Pediatric Resident Coaching Program Meeting
November 11, 2013
Emily F. Ratner, MD, Clinical Professor
Department of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, California
Burnout
Burnout
 Emotional exhaustion
 Depersonalization – cynicism
 Ineffectiveness – Decreased sense of personal
accomplishment
 Work-individual mismatch
 Maslach Burnout Inventory – validated survey
Burnout Assessment
 Single question measures from MBI
 How often do you feel this way about your job?
 I feel burned out from my work
Never = 0
A few times a year = 1
Once a month or less = 2
A few times a month = 3
Once a week = 4
A few times a week = 5
Every day = 6
 I’ve become more callous toward people since I took this
job
West et al, J Gen Intern Med 24(12):1318-21.
Burnout and Satisfaction with Work-Life Balance
Shanafelt, et al. Arch Intern Med 2012;172(18):1377-1385
 > 7000 physicians
 46% of MD’s at least 1 symptom of burnout on MBI
 38 % Emotional exhaustion
 29% Depersonalization
 12% Ineffectiveness
 Physician depression – 38%
 Suicidal ideation in past year - 6.4%
 Poor work-life balance – 37%
 Burnout and poor work-life balance are a bigger problem for
doctors than other professions
Burnout by Specialty
Mean 46%
40%
36%
Shanafelt, Arch Int Med, 2012
faction with work-life balance by specialty
460%
Mean satisfaction 49%
~42%
Shanafelt, Arch Int Med, 2012
Medical Students
 Higher prevalence of psychological distress in med
students vs. age-matched peers Dyrbye et al, Acad Med 2006
 Incidence of burnout – ranges from 21%-53%
depending on source Santen et al, Southern Med J 2010, Dyrbye et al,
JAMA 2011
 Students going into medicine motivated by
personal/family member’s illness or death, higher
incidence of EE Pagnin et al. Med Teach, 2013.
 Lowered academic performance, increased
professional misconduct, decreased empathy,
increased substance abuse, suicide
Resident Burnout
 Incidence: 10-76%
 Internal medicine residents – 76% burnout, Seattle,
WA Shanafelt, Ann Int Med, 2001
 Surgery residents – 56%, UC Irvine, Gelfand, Arch Surg, 2004
 Alexithymic personality style associated w/higher
burnout rates, Daly et al, Med J Aust 2002; 177 (1): 14
 Alexithymia – inability to recognize or describe one’s
emotions
Thomas, JAMA, 2004
Anesthesiology Residents
 > 2700 residents, response rate 54% (>1500)
 MBI, Harvard Depression scale, best practice and
error self-reporting
 41% high burnout risk - associated with 3 factors
 Working > 70 hours/week
 Having > 5 drinks/week
 Female gender
De Oliveira, et al. Anesth Analg 2013;117:182-93
Anesthesiology Residents
 22% with depression
 associated with same factors of burnout risk+ smoking
 23% thought about/wanted to commit suicide - 68
residents
 Best practice scores for burnout +/- depression lower
 33% w/high burnout & depression risk had multiple
medication errors, significantly more than low risk
residents
De Oliveira, et al. Anesth Analg 2013;117:182-93
Causes of Burnout
 According to demand-control-support model
o Intense work demands
o Lack of control
o High degree of work-home interference
Stressors?
Put a photo here
Stressors at work
 Six Areas of Worklife Survey/Maslach
 Workload – includes time pressure, increasing patient
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complexity, documentation, regulations
Control – emergencies, schedule
Reward – appreciation, recognition
Community – lack of support, isolation
Fairness - favoritism
Values – aligned w/co-workers, larger organization
Stressors
 Family issues
 Personal health
 Time management
 Adjusting to current and uncertain
multiple changes in the health care
environment
 Financial – loans, decreased
reimbursement
Technology
Are we too plugged in?
 Electronic medical record
 New
 Upgrades
 Expectations of work at home
 Home access to medical records
 Email
 Cell phones, laptops, desktops,
chargers, batteries, adapters…..
 Time allowance to learn new systems/upgrades
 May be especially difficult for aging MD’s
Implications of Burnout
 Patient care
 Medical errors
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53% of burned out Internal Medicine resident self reported at least one
type of suboptimal patient care event vs. 21%
Shanafelt et al. Ann Int Med, 2002
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Increased surgical error reporting associated with burnout
Shanafelt et al. Ann Surg
2010

“Brian Goldman, MD: Doctors make mistakes. Can we talk about that?”
 http://www.youtube.com/watch?v=iUbfRzxNy20
 Patient compliance
 Adverse patient outcomes
 Patient satisfaction
Implications
 Physician health
 Mental illness, depression
 Physical illness
 Effects of adverse patient outcomes
 Maladaptive responses to stress
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Substance abuse
Denial
Avoidance
Keeping stress to oneself, not seeking help
Self-medication
Ignoring self-care
One MD per day commits suicide in the US
Roberts, Anesthesiology Grand Rounds September 2012
“If we continue to just build in efficiency and not build in
wellness, physicians will burnout. Doctors may still give
good care {for a while}, even when burned out, but it will be
at their own expense.”
Mark Linzer, MD 2012
The cost of replacing a physician is at minimum $250,000.
Buchbinder, Am J
Manag Care, 1999
Arenas to Approach Workplace Wellness
 Individual
 Increased self-awareness
 Stress reduction techniques
 Support network
 Reframing
 Build community
 Peer support groups
 Family and friends support
 Workplace changes
Resilience
 Resilience is that ineffable quality that
allows some people to be knocked down by life and
come back stronger than ever.
 Positive attitude, optimism
 Ability to regulate emotions
 Ability to see failure as a form of helpful feedback
 Reframing
Psychology Today online
Program in Mindful Communication In
Primary Care Physicians
 70 primary care MD’s, year long program
 8 week intensive phase
 10 month maintenance phase
 Curriculum
 Mindfulness meditation
 Self-awareness exercises
 Narratives about meaningful clinical experiences
 Appreciative interviews
 Didactic material, discussion
Krasner, Epstein et al. JAMA 2009
Program in Mindful Communication In
Primary Care Physicians
 Improved mindfulness correlated with
Less burnout
 Better emotional stability, mood and empathy
 Subjectively
 Reduced isolation due to sharing personal
experiences from medical practice w/colleagues
 Mindfulness skills improved patient interactions and
MD’s developed more adaptive reserve
 Transformative to develop greater self-awareness
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Beckman et al. Acad Med 2012;87:815-819
Georgetown Medical Students
 12 week Mind-Body Skills medical student elective, to
promote self-care and self-awareness
 Initial funding by NIH/R25
 12 year history, ~ 800 medical students, 40% class per
year
 ~100 Georgetown medical school faculty trained,
including all clinical rotation directors (except 1),
Dean of Medical Education
 Outside faculty training ~ 50 currently trained
Georgetown Medical Student Study
 2 groups of medical students
 Control group – no intervention
 Intervention group – 12 week MBS course
 Cortisol, testosterone levels measured before intervention
(January) & after course completed (May) just prior to final
exams Spring semester
 Cortisol levels were 240% higher in control group in May
 Testosterone levels were 160% higher in control group in May
 All female cohort
MacLaughlin et al, 2011
Mindfulness ?
 Awareness of the present moment
 Not past, not future
 Being not doing
 Noticing one’s own physical, mental, emotional
state – opposite of alexithymia
 Not acting on it, watching but not judging
 Recognizing that emotional states are all
temporary
 Takes practice
Stanford Anesthesiology Residency
Large program
4 hospitals
75 residents
150 faculty members
Tertiary care center, critically ill patients
Silicon Valley
Stanford duck syndrome
Goals of Resident Wellness Program
 Create an environment to support and promote the well-being of our
residents
 Build community
 Teach/expose residents to skills to promote resiliency
 Prevent burnout, in those who aren’t already
 Intervene early, prevent progression and devastating consequences
Core Components
 Initiated 2010, planning since 2008
1. Mandatory first year resident lecture
 Scientific lecture stress + biofeedback exercise
 Negative recruiting
2. Voluntary offsite weekend retreat CA-1’s
3. Ongoing q 8 week sessions for remaining 3
years of residency, part of required, didactic
program
Wellness Retreat
 1st year residents only
 2010 – 14/26 (54%)
 2011 – 18/26 (69%)
 2012 - 21/24 (88%)
 2013 – 20/26 (77%)
 2 groups lead by 2 facilitators
 2 Georgetown MBM faculty – mental health
professional
 2 Stanford anesthesiology faculty
Guidelines and Agenda
 Confidentiality, mutual respect
 “I Pass” Rule
 Non judgmental - listening, not solving
 Facilitators set the tone
 Experiential exercises: meditation, guided imagery,
yoga, Tai Chi, drawing, journaling exercise
 Opportunity for self-reflection, check-in, sharing
concerns with peers in a supportive environment
 Group meals, room w/peers
Resident Wellness Retreat
 Friday evening through Sunday afternoon
 Friday night - introductions/drawing exercise
 Saturday
8:00 – 8:50am
9:00 - 10:00am
10:00 - 12:00pm
12:00 - 1:30pm
1:30 - 3:00pm
3:00 - 3:30pm
3:30 - 5:30pm
5:30 - 7:30pm
7:30 – 9:00pm
Yoga
Breakfast
Meditation – eating, mindfulness
Lunch
Walking meditation
Break
Reflective Journal Writing
Free time
Dinner
Wellness Retreat Feedback
 Objective surveys
 Subjective survey results
 100% met or exceeded expectations
 Most valuable aspects
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Formation of strong peer support system
Learning new coping and communication skills
“To really feel that stressors..were not only my own”
“To talk openly about my struggles”
“Our interactions were personal and deeply profound.”
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“The time spent here has truly changed me.”
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“Unbelievable investment in our well-being. Thank you!”
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Wellness Sessions
 Meet every 8 weeks, 1 ½ hours
 Protected didactic time
 For all ~ 75 CA-1, CA-2 and CA-3 residents,
mandatory
 Two groups from retreat maintained, same facilitators
 Third group formed with residents who did not
attend retreat, or incorporated into 2 existing groups
 Expanding faculty involvement, facilitator training
 Further curriculum development
Faculty Wellness Pilot Program
 Funded through Dean’s Office
 Purpose: enhance faculty member wellness and build a
model to promote community support amongst the faculty.
 Experiential training
 Not so hidden agenda
 Modified from Anesthesia RWP, Georgetown, Krasner &
Epstein’s program
 Two components:
 Offsite retreat, May 2013
 Monthly sessions for a year
Faculty Wellness Pilot Program
 All Medical School faculty eligible
 Personal statement
 Department Chair/Division Chief letter of support, financial
($500) and time off for retreat & once monthly meetings
 10 participants
 3 Pediatrics (Endocrinology, CCU, Pulmonary)
 3 Medicine (Hospitalist, ICU/VA, General Medicine)
 2 Anesthesiology (VA/SUH)
 1 each from ER, Radiology researcher –PhD
 Diverse backgrounds, all ranks, > 30 year age range
Post Retreat
 Monthly sessions
 Lunch
 Experiential exercise
 Check in
 Informal get togethers
 Request for more frequent meetings
 Twice per month formal meetings
Retreat Subjective Evaluations
 100% exceeded expectations
 “This was my most meaningful experience at Stanford.”
 “This was one of the best experiences of my life. Life
changing.”
 “I did not expect such amazing connections and the close
feelings with others at such a deep level.”
 “This ended the sense of social isolation I’ve felt at
Stanford.”
 “I am overwhelmed with gratitude at the opportunity to
participate in this deeply moving experience.”
Lessons learned
 Buy in from leaders
 Need at least one champion
 Gradual implementation on a yearly basis worked better
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than going from 0 to 75 residents involved
Mental health professional involvement
Jumpstart program with a retreat off campus if possible
Create safe, nonjudgmental confidential environment
Survey once/year
Faculty involvement
Other programs’ and institutions’ curricula
Encourage resident support and input for programming
You can’t force wellness, allow those who don’t want to
participate actively to “pass”. Ask them to not be
disruptive.
Who will pay for physician wellness programs?
InsightfuI Leaders
?
Future
 Expand Faculty Wellness programs
 Peer Support Groups
 Data
 Linking patient outcomes with physician resiliency
 Linking patient satisfaction with physician resiliency
 Decreased cost