April 18, 2019 11:30am EST Dial In: 888.863.0985 Conference ID: - - PowerPoint PPT Presentation

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April 18, 2019 11:30am EST

Dial In: 888.863.0985 Conference ID: 3599125

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Speakers

Clinical Fellow, Child and Adolescent Psychiatry Yale Child Study Center Board-Certified Psychiatrist

DNP, APRN-BC

Lecturer, Yale School of Nursing and Department of Psychiatry, Yale School of Medicine

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Disclosures

• Linda Drozdowicz, M.D., has no real or

perceived conflicts of interest.

• Robert Krause, DNP, APRN-BC, has no real
• r perceived conflicts of interest.

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Objectives

• Define provider wellness
• Define burnout and compassion fatigue, and

understand how each affects quality of care

• Analyze conditions that contribute to burnout

and compassion fatigue

• Discuss ways to enhance provider wellness
• Review self-care strategies for health care

providers

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Clinician Wellness

Mental construct:

• Absence of burnout
• Spiritual well-being
• Lack of depression
• Job/ life satisfaction
• Sense of balance

Physical construct:

• Good health
• Positive personal

health practices

Social construct:

• Social well-being
• Personal life

Brady et al. What do we mean by physician wellness? A systematic review

• f its definition and measurement. Acad Psychiatry (2018) 42:94–108

“I can’t define it, but I know it when I see it.” – Justice Potter Stewart, 1964

“Thriving”

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When Wellness Fades

https://www.healthleadersmedia.com/sites/hlmp/files/styles/article_banner/public/sad-health-care-professional-with-headache-stressed-picture-id663271540.jpg?itok=xYCdyYyg https://www.healthcarefinancenews.com/sites/healthcarefinancenews.com/files/styles/companion_top/public/Burnout2_3.jpg?itok=qulTY7sR https://i.huffpost.com/gen/1644272/thumbs/o-TIRED-DOCTOR-570.jpg?1 https://i.pinimg.com/originals/fd/ee/52/fdee52413128e9ad916f2861dacfd1c6.jpg

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Compassion Fatigue

• “In its simplest form, compassion fatigue implies a state of

psychic exhaustion.” (Boyle 2011).

• “Severe malaise resulting from caring for patients experiencing

varying aspects of pain (i.e., physical, emotional, social)… associated with the ‘cost of caring’ and refers to the resultant strain and weariness that evolves over time.” (Sabo 2006)

• How is this different from burnout?

– Clinician with compassion fatigue can still care and be involved, albeit in a compromised way. – Compassion fatigue may lead to burnout.

• Studies report the prevalence of compassion fatigue as 7.3%-

40%.

Garfield C, Spring C, Ober D. Sometimes My Heart Goes Numb: Caring ina Time of AIDS. San Francisco, CA:Jossey-Bass; 1995. Wright B. Compassion fatigue: how to avoid it. Palliat Med. 2004;18(1):4-5.[PMID: 14982200] Van Mol, M. M. C., Kompanje, E. J. O., Benoit, D. D., Bakker, J., & Nijkamp, M. D. (2015). The Prevalence of Compassion Fatigue and Burnout among Healthcare Professionals in Intensive Care Units: A Systematic Review. PLoS ONE, 10(8), e0136955. http://doi.org/10.1371/journal.pone.0136955

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Burnout: Definition

• A syndrome characterized by:

– Loss of enthusiasm for work – Feelings of cynicism and detachment – Low sense of personal accomplishment

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Physicians

Medscape National Physician Burnout, Depression & Suicide Report 2019

https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056#3

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Cost of Burnout

Shanafelt and Noseworthy. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 1/2017: 92(1): 129-146.

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Depression

• Major Depressive Disorder: Not the same as burnout, but

burnout can be precursor.

• A) ≥5 sx during 2 week period (change from prior functioning) –

MUST have depressed mood and/ or anhedonia

– Depressed mood most of day almost every day – Anhedonia – Unintentional weight loss/ gain and/ or change in appetite – Insomnia or hypersomnia – PMR/ PMA nearly daily (that others notice, not just subjective feeling) – Fatigue or low energy – Worthlessness or excessive/ inappropriate guilt – Poor concentration and/ or indecisiveness – Recurrent thoughts of death, SI, SA

Burnout:

• Loss of enthusiasm for work
• Feelings of cynicism and detachment
• Low sense of personal accomplishment

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On Physician Suicide

• 300-400 physician suicides

yearly – “A doctor a day”

• Male physicians 1.41 times

higher than the general male population

• Female physicians 2.27 times

higher than the general female population

1.Schernhammer, E. S., & Colditz, G. A. (2004). Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). American Journal of Psychiatry AJP, 161(12), 2295-2302. 2.http:/ / www.idealmedicalcare.org/ ive-learned-547-doctor-suicides/

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Burnout: Physicians vs Other Professionals

• MD/ DO’s more likely to have symptoms of burnout than
• ther working adults

– ~7000 physicians surveyed, compared to working, non-physician controls

• >30 % ↑ odds of burnout in physicians

com pared to high school grads

• Bachelor’s, master’s, professional or doctoral

degrees – were at LOWER RISK of burnout than high school grads.

Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012; 172: 1377–85.

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Burnout Among Midwives

• Sample of 100

– Death and dying + conflict with physician were most stressful events

perceived by midwives.

– Mean scores for burnout:

The respondents reported average and high levels of depersonalization, emotional exhaustion and personal accomplishment, respectively.

• Banovcinova. (2014). Sources of work-related stress and their effect on burnout in midwifery.

Procedia, Social and Behavioral Sciences, 132, 248.

Mean

• Std. deviation

Burnout rating Emotional exhaustion 24,25 9,78 Moderate Depersonalization 19,64 5,37 High Personal accomplishment 14,78 7,57 High

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Impact on Patients: Medical Errors

• Survey of ~400 IM residents at Mayo Clinic:

Self-reporting of major med errors

– Surveyed throughout training – Those with medical errors:

• 3.49 times as likely to have depersonalization (p<0.001)
• 5.33 times as likely to have emotional exhaustion (p<0.001)
• 2.25 times as likely to feel sense of low personal accomplishment

(p=0.001)

• Survey of ~8000 surgeons

– Each 1 point ↑ in depersonalization (range 0 –33)  11% ↑ odds of medical error – Each 1 point ↑ in emotional exhaustion (range 0 –54) 5% ↑ odds of medical error

• BURNOUT MATTERS

West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA 2009; 302: 1294–300.

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Impact on Patients

• Study: Work-related stress in doctors:

– 50% reported reduced standards of patient care (taking short cuts, not following procedures).

• Depersonalisation dimension of physician

burnout  ↓ patient satisfaction and ↑ recovery tim e after discharge.

• …

you get it.

Linzer M, Kondrad TR, Douglas J, et al. Predicting and preventing physician burnout: results from the United States and Netherlands. Am J Med 2001; 111: 170–75. Halbesleben JR, Rathert C. Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev 2008; 33: 29–39.

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WHY PHYSICIAN BURNOUT?

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“Mom, Dad – Where Do Physicians Come From?”

• Bachelor’s degree: ~4 yrs
• MCAT – Biology, Physics, Organic Chemistry, Inorganic

Chemistry, Behavioral Science, Critical Analysis and Reasoning

• Medical School: 4 yrs
• Equivalent of ~24+ credits/ semester
• Multiple Board Exams (oy!)
• Residency: 3-7 yrs; 80+ hrs/ wk
• Another Board Exam (oy!)
• Fellowship (if subspecializing): 1-3 yrs
• Specialty Board Exam (double oy!)
• Attending! Pay back loans.
• Median debt: $192,000

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Physician Culture

• Heavy hours: Average 50-60 hrs/ wk when not on

call.

• Care for others but not ourselves.

– “Suck it up” mentality. – Common not to have formal coverage pool. – Study: 30% of young Irish physicians had not been to a general practitioner in the previous 5 years.

• 65% felt unable to take time off from work when they were ill
• Licensing boards can discriminate for seeking

mental healthcare in many states.

• Generally not unionized in U.S.

Williams ES, Rondeau KV, Xiao Q, Francescutti LH. Heavy physician workloads: impact on physician attitudes and outcomes. Health Serv Manage Res 2007; 20: 261–69. Uallachain GN. Attitudes towards self-health care: a survey of GP trainees. Ir Med J 2008; 100: 489–91. Jones et al. Medical Licensure Questions About Mental Illness and Compliance with the Americans with Disabilities Act. J Am Acad Psychiatry Law 46:458–71, 2018.

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Real Life

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Systems Issues

“Although burnout is a system issue, most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician.” – Shanafelt and Noseworthy, Mayo Clinic

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Drivers of Burnout

Shanafelt and Noseworthy. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 1/2017: 92(1): 129-146.

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Obstetrics and Gynecology Considerations

• “Exposure to severe events in maternity

care is part of the professional experience.”

– Miscarriage, stillbirth – Child death or severe asphyxia during birth – Maternal miss or near-death in delivery – Violence, threats

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Obstetrics and Gynecology Considerations

• Study

– ~2300 Swedish obstetricians and midwives – >70% experienced severe event on delivery ward

• 15% with partial symptoms of PTSD
• 7% of obstetricians and 5% of midwives with full

blown PTSD

• Not always just “stress” or “upset”

Wahlberg et al. Post-traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross-sectional retrospective survey. BJOG. 2017 Jul;124(8):1264-1271.

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PTSD

• Does the definition of PTSD cover clinicians?

– Yes! – People exposed to actual or threatened death or serious injury in the following ways:

• Witnessing, in person, the event(s) as it occurred to others
• Experiencing repeated or extrem e exposure to aversive

details of the traum atic event(s)

• Know the signs:
• To be diagnosed with PTSD, an adult m ust have all of

the following for at least 1 m onth:

• ⊲ At least one re-exp eriencing sy m p tom
• ⊲ At least one a v oid a nce sy m p tom
• ⊲ At least two a rousa l a nd rea ctiv ity sy m p tom s
• ⊲ At least two cognition a nd m ood sy m p tom s

https://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/ptsd-508-05172017_38054.pdf

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PTSD and the Stress Response

• PTSD causes specific

changes to the HPA axis.

• Chronic stress

downgrades cortisol response.

– However sensitivity to cortisol increases causing hyperarousal, hypervigilance, chronic anxiety and sleep issues.

Yahuda, R. (2002) Post Traumatic Stress Disorder. NEJM. Vol. 346, No. 2 · https://www.nejm.org/doi/pdf/10.1056/nejmra012941

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Enhancing Wellness: Systems Level

• Physicians

– Those who spend >20% of their professional effort on what they personally valued most in medical practice more likely to avoid burnout.

• Special clinics, teaching, administration
• Leaders

– Choose physician leaders based on ability to listen, engage, develop and lead physicians - not based on meeting organizational performance targets. – Let those they lead rate them.

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• Inefficiency

– Universal driver of dissatisfaction/ burnout, but specific issues vary in each setting/ field. – Ask each specialty/ work unit what would be most helpful for improving wellness.

• Foster community for physicians

– 1 hour protected meeting time every other week can reduce burnout.

• Nix productivity-based physician pay.

Enhancing Wellness: Systems Level

Shanafelt and Noseworthy. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 1/2017: 92(1): 129-146.

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Enhancing Wellness: Individual Level

Yoga and meditation have both been shown to decrease cortisol and reduce amygdala activation.

How?

• By enhancing positive neuroplastic changes in

the PFC (executive functioning) and shrinking amygdala.

• By enhancing prefrontal executive control,

sending inhibitory messages to the amygdala.

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Enhancing Wellness: Individual Level

• Regularly discuss cases and your reactions with at

least one colleague.

• In the same way a patient benefits from talking with

you, you will gain strength from talking with others (e.g. Balint groups).

• Also, remember that basic self-care techniques such

as good sleep hygiene, diet, exercise, and stress reduction (e.g. meditation) should be integrated into a routine self-care protocol.

Recommendations from Mollica, R (2013) Healing the wounds of mass violence and torture. Harvard Program in Refugee Trauma, Cambridge Ma.

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Q&A Session

Press *1 to ask a question

You will enter the question queue Your line will be unmuted by the operator for your turn

A recording of this presentation w ill be m ade available on our w ebsite:

www.safehealthcareforeverywoman.org

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Next Safety Action Series

Mov ing from Surv iv ing to Thriv ing

Ma y 8 , 20 19 2 p m Ea stern

Corey Martin, MD

Lead Physician for Resilience Training and Burnout Prevention, Allina Health

Provider Wellness Mini- Series Session 2