Provider Wellness UCHSC/VAMC TMC - March 2009 Sopheap Na, M.D.Jan McCormack, DMin, BCC Assistant...

Provider WellnessProvider Wellness

UCHSC/VAMCUCHSC/VAMCTMC - March 2009TMC - March 2009

Sopheap Na, M.D.Sopheap Na, M.D. Jan McCormack, DMin, BCCJan McCormack, DMin, BCCAssistant Professor of MedicineAssistant Professor of Medicine

VAMCVAMC

Assistant Professor of Chaplaincy and Assistant Professor of Chaplaincy and Pastoral CounsellingPastoral Counselling

Denver SeminaryDenver Seminary

DrivenDriven MotivatedMotivated CompetitiveCompetitive AmbitiousAmbitious DeterminedDetermined High energyHigh energy

Excels at everythingExcels at everything Top of the classTop of the class Type A personalityType A personality High standardsHigh standards AggressiveAggressive High need for controlHigh need for control PerfectionistPerfectionist

Are You?Are You?

Provider Wellness OutlineProvider Wellness Outline

BackgroundBackground

DefinitionsDefinitions

StudiesStudies

InterventionsInterventions

MCAT Scores and GPAs for U.S. Medical Schools by Sex 2000-2007

3.58

3.60

GPA (science)

3.76

3.70

GPA (nonscience)

GPA (total)BSPSVR

3.6410.49.89.9Female

3.6410.810.79.9Male

VR – verbal reasoning PS – political science BS – biological science

www.aamc.org/data/facts/start.htm

Distribution of Total Educational Debt for Medical Students in the United States at Graduation, 2004–2008. AAMC Graduation Questionnaire All School Reports - premedical or college education debt. 2008, 38% of graduates had debt from premedical education (median amount, $20,000). The distribution of the 23% of students with total debt of $200,000 or more was 15% with $200,000 to $249,999 in debt, 6% with $250,000 to $299,999 in debt, and 3% with $300,000 or more in debt (numbers do not sum to 23% due to rounding).R. Steinbrook. Medical Student Debt — Is There a Limit? NEJM 12/18/2008

Mean Tuition and Fees for Medical Schools and Undergraduate Institutions, 1998–1999 to 2008–2009 (Panel A) and Percent Change in Mean Tuition and Fees, the CPI, and Median Physician Compensation, 1998–2008 (Panel B).

Medical school tuition and fees are from the AAMC tuition and fees report; starting in 2004–2005, figures include health insurance as well as tuition and fees. Mean tuition and fees for 2008–2009 were not available.

Tuition and fees at 4-year undergraduate institutions are from the College Board's Annual Survey of Colleges.

Consumer Price Index (CPI) are from the U.S. Department of Labor.

Medical Group Management Association's Physician Compensation and Production Survey

Medical Student Debt — Is There a Limit? Robert Steinbrook, M.D. NEJM 12/18.2008

BackgroundBackground

All physicians Drug and alcoholism 30-100x general population 3x other profession to spend >60 hrs/wk working,

21% 80 hrs/wk, 16% longer hrs 13% F and 20% M physicians episode of

depression Divorce rates 10-20% higher than general

population

$236,383 to replace family practitioner $264,345 to replace general pediatrician

The Resilient Physician. Sotile, WM.


Work addictionWork addiction

Hurrying and staying busy Need to control Perfectionism Difficulty with relationships Work binges Difficulty relaxing and

having fun Impatience and irritability Self-inadequacy Self-neglect

DefinitionsDefinitionsBurnout Burnout

the cost of working too much 1st described in 1970s Triad

1. Emotional exhaustion2. Negative self-esteem, depersonalization

associated w/ work3. Loss of personal satisfaction at work (work

avoidance, unfriendly or irritable behavior, somatic complaints)

Leads to: absenteeism, turnover, cynicism, decreased job satisfaction, friction in personal relationships, depression, substance abuse

Annals July 2001/CPHP 2008

Causes of BurnoutCauses of Burnout

Workload Specialty choice Practice setting Patient

characteristics Sleep deprivation Personality type Methods of dealing

with medical mistakes

Malpractice suits Lack of control over

practice

The Well-Being of Physicians. Am J Med 4/2003

Environment Problems with work-life balance Rising student debt Increasing govt regulations Business aspect of medicine Increase clinical demands Rapidly expanding knowledge base Less time with patients

DefinitionsDefinitionsCompassion Fatigue Affects caregivers only Not the same as “burnout” “A state of tension & preoccupation with

individual or cumulative trauma to clients & manifested in one or more ways:

• Re-experiencing traumatic events of others• Avoidance/numbing of reminders of the events• Persistent “hyper-arousal

“Cost of caring too/so much”• Many costs• Personal Functioning• Professional Functioning

Compassion Fatigue & PTSDCompassion Fatigue & PTSD PTSD symptoms nightmares, avoidance, on

guard, watchful, easily startled, feeling numbed/detached, increased arousal

Many of the same symptoms as PTSD plus• Repeated negative and disturbing thoughts• Feeling bored and irritable; unable to focus• Not feeling satisfied in one’s work—the energy

output and the rewards coming in don’t match• Lack of physical, psychological and emotional

energy• Avoidance which may lead to drastic

escape/flight measures

Personal FunctioningPersonal Functioning

NightmaresDepletedMinimization

Self-harm behaviorsOverwhelmedPerfectionism

Use of negative coping (smoking/substance abuse)

Emotional roller coasterThoughts of self-harm or harm towards others

Accident pronenessHypersensitivityWhirling thoughts

Losing thingsSadness/depressionDisorientation

Hyper startle responseHelplessnessRigidity

HypervigilanceFearApathy

Appetite changesNumbnessTrauma imagery

Sleep disturbancesShutdownPreoccupation w/ trauma

RegressionSurvivor guiltDecreased self-esteem

MoodyAngerLoss of meaning

IrritableGuiltSpaciness

ImpatientAnxietyConfusion/self-doubt

Clingy or withdrawnPowerlessnessDiminished concentration

BehavioralEmotionalCognitive

Compassion FatigueCompassion Fatigue by Figley, p. 184 by Figley, p. 184

Personal FunctioningPersonal Functioning

DizzinessLoneliness

Impaired immune system

Impact on parenting (protective, concern about aggression)

Questioning of prior religious beliefs

Aches and painsIntoleranceAnger at God

Somatic reactionsProjection of anger or blame

Ennui

Breathing difficultiesIsolation from friendsPervasive hopelessness

Rapid heartbeatMistrustLack of self-satisfaction

SwearingDecreased interest in sexQuestioning the meaning of life

ShockWithdrawnLoss of purpose

PhysicalInterpersonalSpiritual


Professional FunctioningProfessional Functioning

Feelings of incompleteness

Detachment

Lack of appreciationObsession about details

DemoralizationSetting perfectionist standards

ApathyIncrease in mistakes

Negative attitudeAvoidance of job tasks

DissatisfactionLow motivation

Loss of interestDecrease in quantity

Decrease in confidenceDecrease in quality

MoralePerformance of Job Tasks


DefinitionsDefinitionsAdditivity

home and work stress add to each other or when the benefits of home and work satisfaction create greater well-being

“Universal Vulnerability” Attributes which make caregiver vulnerable…same as

make them excellent caregivers Risk increases if…there are back-to-back “heavy”

cases or other forms of secondary trauma May combine with…caregivers own traumatic past


Personal ResiliencePersonal Resilience “The strength, innate or developed, that enables one to

adapt well to extreme stress”, including the capacities to:

• Optimally function• Maintain sound mental health under adverse circumstances• Rebound from the deleterious effects of even overwhelming

stress Factors

1. Age, sex2. Social class, family dynamics3. Social support, temperament4. Self-efficacy, belief in God/spirituality5. Coping skills

Dr. Glenn Schiraldi, U of Maryland

4 Qualities of Resilience4 Qualities of Resilience

• Remain relatively steady during life’s storms• Bend, but don’t break• Rebound, spring back• Become stronger in the face of adversity

OR later as a result of adversity

Three Components of ResilienceThree Components of Resilience

I.I. Healthy belief systemHealthy belief system• Good self-esteem• Clear thinking under pressure• Basically optimistic & hopeful• Self-confident• Realistic expectations• Flexible• Helpful philosophical/spiritual views

Adapted from the work of Glenn Schiraldi


II. Good emotional coping skillsII. Good emotional coping skills• Emotional self-awareness & understanding• Acceptance, use & comfort with a wide• Range of emotions• Managing upsetting emotions appropriately• Empathy skills• Relationship skills



III. Helpful behaviorsIII. Helpful behaviors• Active coping skills• Good social skills• Healthy relationships• Participate in a supportive community• Balanced life: work, play & rest; self & others• Consistent self-care• Good personal & professional boundaries• Active religious/spiritual commitment


The Role of Spirituality & ReligionThe Role of Spirituality & Religionin Personal Resiliencein Personal Resilience

Having faith allows one to open one’s heart to experience the sacred/holy/ divine

The response to that experience is one of awe, reverence, thankfulness, hope, devotion and gratitude

Allows for a healthy “New Normal”

The Benefits of Faith toThe Benefits of Faith toPersonal ResiliencePersonal Resilience

Meaning & Purpose Hope Connection with others Internal calmness—peace Encouragement Peace/security/sense of safety as one’s faith is lived Values beyond the material & immediate Perspective on suffering & evil (the long view) Reconciliation—self, others, a “Higher Power” Reduced fear of death Less Anger

Why is This Important?Why is This Important?

20 yrs ago “burnout” 30-60% specialist and general practitioners

Canadian National Survey 1998 62% workload too heavy 55% family and personal life suffer 65% limited opportunities to change career

Self-care rarely part of professional training and low on the list of priorities

Denial of own emotions and needs as a survival mechanism

The Well-Being of Physicians. Am J Med 4/2003/ CPHP 2008

Professional EthicsProfessional Ethics AMA Council on Ethical and Judicial Affairs

Based on Code of Medical Ethics, Medline-indexed articles and experts

Policy of the Association 12/2003 Promote overall physician health and wellness Recognizes that effective skills and patient safety are

absolute requirement in the practice of medicine Emphasizes continued need for forethought and

sensitivity in addressing physicians’ health and wellness

Physician Health and Wellness. Occup Med 2006

Studies so far…Studies so far…

Studies so far…Studies so far… Kaiser Physicians-Northwest and Ohio

80% response to survey

Factors predicting professional satisfaction, organizational commitment, and burnout

Sense of control over practice environment = #1 Perceived work demands Social support from colleagues Satisfaction with resources Related to physician age and specialty Pediatricians more satisfied

Satisfaction, commitment, and psychological well-being among HMO physicians. WJM Jan 2001

Studies so far…Studies so far… 304/614 completion - Wisconsin Research Network (WReN)

Survey family systems assessment instrument, life-events checklist, measures of happiness, life satisfaction, emotional functioning, assessment of relationship support, practice stress

Open-ended question “How do you solve dilemmas related to your physical, emotional, and spiritual well-being?”

SPWB (Scale of Psychological Well-Being) 18 item instrument

• well-being, self-acceptance, positive relations with other people, autonomy, environmental mastery, purpose in life, personal growth

A Qualitative Study of Physicians’ own wellness-promotion practices. WJM Jan 2001

Studies so far…Studies so far… 5 primary wellness-promotion practices

Relationships involvement and spending time w/ family/friends/ colleague/community

Religion or spirituality Self-care reading, nutrition, exercise, counselling Work certain practice, limiting practice,

satisfaction/meaning Approaches to life being positive, balance

All correlated with increased SPWB scores

“Approaches to life” associated with highest level of psychological well-being

A Qualitative Study of Physicians’ own wellness-promotion practices. WJM Jan 2001

Studies so farStudies so far…… 44 individuals representative of gender, geographic

location, and practice size

Semi-structured interview and focus groups

Factors affecting positively and negatively the health and well-being of GP

low levels of remuneration time pressures unrealistic community expectations government interference effect on personal life

General practitioner health and well-being. WJM Jan 2001

Cohort study John Hopkins SOM 1948-1964

Predictors of NOT having a regular source of care and association with subsequent preventive services?

77% response 35% no RSOC Internist (OR 3.26), surgeons (OR

2.42), pathologist (OR 5.46) more likely not to have RSOC vs pediatrician

Inversely related to belief that health is determined by health professionals (OR 0.45), related to chance (OR 1.90)

Did predict not being screened: breast, colon, or prostate cancer, influenza vaccine

Physician, Heal Thyself? Archives November 2000

Studies so far…Studies so far…

Special Concerns:Special Concerns:Women and MedicineWomen and Medicine

Before 1960s, 95% physicians = M 2003 – F > M med school applications 2010 – 1/3rd physicians ~5% department chairs, 10% dean, ~15% full professorships Avg $22,000 or less/yr (same hours, practice setting, specialty) All reviewers - more critical of grant proposals by F applicants Less institutional support (funding, admin assistance) 2005 WPC (Women Physician Congress) – 49% experienced

sexual harassment in their careers

Stereotypes – conscious/unconscious survey M med students 30% felt F of childbearing age poses significant risk to optimal

department functioning ~50% agree w/ “women who spend long hours at work were

neglecting their responsibilities to home and family”

Colorado Physician Health Program 2007

Special Concerns:Special Concerns:Women and MedicineWomen and Medicine

F ~8.5 months vs M ~1 month interruption to address child care issues

F:M 85% vs 35% change career plans to accommodate children

F physician 10 yr lower life expectancy vs general population 60% more likely vs M physicians s/sx burnout increases

significantly (1-15%) every 5 hrs over 40hrs/wk 3-4x higher risk suicide vs WM >35 y.o. and 4x rate general F

population. tend to present voluntarily for help less likely to be sued by their patients

Colorado Physician Health Program 2007

Women Physicians’ Health StudyWomen Physicians’ Health Study 2500 grad/year from 1950-1989

age 30-70 y.o. 4500 respondents

84% usually/almost always/always satisfied

31% maybe/probably/definitely not choose to be a physician again

38% maybe, probably or definitely prefer to change their specialty

Age, control work environment, work stress, h/o harassment independent predictors

Strongest association work control and career satisfaction OR 11.3 p<0.001

Career Satisfaction of US Women Physicians WPHS. Arch In Med. July 1999

0%10%20%30%40%50%60%70%80%90%

100%

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Being aphysician

ChangingSpeciality

Wellness InterventionsWellness Interventions

Some MythsSome Myths

“I’m trained and therefore invulnerable.” “I’ve seen worse and handled it before.” “I’m a professional, I’m supposed to be

able to handle this.” “If I just follow the protocols, I’ll be OK.” “I’m okay – I have to be, who else is

here to help?” “I have to be strong and show a good

spiritual witness.”

Right Brain InterventionsRight Brain Interventions

Be Value Oriented Promote core values of medical profession Involve physicians in organizing/promoting

mission Minimize Work-Home Interference

Flexible and readily accessible child care Flexibility in scheduling and ready coverage for

life events (births, funerals, family emergencies)

Wellness StrategiesThe Organization's Role

Women in Medicine: Stresses and Solutions. EWJM Jan 2001The Well-Being of Physicians. Am J Med. April 2003

The Resilient Physician. Sotile, WM.Physician Health and Wellness. Occup Med. 2006

Promote Work-Life Balance Adequate vacation time Limit overtime expectations Organization sponsored seminars and retreats Mentoring program and periodic sabbaticals

Promote Physician Autonomy Increase ability to influence environment,

participation in practice decisions, flexibility Increase control over schedule

Women in Medicine: Stresses and Solutions. EWJM Jan 2001The Well-Being of Physicians. Am J Med. April 2003

The Resilient Physician. Sotile, WM.Physician Health and Wellness. Occup Med. 2006

Provide adequate Support Services Adequate coverage to allow time off, adequate and

coordinated nursing, secretarial, admin, social work/chaplain support to promote efficient patient care

Supporting peers in identifying physicians in need Establish approp mechanism to detect impairment Intervene in a prompt and supportive fashion

Cultivate a Collegial Work Environment Fosters healthy relationship (retreats, team building,

social gathering, etc)


Women in Medicine: Stresses and Solutions. EWJM Jan 2001The Resilient Physician. Sotile, WM.

Wellness StrategiesWellness StrategiesSelf responsibilitiesSelf responsibilities

Relationships “protecting” family time, sense of connection with colleagues,

reflect/share emotional/ existential aspects Categories

I – important and urgent (pressing problems, crises, deadlines, bona fide emergencies)II – important and not urgent (planning, prevention, creativity, building relationships,

enjoying re-energizing leisure-time activities, maintaining increased productivity)

III – not important and urgent (unimportant to you but urgent to someone else)IV – not important and not urgent (frivolous and nonhelpful wastes of time)



Wellness StrategiesWellness StrategiesSelf responsibilitiesSelf responsibilities

Religious Beliefs/Spiritual Practice Personal attentiveness, nurturing of spiritual aspects

Work attitudes Finding meaning in work Actively choosing and limiting medical practice (working part-

time, medical education, research interests, managing schedules)

Life Philosophy Positive outlook, indentifying/acting on values, stressing balance between personal/professional life

Self-Care Practices Cultivating personal interests (reading, exercise, self-

expression activities, adequate sleep, nutrition), seeking professional help (personal physical or psychologic illness, medical care)



Intervention examples…Intervention examples…

DGIM UCali San Fran – 2 hr/month since 1996 (residents, faculty) avg group 6-37/session

Existential and spiritual themes difficult patients, balancing personal/professional

responsibilities, medical mistakes, professional competence, grief, role playing, journal, literature/art, anger, boundaries, compassion, fear, refuge, unmet patient needs, “wounded healer”

>70% attended at least 1 session Strengthen personal and professional identity Increased sense of connectedness with colleagues Specific practice techniques Maintaining balance and promoting well-being

Doctoring to Heal. EWJM Jan 2001


Intervention examples…Intervention examples… Hill Physicians largest IPA (Independent Practice

Association ) 2,200 Northern California gen and specialty physicians

14 hour “Finding Balance in Medical Life” Physicians/significant others 50/session Napa Valley,

$400/spouses free Understanding stresses of a medical practice and how it

diminishes productivity Adverse health ramification of stress Learning/evaluating how personality traits contribute to

stresses Learning tools for managing emotional stress Tools and practices to enhance communication skills Evaluation of individual personality structure

Engendering and Marketing Physician Wellness. GPJ Oct 2004


Medical Board of California Mentor program career development and balancing

personal/professional lives Confidential support groups monthly Annual well-being retreat on company time Fitness center membership Contractual requirement for own PCP Sabbatical program COM program on well-being Flexible scheduling

1. Reluctance to confront colleagues and refer them to appropriate resources

2. Incur licensure actions, shame, or stigmatization

3. Reluctance to think of themselves as needing help

4. Inadequate standards to indentify signs of need, difficulty in ascertaining with confidence this need and available resources

5. ?mandatory disclosure about own personal medical information

Physician Health and Wellness. Occup Med 2006

Limits to wellness interventionsLimits to wellness interventions

1. Provider wellness should be a vital part of medical training and practices.

2. Needs more time, energy, education, and financial commitment to make this happen.

3. Do what you tell your patients to do:• Practice behaving in harmony with your decision• Take care of your physical self (engage in physical

activity throughout the day)• Eat healthy• Live according to your values• Express your feelings• Engage in self-awareness activities• Protect your relationships

In Summary…In Summary…

ReadingsReadings

Broyard A. Intoxicated by My Illness. 1992 Frankl V. Man’s Search for Meaning. 1985 Harper R. On Presence. 1991 Remen RN. Kitchen Table Wisdom. 1996 Roberts, SB. Disaster Spiritual Care. 2008. Williams WC. The Doctor Stories. 1984

ResourcesResources CPHP (Colorado Physician Health Program)

899 Logan St., Suite 410Denver, CO 80203303-860-0122 phone 303-860-7426 fax Monday – Friday 8:30 am. – 4:30 pm.

FSPHP (Federation of State Physician Health Programs)Michele Norbeck, Ex Director, (239) 877-7305Vickie Grosso, Staff Assistant, (312) 464-4574.

CPEP (Center for Personalized Education for Physicians) in-depth evaluation is tailored to the physician’s specialty and

practice, and provides detailed information about clinical competence in the areas of medical knowledge, clinical reasoning, documentation, communications, and cognitive function—while also identifying areas of educational need

BibliographyBibliography Barron, V et al. “Engendering and Marketing Physician Wellness: Creating a

Healthier Delivery System.” Group Practice Journal. October 2004. J. Day, E. Vermilyea, J. Wilkerson and E. Giller. Risking Connections in Faith

Communities. Sidran Press, 2006. George Everly Jr. and James Reese. Psychological Body Armor. Chevron

Publishing,2007. Charles Figley. Compassion Fatigue: Secondary Traumatic Stress Disorders

In Those Who Treat the Traumatized. Routledge, 1995. Frank, et al. “Career Satisfaction of US Women Physicians.” Arch Intern Med.

159;1417-1426. July 1999. Freeborn, DK. “Satisfaction, commitment, and psychological well-being among

HMO physicians.” Western Journal of Medicine (WJM). 174;14-18. January 2001.

Gautman, M. “Women in medicine: stresses and solutions.” WJM. 174;37-41. January, 2001

Gendel, MH. “Physician work stress Part I/II.” CPHP website Gross, CP et al. “Physician, Heal Thyself?” Arch Intern Med. 160;3209-321.

November 2000. Gundersen, DC. “Women in Medicine.” CPHP Newsletter. Gundersen, L. “Physician Burnout.” Annals Int Med. 135;145-148. July 2001. Hartwig, E et al. “General practitioner health and well-being.” WJM. 174;25.

January 2007

BibliographyBibliography Myers, MF et al. “The well-being of physician relationships.” WJM. 174;30-

33. January 2001. Schiraldi, Glen. Post-Traumatic Stress Disorder Sourcebook. Chevron Pub,

2000. Shanafelt, TD et al. “The well-being of physicians.” Am J Medicine. 114;513-

519. April 2003. Shanafelt, TD et al. “Relationship between increased personal well-being and

enhanced empathy among internal medicine residents.” JGIM. 559-564. January 2005.

Spickard, A et al. “Mid-Career Burnout in Generalist and Specialist Physicians.” JAMA. 288;1447-1450. September 2002.

Stamm, B. Hudnall Ed. Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators, 2nd Ed. Chevron Pub,1999.

Steinbrook, R. “Medical Student Debt – Is There a Limit?” NEJM. 359;2629-2637. Dec 2008.

Suchman, AL. “The influence of health care organizations on well-being.” WJM. 174;43- 47. January 2001.

Taub, S et al. “Physician health and wellness.” Occup Med. 56;77-82. 2006. Weiner, EL et al. “A qualitative study of physicians’ won wellness-promotion

practices.” WJM. 174;19-23. January 2001. Visionary Productions Inc. Compassion Fatique: The Stress of Caring Too

Much. PBS Satellite Video Conference June 23, 1994.

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