wellness and well-being: avoiding burnout and staying resilient and well-being... · 2014. 1....

1©Jay Kaplan, M.D. 2013

Wellness and Well-Being:Avoiding Burnout and

Staying Resilient

Jay Kaplan, MD, FACEP

Member, ACEP Board of Directors

Practicing Clinician and Director, Service/Operational Excellence, CEP America

Upfront Questions

What do you want?

Are you getting it?

If yes, how do you plan on keeping it?

If no, how do plan on getting it?


Emergency Medicine

Gen Internal Medicine

Int Medicine Subsp

General Pediatrics

General Surgery

Mean

Orthopedic Surgery

Family Medicine

Ob/GYN

Gen Surgery Subsp

Preventive Med/Occ Health

Burnout and Satisfaction with Work-Life Balance – Arch Int Med August 2012Physicians who reported burnout: 45.8%


Medical Residents & Burnout Journal of Medicine 09/12

Residents who reported burnout symptoms

Feelings of depersonalization

Quality of Life “as bad as it could be”

51.5%

28.9%

14.8%

Nursing Morale Survey 2007

Feel they are too busy to provide the care they would like

Would recommend nursing as a career:

Would leave nursing if they could:

55%

49%

28%


Real-Time Professional Sources of StressReal-Time Professional Sources of Stress

Work at all hours of the day and night

Malpractice litigation

Risk of infectious disease exposure

Risk of violence

Illness/impairment

Loss of connection to purpose

Stress (Day to Day)Stress (Day to Day)

Unpredictability of each day

Constant pressure for perfection

diagnosis (risk of malpractice complaint)

service (risk of patient complaint)


More Specifically . . .

Critically ill patients, one after another

“Difficult” Patients (Intoxicated, Angry, Entitled, Drug-Seeking)

Staffing shortages

EHR/Computer anything

Limited resources of facility

Drug shortages

How much of it will

there be?

How Quickly It

Does Burn?

Add to all that, Living in the real world . . .


“Well-Being” “Burnout”“Well-Being” “Burnout”

Involvement and Engagement

Patience and Compassion

Feeling of Fit and being a part of a greater whole

Exhaustion, Cynicism, Indifference

Anger, Bitterness, Frustration

Alienation and Isolation

StressStress

Stress = a nonspecific response of the body to any demand.

Stressors may be pleasant or unpleasant.

One system is the weakest and first affected by stressors.

Stress = a nonspecific response of the body to any demand.

Stressors may be pleasant or unpleasant.

One system is the weakest and first affected by stressors.


Neuroendocrine-NeuroimmuneStress Response SystemNeuroendocrine-NeuroimmuneStress Response System

Immune systemImmunocyte behaviore.g., cytokine release

Limbic SystemHypothalamus

PituitaryAdrenals

Sympathetic nervoussystem

Aminergic Changes

Stress

Stress - Cannon & SelyeStress - Cannon & Selye

Homeostasis - the body’s balancing act

General Adaptation Syndrome (3 stages)

1) Alarm– Shock phase

– Countershock phase

2) Resistance

3) Exhaustion/Renewal

Homeostasis - the body’s balancing act

General Adaptation Syndrome (3 stages)

1) Alarm– Shock phase

– Countershock phase

2) Resistance

3) Exhaustion/Renewal


Homeostasis

Waking

Excitement

RelaxingDigesting

Sleeping

Running

Perceived Threat Sympathetic Outflow

Perceived threat


Parasympathetic Outflow Renewal

Cause and Effect

Causes:

Difficult patients

Difficult families

Difficult consultants

Circadian disruption

Litigation fears

Reimbursement fears

Job security fears

EHR

Staffing shortages

Effects:

Cynicism

Negativity

Difficulty sleeping

Substance use

Anxiety

Marital problems

Depression

Exhaustion

Alienation

Past Learning

Past Learning

PerceivedThreat

PerceivedThreat

Sympathetic DominanceSympathetic Dominance


Parasympathetic v. Sympathetic

Sympathetic Dominance• Compromised Cognitive and

Motor Functioning

• Reactive

• Repeating Same Mistakes

• Coercive or Hesitant Leader

Parasympathetic Dominance• Maximal Cognitive & Motor Functioning

• Intentional

• Creative Problem Solving

• Transformative Leader*Slide courtesy of CEP America Resiliency Course

Optimal Performance:

p


PNI - Effects of StressPNI - Effects of Stress

Increased cortisol and epinephrine

Higher number and NK cell activity

Decrease in % of helper to inducer cells, helper to suppressor-cell ratios

Lower levels of S-Ig A, Ig A, Ig G, Ig M

Increased illness and morbidity

Avoiding Burnout: Tactics for WellnessAvoiding Burnout: Tactics for Wellness

A painting by Edward Hicks (1780)–1849))


1. Don’t miss the boat.

2. Remember we are all in the same boat.

3. Plan ahead. It wasn’t raining when Noah built the Ark.

4. Stay fit. When you’re 600 years old, someone may ask you to do something very big.

5. Don’t listen to critics. Just get on with the job that needs to be done.

6. Build your future on high ground.

Tactics for Wellness Learned From NoahTactics for Wellness Learned From Noah

Lessons

7. For safety’s sake, travel in pairs.

8. Speed isn’t always an advantage. The snails were on board with the cheetahs.

9. When you’re stressed, float a while.

10. Remember the Ark was built by amateurs, the Titanic by professionals.

11. When you’re in a storm, if you feel connected, there will always be a rainbow after the storm.


1. Don’t Miss the Boat

This life is not a dress rehearsal

Identify who you want to be, what is important to you, what you want to do, the legacy you want to leave

Tactic: Personal Mission Statement (Write down what is important to you)

I am:A student of lifeA teacher by exampleA feeler of feelingsA devoted fatherA grateful husbandConnected to people

to spirit andto myself

Willing to love and be lovedAnd to use mind heart and soulTo make a differenceSeeking guidance, inspiration and joy

JAK Mission Statement


2. Remember We’re All in the Same Boat

It is about the people who surround you, and choosing those who will support your strengths and help you with

your opportunities . . . It is about everyone on

board, paddling together . . .

Tactic: Choose carefully who you spend time with and who you surround yourself with.


3. Plan Ahead . . . It Wasn’t Raining When Noah Built the Ark

Determine your key metrics

Define where you are/Set goals for where you want to be

Tactic - Do a Self-Assessment –How Is Your Balance?


The Adult Apgar

– Shay Bintliff, M.D., FACEP

Write out a “Joy List”

Create a formal “Renewal Investment Plan”

1000 Marbles Exercise

Tactics


Treat your body as your temple.

Get enough rest.

Eat whatever diet works for your body.

Exercise is a great drug.

4. Stay Fit – When You’re 600 years Old, Someone May Ask You To Do Something Really Big . . . 4. Stay Fit – When You’re 600 years Old, Someone May Ask You To Do Something Really Big . . .

TacticsTactics

Rest/SleepSet a goal for rest timeAvoid alcohol, caffeine, meals close to bedtimeShift work – family cooperation, heavy curtains, white noise, blindfoldsSet alarm for when to go to bed

Note: If you get < 6 hours of sleep a night, your risk of coronary heart disease is increased 48% and risk of stroke 15%

FoodBreakfast is an important meal.Different strokes for different folks.


Exercise, andregularly.

Exercise is a great drugExercise is a great drug

Get a Heart-Rate Monitor Watch.


5. Don’t Listen to Critics . . . Just Get On with the Job that Needs to be Done

There’s a difference between being a “Winner” and a “Whiner”

Glass Half-Full v. Half-Empty

It’s a choice we make every day, or several times a dayDr. Whiner, c. 2000

No one is going to

create a great place for us to

work or for our patients to receive care unless we

participate . . .

“Where’s There’s No Gardener, There’s No Garden”


“It had long since come to my attention

that people of accomplishment rarely

sat back and let things happen to them.

They went out and happened to things.”

Leonardo De Vinci

Tactic

Do more than just your job.

Attend your department meetings.

Become a medical staff leader in your hospital.

Get involved with your state medical society or with the AMA


6. Build Your Future on High Ground

Integrity

Always act in the best interest of the patient.

We need to be willing to be honest with ourselves and hold ourselves accountable to standards.

Courageous humility – acknowledge and apologize when appropriate . . . and quickly . . .

Make Your Workplace

A Family A School

7. For Safety’s Sake, Travel in Pairs


Colleague as Customer

“What can I do to help you have a great day in working with me today?”

The Simplest Recognition: Saying “Thank you” at the

end of the day (shift)

Say Thank You More


8. Speed Isn’t Always an Advantage . . . The Snails Were On Board with the Cheetahs

“There is more to life than merely increasing its speed.”

--Gandhi

Tactic: Electronics Free Days Off

Turn off your smartphone

Do not feel guilty if you do not answer text messages.

Automatic reply for emails – “I am taking an electronics-free day off . . . Please contact me on _____.


Schedule time off . . . just for you . . .Electronics Free

Time Aloneand

Time Together

9. When You’re Stressed, Float a While

“Burnout is the chronic condition of perceived demands outweighing perceived resources.”- Gentry & Baranowsky 1998

“Compassion fatigue is burnout + secondary traumatization.” - Figley 1995


Tactic - “We are human beings,not human doings.”

Tactic - “We are human beings,not human doings.”

No one ever went to his/her deathbed wishing to have gone to work more.

“Work” harder on yourself/your family than you do on your job.

A Key Tactic to Avoid Overwhelm

Practice saying “NO”

If you can’t say “No,” say “Oh”

Look for the big “YES”

Remember Bob Dylan


Real-Time On-The-Job Self-Regulation Skills

Awareness of the body’s physiologic responses to stress

Intentionality/Mindfulness

Self-regulation

Breathing

Relaxation

Community support

Laugh . . . Have Fun


When you first start doing anything, you are not going to do it well.

Experts become experts through practice.

Tactic: Write down the sayings that help you through difficult times.

10. Remember . . . The Ark was Built by Amateurs, the Titanic by Professionals.

What Are the Sayings That Guide You?

“I’m always doing things I can’t do. That’s how I get to do them.”

Pablo Picasso

“Progress, not perfection; one step at a time.” 12 Step Program

“No one ever learned anything by beating themselves over the head with a mistake.” JAK


11. When You’re in a Storm, if You Feel Connected . . . There’s Always a Rainbow Waiting

Gratitude

Gratitude Journal

5 things for which you feel grateful

One sentence for each

Do once a week

Gratitude visit

Write a 300 word letter to someone who changed your life for the better

Deliver it in person preferably without advanced notice

When you get there, read the whole thing


Passion

“The greatest force on earth is the human soul on

fire”-Foche

“The antidote to exhaustion is not

necessarily rest . . . It’s whole-

heartedness”-Brother David Steindl-Rast

Know How Special You Are . . .

“We work in the dark.

We do what we can.

We give what we have.

Our doubt is our passion.

Our passion is our task.

The rest is the madness of art.”

- Henry James

wellness and well-being: avoiding burnout and staying resilient and well-being... · 2014. 1....

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