Physician Stress and Burnout

1. Physician Stress and Burnout Martin C. Doot, MD, FAAFP, FASAM, FOF Medical Director Illinois Professionals Health Program 847-795-2810 Martin.Doot-MD@advocatehealth.com

3. Learning Objectives: At the conclusion of this activity, participants will be able to: Identify current health policy issues that directly affect physician practice Discuss common challenges to physicians in the current healthcare environment and strategies for overcoming these challenges Explain the significance of ISMS legislative efforts and the impact on Illinois physician practices

4. Physician Stress and Burnout Martin C. Doot, MD, FAAFP, FASAM, FOF Medical Director Illinois Professionals Health Program 847-795-2810 Martin.Doot-MD@advocatehealth.com

5. Adapted from speakers at the International Conference on Physician HealthApril 2000 Rachael Naomi Remen, MD Mamta Gautam, MD George Valliant, MD

6. Nancy W. Dickey, M.D.Past-PresidentAmerican Medical Association “Medicine is a demanding career with rich rewards. However, the diverse claims on a doctor’s time, energy, and intellect threaten his or her well-being and ability to continue to meet the patient’s needs. Learning how to preserve and cultivate one’s own well-being is a key to long fulfilling productivity.”

7. Physician Experience Work harder for less or same money Perception that the future is same or worse Finding alternatives to clinical practice for supplementing income Variance in perception of need to change

8. Reasons for dissatisfaction Sense of being de-valued by society Market forces shifted power to: Employers Payors Patients Owners Inadequate information No reward for responsible change

9. Compensation and BenefitsWhat’s More Important? Satisfying Physicians Increased incomes High capitation rates Restricted physician access Few locations Low overhead Flexible scheduling Daytime hours Overbooking/long patient waits Satisfying Patients Low health care cost Low premium rates Open physician access Several locations Increased service Set appointments Extended hours Short wait times

10. Social Demands Career demands and work related commitments Household responsibilities The “Dream of becoming a physician”: the challenge of integrating reality with the dream of being the best Children, perfection and sanity: can only have 2 of the 3 “Men who help out with housework and children have better sex lives and happier marriages”

11. Productivity and Stress

12. 5 Warning Signs Increase in physical problems Increase in problems with relationships Increase in negative thoughts Significant increase in bad habits Emotional/physical exhaustion

13. BurnoutChronic overstress and emotional exhaustion Emotional exhaustion Depersonalization (withdrawal from others) Reduced personal accomplishment Distinguished from the proactive need to change things to remain productive every 7 years

14. Biologic Factors Poor sleep, eating and exercise habits FH of psychiatric illness and/or addiction Overuse of alcohol and drugs Anxiety, affective and eating disorders

15. Physician, Cherish ThyselfGeorge E. Vaillant: JAMA 1992 Compared to controls physicians are 5 times more likely to take sedatives and minor tranquilizers without medical supervision Self-medication by physicians is a greater danger to the physicians than to their patients. 26 of 180 anesthesiologists who self-prescribed opiates died of suicide or overdose. 3% of physicians in 1972 died of suicide 45 physicians followed for 50 years chosen in college for mental health: 15% had some social or physical damage to themselves from self-prescribing, none hurt a patient.

16. Psychological Factors Overly conscientious People pleasing Sense of responsibility Unrelenting perfectionism Ability to delay gratification Need to control others Uncomfortable with approval Guilt Chronic self doubt Loss of meaning and satisfaction

17. Common Defenses Reaction formation Denial Minimization Rationalization Work

18. Issues from Past Experiences We establish our sense of self as children Believe 3 main assumptions: Parents know everything Parents love them, unconditionally Child is in center of the world This concrete thinking makes them vulnerable if they do not receive the blessing intended by a functional family and tend to think it is their fault if they did not get it. Develops a “Personal Historian” which leads to the 90:10 rule: 90% of our reaction is based on our own personal history and not on the situation

19. Physician, Cherish ThyselfGeorge E. Vaillant: JAMA 1992 “The practice of medicine becomes a strain only when physicians ask themselves to give more than they have been given - long hours, demanding patients, and ready access to mood-altering drugs were not a problem to doctors whose childhood's had been happy and who appeared psychologically sound by the time they reached college. It was the troubled physician and those from barren childhood's who became overly burdened by the demands of their dependent patients and resorted to self-medication.”

20. Calibrating the PhysicianPersonal Awareness & Effective Patient Care(the Emotional Dimension) “However well physicians have learned the science of medicine, they use themselves to practice its art.”

21. Calibrating the PhysicianPersonal Awareness & Effective Patient Care “Using their emotional resources and experiences, physicians connect with patients and support them through myriad distressing situations.” Factors that influence physicians’ reaction to patients include their: Personalities Personal histories Family and cultural backgrounds Values Biases Attitudes Emotional ‘hot buttons’

22. Emotional IntelligenceDaniel Goleman Amygdala: remembers emotions - “strong, sudden, when the dust settles, emotional hijack” Prefrontal Cortex: allows us to orchestrate them effectively Humans were created as “open-loop” systems. Our emotions are contagious. Gives rise to feelings about one’s thoughts - empathy and preference

23. You Know You’re in Trouble if You: Find yourself chronically frustrated with medical colleagues or administrators whose actions complicate, rather than soothe, what stresses you. Find yourself working harder but feeling that you are accomplishing less. Find your colleagues criticize you for not working hard enough while your loved ones complain that you work too much. Find that your relationships with patients, colleagues, and loved ones are generally more stressful than soothing.

24. Effects of Loss of Control “As control is stripped from High-powered copers, a negative emotional chain reaction often results. The attitudes and emotions of key players in any group tend to be ‘contagious’. When the leaders are optimistic they tend to shape a group optimism; when leaders are resilient, the group tends to respond with resilience. However, when people in positions of authority mismanage their emotions, the negative consequences spread like viruses.”

25. Managing Stress Identify the stressor - very specifically Recognize you have more control than you think you do Identify which parts of the stressor you can and cannot control Focus on what you can control; cope with what you cannot

26. How to Improve the Workplace Take a leadership role - identify the problems, research solutions, do homework, document issues Get group support - agree to work together Connect back to the organization - show the benefit of your solutions in the organizational context Recognize it as a process

27. Warren Bennis“On Becoming a Leader” Moral compass (faith based values) Ambition (drive) Competence

28. Mismatches of Person and Job Work overload Lack of control or choice Lack of reward or recognition Lack of community or connection Lack of fairness or respect Conflicting values

29. How to Improve Yourself Address personal issues - keep stress positive Make time for yourself Exercise Eat right Have healthy sex life Get your own family physician Indulge yourself Sleep

30. Time Management Time = energy Choose energy creating vs. energy depleting activities Organize Delegate Schedule - don’t overcommit Set priorities - include yourself and your family in the list of priorities Anticipate and prepare for situations Consider and use options - learn to look for them Learn to say “No” - open mouth, say no, close mouth Stop trying to please everyone

31. Other Suggestions Add fun to work Slow down - remember you’re dead a very long time Don’t take work home - if you do set limits on when and where it is done, give family a choice on limits Take regular time off - don’t end holiday until the next is planned Use support system - 1 good friend, people breaks at work, a pet Share your stories - transform shame/secret to share/support Laugh more often Let go of guilt - acknowledge it, let go of it

32. Relaxation Techniques Many methods to choose from Spiritual relaxation, meditation Rehearse for the performance - don’t expect it to work unless you have practiced it daily

33. Financial Planning Stick to basic financial principles first Have a clear goal - avoid the Columbus syndrome; not knowing where you are going or where you are when you get there

34. Illinois Professionals Health Program Consultation for hospitals, practices, colleagues and family members Coordinate intervention services Case Manager who coordinates care of multiple providers over 5 years Referrals to approved treatment providers for assessment and treatment Written aftercare agreements Random toxicology program Advocacy Research

35. Accept the Change Process

36. Collegiality and Collaboration

37. Finding Meaning in Medicine Groups(the Spiritual Dimension) Teaching medicine involves more than teaching it’s science. Medicine is in crisis, and in crisis we need to find something stronger to hold on to, something more satisfying and sustaining to us as people in this work. We will need to pursue meaning with the same vigor as knowledge. Meaning is the antecedent of commitment. Finding meaning will require us to see the familiar in new ways. Fight for your sense of meaning – against fatigue, numbness, overwork and unreasonable expectations – to find ways to strengthen it together.

38. FMM Groups Methods Monthly meeting in home of a participant Specific topic chosen by participants Share stories from personal or professional lives on the topic Listen to colleague Respect and maintain confidentiality of group Don’t fix a problem, offer advice or interrupt to tell your own story. Offer support, share insights that arise and reflect on what touched us personally.

39. Final Recommendations& Resources Set realistic expectations Remember the 90:10 rule Don’t just try - Just do it! http://www.meaninginmedicine.org/

40. Books

41. Books

42. Question and Answer

43. Thank You for your Participation In order to receive CME for this activity, you must complete a required post-activity evaluation on your computer screen. You will be prompted to complete this evaluation once you leave the Webinar. You will receive your CME certificate in the mail within 4 weeks. Illinois State Medical Society Division of Health Policy Research & Advocacy 312-782-1654