from burnout to engagement: strategies to promote physician wellness and workplace satisfaction

WEBINAR WELCOME!

Dr. Colin WestPhysician and researcher

Departments of Internal Medicine and Health Sciences Research

Mayo Clinic

Dr. Michael KrasnerProfessor of

clinical medicineUniversity of Rochester

Maureen McKinney Editorial Programs

Manager Modern Healthcare

During today’s discussion, feel free to submit questions at any time by using the questions box.

A follow-up e-mail will be sent to all attendees with links to the presentation materials online.

Dr. Ted HamiltonVice president of medical mission

Adventist Health System

Panelists:

FROM BURNOUT TO ENGAGEMENT: Strategies to Promote Physician Wellness and Workplace Satisfaction

WEBINAR HOUSEKEEPING

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WEBINARFROM BURNOUT TO ENGAGEMENT: Strategies to Promote Physician Wellness and Workplace Satisfaction

Maureen McKinneyEditorial Programs


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Mayo Clinic

What is Burnout?

Burnout is a syndrome of:

depersonalization

emotional exhaustion

low personal accomplishment

leading to decreased effectiveness at work.

Burnout among Practicing Physicians

National Data (Shanafelt et al., Arch Intern Med 2012)

Burnout: 45.8%

Emotional exhaustion: 37.9%

Depersonalization: 29.4%

Burnout by Specialty (National)

0 10 20 30 40 50 60 70

Prev Med/Occupat Med/Enviro Med

Dermatology

Pediatrics - General

Pathology

Radiation Oncology

Other

Pediatric Subspecialty

Neurosurgery

Psychiatry

Urology

General Surgery Subspecialty

Ophthalmology

Internal Medicine Subspecialty

General Surgery

Average Burnout All Physicians

Participating

Physical medicine and Rehab

Radiology

Obstetrics and Gynecology

Anesthesiology

Orthopedic Surgery

Otolaryngology

Family Medicine

Neurology

Internal Medicine - General

Emergency Medicine

% Reporting Burnout

Emergency Medicine

General Internal Medicine

Neurology

Family Medicine

Otolaryngology

Orthopedic Surgery

Anesthesiology

OB/GYN

Radiology

Physical medicine/Rehab

Average all physicians

General Surgery

Internal Medicine Subspecialty

Ophthalmology

General Surgery Sub-specialty

Urology

Psychiatry

Neurosurgery

Preventative/Occupational Medicine

Pediatric Subspecialty

Other

Radiation Oncology

Pathology

General Pediatrics

Dermatology

Shanafelt et al.

Arch Intern Med 2012

Consequences of Physician Burnout

• Medical errors1-3

• Impaired professionalism5,6

• Reduced patient satisfaction7

• Staff turnover and reduced hours8

• Depression and suicidal ideation9,10

• Motor vehicle crashes and near-misses11

1JAMA 296:1071, 2JAMA 304:1173, 3JAMA 302:1294, 4Annals IM 136:358, 5Annals Surg 251:995, 6JAMA 306:952, 7Health Psych 12:93, 8JACS 212:421, 9Annals IM 149:334, 10Arch Surg 146:54, 11Mayo Clin Proc 2012

Physician Burnout: Key Drivers

• Excessive workload

• Inefficient environment, inadequate support

• Loss autonomy/flexibility

• Problems with work-life integration

• Loss of meaning in work

Intervention Trial

• RCT testing if an established, portable, low-cost

curriculum administered during regular work hours can

promote meaning and reduce burnout

– Arm A (Intervention):

• meet 90 minutes (12:30-2) every other wk (60 mins protected time, ~1% FTE)

• 9 months

• Facilitated curriculum, small groups of 6-8 physicians

– Arm B (Control):

• Receive 60 minutes every other week for professional/administrative tasks (~1% FTE)

• Outcomes assessed quarterly, 3 months post, 12 months

post

West et al., JAMA Intern Med. 2014:174:527-33

Conclusions

• A small amount of protected time during the workday

resulted in improved meaning from work and

reductions in burnout

– Effects larger in facilitated small group arm than in “free time” control arm, particularly in promoting meaning and reducing depersonalization.

– Follow-up study data found sustained benefits at 1 year after the close of the study.

West et al., JAMA Intern Med 2014:174:527-33

Second Intervention Trial

DOM faculty

N=550

Volunteers

N=125

Non-

volunteers

N=425

Intervention

N=64

Waitlist Control

N=61

Current

Practice

Conclusions

• Compared to the wait-listed control group, the facilitated

small group intervention improved:

– Depersonalization

– Personal accomplishment

– Overall QOL

– Depression

– Meaning from work

– Social isolation at work

– Job satisfaction

– Likelihood of leaving in next 2 years

• Initial intervention shows benefit with sustained changes

over subsequent 6 months.

Individual Strategies

• Identify Values

• Debunk myth of delayed gratification

• What matters to you most (integrate values)

• Integrate personal and professional life

• Optimize meaning in work

• Flow

• Choose/focus practice

• Nurture personal wellness activities

• Calibrate distress level

• Self-care (exercise, sleep, regular medical care)

• Relationships (connect w/ colleagues; personal)

• Religious/spiritual practice

• Mindfulness

• Personal interests (hobbies)

What Can Organizations Do?

• Be value oriented

• Promote values of the medical profession

• Congruence between values and expectations

• Provide adequate resources (efficiency)

• Organization and work unit level

• Promote autonomy

• Flexibility, input, sense control

• Promote work-life integration

• Promote meaning in work

Burnout: Key Drivers

• Excessive workload

• Inefficient environment, inadequate support

• Loss autonomy/flexibility

• Problems with work-life integration

• Loss of meaning in work

NOW SPEAKING



Dr. Michael KrasnerProfessor of clinical medicine

University of Rochester

Medicine in CrisisCrisis of meaning

Crisis of identity

Crisis of purpose

Crisis of role

Sir Luke Fildes, The Doctor 1867 Oil on canvas, The Tate Britain, London

Toll , B. JAMA June 20, 2012

HYPOTHESES:

Resilience is a capacity that can be grown

Lower quality of technical care

Riskier prescribing practices

More medication errors

Lower patient adherence to treatment

More unsafe behaviors (e.g. needlestick injuries, not following protocols)

Lower patient satisfaction

Erosion of altruism and empathy

Unprofessional conduct

Poor relationships with staff and patients

Higher attrition and job turnover � higher recruitment costs

Fahrenkopf et al. 2008; DiMatteo et al. 1991; Williams et al. 2009; Shanafelt et al. 2005; Dyrbye et al. 2010; Haas et al 2000; Sundquist et al 2000; Krasner et al. 2009; Buchbinder et al. 2001

Clinician resilience

(well-being –burnout)

Quality of care(safety –errors)

Quality of caring(compassion -detachment)

Shanafelt, T. D., et al. (2002). Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med, 136, 358-367; Shanafelt, T. D., et al. (2005). Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med, 20, 559-564.

Three components:

� Emotional exhaustion

� I just can’t do any more

� Depersonalization (cynicism)

� Every good deed gets punished

� Low personal accomplishment

� No matter how hard I work, nothing improves

The ability of an individual to respond to stress in a healthy, adaptive way such that personal goals are achieved at minimal psychological and physical cost; resilient individuals not only “bounce back” rapidly after challenges but also grow stronger in the process.

Epstein & Krasner 2013

Howe A et al 2012

Burnout ResilienceWithdrawn Present

Emotionally exhausted Energized

Defeated Bouncing back

Going through the motions Fully engaged

Brittle, rigid Bending, not breaking

Cynical, hopeless Capacity for positivity

Hypercritical A light touch

Feeling ineffective Becoming stronger

Treading water Moving forward

AFGO Welcoming change

Optimism

More and more I have come to admire resilience.Not the simple resistance of a pillow, whose foamreturns over and over to the same shape, but the sinuoustenacity of a tree: finding the light newly blocked on one side,it turns in another. A blind intelligence, true.But out of such persistence arose turtles, rivers,mitochondria, figs -- all this resinous, unretractable earth.

~ Jane Hirshfield ~

Mindfulness• Integral to professional competence

• A quality of consciousness

• Attends to the context in which the contents of consciousness are expressed

• Can be cultivated, grown, expanded

• Attentive observation, critical curiosity, beginner’s mind, presence

• The awareness that arises out of paying attention on purpose, in the present moment, without judgment (Kabat-Zinn 1994)

Why should mindfulness matter to clinicians?

• Quality of care

• Empathy

• Avoids cognitive traps and resulting errors

• Clearer assessments

• Promotes a more participatory medicine

Moment-to-moment purposeful awareness of one’s own mental and physical processes during every day work with the goal of practicing with clarity and compassionEpstein RM 1999

Resilience andwell-being

Quality of care

Quality of caring

Mindful practice

� Participation in a mindful communication program was associated with sustained improvements (<.001) in: � Patient-centered attitudes (empathy, psychosocial orientation)

� Physician well-being (burnout, mood)

� Personality (increased emotional stability).

� Associations were mediated by changes in mindfulness.

� Participants identified three themes: community, skills development, and giving oneself permission to take time for self-development

� Results replicated in Spain and North America

RESILIENCE = INTENTION + COMMUNITY + SKILLS + ENGAGEMENT + SUPPORT

Other programs

Baystate Medical Center

Boston University

Brown University

Dalhousie University

Dartmouth Medical School

Drexel University

Duke University

East Carolina University

Georgetown University

Göteborg, Sweden

Hamilton Ontario Health Systems

Harvard Medical School

Hong Kong University

Jefferson Medical College

Mayo Medical School

McGill University

Monash University

Oakland University

Ohio State University

Oregon Health Sciences University

Universidad Autónoma de Barcelona

University of Iowa

Université de Montreal

University of California, San Diego

University of Massachusetts

University of Rochester

University of Toronto

University of Wisconsin

www.mindfulpractice.urmc.edu

NOW SPEAKING





WALL STREET JOURNAL

American doctors are unhappy . . .

and it’s hurting patients.

If you want to change the culture of an

organization, you don’t have to get

everybody…you have to get the square

root of N. It will take on a life of its own

and drive itself ahead.

W. Edwards Deming

“SQUARE ROOT OF N”

• 649 physicians

• 281 spouses / family members

• 10,249 total number of sessions

PHYSICIAN SUPPORT SERVICES

4

• Clinical burnout

• Depression / mood disorders

• Marital / relationship issues

• Anger management / boundary issues

• Addiction / substance abuse

CLINICAL ISSUES

FINDING MEANING IN MEDICINE

SCHWARTZ ROUNDS

• Physician Support Service

• Meaning in Medicine

• Schwartz Rounds

• Physician On-Boarding

THE BIG FOUR

8

forphysicianwellbeing.org

WEBINAR

TODAY’S PANELISTS


During today’s discussion, feel free to submit questions at any time by using the questions box



Mayo Clinic

Dr. Michael KrasnerProfessor of

clinical medicineUniversity of Rochester

Maureen McKinney Editorial Programs




Expect a follow-up email within two weeks with links to presentation materials and information about how to offer feedback.

For more information about upcoming webinars, please visit ModernHealthcare.com/webinars

WEBINAR THANK YOU FOR ATTENDING

Thanks also to our panelists:

Dr. Colin WestPhysician and researcher Departments of Internal Medicine and Health Sciences ResearchMayo Clinic

Dr. Michael KrasnerProfessor of clinical medicineUniversity of Rochester

Maureen McKinney Editorial Programs Manager Modern Healthcare

Dr. Ted HamiltonVice president of medical missionAdventist Health System


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