compassion without burnout · effectiveness of empathy in general practice a systematic review...

COMPASSION WITHOUT BURNOUT

Copyright © PRIME 2017 www.prime-international.org

Prof Richard Vincent BSc AKC MD FRCP EFESC

Emeritus Professor of Cardiology, BSMS and PRIME Trustee

Dr John Geater MBE MB ChB DRCOG DTM&H

International Consultant PRIME Partnerships in International Medical Education

Dr Rachel Hennessy

Deputy Medical director

SURREY AND BORDERS PARTNERSHIP NHS FOUNDATION TRUST

Dr Shakil Malik, MBBS, DPM,MCPS, FRCPsych

Dr John Caroe MA, MB, BChir, MRCP.

Chair of Trustees PRIME & Volunteer Chaplain EDGH

When I started as a doctor, I’d go to work brimming with pride. But the system soured the love I felt for the NHS.

Every time students achieve what looks like a successful milestone it is, to some of them, the opening of another door to a haunted house, behind which lie demons, suffocating uncertainty and unimaginable challenges.

COMPASSION WITHOUT BURNOUT

for possible discussion:

1. Exploring compassion as a fundamental foundation for our work with benefit for all, both patients and staff.

2. Maintaining cohesive working, mutual respect and support between all who deliver health care, whatever their role.

3. Examining the causes of growing stress in health-care personnel, sharing practical solutions for protecting against its adverse effects.

4. Discerning the subtle signs of damaging stress in our work colleagues and how best to act in supportive response.

COMPASSION WITHOUT BURNOUT

1. Exploring compassion as a fundamental foundation for our work with benefit for all, both patients and staff.

In becoming a health professional...

I want to help people, to heal people, to relieve suffering.

COMPASSION WITHOUT BURNOUT

1. Exploring compassion as a fundamental foundation for our work with benefit for all, both patients and staff.

Why did you enter the health care profession?

The Doctor (1891) Sir Luke Fildes, National Gallery

The Enlightenment -The great divide

Humanities (BA) Religion,

Music, Literature, Art

Communication

“Spiritual”

Science (BSc) Medicine

Physics, Chemistry, Biology

Investigative

Material – “the real world”

With thanks to the Robert Pope Foundation

“….medical training seems to be focussed on how to deal with things – a liver, an MRI scan – rather than how to deal with people, such as patients and colleagues.

This lack of training on how to deal with people could mean doctors are ill equipped for this vital part of their jobs and explains much of their subsequent stress”

British Medical Journal, August 28th 2004

.

The student/junior doctor

Medical students and residents loose compassion during training Newton B et al. 2008, Acad Med: 83 244-249

Callousness was seen as bad, but students saw it in their mentors 20% of the time in years 3 and 4, California, USA.

Rentmeester et al. 2007, Med Teacher 29:358-364

Also: Neumann M, Edelhäuser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med:2011;86:996-1009.

A New Enlightenment -The great reunion

Humanities (BA) Medicine

Science (BSc) Medicine

‘The greatest challenge facing contemporary medicine is for it to … regain its humanity, its caritas — without losing its essential foundation in science … to find a middle way.’

Willis JAR. The sea monster and the whirlpool. Keynote address. Birmingham: Royal College of General Practitioners; 2002

A New Enlightenment -The great reunion

Humanities (BA) Medicine

Science (BSc) Medicine

A New Enlightenment -The great reunion

Humanities (BA) Medicine

Science (BSc) Medicine

fMRI scans showing brain activity in pain and empathy responses. Tania Singer / University College London

Neuronal mirroring

A part of your brain the right supramarginal gyrus recognizes a

lack of empathy and autocorrects.

When this brain region doesn't function properly—or when we

have to make particularly quick decisions—the researchers found

one’s ability for empathy is dramatically reduced. This area of the

brain helps us to distinguish our own emotional state from that of

other people and is responsible for empathy and compassion.

https://www.psychologytoday.com/blog/the-athletes-way/201310/the-

neuroscience-empathy

Findings related to oxytocin and vasopressin research, plus the role of monoamines and endogenous opioids, suggest a tight coupling with attachment processes and love phenomena: happiness, pleasure, compassion and desire.

Dopamine, as a critical part of the biologically important reward process, is a central instrument for

the neurobiology of love.

Med Sci Monit. 2011; 17(3): RA65–RA75

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3524717/

The impact of patient-centred care on outcomes from the Journal of Family Practice, 2000

• 39 family physicians at random, and 315 of their patients

• Consultations were audio-taped and scored for patient-centered communication.

• In addition, patients were asked for their perceptions of the patient-centredness of the visit.

The Impact of Patient-Centred Care on Outcomes

Results

Patient-centered communication was correlated with the patients’ perceptions of finding common ground.

Positive perceptions were associated with better recovery from their discomfort and concern, better emotional health 2 months later, and fewer diagnostic tests and referrals.

Conclusion

Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals.

Stewart M, et al. The Impact of Patient-Centred Care on Outcomes. The Journal of Family Practice; September 2000 Vol. 49, No. 9

Observational study of effect of patient-centredness and

positive approach on outcomes of general practice

consultations

Setting: Three general practices, 865 consecutive patients

Outcomes: Patients' enablement, satisfaction, and burden of symptoms

Doctor factors studied:

Sympathy, interest in patients' worries & expectations, and readiness to discuss & agree about the problem and its treatment

Understanding of the patient and her / his emotional needs

Inclusion of health promotion in the consultation

Positive approach (definite about the problem and when it would settle)

Interest in effect on patient's life

Results

Satisfaction was related to communication and partnership

Enablement was greater with the doctors’ interest in the effect on life, and in health promotion

A positive approach was associated with satisfaction, enablement and a reduced symptom burden at one month

Referrals were fewer if patients felt they had a personal relationship with their doctor

Conclusions

Components of patients' perceptions can be measured reliably and predict different outcomes. If doctors don't provide a positive, patient-centred approach, patients will be less satisfied, less enabled, and may have both a greater symptom burden and higher rates of referral.

Little P, et al. Observational study of effect of patient centredness and positive approach

on outcomes of general practice consultations; BMJ 2001;323:908-911

Observational study of 839 non-pregnant adult women

aged 18-70 presenting with suspected urinary tract

infection in primary care

‘The most interesting finding from this study is the reminder of what is often forgotten—that it is not just what is done that matters but how care is provided.

Symptoms were less severe and of shorter duration when the doctor took a positive approach to diagnosis and prognosis.

Most importantly, in an age of protocols and targets, (this study) shows that the way a doctor provides care can enhance the effectiveness of treatments.

Mangin D. Urinary tract infection in primary care. BMJ 2010; 340:c657

Effectiveness of empathy in General Practice

A systematic review published in the British Journal of General Practice found seven papers (using strict inclusion criteria from an original tranch of 964) published in the last fifteen years, on the effectiveness of physician empathy in general practice.

The effects of empathy in patient–physician communication in the studies included are described as:

• Improvement of patient satisfaction and adherence to treatment,

• Decrease in anxiety and distress

• Better diagnostic and clinical outcomes, and

• More patient enablement (the ability of patients to improve their own health)

Derksen F, et al.; a systematic review. BJGP 2013; 63(606): 76-81

The benefits of compassion

• The least risk of burnout in the doctors studied

• More time spent relieving suffering of patients

• Better patient outcomes

• For doctors, better immune functioning

‘Research has found that developing kindness and compassion for ourselves and others builds our confidence, helps us create meaningful, caring relationships and promotes physical and mental health.

Far from fostering emotional weakness, practical exercises focusing on developing compassion have been found to subdue our anger and increase our courage and resilience to depression and anxiety.’

The Compassionate Mind by Paul Gilbert

Constable & Robinson UK, 2009

The Doctor(2006), Kashmir earthquake aftermath

• What tends to make you

less compassionate?

• What tends to make you

less compassionate?

• What helps to make you more compassionate?

COMPASSION WITHOUT BURNOUT

2. Maintaining cohesive working, mutual respect and support between all who deliver health care, whatever their role.

COMPASSION WITHOUT BURNOUT

2. Maintaining cohesive working, mutual respect and support between all who deliver health care, whatever their role.

How do you build up a cohesive team?

From the Registrar, Royal College of Physicians

18th April 2018

• The job of a doctor is becoming increasingly difficult.

• Specifically, pressure of patient through-put; patient expectations; lack of organisational and social support; increasing isolation - no time to develop teams and communities of practice; and increasingly complex cases and patient co-morbidities.

Feedback from small group at RCPsych - 1

• No sense of belonging

• Depersonalisation– just a number on the Rota

• Feeling no one cares about my life

• Loss of humanity

• No one I can share my problems with; I can’t not

take my problems home with me

• I’m treated as a role and not a person

• Bullied by management

• Terrified of the stigma attached to failure

• Frustration & powerlessness

Feedback from small group at RCPsych - 2

v

The value of values

Being clear about your personal code of values offers these benefits to life:

• The values-based life is meaningful

• Life purpose is clearer when based on values

• Life vision and goals are clear

• Decisions are easier

• Choices are clear

• Stress is reduced. Stress is all about values conflict.

• Life is easier

Level Motivation /need Focus/behaviour/value

7 Service Leading a life of self-less service

6 Making a difference Making a positive difference in the world

5 Internal cohesion Finding personal meaning in existence

4 Transformation

Finding freedom by letting go of our fears about

survival, feeling loved and being respected by

our peers

3 Self-esteem Feeling a sense of personal self-worth

2 Relationship Feeling safe, respected, and loved

1 Survival Satisfying our physical needs

Barrett R 2006

A hierarchy of needs and values

• Look at the values of a good teacher and doctor that you compiled,

• How is the medical school teaching these qualities?

Role modelling, or following….

Good or bad?

Discuss in Small Groups:

• What is a role model?

• Who was a role model to you when you were a student? (medical and non-medical)

• Who are you a role model to? (medical and non-medical)

COMPASSION WITHOUT BURNOUT

3. Examining the causes of growing stress in health-care personnel, sharing practical solutions for protecting against its adverse effects.

Royal College of Physicians Report 2016 A survey of 498 junior doctors

• 80% felt excessive stress

• 70% worked on a permanently under-staffed rota

• 54% reported that their job had a reduced their physical health

• 41% felt that their administrative burden risked patient safety

• 25% reported their work had a serious impact on their mental health

• 18% were given clinical tasks to undertake without adequate training

1 2 3 4 5

Where are you on the stress curve?

Which way are you moving?

Where are you on the stress curve?

Which way are you moving?

What things cause you stress?

Where are you on the stress curve?

Which way are you moving?

What things cause you stress?

How do you avoid excessive stress?

Beating burnout – what can we learn from the military?

Primary Prevention

• Unit cohesion

• Sense of eliteness

• Sharing food

• Debriefing after a hard action

Factors important in avoiding burnout

• Countering isolation (in professional, personal and spiritual realms)

• Developing mindful self-awareness

• Active optimism

• Holistic self-care

• Maintaining clear boundaries

• Professional satisfaction

• Creating meaning

(Harrison and Westwood 2009)

Factors important in avoiding burnout

• Watch non-work commitments ones drain energy

• Learn to say ‘No’

• Don’t take on things that you don’t enjoy

• Manage your time well (ie. clock time not goal time)

• Have clear work/rest boundaries

• Accept you can’t do a perfect job

• Take control

• Delegate where possible

• Take sabbaticals and holidays without taking work with you

• Watch out for escapism

Things that obliterate the pain but don’t

nurture and restore (some of these are alright in small quantities)

• TV

• Rubbish films and books

• Endless internet surfing (evenings especially)

• Junk food

• Alcohol

• Inappropriate emotional/sexual relationships

FIND A GOOD ROLE MODEL

Where are you on the stress curve?

Which way are you moving?

What things cause you stress?

How do you avoid excessive stress?

How do you cope with it?

How are battle fatigued soldiers managed?

• Rest

• Replenishment

• Reassurance

• Restoration

COMPASSION WITHOUT BURNOUT

4. Discerning the subtle signs of damaging stress in our work colleagues and how best to act in supportive response.

COMPASSION WITHOUT BURNOUT

4. Discerning the subtle signs of damaging stress in our work colleagues and how best to act in supportive response.

How can you help a colleague to deal with excessive stress?

Eve Ekman & Michael Krasner: DOI: 10.1080/0142159X.2016.1248925

• empathy can be blocked by personal stress and aversion among health care professionals.

Christina Maslach & Michael P. Leiter: DOI: 10.1080/0142159X.2016.1248918

• improving the balance of civil, respectful social

encounters occurring during a workday. Research

has demonstrated that civility can be increased at work

and that doing so leads to an enduring reduction in

burnout among health care providers.

Recognising the problem in colleagues and students

• Arriving late/leaving early

• Recurrent sickness/absence

• Rudeness

• Complaints from patients/staff

• Uncompleted tasks

• Clinical errors

• Erratic behaviour (eg ‘ward rage’)

Your Role in helping

• Compassionately point out that there is a problem

• Signpost to sources of help

• Make it clear that behaviour needs to change

That is, act like a GP in recognising the problem; but it is not your responsibility to ‘treat’ it, just to ensure that remedial action is taken.