PHYSICIAN BURNOUT Pepi Granat MD November 27 2002

PHYSICIAN BURNOUT Pepi Granat, MD, November 27, 2002.

What we’ll do in this hour (Please fill out Evaluation – really helpful for our improvement) n Dimensions of burnout n Brief activity for residents & faculty n Some research in the field n Recent flurry of articles re: residents, hours, etc n Prevention & treatment n What to do when “bummed out”

PHYSICIAN BURNOUT: PREVENTION, IDENTIFICATION (Post DM, Miller K, Strickland C. FP Recertification vol 21, No. 1 Jan 1999) “Physician burnout syndrome is a psychological impairment caused by chronic job-related stress. It is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment…. . ”

Vol. 288 No. 12, September 25, 2002. JAMA Linking Evidence and Experience Mid-Career Burnout in Generalist and Specialist Physicians Anderson Spickard, Jr, MD; Steven G. Gabbe, MD; John F. Christensen, Ph. D The Silent Anguish of the Healers

Burnout Defined n “A state of fatigue or frustration brought about by devotion to a cause, way of life, or relationship that failed to produce the expected reward. ” -Freudenberger, 1980 – NOT SIMPLY OVERWORK – NOT SIMPLY TIREDNESS – Particularly prevalent in helping professions

Frequent stressors & outcomes n n n Heavy workload Long hours Fatigue Bureaucratic interference Alienation from families and social networks Commercialization of medicine n n n n Few social attachments Inadequacy feelings Cynicism feelings Victimization Disruptive, selfdestructive behavior Chemical dependency Depression, anxiety Suicide

Physician Suicide Burnout a precursor n Estimated rate of physician suicides in 1992: 28 -40 per 100, 000 (vs. nat’l 11. 6) n Physicians adept at disguising intent n Physicians effective in carrying out intent n Rate of successful initial suicide attempts for physicians is exceptionally high: 62% n

What is BURNOUT? First described in 1974: a syndrome stemming from an inability to conserve energy and adapt efficiently n Physical symptoms n Psychological symptoms n Behavioral effects n

Components of Burnout: Physiological Behavioral Psychological Spiritual

Physical and Psychological Symptoms; Behavioral Effects n Physical: – – – n Muscle tension Headaches Tachycardia Anorexia Insomnia Psychological: – – Depression Helplessness Anger Frustration n Behavioral effects: – – – Quickness to anger Frustration responses Suspiciousness bordering on paranoia – Feelings of omnipotence

Manifestations in Clinical Work n n n n Dreading seeing another patient Cynicism toward patients Daydreaming during sessions Hostility toward patients Quickness to diagnose or refer out Blaming patients Constant complaining to coworkers Failure to “complain” in appropriate venues

3 DIMENSIONS OF BURNOUT n. EMOTIONAL EXHAUSTION n. DEPERSONALIZATION n. DIMINISHED FEELINGS OF PERSONAL ACCOMPLISHMENT

What causes BURNOUT? n 3 major factors: n Work (overwork, coping with patients’ problems, administrative duties) n Expectation of others n Personal characteristics

Etiology n Intrapsychic – Lack of reinforcement contingencies – Masked narcissism n Systemic/Environmental Factors

Work Environment Stress n n n n Time pressure Caseload that is excessive in size, scope or intensity Organizational politics Non-supportive peers Excessive paperwork Unrealistic or unreasonable demands by managed care Lack of money or resources Lack of respect from professional colleagues

Self-Induced Stress n n n n Perfectionism Fear of failure Self-doubt Need for approval Emotional depletion Unhealthy lifestyle (self-medication, lack of self care) Lack of faith (not necessarily religious faith)

Major Life Event-Related Stress n n n n Legal actions taken against you Major life transitions Physical or medical problems Family problems Economic cutbacks (layoffs, fluctuations in economy) Money pressures Change in job responsibilities RESIDENCY !!!!! BUT DON’T FORGET – IT’S TEMPORARY !!!!!

Some RESIDENCY ISSUES n n Work hours petition rejected by OSHA ACGME voluntary standards supported – – n n 80 hours/week Minimum 10 hrs. between shifts Burnout said to be linked to overwork & to lead to suboptimal care (Shanafelt, et al. Annals Int Med. Sept. 2002) Some commentators say fewer hours lead to less competence burnout (because of poor academic teaching & inadequate performance). i. e. suboptimal care leads to burnout (from angst), not vice versa (Graham, Annals of Internal Med. Oct. 2002)

Stages of burnout n Early Symptoms – Low energy – Boredom – Still productive, but diminished n Advanced Symptoms – Poor performance evaluations – Presence of physical and psychological symptoms

Prevention Awareness!

Keeping Your Eye on the Ball Exercise: Why You Became A Physician (3 reasons) Exercise: Assessing Joys &Hardships (3 joys; 3 hardships) At this point: Break into groups of 3 (5 minutes) Negotiate & decide the above & present to group (5 -10 minutes)

Communication not Competence = most important skill. n Communication skills training for health care professionals working with cancer patients, their families and/or carers[Protocol]Fellowes, D; Wilkinson, S; Moore, P n Date of Most Recent Update: 9 -4 -2002 n Date of Most Recent Substantive Update: 1 -11 -2001 Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, et al. Burnout and psychiatric disorder among cancer clinicians. British Journal of Cancer 1995; 71(6): 1263 -9. Review in progress……. n n n The Cochrane Database of Systematic Reviews Volume (Issue 4) 2002

Sex differences in physician burnout in the United States and The Netherlands J Am Med Womens Assoc 2002 Fall; 57(4): 191 -3 Linzer M, Mc. Murray JE, Visser MR, Oort FJ, Smets E, de Haes HC Separate physician surveys: United States (n=2326) Netherlands (n=1426 Gender parity in physician burnout in the Netherlands may be due to fewer work hours and greater work control of women compared to those in the United States

Life Satisfaction Among Norwegian Young Doctors: A Longitudinal Study Reidar Tyssen, MD, Ph. D; Per Vaglum, MD, Ph. D; Nina T. Grønvold, MD & Øivind Ekeberg, MD, Ph. D. Department of Behavioral Sciences in Medicine, Faculty of Medicine University of Oslo Paper presented at International Conference on Physician Health in Vancouver, B. C, Oct. 19, 2002 Preliminary and unpublished data, courtesy of the author.

Results: Comparison of Life Satisfaction Among Doctors and Comparison Group Mean : 5. 2 (1. 01) Mean: 5. 6 (0. 98) T-test: t = 7. 0, p<0. 001 NB!: No gender differences

“Very/extremely satisfied” with life n n % n 1/3 among doctors 1/2 (or more) among other people Statistics (doctors vs. controls): Chi-Square = 49. 3 P<0. 001

Dissatisfied with life (any category) n n % n 3. 8% (16/420) among doctors 1. 9% (31/1627) among other people Chi-square = 5. 4 P = 0. 03

Conclusion Young physicians are less satisfied with life than other people in the society n Subjective well-being: - Probably impeding factors: Mental distress (personality trait), work stress and life stress - Probably promoting factors: Having a stable partner, social support, physical training. n About 30% of the variance is predicted at medical school level (personality trait & medical school variables) n

Balancing life Social relationships Working hours Spare time Personal time & self-care

COPING STRATEGIES INDIVIDUAL FACTORS-- the physician’s personality n ORGANIZATIONAL FACTORS -- workplace stressors n ESTABLISHING PRIORITIES n FOCUSING ON MOST TROUBLESOME ISSUES n SET REALISTIC, ATTAINABLE GOALS n

Treatment Self help n Therapy n Psychotropic Medications n Focus on Spirituality n n Resolution to Act!

Barriers to Proper Treatment Often unrecognized until problem is severe n Professionals rarely present with burnout as primary issue n Embarrassment n

SPECIFIC STRATEGIES Self-help books on stress management n Specific books for physicians n Internet resources n Self-assessment tool: Stress. Map n Stress-management workshops n Individual counseling, especially for selfesteem and identity issues n

STRESS-MANAGEMENT TECHNIQUES n n INCREASE SELFAWARENESS SHARE FEELINGS AND RESPONSIBILITES SELF-CARE PERSONAL PHILOSOPHY n n n EXPLORE HOW “HEALTHY” PHYSICIANS DEAL WITH STRESS APPRECIATE YOUR OWN ROLE, DON’T BLAME OTHERS CONSIDER ALL OPTIONS

Strategies to Prevent Physician Burnout Personal Influence happiness through personal values and cho Spending time with family and friends Religious or spiritual activity Self-care (nutrition, exercise) Adopting a healthy philosophical outlook A supportive spouse or partner Work Control over environment: workload Finding meaning in work and setting limits Having a mentor Having adequate administrative support systems

WHAT TO DO WHEN “BUMMED-OUT” “Choose something like a Star” TRY POETRY INSPIRATIONAL (“IF”) OR CALMING(“The Day is Done”)

The Day is Done… Henry Wadsworth Longfellow n n The day is done, and the darkness Falls from the wings of Night, As a feather is wafted downward From an eagle in his flight. n n I see the lights of the village Gleam through the rain and the mist, And a feeling of sadness comes o’er me That my soul cannot resist:

The Day is Done n n A feeling of sadness and longing, That is not akin to pain, And resembles sorrow only As the mist resembles the rain. n n Come, read to me some poem, Some simple and heartfelt lay, That shall soothe this restless feeling, And banish the thoughts of day.

The Day is Done n n Not from the grand old masters, Not from the bards sublime, Whose distant footsteps echo Through the corridors of Time. n n For, like strains of martial music, Their mighty thoughts suggest Life’s endless toil and endeavor; And tonight I long for rest.

The Day is Done n n Read from some humbler poet, Whose songs gushed from his heart, As showers from the clouds of summer, Or tears from the eyelids start; n n Who through long days of labor, And nights devoid of ease, Still heard in his soul the music Of wonderful melodies.

The Day is Done n n Such songs have power to quiet The restless pulse of care, And come like the benediction That follows after prayer. n n Then read from the treasured volume The poem of thy choice, And lend to the rhyme of the poet The beauty of thy voice.

The Day is Done n And the night shall be filled with music n And the cares, that infest the day, n Shall fold their tents, like the Arabs, n And as silently steal away.

IF…. by Rudyard Kipling n n If you can keep your head when all about you Are losing theirs and blaming it on you; If you can trust yourself when all men doubt you, But make allowance for their doubting too: n n If you can wait and not be tired by waiting, Or, being lied about, don’t deal in lies, Or being hated don’t give way to hating, And yet don’t look too good nor talk too wise;

If……. . n n If you can dream-- and not make dreams your master; If you can think-- and not make thoughts your aim, If you can meet with Triumph and Disaster And treat those two impostors just the n n If you can bear to hear the truth you’ve spoken Twisted by knaves to make a trap for fools, Or watch the things you gave your life to broken, And stoop, and build ‘em up with worn-out

If…. . n n If you can make one heap of all your winnings And risk it on one turn of pitch-and-toss, And lose, and start again at your beginnings, And never breathe a word about your loss: n n If you can trust your heart and nerve and sinew To serve your turn long after they are gone, And so hold on when there is nothing in you Except the Will which says to them: “Hold

If…. . n n If you can talk with crowds and keep your virtue, Or walk with Kings-- nor lose the common touch, If neither foes nor loving friends can hurt you, If all men count with you, but none too much: n n If you can fill the unforgiving minute With sixty seconds’ worth of distance run, Yours is the Earth, and everything that’s in it, And -- which is more - you’ll be a Man, my son!

What we’ve done this hour(Please fill out Evaluation – really helpful for our improvement) n Dimensions of burnout n Brief activity for residents & faculty n Some research in the field n Prevention & treatment n What to do when “bummed out”