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September 15 – 17, 2016 | The Biltmore Hotel | Miami, FL

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Douglas Ziedonis, MD, MPHProfessor and Chairman, Department of PsychiatryUMass Medical School/UMass Memorial Medical CenterPresident, UMass Memorial Behavioral Health ServicesWorcester, MA

An Epidemic of Burnout and Increased Risk of Suicide in Medicine: Strategies for Healthcare Providers

Douglas M. Ziedonis, MD, MPH

●Dr. Ziedonis has no disclosures to report.

Disclosures

Thanks

●Steve Adelman●George Abraham●Barry Feldman●Barbara Grimes-Smith

Recognize the risk of burnout and suicide among healthcare providers.

Learning Objective 1

#CHAIR2016

Learn to develop a personal and organizational strategy to increase resilience.

Learning Objective 2

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It’s the Economy & Funds Flow….

http://www.heritage.org/multimedia/infographic/2012/05/medicare-at-risk/the-burden-of-medicare-spending-on-american-households-is-rising. Published May 22, 2012. Accessed September 13, 2016.

Levitan D. http://www.factcheck.org/2015/02/paul-knocks-flies-and-nih-funding/. Published February 19, 2015. Accessed September 13, 2016.

Median Education Debt of Indebted Medical School Graduates, 1992-2012

https://members.aamc.org/eweb/upload/Physician%20Education%20Debt%20and%20the%20Cost%20to%20Attend%20Medical%20School,%202012%20Update.pdf. Published 2013. Accessed September 13, 2016

Burnout Syndrome: What is it?

Maslach Burnout Inventory measures 3 main areas:● Emotional Exhaustion** measures feelings of being emotionally overextended

and exhausted by one's work. Exhaustion is a depletion of emotional energy, distinct from physical exhaustion or mental fatigue. Emotional Exhaustion is a clear signal of distress in emotionally demanding work.

● Cynicism or Depersonalization measures an unfeeling and impersonal response toward recipients of one's service, care treatment, or instruction. The depersonalization measured by this scale is a problem in careers that value and mandate personal sensitivity to service recipients.

● Professional Efficacy / Accomplishment measures feelings of competence and successful achievement in one's work. This sense of personal accomplishment emphasizes effectiveness and success in having a beneficial impact on people.

Source: Maslach Burnout Inventory. The leading measure of burnout. Christina Maslach, Susan E. Jackson, Michael P. Leiter, Wilmar B. Schaufeli, & Richard L. Schwab.

Burnout is Not the Same as Disengagement But They Can Coexist

https://www.advisory.com/research/physician-practice-roundtable/members/expert-insights/2016/three-surprising-truths-about-physician-burnout?wt.mc_id=email%7Cdailybriefing+mostemailed%7Coldfinaldb2016sep12%7Cep%7Cppr%7C2016sep12%7Cphysicianissues%7C#.V9bvyoCOtR8.email

Burnout is Variable Across Tenure, and It’s Root Causes Differ

https://www.advisory.com/research/physician-practice-roundtable/members/expert-insights/2016/three-surprising-truths-about-physician-burnout?wt.mc_id=email%7Cdailybriefing+mostemailed%7Coldfinaldb2016sep12%7Cep%7Cppr%7C2016sep12%7Cphysicianissues%7C#.V9bvyoCOtR8.email

Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):1600-1613.

• Physicians (N = 6880) compared to general population• Measures of Burnout (per MBI) & Satisfaction with Work-Life Balance (WLB)• Burnout has increased from 46% to 54%• WLB satisfaction has decreased from 49% to 41%• All specialties are experiencing increased burnout and more WLB dissatisfaction• Physicians are faring worse than the general population

Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):1600-1613.

Burnout Rising in all Specialties

Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):1600-1613.

Quality of Life Falling in all Specialties

Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):1600-1613.

Work Life Balance + Burnout: Variations by Specialties

Shanafelt TD, et al. Mayo ClinProc. 2015;90(12):1600-1613.

Physicians vs.General Public

Physician / General PublicBurnout Measure Comparisons

Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):1600-1613.

Editorial: How Do Dan Ariely, PhD (Professor of Psychology and Behavioral Economics) and William L. Lanier, MD (Editor-in-Chief of the Mayo Clinic Proceedings) Understand the Mounting Burnout Epidemic?

● Asymmetrical Rewards: – Punishment for mistakes is “particularly substantial in the medical profession.”

● Loss of Autonomy: – “Contemporary medicine’s escalating oversight and control of how physicians spend their

time goes hand in hand with a loss of physician autonomy.” ● Cognitive Scarcity: – The need to continuously make consequential decisions creates stress for physicians

without “time buffers.”● The problem that needs to be solved: – “We view the practice of medicine as a production function, a sort of ‘fixing people production line,’

when, in fact, medicine should be viewed as a research and development activity.”● Conclusion: The system needs to evolve away from managing physicians’

time to focusing on long-term health

Correlates of Resident Job Satisfaction

Chen C, et al. Rhode Island Medical Journal. 2014;97(10):50-54.

Variable Spearman Correlation Coefficient p-valueAge -0.0020 .9818Residency class -0.0304 .7326Physical health 0.3052 .0004Emotional health 0.3973 .0000Income 0.1296 .1676Number of jobs -0.0587 .5071Debt burden 0.0108 .9068Work week hours -0.0641 .4743Hours of sleep 0.0795 .3688Number of children 0.0859 .3294

Online survey results representing 127/227 (56%) of program graduates.

Suicide Rates by Profession

Tiesman HM. NIOSH Science Blog. https://blogs.cdc.gov/niosh-science-blog/2015/04/13/workplace-suicide/. Accessed September 13, 2016.

Rank Profession Odds Ratio 1. Medical Doctors 1.872. Dentists 1.673. Police Officers 1.544. Veterinarians 1.545. Financial Services 1.516. Real Estate Agents 1.387. Electricians 1.368. Lawyers 1.339. Farmers 1.3210. Pharmacists 1.29

In general population of the US, the overall prevalence of suicide is 1-2%

US Data (2013)● 41,149 known suicides (79% males)– 3.7 male completions for each female completion

● 1,028,725 attempts (25:1 ratio of attempts to completions)– 3 female attempts for each male attempt

● Over 500,000 people annually receive medical care for self-inflicted injuries

● Top three methods used in suicides:– Firearm (52%)– Hanging/suffocation (25%)– Poisoning (16%)

Suicide Facts. https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf.

Physician Depression and Suicide: An Epidemic?

● Each year in the US, roughly 300-400 MDs die by suicide● Suicide deaths are 250%-400% higher among female MDs

compared to females in other professions● In the general population, males complete suicide 4x more often

than females—among MDs, rate is equal● Medical students shave rates of depression 15%-30% higher than

the general population● MDs have a higher suicide completion to attempt ratio, which may

be result of greater knowledge of lethality of drugs and easy access

American Foundation for Suicide Prevention website. https://afsp.org/our-work/education/physician-medical-student-depression-suicide-prevention/. Accessed September 7, 2016.

Depression in Medical School and Residency

● In one study of 6 medical schools, 1 in 4 students reported clinically significant symptoms of depression– Almost 7% had thought of suicide in last 2 weeks1

● 29% of residents suffered from significant symptoms of depression2

– Begin with rates similar to general population, but symptoms escalate within a year of starting training3

● Data likely an under-count because suicide not listed on death certificate and not tracked in medical school databases4

1. Goebert D, et al. Acad Med. 2009;84(2):236-241.; 2. Mata DA, et al. JAMA. 2015;314(22):2373-2383.; 3. Thielking M. https://www.statnews.com/2015/12/08/depression-doctors-training/.; 4. Graham J. https://www.statnews.com/2016/07/21/depression-suicide-physicians/.

Stressors

● Sleep deprivation● Competition with peers ● Criticism from faculty who have little tolerance for

ignorance, signs of weakness, or emotional displays● Medical education and training are “a profoundly

dehumanizing experience and it’s drilled into you: Do not show your heart or teas to anyone, every again,” said Dr. Pamela Wible, family physician and author of a book about physician suicide

Graham J. https://www.statnews.com/2016/07/21/depression-suicide-physicians/.

Manifestations of Mental Illness

● Depressed residents made 6.2x more medication errors than their non-depressed peers

● Severe irritability and anger resulting in interpersonal conflict

● Strained professional and personal relationships

● Inappropriate boundaries with patients, staff or peers

● Erratic behavior at the office or hospital

● Marked vacillations in energy, creativity, enthusiasm, confidence, productivity

● Frequent job changes and/or moves● Impulsivity or irrationality in decision

making or action● Diminished or heightened need for

sleep● Sexually inappropriate comments or

behavior● Isolation and withdrawal● Inconsistency in performance,

absenteeismBright RP, Krahn L. Current Psychiatry. 2011;10(4):16-30.

Why are Depression and Mood Disorders Under-recognized and Inadequately Treated in Physicians?●Physicians may be reluctant to seek treatment●Attempt to diagnose and treat themselves●Seek and receive “VIP treatment” from other

health care providers

Bright RP, Krahn L. Current Psychiatry. 2011;10(4):16-30.

Predictors of Depression in Physicians

● Difficult relationships with senior doctors, staff, and/or patients

● Lack of sleep● Dealing with death● Making mistakes● Loneliness● 24-hour responsibility● Self-criticism

Firth-Cozens J. Br J Gen Practice. 1998;48:1647-1651.

The 4th AIM –Physician Wellness

Bodenheimer T, et al. Ann Fam Med. 2014;12:273-576.

Better Physician Health Promotes Better Health in Patients

● Compliant physicians enhance patient compliance (screening and immunization)

● Physicians with better personal health practices counsel patients more (blood pressure and lipids)

● Providers who share health practices are viewed as more credible and motivating

Frank, E. JAMA, 2004;291(5):637.

AMA Steps Forward Module 1: Physician Burnout

AMA Steps Forward. https://www.stepsforward.org/.

AMA – STEPS Forward Modules

● Series of modules for practice redesign

● Among them, one for burnout prevention, another for resiliency

AMA Steps Forward Module 2: Improving Resiliency

AMA Steps Forward. https://www.stepsforward.org/.

Some Sweeping Systemic Changes

● Placing a greater emphasis on identifying emotional intelligence in the medical school admissions process

● Reorganizing the funding of medical education to diminish burdensome debt for early career physicians

● Rebalancing the funding and focus of graduate medical education to produce more ambulatory-based primary care physicians and fewer hospital-based specialists

● Accelerating system migration to value-based care● Enhancing the rewards for practicing physicians who focus on health

maintenance and primary care● Attenuating the macho culture of medicine and restructuring physician work-

life, accommodating the influx of working mothers into the profession

More Sweeping Systemic Changes

Design and implement a coherent and consistent structure for the healthcare system such that it is:● Better-led● Flatter & less siloed● Less beholden to corporate shareholders● Less utilization driven● More in touch with the everyday, human needs of front-line

clinicians

Actionable Burnout Countermeasures (ABC)

● Coaching– For patients (health & wellness)– For physicians (balance, communication, organization, professionalism)– For physician leaders (be coached and learn to coach)

● Concierge practice (saves PCPs)● Fitness centers (on site)● Float pools & Time buffers – life happens and adds 10% to work volume

● Lunch (a la Mayo)● Financial planning

More Actionable Burnout Countermeasures (II)

● Meaning, Purpose, Spirituality (introducing Dr. Sacra) –Recapture the Calling

● Mindfulness (individual, group, institution) ● Peer support–Balint Groups– “Finding the Meaning in Medicine” dialogues (Florida Hospital)–Managing Workplace Complexity discussion groups –Schwartz Rounds

● Salaried positions (a la Mayo)● Scribes

Individual Coping Strategies

●Humor ●Utilize supervision ●Relaxation time●Take care of your body – diet; exercise ●Set boundaries between home and work●Avoid isolation – involvement in professional

organizations

MBSR Formal and Informal Practices

● Formal Practices of Meditation & Gentle Yoga Exercises:– Ex: Awareness of Breathing, Sitting Meditation, Slow Walking Meditation, Body-scan,

Raisin Exercise (mindful eating), Gentle Yoga Exercises, Mountain / Lake Meditation, Loving-kindness Meditation, etc

● Informal Practice: Many opportunities all day to enhance awareness– Any moment – perhaps when you catch yourself being mindless and gently redirect to the

present moment– Consciously increase awareness to current thoughts, feelings, & body sensations– How the weather affects us physically

– Pleasant experiences & unpleasant experiences– Reactivity to stressful situations or events– While communicating with others

● Homework – Consider journal / log of your experiences.

Call to Action

●Commit to one small change to provide work-life balance and develop resilience

Questions Answers &

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