Listening so we can HEAR, talking so we can be HEARD or how to avoid burnout at work

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Listening so we can HEAR, talking so we can be
HEARD (or how to avoid burn-out at work ?)

• Coleen Kivlahan, MD, MSPH
• CMO Aetna Medicaid Programs

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INTRODUCTIONS
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A way to start this morning

• Our initial focus is to take a look at our
  patients and our work environments and why they
  cause us STRESS
• Then we will take an inward look at ourselves,
  understanding more about our own beliefs, biases,
  frustrations in our professional roles.
• Finally we will take a BIG outward look -- how WE
  interact with others around us, our patients,
  other staff.
• Not only can we understand our patients and our
  coworkers better, we can export these lessons to
  our other relationships. People who are happier
  at home tend to be happier and more productive at
  work and vice versa.
• GOAL FOR TODAY increase our curiosity!!

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ONLY RULES ARE

• Being true to what you believe
• Trusting each other as colleagues
• Not judging others
• Keeping an open heart and mind

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List YOUR frustrations with your clinic or our
patients

• Ok, I will start
• People do not call before they cancel or no show
• Our patients do not bring in their glucose
  records
• There is no privacy here
• People do not care about their health in the way
  I would like them to

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What do we believe about our patients?

• Lifestyles?
• Choices?
• Behaviors?
• Priorities?
• Educational status?
• Poverty status?
• Life outside the clinic for them?

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FACTS
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Poverty reality

• Increased mortality (more poor people die)
• Severity of illness (more poor people are sicker)
• Violence Exposure (more poor people commit and
  are victims of violence)
• Less health insurance (more poor people have no
  source of care except ER)
• Competing priorities (housing, transportation,
  food)
• Medication difficulties (access, schedule,
  disease complexity)
• Health care provider reactions (many doctors do
  not take Medicaid and do not care for the
  uninsured they have biases that lead to
  provision of poor care)  

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Shelter and poverty

• Federal minimum wage was raised to 6.55 in July
  08.
• Minimum wage earners cant afford 1-BR rental
  unit anywhere in U.S.  
• Nationally, the housing wage for a 2-BR rental
  unit is 16.31/hour almost three times federal
  minimum wage and rising at twice the rate of
  inflation. In Washington DC, 24.73/hour is
  needed to rent a 2BDR apt
• On average, 2.5 full time jobs per household are
  needed to afford a 2-BR unit at fair market
  rental rate. (2007 data)

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Cross-cultural Facts

• For many of our patients
• Faith and prayer is a method of healing
• They see local and herbal healers at the same
  time they see us
• Believe in supernatural forces that hurt or
  heal/voodoo
• Believe in fate or the will of God
• Believe their families should be involved in all
  decisions
• Believe foods or weather cause disease
• Believe that hospitals kill people
• Believe that the ER is better quality care

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DIVING UNDER THE FACTS

• Exploring what is known and unknown in our
  patients histories

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Case presentations what is KNOWN, what is
UNKNOWN?

• 1) 29 year old Egyptian woman working at airport
  with erratically controlled Type I DM. Thin,
  attentive, bright, brings med and glucose
  readings, food diary. Anxious.
• Unknown Hx of pituitary adenoma on
  bromocriptine. Wants to be pregnant, married to
  her first cousin, only working member of family
• 2) 44 year old Latina with uncontrolled Type II
  DM and obesity.
• Unknown She will not take glipizide because she
  believes it makes her gain weight, but tells the
  nurse she takes all her meds, uses Advil PM to
  sleep. Only son died in MVA in December.
• 3) 45 year old El Salvadoran normal weight woman
  with uncontrolled HTN on 4 meds.
• Unknown 20 year old son in wheelchair with CP
  and psychosis she is unemployed after 16 years
  at KMart because she is sole caregiver for
  children
• 4) 56 year old Ethiopian man with HTN and angina.
  
• Unknown In Ethiopian army, translator for US
  military, now in US and wife filed restraining
  order against him for DV. He tells me that women
  are supposed to be quiet and take care of men.
  He cannot understand that after 30 years of
  marriage his wife seems angry all the time.

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WHAT IS THE REALITY ABOUT GOING TO THE DOCTOR/APN
WHEN YOU HAVE CHRONIC ILLNESSES?

• Scared and afraid
• Confusing
• Nervous
• Angry
• Chronic pain
• Denial
• Bad news

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What is

• KNOWN
• Afraid
• Not being fully truthful or revealing
• Guilt or shame
• Hopeless or helpless
• Angry
• In pain
• Confused

• UNKNOWN
• Afraid of WHAT? (us, their diseases, family
  beliefs, dying)
• What prior health care experiences lead them to
  be not fully revealing
• Shame about what? (family secrets, being
  immigrant or different, being sick or helpless)
• Angry about what?

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PATIENT CHALLENGES

• Poverty is associated with factors that increase
  health care utilization and reduce adherence to
  medical regimens
• There are unique driving forces in poverty
• Relationships
• Survival
• Entertainment
• UNDERLYING FORCES
• Food
• Time
• Power/self-management
• Destiny

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PATIENT PATTERNS

• Focus on survival and crises can increase no
  show rates
• Focus on relationship can increase lack of trust
  in authority
• Focus on destiny can lead to poor self-management
• Focus on entertainment can increase the
  likelihood that YOUR goals and the patients are
  not in alignment, not shared
• Focus on family and time can increase likelihood
  of not doing effective self-management, self-care

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10 RULES for serving low-income, language-diverse
populations

• 1) create a relationship
• 2) focus on the people
• 3) reduce the words
• 4) emphasize action
• 5) invite and involve the whole family
• 6) choose accessible, comfortable program sites
  to reach where THEY are
• 7) choose appropriate times
• 8) feature small group activities
• 9) choose an appropriate length of activities
• 10) spend money on supplies, not paper for
  education
• (Language Sensitive Health EducationLessons from
  the Field California Journal of Health
  Promotion, June 2003 1(2) 312)

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Tips for Staying Healthy A Lifestyle/Medical
Approach

• Dont have poor parents.
• Dont live in a poor neighborhood.
• Practice not losing your job and dont become
  unemployed.
• Dont be illiterate.
• Dont be poor. If you can, stop. If you cant,
  try not to be poor for too long. (CDC)

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So WHY are you here?

• A job?
• A passion?
• Guilt?
• Care?
• Faith?
• Boredom?
• Commitment?

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Burnout

• It is a stress syndrome, felt as emotional
  exhaustion.
• Its parameters often have
• somatic (exhaustion, insomnia, GI symptoms, rapid
  breath)
• emotional (sadness and depressed mood,
  negativism, decreased creativity and increased
  cynicism)
• interpersonal manifestations (quickness to anger,
  defensiveness, edgy and ready to blame others,
  and a negative world -view)
• It is often correlated with the process of grief,
  as a work-life dream is lost.
• Depersonalization of patients and distancing
  develop in patient/staff relations and
  disorganization and ineffectiveness increase.

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Burnout, cont

• People suffering from burnout seem to
  progressively feel a lack of personal
  accomplishment in their work.
• Patients are apparently less satisfied when
  receiving care from burned-out physicians and
  health professionals.
• Staff are less committed and less contributory to
  the continuing success of the practice.
• As the burnout-process progresses burning out
  providers prefer to decrease contact with
  patients/staff, become less respectful listeners,
  behave irritably, order more tests, refer
  patients to others and plan to leave patient care
  as early as possible.

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Causes??

• No single factor causes individual burnout
• BUT, the question Is your personal identity
  bound up with your work role or professional
  identity? is HIGHLY correlated
• Merging personal identity with professional
  identity blends professional and non-work roles,
  usually subverting non-work.

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Burnout Risk Survey

• Are your achievements your self-esteem?
• Do you tend to withdraw from offers of support?
• Will you ask for/accept help?
• Do you often make excuses, like, Its faster to
  do it myself than to show or tell someone?
• Do you always prefer to work alone?
• Do you have a close confidant with whom you feel
  safe discussing problems?
• Do you externalize blame?
• Are your work relationships asymmetrical? Are you
  always giving?
• Is your personal identity bound up with your work
  role or professional identity?
• Do you value commitments to yourself to
  exercise/relax as much as you value those you
  make to others?
• Do you often overload yourselfhave a difficult
  time saying no?
• Do you have few opportunities for positive and
  timely feedback outside of your work role?
• Do you abide by the laws Dont talk, dont
  trust, dont feel?
• Do you easily feel frustrated, sad or angry from
  your regular work tasks?
• Is it hard for you to easily establish warmth
  with your peers and/or service (patients/clients)
  recipients?
• Do you feel guilty when you play or rest?
• Do you get almost all of your needs met by
  helping others?
• Do you put others needs before or above your own
  needs?
• Do you often put aside your own needs when
  someone else needs help?

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Predictors of work stress

• Demands of solo practice, long work hours, time
  pressure, and complex patients
• Lack of control over schedules, pace of work, and
  interruptions
• Lack of support for work/life balance from
  colleagues and/or spouse
• Isolation due to gender or cultural differences
• Work overload and its effect on home life

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BIG risks

• At risk earlier in career
• Lack of Life-partner
• Attribution of achievement to chance or others
  rather than ones own abilities
• Passive, defensive approach to stress
• Lack of involvement in daily activities
• Lack of sense of control over events
• Not open to change

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Signs

• Stress Arousal anxiety, irritability,
  hypertension, bruxism, insomnia, palpitations,
  forgetfulness, and headaches.
• Energy Conservation Work tardiness,
  procrastination, resentment, morning fatigue,
  social withdrawal, increased alcohol or caffeine
  consumption, and apathy.
• Exhaustion Chronic sadness, depression, chronic
  heartburn, diarrhea, constipation, chronic mental
  and physical fatigue, the desire to drop out of
  society.

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Adaptations and Consequences

• Longer Work hours If I work harder, it will get
  better.
• Withdrawal, absenteeism, and reduced
  productivity.
• Depersonalization attempt to create distance
  between self and patients/trainees by ignoring
  the qualities that make them unique individuals.
• Loss of professional boundaries leading to
  inappropriate relationships with
  patients/trainees.
• Compromised patient care.

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Maslach Burnout Inventory(CPP, Inc)

• Designed for use in health care and other service
  industries.
• Evaluates emotional exhaustion,
  depersonalization, and reduced personal
  accomplishment.
• Well-validated readily available utilized by
  Physician Worklife Study.
• 10-15 minutes to complete.
• Cost approximately 1.25 per test, with
  additional fee for scoring key.

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Self Assessment Exercise(Girdin, 1996)

• How often do you . . .a) almost always b) often
  c) seldom d) almost never
• find yourself with insufficient time to do things
  you really enjoy?
• wish you had more support/assistance?
• lack sufficient time to complete your work most
  effectively?
• have difficulty falling asleep because you have
  too much on your mind?
• feel people simply expect too much of you?
• feel overwhelmed?
• find yourself becoming forgetful or indecisive
  because you have too much on your mind?
• consider yourself in a high pressure situation?
• feel you have too much responsibility for one
  person?
• feel exhausted at the end of the day?
• Calculate your total score a) 4, b) 3, c)
  2, d) 1.
• A total of 25-40 indicates a high stress level
  that could be psychologically or physically
  debilitating.

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Additive stressors

• Despite the notion that burnout is primarily
  linked to work-related stress, personal life
  events also demonstrated a strong relationship to
  increased professional burnout
• In spite of achieving career and financial
  success, health professionals are stressed and
  overworked, often losing sight of their career
  goals and personal ambitions. The resulting
  frustration, anger, restlessness, and exhaustion
  adversely affect the quality and costs of patient
  care.
• Additional dangers include compassion
  fatigue/burnout and vicarious post-traumatic
  stress disorder in health care settings,
  especially Medicaid and the uninsured.

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BIO-BREAK? ?
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RESULT?

• WE get frustrated and can give up
• WE begin to believe that our patients are
  non-compliant and they do not value our work,
  we get angry at them or each other
• WE get lost in the complexity of THEIR lives
• WE make assumptions about their choices and their
  behaviors
• WE cannot prioritize what works, what is truly
  impactful action
• WE implement punitive policies, like three
  strikes, can occur
• Burnout can occur for all of us

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COUNTERPRODUCTIVE STRATEGIES

• Our assumptions are wrong at least 50 of the
  time?
• Scare tactics rarely work for any of us
• Punitive approaches to patient accountability
  have been shown to be just that punitive for all
  of us
• Yelling at or arguing with patients
• Belittling or shaming them
• Implying they are bad because they did not
  bring glucose monitors, meds or were not
  compliant
• Rushing people through complex processes
• Three strikes policies

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How do we keep the joy and wonder in everyday
practice?

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OUR TASKS

• Resist depersonalizing our patients
• Practice empathy
• Walk in their shoes ask What can I do for you
  TODAY?
• Hold them and yourself accountable for what we
  CAN do
• STOP talking and listen
• Ask patient to repeat your instructions to
  clarify understanding
• Take a BREAK or talk to other staff after clinic
• Most importantly, Stay curious

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IS THIS POSSIBLE?

• YOU BET!
• Our members/patients deserve our best work
• We can innovate and measure results
• We can focus on the whole person, not their
  disease or collection of diseases
• We can focus on slow and steady steps toward
  goals, with patients priorities as 1
• We can speak up when things are not working and
  volunteer to fix it!

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PROFESSIONAL BURNOUT REDUCTION STRATEGIES

• Curiosity
• Respect (from the Latin respecere to LOOK
  again)
• Adventure (Excitement about the chance to get
  inside the cultures and beliefs of our patients)
• Risk-taking
• Flexibility
• Perspective

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CURIOSITY

• WONDER WHY? Why is she angry, why is he
  uncontrolled on his meds, why is this not
  working, why am I so engaged/attached?
• STAY OPEN to learning more, laughing more

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RESPECTrespectful deference includes being
honest with our patients, showing respect for
their beliefs and culture AND decisions giving
information so they can make decisions
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ADVENTUREif we cannot get excited about
learning about other countries, other cultures,
other people and ourselves, it is time to get
help or get out
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RISK-TAKINGvolunteer for a new role take a
risk with patients, tell them the truth, kindly
and with best intent be fully present and do not
assume you have ANYTHING to offer except your
skills tell your boss that workload, time
pressure or role conflicts are problems
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FLEXIBILITYconsider new ways of doing your
current job take some time off talk to
colleagues new schedules/workloads learn new
skills like mindfulness and meditation
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PERSPECTIVE the PATIENT is the one with the
problem balance empathy and connection with
distance GET A LIFE ? try seeing BOTH the
sacredness of what we do and the small impact we
actually ever make on others lives
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LEARN

• Listen with understanding to the patient's
  perception of the problem
• Explain your perceptions of the problem and your
  strategy for treatment
• Acknowledge and discuss the differences and
  similarities between these perceptions
• Recommend treatment while remembering the
  patient's cultural parameters
• Negotiate agreement. Understand the patient's
  explanatory model so medical treatment fits in
  cultural framework
• (Berlin EA, Fowkes WC.1983) 

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Cultural Humility vs Competence

• Humility demands that we self-evaluate how our
  personal biases may affect care delivery
• Humility changes the power imbalances in
  patient-provider dynamic
• We become more aware of who uses, and who needs
  our services
• We are always learning, every day. We STAY
  CURIOUS.
• The two important paths to cultural competency
  development are self-reflection about ones
  cultural identity and beliefs, and experiences
  with cross-cultural encounters.

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WATCH OUR LANGUAGEA 72 year old lady who falls
and breaks her hip while sweeping her steps

• You shouldnt be sweeping steps at your age
• You need to hire someone to do that for you
• Cant your son help you out?
• Stop worrying about cleaning, lets take care of
  your hip, Dear
• For many people, it can be very scary to break a
  bone I wonder what it is like for you? What does
  this mean for you?

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ADHERENCE

• We know it as Compliance-the obedience of
  patient in following our orders
• By using the word compliant, we assume a power
  differential between us and the patient that
  erodes trust WE are the doctor, YOU are NOT! We
  know your body better than YOU do. We know what
  is RIGHT for you. If you would JUST do what we
  say, you would be better now.
• Adherence relies on RELATIONSHIP, TRUST,
  INFORMATION, CHOICE, ACCEPTANCE
• Adherence implies consensus, a joint or shared
  responsibility to the goals we select together
• It is an ongoing negotiation!

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Active Listening

• Attend and observe
• Resist internal distractions
• Suspend judgment
• Reflect on the content, feeling and meaning of
  what you hear
• Respond as best as you can
• Youre saying ___________. 

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Four types of protective voices

• People need to have to ensure that they have
  access to voices that provide
• Balance (family, partner, hobbies)
• Perspective (humor, distance, silliness)
• Growth (learning, training)
• Challenge (new roles, new work, confront
  imbalance)
• Physicians, nurses, and allied health
  professionals can formulate a personally-designed
  self-care protocol for themselves.
• Overcoming Secondary Stress in Medical and
  Nursing Practice A Guide to Professional
  Resilience and Personal Well-Being by Robert J.
  Wicks offers an extensive bibliography of recent
  research, clinical papers, and books on
  medical-nursing practice and secondary stress.

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Homeless (AND the uninsured) people are the sum
total of our dreams, policies, intentions,
errors, omissions, cruelties, and kindnesses as a
society. (Peter Marin, sociologist) 
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THANK YOU ALL