Faculty Development Committee
Department of Obstetrics and Gynecology
Professional Development Series
October 16th, 2014
Avoiding Burnout: Recovering the Joy of Medical Practice
Professor Emeritus Norman M Jensen, MD,
Department of Medicine
American Academy on Communication in Healthcare
President, 2007-2009
Board Chair, 2011-2013
Faculty Guide for Distance Fellows
Faculty for Clinical Skills Enhancement Courses:
- Philadelphia, PA in June, 2015
Avoiding Burnout: Recovering the Joy of
Medical Practice
Our Aims today are:
1. Understand contribution of physician personal wellbeing to good clinical practice
2. What is burnout?
3. Score our own Ob/Gyn Well-Being Index (clicker
questions)
4. What are the best counter measures for physicians?
5. Resolve to undertake one measure to ward off or
diminish burnout (will be mailed to you in 2 months)
“In a culture where work can be a
religion, burnout is its crisis of faith.”
Jennifer Senior, November 26, 2006, New Yorker Magazine
Burnout
“The cost of caring”
Norm Jensen MD MS
Professor (CHS) Emeritus
Department of Medicine
nmj@medicine.wisc.edu
Personal Bio
Rural Wisconsin, public schools
 UW college and med school
 Harvard - Boston City residency
 Drafted Navy doctor, Viet Nam Years
 UW Grad school - social psychology
 Fellowship - clinical communication
 Teacher - Clinician 44+ years
 Academic focus: clinical skills
 No conflict of interest with this talk

Intended Learning Outcomes
 Cognitive
What’s
burnout
How am I doing?
What helps?
What hurts?
 Attitudinal: just a touch of
Self
awareness
The Story Begins

What is Professional Burnout?

Why is it important?
Burnout, professional (MH)
 An
excessive stress reaction to work.
 manifest by feelings of
– emotional and physical exhaustion
– & sense of frustration and failure.
 (NLM-MESH)
Burnout defined
 Work-related
distress that combines
– Emotional exhaustion
– Depersonalization
 treating
people in an unfeeling,
impersonal way
– Sense of low personal accomplishment
• Ramirez. Lancet 1996;347:724-28.

ICD-10: "Problems related to lifemanagement difficulty".
Research concept
 1970
Maslach & Jackson
– Maslach Burnout Inventory
 exhaustion,
 Maslach
cynicism, inefficacy
& Leiter
– Burnout antithesis = “engagement”
 energy,
involvement, efficacy
7395 Medline Publications
Burnout, professional (MH)
600
500
400
300
# Pub
200
100
0
1977 1982 1987 1992 1997 2002 2007 2012 2017
Updated September 29, 2014
MESH: STRESS, PSYCHOLOGICAL 1983-89, STRESS, PSYCHOLOGIC 1969-72
Burnout: What’s the big deal?
It’s prevalent
It harms the clinician personally
It harms the clinician’s clinical skill
It risks harm to patients
It is costly to the healthcare system
Inefficiency and waste
Professional workforce attrition
Physician’s Well-Being Index
Dyrbye LN, et. al. J Gen Intern Med 2012;28:421-27.
DURING THE PAST MONTH
1. Have you felt burned out from work?
2. Have you worried that your work is
hardening you emotionally?
3. Have you often been bothered by feeling
down, depressed, or hopeless?
4. Have you fallen asleep while stopped in traffic
or driving?
5. Have you felt that all the things you had to do
were pilling up so high that you could not
overcome them?
6. Have you been bothered by emotional
problems, such as feeling anxious, depressed, or
irritable?
7. Has your physical health interfered with your
ability to do your daily work at home or away
from home?
A Personal Inventory
• Each of the next 7 slides has one
personal question.
• Please answer “yes” or “no”, quickly,
the first response that comes to mind.
• Keep a personal count of the number
of “yes” answers.
• Use your “clicker” for anonymous
group prevalence.
Clickers:
press A = yes
press B = no
DURING THE PAST MONTH
1. Have you felt burned out
from work?
Clickers:
press A = yes
press B = no
DURING THE PAST MONTH
2. Have you worried that
your work is hardening
you emotionally?
Clickers:
press A = yes
press B = no
DURING THE PAST MONTH
3. Have you often been
bothered by feeling down,
depressed, or hopeless?
Clickers:
press A = yes
press B = no
DURING THE PAST MONTH
4. Have you fallen asleep
while stopped in traffic or
driving?
Clickers:
press A = yes
press B = no
DURING THE PAST MONTH
5. Have you felt that all the
things you had to do were
pilling up so high that you
could not overcome them?
Clickers:
press A = yes
press B = no
DURING THE PAST MONTH
6. Have you been bothered by
emotional problems, such as
feeling anxious, depressed,
or irritable?
Clickers:
press A = yes
press B = no
DURING THE PAST MONTH
7. Has your physical health
interfered with your ability to
do your daily work at home
or away from home?
Clickers:
press A = yes
press B = no
If you responded “YES” to
four or more, click
“Yes”
now
Clickers:
press A = yes
press B = no
Physician’s Well-Being Index
Dyrbye LN, et. al. J Gen Intern Med 2012;28:421-27.
Likelihood of Low Physician Well Being
 =>
4 “yes”
– Likelihood ratio 3.85
– Specificity 86%
<
4 “yes”
– Likelihood ratio .033
The Story Develops
Prevalence
 Profession
 By specialty
 Life cycle
Consequences
 Personal
 Healthcare
Risk Correlates
 Personal
 Work conditions
Moral Injury concept
Physician Burnout Prevalence

Practicing physicians
– 30 – 65%


Hospitalists 30%


Ann Intern Med 2008
Highest mid-career


BMJ. 2008 Mar 1;336(7642):488-91.
Med Students 50%, > 6% suicide thoughts


JGIM 2011
Pediatric residents 74%


Lancet 2009, JAMA 2009, Mayo Clin Proc 2013, JAMA Intern
Med 2012
Mayo Clinic Proceedings 2013
Difference among specialties …
USA Physician Burnout Survey, Arch Intern Med 2012;172;1381
Burn out %
USA Physician Burnout Survey, Arch Intern Med 2012;172;1381
Work-Life Balance
Mayo Clinic Proceedings 2013;88:1363
Personal correlates

Personal suffering


Stress Hormone excess


YALE J BIOL MED 2002;75:199-205.
Coronary artery disease +



Lancet 1996;347:724-8 (Hospital consultants)
Psych Bulletin 2006;132:327–353
+ metabolic syndrome, HPA dysreg, sympathetic
activation, sleep disturbance, systemic inflammation,
and impaired immunity, blood coagulation, and
fibrinolysis, and poor health behaviors.
Mental health


Anxiety, mood, adjustment, AODA, Suicide
ICD-10: "Problems related to life-management
difficulty"
Healthcare Correlates

On the job error




Ann Surg 2010 Jun;251(6):995-1000 (surgeons)
BMJ. 2008 Mar 1;336(7642):488-91. (Peds res)
Clinician empathy – compassion fatigue
Career & job dissatisfaction - disability
– Sick leave, early retirement, job turnover


Patient dissatisfaction / adherence
€ 20 Billion economic loss (Awa 2010)
– $115 - 587,000 to replace a physician

Threat to & from healthcare reform?
Correlating factors
 Work
load
 Meaning in work
 Work conditions
 Feeling
poorly managed and resourced
– Effort : reward
– Work demands : skills
– Low autonomy & control
 Patient
suffering – “moral injury”
 Intellectual stimulation
 Work variety
 “Work place bullying”
Correlating factors
 Work-life
 Life
balance
style
 Lack
of life partner
 Personal
 Woman
 Personal
management skill
 Communication skills
 Self care – resiliency
 Mid-career
Multivariate Analysis
Mayo Clinic Proc 2013;88:1364
Factor
Odds Ratio
Work hours / week
1.02 / hour
Call nights / week
1.03 / night
Recent home & work conflict 2.47
Resolution favored work
2.13
Have children
0.63
Academic practice
0.63
The Story Develops
What helps?
Work focused
Person focused (resilience)
Work - Person Interaction
State of the art review of evidence
Burnout prevention: A review of
intervention programs. Patient Education
and Counseling 2010;78:184-190.
What helps?
Work Focused
 How
days are organized
– Modulate pace of work
– Minimize hassles, interruptions &
paperwork
– Support staff share tasks requiring
little / no professional judgment
What helps?
 Work
control improvements
– ↑ clinician participation in
management – decentralize control
– Monitoring work load
– Promoting teamwork
– Orientation of the new to set
reasonable job expectations
– Management by goal setting &
feedback
What helps?
Person focused
 Right
job for the right person
 Sabbaticals, vacations, breaks
 Work-home-life balance
 Self care
– AMA book, The Resilient Physician
What helps?
Personal & professional learning
 Mindfullness
training
 Advanced communication skills
– JAMA 2009;302:1284-92.
 Stress
Management skills
– CBT vs Yoga (RCT)
– Cog Behav Therapy
– Physical Exercise
 Conflict
management skills
 Personal Management, life coach
Concept of Resilience
“The long-term ability to survive in and thrive
on adversity.” Med Ed 2012;46:349-356.
Self – efficacy
 Self – control

– Cognitive: plan and act
– Emotional intelligence

Self aware & modulation
– Learn from difficulty
– Persistence

Social intelligence
– Engage help & support
What helps?
Work - Person Interaction
 Employers
/ supervisors must
– Understand sources of work-home
interference & help manage
 Cross
coverage
 Child care
 Part-time practice
 Flexible work hours
 Advocacy
c. 1970s
The Story Continues
ACTIONABLES
Resilience Plan
•
Burnout meter awareness
• How’s the energy supply?
•
Mindfulness skills
• Awareness of me
•
Revise priorities regularly
• Really, is this what you want?
•
Personal maintenance
• “Keep the saw sharp”
Check Burnout Meter Monthly
1. burned out from work?
2. emotionally hardened?
3. mood down, hopeless?
4. daytime sleepiness?
5. overwhelmed by work?
6. emotional problems?
7. physical symptoms?
Enhancing Mindfulness Skills
•
Reading
•
•
•
Training classes, UWHealth
•
•
•
http://www.psychiatry.wisc.edu/uwpMindfulness.html
https://www.uwhealth.org/onlineservices/classes/class/viewClass/21
CME courses
•
•
Jon Kabat-Zinn, Wherever You Go, There You Are. Hyperion, New York,
1994
Zinn J-K, Davidson RJ, The Mind’s Own Physician. New Harbinger
Publications, Oakland, CA, 2011
http://www.urmc.rochester.edu/family-medicine/mindfulpractice/presentations-workshops.aspx
Personal practice
Revise Priorities Annually
•
•
•
•
•
Personal
Family
Professional
Keep dynamic record
Revise New Year’s Day
• Share with significant others
Personal Maintenance
Social life
 Personal physician / clinician
 Optimize personal health

–
–
–
–
–
–
Emotional intelligence
Food intelligence
Weight control
Physical activity
Sleep, R, R, & R
Disease screening
Continue learning


Assess your risk at
http://www.mind
tools.com/stress/B
rn/BurnoutSelfTes
t.htm
AMA book store,
$35, $30 for
members.
CHAPTERS
• Defining & Exploring Personal Assessment
& Management Strategies
• What really stresses physicians?
• Self-Assessment: How are you doing?
• The psychology of physicians
• Stress resilience
• The balancing act
• Understanding & Managing Relationships in
the Medical Workplace
• Conflict self-assessment
• Anger management
• Negotiating conflict
• The disruptive physician
• Listening & communication skills
• Coping with change
• Understanding & managing the stress of
medical training
• Making your workplace a positive
interpersonal culture
Continue learning
•
•
•
•
•
Chapters
Beyond Expertise
• The New Yardstick
• Competencies of the Stars
• Hard case for soft skills
Self Mastery
• The Inner Rudder
• Self Control
• What moves us
People Skills
• Social Radar
• The Arts of Influence
• Collaboration, teams, group IQ
A New Learning Model
• The Billion-Dollar Mistake
• Best Practices
Emotionally Intelligent
Organization
• Taking Organizational Pulse
• The Heart of Performance
Continued learning
A great first read on mindfulness,
especially for one who wants learn it
on their own, or at least begin that
way.
3 Parts -270 pages
1. In the bloom of the present
moment
1. 31 chapters
2. The Heart of Practice
1. 18 chapters
3. In the Spirit of Mindfulness
1. 24 chapters
4. Practice MP3s available
Clinical Skills CME
 MINDFUL PRACTICE:
Enhancing Quality of Care, Quality of
Caring, and Resilience April 27 - May 1,
2015
 Hosted by: The Center for Experiential
Learning, University of Rochester Medical
Center
 http://www.urmc.rochester.edu/familymedicine/mindful-practice/presentationsworkshops.aspx
Clinical Skills CME

ENRICH: Communicating in highly
effective healthcare systems
June 18-21, 2015 at Drexel University
College of Medicine in Philadelphia.
American Academy on Communication in
Healthcare –www.aachonline.org/
N Y Times, July 8, 2003
ERICA GOODE
Doctors' Toughest Diagnosis:
Own Mental Health
Intended Learning Outcomes
 Cognitive
What’s
burnout
How am I doing?
What helps?
What hurts?
 Attitudinal: just a touch of
Self
awareness
I have enjoyed being with you.
•References
available on request
•nmj@medicine.wisc.edu
•If
you wish to share a story please
contact me by email and we’ll
arrange a time to talk.
The lecture ends here!
Questions?
Answers
$0.25
Answers requiring thought $1.00
Correct answers
$2.50
Comments?