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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

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the health and wellness of physicians managing stress burnout and energy

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
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
Objectives
  • Discuss important statistics relative to the professional health and wellness of physicians.
  • Define burnout and list risk factors and common symptoms of burnout.
  • Discuss protective factors to prevent burnout throughout their medical career.
  • Initiate an individual action plan to manage energy and help prevent burnout.
agenda
Agenda
  • Introduction and Importance
  • Professional Health and Wellness Spectrum
  • Stress, Burnout and Energy
  • Action Plans - Intent to Change
  • Summary/Evaluation
importance evidence
Importance & Evidence

Does this apply to me?

importance evidence6
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 evidence7
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 evidence8
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 evidence9
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 evidence10
Importance & Evidence
  • Pediatricians:
    • Some evidence on pediatricians
    • Burnout varies with training, practice, specialty
      • Residents
      • Primary care
      • Specialty peds
pediatrics residents
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):488-91. 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
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
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
Two systems interact

“The Perfect Storm”

The internal system

The external system

Functional & nurturing

Good skills

Hospital/Clinic

Physician

Dysfunctional

Poor skills

importance evidence15
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
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 wellness17
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 wellness18
Professional Health and Wellness
  • Are we ethically obligated to care for ourselves?
  • Do you feel empowered to demand your own self care?
professional health and wellness20
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 wellness21
Professional Health & Wellness

Mind

Body

Work Environment

Home Environment

Soul

Emotion

Self-Care

professional health wellness spectrum
Professional Health & Wellness Spectrum

Work &

Family

Relations

Physical

Mental

Emotional

Spiritual

Fair Functioning

Reduced Productivity

Relationships Suffer

Fair-Not Functioning

Fair-Not Productive

Institution & Family Loses

High Functioning

High Productivity

Fair Functioning

Decreasing Productivity

Burnout

Coping Mechanisms

Failing

Risk of MH issues and suicide

No Coping Mechanisms

Professionally Healthy

& Well

Stressed

Coping Mechanisms Strong

stress burnout
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

“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
Self-Assessments

What stresses you out?

Measure your stress level

The Doctor Dewey Insto-Matic, Stress-O-Meter

Anxious

Engaged

Enthusiastic

Calm

Relaxed

Stress free

Run Down

Stressed out

Exhausted

Overwhelmed

Drained

Ready to cave

Burnt out

definition stress
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
Stress & Productivity

Reduced Cognition

Productive Stress

“Impairment” ???

No Prolonged Stress

Declining Function

Prolonged Stress

Situational Stress

Stressed

Burnout

Non-Functional

managing individual stress
Managing Individual Stress

Seven Key Areas:

  • Sleep
  • Balanced meals
  • Physical activity
  • Socialization
  • Vacations/down times
  • Spiritual engagement
  • Have a physician

Mind

Body

Spirit

Emotion

managing work place stress
Managing Work-Place Stress

Personal Energy

Self-Care

Planning

Office

Reduce

Distractions

Manage energy

  • 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)

stress
Stress

“Into each one’s life, some stress must come…

…but it is how you handle it that is important.”

~me

slide32

Figure 1

Spectrum of Disruptive Behaviors

Passive

Aggressive

Passive

Aggressive

Chronically late

Failure to return calls

Inappropriate/

inadequate chart notes

Avoiding meetings & individuals

Non-participation

Ill-prepared, not prepared

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

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
Definition - Burnout
  • Burnout can be defined as:
    • a: exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustrationb: a person suffering from burnout. Webster’s dictionary
burnout
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
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

six sources of burnout
Work overload*

Lack of control

Insufficient reward

Unfairness

Breakdown of community

Value conflict

Six Sources of Burnout

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
Symptoms of Burnout

Chronic exhaustion

Cynical and detached

Increasingly ineffective at work (distressed behaviors)

Leads to:

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
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 factors39
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 factors40
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
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
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
Preventing & Resolving Burnout

Individual Approach

Organizational Approach

Starts with person

Starts with management

Becomes organizational project

Becomes group 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

The Truth About Burnout
individual action plan
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:
resources
Resources
  • 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
Summary: Take Home Points
  • You are valuable! Self-care is the foundation to faculty vitality and remaining professional.
  • Stress happens: Look for and anticipate stress.
  • Take action immediately to manage energy, reduce stress and avoid burnout.
  • Take advantage of the valuable resources available inside or outside of Vanderbilt – bottom line is get help!
references
References
  • 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 Well-being 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.