Moving beyond burnout to professional engagement and joy. Martina Schulte, MD February 10, 2018

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1 Moving beyond burnout to professional engagement and joy Martina Schulte, MD February 10, 2018

2 Disclosures: None

3 Can we use the word joy? Don Berwick, MD 2017 Perlo. IHI Framework for Improving Joy in Work

4 I heard it through the grapevine

5 Objectives 1. Discuss general facts about burnout 2. Explore drivers of burnout and professional satisfaction 3. Examine current literature on frameworks for addressing burnout and enhancing joy 4. Discover actionable interventions to decrease burnout and enhance joy in the clinical setting

6 Q1 I have attended a lecture, training or webinar on burnout or resilience in the last 1. month months months years 5. I have not heard about or participated in education about this topic

7 International Conference On Physician Health Toronto, Ontario October 11 13, 2018

8 The What: Burnout Syndrome characterized by: Emotional exhaustion Depersonalization Decreased sense of personal accomplishment

Burnout overview first described 1974 by Freudenberger state of fatigue or frustration resulting from professional relationships that fail to produce the expected rewards later defined as the

9 Burnout overview first described 1974 by Freudenberger state of fatigue or frustration resulting from professional relationships that fail to produce the expected rewards later defined as the psychological syndrome by Maslach occurring in professionals working with people in challenging situations occupational hazard for peopleoriented workers environmental factors high demand, low resources settings common norms: be selfless and put others' needs first work long hours do whatever it takes, go the extra mile medicine qualities selected for (Gabbard, JAMA 1985): triad of compulsiveness doubt guilt exaggerated sense of responsibility delay gratification perfectionism

10 Frequency: Burnout Shanafelt. Mayo Clin Proc. 2015

11 Risk vs non physicians Physicians Burnout (MBI) Satisfaction (WLB) Non physician working US adults Burnout (MBI) Satisfaction (WLB) Shanafelt. Mayo Clin Proc. 2015

12 Risk by education RR of burnout versus High School Graduates: Bachelor s OR 0.8 Master s OR 0.71 Professional or doctoral OR 0.64 MD or DO OR 1.36

13 Consequences Shanafelt, Mayo Clin Proc, 2017

14 Yerkes Dodson Curve

15 Canary in the coal mine

16 Work Environment Christine Maslach Workload Control/Autonomy Values/meaning Fairness Community Reward

17 449 physicians from 119 practices Adverse physician reactions strongly associated with: workflow (time pressure and a chaotic work pace) job characteristics (lack of work control) poor organizational culture Linzer. Ann Intern Med, 2009

Workload Control/Autonomy Values/meaning Fairness Community Reward Maslach Work content, allied health

18 Quality of care Electronic health records Autonomy and work control Practice leadership Values alignment Balanced approach to initiatives Collegiality, fairness and respect Work quantity and pace Workload Control/Autonomy Values/meaning Fairness Community Reward Maslach Work content, allied health professionals and support stability Pay/income Regulatory and liability concerns Friedberg. Published online, 2013

19 Richard Branson

20 Drivers of burnout and enhancing joy Workload Driver Individual Organizational Work efficiency/support Work life integration/balance Autonomy/flexibility/contr ol Values/meaning West, Mayo Clinic

21 Approaching interventions

22 Frameworks for developing action

23 Mayo 1. Acknowledge and Assess the Problem 4. Cultivate Community at Work 7. Promote Flexibility and Work Life Integration 2. Harness the Power of Leadership 5. Use Rewards and Incentives Wisely 8. Provide Resources to Promote Resilience And Self care 3. Develop and Implement Targeted Interventions 6. Align Values and Strengthen Culture 9. Facilitate and Fund Organizational Science Shanafelt. Mayo Clin Proc, 2017

25 Key components Culture of Wellness Leadership Values alignment Voice/input Peer support Meaning in work Community/collegiality Appreciation Flexibility Culture compassion Shanafelt. American Conference on Physician Health, 2017

26 Interventions!

28 Mayo 1. Acknowledge and Assess the Problem 4. Cultivate Community at Work 7. Promote Flexibility and Work Life Integration 2. Harness the Power of Leadership 5. Use Rewards and Incentives Wisely 8. Provide Resources to Promote Resilience And Self care 3. Develop and Implement Targeted Interventions 6. Align Values and Strengthen Culture 9. Facilitate and Fund Organizational Science Shanafelt. Mayo Clin Proc, 2017

Targeted interventions Efficiency of practice Primary care clinicians at 34 clinics in Midwest and NY Work condition measurements: time pressure workplace chaos work control clinician outcomes.

29 Targeted interventions Efficiency of practice Primary care clinicians at 34 clinics in Midwest and NY Work condition measurements: time pressure workplace chaos work control clinician outcomes. Work life measurement Chosen interventions fell into 3 categories: 1) improved communication 2) changes in workflow 3) targeted quality improvement (QI) projects Linzer, J Gen Intern Med, 2015

31 Results Intervention clinicians Improvements in burnout and satisfaction Burnout was more likely to improve with workflow interventions targeted QI projects Satisfaction and intention trended toward improvement communication workflow

32 Targeted interventions Efficiency of practice SWAT Intervention Atrius Health, non profit, MA Health Group 740,000 patients Package of EHR related interventions SWAT IT analysis, training, local support, security and interface issues Workflow observation and analysis Pre: provider efficiency score tracked: every screen Click scroll every look at med list, problem list time logged in to system Atrius Health, American Conference on Physician Health, Presented 2017

33 Targeted interventions Efficiency of practice SWAT Intervention Interventions at the elbow support EPIC system configuration changes operational change training for staff Technology changes Dragon, Widescreen, EPCS

34 Outcomes: Click savings estimated 1500 clicks of 4000 estimated/provider/day EPCS adoption rising rapidly Time savings Unswatted Swatted Time in navigator (mins/eval period) Time in notes/letters (mins/eval period)

35 Cultivate community culture of wellness Control and intervention groups Intervention groupo 19 biweekly facilitated discussions o mindfulness, reflection, shared experience, and small group learning Protected time (1 hr of paid time every other week) West. JAMA Intern Med, 2014

36 Cultivate community culture of wellness Facilitated small group curriculum vs control group improved meaning and engagement reduced depersonalization sustained results at 12 months

37 Harness power of leadership Culture of wellness Surveyed 3896 physicians, 72% response Assessed burnout and leadership qualities of immediate and division/department chair 12 leadership dimensions Likert 1 5 Composite leadership score Shanafelt. Mayo Clin Proc, 2015

39 Results Physician team leaders and department chair leadership scores correlated with burnout and satisfaction Leadership qualities are teachable: keeping people informed encouraging reports to suggest ideas for improvement having career development conversations providing feedback and coaching recognizing a job well done

40 For each 1 point increase in composite score 3.3% decreased likelihood of burnout 9% increased likelihood of satisfaction

41 The Big Three! 1. Develop and implement targeted interventions 1. Workplace efficiencies, workload and workflow 2. Address EHR challenges 2. Cultivate community 3. Harness the power of leadership

42 Focus: Individual or Organizational? Lancet. Published online September, 2016 JAMA Intern Med. Published online December, 2016

Interventions Organizational Duty hour requirementsreference Shorter attending rotations Shorter resident shifts in ICU Float pools for planned absences Small amt of

43 Interventions Organizational Duty hour requirementsreference Shorter attending rotations Shorter resident shifts in ICU Float pools for planned absences Small amt of protected time Individual Meditation/Mindfulness Stress management training Communication skills training Narrative medicine Small group curricula and belonging interventions

44 Drivers of burnout and enhancing joy Workload Driver Individual Organizational Work efficiency/support Work life integration/balance Autonomy/flexibility/contr ol Values/meaning West, Mayo Clinic

45 Drivers of burnout Individual and enhancing Organizationaljoy Workload Part time Productivity targets Duty hour requirements Integrated career development Work efficiency/support Efficiency skills training EMR Staff support Workflow redesign Work life integration/balance Autonomy/flexibility/co ntrol Values/meaning Self care Mindfulness MBSR Stress management Mindfulness Engagement Positive psychology Reflection and self awareness Mindfulness Small group approaches Meeting schedules Off hours clinics Curricula during work hours Financial support/counseling Physician engagement Work hour options Core values Protect time with patients Promote community Work learning community

46 What can I do for myself? Purpose, meaning, values positive attitude cognitive flexibility through positive reappraisal embrace a personal moral compass find a resilience role model face your fears develop active coping skills establish and nurture a supportive social network attend to physical well being train regularly and rigorously in multiple areas recognize, utilize and foster signature strengths

47 Purpose & Meaning Career Fit and Burnout Among Academic Faculty 556 physicians sampled, 465 (84%) responded Spending <20% of professional work time on most meaningful activity had higher burnout Time spent on most meaningful activity was the largest predictor of burnout Shanafelt. Arch intern Med, 2009

48 Personal wellness 8 strategies to increase wellness Dyrbye, Mayo Clinic Optimize meaning in work and life I know and live my purpose! Avoid over commitment I know my personal values and make decisions consistent with them Reduce work home conflicts How often do I decide in favor of home versus work? Take vacation Exercise CDC guideline Build relationships I pay attention to family and friends and actively seek connectedness Avoid delayed gratification I am living my bucket list Reduce work hours

49 Q2 Which of these 8 strategies are you doing well for yourself? 1. Optimize meaning in work and life I know and live my purpose! 2. Avoid over commitment I know my personal values and make decisions consistent with them 3. Reduce work home conflicts How often do I decide in favor of home versus work? 4. Take vacation 5. Exercise CDC guideline 6. Build relationships I pay attention to family and friends and actively seek connectedness 7. Avoid delayed gratification I am living my bucket list 8. Reduce work hours

50 Q3 Which of these strategies would you like to incorporate more in your life? 1. Optimize meaning in work and life I know and live my purpose! 2. Avoid over commitment I know my personal values and make decisions consistent with them 3. Reduce work home conflicts How often do I decide in favor of home versus work? 4. Take vacation 5. Exercise CDC guideline 6. Build relationships I pay attention to family and friends and actively seek connectedness 7. Avoid delayed gratification I am living my bucket list 8. Reduce work hours

51 Strategy: What have I tried to make this happen? One step I will take this week to make this happen:

52 Individual interventions help But, burnout is a system issue Creating joy in practice necessitates systems interventions Studies are happening Ways forward are emerging Building community/support Site specific workflow efficiencies & interventions Leadership development

53 Take care of yourself Be clear on what brings you joy you value But while waiting for systems to catch up Let your purpose, joys and values be your guide your decisionmaking

54 Marti Schulte

55 Consequences references Errors/Safety Welp. Front Psychol 2017 Shanafelt. Ann Surg 2010 Williams. Health Care Manage Rev 2007 Shanafelt. Ann Intern Med 2002 Unprofessional behavior/impaired professionalism Dyrbye. JAMA, 2010 Medication adherence Haas. J Gen Intern Med 2000 Staff turnover and reduced hours Shanafelt. J Am Coll Surg 2011 Shanafelt. Mayo Clin Proc 2016 Depression and suicidal ideation Blach. Ann Surg 2011 Shanafelt., Arch Surg 2012 Alcohol use Oreskovich. Arch Surg 2012 Mortality Welp. Front Psychol 2017

Physician Burnout and Distress: Causes, Consequences, and a Structure For Solutions

Physician Burnout and Distress: Causes, Consequences, and a Structure For Solutions January 5, 2017 Presenter: Colin P. West, MD, PhD Professor of Medicine, Medical Education, and Biostatistics Division