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Professional Health and Wellness for Residents. Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration Associate Professor of Medicine Co-Director & Chair William H. Swiggart, M.S.,LPC/MHSP Assistant in Medicine Co-Director.

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professional health and wellness for residents

Professional Health and Wellness for Residents

Charlene M. Dewey, M.D., M.Ed., FACP

Associate Professor of Medical Education and Administration

Associate Professor of Medicine

Co-Director & Chair

William H. Swiggart, M.S.,LPC/MHSP

Assistant in Medicine

Co-Director

Center for Professional Health, Faculty and Physician Wellness Committee, Vanderbilt University School of Medicine

reflection
Reflection
  • How often and how well do you prioritize your personal and professional health and wellness to the top of your to do list?
  • How do you manage stress?
  • Can you list behaviors consistent with burnout?
introduction overview
Introduction & Overview
  • You should document the answers to these questions and modify them as you read this module. Make note of any changes you want to accomplish as a result.
  • Try to write down 1-2 items you plan to improve on.
  • This module should take about 30 minutes to complete.
module goals
Module Goals
  • Review issues related to professional health and wellness.
  • Emphasize self-care and managing workplace stress through various cases.
  • Provide examples residents can use to help prevent burnout and maintain wellness.
  • Provide an overview of key resources at Vanderbilt.
participant objectives
Participant Objectives

Upon completion of the module you should be able to:

  • Identify 2 key areas for maintaining professional health and wellness.
  • Describe risk factors for burnout and behaviors that result from burnout.
  • List resources available at Vanderbilt.
agenda
Agenda
  • Introduction & overview
  • Professional health and wellness
  • Stress and burnout
  • Self-care tips
  • Self-awareness and management tips
  • Case scenarios
  • Resources
  • Summary and evaluations
importance
Importance
  • One physician commits suicide every day.
  • Physicians are subject to stress, depression, anxiety, substance abuse and suicide more than other professionals.
  • Female physicians are more prone to stress, anxiety and suicide.
importance1
Importance
  • This module focuses on how to prevent and manage stress and burnout through maintaining self-care, good coping skills and workplace stress. We want you to be aware of these issues so you can avoid falling prey to stress and burnout both now and throughout your career.
professional health
Professional Health
  • When stress comes, how will you cope? How will you handle it – the long hours, the sleepless nights and the sacrifice of family and personal issues?
  • We hope you will learn a few tips from this module to help you survive and thrive through your residency training.
  • We hope you will build good behaviors and coping mechanisms that you can use throughout your career.
professional health1
Professional Health
  • How do you define professional health and wellness? What does this mean to you?
  • We believe professional health and wellness is the physical, mental and spiritual part of you that comes to work everyday to help serve the greater good of the patient and community.
  • Self care plays a big role, as well as, workplace stress and burnout in your overall physical, mental, emotional and spiritual health. We like to think about this concept as the professional health 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

Professional Health & Wellness Spectrum
professional health2
Professional Health
  • Physicians as a group experience more stress, burnout and depression than the general population and residents are no exception.
    • 30-60% physicians report experience of distress and burnout
    • 10% mild, 4% mod-marked depression (twice that of depression in physician pop.)
    • Increased in younger physicians
    • Repeated study in 2006 – similar results (Schindler et al 2006)

Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82.

professional health3
Professional Health
  • Residents are also prone to stress, burnout, substance abuse and depressions, the latter two increasing their risk of suicide.
  • This is due to a variety of reasons including performance anxiety, difficulty adjusting to changes in environment, feelings of isolation, and even difficult relationships with attending physicians and poor examples of professional conduct from supervising faculty members.
stress burnout
Stress & Burnout

Stress and burnout occurs for different reasons in different individuals.

Work load alone does not mean higher levels of stress or burnout.

Stress is most likely multifactorial in many situations.

Identifying the source is the key to planning a process to reduce stress.

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 can be situational or prolonged. When assessing your situation, determine if this is short term or long term. How it affects you and how you adapt to it may be different if it is short term or prolonged.

stress
Stress
  • Short term stress could results from a flat tire on the way to work. You will be more stressed if you are late for clinic and patients are waiting as opposed to if you are on a day off.
  • Physical, emotional and mental responses will vary. Your response will be more intense in the former example and you may be able to roll with the punches in the latter example.
  • Short term stress can be good or bad, for example stress during a code – can help you focus or can paralyze you.
stress productivity

Productive Stress

No Prolonged Stress

Declining Function

Stress & Productivity

Prolonged Stress

  • Prolonged stress, however, reduces productivity in the long run and can lead to burnout.

Situational Stress

Stressed

Burnout

Non-Functional

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

Prolonged stress can result in burnout. Burnout has effects that can impact you, your colleagues, your family and your ability to cope with stressful situations.

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

burnout1
Burnout

The 6 key areas of mismatch that can lead to burnout include:

  • Work overload
  • Lack of control
  • Insufficient rewards
  • Breakdown of community
  • Absence of fairness
  • Conflicting values

The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

burnout2
Burnout

Examples include:

  • Work overload – exhaustion and sleep depravation
  • Lack of control – being forced to comply; no choice
  • Insufficient rewards – lack of recognition for your hard work
  • Breakdown of community – when individuals feel isolated and not in it together
  • Absence of fairness – when some get privileges while others don’t
  • Conflicting values – when you believe one thing but the culture of your job opposes that belief.

The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

burnout3
Burnout

Burnout results in the following symptoms, actions or behaviors:

  • Emotional exhaustion
  • Isolation
  • Avoidance
  • Feelings of cynicism
  • Impaired productivity
  • Interpersonal conflicts
  • High turnover

The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

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

Risk Factors for Burnout

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

protective factors
Personal:

Influence happiness through personal values and choices

Spend time with family & friends

Engage in religious or spiritual activity

Maintain self-care (nutrition & exercise)

Adapt a healthy philosophy/outlook

A supportive spouse or partner

Work:

Gain control over environment & workload

Find meaning in work

Set limits and maintain balance

Have a mentor

Obtain adequate administrative support systems

Protective Factors

Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):1447-50

professional health4
Professional Health
  • Many things are out of your control but there are a few things you can do to help with your ability to cope and deal with the challenges you will face during your training.
  • Two big categories to think about in maintaining your professional health and wellness include:
    • Self-care
    • workplace stress management
self care
Self-Care

There are seven (7) key areas to focus on in self-care. Self-care issues include:

Sleep

Balanced and healthy meals

Physical activity

Socialization

Vacations/down times

Spiritual engagement

Have a physician

self care 1 sleep
Self-Care #1: Sleep
  • These are critical and often challenging to focus on while in training. Keep sleep as your sacred ritual. Get it often and as much as your body needs. Less than 8 hours of sleep makes you prone to medical errors and professionalism lapses.
  • If you have a family, arrange for older family members to help your spouse and kids during harder rotations or pay baby sitters to sleep over and help with the kids at night so you can sleep uninterrupted.
self care 1 sleep1
Self-Care #1: Sleep
  • Be sure to avoid alcoholic beverages. Alcohol interferes with REM sleep and should be avoided if you want a restful night.
  • Make your sleeping environment conducive to good sleep: cool, dark and comfortable bedding.
  • On services with a time shift (night float or ER shifts), use block–out shades to prevent the sun from entering the room. This will help create a nighttime for you. These can be purchased at most home stores and can be temporary or permanent. You can also try sleep masks.
self care 2 healthy eating
Self-Care #2: Healthy Eating
  • Balanced meals and physical activity – doesn’t mean you need a four course meal and 2 hrs a day at the gym. But it does mean you should grab the salad with fruit and vegetables over the fast foods.
  • Bring healthy, non-perishable snacks that can fit in your white coat pocket just in case you cannot make it to lunch on time. Examples include: fruit (bananas, grapes, apples), vegetables (carrots, celery with peanut butter, broccoli), bars (fiber, energy bars, breakfast), vegetable chips, etc.
self care 2 healthy eating1
Self-Care #2: Healthy Eating
  • When you do have opportunity to sit for a meal, make it a balanced meal with nutrient-rich foods packed with vitamins, minerals and antioxidants.
  • If you are skipping meals, make sure to get a supplement daily – a standard multiple vitamin will do.
  • Many residency programs still provide lunch – make this a priority. Schedule activities around your meals. This allows you to get refueled to continue your activities for the rest of the day.
self care 3 physical activity
Self-Care #3: Physical Activity
  • You can and should incorporate physical activity into your work day: walk fast between patients; take the stairs and take short walks when you can.
  • When you do get down time and easier rotations, look for external venues you enjoy – bike riding, swimming, jogging, hiking, etc.
  • Physical activity helps relieve stress and allows you to feel like you can disconnect from work.
self care 3 physical activity1
Self-Care #3: Physical Activity
  • For those with a family, include the kids and spouse and make it a family affair.
  • Place smaller infants and toddlers in a stroller and walk or jog with your spouse. Talk about family topics and avoid talking shop (unless you are both physicians and enjoy sharing the patient care stories with each other.)
  • Take older kids on bike rides and short runs.
  • Some gyms such as the YMCA will provide child care; check them in and go work off your stress!
self care 4 socialization
Self-Care #4: Socialization
  • Socialization is important. Whether you like hanging with friends or family, laughing is very important to your overall outlook on life and evidence supports people who laugh more live longer.
  • Being around other physicians allows for camaraderie and shared understanding. Sometimes, however, you may just want to disconnect and not “talk shop” at all and focus your time on your family or friends. Try to incorporate both aspects of socializing.
self care 4 socialization1
Self-Care #4: Socialization
  • If you are married with kids, look for programs with parent night out options or hire a baby sitter at least once a month to allow you and your spouse to have time together.
  • Also, make sure your love life keeps its steam. Parenting magazines have a variety of articles on this topic. Some range from, “you’ll be tired any way so just do it” to “plan your evening of romance.”
self care 4 socialization2
Self-Care #4: Socialization
  • Which ever option you chose, just do it! Intercourse and sharing in a love relationship helps you feel grounded, safe, loved and respected.
  • It also makes sure you emphasize to your spouse that it is not all about work but it is all about maintaining the love in your relationship.
  • You both should be equal players in the discussion and set your love making as a priority for your relationship.
self care 5 vacations
Self-Care #5: Vacations
  • A balanced person should seek out and plan their vacations. Allowing your mind and body to rest is important in your ability to cope with stress and challenges as they pop up.
  • We want to warn you about the “trap” of taking vacation. Many think taking a vacation is harder than not taking vacation because the work piles up or it is worse once they return. They feel “trapped” into staying at work because it is easier. While there may be more emails and stacks of mail when you return, there are ways to handle this and you will be more efficient if you are well rested.
self care 5 vacations1
Self-Care #5: Vacations
  • Plan vacations far in advance so patients are not scheduled and coverage is arranged.
  • Allow one-half to one full day on the front and back ends of the vacation. On the front end, complete outstanding charts, plan meetings for your return, schedule in calendar time for overflow issues and prepare for your trip. On the back end, anticipate activities for the week and plan for the transition by having time to settle back into the work routine.
self care 5 vacation
Self-Care #5: Vacation
  • Avoid having clinical days on the morning you return from a vacation. This allows a little time for urgencies, emergencies and catch up.
  • If you don’t have this option, try to build in time over the first 1-2 weeks as an hour here and there.
  • Plan on scanning emails while traveling home – in the airports or in the cab ride home. Do a scan of your emails and prioritize the most important ones into a “must do” file and address these once your return.
self care 5 vacation1
Self-Care #5: Vacation
  • If you cannot connect to emails, try creating a “to do list” and/or list of emails to send in a word document.
  • If you take the blackberry with you, try to limit its use to only while in transport – this allows short periods to address key “must do” issues. If the family is with you, it also sends a strong message that you are there with the family and are focused on them. Plus, can you really disconnect if you stay connected the whole time on vacation?
self care 6 spirituality
Self-Care #6: Spirituality
  • However you chose to grow and support your spiritual side, make it part of your routine. Some find strength in formal services while others prefer finding spirituality within themselves and within their family.
  • Use a variety of resources from self-help books, tapes/CDs, music, yoga, etc. to allow your spirit time to rest, renew and strengthen itself.
  • A good strong spirit helps you stay motivated and enthusiastic about work even at 2 AM and they wake you about a constipated patient!
self care 7 have a physician
Self-Care #7: Have a Physician
  • How many times have we heard the expression, “Physician heal thyself?” Too often, you are almost an impaired physician if you are ill, stressed, depressed, etc. You need a professional to help you focus and keep you on the healing path.
  • Take time to find a physician so you have access to someone when you need it. You will be more likely to seek assistance when the initial barrier of obtaining a physician is removed.
self care 7 have a physician1
Self-Care #7: Have a Physician
  • Unfortunately, many physicians do not have their own PCP and try to manage their own physical and mental health issues. This can be very dangerous and very isolating. You need to have a trusted member of the healthcare team to help you see sometimes what you may not or cannot see for yourself.
  • While stigma may exists around physicians going to the Nth degree before seeking their own care, we feel a balanced physician is one who allows another physician to care for them.
self care 7 have a physician2
Self-Care #7: Have a Physician
  • But we do caution about the colleague PCP problem. Don’t allow another resident to make you their PCP. Just say no and tell them you care enough for them to seek the care of their own PCP. Never prescribe controlled substances to a peer! Ever!
  • Most physicians will take extra care to incorporate you into their schedule and most programs have an employee health program that makes sure you have a PCP or health care employee physician to help care for your needs.
self care 7 have a physician3
Self-Care #7: Have a Physician
  • Make sure you schedule an appointment just to meet your PCP even if just yearly. Hopefully you will remain healthy and strong throughout your training but just in case, you will feel more comfortable seeking help if you can already identify with someone.
  • This also sets up a good habit. It keeps your health as a priority, not to mention you will have them available if needed.
self care 7 have a physician4
Self-Care #7: Have a Physician
  • You have no stigma to overcome unless you allow your own fears to rule you. Physicians are human. They have stress. They develop illnesses and having an MD degree does not give you card blanch for living life without stress and illness.
  • Having a physician allows you a resource that is private, confidential and supportive as well as understanding of the challenges you face. Who else can relate to another physician better than a physician?
self care 7 have a physician5
Self-Care #7: Have a Physician
  • Mental health issues always seem taboo but that is because we as a culture allow it by perpetuating the idea that only happens to patients. Let’s be real. We will all feel stressed, anxious and near burnout by December of our internship year! Seeking help doesn’t make you less of a doctor, it makes you a better person!
  • If you already deal with mental health issues, remaining controlled with medication and under the care of a physician will help make sure you stay on top of things.
work place stress
Work-Place Stress

Five (5) key areas to address regarding work-place stress:

Be your own self-monitor

Manage energy

Reduce distractions

Plan appropriately

Managing failures and successes

1 be your own self monitor
#1: Be Your Own Self-Monitor
  • When you start feeling like the individual in these pictures, it is time to get things in check.
  • Know one can better assess your level of stress than you.
  • Preventing stress is better than suffering through stress.
1 self monitor
#1: Self-Monitor

What stresses you out? Think about these and make a list. How you can deal with or avoid these stressors.

Measure your current stress level on the stress-o-meter.

Stress free

Relaxed

Calm

Engaged

Enthusiastic

Ready to go

Stressed out

Ready to cave in

Anxious

Exhausted

Overwhelmed

At the breaking point

1 self monitor1
#1: Self-Monitor
  • Hopefully you are further on the left side of the meter than the right. But if you are not, then think about ways to help reduce stress. Things that can help include:
    • Exercise
    • Self-reflection and relaxation exercises
    • Meditation
    • Cognitive behavioral therapy
    • Seeking assistance with the employees assistant program
  • What works for you?
2 manage energy
#2: Manage Energy
  • Many focus on managing time, but you must also manage energy – where are you spending your greatest amount of energy? Identify these areas and address these first.
  • Example: Your intern is new and you are getting frustrated because he has missed the time for ordering labs and has not gotten results in on time. So to reduce wasted energy in the future, you must address this deficit now!
2 manage energy1
#2: Manage Energy
  • The best way to handle this is to devote 10 minutes describing the system and why there are priorities, your expectations and how they should be done to be considered acceptable.
  • Write a brief list of morning pre-rounds “Must DO” items and ask him to address these items first.
  • Demonstrating the behaviors is always a plus, pre-round with him and demonstrate what you do and what you will expect and why. Allow time for questions.
3 reduce distractions
#3: Reduce Distractions
  • Stay focused when trying to get tasks on your to do list completed. Standing in the hall and chatting with colleagues is good for socialization but will distract you from your tasks.
  • Exchange pleasantries and say, “Sorry I am in a rush. I will call you later tonight or let’s meet after noon conference to chat about the weekend.” This will keep you efficient and reduce distractions during the day.
  • Keep priorities at the top of the list.
4 plan appropriately
#4: Plan Appropriately
  • The best manager and resident is one who anticipates the next step. Think through your workday and make sure you are planning for the usual and for the potential disasters.
  • Use some time that is convenient for you (early morning, drive home, in the bathroom) to think about the plan for the day, week or even month. Anticipate the heavier periods, get child care early instead of waiting to the last minute (more frustrating), get groceries done during lighter times, etc.
5 managing failures successes
#5: Managing Failures & Successes
  • Being a physician means many successes but also many failures or what seems like failures. Be keep things realistic. You may not have saved the end stage renal cell cancer patient – in some cases it wasn’t for you to save. Do everything you can but remember you are a physician, not a deity. You have limits. Health care has limits. Do the best you can but remember you cannot do it all.
5 managing failures successes1
#5: Managing Failures & Successes
  • If you ever have feeling of doubting yourself, seek counseling. They will help you see your strengths even if you cannot.
  • Also, feeling too full of one’s self due to successes is also dangerous. Set your sights on success but don’t be afraid of failure and realize that sometimes failure is inevitable. Keeping a flexible standpoint will help you manage successes and failures better.
case 1
Case 1:
  • It’s December of your intern year in a program out of your home state. You feel a fair amount of frustration with your current training system and seem to focus on the way things were at your medical school. You comment on the negatives most often even thought the program is tough but doable on time commitment. When off you stay home and read in order to “prove yourself.” You don’t feel connected to anyone just yet and find yourself wishing you could leave.
  • What are your concerns?
case 1 answer
Case 1: Answer
  • In this case this intern is too isolated and is under prolong stress (performance expectations) and may be in a mismatch situation. They are starting to have some cynicisms that could be an early sign for burnout.
  • They need to focus on getting more socialization and feeling like they are apart of the group. They should place more emphasis on their self-care and try to focus on the positives and not the negatives.
case 1 answer1
Case 1: Answer
  • When someone feels isolated they begin to withdraw. They don’t see that others also struggle with the same issues. They think they are the only one “with a problem.” This increases feelings of isolation.
  • This intern needs to know they are not alone and that others experience frustration when changing work environments. Also, most feel the pressure to “perform” but you have to keep it in check and find your own personal rewards.
case 1 answer2
Case 1: Answer
  • This intern should set their own goals and rewards. If they are determined to read for 30 min. every night and they accomplish 90% of their goal, they should reward themselves.
  • This intern will benefit from talking to an expert to help them see the possibilities on how they will adjust, as well as, to receive some extra assistance in “on boarding” or preparation for how to function within the new system. They can be assigned a mentor upper level to help make sure they learn the ropes.
case 2
Case 2:
  • Dr K is a second year resident. Dr K stays awake late most nights, even on days off. Dr K spend 3-4 hrs reading and then another 2-3 hrs playing computer games. During the day Dr K cannot focus during teaching sessions or rounds and often falls asleep in conference. Dr K has gained 15 lbs in the past 2 months and has been eating mostly fast foods and drinking coffee to help stay awake. Dr K cannot recall their last meal with vegetables.
  • What are your concerns?
case 2 answer
Case 2: Answer
  • Dr K is clearly not employing any of the key self-care activities. Dr K needs to plan for regular sleep; become more efficient at reading (by focusing only on 1-2 topics/case a day and filling in only what he/she doesn’t know).
  • Dr K should avoid sacrificing sleep for the video games (limit to one or two plays every few nights or on days off during wake hours). Dr K also needs to plan for better meals and add some physical activity in their day or during days off.
case 3
Case 3:
  • Dr S has struggled for the last year or two. He often seems emotionless and flat. He is considered “unsocial” as he does not participate in any of the program events. He has missed several deadlines, often calls in sick, and is inconsistent in answering pages. Once on his day off you saw him and you could tell he was intoxicated. Just after the holidays he was found dead after a single vehicle MVA.
  • What are your concerns?
case 3 answer
Case 3: Answer
  • This resident was in trouble for a long time. They may have had a serious substance use problem that went unidentified or ignored. His isolation from the rest of the group’s activities on a consistent basis was problematic.
  • If you notice a colleague demonstrating unprofessional behaviors, share it with your program director or chief resident. It is not your job to intervene or make judgment but the program director needs information in order to get individuals the help they need.
resources
Resources
  • So what if a peer brings up their stress level or problems with their spouse? How can you help them?
  • The key is knowing the resources available and directing them to those resources. Allowing them to feel “normal” when asking for help is also important. Let them know it is ok to talk to someone and get assistance.
  • Confidential counseling services are available for all residents and trainees through the EAP.
resources1
Resources
  • Recall the Faculty and physician Wellness Program or Work-Life Connections is the key resource for counseling services (free and confidential) and for any urgent or non-urgent treatment issues.
  • Commit this number to memory: extension 6 – 1327
  • Any individual on the Faculty Physician Wellness Committee is here to help. Contact anyone on the next page if needed.
faculty and physician wellness committee fpwc
Faculty and Physician Wellness Committee (FPWC)

Charlene M. Dewey, M.D., M.Ed., FACP (Chair)

summary
Summary
  • As residents you will have little control over your call schedule and work loads, but you must look toward those things you have control over – your self-care, attitude and behaviors.
  • Your personal and professional health (physical, mental, emotional, and spiritual) is the focus of your self-care and will help you cope with the challenges of residency training if implemented as a priority and maintained early and often during your training.
summary1
Summary
  • We are all prone to challenges in our careers. We hope this information will help you prioritize your professional health and wellness to the top of your to do list.
  • Vanderbilt has some great resources if needed; use them!
  • Now, recall 1 or 2 things you learned during this module. What can you improve on? Write them down and make a plan to prioritize “you” to the top of the list!
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