1. “Professionalism and the Health and Wellness of the Surgeon.” Charlene M. Dewey, M.D., M.Ed., FACP William H. Swiggart, MS, LPC James Pichert, PhD Center for Professional Health Center for Patient and Professional Advocacy Faculty and Physician Wellness Committee Surgery Executive Leadership November 16, 2010

2. Goals The purpose of this session is to provide information on professionalism and professional conduct and how professional health and wellness plays a role in your professional behaviors as well as your colleagues’ behaviors.

3. Objectives 1.Describe the professional health and wellness spectrum. 2.Identify risk factors as well as protective factors for stress and burnout. 3.Define sexual harassment. 4.Discuss the importance of action vs. non- action for distressed behaviors 5.List available resources at Vanderbilt. 6.Reflect on the importance of creating a culture of wellness within your department.

4. Agenda 1.Introduction 2.Professional Health and Wellness Spectrum 3.Stress and Burnout 4.Distressed Behaviors & Sexual Harassment 5.Leadership Roles 6.Q&A 7.Summary

5. The Surgeon - Strengths Takes full responsibility for their patients Appreciates the full experience with pts and family Are problem solvers, fixers Appreciates seeing the results Feels gratification for completing the job Leaves a significant impact on pts Are technical people Appreciates the final product and all the steps from beginning to end Attentive to details Examples from surgeons – gathered by Charlene Dewey November 2010

6. The Surgeon - Challenges Has to balance a lot Cannot be confined to a shift Knows the details needed in each case Must work well with teams Has to shift between teams and patients/family members Can be vulnerable to issues of success and failure Feels a deep sense of personal responsibility for the outcomes Bears the load of being the leaders of the team Examples from surgeons – gathered by Charlene Dewey November 2010

7. Professional Health & Wellness

8. 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

9. Surgeons – in General Direct correlation of burnout with hours/week worked and night calls –30% at burnout when working <60 h/w –44% at burnout working 60-80 h/w –50% at burnout working >80 h/w >2 night shifts/week increases burnout and increases work and home conflicts Depression correlated with h/w & night calls Medical errors increased significantly working >80 h/w vs. <60 h/w (p=0.001) Balch, CM. “Surgeon Distress as Calibrated by Hours Worked & Nights on Call.” J Amer Coll of Surgeons Nov 2010; 211(5):609-19.

10. Surgery at Vanderbilt 37% = more emphasis on wellness >50% - agrees Vandy cultures supports wellness 50-60% works within 41-60 hrs Home vs. work stress levels were 3.69 vs. 5.29 (scale 1-9) 82% had a PCP Fear of loss of leadership support, documentation, rumors = barriers for seeking assistance in >40% *sample N=45

11. Surgery at Vanderbilt >4.0*: Maintaining wellness Identifying and dealing with burnout Stress management and dealing with stress Conflict management** Communication skills** Professionalism** 3.90 -4.0*: Dealing with disruptive team members** Dealing with mistakes Maintaining professional boundaries *Out of a 5 point rating scale; Topics to learn more about. ** 75% or more = felt sessions should be required learning/participation; along with effective teamwork

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

13. 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

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

15. Personal Stress Seven key self-care areas: 1.Sleep 2.Balanced meals 3.Physical activity 4.Health socialization/hobbies 5.Vacations/down times 6.Spiritual engagement 7.Having a personal physician MindBody SoulEmotion

16. Work-Place Stress Work-place stress: –Have a mentor –Manage energy* –Plan appropriately –Reduce distractions –Managing failures and successes Manage Energy Reduce Distractions Planning *Schwartz, T. & McCarthy, C. “Manage Your Energy Not Your Time.” HBR October 2007.

17. 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

18. 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

19. 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

20. 1.Work overload 2.Lack of control 3.Insufficient reward 4.Unfairness 5.Breakdown of community 6.Value conflict Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” Six Sources of Burnout

21. Symptoms of Burnout 1.Emotional exhaustion 2.Depersonalization: cynical and detached 3.Increasingly ineffective/reduced personal accomplishments 4.Leads to: 1. Isolation 2. Avoidance 3. Interpersonal conflicts 4. High turnover Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg 17

22. Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):1447-50 Protective Factors-Personal Tend to the seven self care issues first Address Maslach’s 6 sources of burnout Work overloadLack of controlInsufficient reward UnfairnessBreakdown of communityValue conflict Influence happiness through personal values and choices Mentor(s) 1.Sleep 2.Balanced meals 3.Physical activity 4.Socialization 5.Vacations/down times 6.Spiritual engagement 7.Have a physician

23. Protective Factors-Work Address Maslach’s 6 sources of burnout Create a culture of wellness Find meaning in work Gain control over environment & workload Set limits and maintain balance Mentor (s) Adequate administrative support systems

24. “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

25. Evidence & Importance

26. 46-80% emotional exhaustion 30-60% MD have distress and burnout MDs suicide > other prof. & gen pop. One physician per day Grossly underestimated Depression/bipolar & substance abuse = suicide risk “Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success.” Cole, Goodrich & Gritz, 2009.

27. Evidence & Importance Gender differences: Females > anxiety, depression, burnout F>M MD suicides (>50% vs 40% higher risk) Women chairs more stressed Male physicians (regardless of race) live longer than other professionals. Reduced use of care by physician Stigma & anonymity – slow to prioritize MH issues for physicians; licenses, etc. http://www.aamc.org/members/gwims/statistics/stats09/start.htm Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82. (Schindler et al 2006) “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008

28. Evidence & Importance Academic faculty: –Worked longer hours –Took less vacation 10% with mild depression 27% with elevated anxiety –No sig difference clinical vs. academic Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82. 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 2006 81(1):27-34.

29. Evidence & Importance 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):121-43.

30. 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.

31. 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.

32. Unprofessional Behaviors

33. Barriers to Being Professional Lack of self-care* Lack of supportive environment/culture* Lack of understanding of the rules and consequences* Lack of training Competing priorities

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

35. 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, emails 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. 4/09

36. Key Concepts The physician holds the balance of power over patients, staff and students. Mutual consent is not recognized as a defense for the physician. Patient and physician emotional vulnerabilities are at the core of boundary violations. Self care by the physician is critical to prevent hazardous romantic relationships.

37. “We judge ourselves by our motives others judge us by our behavior.” AA saying

38. The physician is always held responsible for any misconduct, regardless of who provoked it.

39. Risk Factors for Patient and MD Are the Same Prior spiritual wounding-fundamentalist background Personality traits-borderline, narcissistic, sociopath Family of origin-rigid, disengaged most at risk History of addictions in family of origin Untreated mood disorders Sexual abuse/trauma

40. Boundaries Differ in Different Specialties Psychiatry Primary Care Surgeon Pediatrician Anesthesiology OB/Gyn Other

41. Slippery Slope Late appointments with no chaperone Business transactions/dual relationships Excessive physician self-disclosure Some forms of language use Personal gifts Special favors Flirting, jokes etc. Grooming behavior Casual workplace

42. Boundary Violations 1.Sexual Impropriety may comprise behavior, gestures, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. 2.Sexual Violation may include physical sexual contact between a physician and patient, whether or not initiated by the patient, and engaging in any conduct with a patient that is sexual or may be reasonably interpreted as sexual. Addressing Sexual Boundaries: Guidelines for State Medical Boards. Federation of State Medical Boards 2006.

43. Sexual Harassment 3. Sexual harassment can occur in a variety of circumstances, including but not limited to the following: –The victim as well as the harasser may be a woman or man. –The victim does not have to be of the opposite sex. –The harasser can be the victim's supervisor, an agent of the employer, a supervisor in another area, a co-worker, or a non- employee.

44. Sexual Harassment –The victim does not have to be the person harassed but could be anyone affected by the offensive conduct. –Unlawful sexual harassment may occur without economic injury to or discharge of the victim. –The harasser's conduct must be unwelcome.

45. Key Concepts The physician holds the balance of power over patients, staff and students. Mutual consent is not recognized as a defense for the physician. Patient and physician emotional vulnerabilities are at the core of boundary violations. Self care by the physician is critical to prevent hazardous romantic relationships.

46. Leadership Role

47. The Balance Beam Do nothing Do something June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy Center for Patient and professional Advocacy at Vanderbilt

48. Infrastructure for Addressing Disruptive Behavior (DB) 1.Leadership commitment 2.Supportive institutional policies 3.Surveillance tools to capture pt/staff allegations 4.Model to guide graduated interventions 5.Processes for reviewing allegations 6.Multi-level professional/leader training 7.Resources to help disruptive colleagues 8.Resources to help disrupted staff and pts Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring and Addressing Unprofessional Behaviors. Academic Medicine. November, 2007. Center for Patient and professional Advocacy at Vanderbilt

49. Apparent pattern Single “unprofessional" incidents (merit?) Disruptive Behavior Pyramid Mandated Issues "Informal" Cup of Coffee Intervention Level 1 "Awareness" Intervention Level 2 "Authority" Intervention Level 3 "Disciplinary" Intervention Pattern persists No ∆ Vast majority of professionals - no issues Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 Center for Patient and professional Advocacy at Vanderbilt

50. Upcoming CPPA Conferences: The Why and How of Dealing with “Special” Colleagues: Discouraging Disruptive Behavior June 2-3, 2011; November 3-4, 2011 The How and When of Communicating Adverse Outcomes and Errors December 16, 2010 http://www.mc.vanderbilt.edu/centers/cppa/courses.htm 50 Center for Patient and professional Advocacy at Vanderbilt

51. Vanderbilt Internal Resources Abbrev.ProgramFocusContactNumber FPWCFaculty and Physician Wellness Committee All issues of professional health Charlene Deweyx6-0678 FPWPFaculty and Physician Wellness Program – Work/Life Connections EAP Treatment of faculty and employees Mary YarbroughX6-1327 CPHCenter for Professional Health Training physiciansBill Swiggartx6-0678 VCAPVanderbilt Comprehensive Assessment Program for Professionals Fit for duty assessments and treatment Reid FinlaysonX2-4567 CPPACenter for Patient and Professional Advocacy Identification and assistance Jerry HicksonX3-4500

52. Vanderbilt Internal Resources CPH: http://www.mc.vanderbilt.edu/cphhttp://www.mc.vanderbilt.edu/cph CPPA: http://www.mc.vanderbilt.edu/centers/cppa /index.html http://www.mc.vanderbilt.edu/centers/cppa /index.html Work-Life connections: http://worklifeconnections.vanderbilt.edu/ http://worklifeconnections.vanderbilt.edu/ VCAP: http://www.mc.vanderbilt.edu/root/vcap http://www.mc.vanderbilt.edu/root/vcap

53. Vanderbilt Internal Resources Center for Integrated Health (CIH) Health Plus Go for the Gold program Center for Professional Health Educational Resource web page/on-line classroom (in development) Dayani center & ortho exercise facility VERITAS

54. Other Resources State physician health programs Primary care provider Private counseling services (Centerstone, Elam Center, Center for Women Medicine) Substance use related issues (AA, NA, Parthenon, Cumblerland Heights, Evelyn Fry, etc) Suicide prevention hotline: 1-800-273- TALK YMCA/YWCA, Massage envy, etc.

55. Question & Answer

56. Summary: Take Home Points 1.Self-care is the foundation to faculty vitality and remaining professional. 2.Create a culture of wellness. 3.Look for and anticipate stress & burnout. 4.Educate faculty on setting professional boundaries & preventing sexual harassment. 5.Create a plan for addressing distressed behaviors. 6.Take advantage of the valuable resources available.

57. References 1.AMA Code of Ethics 2.Stern, D. “Measuring Medical Professionalism” Oxford Press 2006. 3.Balch, CM. “Surgeon Distress as Calibrated by Hours Worked & Nights on Call.” J Amer Coll of Surgeons Nov 2010; 211(5):609-19. 4.Cole, Goodrich & Gritz. “Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressures of Success.” Humana Press 2009. 5.Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82. 6.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 2006 81(1):27-34. 7.“High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008 8.Faber et al. “Physician’s Experiences with patients who transgress boundaries.” J Gen Int Med 2000;15:770–775. 9.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. 10.Hickson G.B., et al.: A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Acad Med 82:1040–1048, Nov. 2007. 11.Hickson GB, Entman SS. Physician practice behavior and litigation risk: evidence and opportunity. Clin Obstet Gynecol. 2010 Dec;51(4):688-99. 12.The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997 13.Puddester D. “Canadian Medical Association on Policy on Physician Health and Wellbeing.” West J Med 2001;174(1):5- 7. 14.Myers MF. “The Wellbeing of Physician Relationships.” West J Med 2001;174(1):30-33. 15.Gautam M “Women in Medicine: Stressor and Solutions.” West J Med 2001;174(1):37-41. 16.Spickard, Gabbe & Christensen. “Mid-Career Burnout in generalist and Specialist Physicians.” JAMA, September 2002:288(12):1447-50. 17.Schwartz, T. & McCarthy, C. “Manage Your Energy Not Your Time.” HBR October 2007.