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Burned out?

Tools For Promoting Wellness

in Residency EducationMarch 23, 2018

PDW/RPS

Laura McCray, MD MSCE

Associate Professor, Program Director

University of Vermont Family Medicine Residency

No disclosures.

Learning Objectives1. Define burnout and its key drivers and consequences

2. Become familiar with the ACGME common program requirements for well being (Section VI)3. Learn evidence-based tools to promote wellness

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• State of emotional exhaustion and depletion from work-related stress.

–3 components• Emotional exhaustion

• Depersonalization

• Low sense of personal accomplishment

• Physicians at higher risk than other professionals– Professional degree: Odds ratio for burnout is 0.64

– DO or MD: Odds ratio for burnout is 1.36

Burnout: Definition

(Maslach, 1979) (Shanafelt, 2012)

• Medical students– 50% burned out

• 27.2% depression, 11.1% suicidal ideation (JAMA)

• Resident physicians – 50%- 75% burned out

• 28.8% depression

• Practicing physicians– Mean 54%, varies by specialty

– FM PDs less burnout out (27.3%) and are more resilient

Burnout: Epidemiology

(Dyrbye, 2008 and 2014) (Rotenstein, 2016) (Mata, 2015) (Shanafelt, 2012, 2015) (Porter, 2018)

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(Shanafelt Mayo Clinic Proc., 2015)

Changes in Burnout in Physicians Between 2011 and 2014

Burnout: Causes

• Shout it out-

– What is causing burnout?

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Workload

Lack of autonomy

EHR

Work compression

Administrative tasks

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(Shanafelt Mayo Clinic Proc. 2016)

Key Drivers of Burnout

• Preparedness for residency

– Impact of changes in medical school curriculum

• Less hands-on procedural training? Note writing?

• More flexible schedules, autonomy? Impact of TBL?

• Transition in feedback

– Test-based to formative competency-based assessment

– Pass/fail

Medical Training Factors

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• Medical error and cognition– Quality of patient care

– ITE scores

• Mood disturbance– Depression

– Suicide (burnout independent RF- OR 2.33)*

– Anxiety

• ETOH and substance abuse– 13% men and 21% women physicians in AMA study

Burnout: Consequences

(Oreskovic, Arch Surg 2015) (Shanafelt, 2002) (West, 2006, 2009) (West, 2011) (Dyrbye, 2008)

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Are we in crisis mode?

• Depression– Not new (30% in 1986), similar to current estimates (25%)

• Suicide– 20-28 residents per year (15/100,000)

– Current estimates: 380 – 420 physician suicides per year:• Male MDs 1.7 times more likely than non-MDs

• Female MDs 2.4 times more likely than non-MDs

– Age range 45-64: 18/100,000

Physician depression and suicide

(Nasca, 2015 ACGME symposium: Physician suicide and burnout) (Martin, 1986) (Sen, 2010)

National suicide rate: 12.57/100,00

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• System – Excessive work load/work compression

– Loss of autonomy in larger systems

– Loss of meaning

• Couple with stigma– Only 22% of those at risk seek help

• (85% with depression have no treatment!)

– Only 25% of those with suicidal ideation seek help

– Barriers- licensing, state boards*, lack of time• 33% states have question about MH on license app

Physician risk

(AMA Consensus statement 2003*- not much has changed!) (Ey, 2013) (Guille, 2010) (Shanafelt, 2015)

Consequences cont.

• Faculty retention

– Burnout associated with:

• OR 2.5 intent to leave practice within next 2 years

• Increased likelihood reducing FTE

– 1 point change in EE assoc. with 43% increase

– Regardless of age or specialty

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(Arch Surgery 2008, Shanafelt, 2016)

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“We are frogs in the pot and the water is

boiling”

-Tom Nasca (ACGME CEO)2017 ACGME conference

Think, Pair, Share (5 minutes)

• Think of one resident who you believe is

burned-out. – What makes you think the resident is burned out?

– Do you see any consequences?

• Pair, share

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ACGME- Call to Action

• ACGME task force on well being

• Revision Common Program Requirements

– Section VI.C

• The Learning and Work Environment: Well Being

• Went into effect 7/1/2017

• CLER visit focus

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CPR VI.C: Well BeingSummary:• Protect time with

patients• Minimize non-physician

obligations and tasks• Attention to work

intensity/compression • Monitor workplace

safety data

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CPR VI.C: Well Being

Summary: • Need programs and policies that

encourage well-being• Residents must be allowed to go to

doctor’s visits during work hours

CPR VI.C: Well Being

Summary:• Educate faculty and

residents on identifying burnout, depression, and substance abuse

• Alert PD or faculty if concern

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CPR VI.C: Well Being

Summary:

• Must provide access to screening tools

– Free: Well Being Index (Mayo Clinic)

– https://www.mededwebs.com/well-being-index

• Provide access to mental health resources, including 24 hour access

Screening Tool: Well Being Index

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CPR VI.C: Well Being, Last Section

Summary:

• Provide emergency back-up for patient care

Think, Pair, Share (5 minutes)

• After reviewing the new CPRs on well-

being, name:

– 1 requirement you are doing well

– 1 requirement you could improve upon

• Pair, share

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• Evidence for:–Mindfulness techniques, MBSR

–Self-development/coping skills groups

–Conversion to P/F grading system for medical schools

• Mixed data:–Self-care

–Stress management didactics

–Resiliency training

–Duty hours

Toolbox- Evidence Based Strategies

For Reducing Burnout

(McCray, 2008) (Shiralkar, 2013) (Williams, 2015)

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• Many resources– Krasner and Epstein Mindful Practice Curriculum

(Rochester)

– MSBR- Online CME (UMass)- Jon Kabat-Zinn

– ROM method

– Calm.com

• Mindfulness exercise– UVM Center for Health and Wellbeing online meditation– https://soundcloud.com/user-658944755

Toolbox- Mindfulness

(Krasner, JAMA 2009) (Ospina- Kammerer 2003)

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• Self-care–Plummets in medical school

• Decrease in exercise and socialization

• Increase in ETOH use

–Worse in residency

• Self care and burnout (UVM study)–Eating well, sleep, exercise, going outdoors, time with

family and friends- protective

–All other factors- not statistically significant

Toolbox- Self Care

(Ball, 2002) (McCray &Rosen, 2015)

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• Resiliency – Capacity to bounce back, withstand hardship

– Positive adaptation in the face of stress

• Resiliency training– Based on coping, self-care, and personal

relationships

– Professional Provider Resiliency Training (PPRT)• Armed forces- controversial and expensive

– FM curriculum (University of Toledo)

Toolbox- Resiliency

(Adams, 2010) (Brennan, 2015)

–SMART training- MGH Benson Henry Institute (BHI)

• Stress Management and Resiliency Training

• Mind-body focus, EBM based

–SMART-R

• Abbreviated version of full 16 hour curriculum

• Three 2-hour sessions

–SMART-R in FM and OB/GYN residents at UVM

Toolbox- Resiliency

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• Well-being not absence of “disease” or burnout– Positive emotional state

– Related to autonomy, competence, and social relatedness

• Sleep, physical activity, time in nature, PTA (personal time availability) associated with well being

• Interventions-– gym access, coping skills, advising system

Toolbox- Well Being

(Raj, 2016)

Toolbox- Organizational

Approaches

“We’re not going to resilience our way out of

this”- Stuart Slavin

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Toolbox- Organizational

Approaches• Measure current state, compare to

national norms

• Leadership

– Leadership scores independently associated

with burnout (1 point increase assoc. with 3%

reduction in burnout)

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Toolbox-Organizational Approaches

• Decrease work hours->decrease burnout

• Outpatient work flow improvements

• Advanced care team models

• Scribes

• COMPASS groups

– Facilitated small groups

(Shanafelt, 2016) (West, 2014, 2015) (J Gen Intern Med 2015) (JABFM 2015)

(Gidwani, 2017)

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Think, Pair, Share

• Think about the individual and

organizational tools available.

– Pick one tool you would like to implement.

– Name the first step in implementing that tool

in your program.

– Pair, share.

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Summary

• Defined burnout and its key drivers and

consequences

• Became familiar with the ACGME common

program requirements for well being (Section VI)

• Learned evidence-based tools to promote

wellness

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Please

complete the

session evaluation.

Thank you.

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References

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• Ospina-Kammerer, V., & Figley, C. R. (2003). An evaluation of the Respiratory One Method (ROM) in reducing emotional exhaustion among family physician residents. Int J Emerg Ment Health, 5(1), 29-32.

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• Shanafelt, Tait D., Dyrbye, Lotte N., Sinsky, Christine, Hasan, Omar, Satele, Daniel, Sloan, Jeff, & West, Colin P. (2016). Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clinic Proceedings, 91(7), 836-848.

• Shanafelt, Tait D., MD et al. (2016). Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort. Mayo Clinic Proceedings, 91(4), 422-431.

• Shanafelt, T. D. (2015). Impact of Organizational Leadership on Physician Burnout and Satisfaction. Mayo Clinic Proceedings, 90 (4), 432-440.

• Shanafelt, Hasan, Dyrbye, Sinsky, Satele, Sloan, & West. (2015). Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings,90(12), 1600-1613.

• Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., . . . Oreskovich, M. R. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med, 172(18), 1377-1385. doi:10.1001/archinternmed.2012.3199

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References

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• Shiralkar, M. T., Harris, T. B., Eddins-Folensbee, F. F., & Coverdale, J. H. (2013). A systematic review of stress-management programs for medical

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• Thomas, M. R., Dyrbye, L. N., Huntington, J. L., Lawson, K. L., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2007). How do distress and well-being

relate to medical student empathy? A multicenter study. J Gen Intern Med, 22(2), 177-183. doi:10.1007/s11606-006-0039-6

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54. doi:10.1007/s40596-014-0197-5

• Mindfulness Based Stress Reduction– Umass online course

– http://www.umassmed.edu/cfm/stress-reduction/mbsr-online/

• Books– Full Catastrophe Living. Jon Kabat-Zinn, PhD. Delacorte, 1990.

– Wherever you go, There you are: Mindfulness Meditation in Every Day Life. Jon Kabat-Zinn, PhD. Hyperion,1994.

• Curriculum- University of Rochester (Krasner and Epstein)– https://www.urmc.rochester.edu/family-medicine/mindful-practice/presentations-

workshops.aspx

• www.calm.com

• Evans Health Lab– http://www.evanshealthlab.com/9010-stress/

Additional resources- Mindfulness

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