mean (SD) p-value* Stress score baseline74.1 (24.5)81.3 (29.5)0.4 Stress score day (26.6)65.0 (26.6)0.6 Stress score change-2.2 (8.4) (23.8)0.05 P-value for within-group difference * Between-group difference.

Individual stress score changes over days 0-28 by group 10/17 (59%) 15/20 (75%)

Mean stress score and stress score change over days for control group Control Mean (SD) Stress score day (26.6) Stress score day ( 25.1) Stress score change-8.5 (7.6) P-value Is there effect without reinforcement?

* Physicians are at risk for being unwell * Physicians pay suboptimal attention to self- wellness * Unwell physicians negatively affect health- care systems * Physician wellness as an indicator of health-system quality?

Workplace and profession awareness, management and prevention Physician self-care and prevention Physician treatment and recovery Improved patient care and system outcomes Contextual factors -Confidentiality issues -Licensing board responses -Culture of medicine -Health-systems failure to provide wellness resources Physician characteristics -Indifference and neglect of self-care -Coping by denial and avoidance -Conspiracy of silence -Predisposing personality traits Workplace stressors -Workload -Work hours -Fatigue -Cognitive demands -Changes to practice Physician outcomes -Stress, burnout -Depression -Relationship issues -Substance abuse -Risk of suicide Health-system outcomes -Recruitment and retention issues -Lowered productivity and efficiency -Suboptimal quality of patient care -Reduced patient adherence and satisfaction -Increased risk of medical errors Potential interventions

* Promote dialogue among key stakeholders * Increase awareness of the importance of physician wellness * Consider the components of a physician wellness quality indicator * Develop an assessment approach * Continue to develop interventions and study their impact