all stressed out: preventing burnout and promoting reslience · all stressed out: preventing...

1 ©Jay Kaplan, M.D. 2015

All Stressed Out: Preventing Burnout and

Promoting Reslience

Jay Kaplan, MD, FACEP

President-elect, American College of Emergency Physicians

Practicing Clinician and Director, Patient Experience, CEP America

Disclosure

I, Jay Kaplan, M.D., F.A.C.E.P., do not have any relationship(s) with commercial interests.

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

“This Is Your Life” . . . Rate It

What constitutes an “Excellent Life”?

On a 0-10 scale, if 10 were excellent (you are totally happy with your life), how would you rate your life?

Where are you doing well?

Where do you have opportunity?


Stop for a Moment

What do you want?

What do you need?

Are you getting it?

If no, how do plan on getting it?

If yes, how do you plan on keeping it?

Want: “the state or condition of not having any or enough of something; something that is desired.”Need: “a physiological or psychological requirement for the well-being of an organism.”

Emergency Medicine

Gen Internal Medicine

Int Medicine Subsp

General Pediatrics

General Surgery

Mean

Orthopedic Surgery

Family Medicine

Ob/GYN

Gen Surgery Subsp

Preventive Med/Occ Health

Burnout and Satisfaction with Work-Life Balance – Arch Int Med August 2012Physicians who reported burnout: 45.8%


Medical Residents & Burnout Journal of Medicine 09/12

Residents who reported burnout symptoms

Feelings of depersonalization

Quality of Life “as bad as it could be”

51.5%

28.9%

14.8%

Nursing Morale Survey 2013AMN Healthcare

Satisfied with their jobs

Would recommend nursing as a career:

Often feel like resigning:

If had choice, would not be working in same job a year from now:

73%

72%

32%

33%

Real-Time Professional Sources of StressReal-Time Professional Sources of Stress

Work at all hours of the day and night

Malpractice litigation

Risk of infectious disease exposure

Risk of violence

Illness/impairment

Loss of connection to purpose


Stress (Day to Day)Stress (Day to Day)

Unpredictability of each day

Constant pressure for perfection

diagnosis (risk of malpractice complaint)

service (risk of patient complaint)

More Specifically . . .

Critically ill patients, one after another

“Difficult” Patients (Intoxicated, Angry, Entitled, Drug-Seeking)

Staffing shortages

EHR/Computer anything

Limited resources of facility

Drug shortages

And stress doesn’t just happen at work . . .

How much of it will

there be?

How secure will my job

be?

Add to all that, Living in the real world . . .


Burnout Further Defined

“Burnout is the chronic condition of perceived demands outweighing perceived resources.”- Gentry & Baranowsky 1998

“Compassion fatigue is burnout + secondary traumatization.” - Figley 1995

“Well-Being” “Burnout”“Well-Being” “Burnout”

Involvement and Engagement

Patience and Compassion

Feeling of Fit and being a part of a greater whole

Exhaustion, Cynicism, Indifference

Anger, Bitterness, Frustration

Alienation and Isolation

StressStress

Stress = a nonspecific response of the body to any demand.

Stressors may be pleasant or unpleasant.

One system is the weakest and first affected by stressors.

Stress = a nonspecific response of the body to any demand.

Stressors may be pleasant or unpleasant.

One system is the weakest and first affected by stressors.


Neuroendocrine-NeuroimmuneStress Response SystemNeuroendocrine-NeuroimmuneStress Response System

Immune systemImmunocyte behaviore.g., cytokine release

Limbic SystemHypothalamus

PituitaryAdrenals

Sympathetic nervoussystem

Aminergic Changes

Stress

Stress - Cannon & SelyeStress - Cannon & Selye

Homeostasis - the body’s balancing act

General Adaptation Syndrome (3 stages)

1) Alarm– Shock phase

– Countershock phase

2) Resistance

3) Exhaustion/Renewal

Homeostasis - the body’s balancing act

General Adaptation Syndrome (3 stages)

1) Alarm– Shock phase

– Countershock phase

2) Resistance

3) Exhaustion/Renewal

Homeostasis

Waking

Excitement

RelaxingDigesting

Sleeping

Running


Perceived Threat Sympathetic Outflow

Perceived threat

Parasympathetic Outflow Renewal

Cause and Effect

Causes:

Difficult patients

Difficult families

Difficult consultants

Circadian disruption

Litigation fears

Reimbursement fears

Job security fears

EHR

Staffing shortages

Effects:

Cynicism

Negativity

Difficulty sleeping

Substance use

Anxiety

Marital problems

Depression

Exhaustion

Alienation

Past Learning

Past Learning

PerceivedThreat

PerceivedThreat

Sympathetic DominanceSympathetic Dominance


Parasympathetic v. Sympathetic

Sympathetic Dominance• Compromised Cognitive and

Motor Functioning

• Reactive

• Repeating Same Mistakes

• Coercive or Hesitant Leader

Parasympathetic Dominance• Maximal Cognitive & Motor Functioning

• Intentional

• Creative Problem Solving

• Transformative Leader

Optimal Performance:

PNI - Effects of StressPNI - Effects of Stress

Increased cortisol and epinephrine

Lower number and NK cell activity

Decrease in % of helper to inducer cells, helper to suppressor-cell ratios

Lower levels of S-Ig A, Ig A, Ig G, Ig M

Increased illness and morbidity


What is Resilience?

1. the ability to become strong, healthy, or successful again after something bad happens

2. the ability of something to return to its original shape after it has been pulled, stretched, pressed, bent, etc.

3. the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress (medical definition)

Merriam Webster

A Different Context

“Let me tell you something you already know. The world ain't all sunshine and rainbows. It is a very mean and nasty place and it will beat you to your knees and keep you there permanently if you let it. You, me, or nobody is gonna hit as hard as life. But it ain't how hard you hit; it's about how hard you can get hit, and keep moving forward. How much you can take, and keep moving forward. That's how winning is done.” Rocky Balboa

speaking to his son in Rocky Balboa (2006)

1. Don’t miss the boat.

2. Remember we are all in the same boat.

3. Plan ahead. It wasn’t raining when Noah built the Ark.

4. Stay fit. When you’re 600 years old, someone may ask you to do something very big.

5. Don’t listen to critics. Just get on with the job that needs to be done.

6. Build your future on high ground.

Tactics for Resilience Learned From the Story of Noah and His ArkTactics for Resilience Learned From the Story of Noah and His Ark


Lessons

7. For safety’s sake, travel in pairs.

8. Speed isn’t always an advantage. The snails were on board with the cheetahs.

9. When you’re stressed, float a while.

10. Remember the Ark was built by amateurs, the Titanic by professionals.

11. When you’re in a storm, if you feel connected, there will always be a rainbow after the storm.

1. Don’t Miss the Boat

This life is not a dress rehearsal

Identify who you want to be, what is important to you, what you want to do, the legacy you want to leave

Tactic: Be clear about what you want and what you need Personal Mission Statement

I am:A student of lifeA teacher by exampleA feeler of feelingsA devoted fatherA grateful husbandConnected to people

to spirit andto myself

Willing to love and be lovedAnd to use mind heart and soulTo make a differenceSeeking guidance, inspiration and joy

JAK Mission Statement


2. Remember We’re All in the Same Boat

It is about the people who surround you, and choosing those who will

support your strengths and help you with your opportunities . . .

It is about everyone on board, paddling together . . .

Tactic: Choose carefully who you spend time with and who you surround yourself with Join a practice where you fit and where you are treated as a person and feel appreciated.

3. Plan Ahead . . . It Wasn’t Raining When Noah Built the Ark

Determine your key metrics

Define where you are/Set goals for where you want to be


Tactic - Do a Self-Assessment –How Is Your Balance?

The Adult Apgar

– Shay Bintliff, M.D., FACEP

Write out a “Joy List”

Create a formal “Renewal Investment Plan”

1000 Marbles Exercise

Tactics


Treat your body as your temple.

Get enough rest.

Eat whatever diet works for your body.

Exercise is a great drug.

4. Stay Fit – When You’re 600 years Old, Someone May Ask You To Do Something Really Big . . . 4. Stay Fit – When You’re 600 years Old, Someone May Ask You To Do Something Really Big . . .

TacticsTactics

Rest/SleepSet a goal for rest time – Get more than you think you needShift work – family cooperation, heavy curtains, white noise, blindfoldsSet alarm for when to go to bed

Note: If you get < 6 hours of sleep a night, your risk of coronary heart disease is increased 48% and risk of stroke 15%

FoodBreakfast is an important meal.Different strokes for different folks.

Exercise, and

regularly.

Exercise is a great drugExercise is a great drug


Get a Heart-Rate Monitor Watch

5. Don’t Listen to Critics . . . Just Get On with the Job that Needs to be Done

There’s a difference between being a “Winner” and a “Whiner”

Glass Half-Full v. Half-Empty

It’s a choice we make every day, or several times a dayDr. Whiner, c. 2000

No one is going to

create a great place for us to

work or for our patients to receive care unless we

participate . . .

“Where’s There’s No Gardener, There’s No Garden”


“It had long since come to my attention

that people of accomplishment rarely

sat back and let things happen to them.

They went out and happened to things.”

Leonardo De Vinci

Tactic

Be more than just a shift-worker.

Attend your department meetings.

Join your ED’s PI Committee.

Become a medical staff leader in your hospital.

Get involved with your state medical society or with the AMA.

6. Build Your Future on High Ground

Integrity

Always act in the best interest of the patient

Standards are standards only if we adhere to them

Courageous humility – acknowledge and apologize when appropriate . . . and quickly . . .


Make Your Workplace

A Family A School

7. For Safety’s Sake, Travel in Pairs

Colleague as Customer

“What can I do to help you have a great day in working with me today?”

The Simplest Recognition: Saying “Thank you” at the

end of the day (shift)

Say Thank You More


3 to 13 to 1

2 to 12 to 1

1 to 11 to 1

2

1

2

1

1

1

1

1

3

1

3

1

NeutralNeutral

NegativeNegative

Positive!Positive!

Source: Tom Connellan, “Inside the Magic Kingdom”, pages 91-95

The Work EnvironmentCompliment to Criticism Ratio

Create a robust Recognition and Reward Program

8. Speed Isn’t Always an Advantage . . . The Snails Were On Board with the Cheetahs

“There is more to life than merely increasing its speed.”

--Gandhi

Tactic: Electronics Free Days Off

Turn off your smartphone

Do not feel guilty if you do not answer text messages.

Automatic reply for emails – “I am taking an electronics-free day off . . . Please contact me on _____.


Schedule time off . . . just for you . . .Electronics Free

Time Aloneand

Time Together

9. When You’re Stressed, Float a While

“We are human beings, not human doings.”

- David Whyte

“No one ever went to his/her deathbed wishing to have gone to work more.”

- Harold Kushner

Key Tactics to Avoid Overwhelm

Practice saying “NO”

If you can’t say “No,” say “Oh”

Look for the big “YES”

Remember Bob Dylan


Real-Time On-The-Job Self-Regulation Skills

Awareness of the body’s physiologic responses to stress

Intentionality/Mindfulness

Self-regulation

Breathing

Relaxation

Community support

Laugh . . . Have Fun

When you first start doing anything, you are not going to do it well.

Experts become experts through practice.

Tactic: Write down the sayings that help you through difficult times.

Tactic: Develop a creative outlet that helps you channel the stress you will encounter

10. Remember . . . The Ark was Built by Amateurs, the Titanic by Professionals.


What Are the Sayings That Guide You?

“I’m always doing things I can’t do. That’s how I get to do them.”

Pablo Picasso

“Progress, not perfection; one step at a time.” 12 Step Program

“No one ever learned anything by beating themselves over the head with a mistake.” JAK

11. When You’re in a Storm, if You Feel Connected . . . There’s Always a Rainbow Waiting

Gratitude

Gratitude Journal

5 things for which you feel grateful

One sentence for each

Do once a week

Gratitude visit

Write a 300 word letter to someone who changed your life for the better

Deliver it in person preferably without advanced notice

When you get there, read the whole thing


Passion

“The greatest force on earth is the human soul on

fire”-Foche

“The antidote to exhaustion is not

necessarily rest . . . It’s whole-

heartedness”-Brother David Steindl-Rast

Know How Special You Are . . .

“We work in the dark.

We do what we can.

We give what we have.

Our doubt is our passion.

Our passion is our task.

The rest is the madness of art.”

- Henry James

Next Steps

Answer the question:

What is one thing I am going to do

differently for myself today (and for the

next month) to become more resilient?


Connect back to purpose . . .

Never under-estimate the difference you make . . .

Thank you.

Jay Kaplan, M.D., [email protected]

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