Transcript Triage and Treatment of Community

Physician Renewal
From Burnout to Bonfire
Marc Borenstein, MD, FACEP
Professor and Chair
Department of Emergency Medicine
University of Missouri School of Medicine
Put Something Big at Stake
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Ways you could be listening to this presentation
– Interesting/not interesting
– I already know this/I don’t know this
– What really matters to me in my life now
Definition of Physician Burnout
Emotional exhaustion
 Depersonalization
 Low personal accomplishment: loss of drive for
and sense of satisfaction from work
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Definition of Physician Burnout
Differs from depression in that burnout primarily
affects an individual’s relationship to their work
 Deterioration of values, spirit, dignity, and will
 “Silent anguish of the healers”
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Epidemiology of Burnout
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Early concerns for disproportionate levels of
career dissatisfaction
– Shiftwork
– Work intensity
– Lack of respect from medical colleagues
Epidemiology of Burnout
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Early concerns for disproportionate levels of
career dissatisfaction
– Lack of career self-determination
– Hourly worker, low compensation
– Absence of long-term career growth
Epidemiology of Burnout
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ABEM longitudinal study
– Response rate 94% (94), 84% (99), 76% (04)
– 77-80% EM met or exceeded expectations for
career satisfaction
– 32% experienced burnout
Cydulka RK Korte R Ann Emerg Med 2008 51(6):714-22
Epidemiology of Burnout
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ACEP Scientific Assembly attendees
– 60% moderate to high burnout
– Attrition 7.5% at 5 years and 25% at 10 years
– Similar attrition rates in other specialties
Goldberg R Boss RW et al Acad Emerg Med 1996 3(12):1156-64
Epidemiology of Burnout
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ACEP member survey
– 43% response rate
– 32% experienced at least one component of
burnout
– Emotional exhaustion most often
– Anxiety/concern for bad outcomes
Kuhn G Goldberg R Ann Emerg Med 2009 54:106-13
Epidemiology of Burnout
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Mayo Clinic commentary
– 30 - 40% of physicians experience burnout
– ↑Error, ↓empathy, ↑attrition,
– Excessive workloads may increase further
Dyrbye LN Shanfeldt TD JAMA 2011 305(19):2009-10
Risk Factors for Burnout
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Physician personality traits
– Obsessive - compulsive
– Striving talents, pursuit of excellence
– Empathetic
– Repress emotions
Risk Factors for Burnout
↑Paperwork
 ↓Financial reimbursements
 ↓Ancillary support
 ↓Resources to get non-clinical job(s) done
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Risk Factors for Burnout
↑Malpractice litigation
 ↑Compliance and accreditation regulations
 ↑ED crowding/inadequate space
 Feeling of lack of support for EM and/or the ED
from colleagues and/or one’s institution
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Risk Factors for Burnout
↑Debt for residents and attendings
 Difficult patients and absence of pre-existing
patient/family relationships
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Identifying Signs/Symptoms of Burnout
Cynicism, resignation
 Anger
 Isolation
 Apathy, feeling numb or emotionless
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Identifying Signs/Symptoms of Burnout
Work no longer enjoyable or fun
 No sense of humor or lightness
 Increasingly feeling no energy, tired
 Increased or new physical symptoms
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Identifying Signs/Symptoms of Burnout
Negative attitudes towards self, others, patients
 New pattern of lateness, not completing work
 Difficulty focusing at work
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Identifying Signs/Symptoms of Burnout
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Self-medication
– New day, same s**t
– Same day, same s**t
– Same old, same old
Consequences of Burnout
Medical error
 Depression
 Substance and/or ETOH abuse/addiction
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Consequences of Burnout
Partner/relationship discord
 Boundary violations
 Disruptive behavior
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Consequences of Burnout
Physician loss from the workplace
 Diminished ED team effectiveness/productivity
 Loss of nursing and/or mid-level provider staff
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From Burnout to Bonfire
Recognition
 Work/career modification
 Personal life changes
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Burnout Can be Insidious
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You’re accomplishing your work and getting
things done
Burnout Can be Insidious
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Signs/symptoms
– Feeling bored, tired
– Not having much fun at work
– Same old, same old
Burnout Can be Insidious
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The job is not a match for who you are, your
commitments, and what you can contribute
– Is what you’re saying and doing in alignment
with your commitments and values in life?
– If no in part or all, you’re at risk for burnout
From Burnout to Bonfire
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Solutions
– Reclaim your childhood vision/mission
– Invent a new vision/mission
– Take on a bigger game
– Consider taking a (careful) risk
From Burnout to Bonfire
The important thing is this: to be able at any
moment to sacrifice what we are for what we
could become
Charles Dubois
Identifying Burnout
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You’re working on a big, exciting project but have
insufficient time to get the job done and have a
life outside work
Identifying Burnout
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You’re working on a big, exciting project but have
insufficient time to get the job done without a life
outside work
Identifying Burnout
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If the time you spend trying to do it all is taken at
the expense of your personal and family life
– If yes in part or all, you’re at risk for burnout
Identifying Burnout
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Symptoms
– Feeling angry
– I’m working harder than they are
– No one around here cares as much as I do
Identifying Burnout
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Symptoms
– Tired/sleep deprived, working late at home
– Stress with spouse, partner, family
– I need a time management class
Self-monitoring
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Trying to do it all yourself
– May be compensation for a failure to provide
leadership
– Reliance on skills you already have
– Staying within your comfort zone
Self-monitoring
There is insufficient time for you to get everything
done
 All great projects require a team
 Many great projects are not accomplished in a
single lifetime
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From Burnout to Bonfire
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Solutions
– Start from where you are
– Invent a vision and a bold statement
From Burnout to Bonfire
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Solutions
– Live your vision for the future in the present
– Communicate it……Everywhere!
– Be a leader for your life and yourself
From Burnout to Bonfire
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Solutions
– Get a coach
– Build a team
What is Vision?
Future based
Seeing the possibility for something to emerge
Not predicted by past performance or history
What is Vision?
Not defined or determined by circumstances
Invented, created
Exists in language
I’ll Believe It When I See It
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What you already know about yourself, the
world, and your past is in the way of seeing
what’s present and discovering anything new
I’ll Believe It When I See It
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The real voyage of discovery consists not in
seeking new landscapes but in having new eyes
Marcel Proust
Be a Leader for Your Life
Being and living your vision and commitment in
the present
Having your actions, behaviors, and
communication informed by your vision and
commitment
Be a Leader for Your Life
Creating, communicating, and sustaining
purposeful context consistent with your vision
and your commitment
Why Be a Leader for Your Life?
You have a powerful commitment
 Your voice and contribution matter
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Why Be a Leader for Your Life?
Leadership galvanizes a team to accomplish a
job beyond what can be achieved by the
individual
 Leadership creates the leverage needed to move
the world
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The Power of Leverage
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1 EM physician provides care to 3000 pts/yr
Graduate 10 EM residents/yr = 30,000 pts
30 year career/graduate = 900,000 pts
10 year RPD career = 9,000,000 pts
The Power of Leverage
Never doubt that a small, group of thoughtful,
committed citizens can change the world.
Indeed, it is the only thing that ever has
Margaret Mead
The Bonfire Challenge
Discipline to articulate and sustain a vision and
sense of purpose
 New and/or expanded non-intellectual skills and
responsibility
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The Bonfire Challenge
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Effective and disciplined communication
– Ownership of outcomes and the experience of
others
– Creative v. descriptive language
From Burnout to Bonfire
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Willingness to take ownership
Creating the future through language
Prioritizing choices and taking action
Thinking from abundance
From Burnout to Bonfire
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Mining for the gold
Listening for the vision in what other’s say
Embracing change
Incorporating renewal
Seeking the inner journey
Self-awareness
Confidence
– Comfortable with divergent thinking, ambiguity
– Able to consider other points of view
 Accurate, realistic self-view
– Thirst for constructive critique
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Self-awareness
Humility
 Candor, without self-significance
– Self-deprecating sense of humor
 Gratefulness
 The ability to create empowering context
– Turn down the volume on negative thoughts
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Self-regulation
Reflective
– Not impulsive, reactive or emotionally driven
– Invites and considers all points of view before
taking action
 Flexible
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Self-regulation
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Keeping one’s word
– Creates trustworthiness
– Builds integrity
Empathy
Cultural sensitivity
 Appreciates and invites diversity
 Drives service to others
– Patient satisfaction
 Attraction/retention of talent
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Social Skills
Talent for finding common ground
 Team-building
 Leading change
 Creating new and strengthening existing
relationships
– “Schmoozing”
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Social Skills
Affability
 Communication excellence
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Motivation
Innately driven to achieve
– Striving talents
 Availability
 Organizational commitment
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Motivation
Strongly optimistic
 Timeliness
 Perseverance
 The “Yes” mentality
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Time to Give Up
Complaining, whining
– Trashing the hospital, department, or its
leadership publicly
 Not taking ownership of a problem
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Time to Give Up
Being argumentative, stubborn
 Engaging in gossip
 Comparing yourself or others to others
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Start From Where You Are
Right Now
Invent a purposeful context for what you are
already doing
 Create a vision that articulates that purposeful
context for you and for others
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Start From Where You Are
Right Now
Be sure your vision is in alignment with your ED
and institutional values
 Create a bold statement
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Pick Two Areas of Your Life
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Where to look
– Where are you putting up with something or
someone
– An area that looks hopeless
– An area where you feel stuck, trapped
– “This is never going to change”
Pick Two Areas of Your Life
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Where to look
– It’s them, or him, or her!
– An area or person where you used to have a
feeling of affinity
– Sense of humor gone in this area
– An area where it’s very significant
Qualities of a Purposeful Context
Must excite you
 Inclusive
 Leave others with the possibility of participation
in and contribution to something bigger than the
individual
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Why Invent a Purposeful Context?
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The story of the stone cutters
Creating a Vision for Your Life
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To provide dignity, compassion and enhance
the well-being of each and every person
Creating a Vision for Your Life
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To honor the dignity of the human spirit ans
have people leave with an experience of being
valued
Creating a Vision for Life
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The possibility of the workplace as a healing
environment that enhances the well-being of
people
One Possible Vision Statement for Life
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To create a Emergency Department that will
serve as a model for what’s possible for people:
a safe haven where extraordinary emergency
care is delivered with compassion, timeliness,
and a driving sense of honoring the individual
From the Creed of NBIMC
Personal attention notable for its warmth and
sincerity and inspired by a sympathetic
recognition of the human element is the powerful
but gentle handmaiden of science employed by
doctors, nurses, and attendants at Beth Israel
Hospital. Patients are people, not cases at this
hospital….they are men, women, and children,
human beings, and are treated as such
From the Creed of NBIMC
The value of the human touch as a power for
healing is never lost sight of at Beth Israel
Hospital
The Value of a Bold Statement
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Bold statement
– A non-linear future not predicted by the past
– Simple, clear
– Immediately communicates to all
The Value of a Bold Statement
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Bold statements
– NASA
– Coca-Cola
The Value of a Bold Statement
Putting Columbia on the map of academic EM
 Leaving a legacy of extraordinary emergency
medical care for Missouri and beyond for
generations to come
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Practical Tips
Schedule everything you intend to do
– Schedule time for yourself, family, and friends
– Frequently check your schedule with your
family
 Head, heart, body = Total well-being
– Schedule time for the mind, soul, and physical
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Practical Tips
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Create an empowering context for some of your
time at work
– Health fairs
– Community education
– Committees
– ED and non-ED conferences
Practical Tips
Know the rules for the game at work
 Play the game at work by the rules
 Know the outcomes that define winning
 Know the score
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Practical Tips
Learn to say “no”
– Empower and trust others to get the job done
 And “let go”
– Annual inventory of projects
– Give away the ones that no longer excite you,
create income, or forward your career
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Practical Tips
Make requests
– Let people know that you need help
 Communicate breakdowns early
 Know what’s expected of you
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In Conclusion: Burn Brightly
I’ve never seen anyone burnout from being
on fire
Marc Borenstein
In Conclusion: Burn Brightly
This is the true joy of life, the being used for a
purpose recognized by yourself as a mighty one;
the being a force of nature instead of a feverish
little clod of ailments and grievances complaining
that the world will not devote itself to making you
happy.
I am of the opinion that my life belongs to the
whole community and as long as I can live, it is
In Conclusion: Burn Brightly
my privilege to do for it whatever I can.
I want to be thoroughly used up when I die….Life
is no brief candle to me. It is a sort of splendid
torch which I have got hold of for the moment,
and I want to make it burn as brightly as possible
before handing it on to the next generation.
George Bernard Shaw