The Health and Wellness of Physicians: Managing Stress, Burnout and Energy Charlene M. Dewey, M.D., M.Ed., FACP William H. Swiggart, MS, LPC Co-Directors, Center for Professional Health Associate Professor of Medical Education and Administration Associate Professor of Medicine Vanderbilt University School of Medicine Department of Pediatric Grand Rounds February 2, 2011

Goals The purpose of this session is to provide an overview of how stress and burnout affects your professional health and wellness and what you can do to protect yourself as well as your personal and work relationships.

Objectives 1.Discuss important statistics relative to the professional health and wellness of physicians. 2.Define burnout and list risk factors and common symptoms of burnout. 3.Discuss protective factors to prevent burnout throughout their medical career. 4.Initiate an individual action plan to manage energy and help prevent burnout.

Agenda 1.Introduction and Importance 2.Professional Health and Wellness Spectrum 3.Stress, Burnout and Energy 4.Action Plans - Intent to Change 5.Summary/Evaluation

Importance & Evidence Does this apply to me?

Importance & Evidence Little education; evidence building 30-60% MD have distress and burnout MDs suicide > other prof. & gen pop. One physician per day; PhD – unclear Grossly underestimated Depression/bipolar & substance abuse = suicide risk “Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success.” Cole, Goodrich & Gritz, 2009.

Importance & Evidence Gender differences: –Females > anxiety, depression, burnout –Women chairs more stressed –F>M MD suicides –Male physicians (regardless of race) live longer than other professionals. Lin et al Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19): (Schindler et al 2006) “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008

Importance & Evidence Reduced use of care by physician Stigma & anonymity – slow to prioritize MH issues for physicians; licenses, etc. Lin et al Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19): (Schindler et al 2006) “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008

Importance & Evidence Academic faculty: –Worked longer hours –Took less vacation 10% with mild depression 27% with elevated anxiety –No sig difference clinical vs. academic Litigation/named in law suite Lin et al Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19): Schindler et al. The Impact onof the changing Health Care Environment on the Health and Well-being of faculty at Four Medical Schools. Academ Med (1):27-34.

Importance & Evidence Pediatricians: –Some evidence on pediatricians –Burnout varies with training, practice, specialty Residents Primary care Specialty peds

Pediatrics: Residents Harvard: –24 (20%) with criteria for depression –92 (74%) criteria for burnout –Active surveillance = 45 medication errors –Depressed residents made 6.2 times as many medication errors per resident month (P<0.001) –BO alone – did not increase error (P=0.2) US Davis: Residents did not manifest burnout; some experience stress Frahrenkopf, AM et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ Mar 1;336(7642): Epub 2008 Feb 7. (Harvard Children’s Hospital) Milstein JM et al. Med Teach. Burnout assessment in house officers: evaluation of an intervention to reduce stress Apr;31(4): (UC Davis)

Gen vs. Spec Pediatrics General pediatricians less likely to have symptoms of burnout or job stress (13%) Pediatric subspecialists: worked longer hours (59/week) office < hospital higher % of complex patients & with psychosocial problems (46% vs. 25%) reported significantly higher levels of burnout (23%) and job stress (26%) Shugerman R, et al. Pediatric generalists and subspecialists: determinants of career satisfaction. Pediatrics Sep;108(3):E40. (U of Wash)

Specialty Pediatrics 389 physicians pediatric critical care Burnout: –36% at risk –14% burned out (50%) Perceptions of value of their work, feelings of success and satisfaction were highly associated with burnout Fields AL, et al. Physician burnout in pediatric critical care medicine. Crit Care Med Aug;23(8): (GW)

“The Perfect Storm” The external system The internal system PhysicianHospital/Clinic Two systems interact Good skills Poor skills Functional & nurturing Dysfunctional

Importance & Evidence Powerful model how practice environment can impact physician health Stress: physician, environment, patients Environment was the only sig predictor of stress Job stress predicts job satisfaction Job sat is positive predictor of positive mental health Perceived stress was a stronger predictor of both poorer reports of physical and mental health Therefore, environment influenced health Williams et al. Physician, practice and patient characteristics related to primary care physician physical and mental health: Results of the physician’s work-life study. Health Services Research, 2002; 37(1):

Professional Health and Wellness The ethics of self-care: “The medical academy's primary ethical imperative may be to care for others, but this imperative is meaningless if it is divorced from the imperative to care for oneself. How can we hope to care for others, after all, if we ourselves, are crippled by ill health, burnout or resentment?” Cole, Goodrich & Gritz. “Faculty Health in Academic Medicine: Physicians, Scientists and the Pressures of Success.” Humana Press 2009; pg 7.

Professional Health and Wellness The ethics of self-care: (cont.) “…medical academics must turn to an ethics that not only encourages, but even demands care of self.” Cole, Goodrich & Gritz. “Faculty Health in Academic Medicine: Physicians, Scientists and the Pressures of Success.” Humana Press 2009; pg 7.

Professional Health and Wellness Are we ethically obligated to care for ourselves? Do you feel empowered to demand your own self care?

Professional Health & Wellness

Professional Health and Wellness No definition exists. In CPH: –PHW: the health and wellness of an individual’s psychological, physical, emotional and spiritual being in relationship to their work & home environments –Includes the individual, their work environment and their home environment

Work EnvironmentHome Environment Mind Body SoulEmotion Self-Care Professional Health & Wellness

Professional Health & Wellness Spectrum High Functioning High Productivity Fair Functioning Decreasing Productivity Fair Functioning Reduced Productivity Relationships Suffer Fair-Not Functioning Fair-Not Productive Institution & Family Loses Burnout Coping Mechanisms Failing Risk of MH issues and suicide No Coping Mechanisms Professionally Healthy & Well Stressed Coping Mechanisms Strong Physical Mental Emotional Spiritual Work & Family Relations

Stress & Burnout Stress and burnout occurs for different reasons in different individuals. Work load ≠ level of stress or burnout in all situations. Multifactorial

Self-Awareness “Self-awareness means having a deep understanding of one’s emotions, strengths, weaknesses, needs, and drives. People with strong self-awareness are neither overly critical nor unrealistically hopeful. Rather, they are honest – with themselves and with others.” “What Makes a Leader?” by Daniel Goleman, Best of Harvard Business Review (1998)

Self-Assessments What stresses you out? Measure your stress level Anxious Engaged Enthusiastic Calm Relaxed Stress free Stressed out Exhausted Overwhelmed Drained Ready to cave Burnt out The Doctor Dewey Insto-Matic, Stress-O-Meter Run Down

Definition - Stress Stress can be defined as: –d : a state resulting from a stress; especially : one of bodily or mental tension resulting from factors that tend to alter an existent equilibrium Webster’s dictionarystress

Stress & Productivity Declining Function Productive Stress No Prolonged Stress BurnoutStressed Situational Stress Non-Functional Prolonged Stress Reduced Cognition “Impairment” ???

Managing Individual Stress Seven Key Areas: 1.Sleep 2.Balanced meals 3.Physical activity 4.Socialization 5.Vacations/down times 6.Spiritual engagement 7.Have a physician MindBody SpiritEmotion

Managing Work-Place Stress Manage energy 1.Self care at work 2.Plan appropriately 3.Reduce distractions 4.Office culture 5.Work place training on burnout* Office Reduce Distractions PlanningSelf-Care *McCue JD & Sachs CL. A stress management workshop improves residents' coping skills. Arch Intern Med Nov;151(11): (Tufts)

Managing Failures & Successes

Stress “Into each one’s life, some stress must come… …but it is how you handle it that is important.” ~me

Aggressive Passive Aggressive Figure 1 Spectrum of Disruptive Behaviors Inappropriate anger, threats Yelling, publicly degrading team members Intimidating staff, patients, colleagues, etc. Pushing, throwing objects Swearing Outburst of anger & physical abuse Hostile notes, s Derogatory comments about institution, hospital, group, etc. Inappropriate joking Sexual Harassment Complaining, Blaming Chronically late Failure to return calls Inappropriate/ inadequate chart notes Avoiding meetings & individuals Non-participation Ill-prepared, not prepared Swiggart, Dewey, Hickson, Finlayson. “A Plan for Identification, Treatment, and remediation of Disruptive Behaviors in Physicians.” Frontier's of Health Services management, 2009; 25(4):3-11.

Definition - Burnout Burnout can be defined as: –a : exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration b : a person suffering from burnout. Webster’s dictionary

Burnout “In the current climate, burnout thrives in the workplace. Burnout is always more likely when there is a major mismatch between the nature of the job and the nature of the person who does the job.” ~Christina Maslach The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

Risk Factors for Burnout Single Gender/sexual orientation ># of children at home Family problems Mid-late career Previous mental health issues (depression) Fatigue & sleep deprivation General dissatisfaction Alcohol and drugs Minority/international Teaching & research demands Potential litigation Puddester D. West J Med 2001;174:5-7 Myers MJ West J Med 2001;174:30-33 Gautam M West J Med 2001;174:37-41

1.Work overload* 2.Lack of control 3.Insufficient reward 4.Unfairness 5.Breakdown of community 6.Value conflict Maslach & Leiter, “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” *Losek D. Characteristics, workload, and job satisfaction of attending physicians from pediatric emergency medicine fellowship programs. Pediatric Emergency Medicine Collaborative Research Committee. Pediatr Emerg Care Oct;10(5): Six Sources of Burnout

Symptoms of Burnout 1.Chronic exhaustion 2.Cynical and detached 3.Increasingly ineffective at work (distressed behaviors) 4.Leads to: 1. isolation 2. avoidance 3. interpersonal conflicts 4. high turnover Maslach & Leiter, “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg 17

Spickard, Gabbe & Christensen. JAMA, September 2002:288(12): Protective Factors Personal: –Tend to self care issues first –Address Maslach’s 6 sources of burnout –Influence happiness through personal values and choices –Adapt a healthy philosophy/outlook –Spend time with family & friends

Protective Factors –A supportive spouse or partner –Engage in religious or spiritual activity –Hobbies –Mentor (s) Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):

Protective Factors Work: –Address Maslach’s 6 sources of burnout –Gain control over environment & workload –Find meaning in work (value) –Set limits and maintain balance –Have a mentor –Obtain adequate administrative support –Learn about burnout and stress management* *McCue JD & Sachs CL. A stress management workshop improves residents' coping skills. Arch Intern Med Nov;151(11):

Managing Energy at Work Listen to your body Identify your own needs Define limits - Just Say NO! Create your work environment Eliminate distractions Take breaks Plan ahead Schwartz, T. & McCarthy, C. Manage Your Energy Not Your Time. HBR October 2007.

Managing Energy: Case Discussion Dr D is a 46 yo female physician-educator with 2 kids and spouse with significant travel/work schedule. She wears 5 different hats on any given day and is involved is several community activities. Dr D finds s and other interruptions distracting and is feeling stressed due to a grant and several submissions that are due in the next 6 weeks. She has cut down on sleep and exercise to meet the deadlines. Her back hurts by the end of the day. –What are her risk factors for burnout? –Will this lead to burnout? –What changes could we suggest to control energy at work?

Individual ApproachOrganizational Approach Starts with person Becomes group project Connects to organization Outcomes affects related mismatches Outcome is a process Starts with management Becomes organizational project Connects to people Figure 5.1 (pg 80) Maslach, C & Leiter, MP. “The Truth About Burnout: How Organizations Cause Personal Stress and What to do About It.” 1997 Preventing & Resolving Burnout

“The twin goals of preventing and building engagement are possible and necessary in today’s working world. These goals cannot be easily achieved by an individual. Rather, people have to work together to make them happen. And if we all commit ourselves to the long-term process of organizational progress, we will be rewarded with workplaces that are more productive and resilient as well as humane.” ~Maslach & Leiter, pg 127 The Truth About Burnout

Individual Action Plan List three self-care areas you will improve over the next 6 mo. List three ways to manage your energy at work. Identify a resource you will use if needed. Make it happen: Specific and clearPlan/Timetable Behavior not attitudeWhat are your personal barriers? Something you can countWhen will you start?

Resources PFWP/EAP or State physician health programs Primary care provider Private counseling services Personal coaches – Center for Women in Medicine Substance services: AA, NA, etc TALK: suicide prevention hotline Other: YMCA/YWCA, Massage envy, wellness programs, health plus, etc.

Summary: Take Home Points 1.You are valuable! Self-care is the foundation to faculty vitality and remaining professional. 2.Stress happens: Look for and anticipate stress. 3.Take action immediately to manage energy, reduce stress and avoid burnout. 4.Take advantage of the valuable resources available inside or outside of Vanderbilt – bottom line is get help!

References 1.Cole, Goodrich & Gritz. “Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressures of Success.” Humana Press Lin et al Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19): Schindler et al. The Impact of the changing Health Care Environment on the Health and Well- being of faculty at Four Medical Schools. Academ Med (1): Shanafelt et al. Special Report: Suicidal Ideation Among American Surgeons. ARCH SURG JAN 2011:146(1); “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, Schwartz, T. & McCarthy, C. “Manage Your Energy Not Your Time.” HBR October Swiggart, Dewey, Hickson, Finlayson. “A Plan for Identification, Treatment, and remediation of Disruptive Behaviors in Physicians.” Frontier's of Health Services management, 2009; 25(4): Goleman,Daniel. “What Makes a Leader?” Best of Harvard Business Review (1998) 10.The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; Puddester D. “Canadian Medical Association on Policy on Physician Health and Wellbeing.” West J Med 2001;174(1): Myers MF. “The Wellbeing of Physician Relationships.” West J Med 2001;174(1): Gautam M “Women in Medicine: Stressor and Solutions.” West J Med 2001;174(1): Spickard, Gabbe & Christensen. “Mid-Career Burnout in generalist and Specialist Physicians.” JAMA, September 2002:288(12):

“The first wealth is health.” ~ Ralph Waldo Emerson