Is It Better To Burnout Than To Fade Away?

AAO Convocation March 20, 2016

Rosen Shingle Creek, Orlando Eric Snider, DO

Topics

• Burnout • Disease Approach vs Pursue/Cultivate

Wellness • ATSU’s Student Wellness Program

– One example of cultivating a culture of wellness

Burnout • Work-related mental health impairment

• 3 dimensions

– Emotional exhaustion • state of being depleted of one’s emotional resources (loss of

enthusiasm for work) – Depersonalization

• negative, cynical and detached approach to people under ones care – Reduced personal accomplishment

• sense of low self-efficacy and negative feelings towards one’s self

• Leads to decreased effectiveness at work

Burnout Among US Physicians • June 2011 Survey • 89,831 DOs & MDs emailed • 27,276 Surveyed (opened an email) • 7288 (26.7%) Responded • Maslach Burnout Inventory (22 items)

• Compared to 3442 US Working Adults • 2 single item measures from the full MBI

– (good correlation with emotional exhaustion and depersonalization)

• Shanafelt TD, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med Vol 172 (No. 18) 1377-1385.

Burnout Among US Physicians

• Emotional exhaustion (37.9%) • Depersonalization (29.4%) • Reduced Personal Accomplishment (12.4%)

• 45.8% experiencing symptom of high

emotional exhaustion or depersonalization

• Shanafelt TD, et al. Arch Intern Med 2012.

Burnout Among US Physicians

• Positive screen for depression 37.8% • Suicidal ideation in last 12 months 6.4%

• Only 48.2% thought work schedule left

enough time for family and personal time

Burnout By Specialty

Shanafelt TD, et al. Arch Intern Med 2012

Burnout Among US Physicians

• Alarmingly high level • Struggle with work – life integration • A DO or MD degree increases risk for burnout

compared to other professional and advanced degrees

• Burnout among physicians exceeds the larger societal trends

Consequences of Physician Burnout

• Decreased patient satisfaction with care • Decreased professionalism • Decreased medical knowledge • Patient care errors • Motor vehicle collisions

Personal Consequences of Burnout

• Broken personal relationships • Substance abuse • Suicidal ideation

~400 physicians commit suicide each year 1.4-2.3 times the rate of the general population

Key Contributors to Physician Burnout

• Loss of autonomy • Excessive workload • Electronic Health Records • Excessive administrative burdens • Difficulty with work-life integration • Diminished meaning derived from work • Experience with suffering • Loans

Medical Students and Burnout

• Symptoms of burnout present in roughly 50% • Similar consequences

– Professional – Personal

Medical Students and Suicide

• Little data • Schools refuse to participate

– Concerned that they will be known as the “suicide school”

• Medical school culture focuses on pushing students as much as possible

Taking Steps to Treat Student Mental Illness

• Healer Education Assessment and Referral (HEAR) Program at UCSD

• University of Pittsburgh has a full time psychotherapist available to the med students

• ATSU-KCOM & SOMA has a full time MA LPC at each campus and a part time psychiatrist available for med students and a voluntary wellness program

Cause

• Roughly half of physicians and students have symptoms of burnout

• Cause is not likely due to characteristics of a small percentage of susceptible individuals

• Cause originates in the overall environment of the health care delivery system

Interventions

• Personal • Organizational • Societal – Policy makers

Personal Interventions • “To find health should be the object of the doctor.

Anyone can find disease.”

• Disease approach – Focus on treating burnout and depression

• Health approach – Cultivate happiness and wellness

• Still, A. T.: The Philosophy and Mechanical Principles of Osteopathy. Page 75. Reprinted, Osteopathic Enterprise, Kirksville, MO, 1986. Andrew Taylor Still, DO, Physician & Surgeon, Founder of Osteopathy

Happiness

The Constitution only guarantees the American people the right to pursue happiness. You have to catch it yourself.

Benjamin Franklin

From the National Archives

Happiness Definitions

Fave AD, et al. Lay Definitions of Happiness Across Nations: The Primacy of Inner Harmony and Relational Connectedness. Frontiers in Psychology, January 2016; Vol. 7, article 30.

Psychological Definitions of Happiness

Fave AD, 2016

Sustainable Well-being and Happiness as Connectedness

• Inner Harmony – Balanced and positive connectedness among

various aspects of one’s self

• Relational Connectedness – Positive and harmonious family and social

relationships

• Kjell, 20ll; Kuhl, et al. 2015; Wong 2011

Facilitated Physician Small Group Curriculum (West, et.al. 2014)

• Randomized, controlled clinical trial • Physicians, Med Dept., Mayo Clinic • Intervention (n=35)

– Met biweekly, 19 sessions for 90 minutes (60 minutes protected time)

– Facilitated discussion groups, 6-8 physicians per group (shared experience, mindfulness, reflection, small group learning)

• Control (n=37)

– 60 minutes of protected time for administrative tasks – Biweekly, 19 sessions

Facilitated Physician Small Group Curriculum (West, et.al. 2014)

• Improved empowerment and engagement at work

• Decreased rates of high depersonalization • Results sustained 12 months after the

intervention

Mindfulness Training

• Ability to pay attention on purpose, in the present moment, and nonjudgmentally

• 70 Primary Care Physicians, Rochester, NY • Training

– 2.5 hour weekly x 8 weeks – One 7 hour retreat (day long at a retreat center) – 2.5 hour monthly x 10 months

• Subscale Outcome Measures at baseline, 2, 12, &15 months

• Krasner MS, et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA. 2009;302(12):1284-1293

Mindfulness Training

• Trained in and practiced 4 methods of cultivating self awareness – Body Scan

• Notice bodily sensations and reactions to them – Sitting Meditation – Walking Meditation – Mindful Movement (yoga-like)

• Narrative Writing Exercises – Personal experiences in practice, followed a weekly

theme

Mindfulness Training Results

• Significant Improvements at 15 months – Burnout (Maslach) – Empathy (Jefferson Scale of Physician Empathy) – Total Mindfulness (Baer mindfulness scale) – Total Mood (Profile of Mood States) – Personality (Big 5 personality minimarkers)

Resilience Training

• Ability of an individual to withstand adversity • Stress Management and Resiliency Training

(SMART) Program • Single 90 minute one-on-one training • At 8 weeks (n=20) vs control (n=12) (waitlist

group • Sood A, et al. Stress Management and Resilience Training Among

Department of Medicine Faculty: A Pilot Randomized Clinical Trial. J Gen Intern Med 26(8):858–61.

SMART Program Components

• Attention – normally focused on threats and imperfections – Pay greater attention to novelty of their environment

• Interpretations - direct away from fixed prejudices – More flexible disposition – Cultivate gratitude, compassion, acceptance,

forgiveness, and higher meaning • Deep diaphragmatic breathing

– 5 breaths/min; 5-15 minutes; once or twice daily

SMART Program Results

• Significant Improvement 8 weeks post training • Resilience (Conner Davis Resilience Scale) • Stress (Perceived Stress Scale) • Anxiety (Smith Anxiety Scale) • Overall Quality of life (Linear Analog Self

Assessment Scale)

Depression (Plotkin, et.al. 2001)

• Randomized, controlled clinical trial • Women with depression, age 20-50 • 2 groups

– Standard care + OMT (n=8) – Standard care + placebo control (n=9)

• All received Paxil plus weekly psychotherapy for 8 weeks

• Psychiatrists and psychotherapists blinded to group assignment

Depression

• Placebo Control – 30 minute osteopathic structural exam – 142 examination points head to toe

• OMT

– Students under physician supervision – Structural exam + 20 minute treatment based on

findings – Direct, indirect and cranial techniques

Depression Results: (Plotkin, et al. 2001)

Zung Depression Scale OMT Post-treatment decreased versus control (P<.001)

Percent of Patients returning to normal (score < 50 = normal)

Strategies for Individuals: Personal Wellness

• Self care – Exercise, sleep, healthy diet, osteopathic medical care

• Relationships – Connect with colleagues, friends, family

• Religious/Spiritual practice • Mindfulness and Meditation

– Time for reflection • Personal Interests

– hobbies

Strategies for Individuals: values and meaning at work

• Identify what you value

– False beliefs of delayed gratification – What matters to you most

• Optimize meaning in work – Choose and focus your practice

How Can Organizations Help? • Provide adequate resources • Value orientation

– Promote values of our profession – Congruence between values and expectations

• Promote autonomy – Flexibility, receive input, provide sense of control

• Promote meaning in work – “Go where you are celebrated—not tolerated. If they can't see

the real value of you, it's time for a new start.” • Promote work-life integration • Build a culture of health and wellness

– (Kent, et al. 2016)

ATSU’s STILL-WELL Program

• One example of cultivating a culture of wellness on campus

• Program began in the 1980s • Students, faculty, and staff • Participation is voluntary • Generally 50 – 75% of students choose to

participate

ATSU’s STILL-WELL Program: The Interdisciplinary Committee

• Project Director • Faculty • Student Representatives • Co-Medical Directors – Physician Involvement • Director and Assistant Director of Fitness Center • Campus Counselor, Learning Resource Director • Basic Science Representatives • ATSU Kirksville & Mesa Campuses

Developmental Teams Emotional Environmental Intellectual Physical Social Spiritual Vocational (Website)

(Newsletter) (Seminar)

(Research)

*Each team has a leader, members, a primary goal, objectives and activities to achieve the yearly goals.

ATSU’s STILL-WELL Program: Orientation Presentation

On the first day of medical school orientation: Students gain information about the student wellness program and learn the benefits of being involved in Still-Well. Hand out forms to create a nutrition profile. Motivationally ready

ATSU’s STILL-WELL Program

• Nutrition two-day diet analysis

• Holistic Lifestyle Assessment Questionnaire

• Pre-participation physical exam

• Fitness assessment

ATSU’s STILL-WELL Program

Baseline Assessments Early connections Cultural values Emphasis on personal

responsibility Establish healthy lifestyle

pattern Develop a coping

resiliency

ATSU’s STILL-WELL Program: LONG TERM GOAL

Develop a healthy lifestyle as a graduate student which continues into future medical practice partnerships between physician & patient.

ATSU’s STILL-WELL Program • Dan Martin • Director Wellness

Programs • dmartin@atsu.edu • 660 626 2213 • https://www.atsu.edu/stu

dent_affairs/stillwell

• Eric Snider, DO • Co-Medical Director • esnider@atsu.edu

Thank You

• Comments/questions

• esnider@atsu.edu

References • Awa WL, et al. Burnout prevention: A review of intervention programs. Patient

Education and Counseling 78 (2010) 184–190. • Dyrbye LN, et al. Burnout and Suicidal Ideation among U.S. Medical Students. Ann

Intern Med. 2008;149(5):334-341. • Dyrbye LN, et al. Relationship Between Burnout and Professional Conduct and Attitudes

Among US Medical Students. JAMA. 2010;304(11):1173-1180. • Fave AD, et al. Lay Definitions of Happiness Across Nations: The Primacy of Inner

Harmony and Relational Connectedness. Frontiers in Psychology January 2016; Vol. 7, article 30.

• Kent K, et al. Promoting Healthy Workplaces by Building Cultures of Health and Applying Strategic Communications. JOEM. 2016, 58(2):114-122.

• Kjell ONE. Sustainable Well-being: a Potential Synergy Between Sustainability and Well-being Research. Rev. Gen. Psychol. 2011; 15,255–266.

• Krasner MS, et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA. 2009;302(12):1284-1293.

• Kuhl J, et al. Being someone: the integrated self as a neuropsychological system. Soc. Pers. Psychol. Comp. 2015; 9,115–132.

• Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.

References • Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed.

Palo Alto, CA: Consulting Psychologists Press; 1996. • Oreskovich MR, et al. Prevalence of alcohol use disorders among American

surgeons. Arch Surg. 2012;147(2):168-174. • Plotkin BJ, et al. Adjunctive osteopathic manipulative treatment in women

with depression: a pilot study. J Am Osteopath Assoc. 2001,101(9),517-523. • Rath T & Harter J. Well Being: The Five Essential Elements. Gallup Press 2010. • Shanafelt TD, et al. Burnout and Satisfaction With Work-Life Balance Among

US Physicians Relative to the General US Population. Arch Intern Med Vol 172 (No. 18) 1377-1385.

• Shanafelt TD, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.

• Shanafelt TD, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.

• Shanafelt TD, et al. The well-being of physicians. Am J Med. 2003;114(6):513-519.

References • Sood A, et al. Stress Management and Resilience Training Among Department

of Medicine Faculty: A Pilot Randomized Clinical Trial. J Gen Intern Med 26(8):858–61.

• Warde CM, et al. Marital and parental satisfaction of married physicians with children. J Gen Intern Med. 1999;14(3):157-165.

• West CP, et al. Association of Resident Fatigue and Distress With Perceived Medical Errors. JAMA. 2009;302(12):1294-1300.

• West CP, et al. Association of Perceived Medical Errors With Resident Distress and Empathy A Prospective Longitudinal Study. JAMA. 2006;296:1071-1078.

• West CP, et al. Association of Resident Fatigue and Distress With Occupational Blood and Body Fluid Exposures and Motor Vehicle Incidents. Mayo Clin Proc. 2012;87(12):1138-1144.

• West CP, et al. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism: A Randomized Clinical Trial. JAMA Intern Med. 2014;174(4):527-533.

• West CP, et al. Quality of Life, Burnout, Educational Debt, and Medical Knowledge mong Internal Medicine Residents. JAMA. 2011;306(9):952-960.

• Wong PTP. Positive Psychology 2.0: Towards a Balanced Interactive Model of the Good Life. Can.Psychol. 2011; 52,69–81.