Managing burnout in physicians: Individual and System Approaches

Managing burnout in physicians: Individual and System Approaches

Managing burnout in physicians: Individual and System Approaches William A. Norcross, M.D. Director, UC San Diego PACE Program Clinical Professor of Family Medicine, UC San Diego School of Medicine Mark L. Staz, M.A.

Director, Continuing Professional Development Federation of State Medical Boards Coalition for Physician Enhancement (CPE) Webinar Series Presentation Feb 28, 2017 DISCLOSURE In compliance with the ACCME Standards of Commercial support of CME, the following faculty and planning committee members have stated that they do not have any relationships to disclose: William

Norcross MD, Mark Staz MA, Henry Pohl, MD, David Bazzo, MD, and Rob Steele MD Dr. Norcross work is supported by UC San Diego, John A Majda, MD Fund and HEAR Committee There is no commercial support affiliated with this activity. Faculty Disclosure CPE Webinar Managing Burnout in Physicians: Individual and System Approaches Albany Medical College endorses the standards of the Accreditation Council for Continuing Medical Education (ACCME) and the guidelines of the Association of American Medical Colleges (AAMC) that the sponsors, speakers and planners of continuing medical education activities disclose

relationships with commercial interests. Commercial interests are defined as any entity producing, marketing, reselling or distributing health care goods or services consumed by, or used on patients. Relationships include but are not limited to receiving from a commercial company grants (research and other), consultancies, honoraria, travel, other benefits or having a self-managed equity interest in a company. Albany Medical College has implemented a mechanism to identify and resolve all conflicts of interest prior to the educational activity being delivered to learners. Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. The following faculty and planning committee members have stated that they do not have any relationships to disclose. Rob Steele, MD; Dave Bazzo, MD; William Norcross, MD; Mark Staz, MA; and Henry Pohl, MD Evaluation Link is Below Once you have completed the evaluation click on the next button and a certificate of attendance will pop up that can be printed out for your records https://amc.az1.qualtrics.com/SE/?SID=SV_3WxiLSSUuO39GId

Webinar Process There will be up to 100 participants in todays webinar Sound will be muted on the presenters side; youll hear us, but we wont hear you (to limit background noise/feedback). Questions will be taken at the end of the webinar please type them in under the Questions tab. Presentation 45 minutes Q&A 15 minutes

Program Planning/Presenters William Norcross, M.D., (presenter) Executive Director, University of California-San Diego PACE Program Mark Staz, M.D., (presenter) Director of Continuing Professional Development, Federation of State Medical Boards Henry Pohl, M.D., Albany Medical College, CPE Board of Directors David Bazzo, MD, University of California PACE, CPE Board of Directors, and CPE Program, and CPE Program Committee Chair Robert Steele, M.D., (course director); Medical Director Texas A&M KSTAR Texas A&M Rural and Community Health Institute (RCHI), in-kind support of webinar services

Coalition for Physician Enhancement (CPE) A consortium of professionals with expertise in quality assurance, medical education, and the assessment, licensing, and accreditation of referred physicians seeking higher levels of performance in patient care. CPE: The Mission and Vision Mission: To support and develop expertise in assessment and education for physicians and other healthcare providers who seek a higher level of performance.

Vision: CPE will be a leader in the development of a system that fosters safe practice and enhanced performance by physicians and other healthcare providers in North America Upcoming CPE Events! April 18-19, 2017 Meeting in Fort Worth, Texas -- hosted by KSTAR, Critical Transitions in Medical Careers: Implications for Assessment and Medical Education Embassy Suites, Fort Worth October 26-27, 2017 Meeting in Denver, Colorado (hosted by CPEP)

Topic TBA. Stay tuned! For more information: www.cpememberlodge.org The presentation is being recorded and will be made available on the CPE website in the near future. Copies of the slides will also be available. Please go to: http://cpe.memberlodge.org/ & click on the CPE Webinars tab on the left navigation panel.

Burnout: Definition Maslach, 2006 Burnout is a syndrome of: Emotional depletion - Feeling emotionally depleted, frustrated, tired of going to work, hard to deal with others at work. Detachment/Cynicism - Being less empathic with patients/ others, detached from work, seeing patients

as diagnoses/ objects/ sources of frustration. Low personal achievement - Experiencing work as unrewarding, going through the motions. Burnout Shanafelt, et al. Mayo Clin Proc 2015 Dec; 90 (12): 1600 Nationwide survey of 35,922 U.S. physicians with 6880 responses: 45.5% of physicians in 2011 and 54.4% of physicians in 2014 reported one symptom of burnout; higher than U.S. workforce generally

Depression and suicidality in medical students Rotenstein, et al JAMA 2016; 316 (21): 2214 Meta-analysis of 167 cross-sectional studies and 16 longitudinal studies from 43 countries: the global prevalence of depression among medical students was 27.2% current suicidal ideation was 11.1% Nursing literature Fida R, et al., Health Care Manage Rev 2016:1

Same prevalence or worse; Very high rates of suicide; Use different terms: incivility, lateral violence, blame, compassion deficit Who or What is responsible? There are individual factors and

There are systems factors Antecedents or causes of burnout: individual Perfectionism Cognitive rigidity Deficient setting of boundaries Inability to forgive oneself or others Loss of sense of humor Loss of ability to feel joy Possible: a component of resilience may be hard-wired, genetic

Avoiding Burnout: Putting the Balance Back in Life Burnout Epstein RM, Privitera MR. Lancet 2016; 388: published online November 5, 2016 Burnout is not an expected reaction to hard work; deeply satisfying work can involve tremendous personal sacrifice.

Best two-page article on burnout extant, a must-read Mindfulness: Krasner, et al. JAMA 2009; 302 (12): 1284 Before and after study of 70 primary care physicians given a course on mindfulness meditation, self-awareness exercises, clinical narratives, discussion.

Seven hour retreat followed by weekly meetings of 2.5 hours for 8 weeks followed by 2.5 hour meetings monthly for ten months Dramatic improvements in mindfulness, total mood disturbance, empathy, burnout were sustained over one year Burnout: Primary prevention Shanafelt TD, et al. Mayo Clin Proc 2015; 90 (4): 432 Supportive, knowledgeable, organizational leadership Objective measurement of 12 leadership dimensions in a survey of 2813 physicians strongly and positively impacted physician satisfaction,

wellbeing, and burnout (less) Consequences of burnout Suffering Medical errors

Decreased patient satisfaction Decreased employee satisfaction Increased employee turnover

Increased absenteeism Mayo Clinic Physician Opinion of Leadership Qualities of Their Immediate Physician Supervisor: Sample of questions Shanafelt TD, et al. Mayo Clin Proc 2015; 90 (4): 432

Inspires me to do my best Is interested in my opinion Treats me with respect and dignity Executive leadership and physician well-being:

Nine organizational strategies to promote engagement and reduce burnout. Shanafelt TD, Noseworthy JH. Mayo Clin Proc 2017; 92 (1): 129 Identify and develop strong leaders Those physician leaders must know the physician workforce they lead Leaders who receive low scores on leadership behaviors must be remediated or replaced Burnout: System factors Panagioti et. al., JAMA Intern Med. 2017;177(2):195-205

Intervention programs for burnout in physicians were associated with small benefits that may be boosted by adoption of organizationdirected approaches Burnout is a problem of the whole health care organization, rather than individuals System Factors: International Example Stier-Jarmer M, et al. Dtsch Arztebl Int 2016; 113: 781 In Germany 3 weeks annually at a health resort (covered by the statutory health insurance) is associated with lower symptoms of burnout

Treatments include physical therapy, mineral water baths, mud baths, exercise and relaxation therapies Gutenbrunner C, et al. A proposal for a world-wide definition of health resort medicine, balneology, medical hydrology and climatology. (Int J Biometeorol 2010; 54: 495) UCSD Healer Education Assessment and Referral Program (HEAR) Program: A Two-Pronged Approach Series of face-to-face educational programs

about physician depression and suicide to our target groups focused on destigmatizing depression and mental illness treatment. Web-based screening, assessment, and

referral program based on program developed by American Foundation for Suicide Prevention healthsciences.ucsd.edu/som/hear Goals:

Educate Destigmatize Identify Refer Treat depression and prevent suicide

Interactive Screening Program Program classifies respondents into 1 of 3 tiers based on risk Counselor provides a detailed, personalized assessment, following a standardized prototype for each tier

Counselor invites respondents to communicate with her online if they desire further correspondence, using a website dialogue page that requires no identification All Tier 1 and 2 students are urged to call or email the counselor to schedule an in-person evaluation

Counselor evaluates the participant more fully, discusses treatment options and makes referrals as appropriate UC San Diego HEAR Program results since inception (2009) Over 160 formal presentations, mostly to UCSD health professionals and medical students 2600 people have taken our anonymous online survey 20% report depression; 7% with suicidal ideation; 40% report life is too

stressful; 18% report drinking too much 200 people have been referred for treatment, many suicidal, and many saying they would not have sought help if not for UCSD HEAR UCSD HEAR can be exported Haskins J, et al. The Suicide Prevention, Depression Awareness, and Clinical Engagement Program for Faculty and Residents at the University of California, Davis Health System. Acad Psychiatry 2016; 40: 23-29. First Responder Nominations Who amongst the people you

work with is a natural with intentional acts of kindness? Who would you go to if you had a rough day and needed to get it off your chest? Summary thoughts Burnout, second victim syndrome, depression and suicidal ideation are extraordinarily prevalent among all healthcare professionals, of all specialties, and likely in all nations On the ground and in the moment it is enough to know that a colleague is

suffering and needs help Burnout can be viewed in one of two general ways: at the level of the individual health professional or at an organizational level Summary thoughts Although there are many possible factors contributing to burnout, it is primarily due to organizational or systemic issues Approaching burnout only with interventions aimed at the individual is likely to be offensive to the healthcare professional and ineffective at best Summary thoughts

Despite the primacy of the system in the creation and maintenance of burnout, healthcare professionals should: receive training about burnout, learn how to recognize it early in themselves and their colleagues, and have a plan to deal with it very early in training, perhaps even in the premedical years Physicians and nurses with expertise in well-being and promoting resilience should be entrusted to teach and model these skills to learners. This should be an active and planned process; it should not thought that these qualities will passively diffuse into learners

Summary thoughts A structure and incentives for promoting wellness and developing resilience should be purposefully and directly built into every healthcare organization, residency program, and medical/nursing school Burnout and wellness should be regularly measured performance metrics included on the dashboard, routinely, of every healthcare organization Summary thoughts Physician leaders should be specifically taught skills to promote wellness, decrease burnout, and grow resilience

Physician leaders should be sought, hired and promoted for excellence in this area Physician leaders should be regularly evaluated on their ability to provide effective personal leadership, including the promotion of wellness and resilience Summary thoughts Although much work remains to be done, there are a number of useful interventions described to ameliorate and perhaps prevent burnout It may take some work for the individual clinical unit (perhaps as small as a clinic team) to find the processes and interventions that help them the

most Summary thoughts Shanafelt TD, Noseworthy JH. Executive leadership and physician wellbeing: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017; 92 (1): 129 As of February 2017, in my opinion the above article is the most useful blueprint for organizational strategies to reduce burnout and improve physician wellness, engagement, and resilience Regulatory Efforts to Address Physician Wellness and Burnout

Background Initial Discussions Focused on Disruptive Physicians Realization that Disruptive Behavior often has Roots in Burnout Dual Focus on Professionalism/Professional Self-Care AND Systems Factors Creation of FSMB Workgroup on Physician Wellness and Burnout Survey of State Medical Boards Formal Discussions at Board level Importance/Prioritization of the Issue

Licensee Perceptions of Boards Role and Influence Review of Licensure Application Questionnaire Workgroup on Physician Wellness and Burnout Education: Educate state medical boards and physicians through the creation of a compendium of research and resources on identifying, managing and preventing physician burnout

Research and Evaluation: Evaluate current data/research on the impact of physician burnout on patient care Workgroup on Physician Wellness and Burnout Collaboration: Convene stakeholder organizations and experts to discuss physician wellness and recommend best practices for identifying, managing and preventing physician burnout

Stigma Reduction: Raise awareness about the prevalence of burnout; begin a dialogue to help reduce stigma associated with seeking help for burnout symptoms Collaboration Poor well-being persists through medical school and residency into practice (West C, 2015): National physician burnout rate exceeds 54% Affects all specialties

Demonstrates importance of collaboration across the continuum of medical education, training, and practice Collaboration Collaboration Stigma Reduction Licensure Process 45 of 52 Licensure Applications reviewed contained questions about applicant mental health, some without reference to time window

Polfliet, S. J AAPL 2008; 36(3) Presence of questions about mental health or substance use may cause physicians to avoid or delay treatment Schroeder R, et al. Acad Med 2009; 84(6) Women physicians report substantial and persistent fear regarding stigma which inhibits both treatment and disclosure Gold K, Andrew L et al. Gen Hosp Psychiatry 2016; 43 Stigma Reduction Illness vs. Impairment Impairment is the inability of a licensee to practice medicine with reasonable skill and safety as a result of a mental disorder, physical illness or condition, or

substance-related disorders FSMB Policy on Physician Impairment Physical or mental health conditions that interfere with a physicians ability to engage safely in professional activities can put patients at risk, compromise professional relationships, and undermine trust in medicine. AMA Ethical Opinion 9.3.2 Key Points Questions about mental health and addiction, requests for justifications of leave from practice, may contribute to a reluctance among physicians to seek

treatment Licensing and disciplinary processes should focus on current functional impairment, rather than on history of diagnoses or treatment of illness Key Points Regulatory efforts should include support and resources aimed at facilitating licensee efforts to identify and treat circumstances that lead to burnout, while promoting resilience and wellness Where regulatory practice cannot directly remedy circumstances that lead to burnout, the regulator is well-placed to collaborate with other organizations and fields that can

Key Points Medical regulatory authorities duty to protect the public includes a responsibility to ensure physician wellness Thank you!! Please visit www.cpe.memberlodge.org for information about future CPE webinars! Evaluation Link: https://amc.az1.qualtrics.com/SE/?SID=SV_3WxiLSSUuO39GId

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