Well Being in Anesthesiology: Realities and Remedies Amy E. Vinson, - - PowerPoint PPT Presentation

Well Being in Anesthesiology: Realities and Remedies

Amy E. Vinson, MD, FAAP @imswimming3 Boston Children’s Hospital & Harvard Medical School Johns Hopkins Grand Rounds March 12, 2020

Disclosures

 On behalf of myself and my spouse, we have no financial disclosures relevant to the material presented today

Objectives

Understand the definition and manifestations of burnout, in order to address sooner Recognize the sequelae of burnout in patient care, professionalism, physical health and society Understand the importance of peer support Cite examples by which leaders in anesthesia can prevent and ameliorate burnout in those they lead

 By Juan Emilio - Flickr: Canario silvestre, Serinus canarius(♂), CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=18277090  https://www.smithsonianmag.com/smart-news/story-real-canary-coal-mine-180961570/

“Physicians in 2018 are the proverbial ‘canary in the coal mine.’ While the canary may be sick, it is the mine that is toxic. Caring for the sick canary is compassionate, but likely futile until there is more fresh air in the mine.”

• Thomas Schwenk

What is Burnout?

Merriam-Webster: 2a : exhaustion of physical or emotional strength or motivation usually as a result

• f prolonged stress or

frustration

By 4028mdk09 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=8361003

Burnout cascade – taught, reinforced and rewarded throughout medical training

Maslach Burnout Inventory

Maslach (~1980): A syndrome typified by exhaustion, depersonalization and a loss of meaning / accomplishment

Highly validated Wide Application 3 Major Metrics of Burnout

Emotional Exhaustion Low Sense of Personal Accomplishment Depersonalization

Trauma in the ICU

• 27K surveys sent, 7.3K completed (26.7%)
• Utilized MBI and other measures of

depression/SI/balance

• 45.8% Physicians with at least 1 symptom of burnout
• More burnout symptoms and dissatisfaction with

work-life balance than general public

• 37.9% with high emotional exhaustion
• 29.4% with high depersonalization
• 12.4% with low sense of personal accomplishment

 Follow up survey – 36K sent, 6.9K responded (19.2%)  54.4% reported at least 1 symptom of burnout (up from 45.5%)  Satisfaction with WLB worsened (48.5% to 40.9%)  Physicians at increased risk of burnout (OR 1.97), less likely to be satisfied with WLB (OR 0.68)

 ~30K invitations with ~5K responding (17%) (secondary survey to ensure representability)  43.9% with at least 1 major symptom of burnout (better than 2011 & 2014)  42.7% satisfied with WLI (middle)  Anesthesia saw similar trends

Does burnout impact our health?

Self Reported Health & Physical illness Insomnia Musculoskeletal disorders Hospital admits for CVD Increased suicidality among medical students Fatigue and burnout are predictive of one another Sickness absences Hospital admission for mental illness Altered cortisol expression

The association between burnout and physical illness in the general population--results from the Finnish Health 2000 Study. Honkonen T, Ahola K, Pertovaara M, Isometsä E, Kalimo R, Nykyri E, Aromaa A, Lönnqvist J. J Psychosom Res. 2006 Jul;61(1):59-66. Shirom A. Burnout and health: Expanding our knowledge. Stress and Health. 2009;25:281. Gurman GM, Klein M, Weksler N. Professional stress in anesthesiology: a review. J Clin Monit Comput. 2012 Aug;26(4):329-35. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008 Sep 2;149(5):334–41.

Does burnout impact our professionalism?

Dyrbye LN, Massie FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010 Sep 15;304(11):1173–80. Thomas MR, Dyrbye LN, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study. J GEN INTERN MED. Springer-Verlag; 2007 Feb 1;22(2):177–83.

Does burnout impact our career longevity?

Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res. 2014;14(1):254. Ahola K, Gould R, Virtanen M, Honkonen T, Aromaa A, Lönnqvist J. Occupational burnout as a predictor of disability pension: a population-based cohort study. Occup Environ Med. 2009 May;66(5):284–90–discussion282–3.

Does burnout impact medical errors?

Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern

• Med. 2002 Mar 5;136(5):358–67. Ahola K, Gould R, Virtanen M, Honkonen T, Aromaa A, Lönnqvist J. West CP, Tan AD, Habermann TM,

Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. American Medical Association; 2009 Sep 23;302(12):1294–300. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann

• Surg. 2010 Jun;251(6):995–1000.

• Systematic review & meta-analysis
• Quantitative associations between burnout and patient

safety, professionalism, and patient satisfaction

• Burnout associated with:
• Increased risk (OR 1.96) of patient safety incidents
• Poorer quality of care b/c of poor professionalism (OR

2.31)

• Reduced patient satisfaction (OR 2.28)

Our Responsibility?

Physician wellness: a missing quality indicator. Wallace JE, Lemaire JB, Ghali WA. Lancet. 2009 Nov 14;374(9702):1714-21. doi: 10.1016/S0140-6736(09)61424-0. Review. Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA. 2011 May 18;305(19):2009-10.

Adverse Events?

1st, 2nd and 3rd Victims

Wu AW: Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320:726–7

Miracles aren’t always easy

Stiegler MP: What I Learned About Adverse Events From Captain Sully: It's Not What You Think. JAMA 2015; 313:361–2 By Greg L (File:Plane crash into Hudson River.jpg) [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

A tale of 2 patients

 Subsequent patients had longer hospital and ICU stays  After intraop death, 53% of surgeons and 22% of anesthesiologists ceased patient care for that day  ¼ (27% surgeons, 26% anesthesiologists) felt they should not work following an intraop death

Goldstone AR, Callaghan CJ, Mackay J, Charman S, Nashef SAM: Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation. BMJ 2004; 328:379–9

Impact on Anesthesiologists

88% needed time to recover – 19% never did, 12% considered change in career 67% felt subsequent care compromised over next 4 hours 7% were given time off

Gazoni FM, Amato PE, Malik ZM, Durieux ME: The Impact of Perioperative Catastrophes on Anesthesiologists. Anesth. Analg. 2012; 114:596–603

Emotional Impact?

 32 studies relating impact of medical errors on clinicians  Norm: intense emotional response  Errors increase depression & burnout  Cycle develops: future errors more likely  Talking with colleagues most helpful with coping

Schwappach DL, Boluarte TA: The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2009; 139:9–15

• ther symptoms of unwellness

Warner DO, Berge K, Sun H, Harman A, Hanson A, Schroeder DR. Risk and Outcomes of Substance Use Disorder among Anesthesiology Residents: A Matched Cohort Analysis.

• Anesthesiology. 2015 Oct;123(4):929-36.

Data on suicidality

Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004 Dec;161(12):2295- 302.

https://www.washingtonpost.com/national/health-science/what-ive-learned-from-my-tally-of-757-doctor- suicides/2018/01/12/b0ea9126-eb50-11e7-9f92- 10a2203f6c8d_story.html?noredirect=on&utm_term=.8c71ae684c76

https://opmed.doximity.com/why-happy-doctors-die-by-suicide- 8a3a1f9b1543

A New Responsibility

Sir William Osler: “In no relationship is the physician more often derelict than in his duty to himself.” “Begin at once the cultivation

• f some interest other than the

purely professional.”

By Unknown - Page, Public Domain, https://commons.wikimedia.org/w/index.php?curid=30993113

Where do we go from here?

Thomas LR, Ripp JA, West CP. Charter on Physician Well-being. JAMA. 2018 Apr 17;319(15):1541-1542.

A new way forward?

Triple Aim

Improved Outcomes Better Satisfaction of Patients Lower Cost Better Satisfaction

• f Providers (attaining joy in

work)

QUADRUPLE AIM

http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple- aim-four-points-to-help-set-your-strategy

?

Support after adverse events

Vinson AE, Mitchell JD. Assessing levels of support for residents following adverse outcomes: A national survey

• f anesthesia residency programs in the United States. Med Teach. 2014 May 7.

Ranking of Support Resources

Support After Adverse Outcomes

• Peer Support (especially Dept based)
• Leadership
• M&M conference
• Awareness

What do chairs care about?

Vinson AE, Zurakowski D, Randel GI, Schlecht KD. National Survey of US academic anesthesiology chairs on clinician wellness. J Clin Anesth. 2016 Nov;34:623-31.

Interest in Wellness Topics

3.25 3.21 3.04 2.86 2.86 2.75 2.75 2.60 2.56 2.54 2.42 2.35 2.34 2.29 2.24 2.16 2.13 2.09 2.09 1.88 1.82 1.79 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00

Conflict Management (SW) Dealing with Adverse Events Training Stress Management (IW) Burnout Counseling (OW) Addiction Counseling (PW) Peer Support Program (EW) Time Management (OW) Sleep Hygeine (PW) Life Balance (OW) Financial Management (SW) Resiliency Cultivation Training (IW) Physical Fitness (PW) Psychiatric referral network (EW) Positivity Training (IW) Mindfulness Training (IW) Weight Management (PW) Environmental Awareness Training Meditation Training (EW) Nutrition Counseling (PW) Spiritual Wellness (EW) Access to Cultural Events (SW) Spirituality Support (EW)

Ranking of Interest in Wellness Topics

(Average Likert scores with 95% confidence intervals)

#1 Conflict Management #2 Dealing with Adverse Events Training #3 Stress Management #4 Burnout Counseling #5 Addiction Counseling #6 Peer Support Programs #7 Time Management

How do leadership practices impact burnout?

Shanafelt TD, Gorringe G, Menaker R, Storz KA, Reeves D, Buskirk SJ, Sloan JA, Swensen SJ. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015 Apr;90(4):432-40.

How do leadership practices impact burnout?

Surveyed 12 leadership dimensions – ALL strongly correlated to clinician burnout /satisfaction

Highest yield traits?

 Good news! They are equal, so go with your strengths and think of the rest as a bundle.

Closing thoughts

CULTURE, CULTURE, CULTURE Burnout is very real and very impactful Solutions must not focus solely on the individual Leadership in anesthesia has an opportunity to improve the lives of fellow clinicians We can (*must*) fix this!

Thank you

Selected References

 Schwenk TL: Physician Well-being and the regenerative power of caring. JAMA 2018; 319:1543–4  Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR: Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012; 172:1377–85  Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP: Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015; 90:1600–13  Dewa CS, Jacobs P, Thanh NX, Loong D: An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014; 14:254  Warner DO, Berge K, Sun H, Harman A, Hanson A, Schroeder DR: Risk and outcomes of substance use disorder among anesthesiology residents: A matched cohort analysis. Anesthesiology 2015; 123:929–36  Schernhammer ES, Colditz GA: Suicide rates among physicians: a quantitative and gender assessment (meta- analysis). Am J Psychiatry 2004; 161:2295–302  Post PWTW, 2018: What I've learned from my tally of 757 doctor suicides.  Gazoni FM, Amato PE, Malik ZM, Durieux ME: The impact of perioperative catastrophes on anesthesiologists. Anesth Analg 2012; 114:596–603  Sikka R, Morath JM, Leape L: The Quadruple Aim: care, health, cost and meaning in work. BMJ Qual Saf 2015; 24:bmjqs–2015–004160–610  Shanafelt TD, Gorringe G, Menaker R, Storz KA, Reeves D, Buskirk SJ, Sloan JA, Swensen SJ: Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc 2015; 90:432–40  Vinson AE, Zurakowski D, Randel GI, Schlecht KD: National survey of US academic anesthesiology chairs on clinician

• wellness. J Clin Anesth 2016; 34:623–31

 Wu AW: Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320:726–7