The Art of Well-Being

PhysicianWellnessJacquesG.LeBlancMD.,F.R.C.S.C.

January2018

What is Wellness?

Ayurveda

BalancingtheRhythmofLife

International Population Health

Australia USA India

Overweight 62% 69% 72%

Diabetes 14% 14% 21%

CardiacProblems 18% 16% 57%

Smoking 23% 28% 24%

Alcohol 13% 14% 12%

WHOstats2012

“ CALLING “

• Doingsomethingyouaregoodatandlike

• Feelingappreciated

andofworth

• Makinglifebetterfor

• peoplePatientCareisthemostRewardingaspectofourprofession.

Medicine, A Sense of Calling?

• PracticeofMedicinehaslongbeenseenasacalling.• Acallingisdefinedasworkthatisrewarding,thathaspersonalmeaningandserveasocialpurpose,notjustgettingapaycheck

• Senseofcallingisassociatedwithagreatersenseofengagement,butagreatersenseofresponsibilityandthereforepotentialforburnout.

Physician Health The Whole Person

• Physical• Mental

• Emotional

• Spiritual

• Professional

• Lifestyle• Environmental

DeclarationofAlma-Ata:InternationalConferenceonPrimaryHealthCare,Alma-Ata,USSR,6-12September,1978TheConferencestronglyreaffirmsthathealth,whichisastateofcompletephysical,mentalandsocialwellbeing,andnotmerelytheabsenceofdiseaseorinfirmity,isafundamentalhumanrightandthattheattainmentofthehighestpossiblelevelofhealthisamostimportantworld-widesocialgoal………

The Scope of the Problem

DifferencesbetweenStressandBurnout

StressisthestimulusBurnoutisthebehavior

Physicians Work Life Issues

• Burnout• SleepDeprivation• Depression• Substanceabuse:alcohol,cigarettes,food• Drugabuse:narcotics,analgesics,

What is burnout?

• Emotionalexhaustion:Emotionallyoverextended,losingenthusiasm.

• Depersonalization:Negativeattitudes.

• Reducedsenseofaccomplishment:Workisnolongermeaningful.

• Neglectingneeds:Puton“backburner”.

• Interpersonalconflict:Lesstolerant,anger,notattentive.

• Psychiatricsymptoms:Addictivebehaviors,depression,suicide.

Themajorityofpeopleinthisroomhaveexperiencedburnout….

Burnout affects physicians at all levels of training

• MedicalSchool-28-45%• Residency-27%-75%dependingonspecialty• AttendingPhysiciansatvariousstagesofcareer-average37.9%

BurnoutDuringResidencyTraining:ALiteratureReview.WaguihWilliam,MDetal2008BurnoutandSatisfactionwithWork-LifeBalanceAmongUSPhysiciansRelativetotheGeneralUSPopulation.TateD.Shanafeltetal.2012

Burnout among Physicians

20112014Burnout45.8%54.4%EmotionalExhaustion37.9%46.9%Depersonalization29.4%34.6%Dissatisfiedwithwork-lifebalance36.9%44.5%

Shanafeltetal.,ArchIntMed2014 7,000USPhysicianssurvey

Why is burnout increasing?

• Fundamentalchangesinhealthcare• Increasedvolume/demandonproviders• RiseofEHRsmadetoimprovebilling

• Increaseddocumentationtime• Alteredpatientinteraction

• Risingnegativeviewsofdoctors• Dutyhours

• Sameamountofworkinlesstime

Factors Leading to Burnout

TimedemandsIncreasingbureaucratictasks

LackofcontroloverscheduleLackofautonomyWorkload/intensityFinancialstrainUnmetpersonalneedsFeelingoverwhelmedatworkLackofavoiceinimportantmattersLackofcontroloverpracticeenvironment

Selected Factors related to Burnout

• Timeandbureaucraticpressure• Sleepdeprivation• Addictions• Substancesabuse• Suicide

Sleep Deprivation

“Patientshavearighttoexpectahealthy,alert,responsible,andresponsivephysician.”

January1994statementbyAmericanCollegeofSurgeonsRe-approvedandre-issuedJune2002

©AmericanAcademyofSleepMedicine

Perc

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25

50

75

100

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Hours of Sleep< 4 hrs 5-6 hrs > 7 hrs

Work Hrs/wk% Reporting Serious Medical Errors% Reporting Serious Staff Conflicts

*Baldwin and Daugherty, 1998-9 Survey of 3604 PGY1,2 Residents

WorkHours,MedicalErrors,andWorkplaceConflictsbyAverageDailyHoursofSleep*

©AmericanAcademyofSleepMedicine

•Myth:“IfIcanjustgetthroughthe night(oncall),I’mfineinthe morning.”

•Fact:Adeclineinperformance startsafterabout15-16hoursofcontinuedwakefulness.

•Fact:Theperiodoflowest alertnessafterbeingupall nightisbetween6amand 11am(eg,morningrounds).

©AmericanAcademyofSleepMedicine

RecoveryfromSleepLoss

Myth: “All I need is my usual 5 to 6 hours the night after call and I’m fine.”

Fact: Recovery from on-call sleep loss generally takes 2 nights of extended sleep to restore baseline alertness.

Fact: Recovery sleep generally has a higher percentage of deep sleep, which is needed to counteract the effects of sleep loss.

Why Burnout Matters Professional Consequences

• Increasedmedicalerrors/worsepatientoutcomes• Decreasedpatientsatisfaction/lessempathy• Decreasedjobsatisfaction• Difficultyrelaxingandhavingfun• Impatienceandirritability• Decreaseprofessionalism,disruptivebehaviors• Decreasedproductivity• Absenteism• Depression/suicide

Why Burnout Matters Personal Consequences

• Physiciansatisfactionandsafety• Disruptiontofamily/divorce10%higherthanpop.• Higherratesof

• Divorce• Depression• Anxiety• Substanceabuse• Suicide

Physician Suicide

Clinical Case

A41yr.oldmaleMDhadalonghistoryofselfprescribingsedativestotreatanxietyandinsomnia.Hisdrugusegraduallyescalatedtothepointitwasinterferingwithhisworkandhomelife.Hetriedrepeatedlytocontrolhisuseonhisown,butwithoutsuccess.Hebeganseeingapsychiatristwhofelthehadamooddisorder,anddidnotdirectlyaddressthesubstanceabuse.

Hebegantofeelhislifewasintolerableanddiscussedsuicidewithhiswife,althoughhedidnotdiscloseaplan.Hesubsequentlydiedina“huntingaccident”ofaself-inflictedgunshotwoundtothehead.

Physician Suicide• Suicideishardtopredict• Negatingearlysigns• Worseningsignsofdepression• Cripplingeffectsofstigmaofmentalillness• Illphysiciansrefusinghelpandtreatment• Illphysiciansafraidofloosingcolleaguesrespectandtheirjob

• 400Doctorscommitsuicideeachyear(USstats)• Theequivalentofonemedicalschoolislost

eachyeartosuicide• Suicideisthe2ndmostcommoncauseofdeathin

medicalstudents• Moreattemptsandhighersuccessthanaverage

population• Malephysicians–40%higher• Femalephysicians–130%higher

Some Myths

• “I’mtrainedandthereforeinvulnerable.”• “I’veseenworseandhandleditbefore.”• “I’maprofessional,I’msupposedtobeabletohandlethis.”

• “IfIjustfollowtheprotocols,I’llbeOK.”• “I’mokay–Ihavetobe,whoelseisheretohelp?”

• “Ihavetobestrongandshowagoodspiritualwitness.”

Addictions/Substance Abuse

10-15%ofhealthcareprofessionalswillmisusesubstancesatonepointintheircareer

Alcohol–mostcommonlyabusedOpioidsandstimulants–nextmostcommonRecreationaldrugs(marijuana,cocaine)useislessthangeneralpopulation

Prevalence

• >800,000USphysicians(75%male)• 64,000willdevelopSUD• 112,000willexperienceanAlcoholusedisorder

• Prescriptiondruguse(BDZs,opioids)ishigherindoctorsthaningeneralpopulation

Baldisseri.Impairedhealthcareprofessional.CritCareMed2007Vol.35,No.2(Suppl.)

USgenpop DoctorsSubstanceUseDisorder 6.2% 6-8%AlcoholUseDisorder 13.5% 14%

Substance Use by Physicians

• Physicianslesslikelytousecigarettesandillicitsubstancesthanthegeneralpublic

• Physiciansmorelikelytousealcohol• Physiciansmuchmorelikelytouseminoropiatesandbenzodiazepines

• Overall,8%ofphysiciansreportedeverhavingasubstanceabuseordependenceproblem

(Hughes,etal.JAMA1992;267:2333)

Physician Use of Opiates and Sedatives

• Dependingonageandgender,6-23%ofphysicianshadusednon-prescribedopiatesorsedativesinthepastyear

• Thesesubstanceswereusedby1-4%ofthegeneralpopulation• Mostuseofthesesubstancesbyphysicianswasforself-treatmentofsymptoms

Prognosis

Successrates:• Doctorshavehighabstinencerates(74-90%),

likeairlinepilotMandatoryTreatment

• FrequentUrineChecking• PeerAssistancePrograms• Education&Prevention

WHY THE DELAY IN DETECTION?

• Independence• “Malignantdenial”• “Icantakecareofmyself”• “Knowledgeisprotective”• Fearofconsequences• “Conspiracyofsilence”

Denial

“InoticedifIwasstressed,inanemergencysituation,ortimerestricted,Iwouldgointomyautopilotmodewithmyquestions.Iwaslesspatientandlesslikelytolistentothepatientbutjustgettheinformationquickly.Iflipbackintomynaturalcommunicationoffinishingpeople’ssentencesandtalkingoverthemasopposedtolisten.”

Conclusions

• Burnoutispervasiveandincreasing.• Burnoutresultsinpooroutcomesforpatients,doctors,andhospitals.

• Mostofyourresidentsarestruggling.• Individualapproaches(stressmanagement,wellness)arepartofthesolution.

• Systemicchangesareneededtocopewithchanginghealthcarelandscape.

• Facultyplaykeyrolesinrecognizingburnout,talkingtoresidents,andknowingresourcesfortreatment.

Promote Physician Health

• Decreaseworkload• Reducepressure/increasecontrol• Establishprotectedtime• Establishpriorities• Resiliencytraining• Improvelifestyle

Stimulus and Response

“Betweenstimulusandresponse,thereisaspace.Inthatspace,isourpowertochooseourresponse.Inourresponseliesourgrowthandourfreedom.”

Recommendations• Thetoolkitfortheseissueswillcontainmanydifferenttools.

• Thereisnoonesolution…

• …butmanyapproachesofferbenefit!

Medicine Bag for Self Care

• Buildingupresilience• Selfcare• Organizationalrole• Mindfulness• EmotionalIntelligence• Lifestyle• Spirituality

Treatment: no pills

• SELFCARE

• Professional:balance,priorities,workload• Psychological:reflection,mindfulness,relaxation• Physical:exercise,sleep,nutrition• Social:lifebalance,family,friends,communityengagement

First Give to Yourself Sending positive thoughts to oneself

MayIbehappyMayIbehealthyMayIbesafeandsecureMayIlivewithjoyandease

How to Replenish the Tank

Resilience

• Recognizingdifficulty,problems,andtakeappropriatesteps• Recognizingtiredness,fatigue,sleepdeprivationandaddressit• Understandingsurroundings,notgetangryandreactfromawareness

Definitions

PersonalResilience“Thestrength,innateordeveloped,thatenablesonetoadaptwelltoextremestress”,includingthecapacitiesto:

• Abilitytomaintainstabilitydespiteadversity• Reboundfromthedeleteriouseffectsofevenoverwhelmingstress• Itisaprocessthatcanbetaughtorlearned• Clearboundariesarelimitingelectronicaccess,sayingno,schedulingtimeforpersonnaltime/activities

4 Qualities of Resilience

• Remainrelativelysteadyduringlife’sstorms

• Bend,butdon’tbreak

• Rebound,springback

• BecomestrongerinthefaceofadversityOR

laterasaresultofadversity

TREATMENTOFBURNOUT:PROMOTIONOFWELLNESS

• Individualpromotion.• Relationships:ensure“protected”timeforsignificantotherandfamilymembers;collegialconnections.

• Spiritualpractice:personalattentivenessandspiritualaspectsofself.• Workattitudes:findingmeaninginwork;limitingworkpractice–controloverschedule.

• Self-care:cultivatingpersonalinterestsandself-awareness;professionalhelpwhenneeded.

• Lifephilosophy:positiveoutlook,identifyingandactingonvalues,stressingwork/homebalance.

Mindfulness Definition

“theawarenessthatemergesthroughpayingattention,onpurpose,inthepresentmoment,andnon-judgmentallytotheunfoldingofexperiencemomentbymoment”

JonKabat-Zinn,2003

Mindfulness

“Mindfulnessisaskillthatgetsbetterwithpractice.”

Building Emotional Intelligence

“TrainingtopracticereflectionINACTION

AlongsidepracticingreflectionONACTION”

Trainingtobeawarehowtocommunicatewhilecommunicating.

Awe/Astonish

• Aweisnotaluxury• Wecanactivelyseekoutawe• Wecanfindaweinthesmallthings• Positiveemotionshavebenefits

Achieving Success and Wellness

• Giveittime.

• Giveitimportance.

• Giveitpractice.

• BeValueOriented:missionvaluesmeetmedicalprofession• PromotePhysicianautonomy• PromoteadequateSupportServicesandresources• Promoteautonomy,flexibilityandsenseofcontrol• Cultivateacollegialandpeersupportworkenvironment• Promotemeaninginwork• MinimizeWork-HomeInterference:flexibilityinchildcareforwomen• PromoteWork-lifebalance:mentoring,ensuringvacationtime

• Flexibleandreadilyaccessiblechildcare• Flexibilityinschedulingandreadycoverageforlifeevents(births,funerals,familyemergencies)

Wellness Strategies The Organization's Role

Thank You for your Attention