Listening so we can HEAR, talking so we can be HEARD (or how to avoid burn-out at work )

1. Listening so we can HEAR, talking so we can be HEARD (or how to avoid burn-out at work ) Coleen Kivlahan, MD, MSPH CMO Aetna Medicaid Programs

2. INTRODUCTIONS

3. A way to start this morning • Our initial focus is to take a look at our patients and our work environments and why they cause us STRESS • Then we will take an inward look at ourselves, understanding more about our own beliefs, biases, frustrations in our professional roles. • Finally we will take a BIG outward look -- how WE interact with others around us, our patients, other staff. • Not only can we understand our patients and our coworkers better, we can export these lessons to our other relationships. People who are happier at home tend to be happier and more productive at work and vice versa. • GOAL FOR TODAY: increase our curiosity!!

4. ONLY RULES ARE: • Being true to what you believe • Trusting each other as colleagues • Not judging others • Keeping an open heart and mind

5. List YOUR frustrations with your clinic or our patients • Ok, I will start: • People do not call before they cancel or no show • Our patients do not bring in their glucose records • There is no privacy here • People do not care about their health in the way I would like them to

6. What do we believe about our patients? • Lifestyles? • Choices? • Behaviors? • Priorities? • Educational status? • Poverty status? • Life outside the clinic for them?

7. FACTS

8. Poverty reality • Increased mortality (more poor people die) • Severity of illness (more poor people are sicker) • Violence Exposure (more poor people commit and are victims of violence) • Less health insurance (more poor people have no source of care except ER) • Competing priorities (housing, transportation, food) • Medication difficulties (access, schedule, disease complexity) • Health care provider reactions (many doctors do not take Medicaid and do not care for the uninsured; they have biases that lead to provision of poor care)  

9. Shelter and poverty • Federal minimum wage was raised to $6.55 in July ‘08. • Minimum wage earners can’t afford 1-BR rental unit anywhere in U.S.   • Nationally, the housing wage for a 2-BR rental unit is $16.31/hour – almost three times federal minimum wage; and rising at twice the rate of inflation. In Washington DC, $24.73/hour is needed to rent a 2BDR apt • On average, 2.5 full time jobs per household are needed to afford a 2-BR unit at fair market rental rate. (2007 data)

10. Cross-cultural Facts • For many of our patients: • Faith and prayer is a method of healing • They see local and herbal healers at the same time they see us • Believe in supernatural forces that hurt or heal/voodoo • Believe in fate or the ‘will of God’ • Believe their families should be involved in all decisions • Believe foods or weather cause disease • Believe that hospitals kill people • Believe that the ER is better quality care

11. DIVING UNDER THE ‘FACTS’ Exploring what is known and unknown in our patient’s histories

12. Case presentations: what is KNOWN, what is UNKNOWN? • 1) 29 year old Egyptian woman working at airport with erratically controlled Type I DM. Thin, attentive, bright, brings med and glucose readings, food diary. Anxious. • Unknown: Hx of pituitary adenoma on bromocriptine. Wants to be pregnant, married to her first cousin, only working member of family • 2) 44 year old Latina with uncontrolled Type II DM and obesity. • Unknown: She will not take glipizide because she believes it makes her gain weight, but tells the nurse she takes all her meds, uses Advil PM to sleep. Only son died in MVA in December. • 3) 45 year old El Salvadoran normal weight woman with uncontrolled HTN on 4 meds. • Unknown: 20 year old son in wheelchair with CP and psychosis; she is unemployed after 16 years at KMart because she is sole caregiver for children • 4) 56 year old Ethiopian man with HTN and angina. • Unknown: In Ethiopian army, translator for US military, now in US and wife filed restraining order against him for DV. He tells me that women are supposed to be quiet and take care of men. He cannot understand that after 30 years of marriage his wife seems angry all the time.

13. WHAT IS THE REALITY ABOUT GOING TO THE DOCTOR/APN WHEN YOU HAVE CHRONIC ILLNESSES? • Scared and afraid • Confusing • Nervous • Angry • Chronic pain • Denial • Bad news

14. KNOWN: Afraid Not being fully truthful or revealing Guilt or shame Hopeless or helpless Angry In pain Confused UNKNOWN: Afraid of WHAT? (us, their diseases, family beliefs, dying…) What prior health care experiences lead them to be not fully revealing Shame about what? (family secrets, being immigrant or different, being sick or helpless) Angry about what? What is:

15. PATIENT CHALLENGES • Poverty is associated with factors that increase health care utilization and reduce adherence to medical regimens • There are unique driving forces in poverty: • Relationships • Survival • Entertainment • UNDERLYING FORCES: • Food • Time • Power/self-management • Destiny

16. PATIENT PATTERNS • Focus on survival and crises can increase ‘no show’ rates • Focus on relationship can increase lack of trust in authority • Focus on destiny can lead to poor self-management • Focus on entertainment can increase the likelihood that YOUR goals and the patient’s are not in alignment, not shared • Focus on family and time can increase likelihood of not doing effective self-management, self-care

17. 10 RULES for serving low-income, language-diverse populations: 1) create a relationship 2) focus on the people 3) reduce the words 4) emphasize action 5) invite and involve the whole family 6) choose accessible, comfortable program sites to reach where THEY are 7) choose appropriate times 8) feature small group activities 9) choose an appropriate length of activities 10) spend money on supplies, not paper for education (Language Sensitive Health Education—Lessons from the Field; California Journal of Health Promotion, June 2003; 1(2): 3–12)

18. Tips for Staying Healthy :A Lifestyle/Medical Approach • Don’t have poor parents. • Don’t live in a poor neighborhood. • Practice not losing your job and don’t become unemployed. • Don’t be illiterate. • Don’t be poor. If you can, stop. If you can’t, try not to be poor for too long. (CDC)

19. So WHY are you here? • A job? • A passion? • Guilt? • Care? • Faith? • Boredom? • Commitment?

20. Burnout • It is a stress syndrome, felt as emotional exhaustion. • Its parameters often have • somatic (exhaustion, insomnia, GI symptoms, rapid breath) • emotional (sadness and depressed mood, negativism, decreased creativity and increased cynicism) • interpersonal manifestations (quickness to anger, defensiveness, edgy and ready to blame others, and a negative world -view) • It is often correlated with the process of grief, as a work-life dream is lost. • Depersonalization of patients and distancing develop in patient/staff relations and disorganization and ineffectiveness increase.

21. Burnout, cont… • People suffering from burnout seem to progressively feel a lack of personal accomplishment in their work. • Patients are apparently less satisfied when receiving care from burned-out physicians and health professionals. • Staff are less committed and less contributory to the continuing success of the practice. • As the burnout-process progresses burning out providers prefer to decrease contact with patients/staff, become less respectful listeners, behave irritably, order more tests, refer patients to others and plan to leave patient care as early as possible.

22. Causes?? • No single factor causes individual burnout • BUT, the question “Is your personal identity bound up with your work role or professional identity?” is HIGHLY correlated • Merging personal identity with professional identity blends professional and non-work roles, usually subverting non-work.

23. Burnout Risk Survey • Are your achievements your self-esteem? • Do you tend to withdraw from offers of support? • Will you ask for/accept help? • Do you often make excuses, like, “It’s faster to do it myself than to show or tell someone? • Do you always prefer to work alone? • Do you have a close confidant with whom you feel safe discussing problems? • Do you “externalize” blame? • Are your work relationships asymmetrical? Are you always giving? • Is your personal identity bound up with your work role or professional identity? • Do you value commitments to yourself to exercise/relax as much as you value those you make to others? • Do you often overload yourself—have a difficult time saying “no?” • Do you have few opportunities for positive and timely feedback outside of your work role? • Do you abide by the “laws:” “Don’t talk, don’t trust, don’t feel?” • Do you easily feel frustrated, sad or angry from your regular work tasks? • Is it hard for you to easily establish warmth with your peers and/or service (patients/clients) recipients? • Do you feel guilty when you “play” or rest? • Do you get almost all of your needs met by helping others? • Do you put other’s needs before or above your own needs? • Do you often put aside your own needs when someone else needs help?

24. Predictors of work stress • Demands of solo practice, long work hours, time pressure, and complex patients • Lack of control over schedules, pace of work, and interruptions • Lack of support for work/life balance from colleagues and/or spouse • Isolation due to gender or cultural differences • Work overload and its effect on home life

25. BIG risks • At risk earlier in career • Lack of Life-partner • Attribution of achievement to chance or others rather than one’s own abilities • Passive, defensive approach to stress • Lack of involvement in daily activities • Lack of sense of control over events • Not open to change

26. Signs • Stress Arousal: anxiety, irritability, hypertension, bruxism, insomnia, palpitations, forgetfulness, and headaches. • Energy Conservation: Work tardiness, procrastination, resentment, morning fatigue, social withdrawal, increased alcohol or caffeine consumption, and apathy. • Exhaustion: Chronic sadness, depression, chronic heartburn, diarrhea, constipation, chronic mental and physical fatigue, the desire to “drop out” of society.

27. Adaptations and Consequences • Longer Work hours: If I work harder, it will get better. • Withdrawal, absenteeism, and reduced productivity. • Depersonalization: attempt to create distance between self and patients/trainees by ignoring the qualities that make them unique individuals. • Loss of professional boundaries leading to inappropriate relationships with patients/trainees. • Compromised patient care.

28. Maslach Burnout Inventory(CPP, Inc) • Designed for use in health care and other service industries. • Evaluates emotional exhaustion, depersonalization, and reduced personal accomplishment. • Well-validated; readily available; utilized by Physician Worklife Study. • 10-15 minutes to complete. • Cost: approximately $1.25 per test, with additional fee for scoring key.

29. Self Assessment Exercise(Girdin, 1996) How often do you . . .a) almost always; b) often; c) seldom; d) almost never • find yourself with insufficient time to do things you really enjoy? • wish you had more support/assistance? • lack sufficient time to complete your work most effectively? • have difficulty falling asleep because you have too much on your mind? • feel people simply expect too much of you? • feel overwhelmed? • find yourself becoming forgetful or indecisive because you have too much on your mind? • consider yourself in a high pressure situation? • feel you have too much responsibility for one person? • feel exhausted at the end of the day? • Calculate your total score: a) = 4, b) = 3, c) = 2, d) = 1. • A total of 25-40 indicates a high stress level that could be psychologically or physically debilitating.

30. Additive stressors • Despite the notion that burnout is primarily linked to work-related stress, personal life events also demonstrated a strong relationship to increased professional burnout • In spite of achieving career and financial success, health professionals are stressed and overworked, often losing sight of their career goals and personal ambitions. The resulting frustration, anger, restlessness, and exhaustion adversely affect the quality and costs of patient care. • Additional dangers include compassion fatigue/burnout and vicarious post-traumatic stress disorder in health care settings, especially Medicaid and the uninsured.

31. BIO-BREAK? 

32. RESULT? • WE get frustrated and can give up • WE begin to believe that our patients are ‘non-compliant’ and they do not value our work, we get angry at them or each other • WE get lost in the complexity of THEIR lives • WE make assumptions about their choices and their behaviors • WE cannot prioritize what works, what is truly impactful action • WE implement punitive policies, like three strikes, can occur • Burnout can occur for all of us

33. COUNTERPRODUCTIVE STRATEGIES • Our assumptions are wrong at least 50% of the time • Scare tactics rarely work for any of us • Punitive approaches to patient accountability have been shown to be just that: punitive for all of us • Yelling at or arguing with patients • Belittling or shaming them • Implying they are “bad” because they did not bring glucose monitors, meds or were not “compliant” • Rushing people through complex processes • Three strikes policies

34. How do we keep the joy and wonder in everyday practice?

35. OUR TASKS • Resist depersonalizing our patients • Practice empathy • Walk in their shoes; ask What can I do for you TODAY? • Hold them and yourself accountable for what we CAN do • STOP talking and listen • Ask patient to repeat your instructions to clarify understanding • Take a BREAK or talk to other staff after clinic • Most importantly, Stay curious

36. IS THIS POSSIBLE? • YOU BET! • Our members/patients deserve our best work • We can innovate and measure results • We can focus on the whole person, not their disease or collection of diseases • We can focus on slow and steady steps toward goals, with patient’s priorities as #1 • We can speak up when things are not working; and volunteer to fix it!

37. PROFESSIONAL BURNOUT REDUCTION STRATEGIES • Curiosity • Respect (from the Latin “respecere” =to LOOK again) • Adventure (Excitement about the chance to get inside the cultures and beliefs of our patients) • Risk-taking • Flexibility • Perspective

38. CURIOSITY: WONDER WHY? Why is she angry, why is he uncontrolled on his meds, why is this not working, why am I so engaged/attached? STAY OPEN to learning more, laughing more

39. RESPECT:respectful deference includes being honest with our patients, showing respect for their beliefs and culture AND decisions; giving information so they can make decisions

40. ADVENTURE:if we cannot get excited about learning about other countries, other cultures, other people and ourselves, it is time to get help or get out

41. RISK-TAKING:volunteer for a new role; take a risk with patients, tell them the truth, kindly and with best intent; be fully present and do not assume you have ANYTHING to offer except your skills; tell your boss that workload, time pressure or role conflicts are problems

42. FLEXIBILITY:consider new ways of doing your current job; take some time off; talk to colleagues; new schedules/workloads; learn new skills like mindfulness and meditation

43. PERSPECTIVE:the PATIENT is the one with the problem; balance empathy and connection with distance; GET A LIFE ; try seeing BOTH the sacredness of what we do and the small impact we actually ever make on others’ lives

44. LEARN • Listen with understanding to the patient's perception of the problem • Explain your perceptions of the problem and your strategy for treatment • Acknowledge and discuss the differences and similarities between these perceptions • Recommend treatment while remembering the patient's cultural parameters • Negotiate agreement. Understand the patient's explanatory model so medical treatment fits in cultural framework • (Berlin EA, Fowkes WC.1983) 

45. Cultural Humility vs Competence • Humility demands that we self-evaluate how our personal biases may affect care delivery • Humility changes the power imbalances in patient-provider dynamic • We become more aware of who uses, and who needs our services • We are always learning, every day. We STAY CURIOUS. • The two important paths to cultural competency development are self-reflection about one’s cultural identity and beliefs, and experiences with cross-cultural encounters.

46. WATCH OUR LANGUAGE:A 72 year old lady who falls and breaks her hip while sweeping her steps • You shouldn’t be sweeping steps at your age • You need to hire someone to do that for you • Can’t your son help you out? • Stop worrying about cleaning, let’s take care of your hip, Dear • For many people, it can be very scary to break a bone; I wonder what it is like for you? What does this mean for you?

47. ADHERENCE • We know it as: Compliance-the obedience of patient in following our orders • By using the word compliant, we assume a power differential between us and the patient that erodes trust: WE are the doctor, YOU are NOT! We know your body better than YOU do. We know what is RIGHT for you. If you would JUST do what we say, you would be better now. • Adherence relies on RELATIONSHIP, TRUST, INFORMATION, CHOICE, ACCEPTANCE • Adherence implies consensus, a joint or shared responsibility to the goals we select together • It is an ongoing negotiation!

48. Active Listening • Attend and observe • Resist internal distractions • Suspend judgment • Reflect on the content, feeling and meaning of what you hear • Respond as best as you can • “You’re saying ___________.”

49. Four types of protective voices • People need to have to ensure that they have access to voices that provide: • Balance (family, partner, hobbies) • Perspective (humor, distance, silliness) • Growth (learning, training) • Challenge (new roles, new work, confront imbalance) Physicians, nurses, and allied health professionals can formulate a personally-designed self-care protocol for themselves. • Overcoming Secondary Stress in Medical and Nursing Practice: A Guide to Professional Resilience and Personal Well-Being by Robert J. Wicksoffers an extensive bibliography of recent research, clinical papers, and books on medical-nursing practice and secondary stress.

50. Homeless (AND the uninsured) people are the sum total of our dreams, policies, intentions, errors, omissions, cruelties, and kindnesses as a society. (Peter Marin, sociologist)