Addressing Physician Burnout: How to Keep Sane When Things Seem Insane Charles P. Samenow, MD, MPH Department of Psychiatry George Washington University
Goals To describe physician burnout To understand the etiologies, risk factors, and consequences of burnout To explore personal, occupational and cultural changes that might prevent burnout
Vanderbilt Center for Professional Health Continuing Medical Education Courses Prescribing Controlled Drugs Maintaining Proper Boundaries Program for Distressed Physicians www.mc.vanderbilt.edu/cph
Context Physicians are leaving medicine at higher rates. Physicians are less likely to recommend medicine as a career to others. Thirty percent of physicians say they would change their profession if they could. (Hippocrates. April 1994:32-33) Physicians are working harder for less money. Increasing paperwork and less time with patients Increasing malpractice insurance premiums
Engrossed late and soon in professional cares you may so lay waste that you may find, too late, with hearts given way, that there is no place in your habit-stricken souls for those gentler influences which make life worth living. Sir William Osler, 1899
What Is Burnout? Emotional Exhaustion Cynicism Ineffectiveness Depersonalization of relationships Spickard Jr., WA, Gabbe, S, Christenesen, J. Mid-career burnout in generalist and specialist physicians: definitions, risk factors and prevention. JAMA. 2002;288 (12):1447-50.
Prevalence 25-60% of practicing physicians
Maslach Burnout Inventory A 22-item inventory designed to measure three aspects of burnout: emotional exhaustion: I feel emotionally drained from my work Depersonalization: I ve become more callous towards people since I have taken this job. lack of personal accomplishment: I feel I am positively influencing people s lives through this work.
Why do we care? Sleep disturbances and fatigue Irritability, anxiety and depression Marital dysfunction Myocardial Infarction Alcohol and drug addiction Impaired job performance (physician error) Physician turnover
Spectrum of Functioning Healthy Burnout Disruptive Impaired Misuse Abuse Dependence
Burnout and Patient Care Physicians who report burnout write more prescriptions order more tests for their patients have less compliant patients have less satisfied patients. (Gunderson, L. Physician burnout, Annals of Intern Med, 2001;135(2):146-48, Soc Sci Med. 1980;14A:495-9, Health Psychology. 1993;12:93-102, Med Care. 1994;32:745-54)
Risk Factors -- Developmental Childhood: Valliant s longitudinal study of male physicians By caregiving, some physicians give to patients the love and attention that they may not have received.
Risk Factors -- Personality compulsive triad (Gabbard): doubt, guilt, and exaggerated sense of responsibility. Rigidity Stubbornness Inability to delegate Excessive devotion to work Perfectionism
Risk Factors Familial: Supportive marriage may be a protective factor. Environmental (Kaiser): less control = less satisfaction, leadership and management, administrative policies and procedures, and organizational culture. Gender: Women > Men Age: Midcareer > early or late career
Well functioning hospital system Hospital/Clinic Physician MD with good skills; team player; emotional intelligence; knows conflict resolution Partially functioning system Periodic anger outbursts; poor team player Totally inadequate hospital/clinic function Narcissistic traits; recurrent anger outbursts; generally frustrated; passive aggressive; nurses take brunt of anger
Perfect Storm: Individual Pathology + Institutional Pathology Capitalweather.com
Evolution of a Physician
There was nothing so VERY remarkable in that; nor did Alice think it so VERY much out of the way to hear the Rabbit say to itself, `Oh dear! Oh dear! I shall be late!' (when she thought it over afterwards, it occurred to her that she ought to have wondered at this, but at the time it all seemed quite natural); But when the Rabbit actually TOOK A WATCH OUT OF ITS WAISTCOAT- POCKET, and looked at it, and then hurried on, Alice started to her feet, for it flashed across her mind that she had never before seen a rabbit with either a waistcoat-pocket, or a watch to take out of it, and burning with curiosity, she ran across the field after it, and fortunately was just in time to see it pop down a large rabbit-hole under the hedge. (Lewis Carroll) Alice in Wonderland
In another moment down went Alice after it, never once considering how in the world she was to get out again. The rabbit-hole went straight on like a tunnel for some way, and then dipped suddenly down, so suddenly that Alice had not a moment to think about stopping herself before she found herself falling down a very deep well.
Evolution of Physicians Family of Origin Age 18 College Conspiracy of Role Models Medical School Residency Licensed Qualified Certified PTSD MD
Stress Across the Lifespan Medical Students: adjustment to the medical school environment, perceived ethical and professional dilemmas, firsttime exposure to death and human suffering, student abuse, personal life events, and educational debt. Residents: sleep deprivation, student loan debts, extended duty hours, a lack of time for personal life, and efforts to find a job at the completion of training. Practicing physicians: malpractice suits, their degree of autonomy, reimbursement issues, and challenges related to office management. Other sources of distress are similar at all stages of a career, including encounters with patient death and suffering, medical errors, fatigue, and challenges in balancing personal and professional lives.
How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study Journal of General Internal Medicine 2007;22:177 183
Burnout in GW Class of 04 & 05 Overall 41% indicated burnout in at least one category. Combining scores for both the high and medium terciles 69% emotional exhaustion 49% depersonalization 33% personal accomplishment.
Change in Mood and Empathy during Internship Elevated baseline vigor, energy and empathy compared to same age peers After 5 months, interns were significantly more angry, fatigued, and depressed and had decreased empathic concern There was no improvement by the end of the internship year. Bellini L et al. Variation of mood and empathy during internship. JAMA. 2002; 287: 3143-3146.
Burnout and Resident Physicians Recent study of internal medicine residents-76% met the criteria for burnout. Burned out residents said they were more likely to discharge patients early to make their work manageable, did not fully discuss treatment options or answer a patient s questions, and made more medical errors 50% said they rendered suboptimal care at least monthly compared with 21% of residents who did not experience burnout (Shanafelt KA et al, Burnout and self-reported patient care in an internal medicine residency program, Annals of Internal Medicine 2002;136:356-367)
Residents and Burnout Meta-analysis of published articles (n = 15) Cross sectional, small, methodological problems All specialties and international Associated with depression and problems with clinical care (subjective). Sleep deprivation did not increase burnout, work hour restrictions did not improve it! Not strong enough to make causal explanations or use demographic date to predict risk Thomas, 2004 (JAMA)
Residents and Burnout Prevention includes: Restoring meaning Facilitating social interactions Increasing resident work control Separating work from home life
Women and Burnout: The Good, the Bad and the Ugly
Women and Medicine Females more satisfied with specialty and colleague relationships but less satisfied with autonomy, relationship with community, pay and resources (McMurray, 2000). Female physicians had more complex psychosocial patients, needed more time, and made less money
Women and Medicine Female physicians twice as likely to experience stress and burnout compared to male counterparts (Horner-Ibler, 2005) More complex cases, more at odds with organization Canada: women had more group practices, lower salaries, and double loads -- work + family (Williams, 1990) Resident Meta-analysis did not support higher burnout in women.
Women and Medicine More likely to experience harassment and discrimination (example: pregnancy).
Women and Medicine Female suicide rate equals that of males among physicians (General population: Males 4X > Females).
Women and Medicine: The Good More naturally seek balance Smoke less, drink moderate, and attend to health screenings (Frank, 1998). May be setting limits and serving as role models to change culture of medicine
If I stay at home with my baby, I feel guilty about leaving my patients unattended. But when I am with my patients, I feel like a bad mother who is neglecting her child. It s a no-win situation. (Myers and Gabbard, 2008)
Preventing Burnout -- Individual The patient has the ultimate responsibility in maintaining their health. Take control of your work environment (hours) as much as you can (Capacity - Load = Margin) Have a rich personal, spiritual, emotional, and community life outside of work Have your own PCP
Preventing Burnout -- Institutional Factors Intrinsic Factors vs. Extrinsic Factors Rewarded Physician Wellness Committee, Support Groups, Retreats Establish a Mentor Program Offer benefits -- health clubs Involve physicians in leadership decisions Flexible scheduling for critical family events Include physician health in curriculum
Preventing Burnout -- Training Rachel Remen: Finding Meaning Restoring Sense of Service
Resources Medical Society of DC (Barbara Allen) www.msdc.org Center for Professional Health www.mc.vanderbilt.edu/cph