Physician Well-Being: A Crisis of Compassion Andrew J. Shin, J.D., M.P.H. Sr. Director, Policy and Strategic Partnerships ABMS Conference September 27, 2016
Disclosure None 2
At a glance Established in 1995 Developed Schwartz Center Rounds at Massachusetts General Hospital in 1997 Member Organizations 400+ Hospitals, Long-term care, others in U.S. and Canada 150+ Hospitals in United Kingdom National Caregiver of the Year (NCCY) Award Education and Training 2016 Harvard Medical School: Compassion in Practice Interprofessional Education Course 1st Annual Compassion in Action Healthcare Conference, June 2017 Boston, MA 3
Our health care system is making important strides Experience & Outcomes Delivery models Innovations Breakthroughs 4
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Etiam vulputate imperdiet vulputate. Sed a ante quis odio porttitor ultricies ac eu lorem. Duis eget tincidunt tortor, nec venenatis ex. Sed sit amet nunc sollicitudin, facilisis nulla vitae, cursus erat. Donec non feugiat metus. Duis dapibus pulvinar dignissim. In tristique venenatis eros ac feugiat. Slide #1 5
We are at risk Burnout (40% - 60%) (2011) 45% (2014) 54% p <.001 Work/life satisfaction (2011) 49% (2014) 41% p <.001 Physician suicide Rate ratio 2.3 ( ) and 1.4 ( ) vs. general population Shanafelt TD, et. al. Mayo Clin Proc. 2015; 90:1600-13. Schernhammer ES, Colditz GA. Am J Psychiatry. 2004; 161:2295-302. 6
Reprinted from Mayo Clinic Proceedings, vol. 90, Shanafelt TD, et. al., Changes in Burnout and Satisfction With Work-Life Balance in Physicians and the General U.S. Working Ppulation Between 2011 and 2014. December 2015; 90:1600-13, with permission from Elsevier. 7
Reprinted from Mayo Clinic Proceedings, vol. 90, Shanafelt TD, et. al., Changes in Burnout and Satisfction With Work-Life Balance in Physicians and the General U.S. Working Ppulation Between 2011 and 2014. December 2015; 90:1600-13, with permission from Elsevier. 8
High Cost of Clinician Burnout Career Dissatisfaction and Turnover Shanafelt, Journal of Clinical Oncology, 2014 Leiter, Journal of Nursing Administration, 2009 Shanafelt, Annals of Surgery, 2010 Increased Errors Shanafelt, Annals of Surgery, 2010 Farenkopf, British Medical Journal, 2008 West, JAMA, 2009 Lower Patient Satisfaction and Longer Recovery Time Poor Provider Health, Depression and Suicidal ideation Halbesleben, Healthcare Management Review, 2008 Wallace, Lancet, 2009 Dyrbye, Annals IM, 2008 Shanafelt, Arch Sur, 2011 9
What inhibits wellbeing and compassion? Workload, staffing Documentation regulatory requirements Staff input not elicited, acted on Discontinuity, fragmentation of care Time pressure Loss of community Conflicting values Loss of autonomy, sense of control 10
Compassionate care means recognizing the concerns, distress and suffering of patients and their families and taking action to relieve them. It is based on active listening, empathy, strong communication and interpersonal skills, knowledge of the patient as a whole person including his or her life context and perspective, and the ability to work together to relieve distress. - Schwartz Center for Compassionate Healthcare 11
Cognition Feeling as if Feeling with + action Empathy Compassion Sympathy Feeling sorry for Hojat M. Empathy in Patient Care. Springer; 2007. Emotion What distinguishes compassion from empathy and sympathy? 12
physicians are caught in a quagmire between the demands of the health care system and their deeply held desire for a meaningful relationship with their patients based on compassion, trust, and mutual respect. The stark dichotomy between the kind of care clinicians want to provide and what they are able to provide, is leading to burnout. Consequently, the inability to deliver on the promise of patient-centered care has become the breeding ground for disillusionment with the health care system and their professional calling. Shin A., Ghandi, T., Herzig, S. Make the Clinician Burnout Epidemic A National Priority. 2016 April- Available from http://healthaffairs.org/blog/2016/04/21/make-the-clinician-burnout-epidemic-a-national-priority/ 13
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Experience sharing Affective empathy Mentalizing Cognitive empathy Bernhardt C, Singer T. Annual Rev Neurosci. 2012;35:1-23. Emotional resonance and cognitive processing 15
Mediators: Trait empathy Repetitive exposure Perspective taking Emotion regulation Culture, context 16
Empathy - AI, amcc Compassion - mofc, pacc, striatum www.michelleinc.com; www.kenhub.com. Al Omran, et al. Nature Rev Gastro and Hepatol. 2014;11:545-576 17
Jensen et al. Mol Psychiatry. 2014;19:392-8. A pathway to purpose: Compassion feels rewarding 18
The doorknob strategy: Mini-moments of mindfulness Focusing attention 19
Emotion-regulation: Meditation-based compassion training 20
Leiberg, et al. 2011. 1 One-day Compassion Training vs. Memory Training plus home practice or guided sessions x 3 days. Compassion training significantly more helping/collaboration behaviors. Helping correlated with practice time even when no possibility of reciprocity. Weng, et al. 2013. 2 Compassion vs. Cognitive Reappraisal Training 30 minutes per day x 2 weeks. Compassion training significantly more fund redistribution; moderate effect size. Condon, et al. 2013. 3 Compassion/Meditation Training 90 minutes/week plus 20min audio-guides x 8 weeks vs. Wait list control. Compassion training significantly more altruistic behavior towards sufferer on crutches; moderate effect size. 1 Leiberg et al. Plos One.2011;6:e17790. 2 Weng, et al. Psychol Sci. 2013;24:1171-80. 3 Condon, et al. Psychol Sci. 2013;24:2125-7 Meditation-based compassion training and compassionate behavior 21
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https://www.stepsforward.org/modules/physician-burnout 23
Sinksy C., et. al.: In search of joy in practice: a report of 23 highfunctioning primary care practices. Ann. Fam. Med 11(3), 272-278 (2013) 24
Collaboration with teams 2:1 or 3:1 staffing Moving away from physiciancentric to team-based care Communication Co-location Team meetings Systematic Planning Pre-visit planning Workflow mapping Sinksy C., et. al.: In search of joy in practice: a report of 23 high-functioning primary care practices. Ann. Fam. Med 11(3), 272-278 (2013) 25
Source: AAMC 26
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We need more: RCT s for individual wellness and organizational best practices Valid metrics Multi-setting approaches Understanding of other factors such as intensity/compression, clinical block models, etc. Focus on the impact on patient experience, outcomes and mutual engaement 30
Contact us with questions: AShin@theschwartzcenter.org theschwartzcenter.org @thescch @theschwartzcenter 31