physician burnout: an emotionally malignant disease with an … · 2020. 2. 11. · physician...
TRANSCRIPT
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PHYSICIAN BURNOUT: AN EMOTIONALLY MALIGNANT DISEASE WITH AN INNATE CURE
HCMS East Branch
Naim El-Aswad, MD, FACP
Chief Medical Officer
Vital Signs Vital Skills, L.L.C.
March 24th, 2020
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WHY WE ARE HERE?
www.vitalsignsvitalskills.com
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“Life does not get
easier or more
forgiving, we get
stronger and
more resilient”Steve Maraboli
“Medicine arose out
of the primal
sympathy of man
with man; out of the
desire to help those
in sorrow, need and
sickness.”Sir William Osler.
The price of
anything is the
amount of life
you exchange for
it.Henry David Thoreau
CHANGE
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WHERE CHANGE NEEDS TO HAPPEN
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Healthcare Environment
Healthcare Organizations
Healthcare Individuals
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…Intrinsic motivation-performing a task primarily for its own sake is the most
powerful way to change behavior…Jay Kimiecik
LEARNING MODALITY
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BURNOUT DEFINITION
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It is now a DISEASE. (WHO: ICD 11)
“Syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. 3 dimensions:
1- Feelings of energy depletion;
2- Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job;
3- Reduced professional efficacy.
It is an occupational phenomenon.
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BURNOUT CAUSES
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Burnout
Unmet Expectations
Lack of Control
Insufficient Rewards
Leadership
Pressure
Personal characteristics
Purpose and Need
Self-care and wellness
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UNMET EXPECTATIONS, LACK OF CONTROL INSUFFICIENT REWARDS,
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THE PURPOSE OF MEDICINE
Connect, diagnose
Diagnose, Treat, Help
Connect and Treat Patients
Emotions
Behavior
P
Cognition
“Medicine arose out
of the primal
sympathy of man
with man; out of the
desire to help those
in sorrow, need and
sickness.”Sir William Osler.
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PURPOSE AND NEED
Engaged: Best
physician/patient
satisfaction/outcome
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E
B
P
C
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PURPOSE AND NEED
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Connecting to Purpose
Physician’s Self
Determination Theory:
Empathetically Connected
Clinically Competent
Professionally Autonomous
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Behavior
P
Cognition
Emotions
Behavior
P
Cognition
I-THOU I-ITMedical Training
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Emotions“A resident’s views (own learning and practice)
and the modeling they receive (faculty)
produce a deep shift of emotions and
compassion, to self and others, from assets to
liabilities...” (Philips and Dalgarno, 2017)
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COGNITION: WHAT ARE WE THINKING?
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Government
regulations
Insurance
companies
Law suits
Feedbacks,
evaluations
Personal
demands
Business
demands. Non-
medical
responsibilities
Cognitive
Scarcity
Leads to
counter-
productive
behaviors
and mistakes
Draws cognitive
resources to
urgent demands
Induces
impairments
in other
domains
Behavior
P
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BEHAVIOR: WHAT ARE WE DOING?
• “How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers”, Mamykina L et al, Academy of Medicine, 2016
• In a single day, residents spent 364.5 minutes (50.6%) of their shift time using computers, compared with 67.8 minutes (9.4%) interacting with patients.
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To study the phenomenon of
disease without books is to sail
unchartered sea, while to study
books without patients is not to go
to sea at all.William Osler
P
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BEHAVIOR: WHAT ARE WE DOING?
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• In April 2013, researchers at Denver-based Vanguard Communications analyzed 3617 online reviews of 300 internists and Ob/Gyn’s.
• Patients who posted negative reviews were 4 times more likely to complain about a healthcare provider's indifference, bedside manner, or customer service than about his or her medical skills:
• 43.1% included complaints about poor bedside manner;
• 21.5% included complaints about medical skills, such as false diagnoses and surgical mistakes.
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THE EROSION OF PURPOSE/NEED
Connect, diagnose
Diagnose, Treat, Help
Connect and Treat
Emotions
Behavior
P
Cognition
• Step I: Remove the essence of medicine by inhibiting emotions and decreasing empathy
• Step II: Occupy the cognition with non-medical tasks and responsibilities
• Step III: Evaluate behavior NOT based on medical and clinical judgement and performance but on CUSTOMER service, pay for performance, and metric attainment
Empathetically Connected
Clinically Competent
Professionally Autonomous
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PURPOSE AND NEED
Engaged: Best
physician/patient
satisfaction/outcome
Burnout: Worst
physician/patient
satisfaction/outcome
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E
B
P
C
Loss of purpose in the New
World of Medicine:
What are we feeling?
What are we thinking?
What are we doing?
The New Challenge
of Medicine:
Recognize
obstacles, Bypass
obstacles, Protect
against obstacles,
Reconnect with
purpose and satisfy
need
Burnout Cannot Exist Where
Purpose LivesMatt Manero
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PRESSURE VERSUS STRESS
Copyright 2016 Relly Nadler, Psy.D., MCC
Pressure is where the outcome is
important to you, it is uncertain, and
you are accountable and judged for
the results. You must deliver the
goods or suffer dire consequences.
Adversely impacts cognitive success,
downgrades behavioral skills, we
perform below our capability, often
camouflaged and is continually
increasing. Weisenger and Pawliw-Fry, (2015) Performing Under Pressure
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PERSONAL CHARACTERISTICS
• Personal characteristics associated with burnout include:
• Being self-critical
• Matching the personality to the specialty
• Engaging in unhelpful coping strategies
• Perfectionism
• Idealism
• Certain personality types can affect positively or negatively
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Patel S. et al, 2018. Factors Related to Physician Burnout and Its Consequences: A Review. Behavioral Sciences.
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BURNOUT AND PHYSICIAN PERFORMANCE
• Observation, Reason, Human Understanding, Courage; these make the physician. ~Martin H. Fischer (1879–1962)
• Observation: Disconnected, unrealistic, can’t read clues and “checked out”
• Reason: Decreased ability to analyze, assess and think. Loss of clinical skills, and abilities.
• Human Understanding: Can’t understand or relate to others, loss of empathy
• Courage: Distant, insecure, blaming others, explosive, unpredictable and aggressive
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50 % of MD’s are
burned out at 4.2/5
severity
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From: Stress and Burnout Among Surgeons: Understanding and Managing the Syndrome and Avoiding the Adverse Consequences
Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575Vital Signs Vital Skills, L.L.C.
Resiliency/Coping
Abilities
Humanity and
empathy
Purpose/Meaning
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BURNOUT MALIGNANCY MODEL
Environmental and Genetic
FactorsTime
Negative cumulative
Effects
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Lack of defenses and
ability to detect
Intervene:
Resiliency, coping,
EQ/Self-care mindset,
momentum
Use it to our advantage
Develop detection and
defense capabilities:
EQ/Self-care
Positive cumulative CHANGE
CREATE A NEW REALITY
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BURNOUT AND PHYSICIAN PERFORMANCE
• Observation, Reason, Human Understanding, Courage; these make the physician. ~Martin H. Fischer (1879–1962)
• Observation: Disconnected, unrealistic, can’t read clues and “checked out”
• Reason: Decreased ability to analyze, assess and think. Loss of clinical skills, and abilities.
• Human Understanding: Can’t understand or relate to others, loss of empathy
• Courage: Distant, insecure, blaming others, explosive, unpredictable and aggressive
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Intervention
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WHAT HAS WORKED SO FAR ON AN INDIVIDUAL LEVEL?
• Individual targeted approaches
• Focused small group discussions
• Providing physicians with some degree of choice
and control over their lives
• Building comradery
• Opportunity for excellence
• Developing physician leadership
• Culture change within the institution
• Coaching
• Resilience development/training
• Emotional intelligence and self-care
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THE REVISED DECLARATION OF GENEVA: A MODERN-DAY
PHYSICIAN’S PLEDGE
“I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;”
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HOW WELL AND HOW OFF BALANCE ARE YOU INDIVIDUALLY?
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Wellness and
life/work
balance
protect
against and
treat burnout
https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjZp9TAi8XLAhUCyYMKHdZFA1gQjRwIBw&url=https://www.flickr.com/photos/61056899@N06/5751301741&bvm=bv.116954456,d.amc&psig=AFQjCNGaTUU3AdaKrJI_Jqyt8daRIZu0Hw&ust=1458213653017743
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THE ART AND SCIENCE OF MEDICINE
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IQ for Hard Skills (Science of Medicine):
Specific teachable abilities (20 %)
EQ for Soft Skills (Art of Medicine): Leadership,
teamwork, communication, problem solving,
work ethic, flexibility/adaptability and
interpersonal. (80%)
“Illustrious doctors might
have graduated from
books, but books made
not a single physician”.
Sir William Osler quoting
Paracelsus
Success in Medicine
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DEFINITION OF EMOTIONAL INTELLIGENCE
Understanding ourselves,
managing ourselves,
understanding others,
managing others
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EMOTIONAL INTELLIGENCE REALMS
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UNDERSTANDING AND MANAGING SELF
Pain
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Physical
endurance
EQ/IQ
endurance
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UNDERSTANDING AND MANAGING OTHERS
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EMOTIONAL INTELLIGENCE IN MEDICINE
• Decreasing/diagnosing/preventing Burnout
• Needed for the skills of the 21st century physician
• Needed for personal and professional development
• Needed in the ACGME competencies
• Tied to physician satisfaction and mission
• Tied to physician wellness
• Tied to patient satisfaction
• At the core of LEADERSHIP
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PHYSICIAN PERFORMANCE
Resiliency
Coping
abilities
Adaptive
mechanisms
Humanity
and empathy
Physician
Physician-Patient InteractionDecision Making
Engaged Burnout
Emotional Intelligence
Wellness
Institutional
Political
Social
Governmental
Professional
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AAA APPROACH
• A: Awareness
• A: ACKNOWLEDGEMENT and ASSESSMENT
• A: ACTION
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TIME TO CHANGE…BUT
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EMBRACING THE NEW CHANGE
MINDSET
WELLNESS
COACHING
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MOMENTUMEOMTIONAL
INTELLIGENCE
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WHERE CHANGE NEEDS TO HAPPEN
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Healthcare Environment
Healthcare Organizations
Healthcare Individuals
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MINDSET38
Vital Signs Vital Skills, L.L.C.
“A set of beliefs
or a way of
thinking that
determines one’s
behavior,
outlook, and
mental attitude”
“Those who
cannot change
their minds
cannot change
anything”George Bernard Shaw
4 MINUTE MILE - MOTIVATION If Someone Else Has Done it You Can Do It! MUST SEE Best motivation Les Brown.mp4
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SIGNS YOU NEED TO CHANGE YOUR MINDSET
✓ You continuously focus on what is wrong
✓ You mourn your failures without celebrating your success
✓ You don’t want to face the truth
✓ You get angry when your expectations are not met
✓ You feel unsatisfied or unhappy with everything you have
✓ You are constantly fighting with the ones you care about
✓ You think about what you have to do and not what you get to
do
✓ You see yourself as a victim
✓ You hold on to other people’s dreams
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TIPS TO WORK ON YOUR EMOTIONAL INTELLIGENCE
•ACKNOWLEDGE EMOTIONS!!!!!!• Take an assessment test (EQi, MSCEIT,…). Find out where you are, where you
are strong and where you need help.
• Make a mental memory of your own reactions. Self analyze.
• Few times a day, STOP, and observe your emotions. Listen to your own mind.
• Know your positive and negative triggers. Enhance positive reactions, modify negative reactions.
• Identify the emotion: name it to tame it
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WELLNESS/SELF-CARE
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• Rules of wellness:• At the heart of wellness: Self-love,
Self-compassion, and Self-care
• Four steps to successful wellness:• Deciding (Develop the mindset) • Taking control (Take control from what life
robs you off. Take it!)• Taking time (Take time from what prevents
you to do so. Take it!). Your time for your wellness is SACRED
• Creating a habit
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WELLNESS ACTIVITY: WHEEL OF WELLNESS
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• Use a scale of 0 to 10 (0 being the least and 10 being the most) to write down your personal wellness score for each realm using the wheel below.
• Identify one activity that you can do to improve your score along each realm.
• Set a plan of action to achieve that activity.
• Complete the activity.
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BUILDING RESILIENCE*
• Make connections
• Avoid seeing crises as insurmountable problems
• Accept that change is a part of living
• Move toward your goals
• Take decisive actions
• Look for opportunities for self-discovery
• Nurture a positive view of yourself
• Keep things in perspective
• Maintain a hopeful outlook
• Take care of yourself APA: American Psychological Association
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COACHING
SUCCESS
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Assessments:
BurnoutEQ
Personality
Resilience
GritOthers
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INNATE CUREwww.vitalsignsvitalskills.com
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Stress/Burnout
Factors
Training
Practice of
medicine
Positive
Emotions/
Mood
Negative
Emotions/Mood
Mindfulness/Wellness/
EI training/Coaching
Cognitive abilities, self-
control, Emotional
Intelligence, IQ
P/P Satisfaction
Hijack, loss of IQ, loss
of will power, Lower
EQ
Problem solving and
creativity
Choose how to
respond to stressInstitutional
Changes/Outside
Factors
Purpose/Need of
medicine
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BECOME A RED FISH!
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Knowing is not
enough. We mustapply.
Willing is not enough.
We must do.Johann Wolfgang von Goethe
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ADDING THE MISSING INGREDIENT
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Change Should Do Into Must Do And Be Extraordinary.mp4
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WHAT’S NEXT?
• Identify: Your burnout, your abilities, your assets, your limitations
• Mindset: Decide not only that you SHOULD change, but that you MUST and WILL change
• Enhance: Your EQ, self-care, and resilience
• Plan: With or without a coach, outline a plan of action based on your parameters.
• Assess and adjust: “Adapt what is useful, reject what is useless, and add what is specifically your own.” Bruce Lee
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SOME PRACTICAL TIPS: ON AN INSTITUTIONAL LEVEL
• Identify a “champion”. A leader for the cause needs to emerge and take charge.
• Identify the needs (Survey, open communications and discussions, suggestions)
• Outline your goals
• Identify resources (available and needed)
• Develop an action plan
• Assess and reevaluate
• Fine tune, and re-commit
• Involve management
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• “In a battle all you need to make you fight is a little hot blood and the knowledge that it’s more dangerous to lose than to win.” George Bernard Shaw
• “No matter how great the talent or efforts, some things just take time. You can’t produce a baby in one month by getting nine women pregnant.” Warren Buffet
• 21 days to create a habit, 60 days to fix it, 90 days to anchor it
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SOME REFLECTIONS
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To know even one life has
breathed easier because
you have lived, this is to
have succeeded. -Ralph Waldo Emerson
“He who has a Why to
live for can bear almost
any How”Nietzsche
Momentum=(Focus +
Action)*ConsistencyMichael McQueen
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Contact Information:
Naim El-Aswad, MD, FACP
www.vitalsignsvitalskills.com
mailto:[email protected]:[email protected]://www.vitalsignsvitalskills.com/