nh physician’s health program - nhms nhms 11-2013.pdf · residents – prob due to isolation and...
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Sally Garhart MD NH Professionals Health Program
Medical Director 603-491-5036
Disclosure I am the medical director of the NHPHP a 501c3 which
receives funding from the NH Board of Medicine through a $15 a year surcharge in license renewal fees and donations from individuals, malpractice insurers and hospital systems. I am paid to work 20 hours a week.
NH PHP
Provides services to the BOM Consultation is free for all MDs, DOs and PAs licensed
in NH Emphasis is on issues affecting the ability to safely
practice medicine because of: Substance abuse – alcohol, drugs, meds Mental Health Disruptive Behavior Health Issues – sleep, apnea, arthritis, vision loss,
Parkinson’s, aging, seizures, communication, dementia or physical limits
Professional Boundary violations (some) Burn out
YES / NO
Are Doctors “Normal” ?? ‣ Perfectionism –essential to medicine, poison to
a human
‣ Abnormal youth, college, young adulthood
‣ Lower “emotional intelligence” EQ
‣ Hyper focus, compulsive – work and play
‣ Workaholic
‣ Focused on science
‣ Minimal free time
‣ Few hobbies and fewer friends
Mental Health issues ANXIETY – MOST COMMON in NHPHP; what if….
Bipolar – over diagnosed in early recovery and under diagnosed if physician “edits” symptoms
Depression
Suicidal – not compatible with patient care
Requires aggressive evaluation and treatment - OOS
PTSD – childhood abuse or military MDs
Burn out, emotional fatigue
Old School vs New School Work comes first
Work til the job is done
Residency call q 3 or 4
Employed by necessity
Loans paid
Kids in college
Is this all there is?
Balanced work-life
Work 8-6, weekends off
Limited residency hours
Employed by choice
High priced loans
No kids or new babies
This is harder than I thought
Long Work Hours Wreak Havoc in MDs’ Personal Lives Medscape 9/23/13
Mayo survey of 90,000 US physicians and partners
27.7 response rate
Median age 55 years; 89% had children
44% reported a work home conflict (WHC) in past 3 wks
WHC most common in younger, female and academic medical centers (due to excessive hours)
MDs with WHC were more likely to have symptoms of burnout or depression, to be considering divorce and to have lower mental and physical quality of life
This used to be the struggle with medical records.
Physician Burnout Estimated to affect 30-40% of physicians
Incr self-reports of medical error, decr in empathy, incr plans to retire early, decr pt satisfaction and adherence
Caused by excessive workloads, call, loss of workplace control and autonomy
+/- features of the ACA may worsen the problem Incr # of patients needing care
Decr financial margins
No pre-existing exclusion
Many “unknowns”
Burnout Personal Problems
Systems Problems
Common themes
Lack of staff due to retirement, illness or someone quit
Months of unused vacation – no coverage
24/7 call
Stuck and unhappy
Too busy to prioritize, exercise or do basic self-care
Treatments Avoidance
Education and focus on self care Exercise, eat right, sleep, turn off electronics early
Schedule pleasurable pursuits and keep the appt
Mindfulness practice Make all activities focused and meaningful
i.e. one thing at a time
Multi-tasking well is a myth!
Not just drag through the day
5 Breath practice
Falling apart Never planned.
It happens too often.
Very tragic.
Should be prevented or treated early but….
Often the doctor needs to go out on medical leave.
Prodrome – ZERO self-care
What happened??
Where is the safety net for a doctor?
Reported Provider Symptoms Not sleeping
High anxiety
Calling out sick; not answering calls / texts / emails
Can’t stop crying
Not eating well – protein bars / coffee
Falling asleep at work; chronically arriving late
Severe burnout
Personality changes – ANGRY, arguing, talking too much, too physical, withdrawn
Can’t make decisions
Symptoms cont’ Office affairs
Way behind in EMR
Positive drug test – pre-placement for illegalsubstance or something self-prescribed
Death – overdose or suicide
Yelling or passive aggressive or both
Overly distracted – my son was just diagnosed with ADHD……
Depression 15-30% rate of depression in medical students and
residents – prob due to isolation and sleep deprivation
Many stop treatment when they move to new city
CAN trial cognitive behavioral skills prior to residency
Physician depression rates equal to the general population.
Depressed residents made 6.2 times more medication errors than non depressed residents.
Predictors of Depression Valliant et all
Difficult work relationships
Lack of sleep
Making mistakes
Loneliness
24 hour responsibility
Self-criticism
Perfectionist traits
PHYSICIAN SUICIDE 400 a year on average in the US
Suicide is cause of 35% of premature US MD deaths
Barriers to care are shame and stigma
Hopelessness/Helplessness
More than 1/3 of physician suicides had hx of prior drug or alcohol problems
Women physicians – highest rate 5.7 X US average
Male physicians – 3.4 X US average
Profile of a high risk physician Silverman, 2000 The Handbook of Physician Health AMA Press
Workaholic white male >50
Female > 45 divorced, single or currently experiencing marital disruption
Concurrent depression, substance abuse or history of risk-taking behavior (particularly high stakes gambling)
Chronic pain or illness
Starting new job after residency or nearing retirement
Increased work demands
Personal losses
Diminished autonomy
Access to lethal means – firearms, meds
Suicide Protective Factors Effective treatment of depressions or substance abuse
With PHP monitoring for alcohol use
Social and family support
Resilience and coping skills
Religious faith
Restricted access to lethal means
Physician Substance Abuse Lifetime rates 1 in 10 (same as general population)
Affects all specialties and ages
Highest incidence in NH: male PCPs age 40-50 and psychiatrists
Anesthesiologists: highest injected drug rate
Most frequent substance is alcohol
Co-occurring diagnoses. Almost 100% have depression
Probably 90% have anxiety
Sentinel Events for substance abuse
DUI - poor judgment vs dependence
Arrested for domestic disturbance
Admission for depression or detox – get a drug test
Admission for a suicide attempt – get a drug test
Suicide
None - because of shame and denial doctors rarely self-report and work hard not to get caught.
“Controlled” heavy drinking for stress relief and to sleep
Recovery Rates in Physicians for chemical dependence 80-90% estimated for those completing 5
years of monitoring 18% unmonitored, general population
Increased by drug testing Identify and treat early relapses
Physicians are highly motivated for success. Treated physicians spread the concept of
improving self care.
How open are most doctors to asking for help? I don’t want to complain.
I am fine. I don’t drink…..
I don’t want anybody to know.
I’d rather be dead than see a psychiatrist.
Psych meds don’t work.
Treatment doesn’t work.
Barriers to effective treatment Fear of social stigma
Time constraints 8-5
Trouble finding a good provider who isn’t a colleague
Concerns about confidentiality
Fear of discrimination by colleagues, work, or BOM
Disgust with the disease and dislike of their patients with the same conditions
Refusal to give up control
Denial of a problem that “I should be able to solve”.
22% of medical students who
screened positive for depression
sought help
42% of students with suicidal ideation
received treatment
Givens JL, Tjia J. Depressed medical students’ use of mental health
services and barriers to use. Acad Med. 2002;77(9):918-921.
Self-treatment Very common
Attempt to treat mood disorder with self-prescribed medications – too short a time, freq dose changes, excessive side-effects
Use alcohol or drugs for mood disorder symptoms.
Dopamine seeking.
No objectivity.
Poor results reinforces theory that TX is hopeless.
Problems with “VIP” treatment Appointments out of the clinic or after hours
“Hypothetical Patient” hall consult
Underestimate the severity of the crisis
Assumptions – particularly on suicide risk
Inadequate “informed consent” because of not wanting to “insult” the doctor patient
Too much latitude – don’t want to interfere with license, ability to practice
DEA issues for prescriptions written without a note
Serious problems Need quick and effective evaluation and triage
Let the doctor talk, tell their story but then don’t get talked out of insisting on treatment.
Don’t just leave it up to the doctor.
Don’t give too many choices.
Refer out for confidentiality – out of state if possible.
Talk to the referral provider so that the doctor can’t change his story.
Remember, Doctors DO LIE.
Education for Burnout Mental health reading and TED talks
Emotional Intelligence – reading and skills
Encourage seeing a PhD therapist
Positive Psychology reading – Flourish, M Seligman
Cognitive Behavioral Therapy
Skills – books, internet: Mood Gym, E Couch
If not for you, then do it for your patients or family
No medications / No med side effects
Multi-day, multi-discipline Eval A “time-out” away from the stressors.
Serious evaluation of multiple issues
Substance abuse
Depression
Learning disabilities
Cognitive dysfunction
Utilizes multiple opinions
Uses “physicians” as the norm for comparison
Very supportive and positive
Outside Coaching Personalized improvement
Behavior oriented, results driven
Emphasis on the positive goals, neutral
Effective for burnout, time management, EMR problems, anger, communication and disruptive issues
Proactive, very acceptable to providers
Improves the bottom line of organizations
Self- Care Sleep – 8 hours a night Hobbies – astronomy, photography,
gardening Sports group (skiing) or team (hockey, golf) Exercise – daily Balance nutrition with real food! Social groups – cooking, bridge Religion **Old friends with long memories** Pets – the bigger the better
Mental Health Diagnoses Do not spare any demographic
Sleep deprivation and overwork severity
Practice prevention Address work hours, stress, alcohol use,
isolation
Seek HELP for both ourselves and our co-workers
Summary Live in the moment.
Speak up for fair work hours and duties.
Don’t wait for retirement to start living.