Disclosures No disclosures Beyond Burnout What’s new in physician well-being, and what’s next? Larissa Thomas MD, MPH Associate Clinical Professor, UCSF Department of Medicine Let’s Get Real about Physician Well-being Well-being Roadmap Definitions Definitions Scope of the Problem Scope of the Problem Where It Comes from Where It Comes from Why It Matters Why It Matters What to Do About It What to Do About It https://www.pexels.com/photo/backlit-beach-dawn-dusk-588561/ https://www.pexels.com/photo/woman-working-girl-sitting-133021/ 1
Well-being Roadmap Compassion fatigue Definitions Definitions “Vicarious trauma” Scope of the Problem Scope of the Problem Repeatedly seeing/working with human suffering emotional depletion Where It Comes from Where It Comes from Often temporary, but can contribute to Why It Matters Why It Matters burnout What to Do What to Do The “cost of caring” Burnout Burnout vs. Depression Depression also prevalent in 3 components of burnout physicians… (Maslach): 1. Emotional exhaustion 2. Cynicism and depersonalization Burnout 3. Low sense of personal accomplishment Depression Mismatch in the workplace between What about “moral injury” (h/t desired state and reality ZDoggMD)? …but burnout mostly affects work life. 2
What About Resilience? Roadmap Definitions Definitions Positive adaptation in the face of stressors (strong, not tough) Psychological principles: positive psychology, appreciative inquiry Scope of the Problem Scope of the Problem Practices and skills: Gratitude Where It Comes from Where It Comes from Engaging in difficulties Self-awareness/self-acceptance Why It Matters Why It Matters Goal and limit-setting Intellectual stimulation What to Do About It What to Do About It i.e. not simply “bouncing back” or “turning that frown upside down”! Zwack and Schweitzer. Acad Med 2013 Mar; 88(3)): How Serious Is the Problem? Is Burnout Worse in Physicians? Burnout prevalence Physicians Medical All U. S. Up to 50% students Burnout 43.9% 28.1% Residents 40-70% Satisfied 42.7% 61.3% with Practicing 20-60% work-life balance physicians Drybye JAMA 2018; 320(11). Drybye et al. Acad Med. 2015; 89(3). Shanafelt Mayo Clin Proc 2019; epub ahead of print https://doi.org/10.1016/j.mayocp.2018.10.023 Ishak et al. J Grad Med Educ . 2009; 1(2). https://www.pexels.com/photo/black-and-white-zebra-standing-during-daytime-67233/ 3
Roadmap Burnout: What’s the evidence? Individual Contributors Definitions Definitions Unclear Association Likely Association Demographics Major error or adverse Scope of the Problem Scope of the Problem • Women higher burnout event (EE)? Low tolerance of Where It Comes from Where It Comes from • Underrepresented ambiguity backgrounds lower QOL + Why It Matters Why It Matters personal accomplishment? ? Depression What to Do About It What to Do About It Shanafelt Mayo Clin Proc 2019; epub ahead of print https://doi.org/10.1016/j.mayocp.2018.10.023 Drybye Mayo Clin Proc 2006 Nov;81(11) Medical Errors and Well-being Major Major Adverse Adverse Event Event Suboptimal Suboptimal Burnout Burnout Patient Care Patient Care Role of shame + perfectionism West et al. JAMA 2006; 206(9) Shantafelt Mayo Clin Proc 2017;92(1) Shanafelt et al. Ann Int Med 2002; 136(5) 4
Documentation regulations: Length of US notes vs other countries Date night Date night Arndt Ann Fam Med 2017; 15(5) Downing Ann Int Med 2018 epub ahead of print May 8. 2018 www.annals.org 18 Roadmap Consequences of Burnout Definitions Definitions Suboptimal patient care Increased Scope of the Problem Scope of the Problem use of sick leave ? Risk for Decreased depression empathy Where It Comes from Where It Comes from Intent to retire early Decreased Increased satisfaction self- Why It Matters Why It Matters reported Specialty errors choice Suicidal ideation Decreased What to Do About It What to Do About It patient satisfaction JAMA 296:1071, JAMA 304:1173, JAMA 302:1294, Annals IM 136:358, JAMA 306:952, Health Psych 12:93, Annals IM 149:334, 2 Mayo Clin Proc 2016, JAMA IM 2017 5
Shared Humanity Self- Self- actualization actualization Esteem Esteem Belonging/love Belonging/love Thanks…now I feel burned out from this talk! Safety Safety Physiology Physiology iStock photo Maslow AH. Psychological Review . 1943; 50 (4) Roadmap Definitions Definitions 1980-90s 2010-2015 • Burnout Scope of the Problem Scope of the Problem described in • Individually- occupational focused psychology interventions Shared Where It Comes from Where It Comes from Approach 2000-2010 2014- Why It Matters Why It Matters present • Descriptive studies prove • Systems burnout high drivers and What to Do About It What to Do About It in medicine interventions 6
Institute for Healthcare Improvement Triple Aim The “Quadruple Aim” Population Population Health Health Provider Well-being Experience of Care Cost of Care Experience Cost of Care of Care Adapted from www. IHI.org Adapted from Bodenheimer and Sinsky, Ann Fam Med 2014; 12:573-6. Charter on Physician Well-being Charter on Physician Well-being • Inspired by Charter on Professionalism Guiding Principles Guiding Principles Initial Initial • Consensus process: leaders in the field Draft Draft Effective patient care promotes and requires and representatives from national physician well-being physician organizations: • AMA • AAMC Physician well-being is inter-related to well- 2 day 2 day • ACGME being of interprofessional team meeting meeting • AAIM • ABIM Well-being is a quality marker for health • ACP systems • APA Consensus Consensus • IHI • SGIM Well-being is a shared responsibility Charter Charter • SHM Thomas et al JAMA 2018; 319(15) 7
Charter on Physician Well-being: Societal Trustworthy culture Key Commitments Advocacy for policies Supportive systems Societal Organizational Engaged leadership Highly functioning teams Organizational Anticipation/support for challenges Interpersonal and Individual Interpersonal Prioritized mental health and Individual Individual self-care/meaning Adapted from Thomas et al JAMA 2018; 319(15) Trustworthy culture Societal Advocacy for policies Organizational Society: Trustworthy Culture Interpersonal and Individual 8
Culture and well-being Values mismatch at work burnout More prominent driver in Society: Policies and Regulations women Hidden curriculum: Trainees especially Role modeling + authenticity: vulnerable Walk the walk! Culture of medicine Participatory decision-making Shanafelt Mayo Clin Proc 2015;90(4) Leiter Can Fam Phys 2009;55(12) https://hbr.org/2013/05/what-is-organizational-culture Recent successes and ongoing work Societal New well- Supportive systems being core ACGME Organizational program Engaged leadership Licensing requirements questions Highly functioning teams should ONLY ask about FSMB current impairment, align with ADA Interpersonal and Individual Medical student CMS documentation billable https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3971CP.pdf http://www.acgme.org/tabid/116/about.aspx Dyrbye Mayo Clin Proc 2017;92(10) 9
Organizational Competency in Well-Being Novice Beginner Competent Proficient Expert Awareness Understand Understand Understand impact of Well-being driver business case well-being on influences all major dimensions organizational operational objectives decisions Wellness Peer support Practice Well-being considered in Chief Wellness Officer Organizations: Engaged Leadership Committee program redesign operational decisions Strategic investment Individual Cross-sectional Coaching Funded well-being interventions survey resources program Knowledge creation (mindfulness, lifestyle Struggling units Regularly Leadership training Culture of wellness initiatives) identified measure well- being Assessment of systems Well-being interventions considered in Opportunities decisions for community- building Adapted from Shanafelt JAMA IM 2017; 77(12): 1827 Leadership behaviors and burnout • Physicians and scientists Example Questions at Mayo surveyed about Inspires me to do my best leadership behaviors of Empowers me to do my job their chairs Organizations: Supportive Systems and Recognizes me for a job well Highly Functioning Teams • Higher leadership score done less burnout Is interested in my opinion Encourages me to develop Intervention: talents and skills leadership training Shanafelt et al. Mayo Clin Proc 2015;90(4) 10
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