moving beyond burnout to professional engagement cmda... · –triad of compulsiveness •doubt...
TRANSCRIPT
Moving beyond burnout to professional engagement
Martina Schulte, MD
April 26, 2019
1. Explore nature, drivers, and consequences of burnout
2. Learn a framework for developing interventions
3. Discover actionable organizational and individual interventions to decrease burnout and enhance joy
Objectives
International Conference On Physician HealthToronto, Ontario October 11-13, 2018
Syndrome characterized by:
Emotional exhaustion
Depersonalization
Decreased sense of personal
accomplishment
The What: Burnout
Burnout, at its core, is the impaired ability to routinely experience positive emotion.
• first described - 1974 by Freudenberger
state of fatigue or frustration resulting from professional relationships that fail to produce the expected rewards
• later defined as psychological syndrome by Maslach✓ occurring in professionals
working with people in challenging situations
✓ occupational hazard for people-oriented workers
✓ environmental factors – high demand, low resources settings
• common norms:➢ be selfless and put others'
needs first➢ work long hours ➢ do whatever it takes, go the
extra mile
• Healthcare- qualities selected for (Gabbard, JAMA 1985):– triad of compulsiveness
• doubt• guilt• exaggerated sense of
responsibility– delay gratification– perfectionism
Burnout- overview
Yerkes-Dodson Curve
Shanafelt. Mayo Clin Proc. 2015
Frequency: Burnout
2011 2014 2017
Burnout (MBI) 45.5 54.4 43.9
Satisfaction (WLB) 48.5 40.9 42.7
2011 2014 2017
Burnout (MBI) 28.6 28.4 28.1
Satisfaction (WLB) 55.1 60.3 61.0
Physicians
Non-physician working US adults
Shanafelt. Mayo Clin Proc. 2019
Risk vs non-physicians
Shanafelt. Mayo Clin Proc. 2019
Frequency: Burnout
• Nurses – University hospital
nurses1
• 18% met criteria for PTSD
• 86% met criteria for burnout syndrome
– Critical care nurses2
• Half are emotionally exhausted
• 2 out of 3 have trouble sleeping
• 1 our of 4 are clinically depressed
• Physicians3
– 54.4% met criteria for burnout, up from 45.5% in 2011
• Residents4
– 74% burned out
– 20% met criteria for depression
• Medical students5 –49.6%
Burnout - Prevalence
1 Mealer et al. 2009. Depression and Anxiety2 Sexton, et al. 2009. Palliative Care3 Shanafelt et al. 2015. Mayo Clin Proc4 Fahrenkopf et al. 2008. BMJ5 Dyrbye et al. 2011.
Shanafelt, Mayo Clin Proc, 2017
Consequences
• Workload
• Control/Autonomy
• Values/meaning
• Fairness
• Community
• Reward
Work Environment- Christine Maslach
• Quality of care• Electronic health records• Autonomy and work control• Practice leadership
– Values alignment– Balanced approach to initiatives
• Collegiality, fairness and respect• Work quantity and pace• Work content, allied health professionals and support
stability• Pay/income• Regulatory and liability concerns
Friedberg. Published online, 2013
• Workload• Control/Autonomy• Values/meaning• Fairness• Community• Reward
Maslach
Canary in the coal mine
Thinking about intervening
Frameworks for taking action
• Workflow
• Electronic health record
• Team-based care
• Clerical burden
• Regulatory requirements
Efficiency of Practice
• Leadership• Values alignment• Voice/input• Meaning in work• Peer support• Community/collegiality• Appreciation• Flexibility• Culture compassion
Adapted from Shanafelt, American Conference on Physician Health, 2017
Culture of Wellness
Interventions!
Focus: Individual or Organizational?
Lancet. Published online September, 2016
JAMA Intern Med. Published online December, 2016
Organizational
• Duty-hour requirements-reference
• Shorter attending rotations
• Shorter resident shifts in ICU
• Float pools for planned absences
• Small amount of protected time
Individual
• Meditation/Mindfulness
• Stress management training
• Communication skills training
• Narrative medicine
• Small group curricula and belonging interventions
Interventions
Efficiency of practice
• Primary care clinicians at 34 clinics in Midwest and NY
• Work condition measurements:– time pressure– workplace chaos– work control– clinician outcomes
• Work-life measurement
➢Chose interventions for clinical site
Linzer, J Gen Intern Med, 2015
Intervention clinicians
– Improvements in burnout and satisfaction
– Burnout was more likely to improve with
• workflow interventions
• targeted QI projects
➢Site-specific control over intervention
Results
Efficiency of practice
• Atrius Health, non-profit, MA Health Group- 740,000 patients
• Pre: provider efficiency score tracked:– every screen– click– scroll– every look at med list, problem list– time logged in to system
• Package of EHR-related interventions- SWAT– IT analysis, training, local support, security and interface issues– Workflow observation and analysis
Atrius Health, American Conference on Physician Health, Presented 2017
SWAT Intervention
• Outcomes:
– Click savings –estimated 1500 clicks of 4000 estimated/provider/day
– EPCS adoption rising rapidly
– Time savings
Unswatted Swatted
Time in navigator (mins/eval period) 248.2 131.8
Time in notes/letters (mins/eval period) 1020 910
Culture of wellness
• Intervention groupo 19 biweekly facilitated discussions o mindfulness, reflection, shared experience, and small-
group learning
• Facilitated small-group curriculum vs control o improved meaning and engagemento reduced depersonalizationo sustained results at 12 month
West. JAMA Intern Med, 2014
Culture of wellness
• Surveyed 3896 physicians, 72% response
• Assessed burnout and leadership qualities of immediate and division/department chair
• 12 leadership dimensions- Likert 1-5
Shanafelt. Mayo Clin Proc, 2015
➢ Leaders’ scores correlated with burnout and satisfaction
➢ Leadership responsible for 11% of variation in burnout
➢ Leadership rating explained 47% of variation in satisfaction
Results
➢ Leadership qualities are teachable:
o keeping people informed
o encouraging ideas for improvement
o having career development conversations
o providing feedback and coaching
o recognizing a job well done
Good News!!
For each 1 point increase in composite score
– 3.3% decreased likelihood of burnout
– 9% increased likelihood of satisfaction
1. Develop and implement targeted interventions
1. Workplace efficiencies/workflow
2. Workload
3. Address EHR challenges
2. Cultivate community
3. Harness the power of leadership
The Big Three!
Bryan Sexton, National Taskforce forHumanity in Healthcare
• Emotional Thriving• Emotional Recovery
I’m Burned Out
I’m Thriving
Christina Maslach
• Emotional Exhaustion• Depersonalization• Personal Accomplishment
Bohman, Dyrbye, Sinsky, et. al.
• Culture Of Wellness• Efficiency of Practice• Personal Resilience
Personal Energy and Renewal: From Empty to Full
What fills my emotional reservoir?Arenas of Life Exercise
Shanafelt. Arch intern Med, 2009
Purpose & Meaning
• Career Fit and Burnout Among Academic Faculty
➢ 556 physicians sampled, 465 (84%) responded
➢ Spending <20% of professional work time on most meaningful activity had higher burnout
➢ Time spent on most meaningful activity was the largest predictor of burnout
Explore and name your values- actively align decisions with your values
Identify your sense of purpose- consciously make choices that connect with your purpose
Know what brings you joy, make your bucket list and live it
Build and nurture your relationships Work less-actively mange and decrease
work-home conflicts Embrace a growth mindset, engaging in life
from a learning and growing perspective (Dweck, Mindset: The new psychology of success)
Exercise Sleep- 7-9 hours a night Have idle time Vacation- use all your vacation time Reflect, meditate, or engage in a spiritual
practice
Wellness Strategies:Being Intentional
• Individual interventions help
• But, burnout is a system issue
• Creating joy in practice necessitates systems interventions
• Interventions & studies are happening
• Ways forward are emerging– Building community/support
– Site-specific workflow efficiencies & interventions
– Leadership development
– Attend to yourself
• Take care of yourself
• Be clear on what– brings you joy
– you value
• Let your purpose, joys and values be your guide your decision-making
But until the systems catch up …
• Errors/Safety– Welp. Front Psychol 2017– Shanafelt. Ann Surg 2010 – Williams. Health Care
Manage Rev 2007– Shanafelt. Ann Intern Med
2002– Tawfik. Mayo Clin Proc 2018
• Unprofessional behavior/impaired professionalism– Dyrbye. JAMA, 2010
• Medication adherence– Haas. J Gen Intern Med 2000
• Staff turnover and reduced hours– Shanafelt. J Am Coll Surg 2011– Shanafelt. Mayo Clin Proc
2016
• Depression and suicidal ideation– Blach. Ann Surg 2011– Shanafelt., Arch Surg 2012
• Alcohol use– Oreskovich. Arch Surg 2012
• Mortality– Welp. Front Psychol 2017
Consequences - references
Driver Individual Organizational
Workload
Work efficiency/support
Work-lifeintegration/balance
Autonomy/flexibility/control
Values/meaning
Community
Drivers of burnout… and enhancing joy
West, Mayo Clinic