“Professional Health and
Wellness of the Clinician.”
Charlene M. Dewey, M.D., M.Ed., FACP
Co-Director, Center for Professional Health
Associate Professor of Medical Education and Administration
Associate Professor of Medicine
Vanderbilt University School of Medicine
Sept 11, 2011
Goals
• The purpose of this session is to introduce
the importance and the evidence behind
professional health and wellness and how
it plays a role in your professional
behaviors, as well as, how to recognize
and prevent professional burnout.
Objectives
1. Discuss important evidence on the health
and wellness of clinicians.
2. Define professional health and wellness,
stress, and burnout.
3. Describe protective factors help prevent
burnout.
4. Complete an individual action plan.
Agenda
1. Introduction and Importance
2. Professional Health and Wellness
Spectrum
3. Stress and Burnout
4. Take home points
5. Q&A
6. Action Plans - (on own)
Professionalism Model
Altruism
Accountability
Humanism
Excellence
Professionalism
Ethical and Legal Understanding
Communication Skill
Clinical Competence (Knowledge of Medicine)
Professional Health & Wellness
Professional Culture
Dewey & Swiggart. Vanderbilt University School of Medicine, 2009; Adopted from Stern, 2006
Two Systems Interact
The External System
Functional
& Nurturing
“Personal & Institutional Vitality”
Work
Environment
The Internal System
Good Skills
& Well
Clinician
Poor Skills
&/or Not Well
Dysfunctional
“The Perfect Storm”
External - Work Environment
Importance & Evidence
• Powerful model how practice environment
can impact physician health
•
•
•
•
Stress: physician, environment, patients
Environment was the only sig predictor of stress
Job stress predicts job satisfaction
Job sat is positive predictor of positive mental
health
• Perceived stress was a stronger predictor of both
poorer reports of physical and mental health
• Therefore, environment influenced health
Williams et al. Physician, practice and patient characteristics related to primary care physician physical and mental health: Results of
the physician’s work-life study. Health Services Research, 2002; 37(1):121-43.
Importance and Evidence
• Inadequate systems & supports
• Culture – more, faster, better, longer
• Individuals
Importance and Evidence
Disruptive behavior leads to problems with
communication which leads to adverse events1
– Communication breakdown factored in OR errors
50% of the time2
– Communication mishaps were associated with 30% of
adverse events in OB/GYN3
– Communication failures contributed to 91% of
adverse events involving residents4
1. Dayton et al, J Qual & Patient Saf 2007; 33:34-44.
2. Gewande et al, Surgery 2003; 133: 614-621.
3. White et al, Obstet Gynecol 2005; 105(5 Pt1):1031-1038.
4. Lingard et al, Qual Saf Health Care 2004; 13: 330-334
Importance and Evidence
• >95% of MDs agree with reporting conduct
that is unprofessional; yet 45% did not
report witnessed events1
• Ignored unprofessional conduct affects2:
–
–
–
–
–
Hidden curriculum
Individuals & family members
Patients & visitors
Reputation
Liability & cost
Campbell et al. Professionalism in Medicine: Results of a National Survey of physicians. Ann Int Med 2007
Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007.
Importance and Evidence
• Some may adopt behaviors (Dimberg & Ohman, 1996)
• Perceptions of inequality (Kulik & Ambrose, 1992)
• Some will decrease their contributions &
withdraw (Schroeder et al, 2003; Pearson & Porath, 2005)
• Reduces trust & effects both quality and pt safety
(Lewicki & Bunker, 1995; Wageman, 2000)
• High turnover - 50% think about it & 12% actually
quit (Pearson et al, 2000)
• Increased liability and costs (Sutton 2007 and Hickson
2002)
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and
Organizational Behavior, Volume 27, 175-222.
Internal – Individual Clinician
Importance and Evidence
• “Physicians are important citizens of
health-care systems, and evidence
indicates that many physicians are
unwell.”
~Wallace et al, 2009
Jean E Wallace, Jane B Lemaire, William A Ghali, Physician wellness: a missing quality indicator. Lancet 2009.
Importance & Evidence
•
•
•
•
•
30-60% MD have distress and burnout
MDs suicide > other prof. & gen pop.
One physician per day = underestimated?
PhD – unclear
Depression/bipolar & substance abuse =
suicide risk
“Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success.” Cole, Goodrich & Gritz, UTHouston Medical School, 2009.
Importance & Evidence
• Gender differences:
•
•
•
•
•
Females in general experience more anxiety, depression
F-MDs are healthier compared to other women
F>M MD suicides (>50% vs. 40% higher risk)
Women chairs more stressed
F-MDs are 60% more likely to report symp burnout
• Reduced use of care
• Stigma & anonymity – slow to prioritize MH
issues for physicians; licenses, etc.
http://www.aamc.org/members/gwims/statistics/stats09/start.htm
Lin et al.1985; McMurray 2000; Gautam 2001; Spickard 2002; Schindler 2006; “High physician suicide rates suggest lack of treatment for
depression.” - MD Consult News June 11, 2008
Importance & Evidence
• Academic faculty:
– Worked longer hours
– Took less vacation
• 10% with mild depression
• 27% with elevated anxiety
– No sig difference clinical vs. academic
Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA
254(19):2775-82.
Schindler et al. The Impact of the changing Health Care Environment on the Health and Well-being of faculty at Four Medical
Schools. Academ Med 2006 81(1):27-34.
Importance & Evidence
• Various types of unprofessional conduct
• Many reasons for unprofessional conduct
– Reduced wellness
– Stress/burnout
– Genetic/developmental issues: Asperger’s,
non-verbal learning differences, etc.
– MH issues: Personality disorders, depression,
bipolar, etc.
Professional Health and
Wellness
The ethics of self-care:
“The medical academy's primary ethical imperative
may be to care for others, but this imperative is
meaningless if it is divorced from the imperative
to care for oneself. How can we hope to care for
others, after all, if we ourselves, are crippled by
ill health, burnout or resentment?”
Cole, Goodrich & Gritz. “Faculty Health in Academic Medicine: Physicians, Scientists and the Pressures of
Success.” Humana Press 2009; pg 127.
Professional Health and
Wellness
The ethics of self-care: (cont.)
“…medical academics must turn to an ethics
that not only encourages, but even
demands care of self.”
~Craig Irvine
Cole, Goodrich & Gritz. “Faculty Health in Academic Medicine: Physicians, Scientists and the Pressures of
Success.” Humana Press 2009; pg 127.
Professional Health and
Wellness
• Health and wellness of mental, physical,
emotional and spiritual self.
• We propose a professional health and
wellness spectrum to help conceptualize
when health and wellness are present or
are lacking.
Professional Health & Wellness
Spectrum
Work &
Family
Relations
High Functioning
High Productivity
Fair Functioning
Decreasing Productivity
Fair Functioning
Reduced Productivity
Relationships Suffer
Fair-Not Functioning
Fair-Not Productive
Institution & Family Loses
Physical
Mental
Emotional
Spiritual
Stressed
Professionally Healthy
& Well
Coping Mechanisms
Strong
Burnout
Coping Mechanisms
Failing
Risk of MH issues and
suicide
No Coping
Mechanisms
Stress & Burnout
• Stress and burnout occurs
for different reasons in
different individuals.
• Work load ≠ level of stress
or burnout in all situations.
• Multifactorial
Definition - Stress
• Stress can be defined as:
– d : a state resulting from a stress; especially :
one of bodily or mental tension resulting from
factors that tend to alter an existent
equilibrium <job-related stress> Webster’s
dictionary
Self-Assessments
• What stresses you out?
• Measure your stress level.
The Doctor Dewey Insto-Matic Stress-O-Meter
Anxious
Engaged
Enthusiastic
Calm
Run Down
Stressed out
Exhausted
Overwhelmed
Drained
Relaxed
Ready to cave
Stress free
Burnt out
Stress & Productivity
Prolonged
Stress
Reduced
Cognition
“Impairment”
???
No
Prolonged
Stress
Situational Stress
Stressed
Burnout
Non-Functional
Definition - Burnout
• Burnout can be defined as:
– a : exhaustion of physical or emotional
strength or motivation usually as a result of
prolonged stress or frustration b : a person
suffering from burnout. Webster’s dictionary
Burnout
“In the current climate, burnout thrives in the
workplace. Burnout is always more likely
when there is a major mismatch between
the nature of the job and the nature of the
person who does the job.”
~Christina Maslach
The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It.
Maslach & Leiter pg 9; 1997
Risk Factors for Burnout
•
•
•
•
•
•
Single
Gender/sexual orientation
># of children at home
Family problems
Mid-late career
Previous mental health
issues (depression)
• Fatigue & sleep
deprivation
•
•
•
•
General dissatisfaction
Alcohol and drugs
Minority/international
Teaching & research
demands
• Potential litigation
Puddester D. West J Med 2001;174:5-7
Myers MJ West J Med 2001;174:30-33
Gautam M West J Med 2001;174:37-41
Six Sources of Burnout
1. Lack of control
2. Work overload
3. Insufficient reward
4. Unfairness
5. Breakdown of community
6. Value conflict
Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.”
Symptoms of Burnout
1.Chronic exhaustion
2.Cynical and detached
3.Increasingly ineffective at work
4.Leads to:
1.
2.
3.
4.
isolation
avoidance
interpersonal conflicts
high turnover
Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg
17
Self-Awareness
“Self-awareness means having a deep
understanding of one’s emotions, strengths,
weaknesses, needs, and drives. People
with strong self-awareness are neither
overly critical nor unrealistically hopeful.
Rather, they are honest – with themselves
and with others.”
“What Makes a Leader?” by Daniel Goleman, Best of Harvard Business Review (1998)
Individual Factors
Wellness is promoted through good self-care:
1.
2.
3.
4.
5.
6.
7.
Sleep
Balanced meals
Physical activity
Socialization
Vacations/down times
Spiritual engagement
Have a physician
Mind
Body
Soul
Emotion
Individual Factors
• Address Maslach’s 6 sources of burnout
Work overload
Unfairness
Lack of control
Insufficient reward
Breakdown of community Value conflict
• Influence happiness through personal values
and choices
• Mentor(s), coaches, confidants
Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):1447-50
Environmental Factors
Overcoming work-place stress:
1.
2.
3.
4.
5.
6.
Manage Reduce
EnergyDistractions
Address sources of burnout
Gain control
Manage energy
Seek out mentors
Find meaning in work
Managing failures and successes
Planning
Managing Energy at Work
•
•
•
•
•
•
•
Listen to your body
Identify your own needs
Define limits - Just Say NO!
Create your work environment
Eliminate distractions
Take breaks
Plan ahead
Schwartz, T. & McCarthy, C. Manage Your Energy Not Your Time. HBR October 2007.
Managing Failures &
Successes
The Truth About Burnout
“The twin goals of preventing and building
engagement are possible and necessary in today’s
working world. These goals cannot be easily
achieved by an individual. Rather, people have to
work together to make them happen. And if we all
commit ourselves to the long-term process of
organizational progress, we will be rewarded with
workplaces that are more productive and resilient
as well as humane.”
~Maslach & Leiter, pg 127
Preventing & Resolving Burnout
Individual Approach
Organizational Approach
Starts with
person
Starts with
management
Becomes group
project
Becomes organizational
project
Connects to organization
Connects to people
Outcomes affects related
mismatches
Outcome is a process
Figure 5.1 (pg 80) Maslach, C & Leiter, MP. “The Truth About Burnout: How Organizations Cause Personal Stress and What to do
About It.” 1997
Managing Energy: Case
Discussion
Dr D is a 46 yo female physician-educator with 2 kids and
spouse with significant travel/work schedule. She wears 5
different hats on any given day and is involved is several
community activities. Dr D finds emails and other
interruptions distracting and is feeling stressed due to a
grant and several submissions that are due in the next 6
weeks. She has cut down on sleep and exercise to meet
the deadlines.
– What are her risk factors for burnout?
– Will this lead to burnout?
– What changes could we suggest to control energy at work?
Resources
•
•
•
•
•
•
Your PCP
State physician health program
Suicide prevention hotline: 1-800-273-TALK
Private counseling services
Substance use related issues (AA, NA, Evelyn Fry, etc)
YMCA/YWCA, Massage envy, etc.
Take Home Points
1. You are valuable!
2. Seek how to maintain and care for your
professional health and wellness
3. Be self-aware in identifying stress and burnout.
4. Look for and anticipate stress.
5. Manage energy and avoid burnout – once of
prevention is worth a pound of cure!
Individual Action Plan
• Take time to focus on yourself.
• Complete within 24-48 hrs
• Individual action plans found at:
www.mc.vanderbilt.edu/cph
“The first wealth
is
health.”
~ Ralph Waldo Emerson
Questions & Answers