physician-based approaches to burnout: how little …physician-based approaches to burnout: how...
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Physician-based approaches to burnout: How little we know
Dr. Jillian Horton, BA MA MD FRCPC (Internal Medicine)
Associate Chair, Professionalism and Diversity, Department of Internal medicine
Director, Allan Klass Health Humanities Program and Learner Wellness
Assistant Director, Manitoba Practice Assessment Program
Max Rady College of Medicine, Rady Faculty of Health Sciences
www.dreamstime.com
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No conflicts to declare.
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Burnout is:
“Emotional exhaustion, depersonalization, and diminished sense of personal accomplishment, primarily driven by workplace stressors.”
Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. Palo Alto CA: Consulting Psychologists Press; 1996.
http://www.clker.com/clipart-burnt-match.html
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Burnout has personal consequences
Lower work satisfaction
Disruption to personal relationships
Substance misuse
Depression and suicide
-Wurm W, Vogel K, Holl A, et. Al. Depression-burnout in physicians. PLoS One. 2016; 11(3):e0149913.
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Burnout has patient consequences
Increase in medical errors
Reduced quality of patient care
Lower patient satisfaction
-Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010; 251(6): 995-1000
Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008; 336 (7642): 488-491.
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Burnout has organizational consequences
Decreased productivity
High job turnover
Early retirement
-Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. B<C Health Serv Res. 2014; 14: 325
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“Organizational factors* remain the primary drivers of burnout.”
Shanafelt, T, Noseworthy, John H. Executive Leadership and Pysician Well-being: Nine organizational strategies to promote engagement and Reduce Burnout. Mayo Clinic Proceedings. Jan 2017, Vol 92(1), pp. 129-146
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Burnout cannot be dealt with by individual alone
Problem with health care organization
Problem with working environment
Problem with organizational culture
-Montgomery A. The inevitability of physician burnout: implications for interventions. Burnout Research. 2014; 1(1): 50-56
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“Casting the issue as a personal problem can lead individual physicians to pursue solutions that are personally beneficial but detrimental to the organization and society.”
-Shanafelt, T, Noseworthy, John H. Executive Leadership and Pysician Well-being: Nine organizational strategies to promote engagement and Reduce Burnout. Mayo Clinic Proceedings. Jan 2017, Vol 92(1), pp. 129-146
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Change at organizational level(ie work environment interventions)
Change at individual level(ie mindfulness, self-compassion, behavioral training)
Lown M, Lewith G, Simon C, Peters D. Resilience: what it is, why do we need it, and can it help us? Br J Gen Practice. 2015; 65(639):e708-e710
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Physician Interventions
Horton, J and Chomichuk, GMB. Medicine. 2017
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“Human freedom involves our capacity to pause between the stimulus and response and, in that pause, to choose the one response toward which we wish to throw our weight….”
-Rollo May, The Courage to Create. WW Norton, 1994.
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There are physician-directedinterventions associated with small, significant reductions in burnout in controlled* trials…
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Panagioti, M, Panagopoulou, E. Controlled Interventions to Reduce Burnout in Physicians: A systematic review and meta-analysis. JAMA Internal Med. 2017;177(2):195-205.
System AND individual interventions
RCTs, non-RCTs, controlled before-after, interrupted time
2322 articles * 19 articles
12 were MD-directed interventions
*No intervention, no burnout outcome, mixed
sample <70%, uncontrolled before/ after
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The “physician-directed” interventions:
Mindfulness meditation
Communication/ behavioral skills
Empathy, self-compassion, self-examination
Exercise w. accountability
Panagioti, M, Panagopoulou, E. Controlled Interventions to Reduce Burnout in Physicians: A systematic review and meta-analysis. JAMA Internal Med. 2017;177(2):195-205.
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Organizational and physician-directed interventions showed small, significant reductions in burnout
Standardized mean difference –0.29, 95% CI, -0.42 to -0.16 (equals improvement by 3 points on MBI)
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Results:
Organization-directed interventions were more effective: SMD 0.45, 95% CI, -0.62 to -0.28
Physician-directed interventions:SMD 0.18, 95% CI, -0.32 to -0.03
. Panagioti, M, Panagopoulou, E. Controlled Interventions to Reduce Burnout in Physicians: A systematic review and meta-analysis. JAMA Internal Med. 2017;177(2):195-205.
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West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281
System and individual interventions
2617 52 made final cut
20/ 52 were physician-directed interventions.
Most were RCTs or OS.
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“Physician-directed” interventions:
Small group curricula; “belonging”intervention
Stress-management and self-care
Communication training
Mindfulness
West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281
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Organizational and physician-directed interventions showed small, significant reductions in burnout
Overall burnout decreased from 54% to 44% (95% CI 5-14)
If you could apply this result to 2014 national data for US physicians, that 10% reduction would represent an 18% RRR in burnout
West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281
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Results were similar for individual-focused and organizational interventions.
West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281
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For Physician-directed interventions:
“Results generally suggest sustained or even augmented benefits for many months after completion…but finding not universal.”
http://clipart-library.com/pictures-of-syringe.html
West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281
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“No specific interventions are better than are others…
…both strategies are probably necessary. However, their combination has not been studied.”
West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281
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THE BOTTOM LINE:
“…we should not wait for perfect understanding before acting; too much is at stake.”
Epstein, RM, Privitera, M. Doing something about physician burnout. The Lancet. Vol. 388, Issue 10057, 5-11. November 2016.
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THE BOTTOM LINE:
Don’t just sit there…do something !
https://www.aldacenter.org/medical/immersionPhoto: Jillian Horton
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https://www.narrativemedicine.org
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http://www.ronaldepstein.com
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Krasner, Michael S ; Epstein, R et al. Association of an Educational Program in Mindful Communication with Burnout, Empathy and Attitudes among Primary Care Physicians. JAMA, 23 September 2009, Vol.302(12), pp.1284-1293
Improvements in mindfulness: raw score change 8.9%, 95% CI, 7.0-10.8)
Reductions in burnout: -6.8; 95% CI-4.8 to -8.8
Improvements in mindfulness* were correlated with improvements all measured outcomes
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Evidence has linked each 1 point deterioration in burnout scores with an increased likelihood of reduction in FTE in the following 12 months.*
*Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clinic Proc 2016; 91: 422-31
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Bringing it home:
Burnout has individual and organizational remedies
Literature says: use dual approach, but much uncertainty in terms of best practice
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Bringing it home…
A wide variety of individual interventions have some support in the literature
Even small improvements in burnout scale scores can help with attrition (and with other things too)
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For more information on Mindful Practice Programs :
Mindful Practice Courses through Compassion Project at SBGH (next one April 13)
http://www.chcm-ccsm.ca/compassion-project/spring-2019-programming/event-series/mindful-practice/
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Burnout – carrying on the conversation:
Internal Medicine Grand Rounds, May 14, 08:00
Theatre A, BMS, Bannatyne Campus, Rady FHS
Dr. Tait Shanafelt, Director, Well MD Centre
Associate Dean, Stanford School of Medicine
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Dr. Jillian Horton, BA MA MD FRCPC (Internal Medicine)
Associate Chair, Professionalism and Diversity, Department of Internal medicine
Director, Allan Klass Health Humanities Program and Learner Wellness
Assistant Director, Manitoba Practice Assessment Program
Max Rady College of Medicine, Rady Faculty of Health Sciences
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The Mindful Practice Program, University of Rochester
“Before and after” study*
70 primary care MDs (invited all 871 in area)
8-week intensive (2.5h/week, 7 hr retreat) followed by 10-month maintenance phase (2.5h/month)
-Krasner, MS, Epstein, RM, Beckman, H et al. Association of an educational program in mindful communication with burnout, empathy and attitudes among primary care physicians. JAMA. 302 (2009), 1284-1293
*Mercer SL, DeVinney BJ et al. Study designs for effectiveness and translation research: identifying trade-offs. Am. J. Prev. Med. 2007; 33(2): 139-154
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Leading drivers of burnout
Excessive workload
Imbalance between job demands and skills
Lack of job control
Prolonged work stress
-Linzer M, Visser MR, Oort FJ, Smets EM, McMurray JE, de Haes HC; Society of General Internal Meidcine(SGIM) Career Satisfaction Study Group (CSSG). Predicting and preventing physician burnout: results from the Uited States and the Netherlands. Am J Med. 2001; 111(2): 170-175