Jane Lemaire MD and Jean Wallace PhD
William Ghali MD
Health of the Health Professional Conference
Auckland, New Zealand, November 2011
*To increase awareness of the link between
physician wellness and effective health care
systems
“Wellness goes beyond
merely the absence of
distress and includes being
challenged, thriving, and
achieving success in various
aspects of personal and
professional life”
(Shanafelt et al 2003)
“I think quality of life is
being happy both in your
work and your home,
….being allowed to do
what you enjoy to do in
both places, to the quality
and standards to which you
want to do them.”
Lemaire JB, Wallace JE. Well Doc? What constitutes quality of life for physicians? Can J of Gen Int
Med 2009;4:234-36.
*Physicians are at risk for being unwell
*Physicians pay suboptimal attention to self-wellness
*Unwell physicians negatively affect health-care systems
*Physician wellness as an indicator of health-system
quality?
Outline
Wallace JE, Lemaire JB, Ghali WA. Physician Wellness: A Missing Quality Indicator.
Lancet. 2009;374:1714-1721.
*Workload
*Long hours
*Emotional and cognitive
demands
*Frequent systems change
*Emotional exhaustion
*Reduced sense of
accomplishment
*Cynicism
*Inefficacy
*Individual factors
*Profession–related
factors
*Workplace factors
Determinants of Physician Well Being
All physicians within the Calgary Health
Region
Stage One:
Prepared by
Jean E. Wallace
Jane Lemaire
Alyssa Jovanovic
• Physician interviews (N=42)
• Physician job observations (N=44)
• Spouse interviews (N=32)
Stage Two:
• Survey to all physicians in the CHR
• Received 1178 surveys (40% RR)
Jean E Wallace, Jane Lemaire, William Ghali,
Dave Megran, Todd Watkins, Maeve Obeirne,
Alyssa Borkosky
Prepared for the Alberta Heritage Foundation for Medical Research
and the Calgary Health Region
Individual barrier
Lack of Personal Interest Affects my Ability
to Improve my own Health and Well Being
40
% Responses
30
20
10
0
Not Important at All
Not Very Important
Somewhat Important
Very Important
Source: 2009 Determinants of Physician Well Being: Stage Two Report (n=1178)
Individual barrier
Doctors are often Triggered to Seek Medical
Help only after a Significant Physical or
Emotional Event
61
60
% of Responses
50
40
29
30
20
8
10
0
.5
Strongly Disagree
2
Disagree
Neutral
Agree
Strongly Agree
Source: 2009 Determinants of Physician Well Being: Stage Two Report (n=1178)
Coping strategies:
Major themes extracted from the interviews
(n=42)
Coping strategies while at work
Coping strategies outside of work
Deal with stress/work through it
Exercise
Talk with co-workers
Have some quiet time
Take a time out
Talk with spouse
Use humor
Spend time with family
Ignore or deny the stress
Leave work at work
Source: 2008 Determinants of Physician Well Being: Stage One Report
“Usually denial. I just put it on the back burner and just go on ‘cause
you know, if you get too stressed out then you can’t function
and so I usually just suppress it. That’s my coping mechanism at work.”
Source: 2008 Determinants of Physician Well Being: Stage One Report
Frequency of use of coping strategies
100
Most of the Time
Often
Sometimes
% of Responses
80
60
40
20
0
Concentrate Make a plan
on what to do
of action
next
Use humour
to lighten
situation
Keep it to
myself
Talk with
colleagues
Go on as
nothing has
happened
Take a time
out
Lemaire JB, Wallace JE. Not all coping strategies are created equal: a mixed methods study
exploring physicians’ self reported coping strategies. BMC Health Serv Res. 2010;10:208.
*Culture of medicine
*Conspiracy of silence
Profession-related barrier
Profession-related barrier
Negative Peer Pressure Affects my Ability
to Improve my own Health and Well Being
42
40
% of Responses
33
30
21
20
10
4
0
Not Important at All Not Very Important Somewhat Important
Very Important
Source: 2009 Determinants of Physician Well Being: Stage Two Report (n=1178)
“But I’m not sure that the
link between their own
health and patient care is
probably very clear.
Because you can’t believe
that right? You can’t
believe if you’re having a
bad day that you’re going
to provide poor patient
care ‘cause that’s just not
what you do.”
Prepared by
Jean E. Wallace
Jane Lemaire
Alyssa Jovanovic
Prepared for the Alberta Heritage Foundation for Medical Research
and the Calgary Health Region
Wallace JE, Lemaire JB. Physician well being and quality of patient care: an exploratory
study of the missing link. Psychol Health Med. 2009;14:545-52.
“I‘ve been running since 7
o’clock this morning. I have
not had a break for lunch. I’m
happy if I get time to go to the
bathroom during a busy
day… if I’m lucky I’m eating
on the run, like literally, like
going up the elevators, going
down the stairs eating
something… which is not
healthy, but that’s the nature
of my day.”
bookcase
tractor
fork
kitten
towel
letter
computer
stapler
bookcase
tractor
fork
kitten
towel
letter
computer
stapler
appointment
novel
pig
glass
portrait
light bulb
eraser
church
appointment
novel
pig
glass
portrait
light bulb
eraser
church
table
cloud
intersection
blood
mask
banana
bed
prairie
table
cloud
intersection
blood
mask
banana
bed
prairie
Frequency of stressful work environment characteristics
Most of the Time
100
Often
Sometimes
% of Responses
80
60
40
20
0
A high level A high sense
of activity
of urgency
Little time
A lot of
Little time
for a snack interruptions for bathroom
A lot of
clutter
Source: 2009 Determinants
of Physician Well-Being: Stage Two Report (n=1178)
*Indicates a statistically significant difference by specialty (p<.05)
A lot of noise
Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet.
2009;374:1714-1721.
*How do we move forward and
develop a more contemporary
and holistic measure of
physician health and well-being
as it relates to individual
doctors, the medical profession
and health care systems?
Department of Medicine
Well Doc? Module 1
Physician nutrition and cognition
during work hours:
Effect of a nutrition based intervention
Jane Lemaire MD
Jean E. Wallace PhD
Kelly Dinsmore MSc
Adriane M. Lewin MSc
William A. Ghali MD MPH
Delia Roberts PhD
Barriers to nutrition during
the work day
Lack of time
N=15
Limited access to nutrition and
water and/or convenience
N=14
Limited food choices
Work ethic
N=10
N=7
Professionalism and doctors’
attitudes
N=5
Cost
N=3
Lemaire JB, Wallace JE, Dinsmore K, Roberts D. Food for thought: an exploratory
study of how physicians experience poor workplace nutrition. Nutr J. 2011;10:18.
Inadequate nutrition:
Impact on physicians
Emotional symptoms (irritable, frustrated)
N=18
Physical symptoms (tired, hungry,
nauseated)
Cognitive symptoms (can’t focus or think
clearly)
Negative impact on ability to complete
work
Negative impact on interactions with
colleagues
N=17
N=13
N=9
N=7
Lemaire JB, Wallace JE, Dinsmore K, Roberts D. Food for thought: an exploratory
study of how physicians experience poor workplace nutrition. Nutr J. 2011;10:18.
Nutrition and cognition
Lemaire JB, Wallace JE, Dinsmore Kelly, Lewin Adriane, Ghali WA,
Roberts Delia. Physician nutrition and cognition during work hours: effect
of a nutrition based intervention. BMC Health Serv Res. 2010;10:241.
Mean blood glucose (mmol/L)
Mean Glucose
7.0
Baseline
6.5
Intervention
6.0
5.5
5.0
4.5
4.0
07
3
00
9
0
0-
09
3
30
1
1
1-
11
3
30
3
1
1-
13
3
30
5
1
1-
15
3
00
8
1
1-
19
3
00
2
2
0-
22
0
00
1
0
1-
01
0
00
4
0
1-
On intervention day…
Glucose was lower and less variable
Less hypoglycemic symptoms were reported
04
0
29
7
0
1-
Cognition
Baseline
Intervention
p-value
Mean Tput score (SD)
210 (32)
220 (32)
0.003
Mean reaction time in
msec (SD)
293 (52)
279 (55)
0.03
Mean Tput score (SD)
85 (17)
92 (20)
<0.001
Mean reaction time in
msec (SD)
630 (82)
609 (95)
<0.001
Simple reaction time
test
Complex reaction time
test
On intervention day…
Cognition was superior
Knowledge translation

Practical ideas
Make work place nutrition a requirement!
 Role model nutrition breaks
 Raise awareness about the warning signs
and symptoms of lack of nutrition
 Educate your colleagues

Lemaire JB, Wallace JE, Dinsmore K, Roberts D; Nutrition: In A practical
handbook for physician health and well-being: The Royal College of
Physicians and Surgeons of Canada CanMEDS physician health guide. ed
Puddester D, Flynn L, Cohen J. Ottawa 2009.
Well Doc? Module 2
The effect of a portable biofeedback tool
on physician stress
Jane B Lemaire MD
Jean E Wallace PhD
Adriane M Lewin MSc
Jill de Grood MA
Jeffrey P Schaefer MD
Department of Medicine
Study flow chart
Interview
Measures
Stress:
Physicians’ perceptions of how unpredictable,
uncontrollable and overloaded they find their
lives
• Response Set: Never (0), Almost Never (1),
Sometimes (2), Often (3), Very often (4), Always (5)
• Maximum score 200 (40 items)
Heart rate variability
Lemaire JB, Wallace JE, Lewin AM, de Grood J, Schaefer JP. The effect of
a biofeedback-based stress management tool on physician stress: a
randomized controlled clinical trial. Open Med. 2011;5(4):e154–e163.
Mean stress score and stress score change over
days 0-28 by group (RCT)
Stress score baseline
Stress score day 28
Stress score change
P-value for
within-group difference
Control
Intervention
Mean (SD)
74.1 (24.5)
69.8 (26.6)
-2.2 (8.4)
Mean (SD)
81.3 (29.5)
65.0 (26.6)
-14.7 (23.8)
0.3
0.01
* Between-group difference.
p-value*
0.4
0.6
0.05
Individual stress score changes
over days 0-28 by group
Control
Intervention
75
75
50
50
25
25
0
0
-25
-25
10/17 (59%)
Ba
se
l
D
ay
Ba
se
l
28
15/20 (75%)
D
ay
-75
in
e
-75
28
-50
in
e
-50
Mean stress score and stress score change
over days 28-56 for control group
Control
Stress score day 28
Stress score day 56
Stress score change
P-value
Mean (SD)
69.8 (26.6)
61.3 ( 25.1)
-8.5 (7.6)
0.0002
Is there effect without reinforcement?
*Physicians are at risk for being unwell
*Physicians pay suboptimal attention to selfwellness
*Unwell physicians negatively affect healthcare systems
*Physician wellness as an indicator of
health-system quality?
Summary
Workplace stressors
-Workload
-Work hours
-Fatigue
-Cognitive demands
-Changes to practice
Contextual factors
-Confidentiality issues
-Licensing board responses
-Culture of medicine
-Health-systems failure to
provide wellness resources
Physician outcomes
-Stress, burnout
-Depression
-Relationship issues
-Substance abuse
-Risk of suicide
Physician characteristics
-Indifference and neglect of self-care
-Coping by denial and avoidance
-Conspiracy of silence
-Predisposing personality traits
Health-system outcomes
-Recruitment and retention
issues
-Lowered productivity and
efficiency
-Suboptimal quality of patient
care
-Reduced patient adherence
and satisfaction
-Increased risk of medical
errors
Potential interventions
Workplace and profession
awareness, management
and prevention
Physician self-care
and prevention
Physician treatment
and recovery
Improved patient care
and system outcomes
*Promote dialogue among key stakeholders
*Increase awareness of the importance of physician
wellness
*Consider the components of a physician wellness quality
indicator
*Develop an assessment approach
*Continue to develop interventions and study their
impact