Transcript SURGEON PERFORMANCE OPTIMIZATION All of us are performers every day, all the time.

SURGEON PERFORMANCE
OPTIMIZATION
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All of us are performers every day, all the
time. We face obstacles, distractions and
pressures; we are asked to solve complex
problems with inadequate information.
Time is often short and expectations are for
flawless performance.
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IN THE OPERATING ROOM
more
more
more
more
lives are saved
diseases cured
functions restored
suffering alleviated
than in any other place in the hospital.
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HOW ARE WE REALLY DOING?
AT WHAT PRICE?
CAN WE DO BETTER, FOR
OURSELVES AND FOR OUR
TRAINEES?
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The Aching Surgeon: A Survey of
Physical Discomfort and Symptoms
Following Open, Laparoscopic, and
Robotic Surgery
Plerhoples TA, Curet MJ, Hernandez-Boussard T, Wren SM.
1407 surgeons (7% response)
Ergonomics matter.
Patients benefit from laparoscopic technology;
surgeons suffer
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Food for Thought: An Exploratory Study
of How Physicians Experience Poor
Workplace Nutrition
Lemaire JB, Wallace JE, Dinsmore K, Roberts D. Nutrition Journal 2011, 10:18.
Emotional, physical and cognitive symptoms
reported.
We practice hydration and nutrition for our
patients, what about us?
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Hydration and Cognition: A Critical
Review and Recommendations for
Future Research
Lieberman, HR. Journal of the American College of Nutrition.
• Dehydration impairs cognitive performance
• Adverse affects are present at 2%
Might be present at 1%
• Krummel experiment
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Krummel Experiment –
My Typical OR Day
 Coffee for breakfast
 No Lunch
 Finished OR day @ 7 PM
U/O 0.2 cc/kg/hr
AM weight: 80 kg
> 1.5 kg
PM weight: 78.5 kg
TBW
1.5 liter loss
48 liters
> 3% dehydrated
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Work-Related Musculoskeletal
Symptoms in Surgeons
Szeto GPY, Ho P, Ting ACW, Poon JTC, Cheng SWK, Tsang RCC. J Occup
Rehabil (2009), 19:175-184.
High prevalence of work-related musculoskeletal
symptoms.
500 surgeons surveyed
Neck
82.9%
Low Back
68%
Shoulder
58%
Upper Back
52%
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Burnout and Career Satisfaction Among
American Surgeons
Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, Collicott P,
Novotny PJ, Sloan J, Freischlag, JA. Annals of Surgery, Vol 250(3), September
2009.
24,922 surgeons surveyed
7905 respondents (32%)
40% ‘burned out’
30% symptoms of depression
28% mental QOL >0.5 SD below norm
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SPECIAL REPORT: SUICIDAL IDEATION
AMONG AMERICAN SURGEONS
Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D,
Rummans T, Swartz K, Noyotny PJ, Sloan J, Oreshovich MR. Archives of
Surgery 146:54-61.
• 7905 participating surgeons (31.7%)
• 501 (6.3% reported suicidal ideation
within 12 months)
• We have >160 surgeons in this department
• Statistically 10 at risk
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Physician Wellness:
A Missing Quality Indicator
Wallace JE, Lemaire JB, Ghali WA. Lancet 2009 Nov 14:374(9702); 1714-21.
Abstract
When physicians are unwell, the performance of health-care
systems can be suboptimum. Physician wellness might not
only benefit the individual physician, it could also be vital to
the delivery of high-quality health care. We review the work
stresses faced by physicians, the barriers to attending to
wellness, and the consequences of unwell physicians to the
individual and to health-care systems. We show that health
systems should routinely measure physician wellness, …
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THE MAKING OF A
CORPORATE ATHLETE
“If executives [surgeons] are to perform at
high levels over the long haul, they should
train in the same systematic, multi-level way
that world class athletes train.”
Must go beyond wellness  optimization
Physical, emotional, mental, values & purpose
Loehr J and Schwartz T: The Making of a Corporate Athlete,
Harvard Business Review, 2001.
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RESILIENCE
The world breaks everyone.
And afterward some are
strong in the broken places.
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FOR CONSIDERATION
 The best interests of our patients are
served by optimizing surgeon
performance.
 Biggest leverage point is to start with
our trainees.
Dr. Ralph Greco
Drs. Magee, Salles, Teshome, Zak
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A PROGRAM TO CREATE
BALANCE IN THE LIVES
OF OUR RESIDENTS
Dedicated to the memory of
Greg Feldman, M.D.
Chief Resident 2009-2010
© 2011 The Board of Trustees of the Leland Stanford Junior University–
Dr. Ralph S. Greco ([email protected])
Committee on Balance in Life
RALPH S. GRECO, M.D.
JOHNSON AND JOHNSON DISTINGUISHED PROFESSOR AND
COMMITTEE CHAIR
RACHAEL CALLCUT, M.D.
CHAPLAIN BRUCE FELDSTEIN, M.D.
MARC MELCHER, M.D.
CLAUDIA MUELLER, M.D.
SURGERY RESIDENTS:
GREG MAGEE, M.D.
ARGHAVAN SALLES, M.D.
MEDIGET TESHOME, M.D.
YULIA ZAK, M.D.
ANITA HAGAN, RESIDENCY COORDINATOR
THOMAS M. KRUMMEL, M.D.
EMILE HOLMAN PROFESSOR AND CHAIR
PROGRAM DIRECTOR, GENERAL SURGERY RESIDENCY
PROGRAM
The memory of Greg Feldman is extremely
emotional for all of us. He seemed to me to be
extremely good at balancing his work and non work life, and cared about getting other
residents to have fun both at and outside
work. So it seems appropriate both in content
and timing that it be dedicated in honor of
him. In so doing, I feel that it is important to not
lose focus, because the best way to honor him is
to ensure the program has a meaningful and
lasting impact on the residents. In my opinion it
is important to remember that many of the most
impactful aspects of the program are not flashy,
but rather the low hanging fruit like advising our
residents as we advise our patients - making sure
they see their doctor/dentist, telling them to try
to exercise and eat healthy, helping them
develop healthy coping mechanisms, promoting
friendship/socializing among residents, and
putting mechanisms in place that can facilitate
those basics.
Greg Magee, M.D.
Greg Feldman’s Harvard Graduation Speech
(YouTube video)
hmsedited_smaller.wmv
“THE TERRIBLE TOOS”
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too many beeper calls and scut
too little time to study
too little sleep
too little time with family
too many bad outcomes
too little money
too much pressure
too much criticism
too little respect
too little support
too much ridicule
just too much!!
Physical Health
It is the expectation of the Stanford General Surgery Training Program
that all surgical residents will take their physical health seriously and
• Schedule regular appointments with primary care
physicians and dentists
• Eat a healthy diet
• Exercise
“AFTER HOURS”
BROCHURE
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Primary Care Physicians
•
Dentists
•
OB/Gyns
•
Gyms
•
Hiking/Biking Trails
•
Restaurants
•
Local Travel
Resident Refrigerator
in the Goodman Simulation Center
Psychological Health
•Balance in Life Class Meetings
• Lisa Post, Ph.D.
•Finding Meaning in Medicine
• Chaplain Bruce Feldstein, M.D.
Team Building
• Retreats, Ropes Course, Big Sib/Little Sib
Social Program
• Elect---------formulate
Structural Issues
• Space
• Resources
• Forums
• Elect class representatives
• Monthly meetings
• ACGME Presentation-March 2012
Program Management
• Resident Leadership “The Fab Four”
• Greg Magee (2011-2012)
• Mediget Teshome (2012-2013)
• Yulia Zak (2013-2014)
• Arghavan Salles (2014-2015)
What Happens Now
• How do we guarantee that the program doesn’t
dissipate over time?
• Resident leadership at multiple levels
• Endowment
“THE JUST RIGHTS”
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just the right amount of work
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just the right amount of time off
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just the right amount of sleep
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just the right amount of time for family and
friends
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just the right amount of patient contact
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just the right amount of support
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just the right amount of teaching
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just the right amount of OR cases
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just the right amount of respect
Resident Wellness is
Performance Optimization
Greg Magee
Arghavan Salles
Mediget Teshome
Yulia Zak
Poor Occupational Health is Costly
– The total cost of stress to U.S. organizations
is more than $150 billion a year.1
– Occupational stress leads to multiple
problems:1, 2
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Substance abuse
Accident proneness
Sleep dysfunction
Sexual dysfunction
Depression
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Danna, K., & Griffi n, R.W. (199 9). Health and well-being in the workplace: A review
and synthesis of the litera ture. Journal o f Manag ement, 25(3), 357-384.
2
Wallace, J.E., Lemaire, J.B., & Ghali, W.A. (2009). Physician wellness: A missing
quality indicator. Lancet , 374, 1714-1721.
Improving Employee Well-Being
Benefits the Organization1
Improving employee well-being can:
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Reduce absenteeism
Reduce turnover
Improve mental alertness
Improve job satisfaction
Improve productivity
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Which in turn
leads to
better
patient care
Danna, K., & Griffi n, R.W. (199 9). Health and well-being in the workplace: A review
and synthesis of the litera ture. Journal o f Manag ement, 25(3), 357-384.
Well-Being Improves
Productivity3
Employee
Engagement
Positive Affect
Productivity
Gallup’s meta-analysis of data from 21 industries and
nearly 200,000 individuals found that companies with
greater employee engagement had
-lower turnover rates
-higher productivity
-greater profitability
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Harter, J.K., Schmidt, F.L., & Keyes, C.L.M. (2002). Well-being in the Workplace and
its Relationship to Business Outcomes: A Review of the Gallup Studies. In C.L. Keyes &
J. Haidt (Eds.), Flourishing:The Positive Persona and the Good Life (pp. 205-224).
Washington, D.C.: American Psychological Association.
Overview of Proposed Programs
Physical
Well-Being
Leadership
Development
Psychological
Well-Being
Social
Well-Being
Physical
Well-Being
Psychological
Well-Being
Leadership
Development
Social
Well-Being
Health Maintenance
• International issue
42%
• Only
of Australian physicians had a
general practitioner.4
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30% of young Irish physicians had not
been to a general practitioner in the previous 5
years.4
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65% felt unable to take time off from work
when they were ill.5
4
Pullen, D., Lonie, C.E., Lyle, D.M., Cam, D.E. & Doughty, M.V. (1995). Medical care
of doctors. Medical Journal foAustralia, 162, 481Š484.
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Uallachain, G.N. (2008). Attitudes towards self-health care: A survey of GP trainees.
Irish Medical Journal
, 100, 489Š491.
Doctors work despite being ill6
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61% despite vomiting all night
83% despite blood in their urine
76% despite a suspected stomach ulcer
73% despite severe anxiety
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Baldwin, P.J., Dodd, M., & Wrate, R.M. (1997). Young doctors' healthŃ II. Hea lth and
health behavior. Socica l Science in Medicine , 45, 41Š44.
Emergency Coverage
• Description
– It is difficult for residents to take time off to see
their physician or dentist.
– We will now require residents to do so.
• Goal
– Ensure that residents take care of themselves
Healthy Eating
• Description
– Refrigerator in Goodman Surgical
Simulation Center
– Barriers to healthy eating among
physicians are related to food selection
& availability.7
• Goal: To provide access to healthy food options
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Winston, J., Johnson, C., Watson, S. (2008). Barriers to healthy eating by National
Health Service (NHS) hospital doctors in the hospital setting: Results of a cross sectional
survey. BMC Research Notes, 1, 69.
Exercise
• Description
– Encourage residents to exercise regularly
– Provide list of local gyms, outdoor activities
– Exercise is associated with high well-being in
various facets of employees' lives.8
• Goal: To prioritize exercise and healthy living
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Thogerse n-Ntoumani, C., Fox, K.R., Ntoumanis, N. (200 5). Relationships betwee n
exerc ise and three components of mental well-being in corporate employees. Psychology
of Sport and Exercise , 6(6), 609-627.
Psychological
Well-Being
Physical
Well-Being
Leadership
Development
Social
Well-Being
Analyze This
• Employee counseling benefits:9
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Decrease anxiety and depression
Improve productivity
Decrease absences
Lead to greater job satisfaction
• Description
– Residents meet with psychologist Lisa Post
• Goal
– Give residents an opportunity to discuss problems
in a safe environment with a professional
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Cooper, C.L., & Sadri, G. (1995). The Impact of Stress Counseling at Work. In
Occupational Stress: A Handbook , R. Crandall (Ed). Washington, D.C.: Taylor &
Francis.
Lisa Post, PhD
• Director of Health Connect
• Chief, Sports Medicine in
Psychiatry
• Extensive experience in interpersonal dynamics counseling
and psychosocial treatment
• Consulting psychologist for the
San Francisco 49ers
• Instructor, Rookie Conduct
Management/Rookie Success
Program for the National Football
League
Physical
Well-Being
Psychological
Well-Being
Social
Well-Being
Leadership
Development
Class Representation
• Description
– Each class elects a representative to meet with the
Well-being Chief monthly
– Brainstorm solutions to problems
• Goal
– Provide a forum to discuss active issues
– Generate solutions
– “The best way to have a good idea is to have lots
of ideas.”
-Linus Pauling, winner of two Nobel prizes
We’re Looking for
a Few Good Residents
The Value of Mentorship
•
96% of orthopedic
residents considered
mentors critical to their
training.10
• Mentorship plays a
significant role in career
development for physician
leaders.11
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Flint, J., Jahangir, A., Browner, B., Mehta, S. (2009). The value of mentorship in
orthopaedic surgery resident education: The residents' perspective. Journal Bone and
Joint Surgery in America, 91, 1017-1022.
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Taylor, C.A., Taylor ,J.C., Stoller, J.K. (2009). The influence of mentorship and role
modeling on developing physician–leaders: Views of aspiring and established physician–
leaders. Journal of General Internal Medicine, 24(10), 1130–1134.
Peer Mentorship
• Description
– Junior residents will select
senior residents to serve as
mentors.
• Goal
– Help junior residents navigate
the residency experience
Team Building
• Description
– Work together towards a
common goal
– Ropes course
– Workshops
• Team building programs
improve outcomes.12
• Goal: To build trust and collaboration
amongst residents
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Delise L.A., Allen Gorman, C., Brooks, A.M., Rentsch, J.R., Steele-Johnson, D. (2010 ).
The eff ects of team training on team outcomes: A meta-analysis. Performance
Improvement Quarterly , 22(4), 53-80.
Physical
Well-Being
Psychological
Well-Being
Leadership
Development
Social
Well-Being
Social support
• Description
– Organized events such as sports outings,
hiking, biking & exercise, dinner/happy hours
• Social collegial support is positively
correlated with improved physician
satisfaction & organizational
commitment.13
• Goal: To foster a sense of community
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Free born, D.K. (2001 ). Satisfaction, commitment and psychological well-being among
HMO p hysicians. West Journal of Medicine , 174(1), 13-18.
Measuring Impact
• Self-report measures such as:
– Burnout
– Depression
– Belonging
• Behavioral measures such as:
– Absences
– Patient care metrics
Conclusions
• Resident well-being is crucial for optimal
hospital operation.
• We appreciate your support in making
our hospital a safer environment for
both residents and patients.
“Work should ennoble, not kill, the
human spirit. Promoting workers’
well-being isn’t just ethical; it makes
economic sense.”
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Amabile, T., & Kramer, S. (2011, September 4). Do happier people work harder? The
New York Times , p. SR7.