Provider Wellness
Sopheap Na, M.D.
Assistant Professor of Medicine
VAMC
Jan McCormack, DMin, BCC
Assistant Professor of Chaplaincy and
Pastoral Counselling
Denver Seminary
UCHSC/VAMC
TMC - March 2009
Are You?

Driven
 Motivated
 Competitive
 Ambitious
 Determined
 High energy
 Excels at everything
 Top of the class
 Type A personality
 High standards
 Aggressive
 High need for control
 Perfectionist
Provider Wellness Outline
Background
Definitions
Studies
Interventions
MCAT Scores and GPAs for U.S. Medical Schools by Sex 2000-2007
VR
PS
BS
GPA
(science)
GPA
(nonscience)
GPA (total)
Male
9.9
10.7
10.8
3.60
3.70
3.64
Female
9.9
9.8
10.4
3.58
3.76
3.64
VR – verbal reasoning
PS – political science
www.aamc.org/data/facts/start.htm
BS – biological science
Distribution of Total Educational Debt for Medical Students in the United States at Graduation, 2004–2008.
AAMC Graduation Questionnaire All School Reports - premedical or college education debt.
2008, 38% of graduates had debt from premedical education (median amount, $20,000). The distribution of the 23% of students
with total debt of $200,000 or more was 15% with $200,000 to $249,999 in debt, 6% with $250,000 to $299,999 in debt, and
3% with $300,000 or more in debt (numbers do not sum to 23% due to rounding).
R. Steinbrook. Medical Student Debt — Is There a Limit? NEJM 12/18/2008
Mean Tuition and Fees for
Medical Schools and
Undergraduate Institutions,
1998–1999 to 2008–2009
(Panel A) and Percent Change
in Mean Tuition and Fees, the
CPI, and Median Physician
Compensation, 1998–2008
(Panel B).
Medical school tuition and
fees are from the AAMC
tuition and fees report;
starting in 2004–2005, figures
include health insurance as
well as tuition and fees. Mean
tuition and fees for 2008–
2009 were not available.
Tuition and fees at 4-year
undergraduate institutions are
from the College Board's
Annual Survey of Colleges.
Consumer Price Index (CPI)
are from the U.S. Department
of Labor.
Medical Group Management
Association's Physician
Compensation and Production
Survey
Medical Student Debt — Is There a Limit? Robert Steinbrook, M.D.
NEJM 12/18.2008
Background
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All physicians
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Drug and alcoholism  30-100x general population
3x other profession to spend >60 hrs/wk working,
21% 80 hrs/wk, 16% longer hrs
13% F and 20% M physicians  episode of
depression
Divorce rates  10-20% higher than general
population
$236,383 to replace family practitioner
$264,345 to replace general pediatrician
The Resilient Physician. Sotile, WM.
Definitions
Definitions
Work addiction
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Hurrying and staying busy
Need to control
Perfectionism
Difficulty with relationships
Work binges
Difficulty relaxing and
having fun
Impatience and irritability
Self-inadequacy
Self-neglect
Definitions
Burnout




the cost of working too much
1st described in 1970s
Triad
1. Emotional exhaustion
2. Negative self-esteem, depersonalization
associated w/ work
3. Loss of personal satisfaction at work (work
avoidance, unfriendly or irritable behavior,
somatic complaints)
Leads to: absenteeism, turnover, cynicism,
decreased job satisfaction, friction in personal
relationships, depression, substance abuse
Annals July 2001/CPHP 2008
Causes of Burnout
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Workload
Specialty choice
Practice setting
Patient
characteristics
Sleep deprivation
Personality type
Methods of dealing
with medical
mistakes
Malpractice suits
Lack of control over
practice
 Environment
 Problems with work-life
balance
 Rising student debt
 Increasing govt regulations
 Business aspect of
medicine
 Increase clinical demands
 Rapidly expanding
knowledge base
 Less time with patients
The Well-Being of Physicians. Am J Med 4/2003
Definitions
Compassion Fatigue

Affects caregivers only
 Not the same as “burnout”
 “A state of tension & preoccupation with
individual or cumulative trauma to clients &
manifested in one or more ways:
• Re-experiencing traumatic events of others
• Avoidance/numbing of reminders of the events
• Persistent “hyper-arousal
 “Cost
of caring too/so much”
• Many costs
• Personal Functioning
• Professional Functioning
Compassion Fatigue & PTSD


PTSD symptoms  nightmares, avoidance, on
guard, watchful, easily startled, feeling
numbed/detached, increased arousal
Many of the same symptoms as PTSD plus
• Repeated negative and disturbing thoughts
• Feeling bored and irritable; unable to focus
• Not feeling satisfied in one’s work—the energy
output and the rewards coming in don’t match
• Lack of physical, psychological and emotional
energy
• Avoidance which may lead to drastic
escape/flight measures
Personal Functioning
Cognitive
Emotional
Behavioral
Diminished concentration
Powerlessness
Clingy or withdrawn
Confusion/self-doubt
Anxiety
Impatient
Spaciness
Guilt
Irritable
Loss of meaning
Anger
Moody
Decreased self-esteem
Survivor guilt
Regression
Preoccupation w/ trauma
Shutdown
Sleep disturbances
Trauma imagery
Numbness
Appetite changes
Apathy
Fear
Hypervigilance
Rigidity
Helplessness
Hyper startle response
Disorientation
Sadness/depression
Losing things
Whirling thoughts
Hypersensitivity
Accident proneness
Thoughts of self-harm or harm
towards others
Emotional roller coaster
Use of negative coping
(smoking/substance abuse)
Perfectionism
Overwhelmed
Self-harm behaviors
Minimization
Depleted
Nightmares
Compassion Fatigue by Figley, p. 184
Personal Functioning
Spiritual
Interpersonal
Physical
Loss of purpose
Withdrawn
Shock
Questioning the meaning
of life
Decreased interest in sex
Swearing
Lack of self-satisfaction
Mistrust
Rapid heartbeat
Pervasive hopelessness
Isolation from friends
Breathing difficulties
Ennui
Projection of anger or
blame
Somatic reactions
Anger at God
Intolerance
Aches and pains
Questioning of prior
religious beliefs
Impact on parenting
(protective, concern about
aggression)
Impaired immune
system
Loneliness
Dizziness
Compassion Fatigue by Figley, p. 184
Professional Functioning
Performance of Job Tasks
Morale
Decrease in quality
Decrease in confidence
Decrease in quantity
Loss of interest
Low motivation
Dissatisfaction
Avoidance of job tasks
Negative attitude
Increase in mistakes
Apathy
Setting perfectionist standards
Demoralization
Obsession about details
Lack of appreciation
Detachment
Feelings of incompleteness
Compassion Fatigue by Figley, p. 184
Definitions
Additivity

home and work stress add to each other or when the
benefits of home and work satisfaction create greater
well-being
“Universal Vulnerability”
 Attributes which make caregiver vulnerable…same as
make them excellent caregivers
 Risk increases if…there are back-to-back “heavy”
cases or other forms of secondary trauma
 May combine with…caregivers own traumatic past
Definitions
Personal Resilience
“The strength, innate or developed, that enables one to
adapt well to extreme stress”, including the capacities
to:

•
•
•

Optimally function
Maintain sound mental health under adverse circumstances
Rebound from the deleterious effects of even overwhelming
stress
Factors
1. Age, sex
2. Social class, family dynamics
3. Social support, temperament
4. Self-efficacy, belief in God/spirituality
5. Coping skills
Dr. Glenn Schiraldi, U of Maryland
4 Qualities of Resilience
•
•
•
•
Remain relatively steady during life’s storms
Bend, but don’t break
Rebound, spring back
Become stronger in the face of adversity
OR later as a result of adversity
Three Components of Resilience
I. Healthy belief system
•
•
•
•
•
•
•
Good self-esteem
Clear thinking under pressure
Basically optimistic & hopeful
Self-confident
Realistic expectations
Flexible
Helpful philosophical/spiritual views
Adapted from the work of Glenn Schiraldi
Three Components of Resilience
II. Good emotional coping skills
•
•
•
•
•
•
Emotional self-awareness & understanding
Acceptance, use & comfort with a wide
Range of emotions
Managing upsetting emotions appropriately
Empathy skills
Relationship skills
Adapted from the work of Glenn Schiraldi
Three Components of Resilience
III. Helpful behaviors
•
•
•
•
•
•
•
•
Active coping skills
Good social skills
Healthy relationships
Participate in a supportive community
Balanced life: work, play & rest; self & others
Consistent self-care
Good personal & professional boundaries
Active religious/spiritual commitment
Adapted from the work of Glenn Schiraldi
The Role of Spirituality & Religion
in Personal Resilience

Having faith allows one to open one’s heart to
experience the sacred/holy/ divine

The response to that experience is one of awe,
reverence, thankfulness, hope, devotion and
gratitude

Allows for a healthy “New Normal”
The Benefits of Faith to
Personal Resilience
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Meaning & Purpose
Hope
Connection with others
Internal calmness—peace
Encouragement
Peace/security/sense of safety as one’s faith is lived
Values beyond the material & immediate
Perspective on suffering & evil (the long view)
Reconciliation—self, others, a “Higher Power”
Reduced fear of death
Less Anger
Why is This Important?

20 yrs ago  “burnout”  30-60% specialist and general
practitioners

Canadian National Survey 1998
 62% workload too heavy
 55% family and personal life suffer
 65% limited opportunities to change career

Self-care  rarely part of professional training and low
on the list of priorities

Denial of own emotions and needs as a survival
mechanism
The Well-Being of Physicians. Am J Med 4/2003/ CPHP 2008
Professional Ethics

AMA Council on Ethical and Judicial Affairs
 Based on Code of Medical Ethics, Medline-indexed
articles and experts

Policy of the Association 12/2003
 Promote overall physician health and wellness
 Recognizes that effective skills and patient safety are
absolute requirement in the practice of medicine
 Emphasizes continued need for forethought and
sensitivity in addressing physicians’ health and
wellness
Physician Health and Wellness. Occup Med 2006
Studies so far…
Studies so far…

Kaiser Physicians-Northwest and Ohio

80% response to survey

Factors predicting professional satisfaction, organizational
commitment, and burnout
 Sense of control over practice environment = #1
 Perceived work demands
 Social support from colleagues
 Satisfaction with resources
 Related to physician age and specialty
 Pediatricians  more satisfied
Satisfaction, commitment, and psychological well-being among HMO physicians. WJM Jan 2001
Studies so far…

304/614 completion - Wisconsin Research Network (WReN)
 Survey  family systems assessment instrument, life-events
checklist, measures of happiness, life satisfaction, emotional
functioning, assessment of relationship support, practice
stress


Open-ended question  “How do you solve dilemmas related
to your physical, emotional, and spiritual well-being?”
SPWB (Scale of Psychological Well-Being)  18 item
instrument
• well-being, self-acceptance, positive relations with other
people, autonomy, environmental mastery, purpose in life,
personal growth
A Qualitative Study of Physicians’ own wellness-promotion practices. WJM Jan 2001
Studies so far…
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5 primary wellness-promotion practices
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Relationships  involvement and spending time w/
family/friends/ colleague/community
Religion or spirituality
Self-care  reading, nutrition, exercise, counselling
Work  certain practice, limiting practice,
satisfaction/meaning
Approaches to life  being positive, balance

All correlated with increased SPWB scores

“Approaches to life”  associated with highest
level of psychological well-being
A Qualitative Study of Physicians’ own wellness-promotion practices. WJM Jan 2001
Studies so far…
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44 individuals  representative of gender, geographic
location, and practice size
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Semi-structured interview and focus groups
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Factors affecting positively and negatively the health and
well-being of GP
 low levels of remuneration
 time pressures
 unrealistic community expectations
 government interference
 effect on personal life
General practitioner health and well-being. WJM Jan 2001
Cohort study  John Hopkins SOM
1948-1964
 Predictors of NOT having a regular
source of care and association with
subsequent preventive services?


77% response  35% no RSOC
 Internist (OR 3.26), surgeons (OR
2.42), pathologist (OR 5.46) 
more likely not to have RSOC vs
pediatrician
 Inversely related to belief that
health is determined by health
professionals (OR 0.45), related
to chance (OR 1.90)

Did predict not being screened:
breast, colon, or prostate cancer,
influenza vaccine
Studies so far…
Physician, Heal Thyself? Archives November 2000
Special Concerns:
Women and Medicine
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Before 1960s, 95% physicians = M
2003 – F > M  med school applications
2010 – 1/3rd physicians
~5% department chairs, 10% dean, ~15% full professorships
Avg $22,000 or less/yr (same hours, practice setting, specialty)
All reviewers - more critical of grant proposals by F applicants
Less institutional support (funding, admin assistance)
2005 WPC (Women Physician Congress) – 49% experienced
sexual harassment in their careers
Stereotypes – conscious/unconscious  survey M med students
 30% felt F of childbearing age poses significant risk to optimal
department functioning
 ~50% agree w/ “women who spend long hours at work were
neglecting their responsibilities to home and family”
Colorado Physician Health Program 2007
Special Concerns:
Women and Medicine
F ~8.5 months vs M ~1 month  interruption to address child
care issues
 F:M 85% vs 35% change career plans to accommodate
children


F physician
 10 yr lower life expectancy vs general population
 60% more likely vs M physicians  s/sx burnout
increases significantly (1-15%) every 5 hrs over 40hrs/wk
 3-4x higher risk suicide vs WM >35 y.o. and 4x rate general
F population.
 tend to present voluntarily for help
 less likely to be sued by their patients
Colorado Physician Health Program 2007
Women Physicians’ Health Study



Satisfied
Being a
physician
Changing
Speciality
Changing
Speciality

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Being a
physician

2500 grad/year from 1950-1989
age 30-70 y.o.  4500
respondents
84% usually/almost
always/always satisfied
31% maybe/probably/definitely
not choose to be a physician
again
38% maybe, probably or
definitely prefer to change their
specialty
Age, control work environment,
work stress, h/o harassment 
independent predictors
Strongest association  work
control and career satisfaction
 OR 11.3 p<0.001
Satisfied

Career Satisfaction of US Women Physicians WPHS. Arch In Med. July 1999
Wellness Interventions
Some Myths
 “I’m
trained and therefore invulnerable.”
 “I’ve seen worse and handled it before.”
 “I’m a professional, I’m supposed to be
able to handle this.”
 “If I just follow the protocols, I’ll be OK.”
 “I’m okay – I have to be, who else is
here to help?”
 “I have to be strong and show a good
spiritual witness.”
Right Brain Interventions
Wellness Strategies
The Organization's Role

Be Value Oriented
 Promote core values of medical profession
 Involve physicians in organizing/promoting
mission
 Minimize Work-Home Interference
 Flexible and readily accessible child care
 Flexibility in scheduling and ready coverage for
life events (births, funerals, family emergencies)
Women in Medicine: Stresses and Solutions. EWJM Jan 2001
The Well-Being of Physicians. Am J Med. April 2003
The Resilient Physician. Sotile, WM.
Physician Health and Wellness. Occup Med. 2006

Promote Work-Life Balance
 Adequate vacation time
 Limit overtime expectations
 Organization sponsored seminars and retreats
 Mentoring program and periodic sabbaticals

Promote Physician Autonomy
 Increase ability to influence environment,
participation in practice decisions, flexibility
 Increase control over schedule
Women in Medicine: Stresses and Solutions. EWJM Jan 2001
The Well-Being of Physicians. Am J Med. April 2003
The Resilient Physician. Sotile, WM.
Physician Health and Wellness. Occup Med. 2006

Provide adequate Support Services
 Adequate coverage to allow time off, adequate and
coordinated nursing, secretarial, admin, social
work/chaplain support to promote efficient patient
care
 Supporting peers in identifying physicians in need
 Establish approp mechanism to detect impairment
 Intervene in a prompt and supportive fashion

Cultivate a Collegial Work Environment
 Fosters healthy relationship (retreats, team building,
social gathering, etc)
The Well-Being of Physicians. Am J Med 4/2003
Women in Medicine: Stresses and Solutions. EWJM Jan 2001
The Resilient Physician. Sotile, WM.
Wellness Strategies
Self responsibilities

Relationships
 “protecting” family time, sense of connection with colleagues,
reflect/share emotional/ existential aspects
 Categories
I – important and urgent
(pressing problems, crises, deadlines, bona fide emergencies)
II – important and not urgent
(planning, prevention, creativity, building relationships,
enjoying re-energizing leisure-time activities, maintaining
increased productivity)
III – not important and urgent
(unimportant to you but urgent to someone else)
IV – not important and not urgent
(frivolous and nonhelpful wastes of time)
The Well-Being of Physicians. Am J Med 4/2003
Women in Medicine: Stresses and Solutions. EWJM Jan 2001
The Resilient Physician. Sotile, WM.
Wellness Strategies
Self responsibilities
 Religious Beliefs/Spiritual Practice
 Personal attentiveness, nurturing of spiritual aspects
 Work attitudes
 Finding meaning in work
 Actively choosing and limiting medical practice (working parttime, medical education, research interests, managing
schedules)
 Life Philosophy
 Positive outlook, indentifying/acting on values, stressing
balance between personal/professional life
 Self-Care Practices
 Cultivating personal interests (reading, exercise, selfexpression activities, adequate sleep, nutrition), seeking
professional help (personal physical or psychologic illness,
medical care)
The Well-Being of Physicians. Am J Med 4/2003
Women in Medicine: Stresses and Solutions. EWJM Jan 2001
The Resilient Physician. Sotile, WM.
Intervention examples…
Intervention examples…
 DGIM UCali San Fran – 2 hr/month since 1996 (residents,
faculty)  avg group 6-37/session
 Existential and spiritual themes

difficult patients, balancing personal/professional
responsibilities, medical mistakes, professional competence,
grief, role playing, journal, literature/art, anger, boundaries,
compassion, fear, refuge, unmet patient needs, “wounded
healer”
 >70% attended at least 1 session
 Strengthen personal and professional identity
 Increased sense of connectedness with colleagues
 Specific practice techniques
 Maintaining balance and promoting well-being
Doctoring to Heal. EWJM Jan 2001
Intervention examples…

Hill Physicians  largest IPA (Independent Practice
Association ) 2,200 Northern California gen and specialty
physicians

14 hour “Finding Balance in Medical Life”
 Physicians/significant others  50/session  Napa Valley,
$400/spouses free
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Understanding stresses of a medical practice and how it
diminishes productivity
Adverse health ramification of stress
Learning/evaluating how personality traits contribute to
stresses
Learning tools for managing emotional stress
Tools and practices to enhance communication skills
Evaluation of individual personality structure
Engendering and Marketing Physician Wellness. GPJ Oct 2004
Intervention examples…
Medical Board of California

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Mentor program  career development and balancing
personal/professional lives
Confidential support groups monthly
Annual well-being retreat on company time
Fitness center membership
Contractual requirement for own PCP
Sabbatical program
COM program on well-being
Flexible scheduling
Limits to wellness interventions
1. Reluctance to confront colleagues and refer
them to appropriate resources
2. Incur licensure actions, shame, or
stigmatization
3. Reluctance to think of themselves as needing
help
4. Inadequate standards to indentify signs of
need, difficulty in ascertaining with confidence
this need and available resources
5. ?mandatory disclosure about own personal
medical information
Physician Health and Wellness. Occup Med 2006
In Summary…
1.
2.
3.
Provider wellness should be a vital part of medical training
and practices.
Needs more time, energy, education, and financial
commitment to make this happen.
Do what you tell your patients to do:
• Practice behaving in harmony with your decision
• Take care of your physical self (engage in physical
activity throughout the day)
• Eat healthy
• Live according to your values
• Express your feelings
• Engage in self-awareness activities
• Protect your relationships
Readings

Broyard A. Intoxicated by My Illness. 1992
 Frankl V. Man’s Search for Meaning. 1985
 Harper R. On Presence. 1991
 Remen RN. Kitchen Table Wisdom. 1996
 Roberts, SB. Disaster Spiritual Care. 2008.
 Williams WC. The Doctor Stories. 1984
Resources

CPHP (Colorado Physician Health Program)
899 Logan St., Suite 410
Denver, CO 80203
303-860-0122 phone 303-860-7426 fax
Monday – Friday 8:30 am. – 4:30 pm.

FSPHP (Federation of State Physician Health Programs)
Michele Norbeck, Ex Director, (239) 877-7305
Vickie Grosso, Staff Assistant, (312) 464-4574.

CPEP (Center for Personalized Education for Physicians)
 in-depth evaluation is tailored to the physician’s specialty and
practice, and provides detailed information about clinical
competence in the areas of medical knowledge, clinical reasoning,
documentation, communications, and cognitive function—while also
identifying areas of educational need
Bibliography
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Barron, V et al. “Engendering and Marketing Physician Wellness: Creating a
Healthier Delivery System.” Group Practice Journal. October 2004.
J. Day, E. Vermilyea, J. Wilkerson and E. Giller. Risking Connections in Faith
Communities. Sidran Press, 2006.
George Everly Jr. and James Reese. Psychological Body Armor. Chevron
Publishing,2007.
Charles Figley. Compassion Fatigue: Secondary Traumatic Stress Disorders
In Those Who Treat the Traumatized. Routledge, 1995.
Frank, et al. “Career Satisfaction of US Women Physicians.” Arch Intern Med.
159;1417-1426. July 1999.
Freeborn, DK. “Satisfaction, commitment, and psychological well-being among
HMO physicians.” Western Journal of Medicine (WJM). 174;14-18.
January 2001.
Gautman, M. “Women in medicine: stresses and solutions.” WJM. 174;37-41.
January, 2001
Gendel, MH. “Physician work stress Part I/II.” CPHP website
Gross, CP et al. “Physician, Heal Thyself?” Arch Intern Med. 160;3209-321.
November 2000.
Gundersen, DC. “Women in Medicine.” CPHP Newsletter.
Gundersen, L. “Physician Burnout.” Annals Int Med. 135;145-148. July 2001.
Hartwig, E et al. “General practitioner health and well-being.” WJM. 174;25.
January 2007
Bibliography
 Myers, MF et al. “The well-being of physician relationships.” WJM. 174;3033. January 2001.
 Schiraldi, Glen. Post-Traumatic Stress Disorder Sourcebook. Chevron Pub,
2000.
 Shanafelt, TD et al. “The well-being of physicians.” Am J Medicine. 114;513519. April 2003.
 Shanafelt, TD et al. “Relationship between increased personal well-being and
enhanced empathy among internal medicine residents.” JGIM. 559-564.
January 2005.
 Spickard, A et al. “Mid-Career Burnout in Generalist and Specialist Physicians.”
JAMA. 288;1447-1450. September 2002.
 Stamm, B. Hudnall Ed. Secondary Traumatic Stress: Self-Care Issues for
Clinicians,
Researchers, and Educators, 2nd Ed. Chevron Pub,1999.
 Steinbrook, R. “Medical Student Debt – Is There a Limit?” NEJM. 359;26292637.
Dec 2008.
 Suchman, AL. “The influence of health care organizations on well-being.” WJM.
174;43- 47. January 2001.
 Taub, S et al. “Physician health and wellness.” Occup Med. 56;77-82. 2006.
 Weiner, EL et al. “A qualitative study of physicians’ won wellness-promotion
practices.” WJM. 174;19-23. January 2001.
 Visionary Productions Inc. Compassion Fatique: The Stress of Caring Too Much.
PBS Satellite Video Conference June 23, 1994.