Navigating Stress and Burnout

in Health Care

Daniel Friedland, MDMedical Director, Barney and BarneyFounder & CEO, SuperSmartHealth

© 2012 SuperSmartHealth

Roadmap & Objectives

1) Factors predicting burnout

2) Recognizing burnout

3) The 4 in 4 Framework™to navigate burnout 

Burnout

Prevalence of Burnout

• Approximately 50% of students experience burnout and 10% experience suicidal ideation during medical school1

• Between 25-75% of medical residents experience burnout depending on the specialty2

• Approximately 1 in 3 doctors (both medical and surgical) are experiencing physician burnout at any given time3

1. Dyrbye LN, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149:334.2. Ishak WW, Lederer S. J Grad Med Educ. 2009 Dec;1(2):236-42.3. Shanafelt T, et al. JAMA. 2009;302(12):1338.

Prevalence of Burnout

• Survey of 27,276 U.S. physicians, 7288 (26.7%) completed surveys.

• 45.8% of physicians reported at least 1 symptom of burnout.

• Compared with a sample of over 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%).

Shanafelt TD et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population.

Arch Intern Med. 2012 Aug20:1-9.

Effects of Physician Stress

• 1200 practicing physicians surveyed• 6 in 10 have considered leaving medicine• 77% experience fatigue• 67% experience burnout• 33% depression & family discord

ACPE Survey 2006 November-December The Physician Executive

© Lee Lipsenthal 2009

Effects of Physician Stress

• 1200 practicing physicians surveyed• 6 in 10 have considered leaving medicine• 77% experience fatigue• 67% experience burnout• 33% depression & family discord• Contributing causes;

– Low reimbursement– Low autonomy– Patient overload– Lack of respect

ACPE Survey 2006 November-December The Physician Executive

© Lee Lipsenthal 2009

Factors Contributing to Burnout

Work-related stress:• Excessive workloads• Balancing personal and professional life• Deterioration in work conditions• Autonomy• Meaning in the work

Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA. 2011 May 18;305(19):2009-10.

Factors Contributing to Burnout

• Cross-sectional national survey of 2,000 randomly selected physicians in the U.S. with 935 respondents

• The strongest predictor of burnout was having little control over schedule and hours worked (P<.001)

Keeton K, et al. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol. 2007Apr;109(4):949-55.

Results from Canadian Medical Association Physician Resource Questionnaire (PRQ) November 2003http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/PhysicianHealth/news/pdf/Burn-out.pdf

Burnout by Specialty

Shanafelt TD et al. Arch Intern Med. 2012 Aug20:1-9.Copyright © 2012 American Medical Association.

Personality and Burnout• Escape-Avoidance (Self-directedness & Cooperativeness protective)1

• Low sense of stability and increased vigilance and anxiety traits2

• Low self-esteem, feelings of inadequacy, dysphoria and obsessive worry, passivity, social anxiety, and withdrawal from others3

• Higher levels of neuroticism and introversion and lower levels of agreeableness4

• (Higher self-rated Emotional Intelligence protective)5

1. Pejušković B, et al. Burnout syndrome among physicians - the role of personality dimensions and coping strategies. Psychiatr Danub. 2011 Dec;23(4):389-95.

2. Cebrià et al. Personality traits and burnout in family doctors. Aten Primaria. 2001 Apr 30;27(7):459-68.

3. McCranie EW, Brandsma JM. Personality antecedents of burnout among middle-aged physicians.Behav Med. 1988 Spring;14(1):30-6.

4. McManus IC, et al. Stress, burnout and doctors' attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC Med. 2004 Aug 18;2:29.

5. Weng HC, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011 Aug;45(8):835-42.

Maslach Burnout Inventory

1. Emotional exhaustion

2. Depersonalization

3. Reduced personal accomplishment

Maslach, C. & Jackson, S.E. The measurement of experienced burnout. Journal of Occupational Behavior. 1981;2:99-113.

Freudenberger’s 12 Phases of Burnout

1.The compulsion to prove oneself

2.Working harder

3.Neglecting one’s needs

4.Displacement of conflicts

5.Revision of values

6.Denial of emerging problems

7.Withdrawal

8.Obvious behavioral changes

9.Depersonalization

10.Inner emptiness

11.Depression

12.Burnout Syndrome

Freudenberger H.J. & North G. Women's Burnout: How to Spot It, How to Reverse It, and How to Prevent It. (1985). New York: Doubleday.

“Burnout is the index of the dislocation between what people are and what they have to do.

It represents an erosion in value, dignity, spirit, and will – an erosion of the human soul.

It is a malady that spreads gradually and continuously over time, putting people into a downward spiral from which it’s hard to recover.”

Maslach, C. & Leiter, M. P. (1997). The truth about burnout. San Francisco: Jossey Bass.

In summary…

Swank and Marchland 1946; redrawn from Mind-Body Medicine, Watkins 1997

0 10 20 30 40 50 60

Deg

ree

of

com

bat

Days in combat

Soldier becomes"battlewise"

Period ofmaximum efficiency

Combat exhaustion

Hyper-reactivestage

Emotional exhaustionstage

Period ofoverconfidence

Vegetative phase

Battle Stress / Efficiency and Exhaustion

© Lee Lipsenthal 2007

Consequences of Burnout

• Increased medical errors• Decreased empathy• Plans to retire early• Job dissatisfaction

Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat tosuccessful health care reform. JAMA. 2011 May 18;305(19):2009-10.

Physician satisfaction matters

• Strongly linked to patient satisfaction1

• Affects patients’ perception of quality of care1

• Enhances patient confidence2

• Enhances patient adherence with therapies3

1. Haas J, et al. “Is the professional satisfaction of general Internists associated with patient satisfaction?” J Gen Intern Med. 2000;15:122-128.

2. Grembowski D, et al. “Managed care, physician job satisfaction, and the quality of primary care.” J Gen Intern Med.2005;20:271-277.

3. DiMatteo MR, et al. Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol. 1993 Mar;12(2):93-102.

Ten factors enhancing physician satisfaction

• Relationships with colleagues

• Relationships with patients

• Relationships with staff • Community involvement.

• Autonomy• Income• Resources• Administrative support• Free time away from work• Intrinsic satisfaction

Konrad T, et al. “Measuring physician job satisfaction in a changing workplace and a challenging environment.” Med Care. 1999;37:1174-1182.

© Lee Lipsenthal 2009

• Relationships with colleagues

• Relationships with patients

• Relationships with staff • Community involvement.

• Autonomy• Income• Resources• Administrative support• Free time away from work• Intrinsic satisfaction

Ten factors enhancing physician satisfaction

Konrad T, et al. “Measuring physician job satisfaction in a changing workplace and a challenging environment.” Med Care. 1999;37:1174-1182.

© Lee Lipsenthal 2009

• Relationships with colleagues

• Relationships with patients

• Relationships with staff • Community involvement.

• Autonomy• Income• Resources• Administrative support• Free time away from work• Intrinsic satisfaction The nature of the work Achievement Recognition Responsibility Growth

Ten factors enhancing physician satisfaction

Konrad T, et al. “Measuring physician job satisfaction in a changing workplace and a challenging environment.” Med Care. 1999;37:1174-1182.

© Lee Lipsenthal 2009

Values, Workload and Efficacy (in women)

Leiter MP, Frank E, Mathison TJ. Canadian Family Physician December 2009 vol. 55 no. 12 1224-1225.e6

‘‘If all of the knowledge and adviceabout how to beat burnout could be summed up in one word,that word would be balance – balance between giving and getting, balance between stress and calm, balance between work and home.’’

Maslach C. Burnout: The Cost of Caring. Englewood Cliffs, NJ: Prentice-Hall;1982.

- Christina Maslach

If burnout involves exhaustion,

depersonalization and decreased personal efficacy,

how can we become more resilient to better navigate stress and reengage so that we can

experience greater vitality,more fully connect with others, ourselves and our source of

inspiration, as well as thrive with peak performance?

Performance

Arousal/Stress

?

Yerkes–Dodson Law

Performance

Arousal/Stress Yerkes RM, Dodson JD (1908). Journal of Comparative Neurology and Psychology 18: 459–482.

The Foundation

Neuroplastic Transformation

Performance

Arousal / Stress

The 4 in 4 Framework™

IntegratingMental Emotional Social Spiritual

Intelligence

Make the Turn intoWhat’s Truly Important

Cultivate Creativity By Reflecting on

What’s Truly Important

Reappraise Stress and Self-Doubt

Recognize Reactivity

ReactivityFight & Flight

CreativityFulfillment

STRESS & SELF-DOUBT

INSPIRATION

The 4 in 4 Framework™

1 2

34

Recognize Reactivity

ReactivityFight & Flight

CreativityFulfillment

STRESS & SELF-DOUBT

INSPIRATION

The 4 in 4 Framework™

1

Recognize Reactivity:

1. Physical Sensations

2. Feelings

3. Thoughts

4. Behaviors

1

Is it doing more harm than good?

Recognize Reactivity:

1

Reappraise Stress and Self-Doubt

ReactivityFight & Flight

CreativityFulfillment

STRESS & SELF-DOUBT

INSPIRATION

The 4 in 4 Framework™

2Recognize Reactivity

Is it doing moreharm than good?

1

Reappraise Stress and Self-Doubt:

• SCARF1

• What if…• If only...• Judgment and Criticism• Rejection and Abandonment• Neglect and Abuse• Standards and Expectations• Loss• Transition

Triggers of Stress and Self-Doubt:

2

1. Rock, D., Managing with the Brain in Mind. Oxford Leadership Journal. 1(1): p. 1-10.

Reappraise Stress and Self-Doubt:

2

Appraise Reappraise

1) What happened (just the facts)?

2) What is my belief about what happened?

3) Is my belief true or what is the evidence this should be so?

4) How could I view this differently?

Adapted from Albert Ellis et al. Rational Emotive Behavior Therapy. Amer Psychological Assn; 3 edition 2011.

Reappraise Stress and Self-Doubt:

• What if…• If only…• Judgment and Criticism• Rejection and Abandonment• Neglect and Abuse• Standards and Expectations• Loss• Transition

Reappraising the Triggers:

2

In a survey of 314 people at San Francisco International Airporthow many acknowledged they experience doubts of self-worth?

a) 76b) 187c) 235d) 283e) 311

Reappraise Stress and Self-Doubt:

2

Friedland D, SFO Self-Doubt Study 2001, unpublished data

Self-doubt is nothing more

than psychic gas!

Reappraise Stress and Self-Doubt:

2

ReactivityFight & Flight

CreativityFulfillment

STRESS & SELF-DOUBT

INSPIRATION

The 4 in 4 Framework™

Recognize Reactivity

Is it doing moreharm than good?

1Reappraise Stress

and Self-DoubtIt’s nothing more than

Psychic gas!

2

Cultivate Creativity By Reflecting on

What’s Truly Important

3

Cultivate Creativity By Reflecting on

What’s Truly Important

What is your definition of

optimal health?

3

Cultivate Creativity By Reflecting on

What’s Truly Important

• Learning• Connecting• Expressing Potential• Being of Service• Creating Opportunity• Experiencing Significance• Leaving a Legacy

3

Cultivate Creativity By Reflecting on

What’s Truly Important

3

Health Relationships Productivity

V

S

I

R

V=Vision S=Strategy I=Implementation R=Results

ReactivityFight & Flight

CreativityFulfillment

STRESS & SELF-DOUBT

INSPIRATION

The 4 in 4 Framework™

Recognize Reactivity

Is it doing moreharm than good?

1Reappraise Stress

and Self-DoubtIt’s nothing more than

Psychic gas!

2

Cultivate Creativity By Reflecting on

What’s Truly ImportantLearning

ConnectingExpressing Potential

Being of ServiceCreating Opportunity

Experiencing SignificanceLeaving a Legacy

3

Make the Turn intoWhat’s Truly Important

4

1

3

Find

Frame

Apply

Evaluate

1

3

24

Make the Turn intoWhat’s Truly Important

4

Frame-Find-Evaluate-Apply Spiral of Growth™

Cultivate Creativity By Reflecting on

What’s Truly Important

Reappraise Stress and Self-Doubt

Recognize Reactivity

ReactivityFight & Flight

CreativityFulfillment

STRESS & SELF-DOUBT

INSPIRATION

The 4 in 4 Framework™

Is it doing moreharm than good?

It’s nothing more than Psychic gas!

LearningConnecting

Expressing PotentialBeing of Service

Creating OpportunityExperiencing Significance

Leaving a Legacy

Make the Turn intoWhat’s Truly Important

Frame

1

2

3

4

Apply

Evaluate

Find

1 2

34

Fight Flight Trigger

1 2

Fight Flight

Trigger

Give Receive

1 2

GiveReceive

Cycle of Reactivity

Cycle of Creativity

Cultivate Creativity By Reflecting on

What’s Truly Important

Reappraise Stress and Self-Doubt

Recognize Reactivity

ReactivityFight & Flight

CreativityFulfillment

STRESS & SELF-DOUBT

INSPIRATION

The 4 in 4 Framework™

Is it doing moreharm than good?

It’s nothing more than Psychic gas!

LearningConnecting

Expressing PotentialBeing of Service

Creating OpportunityExperiencing Significance

Leaving a Legacy

Make the Turn intoWhat’s Truly Important

Frame

1

2

3

4

Apply

Evaluate

Find

1 2

34

Achieve and Enhance Peak Performance

Performance

Arousal / Stress

Online Program

+

The 4 in 4 Framework™ to Achieve Peak Performance

Workbook• 1 Module per week for 8 weeks, each 45-90 minutes long• 30 minutes of workbook exercises per week• 10-20 minutes of mindfulness practice per day

For more information go to:

http://danielfriedland.com/programs

Contact Information

Daniel Friedland, MDMedical Director, Barney and BarneyFounder & CEO, SuperSmartHealth

daniel@supersmarthealth.comOffice: 858.481.2393 Cell: 858.229.0875