PHYSICIAN WELLNESS

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PHYSICIAN WELLNESS BURNOUT

• (Adapted with permission from ACEP)

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The best interests of patients are served
when emergency physicians practice in a fair,
equitable and supportive environment
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Why is Wellbeing important?

• Happiness and satisfaction Career longevity
• Reasons for Concern
• Burnout Studies
• Substance Abuse Data
• Attrition Rate

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Wellness and the Emergency Physician

• Major Stressors
• Diminished Resources
• Difficult Patients
• Difficult Decisions
• Life in the fish bowl
• Isolation
• Single coverage practices
• Rural practices
• Perceived lack of control

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Coping Techniques Wellness Strategies

• Essential we learn these
• Wellness in the professional environment
• Wellness in personal life
• Close family and social relationships
• Physical fitness
• Methods of relaxation and renewal

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The foundation of wellness is Attitude

• Service commitment
• Vocation - being a healer and helper

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The accomplishment of wellness is time management

• Balancing
• Prioritizing

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Wellness and the Emergency Physician

• Typical Physician Profile
• Perfectionistic
• Driven to succeed
• Willing to work long and irregular hours
• Ideals of individual service and sacrifice

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Personality and genetics

• Adaptation
• Know yourself
• know and accept your limits
• denial does not work
• Expectation vs being realistic
• Type A

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Satisfactions and Joys

• Making a difference
• Teamwork
• Focus on and value these

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Stress is inevitable - its unmanaged consequences
are

• Burnout
• Impairment

Managing ones own stresses is the toughest part
of practicing medicine. Dr. Oscar London
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Burnout

• Feelings of job dissatisfaction due to
  work-related stress
• Three components
• Depersonalization
• Diminished sense of achievement
• Emotional exhaustion

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Stress Exceed Resources

• Maladaptive coping mechanisms
• Responses
• Physical Emotional Illness

• Adaptive coping mechanisms
• balance restored
• responses resolved

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Burnout Severity

• First degree failure to keep up and gradual loss
  of reality
• Second degree accelerated physical and emotional
  deterioration
• Third degree major physical and psychological
  breakdown

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Burnout effects on patient care

• Samkoff and Jacques
• All revealed deleterious effects on mood and
  attitude
• More errors on repetitive tasks
• Deterioration in performance tests requiring
  prolonged vigilance

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Burnout and the Emergency Physician

• Keller and Koenig (1989)
• Surveyed 77 Emergency Physicians
• 60 Medium to High Emotional Exhaustion
• 70 Medium to High Depersonalization
• 34 Low Levels of Personal Achievement

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Burnout and the Emergency Physician

• Gallery (1992)
• Surveyed 763 Emergency Physicians
• 12.4 were likely to leave specialty in one year
• 27 were likely to leave in five years
• 57 planned to leave specialty in ten years

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Burnout and the Emergency Physician

• Goldberg et al (1996)
• Administered Maslach Burnout Inventory (MBI) to
  1,272 emergency physicians over four years at
  ACEP Scientific Assembly
• 60 rated at moderate to high levels of burnout

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Burnout and the Emergency Physician

• Goldberg et al. (1996)
• Correlates of burnout
• Self-recognition of burnout
• Lack of job involvement
• Negative self-assessment of productivity
• Dissatisfaction with career
• Sleep disturbances
• Increased number of shifts per month
• Dissatisfaction with specialty services
• Intent to leave the practice within 10 years
• Higher levels of alcohol consumption
• Lower levels of exercise

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Burnout in Residency

• Koran and Litt- 280 house staff
• 40- anxiety or depression impaired their
  work
• 31- social isolation
• 12- increased use of alcohol or drugs
• 46- concerned that a relationship with a
  significant other would not survive the
  residency

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Stress in EM Residency

• DE Houry, LW Shockley, V Markovchick
• Annals of Emergency Medicine
• 35 (4) 394-397, 2000

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Burnout symptoms

• Somatic
• Headaches, fatigue, sleep disturbance, GI sx
• Cognitive
• Forgetfulness, indecision, poor judgment
• Emotional
• Irritable, depressed, worry
• Spiritual
• Loneliness, inadequacy, absent

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Self Monitoring for Burnout

• Maslach Burnout Inventory (MBI) addresses 3
  general scales
• Emotional exhaustion (feelings of being
  emotionally overextended and exhausted by ones
  work),
• Depersonalization (unfeeling and impersonal
  response toward recipients of ones service,
  care, treatment, or instruction)
• Personal accomplishment (feelings of competence
  and successful achievement in ones work)

• Maslach C, et al. The Maslach Burnout Inventory.
  3rd ed. 1996

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(No Transcript)
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MBI Score Interpretation
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Interventions

• Educating physicians about burnout
• Learning new adaptive coping mechanisms
• assessment and determination of stressors
• specification of life priorities
• sharing and expressing feelings
• Alleviating stress at work
• focusing on positive aspects and small success
• setting daily and weekly goals
• breaks and variation in daily schedule
• utilizing a team approach

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Wellness and the Emergency Physician

• Physician Impairment
• The inability to practice medicine with
  reasonable skill and safety due to physical and
  mental illness
• Emergency medicine is overrepresented with
  chemically dependent physicians compared to other
  specialties

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Intervention

• Initiation of programs to alert physicians to
  stresses
• Re-evaluation and restructuring medical training
• Offering programs and conferences dealing with
  burnout

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Impaired Physicians

• Alcohol
• Drugs
• Mental Illness

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Symptoms of Impairment

• Symptoms
• Denial
• Compulsion
• Progression
• Relapse

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Stages of Dependency

• Use Social functions
• Abuse Using the chemical interferes with life
• Addiction Life interferes with using the drug
• Institutionalization and/or insanity
• Recovery

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Recovery and Help

• State specific programs
• Counseling
• Confidentiality
• Disability

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Strength

• You have it
• Physical and mental
• Trust and sharing
• Boundaries
• Your work and your life

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Life in the Goldfish Bowl

• Unique to emergency medicine
• Team captain
• Interactions with other physicians

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Wellness in the Professional Environment

• Adequate physician and support staffing
• Input on policies and procedures
• Reduction of noise and structural discomforts
• Strategies to deal with difficult patients
• Shift work strategies
• Support groups/CISD

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Frustration and anger

• Overcrowding
• Admitting
• Expectations vs. resources

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Medical Errors

• Admit
• denial does not work
• Apologize
• Constructive learning
• do better next time

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Harassment - towards you

• Still sometimes a gender issue
• EM identity
• still the new guy on the block

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Harassment - by you

• Political correctness
• Everything you say and do will be noticed
• Dont think it cant happen here

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Violence

• Toward you and your staff
• Society and your patients
• Caring for those affected

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Wellness and the Emergency Physician

• The Difficult or Hateful Patient
• Organic brain syndrome / Dementia
• Language or cultural differences
• Hostile patient/borderline personality
• Overly dependent
• Hypochondriac
• Antisocial/self-destructive

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Wellness and the Emergency Physician

• Keys to Dealing with Difficult Patients
• Recognize your negative feelings toward the
  patient and accept them nonjudgementally
• Determine that the patient will not make you
  sick - share your feelings
• Set limits for yourself and the patient - treat
  consistently

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Shift work

• Circadian rhythms
• Scheduling
• Does it contribute to medical errors?

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Shift work effects

• Infertility
• Increased risk of premature birth retarded
  fetal growth
• Higher pregnancy loss
• High rates of drug and alcohol abuse
• Chronic hypertension and increased
  cardiovascular mortality

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Shift work

• Increased rates of worker accidents and errors
• Increased rates of accidents driving to from
  work
• Often cited as the main cause of career
  dissatisfaction
• Chronic fatigue
• Chronic sleep disruption and deprivation
• Increased rates of depression, mood swings and
  divorce

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Circadian Principle

• 25.1 hr. biologic clock
• Temperature cycle correlates well with level of
  alertness
• Temperature troughs at 200PM and 300AM

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Circadian Rhythm
Increases
Sleepiness
Decreases
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Time (h)
University of Virginia Center for Biological
Timing. Available at http//www.cbt.virginia.edu
/tutorial/HUMANCLOCK.html.
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Performance Errors
No. of Errors
Mitler MM, et al. Sleep. 1988.
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Vehicle Accident Data
1200 1100 1000 900 800 700 600 500 400 300 200 100
No. of Accidents
Midnight
6 AM
Noon
6 PM
Midnight
Mitler MM, et al. Sleep. 1988.
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How Do These Things Happen?
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Medical Errors?

• Smith-Coggins et al (1994)
• Sleep deprived attendings ? Mannequin intubation
  and decision-making for four case scenarios
• Intubation ? sig faster for rested subjects,
  accuracy better earlier in shift regardless of
  rest
• Decision-making ? higher for rested subjects,
  but not stat sig

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Recognizing Fatigue/Sleepiness

• Poor motor skills
• Frontal lobe signs
• Apathy, impoverished speech, flattened affect ?
  no motivation, poor communication skills
• Impaired memory
• Inflexible thinking and impaired planning skills
  ? inability to multitask, see big picture
• Irritability, moodiness, and disinhibition ?
  unprofessional behavior
• Intrusive sleepiness
• Microsleeps (5 to 10 seconds) cause lapses in
  attention
• Nodding off when sedentary
• REM phenomena (hypnagogic hallucinations)

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Am I Getting Enough Quality Sleep?

• How do you monitor the effectiveness of your
  sleep?
• Self-assessment methods
• Epworth Sleepiness Scale (ESS)
• Pittsburgh Sleep Quality Index (PSQ)

Johns MW. Sleep. 1991 Buysse DJ, et al. J
Psychiatric Res. 1989
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Epworth Sleepiness Scale (ESS)
0 would never doze 1 slight chance of dozing
2 moderate chance of dozing 3 high chance of
dozing
Johns MW. Sleep. 1991
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ESS Interpretation

• An ESS score of 10 points or higher is indicative
  of daytime sleepiness
• An ESS score of 16 points or higher indicates a
  high level of daytime sleepiness
• ? Re-evaluate sleep strategies

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Wellness and the Emergency Physician

• Scheduling Strategies
• Isolated night shifts
• Clockwise rotations
• Same shift for extended periods
• Older physicians work fewer nights

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Managing the Lifestyle

• Naps, split sleep, anchor sleep, completion sleep
• Exposure to bright light
• Diet and exercise
• Proper sleep environment
• Stimulants/Melatonin/Modafinil
• Night shift full switch
• Support from family and friends

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Healthy Lifestyle

• Family and friends
• Exercise
• Diet
• Vacations

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Wellness and the Emergency Physician

• Exercise Prescription
• Brisk- raise heart rate to 50-75 of maximum
• Sustained- 30-60 min.
• Regular- 3-4 times a week
• Balance of isometric and isotonic

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Wellness and the Emergency Physician

• Beneficial Effects of a Proper Diet
• Lower cholesterol
• Weight control
• Augment blood pressure control
• Lower incidence of certain cancers
• Retard the aging process?

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Wellness and the Emergency Physician

• Current Dietary Recommendations
• Vitamins
• Fiber
• Minerals

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Wellness and the Emergency Physician

• Family and Social Relationships
• Coombs (1991) reviewed 130 studies on rates of
  suicide, alcoholism, psychiatric disorder, etc.
• Conclusion A marital partner who provides
  mutual companionship and psychic aid buffers
  individuals against the physical and emotional
  stresses of life.

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Wellness and the Emergency Physician

• The Medical Marriage Maintenance
• Key elements are Time and Attention
• Devote at least 15-30 min per day to discuss
  substantive issues
• Mutual compromise is necessary and must be
  openly discussed
• Marital therapy may help in developing
  communication skills

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Wellness and the Emergency Physician

• Adverse Effects of Compulsiveness
• Difficulty in relaxing
• Reluctance to take vacation/sick leave
• Chronic feelings of not doing enough
• Difficulty with setting limits
• Guilt feelings and the confusion of healthy
  self-interest with selfishness
• Inappropriate sense of responsibility

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Infectious Disease Exposure

• Prophylaxis
• Prevention

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Exposures

• HIV
• Hepatitis B and C
• SARS, Avian Flu
• Meningococcus
• Pertussis
• TB

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Legal Issues

• Malpractice
• EMTALA
• Fraud and Abuse
• Medical Errors

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Career planning

• Is there any such thing as security?
• Due process
• Contracts

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Financial planning

• Security
• Debt
• Plan B

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Wellness and the Emergency Physician

• The Concept of Renewal
• A single-minded devotion to career is
  impoverishing
• By neglecting restorative activities physicians
  tend to lose their emotional resilience
• We need to establish time for rest,
  revitalization, exploration and emotional as well
  as intellectual growth.

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Stress?

• ..I have spent the last 12 years and 3 nights
  in the Bellevue Hospital ED as the supervising
  attending physician..Compared with many people I
  know who work in the corporate world, with its
  emphasis on earnings, the relentless routine of
  the 9 to 7 workweek, computer depersonalization,
  the threat of downsizing, and the general
  disillusionment, I have always found my job a
  recipe for stress relief...

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Stress?

• It is filled with humanity, wonder at the human
  condition, constant reminders of what is
  important, and social approbation. Its those
  corporate jobs that are stressful.
• Letter to the editor
  New York Times
  November 12, 1999

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Author Credit Physician WellnessLily Conrad MD
Michael Wadman MD

• Questions

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Postresidency Tools of the Trade CD

• 13) Negotiation Ramundo
• 14) ABEM Certifications Cheng
• 15) Patient Satisfaction Cheng
• 16) Billing, Coding Documenting Cheng/Hall
• 17) Financial Planning Hevia
• 18) Time Management Promes
• 19) Balancing Work Family Promes Datner
• 20) Physician Wellness Burnout Conrad /Wadman
• 21) Professionalism Fredrick
• 22) Cases for professionalism ethics SAEM
• 23) Medical Directorship Proctor
• 24) Academic Career Guide Chapter 1-8
  Nottingham
• 25) Academic career Guide Chapter 9-16 Noeller

• 1) Career Planning Garmel
• 2) Careers in Academic EM Sokolove
• 3) Private Practice Career Options - Holliman
• 4) Fellowship/EM Organizations Coates/Cheng
• 5) CV Garmel
• 6) Interviewing Garmel
• 7) Contracts for Emergency Physicians Franks
• 8) Salary Benefits Hevia
• 9) Malpractice Derse/Cheng
• 10) Clinical Teaching in the ED Wald
• 11) Teaching Tips Ankel
• 12) Mentoring - Ramundo