Post on 02-Apr-2015
Developing Physician Resiliency Through Mindfulness and Community
Pediatric Resident Coaching Program MeetingNovember 11, 2013
Emily F. Ratner, MD, Clinical ProfessorDepartment of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of MedicineStanford, California
Burnout
Emotional exhaustionDepersonalization – cynicismIneffectiveness – Decreased sense of
personal accomplishmentWork-individual mismatchMaslach Burnout Inventory – validated
survey
Burnout
Burnout AssessmentSingle question measures from MBIHow often do you feel this way about your job?I feel burned out from my work
Never = 0A few times a year = 1Once a month or less = 2A few times a month = 3Once a week = 4A few times a week = 5Every day = 6
I’ve become more callous toward people since I took this job
West et al, J Gen Intern Med 24(12):1318-21.
Burnout and Satisfaction with Work-Life Balance Shanafelt, et al. Arch Intern Med 2012;172(18):1377-1385> 7000 physicians46% of MD’s at least 1 symptom of burnout on MBI
38 % Emotional exhaustion29% Depersonalization12% Ineffectiveness
Physician depression – 38%Suicidal ideation in past year - 6.4%Poor work-life balance – 37%Burnout and poor work-life balance are a bigger problem for
doctors than other professions
40%
36%
Mean 46%
Burnout by Specialty
Shanafelt, Arch Int Med, 2012
460%
~42%
Mean satisfaction 49%
Satisfaction with work-life balance by specialty
Shanafelt, Arch Int Med, 2012
Medical StudentsHigher prevalence of psychological distress
in med students vs. age-matched peers Dyrbye et al, Acad Med 2006
Incidence of burnout – ranges from 21%-53% depending on source Santen et al, Southern Med J 2010, Dyrbye et al, JAMA 2011
Students going into medicine motivated by personal/family member’s illness or death, higher incidence of EE Pagnin et al. Med Teach, 2013.
Lowered academic performance, increased professional misconduct, decreased empathy, increased substance abuse, suicide
Resident BurnoutIncidence: 10-76%Internal medicine residents – 76% burnout, Seattle,
WA Shanafelt, Ann Int Med, 2001
Surgery residents – 56%, UC Irvine, Gelfand, Arch Surg, 2004
Alexithymic personality style associated w/higher burnout rates, Daly et al, Med J Aust 2002; 177 (1): 14
Alexithymia – inability to recognize or describe one’s emotions
Thomas, JAMA, 2004
Anesthesiology Residents> 2700 residents, response rate 54%
(>1500)MBI, Harvard Depression scale, best
practice and error self-reporting41% high burnout risk - associated with 3
factorsWorking > 70 hours/weekHaving > 5 drinks/weekFemale gender
De Oliveira, et al. Anesth Analg 2013;117:182-93
Anesthesiology Residents22% with depression
associated with same factors of burnout risk+ smoking
23% thought about/wanted to commit suicide - 68 residents
Best practice scores for burnout +/- depression lower
33% w/high burnout & depression risk had multiple medication errors, significantly more than low risk residents
De Oliveira, et al. Anesth Analg 2013;117:182-93
Causes of Burnout
According to demand-control-support modelo Intense work demandsoLack of controloHigh degree of work-home interference
Stressors?Put a photo here
Stressors at workSix Areas of Worklife Survey/MaslachWorkload – includes time pressure, increasing patient
complexity, documentation, regulationsControl – emergencies, scheduleReward – appreciation, recognitionCommunity – lack of support, isolationFairness - favoritismValues – aligned w/co-workers, larger organization
StressorsFamily issuesPersonal healthTime management Adjusting to current and
uncertain multiple changes in the health care environment
Financial – loans, decreased reimbursement
Technology
Are we too plugged in?Electronic medical record
NewUpgrades
Expectations of work at homeHome access to medical recordsEmail
Cell phones, laptops, desktops, chargers, batteries, adapters…..
Time allowance to learn new systems/upgrades
May be especially difficult for aging MD’s
Implications of BurnoutPatient care
Medical errors 53% of burned out Internal Medicine resident self reported at least one
type of suboptimal patient care event vs. 21% Shanafelt et al. Ann Int Med, 2002
Increased surgical error reporting associated with burnout Shanafelt et al. Ann
Surg 2010 “Brian Goldman, MD: Doctors make mistakes. Can we talk about that?”
http://www.youtube.com/watch?v=iUbfRzxNy20Patient complianceAdverse patient outcomesPatient satisfaction
ImplicationsPhysician health
Mental illness, depressionPhysical illness Effects of adverse patient outcomesMaladaptive responses to stress
Substance abuse Denial Avoidance Keeping stress to oneself, not seeking help Self-medication Ignoring self-care
One MD per day commits suicide in the US
Roberts, Anesthesiology Grand Rounds September 2012
“If we continue to just build in efficiency and not build in wellness, physicians will burnout. Doctors may still give good care {for a while}, even when burned out, but it will be at their own expense.”
Mark Linzer, MD 2012
The cost of replacing a physician is at minimum $250,000.
Buchbinder, Am J
Manag Care, 1999
Arenas to Approach Workplace WellnessIndividual
Increased self-awarenessStress reduction techniquesSupport networkReframing
Build communityPeer support groupsFamily and friends support
Workplace changes
ResilienceResilience is that ineffable quality that allows some people to be knocked down by
life and come back stronger than ever.Positive attitude, optimismAbility to regulate emotionsAbility to see failure as a form of helpful
feedbackReframing
Psychology
Today online
Program in Mindful Communication In Primary Care Physicians
70 primary care MD’s, year long program8 week intensive phase 10 month maintenance phase
CurriculumMindfulness meditationSelf-awareness exercisesNarratives about meaningful clinical experiencesAppreciative interviewsDidactic material, discussion
Krasner, Epstein et al. JAMA 2009
Program in Mindful Communication In Primary Care Physicians
Improved mindfulness correlated withLess burnoutBetter emotional stability, mood and empathy
SubjectivelyReduced isolation due to sharing personal
experiences from medical practice w/colleaguesMindfulness skills improved patient interactions and
MD’s developed more adaptive reserveTransformative to develop greater self-awareness
Beckman et al. Acad Med 2012;87:815-819
Georgetown Medical Students
12 week Mind-Body Skills medical student elective, to promote self-care and self-awareness
Initial funding by NIH/R2512 year history, ~ 800 medical students, 40%
class per year ~100 Georgetown medical school faculty trained,
including all clinical rotation directors (except 1), Dean of Medical Education
Outside faculty training ~ 50 currently trained
Georgetown Medical Student Study2 groups of medical studentsControl group – no interventionIntervention group – 12 week MBS courseCortisol, testosterone levels measured before
intervention (January) & after course completed (May) just prior to final exams Spring semester
Cortisol levels were 240% higher in control group in May
Testosterone levels were 160% higher in control group in May
All female cohort
MacLaughlin et al, 2011
Mindfulness ?Awareness of the present moment
Not past, not futureBeing not doingNoticing one’s own physical, mental,
emotional state – opposite of alexithymiaNot acting on it, watching but not judgingRecognizing that emotional states are all
temporaryTakes practice
Stanford Anesthesiology Residency
Large program 4 hospitals75 residents150 faculty members
Tertiary care center, critically ill patientsSilicon ValleyStanford duck syndrome
Goals of Resident Wellness ProgramCreate an environment to support and promote the well-being
of our residentsBuild community
Teach/expose residents to skills to promote resiliency
Prevent burnout, in those who aren’t already
Intervene early, prevent progression and devastating consequences
Core ComponentsInitiated 2010, planning since 2008 1. Mandatory first year resident lecture
Scientific lecture stress + biofeedback exercise
Negative recruiting2. Voluntary offsite weekend retreat CA-1’s3. Ongoing q 8 week sessions for remaining
3 years of residency, part of required, didactic program
Wellness Retreat1st year residents only
2010 – 14/26 (54%)2011 – 18/26 (69%) 2012 - 21/24 (88%)2013 – 20/26 (77%)
2 groups lead by 2 facilitators2 Georgetown MBM faculty – mental
health professional2 Stanford anesthesiology faculty
Guidelines and AgendaConfidentiality, mutual respect“I Pass” RuleNon judgmental - listening, not solvingFacilitators set the toneExperiential exercises: meditation, guided
imagery, yoga, Tai Chi, drawing, journaling exercise
Opportunity for self-reflection, check-in, sharing concerns with peers in a supportive environment
Group meals, room w/peers
Resident Wellness Retreat
Friday evening through Sunday afternoonFriday night - introductions/drawing exerciseSaturday
8:00 – 8:50am Yoga 9:00 - 10:00am Breakfast 10:00 - 12:00pm Meditation – eating, mindfulness 12:00 - 1:30pm Lunch 1:30 - 3:00pm Walking meditation 3:00 - 3:30pm Break 3:30 - 5:30pm Reflective Journal Writing 5:30 - 7:30pm Free time 7:30 – 9:00pm Dinner
Wellness Retreat FeedbackObjective surveysSubjective survey results
100% met or exceeded expectationsMost valuable aspects
Formation of strong peer support systemLearning new coping and communication skills“To really feel that stressors..were not only my own”“To talk openly about my struggles”“Our interactions were personal and deeply
profound.”“The time spent here has truly changed me.”“Unbelievable investment in our well-being. Thank
you!”
Wellness Sessions
Meet every 8 weeks, 1 ½ hoursProtected didactic timeFor all ~ 75 CA-1, CA-2 and CA-3
residents, mandatoryTwo groups from retreat maintained, same
facilitators Third group formed with residents who did
not attend retreat, or incorporated into 2 existing groups
Expanding faculty involvement, facilitator training
Further curriculum development
Faculty Wellness Pilot ProgramFunded through Dean’s OfficePurpose: enhance faculty member wellness and
build a model to promote community support amongst the faculty. Experiential trainingNot so hidden agenda
Modified from Anesthesia RWP, Georgetown, Krasner & Epstein’s program
Two components:Offsite retreat, May 2013Monthly sessions for a year
Faculty Wellness Pilot ProgramAll Medical School faculty eligible
Personal statementDepartment Chair/Division Chief letter of support,
financial ($500) and time off for retreat & once monthly meetings
10 participants3 Pediatrics (Endocrinology, CCU, Pulmonary)3 Medicine (Hospitalist, ICU/VA, General Medicine)2 Anesthesiology (VA/SUH)1 each from ER, Radiology researcher –PhD
Diverse backgrounds, all ranks, > 30 year age range
Post RetreatMonthly sessions
LunchExperiential exerciseCheck in
Informal get togethersRequest for more frequent meetingsTwice per month formal meetings
Retreat Subjective Evaluations 100% exceeded expectations“This was my most meaningful experience at
Stanford.”“This was one of the best experiences of my life.
Life changing.”“I did not expect such amazing connections and
the closefeelings with others at such a deep level.”
“This ended the sense of social isolation I’ve felt at Stanford.”
“I am overwhelmed with gratitude at the opportunity to participate in this deeply moving experience.”
Lessons learnedBuy in from leadersNeed at least one championGradual implementation on a yearly basis worked better
than going from 0 to 75 residents involvedMental health professional involvementJumpstart program with a retreat off campus if possibleCreate safe, nonjudgmental confidential environmentSurvey once/yearFaculty involvementOther programs’ and institutions’ curriculaEncourage resident support and input for programmingYou can’t force wellness, allow those who don’t want to
participate actively to “pass”. Ask them to not be disruptive.
Who will pay for physician wellness programs?
InsightfuI Leaders
?
FutureExpand Faculty Wellness programsPeer Support GroupsData
Linking patient outcomes with physician resiliency
Linking patient satisfaction with physician resiliency
Decreased cost