Moving beyond burnout to professional engagement Martina Schulte, MD April 26, 2019
Objectives 1. Explore nature, drivers, and consequences of burnout 2. Learn a framework for developing interventions 3. Discover actionable organizational and individual interventions to decrease burnout and enhance joy
International Conference On Physician Health Toronto, Ontario October 11-13, 2018
The What: Burnout Syndrome characterized by: Emotional exhaustion Depersonalization Decreased sense of personal accomplishment Burnout, at its core, is the impaired ability to routinely experience positive emotion.
Burnout- overview • • first described - 1974 by common norms: Freudenberger ➢ be selfless and put others' needs first state of fatigue or frustration resulting from professional ➢ work long hours relationships that fail to ➢ do whatever it takes, go the produce the expected rewards extra mile • later defined as psychological • Healthcare- qualities selected syndrome by Maslach for (Gabbard, JAMA 1985) : ✓ occurring in professionals – triad of compulsiveness working with people in • doubt challenging situations • guilt ✓ occupational hazard for people- oriented workers • exaggerated sense of ✓ environmental factors – high responsibility demand, low resources settings – delay gratification – perfectionism
Yerkes-Dodson Curve
Frequency: Burnout Shanafelt. Mayo Clin Proc . 2015
Risk vs non-physicians Physicians 2011 2014 2017 Burnout (MBI) 45.5 54.4 43.9 Satisfaction (WLB) 48.5 40.9 42.7 Non-physician working US adults 2011 2014 2017 Burnout (MBI) 28.6 28.4 28.1 Satisfaction (WLB) 55.1 60.3 61.0 Shanafelt. Mayo Clin Proc . 2019
Frequency: Burnout Shanafelt. Mayo Clin Proc . 2019
Burnout - Prevalence • Nurses • Physicians 3 – 54.4% met criteria for – University hospital burnout, up from 45.5% in nurses 1 2011 • 18% met criteria for PTSD • Residents 4 • 86% met criteria for – 74% burned out burnout syndrome – Critical care nurses 2 – 20% met criteria for depression • Half are emotionally • Medical students 5 – exhausted • 2 out of 3 have trouble 49.6% sleeping • 1 our of 4 are clinically 1 Mealer et al. 2009. Depression and Anxiety 2 Sexton, et al. 2009. Palliative Care depressed 3 Shanafelt et al. 2015. Mayo Clin Proc 4 Fahrenkopf et al. 2008. BMJ 5 Dyrbye et al. 2011.
Consequences Shanafelt, Mayo Clin Proc , 2017
Work Environment- Christine Maslach • Workload • Control/Autonomy • Values/meaning • Fairness • Community • Reward
• Quality of care • Workload • Electronic health records • Control/Autonomy • Autonomy and work control • Values/meaning • Practice leadership • Fairness – Values alignment • Community • – Balanced approach to initiatives Reward Maslach • Collegiality, fairness and respect • Work quantity and pace • Work content, allied health professionals and support stability • Pay/income • Regulatory and liability concerns Friedberg. Published online, 2013
Canary in the coal mine
Thinking about intervening
Frameworks for taking action
Efficiency of Practice • Workflow • Electronic health record • Team-based care • Clerical burden • Regulatory requirements
Culture of Wellness • Leadership • Values alignment • Voice/input • Meaning in work • Peer support • Community/collegiality • Appreciation • Flexibility • Culture compassion Adapted from Shanafelt, American Conference on Physician Health , 2017
Interventions!
Focus: Individual or Organizational? Lancet . Published online September, 2016 JAMA Intern Med . Published online December, 2016
Interventions Organizational Individual • Duty-hour requirements- • Meditation/Mindfulness reference • Stress management training • Shorter attending rotations • Communication skills • Shorter resident shifts in training ICU • Narrative medicine • Float pools for planned • Small group curricula and absences belonging interventions • Small amount of protected time
Efficiency of practice • Primary care clinicians at 34 clinics in Midwest and NY • Work condition measurements: – time pressure – workplace chaos – work control – clinician outcomes • Work-life measurement ➢ Chose interventions for clinical site Linzer, J Gen Intern Med , 2015
Results Intervention clinicians – Improvements in burnout and satisfaction – Burnout was more likely to improve with • workflow interventions • targeted QI projects ➢ Site-specific control over intervention
Efficiency of practice SWAT Intervention • Atrius Health, non-profit, MA Health Group- 740,000 patients • Pre: provider efficiency score tracked: – every screen – click – scroll – every look at med list, problem list – time logged in to system • Package of EHR-related interventions- SWAT – IT analysis, training, local support, security and interface issues – Workflow observation and analysis Atrius Health, American Conference on Physician Health, Presented 2017
• Outcomes: – Click savings – estimated 1500 clicks of 4000 estimated/provider/day – EPCS adoption rising rapidly – Time savings Unswatted Swatted Time in navigator (mins/eval period) 248.2 131.8 Time in notes/letters (mins/eval period) 1020 910
Culture of wellness • Intervention group o 19 biweekly facilitated discussions o mindfulness, reflection, shared experience, and small- group learning • Facilitated small-group curriculum vs control o improved meaning and engagement o reduced depersonalization o sustained results at 12 month West. JAMA Intern Med , 2014
Culture of wellness • Surveyed 3896 physicians, 72% response • Assessed burnout and leadership qualities of immediate and division/department chair • 12 leadership dimensions- Likert 1-5 Shanafelt. Mayo Clin Proc , 2015
Results ➢ Leaders’ scores correlated with burnout and satisfaction ➢ Leadership responsible for 11% of variation in burnout ➢ Leadership rating explained 47% of variation in satisfaction
Good News!! ➢ Leadership qualities are teachable: o keeping people informed o encouraging ideas for improvement o having career development conversations o providing feedback and coaching o recognizing a job well done
For each 1 point increase in composite score – 3.3% decreased likelihood of burnout – 9% increased likelihood of satisfaction
The Big Three! 1. Develop and implement targeted interventions Workplace efficiencies/workflow 1. Workload 2. Address EHR challenges 3. 2. Cultivate community 3. Harness the power of leadership
Personal Energy and Renewal: From Empty to Full I’m Thriving Bryan Sexton, Bohman, Dyrbye, Sinsky, et. al. National Taskforce for Humanity in Healthcare • Culture Of Wellness • Efficiency of Practice • Emotional Thriving • Personal Resilience • Emotional Recovery Christina Maslach • Emotional Exhaustion • Depersonalization • Personal Accomplishment I’m Burned Out
What fills my emotional reservoir? Arenas of Life Exercise
Purpose & Meaning • Career Fit and Burnout Among Academic Faculty ➢ 556 physicians sampled, 465 (84%) responded ➢ Spending <20% of professional work time on most meaningful activity had higher burnout ➢ Time spent on most meaningful activity was the largest predictor of burnout Shanafelt. Arch intern Med , 2009
Wellness Strategies: Being Intentional Explore and name your values- actively align decisions with your values Identify your sense of purpose- consciously make choices that connect with your purpose Know what brings you joy, make your bucket list and live it Build and nurture your relationships Work less-actively mange and decrease work-home conflicts Embrace a growth mindset, engaging in life from a learning and growing perspective (Dweck, Mindset: The new psychology of success ) Exercise Sleep- 7-9 hours a night Have idle time Vacation- use all your vacation time Reflect, meditate, or engage in a spiritual practice
• Individual interventions help • But, burnout is a system issue • Creating joy in practice necessitates systems interventions • Interventions & studies are happening • Ways forward are emerging – Building community/support – Site-specific workflow efficiencies & interventions – Leadership development – Attend to yourself
But until the systems catch up … • Take care of yourself • Be clear on what – brings you joy – you value • Let your purpose, joys and values be your guide your decision- making
Marti Schulte mschulte@schultecpc.com
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