Being well while being a doctor Shelley Aggarwal

Being well while being a doctor Shelley Aggarwal MD, MS Division of Adolescent Medicine 1

Settling in… - Release - Balance - Calm

• What happens in Vegas… ends up on Facebook. • So, let’s keep it between the team. Jen Carlson

3 Things and Choice • #1 • Discuss the concept of stress in the workplace and how it has evolved into the wellness conversation • Recognizing the signs of professional exhaustion • #2 • Discuss some core concepts of being well: resilience, happiness, mindfulness • Practice… • #3 • Discuss how to pass it on (but mainly let’s start with taking care of ourselves)

Stress… in the 20 th century a force exerted when one body or body part presses on, pulls on, pushes against, or tends to compress or twist another body or body part

Stress: Fight or Flight – 1915 • Bodily Changes in Pain, Hunger, Fear and Rage: An Account of Recent Researches into the Function of Emotional Excitement • Concept: animals react Walter Bradford Cannon, M. D. to threat by a discharge in the nervous system

Stress: General Adaptation Syndrome – 1936 • Diseases of adaptation: ulcers, high blood pressure, arteriosclerosis, arthritis, kidney disease, and allergic reactions. Hans Selye

Stress: seen and unseen The Stress System • Hypothalamic-Pituitary- Adrenal Axis • Increased blood pressure • Increased heart rate • Pain and discomfort • Anxiety • And on and on… Brain • Mental Activity Can Lead to Changes in the Brain • Dendritic remodeling and stress exposure • The Hippocampus • Memory impairment? • The Pre-Frontal Cortex • Executive functioning? • The Amygdala • Anxiety and hypertrophy • More to be learned about the adolescent brain (Romeo 2006) (Lupien 2009) (Romeo 2013)

Stress…good, bad, and chronic

History From: Constance Ange. Clinician burnout in Contemporary Medicine

Stress Burnout

Burnout • What is happening to doctors? • “Life is never made unbearable by circumstances, but only by lack of meaning and purpose. ” • Viktor Frankl

Burnout…

Burnout… Physical, emotional and mental exhaustion caused by long term involvement in emotionally demanding situations

Burnout • Role Overload – expectations of others exceed one’s ability to perform • Role Conflict – forced to make a choice about which demand to satisfy • ex) child’s soccer game vs. staying late to see patient or complete paperwork

Burnout in Healthcare Definition • 3 Dimensions • Emotional exhaustion • Feeling low personal accomplishment • Depersonalization of the patient Contributing Factors • Professional isolation • Working with a difficult population • Long hours with limited resources • Ambiguous success • Unreciprocated giving • Failure to live up to one’s own expectations • Personality Variables

The cost of a burned out doc • Effect on patient care and safety • Patient medication adherence • Physician recommended evidence based screening and health counseling reduced when physicians have poor personal health • Reduced workplace productivity and efficiency • Cost of replacing a physician (150 -300 K, maybe 1 million) (Wallace, 2009)

Burnout • Why is it happening to doctors? To the people who choose to become doctors? • “I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant: ” Hippocratic Oath

Declaration of Geneva of the World Medical Association: (adopted 1948, amended 1966 and 1983) • I solemnly pledge myself to consecrate my life to the service of • • • humanity; I will give my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; The health of my patient will be my first consideration; I will respect the secrets which are confided in me, even after the patient has died; I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; My colleagues will be my brothers; I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from its beginning even under threat and I will not use my medical knowledge contrary to the laws of humanity; I make these promises solemnly, freely and upon my honor.

(Nedrow 2012)

Compassion Fatigue (CF) Definition • State of exhaustion and dysfunction (biologically, psychologically, and socially) as a result of prolonged exposure to secondary trauma or a single intensive event Contributing Factors • Helplessness • Feeling incapable of effecting successful patient outcomes • Confusion • Isolation • Exhaustion • Feeling of being overwhelmed by work

CF – PTSD? • Most empathetic most likely to experience CF • No quick fix for traumatized patients • Challenging for the empathetic provider • Participating in the patient’s anguish • Hyperarousal: • disturbed sleep, irritability or outbursts of anger, hypervigilance • Avoidance: • “not wanting to go there again” and the desire to avoid thoughts, feelings, and conversations • Reexperiencing: • intrusive thoughts or dreams, and psychological or physiological

Self care – Doctors are miserable at this • Less doctor visits for themselves • Self-prescribe drugs (i. e. will not see a doctor) • Perceived (? ? ) stigma around seeking help or support • Willing to work when sick… and expect the same from colleagues (but not patients) • Denial and avoidance – physician coping strategies • Poor record of mutual support and positive feedback in the field • Protecting the privacy of colleagues • Doctors are self-reliant, individually driven, achievers who are industrious and self-sacrificing (Wallace, 2009)

Heading off the rails… Emotional exhaustion Fatigue, insomnia, impaired concentration, somatic symptoms, repeated illness, loss of appetite, anxiety, depression, anger Feeling low personal accomplishment Loss of enjoyment, pessimism, sarcasm (in excess), isolation, detachment Depersonalization of the patient Apathy, irritability (with staff, trainees, patients), lack of productivity

When it’s more? • 2 weeks or more of persistently diminished mood, loss of motivation, feelings of guilt or worthlessness • Persistent social isolation, changes in relationships • Life interfering anxiety symptoms • Use of alcohol, non-prescribed medications, illicit substances • Sustained decline in function • Changes in eating patterns or weight loss/gain • Suicidal thoughts or self-harming behaviors

Conclusion • Burnout and CF exist and they are damaging, and therefore we should be well. • Has anyone ever taught you how to be well? • At work • In marriage • In balanced nutrition • In life… • Who taught you? How did they teach you? • The impact of modeling

Awareness Being well

10 commandments of physician wellness Thou shall not expect someone else to reduce your stress. II. Though shall not resist change. III. Thou shall not take thyself in vain. IV. Remember what is holy to thee. V. Honor thy limits. VI. Thou shall not work alone. VII. Thou shall not kill or take it out on others. VIII. Thou shall not work harder. Thou shall work smarter. IX. Seek to find joy and mastery in thy work. X. Thou shall continue to learn. I. (Krall 2014)

Choice… • #1: Thou shall not expect someone else to reduce your stress. • “Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom. ” • Viktor Frankl. • Man’s Search for Meaning

Habit • Common sense and common action • Just because we know what to do doesn’t mean we do it. • Tetris • We are what we repeatedly do. Aristotle

Wellness Strategy

Resilience: Self- compassion • Fear of failure • I am trying… and that • Fear of inadequacy is good • I am a good… parent, friend, sibling, colleague, etc. • I love my family and I don’t have to show it in just one way. • Disappointing… colleagues, friends, family

-May you be happy. -May you be healthy. -May you be free from internal and external harm. -May you experience love, joy, and wonder just as it is. -May you have ease of the day.

Resilience: Reframing • The “black cloud” • Why are all the difficult patient’s drawn to me? • Language frames our thoughts and thoughts frame our language

Resilience: Appreciation and Gratitude • Gratitude journal • Performing kind acts and writing it down • Deliberately make connections during the day with colleagues and with patients • Use humor; look for something particular or unusual in the patient’s room; or notice the patient’s birth date or age.

When are we happy? • When we are in the present. • When we get what we want AND when we want what we have. • When we have slept. • When we have eaten well and consistently. • When we have manageable work loads. • When we have healthy connections to others. • When we are kind. • And many more reasons… (Achor, 2010) (Hanson, 2009)

Partner up • 10 seconds • Discipline • Resolve • Strength • Rejection and pain • Yawning

How do you increase your happiness? • https: //www. youtube. com/watch? v=RP 4 abi. Hd. Qpc

Duchenne smile vs “say cheese” • Voluntary and involuntary contraction from two muscles: • The zygomatic major (raising the corners of the mouth) and the orbicularis oculi (raising the cheeks and producing crow's feet around the eyes) • Limbic system vs. motor cortex

Mindfulness • Paying attention on purpose, in the As a magical cure As enlightenment As a burden… present moment, and nonjudgmentally, to the unfolding of experience moment to moment. Jon Kabat-Zinn • You can use your mind to strengthen the structure of your brain. Dan Siegal

Benefits of Meditation • The primary health benefit from meditation practices appears to be a general shift in the autonomic nervous system that decreases sympathetic tone and increases parasympathetic tone. • • Depression Anxiety Sleep Immune Function Cortisol Levels Decision Making Coping • As the parasympathetic system is stimulated, heart rate and breathing slow, stress hormones decrease, blood vessels dilate, and digestion is facilitated. PIMR (2016)

The Brain of Meditators • Hippocampus – increased gray matter • Governs learning and memory • Decreased in depression and PTSD • Amygdala • Decreased gray matter • Smaller amygdala • Participants had less reported stress

Brain Training Anchor attention with breath Return attention to the sensation of breathing Choosing the reaction - Frustration vs. compassion Notice our reaction Attention wanders Notice that attention has wandered Juliet Adams – UK

The Mindful Brain – Physiology • Gray Matter • Limbic System • Autonomic Nervous System • Implications for the adolescent brain Lazar (2005). Hutchinson (2008). Hanson (2009). Holzel (2011). Murakami (2012. Adams (2013). Seigal (2013). Zeidan (2013). Sanger (2015). 48

The Practitioner and Health Care • Interestingly, studies in psychotherapists in training who received mindfulness training showed an improvement in the efficacy of their counseling skills in this area as compared to controls—mirroring the outcomes of studies showing physicians who have adopted a healthy lifestyle as more efficacious counselors to their patients Grepmair (2007) Frank (2000)

What does self care look like for you… • Self-compassion • Reframing • Gratitude and appreciation • Humor • ? Financial goals • Time for yourself • Sleep • Food • Aligning with your values

Stanford Well. Md: http: //wellmd. stanford. edu/. Faculty and Staff Help Center – 10 Free Counseling Sessions Pediatric Housestaff: http: //peds. stanford. edu/Resident_Life/wellness. html

Resources To Access Information • SELF-AWARENESS AND SELF-CARE • Professional Quality of Life Scale • http: //ww • Institute for the Study of Health and Illness at Commonweal • http: //www. commonweal. org/ishiw. proqol. org/Pro. Qol_Test. html • Center for Practitioner Renewal • http: //www. practitionerrenewal. ca • MINDFULNESS MEDITATION Spirit Rock Meditation Center • http: //spiritrock. org • University of Massachusetts Medical School Center for Mindfulness in Medicine, Health Care, and Society • http: //www. umassmed. edu/cfm/mbsr • REFLECTIVE WRITING Writing and Health • http: //homepage. psy. utexas. edu /Home. Page/Faculty/Pennebaker/home 2000/Writingand. Healt h. html

Technology: Apps for stress • http: //www. t 2 health. org/apps/tactical-breather • http: //www. t 2 health. org/apps/breathe 2 relax • https: //itunes. apple. com/us/app/stop-breathe • • • think/id 778848692? mt=8 http: //www. huffingtonpost. com/david-magone/stress-meditation_b_1671435. html http: //www. marquette. edu/counseling/documents/Deep. Breathin g. pdf http: //www. youtube. com/watch? v=g 3 k_-mci. E 6 o http: //www. marquette. edu/counseling/files/musclerelaxation. mp 3 http: //www. marquette. edu/counseling/files/guidedimagery. mp 3 www. calm. com

Questions…

References • Adams, J. (2013). hat happens in our brain when we practice mindfulness? Retrieved from: http: //mindfulnet. org/page 8. htm. • Achor, S. (2010). The Happiness Advantage: The seven principles of Positive Psychology that fuel success at work. New York: Random House, Inc. • Baime, M. (2011). This is Your Brain on Mindfulness. Shambala Sun. Retrieved from: http: //www. nmr. mgh. harvard. edu/~britta/SUN_July 11_Baime. pdf • Casey, B. J. , S. Getz and A. Galvan (2008). "The adolescent brain. " Dev Rev 28(1): 62 -77. • Gogtay, N. , J. N. Giedd, L. Lusk, K. M. Hayashi, D. Greenstein, A. C. Vaituzis, T. F. Nugent, 3 rd, D. H. • • Herman, L. S. Clasen, A. W. Toga, J. L. Rapoport and P. M. Thompson (2004). "Dynamic mapping of human cortical development during childhood through early adulthood. " Proc Natl Acad Sci U S A 101(21): 8174 -8179. Grepmair, L. , F. Mitterlehner, T. Loew and M. Nickel (2007). "Promotion of mindfulness in psychotherapists in training: preliminary study. " Eur Psychiatry 22(8): 485 -489. Holzel, B. K. , J. Carmody, M. Vangel, C. Congleton, S. M. Yerramsetti, T. Gard and S. W. Lazar (2011). "Mindfulness practice leads to increases in regional brain gray matter density. " Psychiatry Res 191(1): 3643. Hutcherson, C. A. , E. M. Seppala and J. J. Gross (2008). "Loving-kindness meditation increases social connectedness. " Emotion 8(5): 720 -724. Johnson, S. B. and R. W. Blum (2012). "Stress and the brain: how experiences and exposures across the life span shape health, development, and learning in adolescence. " J Adolesc Health 51(2 Suppl): S 1 -2. Krall, E. J. (2014). “Ten Commandments of Physician Wellness” 12: 6 -9. Lazar, S. W. , C. E. Kerr, R. H. Wasserman, J. R. Gray, D. N. Greve, M. T. Treadway, M. Mc. Garvey, B. T. Quinn, J. A. Dusek, H. Benson, S. L. Rauch, C. I. Moore and B. Fischl (2005). "Meditation experience is associated with increased cortical thickness. " Neuroreport 16(17): 1893 -1897. Luna, B. , D. J. Paulsen, A. Padmanabhan and C. Geier (2013). "Cognitive Control and Motivation. " Curr Dir Psychol Sci 22(2): 94 -100. Lupien, S. J. , B. S. Mc. Ewen, M. R. Gunnar and C. Heim (2009). "Effects of stress throughout the lifespan on the brain, behaviour and cognition. " Nat Rev Neurosci 10(6): 434 -445.

References • Murakami, H. , T. Nakao, M. Matsunaga, Y. Kasuya, J. Shinoda, J. Yamada and H. Ohira (2012). "The structure of mindful brain. " PLo. S One 7(9): e 46377. • Nedrow A. , Steckler N. A. , Hardman, J. , (2013). “Physician Resilience and Burnout: Can you make the switch. ” Fam Prac Man. 25 -29. • Neinstein L, G. C. (2008). Adolescent Health, A Practical Guide. Philadelphia: Lippincott Williams & Wilkins. • Romeo, R. D. (2013). "Introduction to the special issue on stress and the adolescent brain. " Neuroscience • • 249: 1 -2. Romeo, R. D. (2013). "The Teenage Brain: The Stress Response and the Adolescent Brain. " Curr Dir Psychol Sci 22(2): 140 -145. Romeo, R. D. and B. S. Mc. Ewen (2006). "Stress and the adolescent brain. " Ann N Y Acad Sci 1094: 202214. Sanger, K. L. and D. Dorjee (2015). "Mindfulness training for adolescents: A neurodevelopmental perspective on investigating modifications in attention and emotion regulation using event-related brain potentials. " Cogn Affect Behav Neurosci. Seigel, D. (2013). the Power and the Purpose of the Teenage Brain. Retrieved from: http: //ibme. info/mindfulness-teen-brain/ Steinberg, L. (2004). "Risk taking in adolescence: what changes, and why? " Ann N Y Acad Sci 1021: 51 -58. Steinberg, L. , D. Albert, E. Cauffman, M. Banich, S. Graham and J. Woolard (2008). "Age differences in sensation seeking and impulsivity as indexed by behavior and self-report: evidence for a dual systems model. " Dev Psychol 44(6): 1764 -1778. Wallace J. E. , Lemaire, J. B. , Ghlai, W. A. , (2009). “Physician Wellness: a missing quality indicator. ” 374: 1714 -1721. Zeidan, F. , K. T. Martucci, R. A. Kraft, J. G. Mc. Haffie and R. C. Coghill (2014). "Neural correlates of mindfulness meditation-related anxiety relief. " Soc Cogn Affect Neurosci 9(6): 751 -759.

Additional Slides

The Mindful Brain – Physiology Less aware of environment and less aware of space and time Attention increases BUT Pre-frontal cortex activity (emotional responses, planning, decisions, etc. decreases ) Activate d - Assign emotional significance to our experiences – modify activity of nervous system Changes in limbic system leads to modified activity of the autonomic nervous system

Compassion • Virtue? Moral Tenet? Fundamental to provider-patient relationship? Role Requirement for a Health Care Professional? • Compassion Satisfaction: • Positive sentiment the provider experiences when able to empathetically connect and feel a sense of achievement in the care -providing process • Positive reinforcement with patient’s improve and belief that provider has made a positive impact • Emotionally fulfilled by one’s work in the “human service fields”

Research in cognitive neuroscience • J. Decety: Physicians and down regulation of the pain-empathy response • Additional Research • R. Davidson: • resilience and stress, prefrontal cortex vs. limbic system Fig. 2. Expertise effects on the cortical responses elicited by the perception of body parts pricked by a needle and body parts touched by a Q-tip. (a) N 110 at FZ. (b) P 3 at Cz. (c) P 3 at Pz. The ERP responses are signi ficantly different when the Controls watched the painful relative to the non-painful stimuli. No signi ficant differences were detected in the Physicians. Values are expressed as mean±SE ( � Pb 0. 01).