APA Annual Meeting Disclosure: Sermsak Lolak, MD With respect to - - PowerPoint PPT Presentation

APA Annual Meeting Disclosure: Sermsak Lolak, MD

With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the party listed above (and/or spouse/partner) and any for-profit company in the past 24 months which could be considered a conflict of interest.

My background & interests

• Psychosomatic Medicine/ Psycho-Oncology
• Medical Education
• Development of rapport, empathy at bedside
• Contemplative practices

– Mindfulness, Compassion cultivation

• Life balance/ Physicians & Trainees burnout

Goals

• Understand the syndrome of burnout
• Be familiar with the basic concept and

exercises in mindfulness and compassion cultivation as a potential tool to prevent burnout

• Apply these concepts to your personal and

professional areas

Outline

Didactics & brief experiential exercises

• Burnout & Compassion fatigue
• Self-awareness / mindfulness
• Compassion cultivation

Reflection, discussion, sharing, Q&A

What is burnout?

• Emotional exhaustion*

Emotionally overextended losing enthusiasm for work

• Depersonalization

Negative, cynical attitude, treating patients as

• bjects
• Reduced sense of personal

accomplishment

having a sense that work is no longer meaningful

Maslach, 1981; Shanafelt, 2009

* Hallmark of Burnout

Contributory Factors

Seritan A, in Roberts L (ed.) The Academic Medicine Handbook

• Excessive workload
• Effort-Reward imbalance
• Lack of flexibility
• Misalignment

Other symptoms of burnout

• Neglecting needs: non-medical interests put on “back burner”,

poor self care, poor sleep

• Interpersonal conflicts : less tolerant to colleagues/trainees,

avoidance of emotionally difficult clinical situations, socially isolated, cutting corners at work, sarcasm, blame increasing problems on time pressure and work (vs how they engage)

• Wish they are sick so not to come to work,

thinking often about retirement

• Psychiatric symptoms : addictive behaviors,

mood, PTSD, somatic symptoms can lead to full clinical syndromes including suicide

Kearney 2009, Shanafelt, 2003, Dyrbye, 2006, Kraft 2006

How common is burnout?

• More than1 of every 3 physicians is experiencing

burnout at any given time

• Situation is worsening over past few years

– 54.4% (n=3680) of the physicians reported at least 1 symptom of burnout in

2014 compared with 45.5% (n=3310) in 2011

• Highest rates : emergency med, internal med, family

med, neurology, radiology - even aft adjustment. (psychiatry = 40 %, derm = 30%)

• Physician are at higher risk for burnout and less likely to be

satisfied with work-life balance compared to US working population

Shanafelt, 2003, 2011, 2012, 2014

• Also very common among medical students

(up to 52 %) and residents (up to 75%)

• Associated with depression, problematic

patient care, and unprofessional behaviors

Shanafelt, 2003; Thomas, 2004; Dyrbye, 2010

Impact

Negative effects on

• Patient-physician relationship, empathy
• Quality of care
• Patient outcomes, satisfaction
• Professionalism, behaviors
• Personal /family/ career decision

Shanafelt, 2009

Interventions

• SELF CARE

eat, sleep, rest, exercise, socialize, laugh, play, “pray” WELL

• Identify what is meaningful to you in your job and do

that at least a day a week (more is better !)

• Create a community at work, with positive interpersonal

interactions, find support & mentoring

• Change the work environment to reward people for good

work and be clear & fair about the goals

• Learn techniques to reduce stress and to be “present” –

Mindfulness

Shanafelt, 2009 Nedrow 2013

Wounded Healer

MD PATIENT

HEALER WOUNDED

Healing

MD PATIENT

HEALER/

WOUNDED

WOUNDED/

HEALER Healing

“Co Compassion passion is not a relationship between the healer and the wounded. It's a relationship between eq equals

• ls. Only when we know our own

darkness well can we be present with the darkness of others. Compassion becomes real when we recognize our shared red huma manity nity.”

Pema Chödrön, The Places That Scare You: A Guide to Fearlessness in Difficult Times

Burnout Compassion fatigue Depression Pity Anger Avoidance Mindlessness

Self-Awareness

Self-awareness

• combination of self- knowledge and development of

“dual-awareness”

– simultaneously attend to and monitor the needs of the patient, the work environment, and his or her own subjective experience – without reacting (or with awareness of our reactivity or needs)

• “presence” / “compassionate presence”
• “mindfulness”

Kearney MK in Hutchinson (ed) : “Whole Person Care”

What is mindfulness ?

“The awareness that emerges through paying attention on purpose, in the present moment, and non- judgmentally to the unfolding of experience moment to moment”

(Kabat-Zinn, 2003)

Core Elements of Mindfulness

Paying attention = Attention On purpose = Intention Non-judging = Attitude

Shapiro S et al , 2006

Mindfulness helps us see things clearly

Space between stimulus and response

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

Viktor E. Frankl Man’s Search for Meaning

“ A wondering mind is an unhappy mind”

Killingsworth & Gilbert, Science 2010

NYT Well blog 10/7/2011

Krassner et al, JAMA 2009 Beckman et al Acad Med 2012

Beach et al. Ann Fam Med Sep 2013

clinicians who had the highest self-rated scores for mindfulness were more likely to be patient-centered in their communications, more positive in their emotional tone with patients, and more likely to be rated highly on communication

• RCT (N=74) of intervention for physicians
• facilitated small-group curriculum
• paid, 1 hour every other week X 9 mos
• incorporating elements of mindfulness, reflection, shared

experience, and small-group learning

• Improved meaning and engagement in work and

reduced depersonalization, with sustained results at 12 months after the study

• No statistically significant differences in stress, symptoms of

depression, overall quality of life, or job satisfaction were seen

West et al JAMA Int Med, 2014

Steps to practice mindfulness

James Ishmael Ford on mindfulness practice. Shambala Sun July2012.

1.Sit down 2. Shut up 3. Pay attention

Mindfulness Compassion

What is compassion ?

• A basic kindness, with deep awareness of

the suffering of oneself and of other living things, coupled with the wish and effort to relieve it. (Paul Gilbert, PhD)

• CCARE’s multi-stage model:
• 1. Recognition of suffering
• 2. A feeling of concern and connection
• 3. A desire to relieve suffering
• 4. A willingness to act

engagement Wishes & efforts

3 Components of Compassion for Self and Others

• Mindfulness
• noticing suffering of self/others

without avoidance or aversion

• Kindness
• treating self/others with care and understanding
• soothing, comforting, mentoring
• Common Humanity
• seeing the experience of self/others as part of larger

human experience

Kristin Neff, PhD

Self-compassion

• Self Acceptance , Self care
• NOT self-indulgence, letting off the hook
• “Heart must first pump blood to itself”

“At a cardiac arrest, the first procedure is to take your own pulse.”

Law #3 from The House of God: Samuel Shem

“open” your heart to the suffering

“We cannot selectively numb emotions, when we numb the painful emotions, we also numb the positive emotions.”

Brené Brown, The Gifts of Imperfection

"

• Francisco J Varela

Shared common humanity

“appreciation that what you are going through are also being felt by millions people in the world”

• Interconnectedness
• Commonalities > Differences
• Suffering is the same
• We are all in this together

Perspective, humility, sense of connection Increase compassion to oneself and others

Desire to relieve suffering & Willingness to act

• Sincere wishes
• Balance with equanimity
• “Show up” and stay put even though we don’t

know what to do “While I don’t have a magic wand, perhaps my ability to be

present and caring will help in some small way”

• It is not always about what we do,

Good intent means a lot and can be healing both for ourselves and for others

Slide adapted from J Hallenbeck, MD

sadness anger, schadenfreude shame Suffering Compassion pity avoidance

Our energy, will power, empathy are limited

• suffering is draining
• Manage by using it smarter not harder

– narrowing the input of suffering – good idea?

• Replenish the tank

– rest, play, exercise, hobby, connection – mindfulness/compassion/gratitude/meaning as a way to auto-replenish. – change your relationship with suffering which transform it into positive energy

Cultivating Compassion

• Evidence suggests compassion can be

strengthened through targeted exercises and practice

• Components of Compassion training programs

– Mindfulness training – Self-compassion component – Guided experiential practices – Delivered in group setting with interactive format – Home work, meditation

8 WEEK TRAINING

Mindfulness/S ettling the Mind Compassion for Loved One Compassion for Self Loving Kindness for Self

Leah Weiss, PhD : CCARE Shared Common Humanity Compassion for Others Active Compassion Integrated Compassion

Compassion letter writing exercise

• Bring to mind a recent difficult experience, or some kind of stress or suffering that

is present in your life. It could be a setback you have had in reaching a goal, a health challenge, or a difficult relationship.

• Write a self compassion letter to yourself, in the second person, about this

experience, using the following guidelines. Dear______ I know you are feeling...(sad/afraid/angry/disappointed, etc) about…… (validate experience, offer understanding of the difficulty) You were really (looking forward to, hoping, needing to, trying your best to....)

• Then write about stress and underlying need behind it.(e.g. desire for safety, love,

appreciation, connection)

• Common humanity ( ie. all humans make mistakes, )
• Self kindness/mentor self (what would you say to a loved one) Mentor yourself

with some compassionate advice or encouragement.

• Choose from the values that you pick and write about how you can use this value

to support or guide yourself. (adapted from CCT- based on Gilbert’s work)

Ways to reduce stress during work

• In AM : be quiet and meditate

(before checking emails, FB)

• While driving, become aware of body tension
• Attend carefully to the sensation of contact
• While sitting , pay attention to bodily

sensations and position

• Take frequent stretches, standing, yoga posts,
• r try taking a short walk
• Set alarm & pause to perform simple act of

centering

Adapted from S Santorelli, Engaged Buddhist Reader

Embodiment

Use your body sensation as an “anchor”

• Walking
• Sitting
• Stretching

Ways to reduce stress during work (con’t)

• 3Is : Introspection, Intention, Inspiration
• Before doing the next thing, pause (and breath)
• Eat one or two lunches per week in silence
• At the end of the work day, sit quietly and

consciously make the transition

• Say hello to each of the people you live with.

Look in their eyes

• Take 5-10 mins to be quiet and still before going

to bed

Adapted from S Santorelli in Engaged Buddhist Reader

Summary

• Burnout – occupational risks
• How we engage/relate to the suffering can

make a difference

• Suggestion:

– Reflection on the process – Establish a practice and community of support

• Mindfulness/Compassion is a muscle that

must be exercised to be strong

Thank You

Lifewithcancer.org