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 …

Marti Schulte

mschulte@schultecpc.com

• 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