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PHYSICIAN WELLNESS & BURNOUT

PHYSICIAN WELLNESS & BURNOUT. (Adapted with permission from ACEP). The best interests of patients are served when emergency physicians practice in a fair, equitable and supportive environment. Why is Wellbeing important?. Happiness and satisfaction = Career longevity Reasons for Concern

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PHYSICIAN WELLNESS & BURNOUT

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  1. PHYSICIAN WELLNESS & BURNOUT (Adapted with permission from ACEP)

  2. The best interests of patients are served when emergency physicians practice in a fair, equitable and supportive environment

  3. Why is Wellbeing important? • Happiness and satisfaction = Career longevity • Reasons for Concern *Burnout Studies *Substance Abuse Data *Attrition Rate

  4. Wellness and the Emergency Physician • Major Stressors *Diminished Resources *Difficult Patients *Difficult Decisions *Life in the fish bowl *Isolation • Single coverage practices • Rural practices *Perceived lack of control

  5. Coping Techniques Wellness Strategies • Essential we learn these • Wellness in the professional environment • Wellness in personal life *Close family and social relationships *Physical fitness *Methods of relaxation and renewal

  6. The foundation of wellness is Attitude • Service commitment • Vocation - being a healer and helper

  7. The accomplishment of wellness is time management • Balancing • Prioritizing

  8. Wellness and the Emergency Physician • Typical Physician Profile *Perfectionistic *Driven to succeed *Willing to work long and irregular hours *Ideals of individual service and sacrifice

  9. Personality and genetics • Adaptation • Know yourself *know and accept your limits *denial does not work • Expectation vs being realistic *Type A

  10. Satisfactions and Joys • Making a difference • Teamwork • Focus on and value these

  11. Stress is inevitable - its unmanaged consequences are: • Burnout • Impairment • “Managing one’s own stresses is the toughest part of practicing medicine.” • Dr. Oscar London

  12. Burnout • Feelings of job dissatisfaction due to work-related stress *Three components • Depersonalization • Diminished sense of achievement • Emotional exhaustion

  13. Maladaptive coping mechanisms Responses Physical & Emotional Illness Adaptive coping mechanisms balance restored responses resolved Stress Exceed Resources

  14. Burnout Severity • First degree: failure to keep up and gradual loss of reality • Second degree: accelerated physical and emotional deterioration • Third degree: major physical and psychological breakdown

  15. Burnout effects on patient care *Samkoff and Jacques • All revealed deleterious effects on mood and attitude • More errors on repetitive tasks • Deterioration in performance tests requiring prolonged vigilance

  16. Burnout and the Emergency Physician • Keller and Koenig (1989) *Surveyed 77 Emergency Physicians *60% Medium to High Emotional Exhaustion *70% Medium to High Depersonalization *34% Low Levels of Personal Achievement

  17. Burnout and the Emergency Physician • Gallery (1992) *Surveyed 763 Emergency Physicians *12.4% were likely to leave specialty in one year *27% were likely to leave in five years *57% planned to leave specialty in ten years

  18. Burnout and the Emergency Physician • Goldberg et al (1996) *Administered Maslach Burnout Inventory (MBI) to 1,272 emergency physicians over four years at ACEP Scientific Assembly *60% rated at moderate to high levels of burnout

  19. Burnout and the Emergency Physician • Goldberg et al. (1996) • Correlates of burnout *Self-recognition of burnout *Lack of job involvement *Negative self-assessment of productivity *Dissatisfaction with career *Sleep disturbances *Increased number of shifts per month *Dissatisfaction with specialty services *Intent to leave the practice within 10 years *Higher levels of alcohol consumption *Lower levels of exercise

  20. Burnout in Residency • Koran and Litt- 280 house staff *40%- anxiety or depression impaired their work *31%- social isolation *12%- increased use of alcohol or drugs *46%- concerned that a relationship with a significant other would not survive the residency

  21. Stress in EM Residency • DE Houry, LW Shockley, V Markovchick Annals of Emergency Medicine 35 (4): 394-397, 2000

  22. Burnout symptoms • Somatic *Headaches, fatigue, sleep disturbance, GI sx • Cognitive *Forgetfulness, indecision, poor judgment • Emotional *Irritable, depressed, worry • Spiritual *Loneliness, inadequacy, absent

  23. Self Monitoring for Burnout • Maslach Burnout Inventory (MBI) addresses 3 general scales *Emotional exhaustion (feelings of being emotionally overextended and exhausted by one’s work), *Depersonalization (unfeeling and impersonal response toward recipients of one’s service, care, treatment, or instruction) *Personal accomplishment (feelings of competence and successful achievement in one’s work) Maslach C, et al. The Maslach Burnout Inventory. 3rd ed. 1996

  24. MBI Score Interpretation

  25. Interventions • Educating physicians about burnout • Learning new adaptive coping mechanisms: *assessment and determination of stressors *specification of life priorities *sharing and expressing feelings • Alleviating stress at work: *focusing on positive aspects and small success *setting daily and weekly goals *breaks and variation in daily schedule *utilizing a team approach

  26. Wellness and the Emergency Physician • Physician Impairment *The inability to practice medicine with reasonable skill and safety due to physical and mental illness *Emergency medicine is overrepresented with chemically dependent physicians compared to other specialties

  27. Intervention • Initiation of programs to alert physicians to stresses • Re-evaluation and restructuring medical training • Offering programs and conferences dealing with burnout

  28. Impaired Physicians • Alcohol • Drugs • Mental Illness

  29. Symptoms of Impairment • Symptoms *Denial *Compulsion *Progression *Relapse

  30. Stages of Dependency • Use: Social functions • Abuse: Using the chemical interferes with life • Addiction: Life interferes with using the drug • Institutionalization and/or insanity • Recovery

  31. Recovery and Help • State specific programs • Counseling • Confidentiality • Disability

  32. Strength • You have it *Physical and mental • Trust and sharing • Boundaries *Your work and your life

  33. Life in the Goldfish Bowl • Unique to emergency medicine • Team captain • Interactions with other physicians

  34. Wellness in the Professional Environment • *Adequate physician and support staffing • *Input on policies and procedures • *Reduction of noise and structural discomforts • *Strategies to deal with difficult patients • *Shift work strategies • *Support groups/CISD

  35. Frustration and anger • Overcrowding • Admitting • Expectations vs. resources

  36. Medical Errors • Admit *denial does not work • Apologize • Constructive learning *do better next time

  37. Harassment - towards you • Still sometimes a gender issue • EM identity *still the new guy on the block

  38. Harassment - by you • Political correctness *Everything you say and do will be noticed *Don’t think it can’t happen here

  39. Violence • Toward you and your staff • Society and your patients *Caring for those affected

  40. Wellness and the Emergency Physician • The Difficult or Hateful Patient *Organic brain syndrome / Dementia *Language or cultural differences *Hostile patient/borderline personality *Overly dependent *Hypochondriac *Antisocial/self-destructive

  41. Wellness and the Emergency Physician • Keys to Dealing with Difficult Patients *Recognize your negative feelings toward the patient and accept them nonjudgementally *Determine that the patient will not make you sick - share your feelings *Set limits for yourself and the patient - treat consistently

  42. Shift work • Circadian rhythms • Scheduling • Does it contribute to medical errors?

  43. Shift work effects • Infertility • Increased risk of premature birth & retarded fetal growth • Higher pregnancy loss • High rates of drug and alcohol abuse • Chronic hypertension and increased cardiovascular mortality

  44. Shift work • Increased rates of worker accidents and errors • Increased rates of accidents driving to & from work • Often cited as the main cause of career dissatisfaction • Chronic fatigue • Chronic sleep disruption and deprivation • Increased rates of depression, mood swings and divorce

  45. Circadian Principle • 25.1 hr. biologic clock • Temperature cycle correlates well with level of alertness • Temperature “troughs” at 2:00PM and 3:00AM

  46. Circadian Rhythm Increases Sleepiness Decreases 12 24 Time (h) University of Virginia Center for Biological Timing. Available at: http://www.cbt.virginia.edu/tutorial/HUMANCLOCK.html.

  47. Sweden 11,000 N = 74,927 10,000 9000 8000 7000 6000 5000 4000 Midnight Noon 6 PM Midnight 6 AM Performance Errors No. of Errors Mitler MM, et al. Sleep. 1988.

  48. International Data N = 6052 Vehicle Accident Data 1200 1100 1000 900 800 700 600 500 400 300 200 100 No. of Accidents Midnight Midnight 6 AM Noon 6 PM Mitler MM, et al. Sleep. 1988.

  49. How Do These Things Happen? Midnight Noon 6 PM Midnight 6 AM

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