The Health and Wellness of Physicians: Managing Stress, Burnout and Energy

1
The Health and Wellness of Physicians Managing
Stress, Burnout and Energy

• Charlene M. Dewey, M.D., M.Ed., FACP
• William H. Swiggart, MS, LPC
• Co-Directors, Center for Professional Health
• Associate Professor of Medical Education and
  Administration
• Associate Professor of Medicine
• Vanderbilt University School of Medicine
• Department of Pediatric Grand Rounds
• February 2, 2011

2
Goals

• The purpose of this session is to provide an
  overview of how stress and burnout affects your
  professional health and wellness and what you can
  do to protect yourself as well as your personal
  and work relationships.

3
Objectives

• Discuss important statistics relative to the
  professional health and wellness of physicians.
• Define burnout and list risk factors and common
  symptoms of burnout.
• Discuss protective factors to prevent burnout
  throughout their medical career.
• Initiate an individual action plan to manage
  energy and help prevent burnout.

4
Agenda

• Introduction and Importance
• Professional Health and Wellness Spectrum
• Stress, Burnout and Energy
• Action Plans - Intent to Change
• Summary/Evaluation

5
Importance Evidence
Does this apply to me?
6
Importance Evidence

• Little education evidence building
• 30-60 MD have distress and burnout
• MDs suicide gt other prof. gen pop.
• One physician per day PhD unclear
• Grossly underestimated
• Depression/bipolar substance abuse suicide
  risk

Faculty Health in Academic Medicine Physicians,
Scientists, and the Pressure of Success. Cole,
Goodrich Gritz, 2009.
7
Importance Evidence

• Gender differences
• Females gt anxiety, depression, burnout
• Women chairs more stressed
• FgtM MD suicides
• Male physicians (regardless of race) live longer
  than other professionals.

http//www.aamc.org/members/gwims/statistics/stats
09/start.htm Lin et al.1985. Health status, job
satisfaction, job stress, and life satisfaction
among academic and clinical faculty. JAMA
254(19)2775-82. (Schindler et al 2006) High
physician suicide rates suggest lack of treatment
for depression. - MD Consult News June 11, 2008
8
Importance Evidence

• Reduced use of care by physician
• Stigma anonymity slow to prioritize MH issues
  for physicians licenses, etc.

http//www.aamc.org/members/gwims/statistics/stats
09/start.htm Lin et al.1985. Health status, job
satisfaction, job stress, and life satisfaction
among academic and clinical faculty. JAMA
254(19)2775-82. (Schindler et al 2006) High
physician suicide rates suggest lack of treatment
for depression. - MD Consult News June 11, 2008
9
Importance Evidence

• Academic faculty
• Worked longer hours
• Took less vacation
• 10 with mild depression
• 27 with elevated anxiety
• No sig difference clinical vs. academic
• Litigation/named in law suite

Lin et al.1985. Health status, job satisfaction,
job stress, and life satisfaction among academic
and clinical faculty. JAMA 254(19)2775-82.
Schindler et al. The Impact onof the changing
Health Care Environment on the Health and
Well-being of faculty at Four Medical Schools.
Academ Med 2006 81(1)27-34.
10
Importance Evidence

• Pediatricians
• Some evidence on pediatricians
• Burnout varies with training, practice, specialty
• Residents
• Primary care
• Specialty peds

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Pediatrics Residents

• Harvard
• 24 (20) with criteria for depression
• 92 (74) criteria for burnout
• Active surveillance 45 medication errors
• Depressed residents made 6.2 times as many
  medication errors per resident month (Plt0.001)
• BO alone did not increase error (P0.2)
• US Davis Residents did not manifest burnout
  some experience stress

Frahrenkopf, AM et al. Rates of medication errors
among depressed and burnt out residents
prospective cohort study. BMJ. 2008 Mar
1336(7642)488-91. Epub 2008 Feb 7. (Harvard
Childrens Hospital) Milstein JM et al. Med
Teach. Burnout assessment in house officers
evaluation of an intervention to reduce stress.
2009 Apr31(4)338-41. (UC Davis)
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Gen vs. Spec Pediatrics

• General pediatricians less likely to have
  symptoms of burnout or job stress (13)
• Pediatric subspecialists
• worked longer hours (59/week)
• office lt hospital
• higher of complex patients with psychosocial
  problems (46 vs. 25)
• reported significantly higher levels of burnout
  (23) and job stress (26)

Shugerman R, et al. Pediatric generalists and
subspecialists determinants of career
satisfaction. Pediatrics. 2001 Sep108(3)E40. (U
of Wash)
13
Specialty Pediatrics

• 389 physicians pediatric critical care
• Burnout
• 36 at risk
• 14 burned out (50)
• Perceptions of value of their work, feelings of
  success and satisfaction were highly associated
  with burnout

Fields AL, et al. Physician burnout in pediatric
critical care medicine. Crit Care Med. 1995
Aug23(8)1425-9. (GW)
14
Two systems interact
The internal system
The external system
Functional nurturing
Good skills
Poor skills
Dysfunctional
15
Importance Evidence

• Powerful model how practice environment can
  impact physician health
• Stress physician, environment, patients
• Environment was the only sig predictor of stress
• Job stress predicts job satisfaction
• Job sat is positive predictor of positive mental
  health
• Perceived stress was a stronger predictor of both
  poorer reports of physical and mental health
• Therefore, environment influenced health

Williams et al. Physician, practice and patient
characteristics related to primary care physician
physical and mental health Results of the
physicians work-life study. Health Services
Research, 2002 37(1)121-43.
16
Professional Health and Wellness

• The ethics of self-care
• The medical academy's primary ethical imperative
  may be to care for others, but this imperative is
  meaningless if it is divorced from the imperative
  to care for oneself. How can we hope to care for
  others, after all, if we ourselves, are crippled
  by ill health, burnout or resentment?

Cole, Goodrich Gritz. Faculty Health in
Academic Medicine Physicians, Scientists and the
Pressures of Success. Humana Press 2009 pg 7.
17
Professional Health and Wellness

• The ethics of self-care (cont.)
• medical academics must turn to an ethics that
  not only encourages, but even demands care of
  self.

Cole, Goodrich Gritz. Faculty Health in
Academic Medicine Physicians, Scientists and the
Pressures of Success. Humana Press 2009 pg 7.
18
Professional Health and Wellness

• Are we ethically obligated to care for ourselves?
• Do you feel empowered to demand your own self
  care?

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Professional Health Wellness
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Professional Health and Wellness

• No definition exists.
• In CPH
• PHW the health and wellness of an individuals
  psychological, physical, emotional and spiritual
  being in relationship to their work home
  environments
• Includes the individual, their work environment
  and their home environment

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Professional Health Wellness
Work Environment
Home Environment
22
Professional Health Wellness Spectrum
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Stress Burnout

• Stress and burnout occurs for different reasons
  in different individuals.
• Work load ? level of stress or burnout in all
  situations.
• Multifactorial

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Self-Awareness

• Self-awareness means having a deep understanding
  of ones emotions, strengths, weaknesses, needs,
  and drives. People with strong self-awareness
  are neither overly critical nor unrealistically
  hopeful. Rather, they are honest with
  themselves and with others.

What Makes a Leader? by Daniel Goleman, Best of
Harvard Business Review (1998)
25
Self-Assessments

• What stresses you out?
• Measure your stress level

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Definition - Stress

• Stress can be defined as
• d a state resulting from a stress especially
  one of bodily or mental tension resulting from
  factors that tend to alter an existent
  equilibrium ltjob-related stressgt Websters
  dictionary

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Stress Productivity
Prolonged Stress
Burnout
Stressed
Situational Stress
Non-Functional
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Managing Individual Stress

• Seven Key Areas
• Sleep
• Balanced meals
• Physical activity
• Socialization
• Vacations/down times
• Spiritual engagement
• Have a physician

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Managing Work-Place Stress

• Manage energy
• Self care at work
• Plan appropriately
• Reduce distractions
• Office culture
• Work place training on burnout

McCue JD Sachs CL. A stress management
workshop improves residents' coping skills. Arch
Intern Med. 1991 Nov151(11)2273-7. (Tufts)
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Managing Failures Successes
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Stress

• Into each ones life, some stress must come
• but it is how you handle it that is important.
  
• me

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Swiggart, Dewey, Hickson, Finlayson. A Plan for
Identification, Treatment, and remediation of
Disruptive Behaviors in Physicians. Frontier's
of Health Services management, 2009 25(4)3-11.
33
Definition - Burnout

• Burnout can be defined as
• a exhaustion of physical or emotional strength
  or motivation usually as a result of prolonged
  stress or frustration b a person suffering from
  burnout. Websters dictionary

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Burnout

• In the current climate, burnout thrives in the
  workplace. Burnout is always more likely when
  there is a major mismatch between the nature of
  the job and the nature of the person who does the
  job.
• Christina Maslach

The Truth About Burnout How Organizations cause
Personal Stress and What to Do About It. Maslach
Leiter pg 9 1997
35
Risk Factors for Burnout

• Single
• Gender/sexual orientation
• gt of children at home
• Family problems
• Mid-late career
• Previous mental health issues (depression)
• Fatigue sleep deprivation

• General dissatisfaction
• Alcohol and drugs
• Minority/international
• Teaching research demands
• Potential litigation

Puddester D. West J Med 20011745-7 Myers MJ
West J Med 200117430-33 Gautam M West J Med
200117437-41
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Six Sources of Burnout

• Work overload
• Lack of control
• Insufficient reward
• Unfairness
• Breakdown of community
• Value conflict

Maslach Leiter, 1997. The Truth About Burnout
How Organizations Cause Personal Stress and What
to Do About It. Losek D. Characteristics,
workload, and job satisfaction of attending
physicians from pediatric emergency medicine
fellowship programs. Pediatric Emergency Medicine
Collaborative Research Committee. Pediatr Emerg
Care. 1994 Oct10(5)256-9.
37
Symptoms of Burnout

• Chronic exhaustion
• Cynical and detached
• Increasingly ineffective at work (distressed
  behaviors)
• Leads to
• isolation
• avoidance
• interpersonal conflicts
• high turnover

Maslach Leiter, 1997. The Truth About Burnout
How Organizations Cause Personal Stress and What
to Do About It. pg 17
38
Protective Factors

• Personal
• Tend to self care issues first
• Address Maslachs 6 sources of burnout
• Influence happiness through personal values and
  choices
• Adapt a healthy philosophy/outlook
• Spend time with family friends

Spickard, Gabbe Christensen. JAMA, September
2002288(12)1447-50
39
Protective Factors

• A supportive spouse or partner
• Engage in religious or spiritual activity
• Hobbies
• Mentor (s)

Spickard, Gabbe Christensen. JAMA, September
2002288(12)1447-50
40
Protective Factors

• Work
• Address Maslachs 6 sources of burnout
• Gain control over environment workload
• Find meaning in work (value)
• Set limits and maintain balance
• Have a mentor
• Obtain adequate administrative support
• Learn about burnout and stress management

McCue JD Sachs CL. A stress management
workshop improves residents' coping skills. Arch
Intern Med. 1991 Nov151(11)2273-7.
41
Managing Energy at Work

• Listen to your body
• Identify your own needs
• Define limits - Just Say NO!
• Create your work environment
• Eliminate distractions
• Take breaks
• Plan ahead

Schwartz, T. McCarthy, C. Manage Your Energy
Not Your Time. HBR October 2007.
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Managing Energy Case Discussion

• Dr D is a 46 yo female physician-educator with 2
  kids and spouse with significant travel/work
  schedule. She wears 5 different hats on any
  given day and is involved is several community
  activities. Dr D finds emails and other
  interruptions distracting and is feeling stressed
  due to a grant and several submissions that are
  due in the next 6 weeks. She has cut down on
  sleep and exercise to meet the deadlines. Her
  back hurts by the end of the day.
• What are her risk factors for burnout?
• Will this lead to burnout?
• What changes could we suggest to control energy
  at work?

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Preventing Resolving Burnout
Figure 5.1 (pg 80) Maslach, C Leiter, MP. The
Truth About Burnout How Organizations Cause
Personal Stress and What to do About It. 1997
44
The Truth About Burnout

• The twin goals of preventing and building
  engagement are possible and necessary in todays
  working world. These goals cannot be easily
  achieved by an individual. Rather, people have
  to work together to make them happen. And if we
  all commit ourselves to the long-term process of
  organizational progress, we will be rewarded with
  workplaces that are more productive and resilient
  as well as humane.
• Maslach Leiter, pg 127

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Individual Action Plan

• List three self-care areas you will improve over
  the next 6 mo.
• List three ways to manage your energy at work.
• Identify a resource you will use if needed.
• Make it happen

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Resources

• PFWP/EAP or State physician health programs
• Primary care provider
• Private counseling services
• Personal coaches Center for Women in Medicine
• Substance services AA, NA, etc
• 1-800-273-TALK suicide prevention hotline
• Other YMCA/YWCA, Massage envy, wellness
  programs, health plus, etc.

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Summary Take Home Points

• You are valuable! Self-care is the foundation to
  faculty vitality and remaining professional.
• Stress happens Look for and anticipate stress.
• Take action immediately to manage energy, reduce
  stress and avoid burnout.
• Take advantage of the valuable resources
  available inside or outside of Vanderbilt
  bottom line is get help!

48
References

• Cole, Goodrich Gritz. Faculty Health in
  Academic Medicine Physicians, Scientists, and
  the Pressures of Success. Humana Press 2009.
• http//www.aamc.org/members/gwims/statistics/stats
  09/start.htm
• Lin et al.1985. Health status, job satisfaction,
  job stress, and life satisfaction among academic
  and clinical faculty. JAMA 254(19)2775-82.
• Schindler et al. The Impact of the changing
  Health Care Environment on the Health and
  Well-being of faculty at Four Medical Schools.
  Academ Med 2006 81(1)27-34.
• Shanafelt et al. Special Report Suicidal
  Ideation Among American Surgeons. ARCH SURG JAN
  2011146(1)54-62.
• High physician suicide rates suggest lack of
  treatment for depression. - MD Consult News
  June 11, 2008
• Schwartz, T. McCarthy, C. Manage Your Energy
  Not Your Time. HBR October 2007.
• Swiggart, Dewey, Hickson, Finlayson. A Plan for
  Identification, Treatment, and remediation of
  Disruptive Behaviors in Physicians. Frontier's
  of Health Services management, 2009 25(4)3-11.
• Goleman,Daniel. What Makes a Leader? Best of
  Harvard Business Review (1998)
• The Truth About Burnout How Organizations cause
  Personal Stress and What to Do About It. Maslach
  Leiter pg 9 1997
• Puddester D. Canadian Medical Association on
  Policy on Physician Health and Wellbeing. West J
  Med 2001174(1)5-7.
• Myers MF. The Wellbeing of Physician
  Relationships. West J Med 2001174(1)30-33.
• Gautam M Women in Medicine Stressor and
  Solutions. West J Med 2001174(1)37-41.
• Spickard, Gabbe Christensen. Mid-Career
  Burnout in generalist and Specialist Physicians.
  JAMA, September 2002288(12)1447-50.

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The first wealthishealth. Ralph Waldo
Emerson
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