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Developing Physician Resiliency Through Mindfulness and Community

Developing Physician Resiliency Through Mindfulness and Community. Pediatric Resident Coaching Program Meeting November 11, 2013. Emily F. Ratner, MD, Clinical Professor Department of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine

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Developing Physician Resiliency Through Mindfulness and Community

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  1. Developing Physician Resiliency Through Mindfulness and Community Pediatric Resident Coaching Program Meeting November 11, 2013 Emily F. Ratner, MD, Clinical Professor Department of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine Stanford, California

  2. Burnout Burnout • Emotional exhaustion • Depersonalization – cynicism • Ineffectiveness – Decreased sense of personal accomplishment • Work-individual mismatch • Maslach Burnout Inventory – validated survey

  3. Burnout Assessment • Single question measures from MBI • How often do you feel this way about your job? • I feel burned out from my work Never = 0 A few times a year = 1 Once a month or less = 2 A few times a month = 3 Once a week = 4 A few times a week = 5 Every day = 6 • I’ve become more callous toward people since I took this job West et al, J Gen Intern Med 24(12):1318-21.

  4. Burnout and Satisfaction with Work-Life BalanceShanafelt, et al. Arch Intern Med 2012;172(18):1377-1385 • > 7000 physicians • 46% of MD’s at least 1 symptom of burnout on MBI • 38 % Emotional exhaustion • 29% Depersonalization • 12% Ineffectiveness • Physician depression – 38% • Suicidal ideation in past year - 6.4% • Poor work-life balance – 37% • Burnout and poor work-life balance are a bigger problem for doctors than other professions

  5. Burnout by Specialty Mean 46% 40% 36% Shanafelt, Arch Int Med, 2012

  6. Satisfaction with work-life balance by specialty 460% Mean satisfaction 49% ~42% Shanafelt, Arch Int Med, 2012

  7. Medical Students • Higher prevalence of psychological distress in med students vs. age-matched peers Dyrbye et al, Acad Med 2006 • Incidence of burnout – ranges from 21%-53% depending on source Santen et al, Southern Med J 2010, Dyrbye et al, JAMA 2011 • Students going into medicine motivated by personal/family member’s illness or death, higher incidence of EE Pagnin et al. Med Teach, 2013. • Lowered academic performance, increased professional misconduct, decreased empathy, increased substance abuse, suicide

  8. Resident Burnout • Incidence: 10-76% • Internal medicine residents – 76% burnout, Seattle, WA Shanafelt, Ann Int Med, 2001 • Surgery residents – 56%, UC Irvine, Gelfand, Arch Surg, 2004 • Alexithymic personality style associated w/higher burnout rates, Daly et al, Med J Aust 2002; 177 (1): 14 • Alexithymia – inability to recognize or describe one’s emotions Thomas, JAMA, 2004

  9. Anesthesiology Residents • > 2700 residents, response rate 54% (>1500) • MBI, Harvard Depression scale, best practice and error self-reporting • 41% high burnout risk - associated with 3 factors • Working > 70 hours/week • Having > 5 drinks/week • Female gender De Oliveira, et al. Anesth Analg 2013;117:182-93

  10. Anesthesiology Residents • 22% with depression • associated with same factors of burnout risk+ smoking • 23% thought about/wanted to commit suicide - 68 residents • Best practice scores for burnout +/- depression lower • 33% w/high burnout & depression risk had multiple medication errors, significantly more than low risk residents De Oliveira, et al. Anesth Analg 2013;117:182-93

  11. Causes of Burnout • According to demand-control-support model • Intense work demands • Lack of control • High degree of work-home interference

  12. Stressors? Put a photo here

  13. Stressors at work • Six Areas of Worklife Survey/Maslach • Workload – includes time pressure, increasing patient complexity, documentation, regulations • Control – emergencies, schedule • Reward – appreciation, recognition • Community – lack of support, isolation • Fairness - favoritism • Values – aligned w/co-workers, larger organization

  14. Stressors • Family issues • Personal health • Time management • Adjusting to current and uncertain multiple changes in the health care environment • Financial – loans, decreased reimbursement

  15. Technology

  16. Are we too plugged in? • Electronic medical record • New • Upgrades • Expectations of work at home • Home access to medical records • Email • Cell phones, laptops, desktops, chargers, batteries, adapters….. • Time allowance to learn new systems/upgrades • May be especially difficult for aging MD’s

  17. Implications of Burnout • Patient care • Medical errors • 53% of burned out Internal Medicine resident self reported at least one type of suboptimal patient care event vs. 21% Shanafelt et al. Ann Int Med, 2002 • Increased surgical error reporting associated with burnout Shanafelt et al. Ann Surg 2010 • “Brian Goldman, MD: Doctors make mistakes. Can we talk about that?” • http://www.youtube.com/watch?v=iUbfRzxNy20 • Patient compliance • Adverse patient outcomes • Patient satisfaction

  18. Implications • Physician health • Mental illness, depression • Physical illness • Effects of adverse patient outcomes • Maladaptive responses to stress • Substance abuse • Denial • Avoidance • Keeping stress to oneself, not seeking help • Self-medication • Ignoring self-care

  19. One MD per day commits suicide in the US Roberts, Anesthesiology Grand Rounds September 2012

  20. “If we continue to just build in efficiency and not build in wellness, physicians will burnout. Doctors may still give good care {for a while}, even when burned out, but it will be at their own expense.” Mark Linzer, MD 2012

  21. The cost of replacing a physician is at minimum $250,000. Buchbinder, Am J Manag Care, 1999

  22. Arenas to Approach Workplace Wellness • Individual • Increased self-awareness • Stress reduction techniques • Support network • Reframing • Build community • Peer support groups • Family and friends support • Workplace changes

  23. Resilience • Resilience is that ineffable quality that allows some people to be knocked down by life and come back stronger than ever. • Positive attitude, optimism • Ability to regulate emotions • Ability to see failure as a form of helpful feedback • Reframing Psychology Today online

  24. Program in Mindful Communication In Primary Care Physicians • 70 primary care MD’s, year long program • 8 week intensive phase • 10 month maintenance phase • Curriculum • Mindfulness meditation • Self-awareness exercises • Narratives about meaningful clinical experiences • Appreciative interviews • Didactic material, discussion Krasner, Epstein et al. JAMA 2009

  25. Program in Mindful Communication In Primary Care Physicians • Improved mindfulness correlated with • Less burnout • Better emotional stability, mood and empathy • Subjectively • Reduced isolation due to sharing personal experiences from medical practice w/colleagues • Mindfulness skills improved patient interactions and MD’s developed more adaptive reserve • Transformative to develop greater self-awareness Beckman et al. Acad Med 2012;87:815-819

  26. Georgetown Medical Students • 12 week Mind-Body Skills medical student elective, to promote self-care and self-awareness • Initial funding by NIH/R25 • 12 year history, ~ 800 medical students, 40% class per year • ~100 Georgetown medical school faculty trained, including all clinical rotation directors (except 1), Dean of Medical Education • Outside faculty training ~ 50 currently trained

  27. Georgetown Medical Student Study • 2 groups of medical students • Control group – no intervention • Intervention group – 12 week MBS course • Cortisol, testosterone levels measured before intervention (January) & after course completed (May) just prior to final exams Spring semester • Cortisol levels were 240% higher in control group in May • Testosterone levels were 160% higher in control group in May • All female cohort MacLaughlin et al, 2011

  28. Mindfulness ? • Awareness of the present moment • Not past, not future • Being not doing • Noticing one’s own physical, mental, emotional state – opposite of alexithymia • Not acting on it, watching but not judging • Recognizing that emotional states are all temporary • Takes practice

  29. Stanford Anesthesiology Residency Large program 4 hospitals 75 residents 150 faculty members Tertiary care center, critically ill patients Silicon Valley Stanford duck syndrome

  30. Goals of Resident Wellness Program • Create an environment to support and promote the well-being of our residents • Build community • Teach/expose residents to skills to promote resiliency • Prevent burnout, in those who aren’t already • Intervene early, prevent progression and devastating consequences

  31. Core Components • Initiated 2010, planning since 2008 • Mandatory first year resident lecture • Scientific lecture stress + biofeedback exercise • Negative recruiting • Voluntary offsite weekend retreat CA-1’s • Ongoing q 8 week sessions for remaining 3 years of residency, part of required, didactic program

  32. Wellness Retreat • 1st year residents only • 2010 – 14/26 (54%) • 2011 – 18/26 (69%) • 2012 - 21/24 (88%) • 2013 – 20/26 (77%) • 2 groups lead by 2 facilitators • 2 Georgetown MBM faculty – mental health professional • 2 Stanford anesthesiology faculty

  33. Guidelines and Agenda • Confidentiality, mutual respect • “I Pass” Rule • Non judgmental - listening, not solving • Facilitators set the tone • Experiential exercises: meditation, guided imagery, yoga, Tai Chi, drawing, journaling exercise • Opportunity for self-reflection, check-in, sharing concerns with peers in a supportive environment • Group meals, room w/peers

  34. Resident Wellness Retreat • Friday evening through Sunday afternoon • Friday night - introductions/drawing exercise • Saturday 8:00 – 8:50am         Yoga         9:00 - 10:00am        Breakfast       10:00 - 12:00pm       Meditation – eating, mindfulness  12:00 - 1:30pm         Lunch                      1:30 - 3:00pm          Walking meditation 3:00 - 3:30pm          Break 3:30 - 5:30pm          Reflective Journal Writing 5:30 -  7:30pm         Free time 7:30 – 9:00pm         Dinner                   

  35. Wellness Retreat Feedback • Objective surveys • Subjective survey results • 100% met or exceeded expectations • Most valuable aspects • Formation of strong peer support system • Learning new coping and communication skills • “To really feel that stressors..were not only my own” • “To talk openly about my struggles” • “Our interactions were personal and deeply profound.” • “The time spent here has truly changed me.” • “Unbelievable investment in our well-being. Thank you!”

  36. Wellness Sessions • Meet every 8 weeks, 1 ½ hours • Protected didactic time • For all ~ 75 CA-1, CA-2 and CA-3 residents, mandatory • Two groups from retreat maintained, same facilitators • Third group formed with residents who did not attend retreat, or incorporated into 2 existing groups • Expanding faculty involvement, facilitator training • Further curriculum development

  37. Faculty Wellness Pilot Program • Funded through Dean’s Office • Purpose: enhance faculty member wellness and build a model to promote community support amongst the faculty. • Experiential training • Not so hidden agenda • Modified from Anesthesia RWP, Georgetown, Krasner & Epstein’s program • Two components: • Offsite retreat, May 2013 • Monthly sessions for a year

  38. Faculty Wellness Pilot Program • All Medical School faculty eligible • Personal statement • Department Chair/Division Chief letter of support, financial ($500) and time off for retreat & once monthly meetings • 10 participants • 3 Pediatrics (Endocrinology, CCU, Pulmonary) • 3 Medicine (Hospitalist, ICU/VA, General Medicine) • 2 Anesthesiology (VA/SUH) • 1 each from ER, Radiology researcher –PhD • Diverse backgrounds, all ranks, > 30 year age range

  39. Post Retreat • Monthly sessions • Lunch • Experiential exercise • Check in • Informal get togethers • Request for more frequent meetings • Twice per month formal meetings

  40. Retreat Subjective Evaluations • 100% exceeded expectations • “This was my most meaningful experience at Stanford.” • “This was one of the best experiences of my life. Life changing.” • “I did not expect such amazing connections and the close feelings with others at such a deep level.” • “This ended the sense of social isolation I’ve felt at Stanford.” • “I am overwhelmed with gratitude at the opportunity to participate in this deeply moving experience.”

  41. Lessons learned • Buy in from leaders • Need at least one champion • Gradual implementation on a yearly basis worked better than going from 0 to 75 residents involved • Mental health professional involvement • Jumpstart program with a retreat off campus if possible • Create safe, nonjudgmental confidential environment • Survey once/year • Faculty involvement • Other programs’ and institutions’ curricula • Encourage resident support and input for programming • You can’t force wellness, allow those who don’t want to participate actively to “pass”. Ask them to not be disruptive.

  42. Who will pay for physician wellness programs?

  43. InsightfuI Leaders ?

  44. Future • Expand Faculty Wellness programs • Peer Support Groups • Data • Linking patient outcomes with physician resiliency • Linking patient satisfaction with physician resiliency • Decreased cost

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