Who heals the healers? March 28, 2016 Disclosure There are no conflicts of interest or relevant financial interests in making this presentation and have indicated that my presentation does not include discussion of an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose. Laurie C. Drill-Mellum, MD, MPH Chief Medical Officer Vice President of Patient Safety Objectives Why caring for the healer matters Acquire an awareness of the scientific data and research on health care professional burnout and resilience Describe how health care professional burnout affects the health care organization and patient safety Develop effective resiliency skills for the individual and his or her organization Burnout and emotional exhaustion Reduced capacity for empathy Reduced patient satisfaction Increased medical errors Increased malpractice risk Increased hospital mortality rates * Journal of Nursing Care Quality April 1996 - Volume 10 - Issue 3 Dugan et al. Stressful nurses: the effect on patient outcomes. ** Journal of Applied Psychology, Vol 73(4), Nov 1988, 727-735 Jones et al Stress and medical malpractice: Organizational risk assessment and intervention. *** Stress and Health Volume 22, Issue 2, pages 131 137, April 2006, A proposed physician patient cycle model **** AHRQ May 2003, David H Hickam, MD, MPH, The Effect of Health Care Working Conditions on Patient Safety Depersonalization Emotional exhaustion Sense of low personal accomplishment Clinician burnout Decreased effectiveness at work Maslach D., Jackson, SSE, Leiter MP. Maslach Burnout Inventory Manual. 3d ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
Physician burnout Emotional exhaustion Depersonalization The cost of physician burnout Intermediate 19% Low 43% High 38% Intermediate 21% Low 50% 38% had positive screen for depression 6.4% had thought of suicide in past year High 29% Shanafelt, T, et al (2012) Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Arch Intern Med.172(18):1377-1385. Productivity loss (including ramp-up time for replacement) Recruitment costs Reduced patient satisfaction Impact on other providers and referral patterns Impact on continuity of QI initiatives Cost to replace a single physician $200,000 - $1,000,000 Critical care nurses Half are emotionally exhausted 2 of 3 have difficulty sleeping 1 of 4 are clinically depressed Critical care nurses 18% met diagnostic criteria for PTSD 86% met criteria for burnout Sexton, et al. (2009), Palliative Care Mealer, M., et al. (2009). The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses. Depression and Anxiety, 26: 1118 1126. Protective factors for nurses Opportunity to participate in research Better palliative care options for patients Number of decisions to forego life-sustaining treatments in the previous week Ability to choose days off Quality of working relationships with patients, managers and MDs 50% 40% 30% 20% 10% 0% Patient care practices of residents suffering burnout Discharged patients because team was too busy Weekly Monthly Several Times a Year Did not fully discuss treatment options or answer patient's questions Made treatment or medication errors not due to inexperience Ordered restraints or medication for an agitated patient before evaluation Discharged patient rather than perform diagnostic test Shanafelt, T, et al (2002). Burnout and self-reported patient care in an internal medicine residency program. ANN INT MED 136(5):358-367.
Patient care attitudes of residents suffering burnout The emotional impact of medical errors 50% 40% 30% 20% 10% 0% Paid little attention to social or personal impact of illness on patient Weekly Monthly Several Times a Year Had little emotional reaction to patient's death Felt guilty about my treatment of patient from humanitarian standpoint Reputation < Satisfaction Sleeping problems Loss of confidence Anxiety 0% 10% 20% 30% 40% 50% 60% 70% Shanafelt, T, et al (2002). Burnout and self-reported patient care in an internal medicine residency program. ANN INT MED 136(5):358-367. Waterman, A.D., et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Joint Commission Journal August 2007, 33(8) 467-76. Relationship of error to risk Proportion of a physician s career spent with an open malpractice claim, by physician specialty Guilt Frustration Error involvement Responses to distress: burnout, depression, diminishing empathy Quality of care, Patient safety Fear Schwappach D., Boluarte T., The emotional impact of medical error involvement on physicians: a call for leadership and organizational accountability. Swiss Med Wkly 2008: 138(1-2):9-15. Jena, AB, et al (2011). Malpractice risk according to physician specialty. NEJM 365(7):629-636.119. 16 Stress management reduces errors and risk To achieve the Triple Aim Reported medication errors cut in half Malpractice claims reduced from 1.4 to 0.4 per year Better health outcomes Better patient experience Reduced costs Bartlett, E., Physician stress management: a new approach to reducing medical errors and liability risk. ASHRM Journal Spring 2002 Make it the Quadruple Aim: Provider well-being Thomas Bodenheimer, MD et al, From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider, The Annals of Family Medicine, Nov/Dec 2014
Redefining quality How we take care of our patients How we take care of each other How we take care of ourselves Clinician health and well-being Value it! Is something missing from your mission? Name it! Invest in training (communications, empathy) Incorporate feedback tools in staff development Encourage self-care and promote resiliency practices Promote it! Collaborative culture Quality conversations Self-awareness Importance of self-care THE STRESS OF LIFE
Stress = lack of control and predictability Measuring the effects of stress Stress response triggered by: Perceived lack of control Loss of social support Loss of ability to relieve frustrations Perceived lack of predictability Perception that things are getting worse We now have tools to measure physical changes in the body caused/influenced by the mind (functional MRIs, hormone levels, antibodies, heart rate variability) We can measure the effects of the mind and emotions on the heart, digestive tract, immune system, and individual cells We see that physical symptoms can change emotional health and vice versa Emotions and healing Stress can Slow wound healing Diminish strength of immune response to vaccines Enhance susceptibility to infections illness Boost allergy symptoms Reactivate latent viruses Stress at the cellular level Resiliency An individual s ability to overcome adversity and continue his or her normal development.
How are we going to fill up? The five pillars of resilience Rx for building resiliency Relationships Self Care Self Awareness Mindfulness Purpose Good nutrition and sleep Exercise 4-7-8 breathing technique Meditation/mindfulness Gratefulness journal Random acts of kindness Support groups Social connection/spiritual practice Sexton, B, Duke University Health System Patient Safety Center, Enhancing Caregiver Resilience: Burnout and Quality Improvement Full Course, May 2013. Self care why do we sleep? Improve immune function (repair and rejuvenate) Consolidate memories Regulate emotions Brain cleansing
Tips for a better night s sleep Skip the snooze button (makes you more tired) Avoid caffeine within 4-6 hours of sleep onset Get outside in the natural afternoon light (even if cloudy) to reset circadian rhythms Avoid eating within 2-3 hours of sleep onset because digestion disrupts sleep Morning exercise provides boost of energy, decreases stress hormones, and improves sleep quality (75% more time in deep sleep) 4-7-8 breathing technique Get comfortable Inhale deeply through your nose to a count of Hold for a count of 7 Exhale through your mouth for a count of 8 with tip of tongue against inside of teeth 4 JAMA. 2009 Sep 23;302(12):1338-40.
Random acts of kindness Doing a kindness produces the single most reliable momentary increase in well-being of any exercise that has been tested. Practice 3 Good Things Find one wholly unexpected kind thing to do tomorrow and just do it. Notice what happens to your mood. Martin Seligman, 2011 Gratitude/awe exercises Gratitude exercise Close your eyes. Think of someone who has done something amazing for you; this person can be alive or no longer with us. This person contributed to your well-being in a big way. Spend the next few minutes writing a brief note telling this person what they did, how it impacted you, and the benefits you have received. Call this person or meet with this person or someone who knew them, and read what you wrote. This will increase your happiness. Sense of Awe exercise Write for 5 minutes about something that you can remember within the recent past that brought you a sense of awe. We can live without religion and meditation, but we cannot survive without human affection. The Dalai Lama
The top five regrets of the dying 1. I wish I'd had the courage to live a life true to myself, not the life others expected of me. 2. I wish I hadn't worked so hard. 3. I wish I'd had the courage to express my feelings. 4. I wish I had stayed in touch with my friends. 5. I wish that I had let myself be happier. - Bronnie Ware, author and blogger Additional resources DrWeil.com Flourish by Dr. Martin Seligman Gratefulness.org Drrachelremen@commonweal.org Daring Greatly by Brene Brown The Chemistry of Joy by Henry Emmons, M.D. Enjoy Every Sandwich and Finding Balance in a Medical Life by Lee Lipsenthal, Healthy Aging by Andrew Weil, M.D.
References References (cont d) Bartlett, E (Spring 2002). Physician stress management: A new approach to reducing medical errors and liability risk. ASHRM J: 3-7. Bodenheimer, Thomas, et al (2014). From triple to quadruple aim: care of the patient requires care of the provider, Ann Fam Med 2014 Nov-Dec;12(6):573-6. Crous-Bou, M, et al (2014). Mediterranean diet and telomere length in Nurses Health Study: population based cohort study. BMJ 2014;349:g6674. Jena, AB, et al (2011). Malpractice risk according to physician specialty. NEJM 365(7):629-636.119. Maslach D., Jackson, SSE, Leiter MP. Maslach Burnout Inventory Manual. 3d ed. Palo Alto, CA: Consulting Psychologists Press; 1996. Seabury, S, et al (2013). On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim. HLTH AFF 32(1):111-119. Shanafelt, T, et al (2002). Burnout and self-reported patient care in an internal medicine residency program. ANN INT MED 136(5):358-367. Shanafelt, T, et al (2012) Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Arch Intern Med.172(18):1377-1385. Schwappach D, Boluarte T., The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2008: 138(1-2):9-15. Waterman, AD et al (2007). The emotional impact of medical errors on practicing physicians in the United States and Canada. JNT COMM J 33(8):467-76. Laurie Drill-Mellum, MD, MPH 952.838.6874 laurie.drill-mellum@mmicgroup.com