R2 - Research presentations

Transcription

1 R2 - Research presentations A randomized controlled trial evaluating the effect of facilitated small group sessions on physician well-being and job satisfaction (C. West, L. Dyrbye, J. Sloan, T. Shanafelt) Ville-Marie, Friday, Oct. 26, 2012 (11 am-12:30 pm)

2 Outline Background Potential Solutions The DOM Intervention Trial Future Steps

3 Outline Background Potential Solutions The DOM Intervention Trial Future Steps

4 Physician well-being has come under increased scrutiny in recent years Common: Burnout Low job satisfaction High stress Low quality of life Background

5 Physician well-being has come under increased scrutiny in recent years Common: Burnout Low job satisfaction High stress Low quality of life Affects all stages of physician training and practice Affects all specialties Background

6 Consequences of Physician Burnout Medical errors 1-3 Impaired professionalism 5,6 Reduced patient satisfaction 7 Staff turnover and reduced hours 8 Depression and suicidal ideation 9,10 1 JAMA 296:1071, 2 JAMA 304:1173, 3 JAMA 302:1294, 4 Annals IM 136:358, 5 Annals Surg 251:995, 6 JAMA 306:952, 7 Health Psych 12:93, 8 JACS 212:421, 9 Annals IM 149:334, 10 Arch Surg 146:54

7 Outline Background Potential Solutions The DOM Intervention Trial Future Steps

8 Recommendations in the Literature Choices with regard to work-life balance Stress management techniques Spiritual nurturing Positive life philosophy Self-care (exercise, health, recognition of place on the stress curve : reflection, mindfulness) Search for meaning in work Shanafelt et al., Am J Med 2003; Dyrbye et al., Mayo Clin Proc 2005

9 SMART program Studied Approaches Personal stress reduction training Fostering self-awareness ( mindfulness training ) Balint groups Informal Doctoring to Heal physician discussion groups

10 Limitations of the Literature Interventions to reduce distress and promote wellbeing limited by: Small samples Uncontrolled studies Focus on personal rather than shared responsibility with organization Most interventions on personal time Limited and poorly validated outcomes

11 An Intriguing Model Krasner et al. reported large effects of a 52-hour mindfulness training program administered over 1 year Markedly improved burnout in all domains Improved empathy Improved mindfulness Results sustained 3 months post-intervention Limitations No comparative control group Volunteer bias All participants were primary care providers Training occurred after hours and on weekends Krasner et al., JAMA 2009;302:

12 Outline Background Potential Solutions The DOM Intervention Trial Future Steps

13 Intervention Trial Develop intervention to promote meaning in work among Department of Medicine (DOM) practicing physicians Key driver of physician satisfaction and well-being Mechanism to reduce burnout related to work engagement

14 Intervention Trial RCT testing if an established, portable, low-cost curriculum administered during regular work hours can promote meaning and reduce burnout Arm A (Intervention): meet 90 minutes (12:30-2) every other wk (60 mins protected time, ~1% FTE) 9 months Facilitated curriculum, small groups of 6-8 physicians Arm B (Control): Receive 60 minutes every other week for professional/administrative tasks (~1% FTE) Outcomes assessed quarterly, 3 months post, 12 months post (final survey results currently under analysis)

15 Intervention Trial Intervention DOM faculty N=550 Volunteers N=74 Nonvolunteers N=476 N=37 Control N=37 Current Practice

16 Intervention Trial Participants: Randomization in blocks to match sex and specialty 58% men (DOM ~70%) 40% generalists (DOM ~25%) Prior data suggests generalists and women may have higher rates of burnout and many other markers of distress. Small groups constructed to have mix of generalists/subspecialists and men/women.

17 Intervention Trial Expert facilitators Lead: Jeff Rabatin, MD, MSc Tim Call, MD John Davidson, MD Ada Multari, MD Susan Romanski, MD Qualitative methods Joan Henriksen Hellyer, RN, PhD Facilitator training sessions Debriefing sessions after each small group meeting

18 Intervention Trial Intervention broad and varied: Built on prior literature Goals: Identify and promote meaning in work Foster collegiality and community Share techniques for dealing with challenging professional issues Identify and share ways to promote personal and professional satisfaction Learn specific skills: self-reflection, mindfulness, effective coping strategies

19 Intervention Trial Topics: 3 Modules SELF Physician well-being Physician distress Meaning in work Personal resources Thriving BALANCE Personal/professional balance Personal/professional identity Personal/professional relationships Gender and generational differences Resiliency PATIENT Patient connectedness Barriers to care Bad news Medical mistakes and errors Being present

20 Intervention Trial Session structure (60 minutes) Check-in (5 minutes) Cueing exercise (15 minutes) Group discussion (20 minutes) Skills and solutions (15 minutes) Check-out/summary (5 minutes)

21 Intervention Trial Example: Session 12 (Medical mistakes and errors) Specific Themes to Address: Experiences of error and reactions from peers/system Impact on physicians

22 12:30-12:45: Lunch 12:45-12:50: Check-in Intervention Trial 12:50-1:05: Prepare the Environment (cueing exercise): Personal reflection/journaling exercise about a personal error Questions for participants to consider: How common are medical errors (i.e., what proportion of physicians make an error over the course of their career)? What factors contribute to errors? How do errors affect the physicians who make them? 1:05-1:25: Group Discussion: Shared reflections How common are errors? What impacts do they have on physicians?

23 Intervention Trial 1:25-1:40: Skills/Solutions: Main messages: errors are an unavoidable part of human practice, and they can have major negative impact on physicians acknowledging these impacts is a major piece of managing them, even as we strive for a zero-error ideal. Note coping strategies suggested in literature, including elements of mindfulness, acknowledge/analyze/improve (see below for suggestions from literature) 1. Accept responsibility for the mistake. 2. Discuss with colleagues. 3. Disclose and apologize to the patient. 4. Conduct an error analysis. 5. Make changes in practice or practice setting designed to reduce future errors. 6. Work at local and national levels to change the culture of the medical profession with regard to the management of medical mistakes.

24 Intervention Trial 1:40-1:45: Check-out/Summary 1:45-2:00: Travel time Resources: i) Wu article in BMJ, Medical error: the second victim ii) Goldberg article, Coping with errors iii) Wears article, Dealing with failure iv) Rowe article, Doctors responses to errors v) Errors at Mayo: West et al., JAMA 2006 and 2009 vi) 1999 IOM report: To Err is Human

25 Results

26 Results 3 Groups Comparison of trial arms with DOM non-study participants, using data from the annual DOM surveys coordinated by the PPWB (n=340 responding to both 2010 and 2011 surveys) Timing matches baseline and 12 month (3 month post-study) surveys from intervention trial Allows usual care control arm, control for secular trends Analyses adjusted for baseline levels of burnout, etc. to account for baseline differences across groups Baseline End Study 3 Month Post 1 Year Post DOM Survey DOM Survey

27 % 100 Strongly Agree That Work is Meaningful Δ=-13.4 Intervention Control Non-Study DOM 50 Baseline 1 year

28 % 100 Strongly Agree That Work is Meaningful 90 Intervention 80 Δ=-6.3 Control Δ=-13.4 Non-Study DOM 50 Baseline 1 year

29 % Strongly Agree That Work is Meaningful 100 p= Intervention 80 Δ=+6.3 Δ=-6.3 Control Δ=-13.4 Non-Study DOM 50 Baseline 1 year

30 % High Emotional Exhaustion 50 p= Intervention 30 Δ=+4.3 Control Δ=-5.3 Δ=-20.4 Non-Study DOM 0 Baseline 1 year

31 % High Depersonalization p=0.03 Δ=+2.5 Δ=-8.3 Intervention Control Non-Study DOM 0 Baseline 1 year Δ=-13.3

32 % Overall Burnout 50 p= Intervention 30 Δ=+4.9 Control Δ=-13.8 Δ=-25.8 Non-Study DOM 0 Baseline 1 year

33 % Poor QOL 50 p= Intervention Δ=+0.6 Δ=-7.3 Δ=-15.2 Control Non-Study DOM 0 Baseline 1 year

34 Conclusions A small amount of protected time during the workday resulted in improved meaning from work and reductions in burnout Effects larger in facilitated small group arm than in free time control arm 2010 MFMER slide-34

35 Results 2 Groups Comparison of two intervention arms Small trial: detectable effect size 0.66 (medium to large) Assess quarterly longitudinal data Broader array of variables, e.g.: Full meaning instrument Full MBI rather than 2-item screen SF-8 well-being index Depression screening, empathy, stress, job satisfaction Baseline End Study 3 Month Post 1 Year Post (Pending)

36 EWS Score Meaning from Work 70 p= Δ=+0.8 Δ=+2.6 Intervention Control 50 Baseline Month

37 % High Emotional Exhaustion 50 p= Δ=-4.0 Δ=-19.4 Intervention Control 10 0 Baseline Month

38 % High Depersonalization 50 p= Δ=+0.8 Intervention Control 10 Δ= Baseline Month

39 % Overall Burnout p= Δ=-6.5 Δ=-24.7 Intervention Control 10 0 Baseline Month

40 % PSS Score Stress 40 p= Δ=-3.1 Δ=-1.8 Intervention Control 0 Baseline Month Poor QOL p=0.53 Δ=-12.3 Δ=-4.8 Baseline Month Intervention Control

41 JSPE Score PJSS Score SF-8 Score % Mental Well-Being Positive Depression Screen p=0.14 Δ=+1.2 Δ=+4.5 Intervention Control Δ=+5.0 Δ=-6.2 p=0.32 Intervention Control 40 Baseline Month 0 Baseline Month Empathy Job Satisfaction Δ=+1.2 Δ=+5.0 p=0.24 Intervention Control p=0.69 Δ=+0.15 Δ=+0.23 Intervention Control 110 Baseline Month 1 Baseline Month

42 Conclusions Compared to the unstructured control group, the facilitated small group intervention improved: Meaning from work Depersonalization No statistically significant improvements in: Emotional exhaustion Overall burnout QOL Mental well-being and depressive symptoms Empathy Stress Job satisfaction However, the small group intervention outperformed the control in every one of these domains 2010 MFMER slide-42

43 Outline Background Potential Solutions The DOM Intervention Trial Future Steps

44 Future Steps Evaluate sustained effects at 12 months post-study Understand what aspects of intervention are most effective (and least effective) Study other specialty areas and practices Build sample size to improve power Study other care provider groups Study alternative interventions

45 Mayo DOM Program on Physician Well-Being Director: Tait Shanafelt, MD Associate Directors: Lotte Dyrbye, MD, MHPE Colin West, MD, PhD Statistician: Jeff Sloan, PhD Administrator: Tim Burriss Administrative Assistant: Kara Kuisle

46 Comments/questions Thank You! 2010 MFMER slide-46