Developing Physician Resiliency Through Mindfulness and Community

Pediatric Resident Coaching Program MeetingNovember 11, 2013

Emily F. Ratner, MD, Clinical ProfessorDepartment of Anesthesiology, Perioperative and Pain Medicine

Stanford University School of MedicineStanford, California

Burnout

Emotional exhaustionDepersonalization – cynicismIneffectiveness – Decreased sense of

personal accomplishmentWork-individual mismatchMaslach Burnout Inventory – validated

survey

Burnout

Burnout AssessmentSingle question measures from MBIHow often do you feel this way about your job?I feel burned out from my work

Never = 0A few times a year = 1Once a month or less = 2A few times a month = 3Once a week = 4A few times a week = 5Every day = 6

I’ve become more callous toward people since I took this job

West et al, J Gen Intern Med 24(12):1318-21.

Burnout and Satisfaction with Work-Life Balance Shanafelt, et al. Arch Intern Med 2012;172(18):1377-1385> 7000 physicians46% of MD’s at least 1 symptom of burnout on MBI

38 % Emotional exhaustion29% Depersonalization12% Ineffectiveness

Physician depression – 38%Suicidal ideation in past year - 6.4%Poor work-life balance – 37%Burnout and poor work-life balance are a bigger problem for

doctors than other professions

40%

36%

Mean 46%

Burnout by Specialty

Shanafelt, Arch Int Med, 2012

460%

~42%

Mean satisfaction 49%

Satisfaction with work-life balance by specialty

Shanafelt, Arch Int Med, 2012

Medical StudentsHigher prevalence of psychological distress

in med students vs. age-matched peers Dyrbye et al, Acad Med 2006

Incidence of burnout – ranges from 21%-53% depending on source Santen et al, Southern Med J 2010, Dyrbye et al, JAMA 2011

Students going into medicine motivated by personal/family member’s illness or death, higher incidence of EE Pagnin et al. Med Teach, 2013.

Lowered academic performance, increased professional misconduct, decreased empathy, increased substance abuse, suicide

Resident BurnoutIncidence: 10-76%Internal medicine residents – 76% burnout, Seattle,

WA Shanafelt, Ann Int Med, 2001

Surgery residents – 56%, UC Irvine, Gelfand, Arch Surg, 2004

Alexithymic personality style associated w/higher burnout rates, Daly et al, Med J Aust 2002; 177 (1): 14

Alexithymia – inability to recognize or describe one’s emotions

Thomas, JAMA, 2004

Anesthesiology Residents> 2700 residents, response rate 54%

(>1500)MBI, Harvard Depression scale, best

practice and error self-reporting41% high burnout risk - associated with 3

factorsWorking > 70 hours/weekHaving > 5 drinks/weekFemale gender

De Oliveira, et al. Anesth Analg 2013;117:182-93

Anesthesiology Residents22% with depression

associated with same factors of burnout risk+ smoking

23% thought about/wanted to commit suicide - 68 residents

Best practice scores for burnout +/- depression lower

33% w/high burnout & depression risk had multiple medication errors, significantly more than low risk residents

De Oliveira, et al. Anesth Analg 2013;117:182-93

Causes of Burnout

According to demand-control-support modelo Intense work demandsoLack of controloHigh degree of work-home interference

Stressors?Put a photo here

Stressors at workSix Areas of Worklife Survey/MaslachWorkload – includes time pressure, increasing patient

complexity, documentation, regulationsControl – emergencies, scheduleReward – appreciation, recognitionCommunity – lack of support, isolationFairness - favoritismValues – aligned w/co-workers, larger organization

StressorsFamily issuesPersonal healthTime management Adjusting to current and

uncertain multiple changes in the health care environment

Financial – loans, decreased reimbursement

Technology

Are we too plugged in?Electronic medical record

NewUpgrades

Expectations of work at homeHome access to medical recordsEmail

Cell phones, laptops, desktops, chargers, batteries, adapters…..

Time allowance to learn new systems/upgrades

May be especially difficult for aging MD’s

Implications of BurnoutPatient care

Medical errors 53% of burned out Internal Medicine resident self reported at least one

type of suboptimal patient care event vs. 21% Shanafelt et al. Ann Int Med, 2002

Increased surgical error reporting associated with burnout Shanafelt et al. Ann Surg 2010

“Brian Goldman, MD: Doctors make mistakes. Can we talk about that?” http://www.youtube.com/watch?v=iUbfRzxNy20

Patient complianceAdverse patient outcomesPatient satisfaction

ImplicationsPhysician health

Mental illness, depressionPhysical illness Effects of adverse patient outcomesMaladaptive responses to stress

Substance abuse Denial Avoidance Keeping stress to oneself, not seeking help Self-medication Ignoring self-care

One MD per day commits suicide in the US

Roberts, Anesthesiology Grand Rounds September 2012

“If we continue to just build in efficiency and not build in wellness, physicians will burnout. Doctors may still give good care {for a while}, even when burned out, but it will be at their own expense.” Mark Linzer, MD 2012

The cost of replacing a physician is at minimum $250,000.

Buchbinder, Am J Manag Care, 1999

Arenas to Approach Workplace WellnessIndividual

Increased self-awarenessStress reduction techniquesSupport networkReframing

Build communityPeer support groupsFamily and friends support

Workplace changes

ResilienceResilience is that ineffable quality that allows some people to be knocked down by

life and come back stronger than ever.Positive attitude, optimismAbility to regulate emotionsAbility to see failure as a form of helpful

feedbackReframing

Psychology

Today online

Program in Mindful Communication In Primary Care Physicians

70 primary care MD’s, year long program8 week intensive phase 10 month maintenance phase

CurriculumMindfulness meditationSelf-awareness exercisesNarratives about meaningful clinical experiencesAppreciative interviewsDidactic material, discussion

Krasner, Epstein et al. JAMA 2009

Program in Mindful Communication In Primary Care Physicians

Improved mindfulness correlated withLess burnoutBetter emotional stability, mood and empathy

SubjectivelyReduced isolation due to sharing personal

experiences from medical practice w/colleaguesMindfulness skills improved patient interactions and

MD’s developed more adaptive reserveTransformative to develop greater self-awareness

Beckman et al. Acad Med 2012;87:815-819

Georgetown Medical Students

12 week Mind-Body Skills medical student elective, to promote self-care and self-awareness

Initial funding by NIH/R2512 year history, ~ 800 medical students, 40%

class per year ~100 Georgetown medical school faculty trained,

including all clinical rotation directors (except 1), Dean of Medical Education

Outside faculty training ~ 50 currently trained

Georgetown Medical Student Study2 groups of medical studentsControl group – no interventionIntervention group – 12 week MBS courseCortisol, testosterone levels measured before

intervention (January) & after course completed (May) just prior to final exams Spring semester

Cortisol levels were 240% higher in control group in MayTestosterone levels were 160% higher in control group in

MayAll female cohort

MacLaughlin et al, 2011

Mindfulness ?Awareness of the present moment

Not past, not futureBeing not doingNoticing one’s own physical, mental,

emotional state – opposite of alexithymiaNot acting on it, watching but not judgingRecognizing that emotional states are all

temporaryTakes practice

Stanford Anesthesiology Residency

Large program 4 hospitals75 residents150 faculty members

Tertiary care center, critically ill patientsSilicon ValleyStanford duck syndrome

Goals of Resident Wellness ProgramCreate an environment to support and promote the well-being

of our residentsBuild communityTeach/expose residents to skills to promote resiliencyPrevent burnout, in those who aren’t already Intervene early, prevent progression and devastating

consequences

Core ComponentsInitiated 2010, planning since 2008 1. Mandatory first year resident lecture

Scientific lecture stress + biofeedback exercise

Negative recruiting2. Voluntary offsite weekend retreat CA-1’s3. Ongoing q 8 week sessions for remaining

3 years of residency, part of required, didactic program

Wellness Retreat1st year residents only

2010 – 14/26 (54%)2011 – 18/26 (69%) 2012 - 21/24 (88%)2013 – 20/26 (77%)

2 groups lead by 2 facilitators2 Georgetown MBM faculty – mental

health professional2 Stanford anesthesiology faculty

Guidelines and AgendaConfidentiality, mutual respect“I Pass” RuleNon judgmental - listening, not solvingFacilitators set the toneExperiential exercises: meditation, guided

imagery, yoga, Tai Chi, drawing, journaling exercise

Opportunity for self-reflection, check-in, sharing concerns with peers in a supportive environment

Group meals, room w/peers

Resident Wellness Retreat

Friday evening through Sunday afternoonFriday night - introductions/drawing exerciseSaturday

8:00 – 8:50am         Yoga        9:00 - 10:00am        Breakfast      10:00 - 12:00pm       Meditation – eating, mindfulness  12:00 - 1:30pm         Lunch                      1:30 - 3:00pm          Walking meditation 3:00 - 3:30pm          Break 3:30 - 5:30pm          Reflective Journal Writing 5:30 -  7:30pm         Free time 7:30 – 9:00pm         Dinner                   

Wellness Retreat FeedbackObjective surveysSubjective survey results

100% met or exceeded expectationsMost valuable aspects

Formation of strong peer support systemLearning new coping and communication skills“To really feel that stressors..were not only my own”“To talk openly about my struggles”“Our interactions were personal and deeply

profound.”“The time spent here has truly changed me.”“Unbelievable investment in our well-being. Thank

you!”

Wellness Sessions

Meet every 8 weeks, 1 ½ hoursProtected didactic timeFor all ~ 75 CA-1, CA-2 and CA-3

residents, mandatoryTwo groups from retreat maintained, same

facilitators Third group formed with residents who did

not attend retreat, or incorporated into 2 existing groups

Expanding faculty involvement, facilitator training

Further curriculum development

Faculty Wellness Pilot ProgramFunded through Dean’s OfficePurpose: enhance faculty member wellness and

build a model to promote community support amongst the faculty. Experiential trainingNot so hidden agenda

Modified from Anesthesia RWP, Georgetown, Krasner & Epstein’s program

Two components:Offsite retreat, May 2013Monthly sessions for a year

Faculty Wellness Pilot ProgramAll Medical School faculty eligible

Personal statementDepartment Chair/Division Chief letter of support,

financial ($500) and time off for retreat & once monthly meetings

10 participants3 Pediatrics (Endocrinology, CCU, Pulmonary)3 Medicine (Hospitalist, ICU/VA, General Medicine)2 Anesthesiology (VA/SUH)1 each from ER, Radiology researcher –PhD

Diverse backgrounds, all ranks, > 30 year age range

Post RetreatMonthly sessions

LunchExperiential exerciseCheck in

Informal get togethersRequest for more frequent meetingsTwice per month formal meetings

Retreat Subjective Evaluations 100% exceeded expectations“This was my most meaningful experience at

Stanford.”“This was one of the best experiences of my life. Life

changing.”“I did not expect such amazing connections and the

closefeelings with others at such a deep level.”

“This ended the sense of social isolation I’ve felt at Stanford.”

“I am overwhelmed with gratitude at the opportunity to participate in this deeply moving experience.”

Lessons learnedBuy in from leadersNeed at least one championGradual implementation on a yearly basis worked better

than going from 0 to 75 residents involvedMental health professional involvementJumpstart program with a retreat off campus if possibleCreate safe, nonjudgmental confidential environmentSurvey once/yearFaculty involvementOther programs’ and institutions’ curriculaEncourage resident support and input for programmingYou can’t force wellness, allow those who don’t want to

participate actively to “pass”. Ask them to not be disruptive.

Who will pay for physician wellness programs?

InsightfuI Leaders

?

FutureExpand Faculty Wellness programsPeer Support GroupsData

Linking patient outcomes with physician resiliency

Linking patient satisfaction with physician resiliency

Decreased cost