Moving beyond burnout to professional engagement Martina Schulte, - - PowerPoint PPT Presentation

Moving beyond burnout to professional engagement

Martina Schulte, MD April 26, 2019

• 1. Explore nature, drivers, and consequences of

burnout

• 2. Learn a framework for developing interventions
• 3. Discover actionable organizational and

individual interventions to decrease burnout and enhance joy

Objectives

International Conference On Physician Health Toronto, Ontario October 11-13, 2018

Syndrome characterized by:

 Emotional exhaustion  Depersonalization  Decreased sense of personal accomplishment

The What: Burnout

Burnout, at its core, is the impaired ability to routinely experience positive emotion.

• first described - 1974 by

Freudenberger

state of fatigue or frustration resulting from professional relationships that fail to produce the expected rewards

• later defined as psychological

syndrome by Maslach

✓ occurring in professionals

working with people in challenging situations

✓ occupational hazard for people-

• riented workers

✓ environmental factors – high

demand, low resources settings

• common norms:

➢ be selfless and put others'

needs first

➢ work long hours ➢ do whatever it takes, go the

extra mile

• Healthcare- qualities selected

for (Gabbard, JAMA 1985):

– triad of compulsiveness

• doubt
• guilt
• exaggerated sense of

responsibility – delay gratification – perfectionism

Burnout- overview

Yerkes-Dodson Curve

• Shanafelt. Mayo Clin Proc. 2015

Frequency: Burnout

2011 2014 2017 Burnout (MBI) 45.5 54.4 43.9 Satisfaction (WLB) 48.5 40.9 42.7 2011 2014 2017 Burnout (MBI) 28.6 28.4 28.1 Satisfaction (WLB) 55.1 60.3 61.0

Physicians Non-physician working US adults

• Shanafelt. Mayo Clin Proc. 2019

Risk vs non-physicians

• Shanafelt. Mayo Clin Proc. 2019

Frequency: Burnout

• Nurses

– University hospital nurses1

• 18% met criteria for PTSD
• 86% met criteria for

burnout syndrome

– Critical care nurses2

• Half are emotionally

exhausted

• 2 out of 3 have trouble

sleeping

• 1 our of 4 are clinically

depressed

• Physicians3

– 54.4% met criteria for burnout, up from 45.5% in 2011

• Residents4

– 74% burned out – 20% met criteria for depression

• Medical students5 –

49.6%

Burnout - Prevalence

1 Mealer et al. 2009. Depression and Anxiety 2 Sexton, et al. 2009. Palliative Care 3 Shanafelt et al. 2015. Mayo Clin Proc 4 Fahrenkopf et al. 2008. BMJ 5 Dyrbye et al. 2011.

Shanafelt, Mayo Clin Proc, 2017

Consequences

• Workload
• Control/Autonomy
• Values/meaning
• Fairness
• Community
• Reward

Work Environment- Christine Maslach

• Quality of care
• Electronic health records
• Autonomy and work control
• Practice leadership

– Values alignment – Balanced approach to initiatives

• Collegiality, fairness and respect
• Work quantity and pace
• Work content, allied health professionals and support

stability

• Pay/income
• Regulatory and liability concerns
• Friedberg. Published online, 2013
• Workload
• Control/Autonomy
• Values/meaning
• Fairness
• Community
• Reward

Maslach

Canary in the coal mine

Thinking about intervening

Frameworks for taking action

• Workflow
• Electronic health record
• Team-based care
• Clerical burden
• Regulatory requirements

Efficiency of Practice

• Leadership
• Values alignment
• Voice/input
• Meaning in work
• Peer support
• Community/collegiality
• Appreciation
• Flexibility
• Culture compassion

Adapted from Shanafelt, American Conference on Physician Health, 2017

Culture of Wellness

Interventions!

Focus: Individual or Organizational?

• Lancet. Published online September, 2016

JAMA Intern Med. Published online December, 2016

Organizational

• Duty-hour requirements-

reference

• Shorter attending rotations
• Shorter resident shifts in

ICU

• Float pools for planned

absences

• Small amount of protected

time Individual

• Meditation/Mindfulness
• Stress management training
• Communication skills

training

• Narrative medicine
• Small group curricula and

belonging interventions

Interventions

Efficiency of practice

• Primary care clinicians at 34 clinics in Midwest

and NY

• Work condition measurements:

– time pressure – workplace chaos – work control – clinician outcomes

• Work-life measurement

➢Chose interventions for clinical site

Linzer, J Gen Intern Med, 2015

Intervention clinicians

– Improvements in burnout and satisfaction – Burnout was more likely to improve with

• workflow interventions
• targeted QI projects

➢Site-specific control over intervention

Results

Efficiency of practice

• Atrius Health, non-profit, MA Health Group- 740,000 patients
• Pre: provider efficiency score tracked:

– every screen – click – scroll – every look at med list, problem list – time logged in to system

• Package of EHR-related interventions- SWAT

– IT analysis, training, local support, security and interface issues – Workflow observation and analysis

Atrius Health, American Conference on Physician Health, Presented 2017

SWAT Intervention

• Outcomes:

– Click savings –estimated 1500 clicks of 4000 estimated/provider/day – EPCS adoption rising rapidly – Time savings

Unswatted Swatted Time in navigator (mins/eval period) 248.2 131.8 Time in notes/letters (mins/eval period) 1020 910

Culture of wellness

• Intervention group
• 19 biweekly facilitated discussions
• mindfulness, reflection, shared experience, and small-

group learning

• Facilitated small-group curriculum vs control
• improved meaning and engagement
• reduced depersonalization
• sustained results at 12 month
• West. JAMA Intern Med, 2014

Culture of wellness

• Surveyed 3896 physicians, 72% response
• Assessed burnout and leadership qualities of

immediate and division/department chair

• 12 leadership dimensions- Likert 1-5
• Shanafelt. Mayo Clin Proc, 2015

➢ Leaders’ scores correlated with burnout and

satisfaction

➢ Leadership responsible for 11% of variation in

burnout

➢ Leadership rating explained 47% of variation

in satisfaction

Results

➢ Leadership qualities are teachable:

• keeping people informed
• encouraging ideas for improvement
• having career development conversations
• providing feedback and coaching
• recognizing a job well done

Good News!!

For each 1 point increase in composite score

– 3.3% decreased likelihood of burnout – 9% increased likelihood of satisfaction

• 1. Develop and implement targeted interventions

1.

Workplace efficiencies/workflow

2.

Workload

3.

Address EHR challenges

• 2. Cultivate community
• 3. Harness the power of leadership

The Big Three!

Bryan Sexton, National Taskforce for Humanity in Healthcare

• Emotional Thriving
• Emotional Recovery

I’m Burned Out I’m Thriving

Christina Maslach

• Emotional Exhaustion
• Depersonalization
• Personal Accomplishment

Bohman, Dyrbye, Sinsky, et. al.

• Culture Of Wellness
• Efficiency of Practice
• Personal Resilience

Personal Energy and Renewal: From Empty to Full

What fills my emotional reservoir? Arenas of Life Exercise

• Shanafelt. Arch intern Med, 2009

Purpose & Meaning

• Career Fit and Burnout Among Academic

Faculty

➢ 556 physicians sampled, 465 (84%) responded ➢ Spending <20% of professional work time on most

meaningful activity had higher burnout

➢ Time spent on most meaningful activity was the

largest predictor of burnout



Explore and name your values- actively align decisions with your values



Identify your sense of purpose- consciously make choices that connect with your purpose



Know what brings you joy, make your bucket list and live it



Build and nurture your relationships



Work less-actively mange and decrease work-home conflicts



Embrace a growth mindset, engaging in life from a learning and growing perspective

(Dweck, Mindset: The new psychology of success) 

Exercise



Sleep- 7-9 hours a night



Have idle time



Vacation- use all your vacation time



Reflect, meditate, or engage in a spiritual practice

Wellness Strategies: Being Intentional

• Individual interventions help
• But, burnout is a system issue
• Creating joy in practice

necessitates systems interventions

• Interventions & studies are

happening

• Ways forward are emerging

– Building community/support – Site-specific workflow efficiencies & interventions – Leadership development – Attend to yourself

• Take care of yourself
• Be clear on what

– brings you joy – you value

• Let your purpose, joys

and values be your guide your decision- making

But until the systems catch up …

Marti Schulte

mschulte@schultecpc.com

• Errors/Safety

– Welp. Front Psychol 2017 – Shanafelt. Ann Surg 2010 – Williams. Health Care Manage Rev 2007 – Shanafelt. Ann Intern Med 2002 – Tawfik. Mayo Clin Proc 2018

• Unprofessional

behavior/impaired professionalism

– Dyrbye. JAMA, 2010

• Medication adherence

– Haas. J Gen Intern Med 2000

• Staff turnover and reduced

hours

– Shanafelt. J Am Coll Surg 2011 – Shanafelt. Mayo Clin Proc 2016

• Depression and suicidal

ideation

– Blach. Ann Surg 2011 – Shanafelt., Arch Surg 2012

• Alcohol use

– Oreskovich. Arch Surg 2012

• Mortality

– Welp. Front Psychol 2017

Consequences - references

Driver Individual Organizational

Workload Work efficiency/support Work-life integration/balance Autonomy/flexibility/co ntrol Values/meaning Community

Drivers of burnout… and enhancing joy

West, Mayo Clinic