Psych Nursing Presentation.pptx

AGENDA This presentation will cover: • Motivation for addressing physician wellbeing • Burnout definitions and drivers • Depression and suicide in physicians • Resilience and protective factors • Literature on evidence-based interventions

• Examples of programs and national initiatives • 6-step plan to implementing interventions at your institution

KEY POINTS

• Burnout is the individual’s response to a systemic problem! • Burnout needs a systemic organizational response • Both individual focused and organization focused interventions can reduce burnout • Organization based interventions are more effective for burnout

A CALL TO ACTION

THE TIP OF THE ICEBERG

This is NOT a New Problem

BURNOUT 101

BURNOUT: DEFINITIONS • Emotional depletion: feeling frustrated, tired of going to work, hard to deal with others at work • Detachment/cynicism: being less empathic with patients/others, detached from work, seeing patients as diagnoses/objects/sources of frustration • Low personal achievement: experiencing work as unrewarding, “going through the motions” • Depersonalization: thoughts and feelings seem unreal or not belonging to oneself

DRIVERS OF BURNOUT • Excess stress mediated by long hours, fatigue and work compression as well as the intensity of work environment • Loss of meaning in medicine and patient care: Decreased support, increased responsibility, without autonomy and flexibility • Challenges in institutional cultures: perceived lack of peer support, lack of professionalism, disengaged leadership • Problems with work-life balance

POOR STRESS RESPONSE  BURNOUT

Yerkes-Dodson Curve 1908

GENERAL RISK FACTORS FOR BURNOUT/DISTRESS • • • • • • • •

Sleep deprivation High level of work/life conflict Work interrupted by personal concerns High level of anger, loneliness, or anxiety Stress of work relationships Anxiety about competency Difficulty “unplugging” after work Regular use of alcohol and other drugs

Sargent MC, et al. J Bone Joint Surg Am 2009

EFFECTS OF MEDICAL ERRORS ON PHYSICIAN WELLBEING: “THE SECOND VICTIM” • Guilt

• Loss of confidence

• Shame

• Trouble sleeping

• Feelings of inadequacy

• Difficulty enjoying leisure

• Difficulty concentrating • Declining clinical judgment

activities and daily life

• Depression • Worry about reputation

• Avoidance of some procedures • ~PTSD Helo S & Moulton CE, Transl Androl Urol, 2017

EPIDEMIOLOGY OF BURNOUT IN PHYSICIANS • Medical students matriculate with BETTER wellbeing than their age-group peers • Early in medical school this reverses

• Poor well-being persists through medical school and residency into practice: - National physician burnout rate exceeds 54% - Affects all specialties, perhaps worst in “front line” areas of medicine West C, et al., J Gen Intern Med, 2015

BURNOUT IN TRAINING • Highly prevalent among medical students, residents and physicians – In residents, studies show burnout rates of 41-90% • Levels rise quickly within the first few months of residency • ACGME work hour changes do not appear to have improved sleep, burnout, depression symptoms or errors • Resident distress (e.g. burnout and depression) associated with perceived medical errors and poorer patient care West, CP et al, JAMA 2006; Desai et al, JAMA 2013; Sen S, JAMA Intern Med 2013

BURNOUT AND WORK-LIFE BALANCE

Shanafelt,.et.al., Mayo Clinic Proceedings, December 2015

BURNOUT AT CAREER STAGE

Dyrbye et al. Mayo Clinic Proc, 2013

Shanafelt et al Mayo Clin Proc 2015

BURNOUT, DEPRESSION, AND SUICIDE

BURNOUT, DEPRESSION, AND SUICIDE ACROSS THE CONTINUUM

Medical Student

Resident

Early Career < 5yr

Burnout

56%

51%

40%

Depression*

58%

51%

40%

Suicidal Ideation (last 12 months)

9.4%

8.1%

6.3%

* - Depression screen using 2-item PRIME MD Dyrbye, Acad Med. 2014;89(3):443

DEPRESSION – DSM-5 • 5 or more of the following symptoms for ≥2 weeks: – – – – – – – – –

Depressed mood most of the day Diminished interest or pleasure Significant weight loss or gain Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation Fatigue of loss of energy Feelings of worthlessness or excessive guilt Diminished ability to concentrate Recurrent thoughts of death or suicidal ideation with or without a plan

APA, 2013: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

DEPRESSION DURING INTERNSHIP Specialty (N=740) • • • • • • • •

Internal medicine 358 (48.5) General surgery 98 (13.3) OB/gynecology 42 (5.7) Pediatrics 94 (12.7) Psychiatry 63 (8.5) Emergency medicine 47 (6.3) Medicine/pediatrics 19 (2.6) Family medicine 19 (2.6)

Sen et al. Arch Gen Psych, 2010

Percentage with “Depression” (PHQ >10)

DEPRESSION DURING INTERNSHIP (CONT.) • Rate of depression increased dramatically during internship from 3.9% meeting PHQ-9 criteria (scores ≥10) up to 25.3% at intervals during the year • Mean PHQ-9 increased from 2.4 to 6.4 • Depression results in increased medical errors and errors may also cause depression • Direct association between the number of hours worked and the risk of depression • No evidence that depressive symptom score before internship predicted an increase in work hours Sen et al. Arch Gen Psych, 2010

PREDICTORS OF INCREASED DEPRESSIVE SYMPTOMS DURING INTERNSHIP Baseline Factors • Neuroticism • Personal history of depression • Lower baseline depressive symptoms • Female sex • US medical graduate • Difficult early family environment • 5-HTTLPR polymorphism Within-Internship Factors • Higher mean work hours • Perceived medical errors • Stressful life events Sen et al. Arch Gen Psych, 2010

MULTISITE STUDY OF RESIDENT AND PROGRAM DIRECTOR PERSPECTIVES

• • • • •

307 residents across multiple specialties (61% response rate) 69% met burnout criteria 17% screened positive for depression (PH-Q 9) Lack of work/life balance major issue Residents reported that more vacation time and increased support from mid-levels and scribes rather than adverse outcome support and mentoring would be helpful • PDs most supportive of on-site childcare, debriefing after adverse events and formalized peer support as mitigating strategies (PDs also underestimated burnout rates) Holmes, et.al., Academic Psychiatry, 41:2, April 2017

SUICIDES AMONG US PHYSICIANS

• National Violent Death Reporting System (NVDRS) from 2003-2008 across 16 states • Adults, 18 years or older who died by suicide • Multiple data sources: death certificates, coroner data, medical examiner information, toxicology information, law enforcement reports • 31,636 victims total • 203 physicians

Gold, et. al, General Hospital Psychiatry, January 2013

DIFFERENCES IN ASSOCIATED FACTORS IN PHYSICIAN SUICIDE VS. THE GENERAL POPULATION

• Less likely to have had a recent death of friend/family • More likely to have had a job problem • Higher measurable levels of benzodiazepines and barbiturates • Older • Presence of known mental illness • Major barriers to help-seeking, diagnosis and treatment due to stigma Gold, et. al, General Hospital Psychiatry, January 2013

GENDER DISCREPANCIES IN SUICIDE RATES

• Multiple studies • Suicide ratio for physicians compared with aged matched controls in the general population: – 1.41 times higher for men – 2.27 times higher for women

Schernhammer E, Colditz G. Am J Psych, 2004

Completed Suicides per 100.000 person years

INCIDENCE OF SUICIDE AMONG WHITE MALE PHYSICIANS, DENTISTS, AND GENERAL POPULATION Physician

Dentist

Population

60 50 40 30 20 10 0

25–29

30–34

Occup Med (Lond). 2008. 58 (1): 25-29.

35–39

40–44 Age Cohort

45–49

50–54

55–59

60–64

CAUSES OF DEATH AMONG RESIDENTS • 380,000 residents over 14 years from 2000-2014 • 324 died during residency (220 men and 104 women) • Leading causes: neoplastic disease, followed by suicide and then accidents • For men, suicide was the leading cause • For women, malignancies was the leading cause • Lower than in age and gender matched controls in the population • Deaths by suicide higher earlier in training

Yaghmour, et.al. Academic Medicine, July 2017

BARRIERS TO TREATMENT

UTILIZATION OF MENTAL HEALTH SERVICES AMONG DEPRESSED MEDICAL INTERNS 85.2% 90% 80% 70% 60% 50%

Med & Therapy

40%

Therapy Alone

30%

No Treatment

20%

6.7% 8.1%

10% 0%

Guille, C. et al. J Grad Med Educ. 2010 Jun; 2(2): 210–214.

Reasons for No Treatment: • Lack of time (92%) • Preference for self-management (75%) • Lack of convenient access (62%) • Concerns regarding confidentiality (57%) • Concerns about stigma (52%) • Concerns about cost (50%) • Belief that treatment does not work (25%)

BURNOUT IS NOT ONLY BAD FOR PHYSICIANS, BUT FOR THE BUSINESS OF MEDICINE AND FOR OUR PATIENTS

BUSINESS CASE FOR PHYSICIAN WELL-BEING • Costs Associated with Turnover – Burnout is a major driver of physician turnover – Cost to replace a physician is 2-3 times the physicians annual salary – Mean cost of replacing a physician=$500,000 to $1,000,000. • Costs associated with decreased productivity • Financial risk to organizations long term viability – Relationship between physician burnout and quality of care, patient safety and patient satisfaction

Shanafelt TD et al. JAMA Int Med. 2017

PATIENT CARE AND PHYSICIAN WELL-BEING • Physicians who care for themselves do a better job of caring for others – They are less likely to make errors – Have a higher patient satisfaction

• Habits of practice to promote well-being and resilience need to be cultivated across the continuum • A healthy learning environment will lead to improved health care for all, physicians and patients

Shanafelt TD et al. JAMA Int Med. 2017

POTENTIAL PROTECTIVE FACTORS

RESILIENCE • The capacity to bounce back, to withstand hardship, and to repair yourself • Positive adaptation in the face of stress or disruptive change

• Based on a combination of factors: • Internal attributes (genetics, optimism) • External (modeling, trauma) • Skills (problem solving, finding meaning/purpose, practicing mindfulness) Wolin 1993, Werner & Smith, 1992

BUILDING RESILIENCE

Br J Gen Pract. 2016 Jul;66(648):e507-15

CAN WE BUILD RESILIENCE?  Realistic recognition (Overcoming denial/culture)

 Hobbies outside medicine

 Exercise, sleep, nutrition

 Supportive personal relationships

 Supportive professional relationships  Boundaries  Time away from work

 Passion for one’s work Swetz, J Palliative Med, 2009

 Humor

 Practicing mindfulness  Focusing on positive emotions like gratitude and optimism

ASSOCIATION BETWEEN A SENSE OF CALLING AND PHYSICIAN WELLBEING • 2009-2010 survey, 1504 primary care physicians and 512 psychiatrists • 42% agreed that medicine is a calling • Physicians who reported that medicine was a calling may be experiencing higher levels of career satisfaction and resilience from burnout

Yoon, et. al., Academic Psychiatry 41.3, April 2017

EVIDENCE-BASED WELLBEING INTERVENTIONS

FINDING SOLUTIONS TO COMPLEX PROBLEMS • Solutions are complex and local to each organization • Solutions can target a: – Patient care team – Division – Department – Hospital or academic institution • There are a few common categories of interventions that can be used to generate specific local solutions

CONTROLLED INTERVENTIONS TO REDUCE BURNOUT IN PHYSICIANS • 20 independent comparisons from 19 studies (1550 physicians) • Used the emotional exhaustion domain of the Maslach • Organization-directed interventions are more likely to lead to reductions in burnout than physician-directed interventions – Structural changes – Fostering communication between members of the health care team – Cultivating teamwork • Interventions targeting experienced physicians showed greater evidence of effectiveness Panagioti, et.al., JAMA Internal Medicine, December, 2016

META-ANALYSIS OF INTERVENTIONS TO REDUCE BURNOUT IN PHYSICIANS • 2617 articles including 15 randomized trials of 716 physicians and 37 cohort studies of 2914 physicians • 230 articles met criteria for full review • Most studies reported on changes in burnout domain score • Both individually-focused and organizational interventions can reduce burnout • Both individual and organizational strategies are probably necessary, but there are no studies to date which include both.

West, et.al., Lancet, November, 2016

WELLBEING INTERVENTIONS: AN EVIDENCE-BASED FRAMEWORK A wellbeing plan may include the following types of organizational interventions: 1. Educate and Increase Awareness – –

Using these slides! Create a Speaker’s Bureau

2. Designate Time for Reflection –

Groups, debrief protocols

3. Teach Practical Skills –

Mindfulness, CBT, exercise

4. Build Community – – –

Diversity Mentoring and coaching programs Opportunities to socialize at work

Developed by ML Goldman, CA Bernstein, LS Mayer

5. Ensure Access to Care – – –

Confidential, easy to access, available both during and after work hours 24-hour emergency phone line Online resources with screening tools for burnout, depression and suicide

6. Improve Workplace Environment – –

–

Review workloads and schedules with physician input, autonomy, flexibility Adequate staffing to reduce admin/clerical tasks for physicians Personnel optimized to work at top of licenses in most meaningful work

7. Transform Institutional Culture

1. EDUCATE AND INCREASE AWARENESS •

•

Offer educational opportunities about: – Burnout, depression, substance abuse, suicide, and stigma – Epidemiology of psychiatric illness and comorbidity – Effectiveness of treatment options for depression and other mental illnesses – Sleep hygiene, nutrition, gyms, housing, fun activities – Both mental and physical health resources High-yield venues include: – Orientation sessions for incoming trainees or employees – Departmental grand rounds – Didactic sessions either in training curricula or Graduate Medical Education (GME) and Continuing Medical Education (CME) settings

Developed by ML Goldman, CA Bernstein, LS Mayer

1. EDUCATE AND INCREASE AWARENESS (CONT.) • Create an electronic resource library or institutional website that includes online modules and links to well-being resources • Make information about access to mental health resources visible in multiple high-traffic areas, where physicians can learn how to access care without having to draw attention to themselves • Organize a “Speaker’s Bureau” to include: – Local “Physician Wellness Champions” – Staff psychiatrists who are knowledgeable about depression and suicide • This is what you are doing as you use this slide deck!

Developed by ML Goldman, CA Bernstein, LS Mayer

2. DESIGNATE TIME FOR REFLECTION • Provide physicians protected time for structured discussion groups – Membership: ideally 10-15 participants with consistent attendance – Facilitation: faculty (from psychiatry and/or within each department), chaplains, peer co-facilitators, etc. – Structure: follow protocol (e.g. Balint) or allow for open-ended processing

• Disseminate debrief protocols for seminal events (deaths, codes, errors, etc.) • Have senior physicians recount medical errors they have made and how they got through it • Policies for flexible work scheduling and regularly planned days off for wellbeing

Developed by ML Goldman, CA Bernstein, LS Mayer

2. DESIGNATE TIME FOR REFLECTION: THE EVIDENCE • 12 studies involved individual-focused interventions • Interventions included • Facilitated small group curricula • Stress management and self-care training • Communication skills training

• Four of these studies indicated funding or coverage for physicians to participate during the workday

West, et.al., Lancet, November, 2016

3. TEACH PRACTICAL SKILLS • Develop and maintain training in: – Mindfulness-based stress reduction techniques – Stress awareness and Cognitive-Behavioral techniques – Positive psychology • Facilitate narrative practice and medical humanities • Arrange physical exercise groups (e.g. yoga classes)

Developed by ML Goldman, CA Bernstein, LS Mayer

3. TEACH PRACTICAL SKILLS: THE EVIDENCE • 12 studies implemented physician-directed interventions – Interventions included • Mindfulness-based stress reduction techniques • Educational interventions targeting – – – –

Physicians’ self confidence Communication skills Exercise A combination of above

Panagioti, et.al., JAMA Internal Medicine, December, 2016

4. BUILD COMMUNITY • Expand structured mentorship and professional development programs – Vital for younger physicians who are prone to burnout. – “Buddy/big sib” programs among trainees help promote camaraderie and informal support – Coaching programs between faculty members and trainees or early career physicians provide opportunities for reflection and support

• Recurring social events and shared community resources (e.g. childcare) • Department led team-building activities and funded annual retreats

Developed by ML Goldman, CA Bernstein, LS Mayer

5. ENSURE ACCESS TO CARE • • • • •

Screen for burnout and depression Define a clear system for referrals to individual mental health services Provide in-house mental health services for physicians Develop walk-in well-being center Arrange after-hours emergency phone line

Developed by ML Goldman, CA Bernstein, LS Mayer

EVIDENCE-BASED INTERVENTIONS FOR DEPRESSION: THERAPY • Recommended therapies for treatment of acute mild to moderate depression: – – – –

Cognitive Behavioral Therapy (CBT) Interpersonal Psychotherapy (IPT) Psychodynamic Therapy Problem-Solving Therapy

• Effectiveness varies with skill and training of therapist, but thought to be equal to medication for mild to moderate depression • Consider adding medication or adjusting therapy approach if no response in 4-8 weeks with therapy alone • If moderate to severe depression, initiate both medication and therapy • Therapy may have longer term effects than medication alone after cessation of treatment http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

EVIDENCE-BASED INTERVENTIONS FOR DEPRESSION: MEDICATION • Consider medication if: – – – – – –

Moderate to severe symptoms Prior positive response to antidepressants Significant sleep or appetite disturbances Agitation Patient preference Anticipation of need for maintenance therapy

• Antidepressant response rates in clinical trials: 50-75% • Generally comparable efficacy: – – – – –

selective serotonin reuptake inhibitors (SSRIs) selective norepinephrine reuptake inhibitors (SNRIs) tricyclic antidepressants (TCAs) monoamine oxidase inhibitors (MAOIs) others (bupropion, nefazodone, trazodone, mirtazapine)

http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

WEB-BASED COGNITIVE BEHAVIORAL THERAPY • Randomized clinical trial – 119 interns at 2 hospitals, multiple specialties • Two groups: wCBT versus attention control (email once/week for 4 weeks with educational information and how to access resources)

• PHQ-9 to assess suicidal ideation at start of internship and 3 month intervals • 12% of interns in the wCBT group endorsed suicidal ideation compared to 21.2% in the control group

Guille, et.al, JAMA Psychiatry, 2015

POSITIVE OUTCOMES FOR TREATMENT OF SUBSTANCE USE DISORDERS IN PHYSICIANS • More than 10% US physicians have a substance use disorder • Physician Health Programs arrange evaluation, referral to treatment, monitoring and contractual agreement with licensing boards • With satisfactory treatment and monitoring, majority of physicians can return to practice • Success rates of >75% in five-year, longitudinal, large cohort study of 16 state physician programs from 1995-2001 – ~1/3 prescribed an antidepressant for comorbid anxiety or depression

McLellan et al., BMJ 2008; 337:a2038.

6. IMPROVE WORKPLACE ENVIRONMENT • Involve staff in Quality Improvement to address workflow issues including: – Health information technology updates to improve user experience – Physical infrastructure with shared spaces conducive to collaboration and team building – Personnel optimized to work at top of licenses (e.g. task shifting) – Physicians given autonomy to spend at least 20% of day in most meaningful work

• Hold regular meetings with leadership to improve work environment with follow-up • Develop a comprehensive strategic plan with operations management to address workforce issues

Developed by ML Goldman, CA Bernstein, LS Mayer

6. IMPROVE WORKPLACE ENVIRONMENT: THE EVIDENCE

• 3 studies examined structural interventions within the work environment – Interventions included: • Shortened attending rotation length • Various modifications to clinical work processes • Shortened resident shifts

West, et.al., Lancet, November, 2016

6. IMPROVE WORKPLACE ENVIRONMENT: THE EVIDENCE • 5 studies examined simple workload interventions that focused on rescheduling hourly shifts and reducing workload. • 3 Studies tested more extensive organization directed interventions – Interventions focused on • Teamwork and leadership, • Structural changes, and • Elements of physician interventions such as communication skills training and mindfulness.

Panagioti, et.al., JAMA Internal Medicine, December, 2016

7. TRANSFORM INSTITUTIONAL CULTURE • Encourage department chairs and executives to engage in participatory leadership styles to facilitate a culture of wellbeing • Promote clear and standardized policies for taking personal days to care for self, sick coverage, and parental leave • Establish an institutional Well-Being Committee with broad member input • Participate in existing and innovative research studies • Assess adherence to regulatory guidelines and requirements

Developed by ML Goldman, CA Bernstein, LS Mayer

TAKEAWAY – Variety of interventions have been effective in reducing burnout – One Size Does Not Fit All – Solutions are complex and can target a: • • • •

Patient care team Division Department Hospital or academic institution

HOW TO START IMPLEMENTING INTERVENTIONS AT YOUR ORGANIZATION

6-STEP PLAN TO WELLBEING 1. 2. 3. 4. 5. 6.

Get Organized Assess Your Needs Choose Your Priorities Engage Leadership Stay Accountable Anticipate Obstacles

For additional resources, including a how-to manual for wellbeing ambassadors, visit: www.psychiatry.org/burnout

#1: GET ORGANIZED • Clearly Designated Intervention Group – Wellbeing Taskforce

and/or – Wellbeing Committee – Wellbeing Champions at each organizational level

Useful Tip: Including junior and senior colleagues will enrich your taskforce!

#2: ASSESS YOUR NEEDS • Assess Your Needs: – Formal

• Depression screening • Physician burnout surveys • Physician satisfaction with work life – Informal

• • • •

Meetings Focus groups Town halls Suggestion boxes

Useful Tip: Acknowledging that physician burnout is a problem for your organization can be a good start

#3: CHOOSE YOUR PRIORITIES • Choose a few interventions based on – Urgency – Impact – Feasibility

• Interventions can be a mix of – Low-, Medium- or High-resource interventions – Short- or Long-Term interventions Useful Tip: There is no perfect universal solution! Don’t wait for a comprehensive solution. Just get started.

FRAMEWORK OF INTERVENTIONS Key components of Well-Being Initiatives

Stage of Intervention Preliminary

Intermediate

Advanced

1. Educate and Increase Awareness

Presentations at employee orientation and regularly planned didactics and workshops

Institutional website that includes online modules and links to wellbeing resources

Established Speaker’s Bureau and curriculum including interdepartmental Grand Rounds

2. Designate Time for Reflection

Voluntary groups led by peers as needed (e.g. debrief protocols for seminal events)

Structured, regularly scheduled groups with consistent membership and expert facilitation

Policies for flexible work scheduling and regularly planned days off for wellbeing

3. Teach Practical Skills

Health-oriented classes available in the community (e.g. yoga, gym, etc.)

Facilitated evidence-based workshop to teach mindfulness and CBT skills

Designated time and specified availability for skills groups and physical exercise classes

4. Build Community

Recurring social events and shared community resources (e.g. childcare)

Structured mentorship and professional development programs (e.g. peer-to-peer coaching)

Department led team-building activities and funded annual retreats

5. Ensure Access to Care

Employee health insurance that appropriately covers mental health benefits

Internal mental health service that provides referrals to the community

In-house, fully staffed mental health services, including short-term free services and 24/7 crisis support

6. Improve Workplace Environment

Health information technology updated to improve user experience, with regular feedback

Physical infrastructure with shared spaces conducive to collaboration and team building

Personnel optimized to work at top of licenses in most meaningful work (e.g. task shifting)

7. Transform Institutional Culture

Institutional wellbeing committee established with broad member input

Department chairs and executive leadership engaged in culture of wellbeing

Innovative policies to maintain wellbeing (e.g. sick coverage, parental leave)

Developed by ML Goldman, CA Bernstein, LS Mayer Developed by Matthew L. Goldman, MD, MS, Carol A. Bernstein, MD, and Laurel S. Mayer, MD

Au

#4: ENGAGE LEADERSHIP • Establish an institutional wellbeing committee charged with rolling out the goals identified in the needs assessment • Create a task force with institutional GME to review adherence to revised ACGME policies • Compensate for volunteering, teaching, and committee work • Celebrate team achievements and milestones • Role model how to voice empathy and concern for colleagues • Promote effective leadership and hire more leaders who care

Shanafelt TD, Noseworthy JH. Mayo Clin Proc. 2017

#4: ENGAGE LEADERSHIP (CONT.) • Make the case to executive leadership: – Improve the patient experience and reduce medical errors – Improve retention of valued members of the medical staff and prevent resourceintensive adverse outcomes among physicians (e.g. leave of absence, attrition, suicide) – Enhance creativity and flexibility in responding to the challenges of the changing health care system – Establish your institution as a leader on an issue of national importance

Shanafelt TD, Noseworthy JH. Mayo Clin Proc. 2017

#5: STAY ACCOUNTABLE

• Accountability – Communicate the proposed plans – Give regular updates • Include successes, failures and roadblocks

• Assess the impact of your interventions – Reuse the baseline measures

Useful Tip: Goal alignment and accountability by themselves can be wellness intervention

#6: ANTICIPATE OBSTACLES • Some challenges are likely to arise: – Limitations of your own energy and resources – don’t burn out on burnout! – Insufficient mental health services may limit referral options – Perceived concerns among physicians about repercussions of seeking mental health treatment on medical licensure – Stigma – Tragedy such as the loss of a colleague to suicide

• Be in touch with the members of the APA Workgroup to share your experiences and seek further assistance whenever needed!

KEY POINTS • Burnout is the individual’s response to a systemic problem! • Burnout needs a systemic organizational response • Both individual focused and organization focused interventions can reduce burnout • Organization based interventions are more effective for burnout

DISCUSS: WHAT ARE YOUR GREATEST NEEDS AND PRIORITIES AT YOUR INSTITUTION?

EXAMPLES OF PROGRAMS

MGH – SMART-R CURRICULUM • Stress Management and Resiliency Training for Residents • Adapted from Benson Henry Institute’s “Relaxation Response and Resiliency Program” • Basic Tenets: – – – –

Relaxation Techniques and Meditation Stress Awareness and Cognitive Reframing Positive Perspective Taking and Meaning Finding During Protected Time

Chaukos, D et al. Acad Psychiatry. 2017

OREGON HEALTH SCIENCES UNIVERSITY • Wellness and Suicide Prevention Program (2300 trainees and faculty) • Two psychologists and 2 psychiatrists (2.4 FTEs)

DESIGN: • Wellness promotion workshops • Orientation presentations • Suicide prevention screening offered • Resident support groups • Records stored in encrypted database in secure location – not documented in EHR • 85% of expense is for clinicians • $200,000 estimated start up cost Ey et al, JGME, 2016

OHSU CONTINUED Interventions: • Individual coaching and CBT, mindfulness, brief insight-oriented treatments • Psychiatric evaluation and medication management • Consultation with GME, program leaders and chief residents about distressed trainees and faculty • Referrals to the community for fitness for duty, neuropsychological testing, hospitalization • 25% increase in utilization of services over 10 years

Ey et al, JGME, 2016

PROGRESS ACROSS THE CONTINUUM

CURRENT NATIONAL INITIATIVES (A SAMPLE) • APA Workgroup on Psychiatrist Wellbeing and Burnout • Coalition for Physician Accountability • AMA • National Academy of Medicine • AAMC • FSMB

• Emergency Medicine • CHARM • Osteopathic Community • Nursing Community

ACGME REVISIONS TO CPRS •

Accreditation Council for Graduate Medical Education (ACGME) released new Common Program Requirements, including section VI.C on Well-Being, effective 7/1/2017: –

Helping residents find meaning in work: protected time with patients; minimizing nonphysician obligations; administrative support; progressive autonomy and flexibility; enhancement of professional relationships

–

Attention to scheduling, work intensity, and work compression

–

Evaluating the safety of residents and faculty members in the learning and working environment

–

Establishing policies and programs supporting optimal resident and faculty member well-being, including the opportunity to attend appointments for personal care, even during working hours

–

Attention to and education in resident and faculty member burnout, depression, and substance abuse in themselves and others; provision of services and resources for care, and tools to identify symptoms and report them; and availability and access to confidential, affordable mental health counseling and treatment, including access to urgent and emergent care 24 hours a day, seven days a week.

–

Establishing policies and procedures ensuring continuity of patient care in support of patient and physician safety when residents and faculty members are unable to work, including but not limited to circumstances related to fatigue, illness, and family emergencies.

http://acgme.org/What-We-Do/Initiatives/Physician-Well-Being

APA WORKGROUP ON PHYSICIAN WELLBEING AND BURNOUT •

Review prevalence, incidence, causes for burnout, depression and suicidality and evidence-based interventions

•

Develop web portal/app for self assessment, education and resources

•

Recommend actions for the APA to take to support and educate other physicians, including other specialty societies

•

Develop an annotated list of assessment tools for burnout and depression

•

Disseminate toolkit and this slide deck to provide guidance to: – Spread awareness at your home institutions with the use of a comprehensive slide deck and a Speaker’s Bureau; – Assist your organization in conducting a needs assessment to identify best practices for advocacy and specific interventions to promote wellbeing within your organization; and – Gain access to additional resources including a recommended reading list and an inventory for screening tools.

QUESTIONS? The APA Workgroup on Physician Wellbeing and Burnout was convened in 2016 by Anita Everett, MD, APA President, 2017-2018.

Members: Rick Summers, M.D. – Chair Rashi Aggarwal, M.D. Carol Bernstein, M.D. Deanna Chaukos, M.D. Julie Chilton, M.D. Kimberly Gordon, M.D. Connie Guille, M.D. Matthew L. Goldman, M.D., M.S.

James Lomax, M.D. Terrance McGill, M.D. Theresa Miskimen, M.D. Steve Moffic, M.D. David Pollack, M.D. Tony Rostain, M.D. Suzanne Thomas, M.D. Linda Worley, M.D. Glenda Wrenn, M.D.