Beyond Burnout Whats new in physician well-being, and whats next? - - PDF document

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Beyond Burnout Whats new in physician well-being, and whats next? - - PDF document

Jun 05, 2023 275 likes •426 views

Disclosures No disclosures Beyond Burnout Whats new in physician well-being, and whats next? Larissa Thomas MD, MPH Associate Clinical Professor, UCSF Department of Medicine Lets Get Real about Physician Well-being Well-being Roadmap

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/20/19 1

Beyond Burnout

What’s new in physician well-being, and what’s next?

Larissa Thomas MD, MPH Associate Clinical Professor, UCSF Department of Medicine

Disclosures No disclosures

Let’s Get Real about Physician Well-being

https://www.pexels.com/photo/backlit-beach-dawn-dusk-588561/ https://www.pexels.com/photo/woman-working-girl-sitting-133021/

Well-being Roadmap

Definitions Scope of the Problem Where It Comes from Why It Matters What to Do About It

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Well-being Roadmap

Definitions Scope of the Problem Where It Comes from Why It Matters What to Do

Compassion fatigue

§“Vicarious trauma” §Repeatedly seeing/working with human sufferingàemotional depletion §Often temporary, but can contribute to burnout The “cost of caring”

Burnout

3 components of burnout (Maslach):

1. Emotional exhaustion 2. Cynicism and depersonalization 3. Low sense of personal accomplishment Mismatch in the workplace between desired state and reality

What about “moral injury” (h/t ZDoggMD)?

Burnout vs. Depression

Depression also prevalent in physicians…

Burnout Depression

…but burnout mostly affects work life.

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What About Resilience?

Practices and skills: Gratitude Engaging in difficulties Self-awareness/self-acceptance Goal and limit-setting Intellectual stimulation Positive adaptation in the face of stressors (strong, not tough) Psychological principles: positive psychology, appreciative inquiry i.e. not simply “bouncing back” or “turning that frown upside down”!

Zwack and Schweitzer. Acad Med 2013 Mar; 88(3)):

Roadmap

Definitions Scope of the Problem Where It Comes from Why It Matters What to Do About It

How Serious Is the Problem?

Drybye JAMA 2018; 320(11). Drybye et al. Acad Med. 2015; 89(3). Ishak et al. J Grad Med Educ . 2009; 1(2). https://www.pexels.com/photo/black-and-white-zebra-standing-during-daytime-67233/

Burnout prevalence

Medical students

Up to 50%

Residents

40-70%

Practicing physicians

20-60%

Is Burnout Worse in Physicians?

Shanafelt Mayo Clin Proc 2019; epub ahead of print https://doi.org/10.1016/j.mayocp.2018.10.023

Physicians

All U. S.

Burnout

43.9% 28.1%

Satisfied with work-life balance

42.7% 61.3%

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Roadmap

Definitions Scope of the Problem Where It Comes from Why It Matters What to Do About It

Burnout: What’s the evidence?

Individual Contributors Unclear Association Likely Association

Demographics

  • Women à higher burnout

(EE)?

  • Underrepresented

backgrounds à lower QOL + personal accomplishment? Major error or adverse event Low tolerance of ambiguity ? Depression

Shanafelt Mayo Clin Proc 2019; epub ahead of print https://doi.org/10.1016/j.mayocp.2018.10.023 Drybye Mayo Clin Proc 2006 Nov;81(11)

Medical Errors and Well-being

West et al. JAMA 2006; 206(9) Shanafelt et al. Ann Int Med 2002; 136(5)

Major Adverse Event Burnout Suboptimal Patient Care Role of shame + perfectionism

Shantafelt Mayo Clin Proc 2017;92(1)

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Documentation regulations: Length of US notes vs other countries

Downing Ann Int Med 2018 epub ahead of print May 8. 2018 www.annals.org 18

Arndt Ann Fam Med 2017; 15(5) Date night

Roadmap

Definitions Scope of the Problem Where It Comes from Why It Matters What to Do About It

Consequences of Burnout

Suboptimal patient care Decreased empathy Increased self- reported errors Decreased patient satisfaction Increased use of sick leave Intent to retire early Specialty choice ? Risk for depression Decreased satisfaction Suicidal ideation

JAMA 296:1071, JAMA 304:1173, JAMA 302:1294, Annals IM 136:358, JAMA 306:952, Health Psych 12:93, Annals IM 149:334, 2Mayo Clin Proc 2016, JAMA IM 2017

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Shared Humanity

Self- actualization

Esteem Belonging/love Safety Physiology

Maslow AH. Psychological Review. 1943; 50(4)

Thanks…now I feel burned out from this talk!

iStock photo

Roadmap

Definitions Scope of the Problem Where It Comes from Why It Matters What to Do About It

1980-90s

  • Burnout

described in

  • ccupational

psychology

2000-2010

  • Descriptive

studies prove burnout high in medicine

2010-2015

  • Individually-

focused interventions

2014- present

  • Systems

drivers and interventions

Shared Approach

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Population Health Experience of Care Cost of Care

Institute for Healthcare Improvement Triple Aim

Adapted from www. IHI.org

Population Health Experience of Care Cost of Care Provider Well-being

The “Quadruple Aim”

Adapted from Bodenheimer and Sinsky, Ann Fam Med 2014; 12:573-6.

Initial Draft 2 day meeting Consensus Charter

Charter on Physician Well-being

  • Inspired by Charter on Professionalism
  • Consensus process: leaders in the field

and representatives from national physician organizations:

  • AMA
  • AAMC
  • ACGME
  • AAIM
  • ABIM
  • ACP
  • APA
  • IHI
  • SGIM
  • SHM

Charter on Physician Well-being

Guiding Principles

Effective patient care promotes and requires physician well-being Physician well-being is inter-related to well- being of interprofessional team Well-being is a quality marker for health systems Well-being is a shared responsibility

Thomas et al JAMA 2018; 319(15)

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 5/20/19 8 Societal

Charter on Physician Well-being: Key Commitments

Interpersonal and Individual Organizational Societal

Anticipation/support for challenges Prioritized mental health Individual self-care/meaning Supportive systems Engaged leadership Highly functioning teams Trustworthy culture Advocacy for policies

Adapted from Thomas et al JAMA 2018; 319(15)

Interpersonal and Individual Organizational

Societal

Organizational Interpersonal and Individual

Trustworthy culture Advocacy for policies

Society: Trustworthy Culture

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Culture and well-being

§Values mismatch at workàburnout §More prominent driver in women §Hidden curriculum: Trainees especially vulnerable §Culture of medicine

Shanafelt Mayo Clin Proc 2015;90(4) Leiter Can Fam Phys 2009;55(12) https://hbr.org/2013/05/what-is-organizational-culture

Role modeling + authenticity: Walk the walk! Participatory decision-making

Society: Policies and Regulations Recent successes and ongoing work

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3971CP.pdf http://www.acgme.org/tabid/116/about.aspx Dyrbye Mayo Clin Proc 2017;92(10)

ACGME

New well- being core program requirements

FSMB

Licensing questions should ONLY ask about current impairment, align with ADA

CMS

Medical student documentation billable

Societal Interpersonal and Individual

Organizational

Supportive systems Engaged leadership Highly functioning teams

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Organizational Competency in Well-Being

Novice Beginner Competent Proficient Expert

Awareness

Wellness Committee Individual interventions (mindfulness, lifestyle initiatives)

Understand driver dimensions

Peer support program Cross-sectional survey Struggling units identified Well-being considered in decisions

Understand business case

Practice redesign Coaching resources Regularly measure well- being Opportunities for community- building

Understand impact of well-being on

  • rganizational
  • bjectives

Well-being considered in

  • perational decisions

Funded well-being program Leadership training Assessment of systems interventions

Well-being influences all major

  • perational

decisions

Chief Wellness Officer Strategic investment Knowledge creation Culture of wellness

Adapted from Shanafelt JAMA IM 2017; 77(12): 1827

Organizations: Engaged Leadership Leadership behaviors and burnout

Shanafelt et al. Mayo Clin Proc 2015;90(4)

  • Physicians and scientists

at Mayo surveyed about leadership behaviors of their chairs

  • Higher leadership scoreà

less burnout Intervention: leadership training Example Questions Inspires me to do my best Empowers me to do my job Recognizes me for a job well done Is interested in my opinion Encourages me to develop talents and skills

Organizations: Supportive Systems and Highly Functioning Teams

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Organizational Interventions: Promising Directions

Linzer et al. JGIM 2015; 30(8) Helfrich et al. JGIM 2014; 29(2) Sinsky Ann Fam Med 2013;11(3) West et al. JAMA IM 2014; 174(4)

Supportive systems: Rightsizing workload and workflow:

Job and schedule structure Adequate staffing Schedule flexibility Coverage for illness Variety in practice Protected time for self-care Reduce admin burden: Scribes In-box support Verbal orders/order sets Workplace redesign Co-locating teams

West et al. JAMA IM 2014; 174(4) https://www.washingtonpost.com/news/inspired-life/wp/2015/08/20/the-innovative-stanford-program-thats- saving-emergency-room-doctors-from-burnout/?utm_term=.c8e46ace4bdd

https://www.pexels.com/photo/achievement-adult-agreement-arms-1153213/

Stanford: WellMD time-banking program Mayo Clinic: Protected time for well-being: decreased burnout, persistent effects 12 months after study end

Lessons from Other Fields?

Societal Organizational

Interpersonal Individual

Anticipation/support for challenges Prioritized mental health Individual self-care/meaning

Interpersonal and Individual : Anticipating Inherent Challenges

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Support for Adverse Events

Value of peer support

Scott SD, et al. Qual Saf Health Care. 2009;18:325-330.

Chaos Intrusive reflection Restore integrity Endure the inquisition Obtain emotional first aid Move on

Stages of Coping

Compassion (from others) Self- compassion (from self)

Reduce shame associated with errors

Interpersonal and Individual : Mental health care and self care

Interventions at the Individual Level Mental Health, Meaning and Engagement

Intervention Evidence

CBT training Less SI when done proactively Mindfulness Decreased burnout, persistent effect Group reflection Decreased burnout, improved satisfaction Positive psychology/ gratitude practice Higher satisfaction

Summary of evidence (West 2016 metanalysis):

  • Both individual and organizational interventions are effective
  • Modest but clinically meaningful effects on burnout (in volunteers)
  • Pooled absolute reduction ~10%, relative ~ 20%

West et al. Lancet 2016; 388 (10057)

Balint-type support groups

Clinical case conferences on physician-patient relationship

http://americanbalintsociety.org RabowMW , McPhee SJ. West J Med. 2001;174(1):66–99.

https://www.pexels.com/photo/landscape-nature-night-blue-35796/

Individual-level Interventions Reflection and meaning/values

Personal reflection/reflective writing

“Doctoring to Heal” (Rabow/McPhee)

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  • From Buddhist tradition emphasizing

remaining in the present.

  • 2009 JAMA Study:

‒ Decreased burnout ‒ Persistent after end of intervention

  • Lower intensity intervention in residents

(weekend training) also successful

  • However, mandatory training may not be

effective.

Krasner et al. JAMA 2009; 302(12) Fortney L. Ann Fam Med 2013; 11(5): 412-20 Drybye JGIM 2017 Dec;32(12)

https://www.pexels.com/photo/dog-lying-on-beach-928449/

Individual-level Interventions Mindfulness

  • The “good life”: how do

you get it?

  • Influence of memory on

final impressions of an experience (Kahneman)

  • Evidence for benefit of

coaching

Individual-level Interventions Resilience /Positive Psychology

My strategy: Gold in the mental treasure box

Kahneman, Daniel Thinking Fast and Slow, 2011. U Penn Positive Psychology Center: https://ppc.sas.upenn.edu/ Palamara JGME 2015; 7(4)

https://www.pexels.com/photo/analogue-art-box-chest-366791/ Eisenstein N Engl J Med 2018; 379

Individual-level Interventions Reflection and meaning/values What is your fuel? How can you feed your fire?

Acknowledgment: Nandiwada, Lebduska, Sgro (U of Pittsburgh) and Asher Tulsky (Boston University), Denah Joseph

Individual-level Interventions Key: Integration into Practice

Mindfulness and Positive Psychology in Everyday Work

Three good things

Each day (or week or month), think back to three things you are thankful for.

Low-high reflection

Each member of the team discusses something that was frustrating or disappointing and something that went well

  • r they are proud of

Perspective-taking

Think back to a frustrating in interaction with a [patient] [team member] and reimagine it from the other person’s perspective

Goal setting

At start of each rotation (or week), set a personal well- being goal in addition to clinical learning goals.

Moved, surprised, learned

Share something that moved or distressed you, something that surprised you, and something you learned about yourself in in the last week/month.

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Well-being Roadmap

Definitions Scope of the Problem Where It Comes from Why It Matters What to Do About It Societal Organizational Interpersonal and Individual

Anticipation/support for challenges Prioritized mental health Individual self-care/meaning Supportive systems Engaged leadership Highly functioning teams Trustworthy culture Advocacy for policies

A way forward?

AMA AAMC IHI ACP SGIM SHM NMA NHMA ABIM APA AAIM CORD-EM ASA

Thank you!

Email larissa.thomas@ucsf.edu

  • Additional resources:

‒ ACGME: http://www.acgme.org/What-We-Do/Initiatives/Physician- Well-Being ‒ National Academy of Medicine Clinician Well-being Knowledge Hub: https://nam.edu/clinicianwellbeing/resource-center/ ‒ AMA Practice Transformation Website: https://www.ama- assn.org/amaone/practice-transformation ‒ Collaborative for Healing and Renewal in Medicine Annotated Bibliography on Evidence-Based Well-being Interventions: https://www.im.org/resources/wellness-resiliency/charm/best- practice-group