Well Being in Anesthesiology: Realities and Remedies Amy E. Vinson, MD, FAAP @imswimming3 Boston Children’s Hospital & Harvard Medical School Johns Hopkins Grand Rounds March 12, 2020
Disclosures On behalf of myself and my spouse, we have no financial disclosures relevant to the material presented today
Objectives Understand the definition and manifestations of burnout, in order to address sooner Recognize the sequelae of burnout in patient care, professionalism, physical health and society Understand the importance of peer support Cite examples by which leaders in anesthesia can prevent and ameliorate burnout in those they lead
By Juan Emilio - Flickr: Canario silvestre, Serinus canarius( ♂ ), CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=18277090 https://www.smithsonianmag.com/smart-news/story-real-canary-coal-mine-180961570/
“Physicians in 2018 are the proverbial ‘canary in the coal mine.’ While the canary may be sick, it is the mine that is toxic. Caring for the sick canary is compassionate, but likely futile until there is more fresh air in the mine.” - Thomas Schwenk
What is Burnout? Merriam-Webster: 2 a : exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration By 4028mdk09 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=8361003
Burnout cascade – taught, reinforced and rewarded throughout medical training
Maslach Burnout Inventory Maslach (~1980): A syndrome typified by exhaustion, depersonalization and a loss of meaning / accomplishment Highly validated Wide Application 3 Major Metrics of Burnout Emotional Exhaustion Low Sense of Personal Accomplishment Depersonalization
Trauma in the ICU
27K surveys sent, 7.3K completed (26.7%) • Utilized MBI and other measures of • depression/SI/balance 45.8% Physicians with at least 1 symptom of burnout • More burnout symptoms and dissatisfaction with • work-life balance than general public 37.9% with high emotional exhaustion • 29.4% with high depersonalization • 12.4% with low sense of personal accomplishment •
Follow up survey – 36K sent, 6.9K responded (19.2%) 54.4% reported at least 1 symptom of burnout (up from 45.5%) Satisfaction with WLB worsened (48.5% to 40.9%) Physicians at increased risk of burnout (OR 1.97), less likely to be satisfied with WLB (OR 0.68)
~30K invitations with ~5K responding (17%) (secondary survey to ensure representability) 43.9% with at least 1 major symptom of burnout (better than 2011 & 2014) 42.7% satisfied with WLI (middle) Anesthesia saw similar trends
Does burnout impact our health? Self Reported Health & Fatigue and burnout are Physical illness predictive of one another Insomnia Sickness absences Musculoskeletal disorders Hospital admission for mental illness Hospital admits for CVD Altered cortisol expression Increased suicidality among medical students The association between burnout and physical illness in the general population--results from the Finnish Health 2000 Study. Honkonen T, Ahola K, Pertovaara M, Isometsä E, Kalimo R, Nykyri E, Aromaa A, Lönnqvist J. J Psychosom Res. 2006 Jul;61(1):59-66. Shirom A. Burnout and health: Expanding our knowledge. Stress and Health. 2009;25:281. Gurman GM, Klein M, Weksler N. Professional stress in anesthesiology: a review. J Clin Monit Comput. 2012 Aug;26(4):329-35. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008 Sep 2;149(5):334 – 41.
Does burnout impact our professionalism? Dyrbye LN, Massie FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010 Sep 15;304(11):1173 – 80. Thomas MR, Dyrbye LN, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study. J GEN INTERN MED. Springer-Verlag; 2007 Feb 1;22(2):177 – 83.
Does burnout impact our career longevity? Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res. 2014;14(1):254. Ahola K, Gould R, Virtanen M, Honkonen T, Aromaa A, Lönnqvist J. Occupational burnout as a predictor of disability pension: a population-based cohort study. Occup Environ Med. 2009 May;66(5):284 – 90 – discussion282 – 3.
Does burnout impact medical errors? Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002 Mar 5;136(5):358 – 67. Ahola K, Gould R, Virtanen M, Honkonen T, Aromaa A, Lönnqvist J. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. American Medical Association; 2009 Sep 23;302(12):1294 – 300. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010 Jun;251(6):995 – 1000.
• Systematic review & meta-analysis • Quantitative associations between burnout and patient safety, professionalism, and patient satisfaction • Burnout associated with: • Increased risk (OR 1.96) of patient safety incidents • Poorer quality of care b/c of poor professionalism (OR 2.31) • Reduced patient satisfaction (OR 2.28)
Our Responsibility? Physician wellness: a missing quality indicator. Wallace JE, Lemaire JB, Ghali WA. Lancet. 2009 Nov 14;374(9702):1714-21. doi: 10.1016/S0140-6736(09)61424-0. Review. Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA. 2011 May 18;305(19):2009-10.
Adverse Events?
1 st , 2 nd and 3 rd Victims Wu AW: Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320:726 – 7
Miracles aren’t always easy Stiegler MP: What I Learned About Adverse Events From Captain Sully: It's Not What You Think. JAMA 2015; 313:361 – 2 By Greg L (File:Plane crash into Hudson River.jpg) [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
A tale of 2 patients Subsequent patients had longer hospital and ICU stays After intraop death, 53% of surgeons and 22% of anesthesiologists ceased patient care for that day ¼ (27% surgeons, 26% anesthesiologists) felt they should not work following an intraop death Goldstone AR, Callaghan CJ, Mackay J, Charman S, Nashef SAM: Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation. BMJ 2004; 328:379 – 9
Impact on Anesthesiologists 88% needed time to recover – 19% never did, 12% considered change in career 67% felt subsequent care compromised over next 4 hours 7% were given time off Gazoni FM, Amato PE, Malik ZM, Durieux ME: The Impact of Perioperative Catastrophes on Anesthesiologists. Anesth. Analg. 2012; 114:596 – 603
Emotional Impact? 32 studies relating impact of medical errors on clinicians Norm: intense emotional response Errors increase depression & burnout Cycle develops: future errors more likely Talking with colleagues most helpful with coping Schwappach DL, Boluarte TA: The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2009; 139:9 – 15
other symptoms of unwellness Warner DO, Berge K, Sun H, Harman A, Hanson A, Schroeder DR. Risk and Outcomes of Substance Use Disorder among Anesthesiology Residents: A Matched Cohort Analysis. Anesthesiology. 2015 Oct;123(4):929-36.
Data on suicidality Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004 Dec;161(12):2295- 302.
https://www.washingtonpost.com/national/health-science/what-ive-learned-from-my-tally-of-757-doctor- suicides/2018/01/12/b0ea9126-eb50-11e7-9f92- 10a2203f6c8d_story.html?noredirect=on&utm_term=.8c71ae684c76
https://opmed.doximity.com/why-happy-doctors-die-by-suicide- 8a3a1f9b1543
A New Responsibility Sir William Osler: “In no relationship is the physician more often derelict than in his duty to himself.” “Begin at once the cultivation of some interest other than the purely professional.” By Unknown - Page, Public Domain, https://commons.wikimedia.org/w/index.php?curid=30993113
Where do we go from here?
A new way forward? Thomas LR, Ripp JA, West CP. Charter on Physician Well-being. JAMA. 2018 Apr 17;319(15):1541-1542.
Triple Aim QUADRUPLE AIM Improved Outcomes Better Satisfaction of Patients Lower Cost Better Satisfaction of Providers (attaining joy in ? work) http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple- aim-four-points-to-help-set-your-strategy
Support after adverse events Vinson AE, Mitchell JD. Assessing levels of support for residents following adverse outcomes: A national survey of anesthesia residency programs in the United States. Med Teach. 2014 May 7.
Ranking of Support Resources
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