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 • • • • 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???? • • • • • • 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 • • • • • 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 • • • • 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????