Are We Healthy?
Caring for Ourselves
Linda Blust, MD
Center for Palliative Medicine
“How often do you . . .”
a) Almost Always
b) Often
c) Seldom
d) Almost Never
Case
• It’s been a very busy six months. At the
request of your supervisor, you have taken
on new committee responsibilities in
addition to your teaching and
clinical/research duties. Your co-workers
are beginning to grumble that you’re not
available when they need you. Tenure is
looming, but you can’t seem to complete
the portfolio.
What’s happening?
• Physical Stress
• Your working harder with the same amount of
time
• Emotional Stress
• You can’t be in two places at once
• Spiritual Stress
• Is this really why you choose to do your work?
Intro to Humans:
Care and Feeding
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Adequate Sleep: 6-9 hours/day
Nutrition: 1500-1800 kcal/day; balanced
Exercise: Aerobic
Safety
• Injury avoidance
• Illness avoidance
• Regular check-ups
Facts
• Direct patient care largest cause of low back injury
in U.S.
• 2/3 docs DO NOT have a PMD
• Sleep deprivation increases work-related errors
• Women encounter a glass ceiling in academia
Strategies
• Recognize physical signs
• Irritability
• Inattention
• Insomnia
• Value your physical health
• Sleep when you need
• See the Doctor
• Etc.
Emotional Health
• Do I get what I need from my job????
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Workload
Control
Reward
Community
Fairness
Values
Emotional Health
• Workload
• Appropriate number/resources/training
• Control
• Empowerment without abandonment
• Reward
• Is it meaningful to you?
Emotional Health
• Community/Co-workers
• Supportive
• Fairness
• Workload/resources/reward
• Values
• Organization shares your basic values
Facts
• No job is perfect!!
• Know yourself well
• What is essential
• What is intolerable
• What is negotiable
Strategies
• Don’t just sit there, do something!
• Identify the problem: name it truthfully!
• Plan an intervention: what can I realistically do
about it?
• ACT: address problem directly. Remember,
• What is essential
• What is negotiable
• What is intolerable
Strategies
• Be Creative
• Can I work a different schedule?
• Can I work with different people?
• Can I get different rewards?
Strategies
• Return to beginning
• Why did I choose this?
• Does that reasoning still hold?
• Eyes on the Prize
Caveat Emptor
• Realize the cost of addressing/not
addressing the problem
• Impaired work performance
• Burn-out
• Depression
• You may need to explore other options
Spiritual Health
• Does what I do reflect who I am?
• Can I nurture/protect my essential beliefs?
• Does this make sense to me?
Facts
• It is impossible to sustain competence doing
something that “isn’t you”
• Patients/families/coworkers often challenge
our belief systems
• “Crazy-making” will make you crazy
Strategies
• Identify: Be Truthful!
• Plan: Realistically, what can be done?
• Act: Your essential self is at stake: DON’T
IGNORE THIS!
Consequences
• Burnout
• Illness
• Addiction
• Poor work performance
• Unprofessional conduct
• Suicide
What is Burnout?
• Syndrome
• Emotional Exhaustion
• Depersonalization/Cynicism
• Sense of Low Personal Accomplishment/
Sense of Inefficacy
Emotional Exhaustion
• “I feel drained. . .”
• Likely a result of high workload and time
pressure
• Precursor to Depersonalization/Cynicism
Depersonalization
• Distance Self from Patients/Clients/co-workers
• Ignore unique qualities of patients/co-workers
• Creation of “other”
• Easier to manage demands
• Protects self from emotional demands of work
Sense of Inefficacy
• “I’m not doing a good job . . .”
• Concurrent with exhaustion/cynicism
• Linked to lack of resources
Stages of Burnout
• Stress Arousal
• Energy Conservation
• Exhaustion
• Proceed in order
• Cycle can be interrupted at any point
Risk Factors
• Individual
• demographics, personality, attitudes
• Situational
• job, occupation, organization
• Situational Risks More Predictive of
Burnout than Individual Risks!!!!!
Demographic Risks
• Young: survival bias?
• Unmarried
• Highly educated
• Gender NOT predictive
Risks: Attitudes
• High job expectations
• nature of work
• achievement
• Unclear if this correlates with burnout
Individual Risks for Burnout
• Type-A Behavior
• Lack of “Hardiness”
• Open to change
• Sense of control
• Involved with daily function
• Low Self Esteem
Poor Work Performance
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Lateness for Work
Needed 3-day weekends
Turning in work late
Resentfulness
Suboptimal performance
• Practice
• Attitudes
Addiction
• 10-14% MDs become addicted during
career
• Alcohol is primary drug of choice
• Addiction is cause for impairment over 70%
of the time
• We police ourselves and each other
Unprofessional Conduct
• Unprofessional students are THREE
TIMES more likely to receive disciplinary
action as MDs
• Severely irresponsible: odds ratio of 8.5 for
disciplinary action
• Severely unable to improve behavior: odds
ratio of 3.1
• We police ourselves and each other
Suicide
• Male MDs: relative risk 3.4
• Female: 5.7
• Completed suicide = male rate
• More likely to die of suicide than other
professionals
Conclusion
• Health has 3 major elements: Don’t ignore
any of them!
• Know who you are and what you need
• Don’t complain: ACT
• Remember, no job is worth your physical,
emotional, or spiritual health.
References
• Booth, JV et al. Substance Abuse Among Physicians: A
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Survey of Academic Anesthesiology Programs.
Anesthesia and Analgesia 2002;95:1024-30.
Center, C et al. Confronting Depression and Suicide in
Physicians: A Consensus Statement. JAMA
2003;289:3161-3167.
Girdino, DA et al. Controlling Stress and Tension, Allyn &
Bacon, Needham Heights MA, 1996.
Gross, CP et al. Physician, Heal Thyself? Archives of
Internal Medicine 2000;160:3209-3214.
Gundersen, L. Physician Burnout. Annals of Internal
Medicine 2001;135:145-148.
References, II
• Maslach, C et al. Job Burnout. Annual Review of
Psychology 2001;52:397-422.
• Papadakis, MA et al. Disciplinary Action by Medical
Boards and Prior Behavior in Medical School.
NEJM;353:2673-2682.
• Shanafelt, TD et al. Burnout and Self-Reported Patient
Care in an Internal Medicine Residency Program. Annals
of Internal Medicine 2002;136:358-367.
• Texas Medical Association CME website.
www.texmed.org/cme/phn/psb/burnout.asp
Case
• An elderly man has been transferred to
4NW with a grave prognosis from
neurologic injury. Tube feedings were
stopped 3 weeks ago, and hydration consists
of 120 cc/day from his PCA. He continues
to make stool and >1L urine/day. All
involved with his care are irritable and
angry with the primary care team.
What’s happening?
• Physical stress
• Caring for dying patient for 3 weeks
• Emotional stress
• Am I doing this right?
• Spiritual stress
• Why isn’t he dying????