Physician Margin, Overload and Burnout Black Hills Pediatric Symposium June 23, 2017 Craig J. Uthe, MD AAFP ASAM Sanford Family Physician, Internal Locum Tenens Sanford Medical Director of Clinic Services, Physician Wellbeing & Professional Development
Self-disclosure Sanford Family Physician ++++++ Internal Locum Tenens +++++ Medical Advisor, South Dakota Health Professionals Assistance Program +++++ No specific conflicts of interest.
Physician Margin, Overload and Burnout - Objectives Understand margin, overload & physician burnout -Know 3 main characteristics of burnout -Understand contribution of technological advancements -Review demographics of burnout from med school to retirement Explore options for preventing and treating burnout -Identify personal health resources -Consider institutional/organizational resources -Consider your own Functional-Stress Level
Being a physician can be? hard work heavy work
So why is medicine worth it? Secuirty Calling Intellectual Curiosity Altruism Hard Work Heavy Work
Factors Influencing Medical School Attendance
Biggest Factor In Specialty Choice
New Doctor Concerns
Depression and suicidality in medical students Rotenstein, et al JAMA 2016; 316 (21): 2214 Meta-analysis of 167 cross-sectional studies and 16 longitudinal studies from 43 countries: The global prevalence of depression among medical students was 27.2% Current suicidal ideation was 11.1%
Depression in resident physicians Mata, et al. JAMA. 2015;314(22):2373-2383. Meta-analysis of 31 cross-sectional studies and 23 longitudinal studies from 15 countries: Prevalence of depression or depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2%
Burnout Shanafelt, et al. Mayo Clin Proc 2015 Dec; 90(12): 1600 Nationwide survey of 35,922 U.S. physicians with 6880 responses: 45.5% of physicians in 2011 and 54.4% of physicians in 2014 reported one symptom of burnout; higher than U.S. workforce generally
Physician Burnout What is it? Burnout is a syndrome of: Emotional exhaustion - Feeling emotionally depleted, frustrated, tired of going to work, hard to deal with others at work. Depersonalization/Cynicism - Being less empathic with patients/ others, detached from work, seeing patients as diagnoses/ objects/ sources of frustration. Low personal achievement - Experiencing work as unrewarding, going through the motions. - Maslach, 2006
The Physician Personality Adaptive Diagnostic rigor Thoroughness Commitment to patients Desire to stay current Recognize responsibility of patients trust Maladaptive Difficulty relaxing Problem allocating time for family Sense responsibility beyond what you control Sense not doing enough Difficulty setting limits Confusion of selfishness vs. healthy self-interest Difficulty taking time off
Antecedents or causes of burnout: Individual Perfectionism Cognitive rigidity Deficient setting of boundaries Inability to forgive oneself or others Loss of sense of humor Loss of ability to feel joy Possible: a component of resilience may be hard-wired, genetic
The Physician Personality The compulsive triad Chronic self doubt Exaggerated sense of responsibility Guilt feelings
Human Capacity and Technology: Can We Keep Up? Human capacity: Technological Advancement: Time 1900 1950 2000
Seeking Margin Capacity > Workload = MARGIN Workload > Capacity = OVERLOAD Workload >> Capacity = BURNOUT
Energy Healthy Environment When Capacity > Work Load, the result is Margin. Margin Capacity Time Work Load
Energy Concerning Environment When Work Load > Capacity, the result is Overload. Overload t = limiting factor Work Load Capacity Time
Time Dangerous Environment When Work Load >>> Capacity, the result is Burnout. Burnout Energy Capacity Work Load Capacity
Figure 1 Consequences of Physician Burnout Mayo Clinic Proceedings 2017 92, 129-146DOI: (10.1016/j.mayocp.2016.10.004) Copyright 2016 Mayo Foundation for Medical Education and
How much is too much? There are increased risks for alcohol-related problems for Men who drink more than: 4 standard drinks in a day 14 standard drinks in a week Women who drink more than: 3 standard drinks in a day 7 standard drinks in a week https://www.rethinkingdrinking.niaaa.nih.gov/how-much-is-too-much/ Boule/shu*erstock.com
A standard drink is
The Six I s Be alert to these six Indicators that a team member may be at risk of Impairment: 1. Irritability 2. Irresponsibility 3. Inaccessibility 4. Isolation 5. Inability 6. Incidentals
Figure 1 Consequences of Physician Burnout Mayo Clinic Proceedings 2017 92, 129-146DOI: (10.1016/j.mayocp.2016.10.004) Copyright 2016 Mayo Foundation for Medical Education and
Contributing factors to burnout: Organizational Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout
Electronic Health Record Infiltration EHRs dominate docs time Physicians time allocation during office hours Direct clinical face time with patients, 26% Face time with staff, 6% EHR and desk work, 48% Administrative tasks, 1% Other tasks, 19% Source: American Medical Association
How can you be resilient?
JAMA Internal Medicine I Original Investigation I PHYSICIAN WORK ENVIRONMENT AND WELL-BEING Controlled Interventions to Reduce Burnout in Physicians A Systematic Review and Meta-analysis Maria Panagioti, PhD; Efharis Panagopoulou, PhD; Peter Bower, PhD; George Lewith, MD; Evangelos Kontopantelis, PhD; Carolyn Chew-Graham, MD; Shoba Dawson, PhD; Harm van Marwijk, MD; Keith Geraghty, PhD; Aneez Esmail, MD 19 studies 1550 physicians Small reductions in MBI scores Organizational interventions superior to physician-directed interventions JAMA Internal Medicine Published online December 5, 2016
Shanafelt et al, 2015 Mayo Clinic Proceedings
9 Organizational Strategies to Promote Engagement and Reduce Burnout Shanafelt and Noseworthy, Mayo Clin Proc 2016
Measuring Burnout
Physician Burnout Resources
Physician Leadership Items Used To Evaluate Leadership Qualities of Physician Supervisors (Dep t Chairs): Holds career development conversations with me Inspires me to do my best Empowers me to do my job Is interested in my opinion Encourages employees to suggest ideas for improvement Treats me with respect and dignity Provides helpful feedback and coaching on my performance Recognizes me for a job well done Keeps me informed about changes taking place at Mayo Clinic Encourages me to develop my talents and skills I would recommend working for (name of immediate supervisor) - Shanafelt, et al. Mayo Clin Proc. 2015;90(4):432-440
Energy Healthy Environment When Capacity > Work Load, the result is Margin. Margin Capacity Time Work Load
Establishing balance in your life
Physician Burnout: Individual Focused Interventions Meditation techniques Stress management training, including MBSR Communication skills training Self-care workshops, exercise program Identify Values Debunk myth of delayed gratification What matters to you most (integrate values) Integrate personal and professional life Nurture personal wellness activities Calibrate distress level Self-care (exercise, sleep, regular medical care) Relationships (connect w/ colleagues; personal) Religious/spiritual practice Mindfulness Personal interests (hobbies)
Establishing balance in your life Self-Care Exercise Healthy nutrition Adequate rest and sleep Activities to recharge batteries Attending own personal health Self-Awareness Recognizing own triad and risky coping Setting limits Healthy boundaries Watching for red flags Accepting own limits Formal and informal practices
Emotional Exhaustion! De-personalization Lack of Meaning/ Purpose in work 5 0 2.5 7.5 10