TEMPERED BY FIRE: BURNOUT TO ENGAGEMENT IN PEDIATRICS OBJECTIVES BURNOUT SYNDROME 7/24/2018 DISCLOSURES

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1 TEMPERED BY FIRE: BURNOUT TO ENGAGEMENT IN PEDIATRICS Jocelyn Wilson Harmon, MD FAAP Assistant Professor of Pediatrics, Palmetto Health USC Medical Group July 27th, 2018 I have no actual or potential conflicts of interest to disclose DISCLOSURES Understand the burnout syndrome Literature on burnout specific to pediatrics Model for understanding driver dimensions in burnout and engagement High-impact interventions for departments Healthy living and individual resilience practices OBJECTIVES BURNOUT SYNDROME 1. Emotional exhaustion 2. Depersonalization 3. Reduced sense of personal accomplishment Burnout Engagement A psychological syndrome that involves a prolonged response to chronic interpersonal stressors on the job. - Leiter & Maslach 1

2 22 questions across the 3 domains of burnout Pros: correlates with personal and professional outcomes Cons: no cut-off score to establish a diagnosis of burnout MASLACH BURNOUT INVENTORY REPERCUSSIONS OF BURNOUT ble Shanafelt et al, 2017 RESILIENCE ENGAGEMENT Resilience is the capacity to respond to stress in a healthy way such that goals are achieved at minimal psychological and physical cost; resilient individuals "bounce back" after challenges while also growing stronger. Ronald Epstein, MD An energetic state of involvement with personally fulfilling activities that enhance one s sense of professional efficacy. Leiter & Maslach VITALITY The synergy between high levels of satisfaction, productivity, and engagement that enables [a] faculty member to maximize her/his professional success and achieve goals in concert with institutional goals. LITERATURE ON BURNOUT The answers you get depend on the questions you ask. Thomas Kuhn 2

3 CAVEATS No diagnostic criteria for burnout Simplification of burnout to a one-dimensional construct of exhaustion or depersonalization Survey data affected by bias ARE GENERAL PEDIATRICIANS SATISFIED? High satisfaction with allocation of professional time (89%) and allocation of clinical time (94%) More likely if working part-time Less likely if female 44% plan to retire before age 65 Higher odds if female, or in a non-academic position Lower odds if further out from training, working full-time or IMG ARE PEDIATRIC SUBSPECIALISTS SATISFIED? High satisfaction with allocation of professional time (83%) and clinical time (93%) More likely if in critical care or neonatology (1.32 times higher) More likely if 20 years since training compared with those < 10 years 31% plan to retire before age 65 Least likely for those 20 years since training Most likely for those <10 years since training IF YOU COULD AFFORD TO, WOULD YOU RETIRE NOW? PEDIATRICIAN LIFE AND CAREER EXPERIENCE STUDY (2013) High satisfaction with career as physician and life overall (82.7% and 70.8%) 43% agreed or strongly agreed that the balance of personal and professional commitments was about right 30% agreed that I am currently experiencing burnout in my work. 3

4 More likely if: Sad or depressed Experienced negative life events Working in hectic/chaotic work setting Working for 4 years in current position Protective factors Being in excellent/very good self-reported health Personal support from physician colleagues Adequate resources for patient care PLACES: EARLY CAREER PEDIATRICIANS PLACES, 5 YEARS LATER 58% experienced burnout at least once in 5 years Burnout attenuated by Flexible work schedule Decreased work busyness Job change Increasing exercise Increasing sleep HIGHER RISK PEDIATRIC SUBSPECIALITIES Pediatric EM (2013) 53.5% endorsed feeling burned out at least a few times per month 13% plan to leave PEM entirely Pediatric Intensive Care (2018) Burnout affecting 49% Twice as likely in women 65% have considered leaving critical care in the recent past Inverse relationship between burnout and exercise Pediatric Oncology (2011) 87% reported being satisfied with their work 72% experiencing at least moderate levels of burnout RETENTION RATES IN ACADEMIC MEDICINE 4.6% pediatric faculty reported intent to leave Intent to leave correlated with: Satisfaction with quality and function of patient care Aspects of workplace culture ACADEMIC MEDICINE IN 2018? Pressure to increase clinical productivity Duty hours restrictions Decreased funding for scholarly activities Increased oversight and regulatory requirements affecting work flow BURNOUT AND CAREER FIT (2007) Burnout affecting 34% of internal medicine faculty Spending less than 20% of time in the most meaningful activity increased burnout by 54% 4

5 ARE PEDIATRIC RESIDENTS BURNED OUT? Burnout affecting 39.1% Statistically significant higher rates of suboptimal patient care attitudes and behaviors Perceived sleep deprivation a predictor of burnout Sleep deprivation not collinear with burnout in regression model of patient care attitudes RPEDIATRIC RESIDENTS WITH BURNOUT Length of work hours or work schedules NOT predictive Pediatricians are satisfied with their career choice 1/4 would retire early if they could 20-75% of us experiencing burnout Stage of career Gender Specialty Career fit Degree of flexibility and control Support from colleagues Exercise Sleep TAKE-AWAYS ARE WE BURNED OUT OR DEPRESSED?..Regardless of whether or not one favors a social perspective, burnout is in the end experienced by people. Because burnout is individually embodied, individual diagnosis and individualized assistance are required if we are to help sufferers recover. Tackling the question of stigma to the detriment of the concern for diagnosis is therefore not a solution. NOW WHAT? For every complex problem there is an answer that is clear, simple, and wrong. H.L. Mencken studies: Shortened attending rotation length Modifications to clinical work processes Shortened residents shifts EVIDENCE-BASED INTERVENTIONS 2016 systematic review of 15 RCTs and 27 observational Stress management Self care training Communication skills training Mindfulness based approaches Small group curricula Bottom Line: Organizational interventions are more effective at improving overall burnout scores than individually-focused interventions 5

6 DRIVER DIMENSIONS DEVELOP TARGETED INTERVENTIONS Use the framework of the 7 driver dimensions to structure the conversation Led by leadership consulting team Meet with local leadership Conduct focus groups Follow-through by local leadership team 1. LEADERSHIP DEVELOPMENT HIGH-IMPACT INTERVENTIONS Leadership behaviors impact physician well-being Each 1 point increase in the leadership score of a physician s immediate supervisor associated with 3.5% decrease in likelihood of burnout and 9% increase in satisfaction 11% variation in burnout and 47% variation in satisfaction in work units explained by aggregate leadership rating of work unit supervisor 6

7 GROW YOUR LEADERS IHI FOUR STEPS FOR LEADERS Effective listeners and transparent communicators Model emotional management Know each team member s 20% Champion burnout prevention Adequate FTE to focus on needs of the division Annual performance review 2. MENTORSHIP A formal social support that provides a range of benefits including emotional support, empathy, practical assistance, advice and information, feedback and encouragement. Pane et al, 2012 EFFECTIVE MENTORSHIP WILL YOU BE MY MENTOR? Drawbacks of an arranged marriage Ideal relationship characterized by support, mutual respect and compatibility Facilitated peer group mentoring mentorship@aap.org 7

8 3. BECOME A RELATIONSHIP- CENTERED DEPARTMENT Get your group together! Regular departmental and division meetings Social events Community service projects Facilitated colleague support groups Finding Meaning in Medicine COMPREHENSIVE SELF-CARE Love your body and teach your mind to respect it. Anonymous RX: GOOD NUTRITION RX: REGULAR EXERCISE Minimum of 2.5hrs/week of moderate-intensity aerobic exercise OR 1.25hrs/week of vigorous-intensity aerobic exercise Brisk walk 30 minutes/day 5 days a week High-intensity 45 min spin class + 30 min jog Muscle strengthening at least twice per week RX: SLEEP RX: MINDFULNESS Paying attention in a particular way, on purpose, in the present moment and without judgement. John Kabat-Zinn lness 8

9 THE GOALS OF MINDFUL PRACTICE ARE TO BECOME MORE AWARE OF ONE S OWN MENTAL PROCESSES, LISTEN MORE ATTENTIVELY, BECOME FLEXIBLE, AND RECOGNIZE BIAS AND JUDGMENTS, AND THEREBY ACT WITH PRINCIPLES AND COMPASSION. RONALD EPSTEIN 3 Good Things RX: CULTIVATE GRATITUDE Every night before you go to bed, think back over your day and recall three good things that happened Write them down in a journal, or an online app Think about why write down the details of why that thing happened, and why you feel good about it Keep it up try the practice for at least 2 weeks and notice how you may start to appreciate good things more as they are happening Quality time with family and friends Religious/spiritual practices Time in nature Listening to music Hobbies Retreat/sabbatical Individualized therapy SESELF-CARE UNLIMITED Burnout is not a disease, but is a common experience CONCLUSIONS Leaders at all levels of organizations/institutions need to take responsibility for implementing targeted inventions Importance of mentorship and fostering a supportive culture within departments Self-care practices make a difference, particularly in addressing emotional exhaustion Baer TE, Feraco AM, Sagalowsky ST, Wiliams D, Litman H, V inci RJ. Pediatric resident burnout and attitudes toward patients. Pediatrics. 2017; 139(3):e Barnes N, Hattan P, Black D, Schuman-Olivier Z. An examination of mindfulness-based programs in US medical schools. Mindfulness. Published online 06 October 2016 Bianchi R, Schonfeld IS, V andel P, Laurent E. On the depressive nature of the burnout syndrome : A clarification. European Psychiatry. 2017; 41: Corrice AM, Fox S, Bunton SA. Retention of full-time clinical MD faculty at US medical schools. Analysis in Brief. 2011; 11(2);1-2. Freed GL, Morgan LM, V an KD, Leslie LK et al. Current workforce of general pediatricians in the United States. Pediatrics. 2016; 137(4): e Freed GL, Moran LM, V an KD, Leslie LK et al. Current workforce of pediatric subspecialists in the United States. Pediatrics. 2017; 139 (5): Gorelick MH, Schremmer R, Ruch-Ross H, Radabaugh C, Selbst S. Current workforce characteristics and burnout in pediatric emergency medicine. Academic Emergency Medicine. 2016; 23: Gusic ME. Cultivating Resilience: Personally and for Our Profession. Academic Pediatrics. 2016; 16 (7); Maslach C, Leiter MP. Early predictors of job burnout and engagement. Journal of Applied Psychology. 2008; 93 (3): Pololi L, Knight S. Mentoring faculty in academic medicine: a new paradigm? J Gen Intern Med. 2005; 20: Perlo J, Balik B, Swenson S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare improvement; Pololi L, Conrad P, Knight S, Carr P. A study of the relational aspects of the culture of academic medicine. Academic Medicine. 2009; 84 (1): Pololi LH, Evans AT, Civian JT, Gibbs BK, Gillum LH, Brennan RT. A novel measure of good mentoring: testing reliability and validity in four academic health centers. JCEHP. 2016; 36 (4): Roth M, Morrone K, Moody K, Kim M, Wang D, Moadel A, Levy A. Career burnout among pediatric oncologists. Pediatr Blood Cancer. 2011; 57: REFERENCES Rimza ME, Ruch-Ross H, Simon HK, Pendergrass TW, Mulvey H. Factors influencing pediatrician retirement: A survey of American Academy of Pediatrics survey members. The Journal of Pediatrics. 2017; 188: Shenoi AN, Kalyanaraman M, Pillai A, Raghava PS, Day S. Burnout and psychological distress among pediatric critical care physicians in the United States. Critical Care Medicine. 2018; 46: Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012; 172 (18): Shanafelt TD, West CP, Sloan JA, Novotny PJ, Poland GA, Menaker R, Rummans TA, Dyrbye LN. Career fit and burnout among academic faculty. Arch Intern Med. 2009; 169 (10): Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017; 92 (1): Starmer AJ, Frintner MP, Freed GL. Work-life balance, burnout, and satisfaction of early career pediatricians. Pediatrics. 2016; 137(4):e Sweeney, F. (Producer). Burnout with Christina Maslach (Audio podcast). Retrieved from West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016; 388: QUESTIONS? jocelyn.harmon@palmettohealth.org 9