OVERCOMING RESISTANCE TO RESILIENCY PROGRAMS: ONE STEP AT A TIME!

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Griselda Norton
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1 OVERCOMING RESISTANCE TO RESILIENCY PROGRAMS: ONE STEP AT A TIME! CENTILE International Conference Washington DC, October 24, 2107 Emily Ratner, MD Director, Integrative Medicine Initiatives, MedStar Institute of Innovation (MI2) Medical Director, MedStar Health Center for Integrative Medicine

2 Disclosures and Disclaimers No financial conflicts of interest Not a mental health professional Physician with > 20 years experience in academic medicine who has seen the results of burnout

3 MD burnout increased from 45.5% to 54.4% Satisfaction with work-life balance decreased from 49% to 41% Non physicians had minimal changes in burnout rates and work-life balance satisfaction over the same time period

lack of change in healthcare system is due to lack of proper organizational incentivization vs.

4 MacKinnon, Murray. Acad Psychiatry, 2017 Include industrial & organizational psychology literature in examining MD burnout Suggest lack of change in healthcare system is due to lack of proper organizational incentivization vs. incomplete academic understanding of problem & solutions Reframe MD burnout as problem that extends beyond individual sufferers and effects entire organizational system Focus on increasing engagement vs. decreasing burnout

5 Arenas to Approach Workplace Wellness Individual Increased self-awareness Stress reduction, reframing Resiliency training Work Unit Peer support groups Resiliency training Organizational Factors National Factors Shanafelt et al 2016

6 Mayo Clin Proc 2016 Most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician Burnout is a systems issue Strong business case for institutions to reduce burnout and promote engagement LEADERSHIP and SUSTAINED ATTENTION from the HIGHEST LEVEL of the organization are the KEYS to making progress

meditation Self-awareness exercises Narratives about meaningful clinical experiences

7 Program in Mindful Communication In Primary Care Physicians 70 primary care MD s, year long program 8 week intensive phase 10 month maintenance phase Curriculum Mindfulness meditation Self-awareness exercises Narratives about meaningful clinical experiences Appreciative interviews Didactic material, discussion Krasner, Epstein et al. JAMA 2009

8 Program in Mindful Communication In Primary Care Physicians Improved mindfulness correlated with Less burnout Better emotional stability, mood and empathy Subjectively Reduced isolation due to sharing personal experiences from medical practice w/colleagues Mindfulness skills improved patient interactions and MD s developed more adaptive reserve Transformative to develop greater self-awareness Beckman et al. Acad Med 2012;87:

9 Mindfulness? Awareness of the present moment Not past, not future Being not doing Noticing one s own physical, mental, emotional state Not acting on it, watching but not judging Recognizing that emotional states are all temporary Takes practice

10 Stanford Anesthesiology Residency PRIME (Peer support and Resiliency In MEdicine) Large program 4 Hospitals 75 residents 150 Faculty members Tertiary care center Silicon Valley Stanford duck syndrome

residents to skills to promote resiliency Prevent burnout, in those

11 Goals of Resident Program Create an environment to support and promote the wellbeing of residents Build community Teach/expose residents to skills to promote resiliency Prevent burnout, in those who aren t already Intervene early, prevent progression and devastating consequences

12 Core Components Initiated in 2010, planning since 2008 ** 1. Mandatory first year resident lecture Scientific lecture Stress + biofeedback exercise 2. Voluntary offsite weekend retreat CA-1 s 3. Ongoing q8 week sessions for remaining 3 years of residency, embedded in required didactic program

13 Initial Retreat 4 facilitators 2 groups led by 2 facilitators 2 Stanford anesthesiologists w/ MBM facilitation training 2 Georgetown MBM faculty (Nancy Harazduk, MSW, MEd, Michael Lumpkin PhD) for first few years Critical to have mental health professional present or available

Wellness Retreat Attendance CA-1 residents only 2010 14/26 (54%) 2011 18/26 (69%) 2012

14 Wellness Retreat Attendance CA-1 residents only /26 (54%) /26 (69%) /24 (88%) /26 (77%) /27 (74%) /25 (72%) /26 (84%) /28 (89%)

Guidelines and Agenda Opportunity for self-reflection,

environment Confidentiality, mutual respect I pass rule

tone Experiential exercises: meditation, guided imagery,

15 Guidelines and Agenda Opportunity for self-reflection, sharing concerns with peers in a safe, supportive environment Confidentiality, mutual respect I pass rule Nonjudgmental listening, not solving Facilitators set the tone Experiential exercises: meditation, guided imagery, yoga, Tai Chi, drawing, journaling exercise, 3 good things Group meals, room with peers

Retreat Feedback Objective surveys Subjective survey results 100% met or exceeded expectations Most valuable aspects Formation of strong peer support system Learning new coping and communication

16 Retreat Feedback Objective surveys Subjective survey results 100% met or exceeded expectations Most valuable aspects Formation of strong peer support system Learning new coping and communication skills To really feel that stressors were not only my own To talk openly about my struggles Our interactions were personal and deeply profound The time spent here has truly changed me Unbelievable investment in our well-being. Thank you!

17 Ongoing Sessions Meet every 8 weeks, 1 ½ hours Protected didactic time For all ~75 CA-1, CA-2, CA-3 residents mandatory Two groups from retreat maintained, same facilitators Expanding faculty involvement, facilitator training Further curriculum development

18 What do I need to do to start a resiliency program Assess local landscape Identify which group I want to target(may not be the same as group with biggest need) residents, medical students, faculty, nurses, etc Identify respected champion Identify and cultivate leadership support Identify supporters/detractors/neutrals at numerous levels faculty, residency/clerkship directors, dept chair, dean, GME leadership, administration Cultivate supporters, engage all groups involved Identify open doors vs. barriers; easier to proceed through open doors than knock them down. Pull vs push strategy Funding time and/or $

19 Highlight Real and Local Events to Support Need Accentuate problem issues potentially due to burnout Increasing turnover Substance abuse Behavioral problems Patient complaints especially repeated Mental health issues/exacerbations Suicide If no local events, look harder. Look in other dept locally or in same specialty elsewhere

20 Education Burnout

21 Burnout Emotional exhaustion Depersonalization Decreased sense of personal accomplishment Maslach Burnout Inventory validated survey

22 Burnout Assessment Single question measures from MBI How often do you feel this way about your job? I feel burned out from my work Never = 0 A few times a year = 1 Once a month or less = 2 A few times a month = 3 Once a week = 4 A few times a week = 5 Every day = 6 I ve become more callous toward people since I took this job West et al, J Gen Intern Med 24(12):

out vs. 21% non-burned out had at least one suboptimal patient care event Shanafelt et al.

23 Burnout: Implications Physician Health Mental and physical illness Maladaptive responses to stress Ignoring self-care, denial, avoidance, isolation Self-medication, substance abuse Patient care Medical errors Internal Medicine residents - 53% of burned out vs. 21% non-burned out had at least one suboptimal patient care event Shanafelt et al. Ann Int Med, 2002 Increased surgical error reporting associated with burnout Shanafelt et al. Ann Surg 2010 Adverse patient outcomes Patient compliance and satisfaction

Resident Burnout Incidence: 10-76% Internal medicine residents 76% burnout, Seattle, WA Shanafelt, Ann Int Med, 2001 Surgery residents 56%, UC Irvine, Gelfand, Arch Surg, 2004

25 Resident Burnout Incidence: 10-76% Internal medicine residents 76% burnout, Seattle, WA Shanafelt, Ann Int Med, 2001 Surgery residents 56%, UC Irvine, Gelfand, Arch Surg, 2004 Alexithymic personality style associated w/higher burnout rates, Daly et al, Med J Aust 2002; 177 (1): 14 Alexithymia inability to recognize or describe one s emotions Thomas, JAMA, 2004

Residents As residents progress in training, emotional exhaustion decreases However, rates of depersonalization increase Depersonalization -

26 Residents As residents progress in training, emotional exhaustion decreases However, rates of depersonalization increase Depersonalization - seems to fx as protective buffer to protect MD from emotional impact of patient suffering West et al JAMA, 2011 MacKinnon, et al Acad Psychiatry, 2017

27 In other fields If > 50% of workers had the same problem, it would likely be recognized that the problem is not due to an individual s issue But a system, workplace, or culture problem.

28 Education Burnout Resiliency Better patient outcomes Medical student/resident/faculty recruitment strategy Financial implications decreases high cost of turnover if MDs don t leave/have decreased productivity due to burnout

29 The cost of replacing a physician is three times the salary. Misra-Hebert, 2004

30 Other Details.. Schedule, schedule, schedule tailored to fit local May require gradual implementation vs. starting all at once. Stanford experience - Gradual implementation on a yearly basis worked better than going from 0 to 75 residents involved Mental health professional involvement Create safe, nonjudgmental confidential environment Embed in existing educational curriculum (thank you Haleh Saadat, MD!) Share and learn from other programs and institutions You can t force wellness, allow those who don t want to participate actively to pass. Ask them to not be disruptive. Almost always works if framed that they are supporting practices that help their colleagues

31 Take home messages. Self awareness, mind body skills training, community building and other training programs can promote resiliency. Implement resiliency programs using a well thought out strategy. Yet remember, the workplace, institutional, and national issues that allow burnout to exist still require addressing.

32 The most resilient individual, if placed in a fire Will still burn!

33 WE NEED FIRE PREVENTION In addition to a great fire department

34 And now, for the science behind it all

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