RECOGNITION AND PREVENTION OF BURNOUT –

YOURS AND THEIRSRebecca P. McAlister, M.D.

Washington University School of Medicine

EDUCATIONAL OBJECTIVES

• This presentation will discuss the syndrome of burnout, its causes and effects. We will examine how it may affect residents, attending physicians, other health professionals and support staff, and ourselves. Strategies for identification and prevention will be reviewed.

BURNOUT DEFINED

• “A PROLONGED RESPONSE TO CHRONIC EMOTIONAL AND INTERPERSONAL STRESSORS ON THE JOB”

• DEFINED BY THREE DIMENSIONS– EXHAUSTION– CYNICISM– INEFFICACY

EXHAUSTION

• BASIC INDIVIDUAL STRESS DIMENSION

• FEELINGS OF BEING OVEREXTENDED

• FEELING DEPLETED OF EMOTIONAL AND PHYSICAL RESOURCES

• PROMPTS DISTANCING ONESELF TO COPE WITH WORK OVERLOAD

CYNICISM

DEPERSONALIZATION

• A NEGATIVE, CALLOUS, OR EXCESSIVELY DETACHED RESPONSE TO VARIOUS ASPECTS OF THE JOB

• DISTANCE ONESELF BY ACTIVELY IGNORING PERSONAL QUALITIES

INEFFICACY

• THE SELF EVALUATION COMPONENT

• FEELINGS OF INCOMPETENCE, LACK OF ACHIEVEMENT AND PRODUCTIVITY AT WORK

• SEEMS TO ARISE FROM A LACK OF RELEVANT RESOURCES

ROOTS IN 1970’S

• FOCUSED ON CARE GIVING AND SERVICE OCCUPATIONS

• CORE OF THE JOB WAS RELATIONSHIP BETWEEN PROVIDER AND RECIPIENT

• HEALTH CARE PROFESSIONALS, SOCIAL WORKERS, TEACHERS

MASLACH BURNOUT INVENTORY

• MASLACH & JACKSON DEVELOPED MBI IN 1981

• MBI-HUMAN SERVICES SURVEY– MBI-HSS

• MBI-EDUCATORS SURVEY - MBI-ES• MBI-GENERAL SURVEY – MBI-GS• SUBSCALES

– EMOTIONAL EXHAUSTION– DEPERSONALIZATION– REDUCED PERSONAL ACCOMPLISHMENT

EFFECTS OF BURNOUT

• JOB PERFORMANCE– ABSENTEEISM– JOB TURNOVER– LOWER PRODUCTIVITY / EFFECTIVENESS– “CONTAGIOUS”

• HEALTH– STRESS RELATED HEALTH OUTCOMES– NEUROTICISM– NEGATIVE MENTAL HEALTH EFFECTS

• ?spectrum with depression

WHERE DOES BURNOUT OCCUR?

• JOB CHARACTERISTICS

• OCCUPATIONAL CHARACTERISTICS

• ORGANIZATIONAL CHARACTERISTICS

JOB CHARACTERISTICS

• WORK OVERLOAD AND TIME PRESSURE• ROLE CONFLICT / AMBIGUITY• SEVERITY OF CLIENTS PROBLEMS• ABSENCE OF JOB RESOURCES• LACK OF SOCIAL SUPPORT• LACK OF SUPERVISOR SUPPORT• LACK OF FEEDBACK• LACK OF CONTROL / DECISION MAKING

OCCUPATIONAL CHARACTERISTICS

• FOCUSED ON HUMAN SERVICES AND EDUCATION

• REQUIREMENT TO EXPRESS OR SUPPRESS EMOTIONS ON THE JOB

• REQUIREMENT TO BE EMOTIONALLY EMPATHETIC

ORGANIZATIONAL CHARACTERISTICS

• RULES THAT VIOLATE BASIC EXPECTATIONS OF FAIRNESS / EQUITY

• VIOLATION OF THE PSYCHOLOGICAL CONTRACT (WHAT EMPLOYER IS OBLIGED TO PROVIDE FOR RECIPROCAL WORK EXCHANGED)

WHO IS AT RISK?

• ? LESS THAN AGE 30 OR 40• ? FEMALE (MALES MORE CYNICAL)• ?UNMARRIED, ESP. SINGLE• HIGHER LEVEL OF EDUCATION• EXTERNAL FOCUS OF CONTROL• PASSIVE / DEFENSIVE COPING• POOR SELF ESTEEM• NEUROTICISM / TYPE “A” BEHAVIOR• “DISORGANIZED” PERSONALITY

THE PEOPLE YOU WORK WITH

• PHYSICIANS IN GENERAL / OBGYNs

• RESIDENTS IN TRAINING– STUDIES IN PGY-1s

• Acad Med 2006;81:82-5

• HEALTH PROFESSIONALS / EDUCATORS / SUPPORT STAFF

BURNOUT IN PHYSICIANS

• 25 – 60% MEET MBI CRITERIA FOR BURNOUT

• CAN LEAD TO INCREASED MEDICAL ERROR (SELF REPORTED V. OBSERVED)

• DISSATISFACTION AND DISTRESS INCREASE COSTS TO SYSTEM

• $240K – 260K TO REPLACE PRIMARY CARE PHYSICIAN

CAREER SATISFACTION IN OBGYN PHYSICIANS

CAREER SATISFACTION WORK-LIFE BALANCE

BURNOUT

Keeton K, et al. Obstet Gynec April 2007

OBGYNs more personal accomplishment and work/life balance than general surgeons

More career satisfaction than general internists

BURNOUT IN OBGYN CHAIRS

• 88% MODERATE BURNOUT• 4% HIGH BURNOUT• HIGH EMOTIONAL EXHAUSTION• MODERATE – HIGH

DEPERSONALIZATION• HIGH PERSONAL ACCOMPLISHMENT

» GABBE, AM J OBSTET GYNECOL 2002

STRESS / BURNOUT IN RESIDENCY

• 76% INTERNAL MEDICINE RESIDENTS MET CRITERIA FOR BURNOUT– ASSOCIATED WITH SELF REPORTED

SUBOPTIMAL PATIENT CARE» SHANAFELT, ET AL, ANN INTERN MED, 2002

• OBGYN RESIDENTS– 9X MORE LIKELY TO LACK EFFECTIVE COPING

MECHANISMS– 14X MORE COMMON MALADAPTIVE STRESS

SCORES» SCHNEIDER, ET AL, AM J OBSTET GYNECOL 2002

BURNOUT AND DEPRESSION

• FAHRENKOPF et al (BMJ 2012) surveyed 123 Peds residents with MBI & Harvard nat’l depression screening day scale

• 75% burnout, 20% depression (of which 96% also burned out)

BURNOUT AND DEPRESSION

• Burnout- no increase observed errors, increased reported errors, diff. concentrating

• Depressed- 6X increased observed errors, difficulty concentrating, poor health (few on antidepressants)

• Not assoc with age, sex, PGY, logged sleep or work hours

THREE LIKELY BURNOUT SCENARIOS

• PGY4 overheard making derogatory remarks about clinic patients

• PGY1 tells PD he/she is considering transferring to Dermatology

• OBGYN PD had poor internal review. DIO said “terrible data collection.” He/she yells at coordinator who promptly quits.

BUILDING JOB ENGAGEMENT

• BURNOUT IS THE EROSION OF ENGAGEMENT WITH THE JOB– RELATED TO JOB DEMANDS

• ENGAGEMENT CHARACTERIZED BY ENERGY, INVOLVEMENT, EFFICACY– RELATED TO JOB RESOURCES

Loss of Control in the Practice of Medicine

• Frequently part of patient encounters– Difficult encounters, noncompliance, end-of-

life care, uncertainty/ambiguity in dx/mx• Institutional and systemic factors

– Lack of control over work environment, team vs. captain, “limit the territory”

• Need to identify constructive ways to respond to lack of control

EXAMPLES OF TRAINING IN COPING MECHANISMS

• Reflection /critical incident journaling• Peer group discussions• Balint training• Mindful emotion regulation• Positive vs. Negative Assertion vs.

Yielding• Journal of Graduate Medical Education Dec 2009

TEACHING /CHANGING THE INDIVIDUAL

• PEOPLE CAN LEARN NEW COPING SKILLS

• ?CAN PEOPLE APPLY THIS TO THE WORKPLACE?

• CAN REDUCE EXHAUSTION, LITTLE CHANGE IN CYNICISM, INEFFICACY

ORGANIZATIONAL CHANGE

• MUCH MORE DIFFICULT BUT LIKELY MOST EFFECTIVE

• EXPAND RANGE OF WORK OPTIONS• PEOPLE TOLERATE GREATER WORK

LOADS IF FEEL REWARDED/VALUED• BUILD SENSE OF FAIRNESS /EQUITY• EMPOWER WITH SENSE OF CONTROL

STEPS TO PROMOTE ENGAGEMENT

PERSONAL WELLNESS– EXERCISE, COUNSELING, TX PSYCH DZ

ORGANIZATIONAL ENVIRONMENT– CHOICES, FEEDBACK, FAIRNESS,

CULTURE CHANGE

PROMOTING WELLNESS IN THOSE YOU WORK WITH

IT’S A BALANCING ACT

“If all of the knowledge and advice about how to beat burnout could be summed up in one word, that word would be balance-balance between giving and getting, balance between stress and calm, balance between work and home.”

» Maslach 1982