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April 18, 201911:30am EST

Dial In: 888.863.0985 Conference ID: 3599125

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Speakers

Clinical Fellow, Child and Adolescent PsychiatryYale Child Study CenterBoard-Certified Psychiatrist

DNP, APRN-BCLecturer,Yale School of Nursing andDepartment of Psychiatry,Yale School of Medicine

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Disclosures

Linda Drozdowicz, M.D., has no real or perceived conflicts of interest.

Robert Krause, DNP, APRN-BC, has no real or perceived conflicts of interest.

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ObjectivesDefine provider wellnessDefine burnout and compassion fatigue, and

understand how each affects quality of careAnalyze conditions that contribute to burnout

and compassion fatigueDiscuss ways to enhance provider wellnessReview self-care strategies for health care

providers

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Clinician WellnessMental construct:• Absence of burnout• Spiritual well-being• Lack of depression• Job/life satisfaction• Sense of balance

Physical construct:• Good health• Positive personal

health practices

Social construct:• Social well-being• Personal life

Brady et al. What do we mean by physician wellness? A systematic review of its definition and measurement. Acad Psychiatry (2018) 42:94–108

“I can’t define it, but I know it when I see it.” –Justice Potter Stewart, 1964

“Thriving”

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When Wellness Fades

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Compassion Fatigue• “In its simplest form, compassion fatigue implies a state of

psychic exhaustion.” (Boyle 2011).• “Severe malaise resulting from caring for patients experiencing

varying aspects of pain (i.e., physical, emotional, social)…associated with the ‘cost of caring’ and refers to the resultant strain and weariness that evolves over time.” (Sabo 2006)

• How is this different from burnout?– Clinician with compassion fatigue can still care and be involved, albeit in a

compromised way. – Compassion fatigue may lead to burnout.

• Studies report the prevalence of compassion fatigue as 7.3%-40%.

Garfield C, Spring C, Ober D. Sometimes My Heart Goes Numb: Caring ina Time of AIDS. San Francisco, CA:Jossey-Bass; 1995.Wright B. Compassion fatigue: how to avoid it. Palliat Med. 2004;18(1):4-5.[PMID: 14982200]Van Mol, M. M. C., Kompanje, E. J. O., Benoit, D. D., Bakker, J., & Nijkamp, M. D. (2015). The Prevalence of Compassion Fatigue and Burnout among Healthcare Professionals in Intensive Care Units: A Systematic Review. PLoS ONE, 10(8), e0136955. http://doi.org/10.1371/journal.pone.0136955

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Burnout: Definition

• A syndrome characterized by:– Loss of enthusiasm for work– Feelings of cynicism and detachment– Low sense of personal accomplishment

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PhysiciansMedscape National Physician Burnout, Depression & Suicide Report 2019

https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056#3

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Cost of Burnout

Shanafelt and Noseworthy. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 1/2017: 92(1): 129-146.

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Depression• Major Depressive Disorder: Not the same as burnout, but

burnout can be precursor.

• A) ≥5 sx during 2 week period (change from prior functioning) –MUST have depressed mood and/or anhedonia– Depressed mood most of day almost every day– Anhedonia– Unintentional weight loss/gain and/or change in appetite– Insomnia or hypersomnia– PMR/PMA nearly daily (that others notice, not just subjective feeling)– Fatigue or low energy – Worthlessness or excessive/inappropriate guilt– Poor concentration and/or indecisiveness– Recurrent thoughts of death, SI, SA

Burnout: • Loss of enthusiasm for work• Feelings of cynicism and detachment• Low sense of personal accomplishment

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On Physician Suicide

• 300-400 physician suicides yearly– “A doctor a day”

• Male physicians 1.41 times higher than the general male population

• Female physicians 2.27 times higher than the general female population

1.Schernhammer, E. S., & Colditz, G. A. (2004). Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). American Journal of Psychiatry AJP, 161(12), 2295-2302. 2.http://www.idealmedicalcare.org/ive-learned-547-doctor-suicides/

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Burnout: Physicians vs Other Professionals

• MD/DO’s more likely to have symptoms of burnout than other working adults– ~7000 physicians surveyed, compared to working,

non-physician controls• >30% ↑ odds of burnout in physicians

compared to high school grads• Bachelor’s, master’s, professional or doctoral

degrees – were at LOWER RISK of burnout than high school grads.

Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction withwork-life balance among US physicians relative to the generalUS population. Arch Intern Med 2012; 172: 1377–85.

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Burnout Among Midwives• Sample of 100

– Death and dying + conflict with physician were most stressful events perceived by midwives.

– Mean scores for burnout:

The respondents reported average and high levels of depersonalization, emotional exhaustion and personal accomplishment, respectively.

Banovcinova. (2014). Sources of work-related stress and their effect on burnout in midwifery. Procedia, Social and Behavioral Sciences, 132, 248.

Mean Std. deviation Burnout rating

Emotional exhaustion

24,25 9,78 Moderate

Depersonalization 19,64 5,37 High

Personal accomplishment

14,78 7,57 High

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Impact on Patients: Medical Errors

• Survey of ~400 IM residents at Mayo Clinic: Self-reporting of major med errors– Surveyed throughout training– Those with medical errors:

• 3.49 times as likely to have depersonalization (p<0.001)• 5.33 times as likely to have emotional exhaustion (p<0.001)• 2.25 times as likely to feel sense of low personal accomplishment

(p=0.001)• Survey of ~8000 surgeons

– Each 1 point ↑ in depersonalization (range 0 –33) 11% ↑ odds of medical error

– Each 1 point ↑ in emotional exhaustion (range 0 –54) 5% ↑ odds of medical error

• BURNOUT MATTERS

West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA 2009; 302: 1294–300.

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Impact on Patients

• Study: Work-related stress in doctors:– 50% reported reduced standards of patient care (taking

short cuts, not following procedures).

• Depersonalisation dimension of physician burnout ↓ patient satisfaction and ↑recovery time after discharge.

• …you get it.

Linzer M, Kondrad TR, Douglas J, et al. Predicting and preventing physician burnout: results from the United States and Netherlands. Am J Med 2001; 111: 170–75.Halbesleben JR, Rathert C. Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev 2008; 33: 29–39.

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WHY PHYSICIAN BURNOUT?

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“Mom, Dad – Where Do Physicians Come From?”

• Bachelor’s degree: ~4 yrs• MCAT – Biology, Physics, Organic Chemistry, Inorganic

Chemistry, Behavioral Science, Critical Analysis and Reasoning

• Medical School: 4 yrs• Equivalent of ~24+ credits/semester• Multiple Board Exams (oy!)

• Residency: 3-7 yrs; 80+ hrs/wk• Another Board Exam (oy!)

• Fellowship (if subspecializing): 1-3 yrs• Specialty Board Exam (double oy!)• Attending! Pay back loans.

• Median debt: $192,000

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Physician Culture• Heavy hours: Average 50-60 hrs/wk when not on

call.• Care for others but not ourselves.

– “Suck it up” mentality.– Common not to have formal coverage pool. – Study: 30% of young Irish physicians had not been to

a general practitioner in the previous 5 years.• 65% felt unable to take time off from work when they were ill

• Licensing boards can discriminate for seeking mental healthcare in many states.

• Generally not unionized in U.S.

Williams ES, Rondeau KV, Xiao Q, Francescutti LH. Heavy physician workloads: impact on physician attitudes and outcomes. Health Serv Manage Res 2007; 20: 261–69.Uallachain GN. Attitudes towards self-health care: a survey of GP trainees. Ir Med J 2008; 100: 489–91.Jones et al. Medical Licensure Questions About Mental Illness and Compliance with the Americans with Disabilities Act. J Am Acad Psychiatry Law 46:458–71, 2018.

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Real Life

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Systems Issues

“Although burnout is a system issue, most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of

the individual physician.” – Shanafelt and Noseworthy, Mayo Clinic

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Drivers of Burnout

Shanafelt and Noseworthy. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 1/2017: 92(1): 129-146.

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Obstetrics and Gynecology Considerations

• “Exposure to severe events in maternity care is part of the professional experience.”– Miscarriage, stillbirth– Child death or severe asphyxia during birth– Maternal miss or near-death in delivery– Violence, threats

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Obstetrics and Gynecology Considerations

• Study– ~2300 Swedish obstetricians and midwives– >70% experienced severe event on delivery

ward• 15% with partial symptoms of PTSD• 7% of obstetricians and 5% of midwives with full

blown PTSD

• Not always just “stress” or “upset”

Wahlberg et al. Post-traumatic stress symptoms in Swedish obstetricians and midwives aftersevere obstetric events: a cross-sectional retrospective survey. BJOG. 2017 Jul;124(8):1264-1271.

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PTSD• Does the definition of PTSD cover clinicians?

– Yes!– People exposed to actual or threatened death or serious injury in

the following ways:• Witnessing, in person, the event(s) as it occurred to others• Experiencing repeated or extreme exposure to aversive

details of the traumatic event(s)

• Know the signs:• To be diagnosed with PTSD, an adult must have all of

the following for at least 1 month: • ⊲ At least one re-experiencing symptom • ⊲ At least one avoidance symptom • ⊲ At least two arousal and reactivity symptoms • ⊲ At least two cognition and mood symptoms

https://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/ptsd-508-05172017_38054.pdf

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PTSD and the Stress Response• PTSD causes specific

changes to the HPA axis.

• Chronic stress downgrades cortisol response.– However sensitivity to

cortisol increases causing hyperarousal, hypervigilance, chronic anxiety and sleep issues.

Yahuda, R. (2002) Post Traumatic Stress Disorder. NEJM. Vol. 346, No. 2 · https://www.nejm.org/doi/pdf/10.1056/nejmra012941

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Enhancing Wellness:Systems Level

• Physicians– Those who spend >20% of their professional effort on

what they personally valued most in medical practice more likely to avoid burnout.

• Special clinics, teaching, administration

• Leaders– Choose physician leaders based on ability to listen,

engage, develop and lead physicians - not based on meeting organizational performance targets.

– Let those they lead rate them.

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• Inefficiency – Universal driver of dissatisfaction/burnout, but

specific issues vary in each setting/field.– Ask each specialty/work unit what would be most

helpful for improving wellness.

• Foster community for physicians – 1 hour protected meeting time every other week can

reduce burnout.

• Nix productivity-based physician pay.

Enhancing Wellness:Systems Level

Shanafelt and Noseworthy. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 1/2017: 92(1): 129-146.

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Enhancing Wellness:Individual Level

Yoga and meditation have both been shown to decrease cortisol and reduce amygdala activation.

How?• By enhancing positive neuroplastic changes in

the PFC (executive functioning) and shrinking amygdala.

• By enhancing prefrontal executive control, sending inhibitory messages to the amygdala.

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Enhancing Wellness:Individual Level

• Regularly discuss cases and your reactions with at least one colleague.

• In the same way a patient benefits from talking with you, you will gain strength from talking with others (e.g. Balint groups).

• Also, remember that basic self-care techniques such as good sleep hygiene, diet, exercise, and stress reduction (e.g. meditation) should be integrated into a routine self-care protocol.

Recommendations from Mollica, R (2013) Healing the wounds of mass violence and torture. Harvard Program in Refugee Trauma, Cambridge Ma.

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Q&A Session Press *1 to ask a question

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A recording of this presentation will be made available on our website: www.safehealthcareforeverywoman.org

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Next Safety Action SeriesMoving from Surviving to Thriving

May 8, 20192 pm Eastern

Corey Martin, MD Lead Physician for Resilience Training

and Burnout Prevention,Allina Health

Provider Wellness

Mini-Series

Session 2