Transcript The Health and Wellness of Physicians: Managing Stress, Burnout and Energy Charlene M.

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.
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
Importance & Evidence
• 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
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.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.
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. 2008 Mar 1;336(7642):48891. 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. 2009 Apr;31(4):338-41. (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. 2001
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. 1995 Aug;23(8):1425-9. (GW)
Two systems interact
The internal system
The external system
Functional &
nurturing
Good skills
Hospital/Clinic
Physician
Dysfunctional
Poor skills
“The Perfect Storm”
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):121-43.
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
Professional Health & Wellness
Work Environment
Mind
Home Environment
Body
Self-Care
Soul
Emotion
Professional Health & Wellness
Spectrum
Work &
Family
Relations
High Functioning
High Productivity
Fair Functioning
Decreasing Productivity
Fair Functioning
Reduced Productivity
Relationships Suffer
Fair-Not Functioning
Fair-Not Productive
Institution & Family Loses
Physical
Mental
Emotional
Spiritual
Stressed
Professionally Healthy
& Well
Coping Mechanisms
Strong
Burnout
Coping Mechanisms
Failing
Risk of MH issues and
suicide
No Coping
Mechanisms
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
The Doctor Dewey Insto-Matic, Stress-O-Meter
Anxious
Engaged
Enthusiastic
Calm
Run Down
Stressed out
Exhausted
Overwhelmed
Drained
Relaxed
Ready to cave
Stress free
Burnt out
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 <job-related stress> Webster’s
dictionary
Stress & Productivity
Prolonged
Stress
Reduced
Cognition
“Impairment”
???
No
Prolonged
Stress
Situational Stress
Stressed
Burnout
Non-Functional
Managing Individual Stress
Seven Key Areas:
1.
2.
3.
4.
5.
6.
7.
Sleep
Balanced meals
Physical activity
Socialization
Vacations/down times
Spiritual engagement
Have a physician
Mind
Body
Spirit
Emotion
Managing Work-Place Stress
Manage energy
1.
2.
3.
4.
5.
Self care at work
Plan appropriately
Reduce distractions
Office culture
Work place training
on burnout*
*McCue JD & Sachs CL. A stress management workshop improves residents' coping skills. Arch Intern Med. 1991
Nov;151(11):2273-7. (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
Figure 1
Spectrum of Disruptive Behaviors
Aggressive
Inappropriate anger,
threats
Passive
Passive
Aggressive
Hostile notes, emails
Yelling, publicly degrading
team members
Intimidating staff,
patients, colleagues, etc.
Derogatory comments about
institution, hospital, group,
etc.
Inappropriate joking
Pushing, throwing objects
Swearing
Outburst of anger &
physical abuse
Sexual
Harassment
Chronically late
Failure to return calls
Inappropriate/
inadequate chart notes
Avoiding meetings & individuals
Non-participation
Ill-prepared, not prepared
Complaining,
Blaming
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
•
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•
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•
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
Six Sources of Burnout
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.”
*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. 1994 Oct;10(5):256-9.
Symptoms of Burnout
1.Chronic exhaustion
2.Cynical and detached
3.Increasingly ineffective at work (distressed behaviors)
4.Leads to:
1.
2.
3.
4.
isolation
avoidance
interpersonal conflicts
high turnover
Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg
17
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
Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):1447-50
Protective Factors
– A supportive spouse or partner
– Engage in religious or spiritual activity
– Hobbies
– Mentor (s)
Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):1447-50
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. 1991
Nov;151(11):2273-7.
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 emails 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?
Preventing & Resolving Burnout
Individual Approach
Organizational Approach
Starts with
person
Starts with
management
Becomes group
project
Becomes organizational
project
Connects to organization
Connects to people
Outcomes affects related
mismatches
Outcome is a process
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
The Truth About 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
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 clear
Plan/Timetable
Behavior not attitude
What are your personal barriers?
Something you can count
When will you start?
Resources
•
•
•
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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
• 1-800-273-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.
2.
3.
4.
5.
6.
7.
8.
9.
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11.
12.
13.
14.
Cole, Goodrich & Gritz. “Faculty Health in Academic Medicine: Physicians, Scientists, and the
Pressures of Success.” Humana Press 2009.
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. The Impact of the changing Health Care Environment on the Health and Wellbeing of faculty at Four Medical Schools. Academ Med 2006 81(1):27-34.
Shanafelt et al. Special Report: Suicidal Ideation Among American Surgeons. ARCH SURG JAN
2011:146(1);54-62.
“High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June
11, 2008
Schwartz, T. & McCarthy, C. “Manage Your Energy Not Your Time.” HBR October 2007.
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.
Goleman,Daniel. “What Makes a Leader?” Best of Harvard Business Review (1998)
The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It.
Maslach & Leiter pg 9; 1997
Puddester D. “Canadian Medical Association on Policy on Physician Health and Wellbeing.” West
J Med 2001;174(1):5-7.
Myers MF. “The Wellbeing of Physician Relationships.” West J Med 2001;174(1):30-33.
Gautam M “Women in Medicine: Stressor and Solutions.” West J Med 2001;174(1):37-41.
Spickard, Gabbe & Christensen. “Mid-Career Burnout in generalist and Specialist Physicians.”
JAMA, September 2002:288(12):1447-50.
“The first wealth
is
health.”
~ Ralph Waldo Emerson