1. February 19 th -21 st Sinclair Community College Ponitz Center

2. Clinician Burnout in Contemporary Medicine Constance Ange, D.O. www.DoctorAnge.com (937) 498-0068 AOA Board Certified Adult Psychiatry AOA Board Certified Child Psychiatry AMA Board Certified Adult Psychiatry AMA Board Certified Child Psychiatry American Board of Forensic Medicine

3. Physicians are less likely to experience burnout because ____________ 1.they have rewarding careers. 2.they have supportive friends and families. 3.they generally work with a strong team. 4.None of the above, physicians have a high risk of burnout. 10

4. Which of the following can be used to help prevent physician burnout? 1.Include self-care as part of medical professionalism 2.Promote physician control of the work environment 3.Incorporate mindfulness and teamwork into practice 4.All of the above 10

5. Outline I.Medicine II. Physician Paradox III. Self Check-Up IV. History V. Conundrum VI. Suggested Reasons VII. Epidemiology VIII. EMR IX. Definitions X. Prevention XI. Intervention

6. Medicine Medicine is not a job. It is not a career—at its heart medicine is a calling. It represents one of life's greatest opportunities to become fully human through service to others. (Starling, Rodgers, & Winkler, 2014)

7. Physicians Paradox “If we’re forced to be at the forefront of our field, if we are going to mentor others, if we are going to be good role models for our patients, should we be taking care of ourselves? And we don’t take the time because we’re always worried about everybody else. The very thing, the very essence of what makes us good physicians also is the source of our own downfall.” Duke Study (Schneider, Kingsolver, & Rosdahl, 2014)

8. Self Check Up  Have you felt burned out from work/medical school?  Have you worried that work/medical school is hardening you emotionally?  Have you often been bothered by feeling down, depressed, or hopeless?  Have you fallen asleep while stopped in traffic or driving?  Have you felt that all the things you had to do were piling up so high that you could not overcome them?  Have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?  Has your physical health interfered with your ability to do your daily work at home and/or away from home? Minnesota Medicine (Bell, 2013)

9. YearResearcherEvent 1966DonabedianQuality of services is directly related to work satisfaction 1970McGrathDefined the term “work stress” 1974FreudenbergerTalks of “work disease” and “burnout syndrome” which he found more frequent in healing professionals 1982MaslachDefined “burnout syndrome” by 3 characteristics— known as the Maslach Burnout Inventory (MBI) and is considered the gold standard: Emotional exhaustion Depersonalization Lack of personal fulfillment History BMC Family Practice (Gómez-Gascón et al., 2013)

10. History Continued CharacteristicDefined By Emotional Exhaustion Feeling of fatigue mental (anxiety, anguish, sexual dysfunction, chronic fatigue) physical (spastic colon, dyspepsia, headache, myalgia, etc.) DepersonalizationIsolation behaviors Insensitivity Dehumanization Negativity Distancing from patients Low personal fulfillment Lack of Personal Fulfillment Negative attitude towards oneself and work Loss of interest towards work Irritability Low productivity Low self-esteem BMC Family Practice (Gómez-Gascón et al., 2013)

11. History Continued “Thus, the burnout syndrome has important family and social repercussions, as well as for the work environment and organization, which translate into: absenteeism from work, decrease of worker and user satisfaction, job mobility, and loss of productivity.” BMC Family Practice (Gómez-Gascón et al., 2013)

12. History Continued Health professionals work with the most intense emotional facets of humans including: – Suffering – Fear – Sexuality – Death Thus, it is easy for them to be subjected to: – Chronic stress – Physical exhaustion – Psychological exhaustion BMC Family Practice (Gómez-Gascón et al., 2013)

13. History Continued Stress is the response of beings when facing events, situations, people, or objects perceived as stressful, which consequently induces a stress response that is essential for survival. According to Hans Seyle, there are 3 physiological phases that the response follows: – Alarm – Adaptation or resistance – Exhaustion BMC Family Practice (Gómez-Gascón et al., 2013)

14. History Continued During stressful situations attention increases and the brain focuses on the perceived challenge When stress becomes chronic it stops being a physiological stimulus and becomes detrimental to health BMC Family Practice (Gómez-Gascón et al., 2013)

15. Conundrum Maureen Baker said, “GP fatigue is a clear and present danger to patient safety—and we urgently need to find workable solutions that will keep our patients safe now and in the future.” 1 Some findings reveal a lack of research linking physician burnout with performance 2 Institutions and regulators want to minimize the risk of medical errors while maximizing quality of care; individual doctors want to help their patients while leading fulfilling lives 3 2. BMJ (O’Dowd, 2015) 1. Human Resources for Health (Lee, Seo, Hladkyj, Lovell, & Schwartzmann, 2013) 3. CMAJ (Albuquerque & Deshauer, 2014)

16. Conundrum Continued Transformation of physician health to a proxy for risk, it is not surprising that health itself is becoming a core professional value – Shifts physician health from private to public Question: Public right to safety versus doctors’ right to privacy? – It is a political issue CMAJ (Albuquerque & Deshauer, 2014)

17. Conundrum Continued Do programs work? 1 The only thing worse than physicians suffering from burnout is also having their patients suffer because of it. 2 1. (Bell, 2013) 2. (Starling, Rodgers, & Winkler, 2014)

18. Conundrum Continued How does burnout impact physician productivity? – No sufficient data yet Estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada – At least CAN $213 million BMC (Dewa, Loong, Bonato, Thanh, & Jacobs, 2014)

19. Suggested Reasons Burnout more common among physicians than other professionals 1 Burnout level (in residents) had no measurable associations with medication errors 2 – concluded that this is an important finding, as burnt out residents reported making significantly more medical errors than their non-burnt out colleagues Widely held belief that burnout is detrimental to health care quality—existing literature does not support that so far 2 2. (Kushnir, Greenberg, Madjar, Hadari, Yermiahu, & Bachner, 2014) 1. (Fortney, Luchterband, Zakletskaia, Zgierska, & Rakel, 2013)

20. Suggested Reasons Continued Physicians… 1.Do not seek regular medical or mental health care 2.Rarely take time off for ill health 3.Do not get adequate rest and nutrition 4.Offered inadequate self-care training 5.Work within cultures that do NOT promote personal wellness (Schneider, Kingsolver, & Rosdahl, 2014)

21. Suggested Reasons Continued A physician’s job dissatisfaction is the most powerful predictor of departure 1 Burnout associated with self-reported unprofessional conduct 1 Factors that increase the risk 1 : – Work hours – Increased patient panels – High productivity requirements – Shrinking resources – Expanding adult population 2 – Increased bureaucratized health care 2 1. (Nedrow, Steckler, & Hardman, 2012) 2. (Fortney, Luchterband, Zakletskaia, Zgierska, & Rakel, 2013)

22. Suggested Reasons Continued Lack of career fit to one’s values, life goals, or passion 1 10% of physicians moving into concierge medicine 2 20% difference between Medicare payments and the cost of treating patients 3 Gallup Poll—small business owners as a whole are among the happiest of professions 3 – The number of physicians who own their own practice has been declining at a rate of 2% annually for the past 25 years 1. (Nedrow, Steckler, & Hardman, 2012) 2. (Starling, Rodgers, & Winkler, 2014) 3. (Joshi, Mehaul, & Broome, 2013)

23. Suggested Reasons Continued High prevalence of burnout among U.S. physicians suggests that the problem lies more with the system and environment in which physicians work rather than being due to innate vulnerabilities in a few susceptible individuals (Shanafelt, Dyrbye, & West, 2013)

24. FIGURE. Prevalence of burnout among middle career physicians compared with early or late career physicians according to sex (A), specialty area (B), and practice setting (C), with differences statistically significant for all variables (all P ≤.01) except for the veterans’ hospital settings (P=.59). Mayo Clinic (Dyrbye, Varkey, Boone, Satele, Sloan, & Shanafelt, 2013)

25. Suggested Reasons Continued Early Career Physicians Lowest career satisfaction Greatest rates of work-home conflicts More difficulty resolving work-home conflicts Middle Career Physicians Work more hours Took more calls Reported lowest specialty satisfaction Dissatisfied with their work balance Struggles more with emotional exhaustion Late Career Physicians Most satisfied Lowest rates of stress (Dyrbye et al., 2013)

26. Epidemiology Conferences on physician health 1 – Existed since 1975 in the U.S. – International meetings have occurred since 1991 1/3 to 1/2 of practicing physicians meet criterion for burnout 2 Women are 1.6 times greater than men to report 2 Issues that affect 2 : – Professional fulfillment positively correlated with patients’ adherence to medication, exercise, and diet regimens 1. (Albuquerque & Deshauer, 2014) 2. (Nedrow, Steckler, & Hardman, 2012)

27. Epidemiology Continued 30%-65% burnout rate across medical specialties, with the highest rates by those at the front line of care—ER and general internal medicine 1 Physicians experiencing burnout are more likely to leave 1 Replacement cost ≈ $250,000/primary care physician 1 When academic physicians have less than 10-20% tie to do what they care about most—burnout rates increase to 75% 1 Part time workers can fare better 1 Burnout stronger in outpatient physicians than in inpatient 2 – Possibly due to demands of clinical practice 1. (Linzer et al., 2013) 2. (Lee et al., 2013)

28. EMR Full EMR implementation: 2008 = 4% of practices 2012 = 72% of practices Low Function UseLess Stress Moderate Function Use Increased stress Decreased job satisfaction High Function UseTime allotted is not equal to the time perceived as necessary to provide quality care—producing a time pressure factor EMR systems may not match workplace processes and flow—leaving the physician to fix quickly while patient is present Fully functioning EMR Increased task (health maintenance, quality measures, chronic disease management, etc.) Increase in task but no increase in time Associated with more adverse physician outcomes EMR Use and Physician Stress (Babbott et al., 2014)

29. Definitions Burnout Using Maslach Burnout Inventory 1 – Emotional exhaustion (38%) – Ineffectiveness (17%) – Depersonalization (29%) Long-term stress reaction which includes emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment 2 Linked to (but not the same as) depression, anxiety, fatigue, impaired performance, impaired immune function, inflammation, elevation of cardiovascular risk factors 3 – Higher divorce rates 4 – Suicides 4 – Job turnover 4 – Drug and alcohol abuse 4 – Caffeine and nicotine addiction 4 – Shorter life expectancy 4 “Collapse of the human spirit” 4 1. (Nedrow, Steckler, & Hardman, 2012) 2. (Linzer et al., 2013) 4. (Starling, Rodgers, & Winkler, 2014) 3. (McClafferty, Brown, Section on Integrative Medicine, & Committee on Practice and Ambulatory Medicine, 2014)

30. Definitions Continued Degree of Burnout Defined By First Physical/behavioral changes Failure to keep up Complacency regarding status quo Gradual loss of reality Second Accelerated deterioration Problems sleeping Decreasing energy Third Major physical and/or psychological breakdown Heart attack Ulcer Mental illness Depression (Starling, Rodgers, & Winkler, 2014)

31. Have you thought… “Going through the motions” “Medicine is changing; it’s not rewarding—too much paperwork, administration, and hassle” “I have had it” (Starling, Rodgers, & Winkler, 2014)

32. Definitions Continued Burnout Often defined as emotional exhaustion, ineffectiveness, and depersonalization Values“Dark Side”Burnout Factor(s) ServiceDeprivationCompassion fatigue Entitlement ExcellenceInvincibilityEmotional exhaustion Curative CompetenceOmnipotenceIneffectiveness cynicism CompassionIsolationDepersonalization (Nedrow, Steckler, & Hardman, 2012)

33. Definitions Continued (Nedrow, Steckler, & Hardman, 2012) Service “Bright Side”“Dark Side” Physicians are first drawn to the calling, or service aspect of medicine. It is compelling and rewarding—make a difference 1.Service feels more like duty 2.Personal sacrifice—feel more like deprivation, victimization, or martyrdom 3.Self-sacrifice becomes exhausting 4.Sense of entitlement—I deserve it 5.Destructive financial or relationship decisions

34. Definitions Continued (Nedrow, Steckler, & Hardman, 2012) Excellence “Bright Side”“Dark Side” Physicians are committed to the highest standard of excellence In the information age infinite reservoirs of knowledge and memory are assumed—zero tolerance for mistakes Breeds perfectionism Breeds invincibility (safe revenues to discussing errors are not available) Breeds blame

35. Definitions Continued (Nedrow, Steckler, & Hardman, 2012) Curative Competence “Bright Side”“Dark Side” Physicians take responsibility for patient outcomes— sometimes that outcome is not within the physician’s control 1.Breeds urgency 2.Breeds action with unclear diagnosis 3.Breeds discomfort 4.Breeds omnipotence 5.Breeds intolerance for ambiguity 6.Breeds with patients who challenge 7.Breeds fear of exposure—sense of inadequacy 8.Breeds cognitive dissonance between expectations and physician’s limitations

36. Definitions Continued (Nedrow, Steckler, & Hardman, 2012) Compassion “Bright Side”“Dark Side” A delicate balance between empathy and appropriate emotional boundaries with patients and their families 1.Breeds suppressing emotions—both positive and negative 2.Breeds emotional isolation— alone in a sea of people

37. Definitions Continued (Nedrow, Steckler, & Hardman, 2012)

38. How do you inoculate yourself against the burnout risk of being a physician?

39. Prevention Improve self-awareness and work-life balance—set healthy boundaries between work and non-work areas Lower stress by learning effective leadership skills Exert control over your work hours—consider a flexible work schedule Focus on work activities that provide the most meaning to you Attend a CME program teaching Personal Burnout Measures (Starling, Rodgers, & Winkler, 2014)

40. Prevention Continued Institutional Metrics Make clinician satisfaction and wellbeing quality indicators Incorporate mindfulness and teamwork into practice Decrease stress from electronic health records Work Conditions Allocate needed resources to primary care clinics to reduce health care disparities Hire physician floats to cover predictable life events Promote physician control of the work environment Maintain manageable primary care practice sizes and enhanced staffing ratios Career Development Preserve physician “career fit” with protected time for meaningful activities Promote part-time careers and job sharing Self-Care Make self-care a part of medical professionalism (Linzer et al., 2013)

41. (Hansen, Pit, Honeyman, & Barclay, 2013)

42. (Hansen et al., 2013)

43. Interventions Mindfulness: form of mental training that enables to attend to aspects of experience in a nonjudgmental, nonreactive way, which in turn helps to cultivate clear thinking, equanimity, compassion, and open- heartedness – Goal: Maintain awareness in one’s experience in a way that generates a greater sense of emotional balance and well-being – Helps to recognize unhelpful habitual thoughts and behaviors (Fortney et al., 2013)

45. Interventions Continued 1.Change 2.Change what—thought patterns 3.Like lifting weights—if you do not do them then you cause atrophy

46. Interventions Continued 1. Self Compassion 2. Reframing 3. Appreciation and gratitude 4. Self-awareness 5. Self-care

47. Interventions Continued Coaching’s Influence on Patient Care 1.More “refreshed” 2.More clear headed 3.Present with the patient 4.Use some of the techniques with patients 5.Supported patients in their life style changes 6.If not there for yourself—hard to be there for your patients (Schneider, Kingsolver, & Rosdahl, 2014)

48. (Nedrow, Steckler, & Hardman, 2012) This diagram shows the interaction between a physician’s values, level of insight, and dedication to a healthy lifestyle that makes him or her better able to cope with the challenges of the medical profession. Resiliency Triangle Interventions Continued

49. (Nedrow, Steckler, & Hardman, 2012)

50. Interventions Continued (Nedrow, Steckler, & Hardman, 2012)

51. Interventions Continued Oregon Health & Science University’s Integrative Self-Care Initiative for Students Taught through skills training and small group experiences—mindfulness meditation, guided imagery, creative expression, journaling, laughter yoga, appreciative inquiry, biofeedback, social support Providing a context for authentic and confidential connection with a group of peers and mentors to counter isolation Practicing mindful self-awareness using a variety of techniques aimed at emotional knowledge and self-compassion to foster intervention earlier in the stress response Learning cognitive reappraisal skills to expand perspectives, embrace complexity, and increase coping Learning holistic self-care and positivity skills to expand resiliency Practicing empathy with an emphasis on professional models of “exquisite empathy,” which allows heartfelt and sensitive engagement with those who are ill but with boundaries that allow for regeneration rather than depletion (Nedrow, Steckler, & Hardman, 2012)

52. Almost Done

53. 10 Commandments of Physician Wellness I.Thou shall not expect someone else to reduce your stress. II.Though shall not resist change. III.Thou shall not take thyself in vain. IV.Remember what is holy to thee. V.Honor thy limits. VI.Thou shall not work alone. VII.Thou shall not kill or take it out on others. VIII.Thou shall not work harder. Thou shall work smarter. IX.Seek to find joy and mastery in thy work. X.Thou shall continue to learn. (Krall, 2014)

54. Our thought patterns are deep and consciously developed, and rewiring them requires regular practice. (Nedrow, Steckler, & Hardman, 2012)

55. An individual’s ability to recognize when his or her attitudes are deteriorating, and then do something about it, may be a key difference between those with a healthy engagement in the practice of medicine and those suffering from burnout. (Nedrow, Steckler, & Hardman, 2012)

56. Burnout is not a disease; it is a symptom and combating burnout is a win for everyone—physicians, patients, family, and staff.

57. Physicians are less likely to experience burnout because ____________ 1.they have rewarding careers. 2.they have supportive friends and families. 3.they generally work with a strong team. 4.None of the above, physicians have a high risk of burnout. 10

59. Which of the following can be used to help prevent physician burnout? 1.Include self-care as part of medical professionalism 2.Promote physician control of the work environment 3.Incorporate mindfulness and teamwork into practice 4.All of the above 10

61. Thank You!

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