recognizing burnout and finding the path to recovery...

Christina M. Surawicz, MD, MACG

Recognizing Burnout and Finding the Path to Recovery

Keynote Lecture

Christina M. Surawicz, MD MACGProfessor of Medicine

Keynote Lecture2014 ACG/VGS/ODSGNA Regional Postgraduate Course

Williamsburg, Virginia September 6-7, 2014

Professor of MedicineDivision of Gastroenterology

University of Washington

Definition of burnout

1. The term burnout was coined in the 1970s by th A i h l i t H b tthe American psychologist Herbert Freudenberger

2. Describes the consequences of severe stress and high ideals experienced by people working in the “helping” professionsg p g p

3. Doctors and nurses who may sacrifice themselves for others, would often end up being “burned out”- exhausted, listless and unable to cope

ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2014 American College of Gastroenterology

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Disclosure

I have no industry relationshipsI am no expert on burnout, but I have

experienced it, though I probably didn’t recognize it at the time.


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Burnout has 3 components

Emotional exhaustion–Overworked, overextendedOverworked, overextended

Depersonalization–Unfeeling in response to patients + peers

Decreased sense of personal accomplishments + successes

A measurable outcome – 22 items in the MaslachBurnout Inventory (MBI)Burnout Inventory (MBI)

Two questions from the MBI correlated well with survey

1. I feel burned out from my work (feeling emotionally depletedemotionally depleted

2. I have become more callous toward people since I took this job (treating patients and peers as objects).

A few times a year vs. a few times a week (90% correlation)--No one put “never”This correlated well with the whole survey

West et al. J Gen Intern Med 2009; 24: 1318-21; Balch + Shanafelt, Adv in Surg 2010; 44: 29-47


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Burnout – Disconnects

• Work life- quality• Work load- quantity• Control• Reward• Communications• Fairness• Values

Maslach + Leiter, The Truth About Burnout 1997

An Epidemic of Burnout? –Last 10 Years

• There is a large amount of data on burnout in h i iphysicians

• Greatest risk: younger colleagues• Rates:

– Physicians overall 44%Medical students 28 45%– Medical students 28-45%

– Residents 27-75%

AMA SurveyIshak, SGME Dec 2009; 236-41


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Contributing Factors

• Long hours at work + more nights on call– General surgery

• High volume, rapid pace– Emergency medicine– Intensive care

American College of Surgeons –Burnout survey 2009

• 7905 replies; 32% response rate• Burnout • Depression• Less Career satisfaction• More Work-home conflicts• More Nights on call• Longer Hours worked

Source: American College of Surgeons Survey ; Balch et al, J Am Coll Surg. 2010


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Burnout in Surgeons- 39%

• Emotional exhaustion 32%• Depersonalization 26%• Low sense of personal accomplishment 13%

Surgeons – Work Hours

Burnout Work Hrs/wk30% < 6044% 60-8050% > 80

P < .001

Balch et al J Am Coll Surg. 2010


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Work Hours and Career Satisfaction … Not Just Surgeons

• Community tracking physician survey – all MD 1996 2008MDs 1996-2008;4720 respondents in 2008

• Medically relevant work hoursDirect patient careAdministrative & professionalCharity care

Christopher et al. Am J Med 2014; 127:674-680

Increased Career Satisfaction

Somewhat 1 – 5 Very

Fewer hours / weekFewer weeks / year


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Work-Home Conflicts Have an Impact

Same survey– 52% – conflict in past 3 wks– Association with

• Burnout 37% vs 17%• Depression 51% vs 28%• Alcoholism 17% vs 14%

Dyrbye et al Arch Surg 2012; 147: 933-9

Work home conflicts

h h fFor surgeons higher if : 2 career coupleMarried to another doctorMarried to another surgeon---highest i idincidence


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The Paradox – A Fine Line

Dedication Overwork

• The most dedicated are the most susceptible

• Traits that predispose– Idealism– Perfectionism– Responsibility

Balch + Shanafelt Adv in Surg 2010; 44: 29-47

Denial

• Physicians tend to deny their:– Anxiety– Fears– Desires– Fatigue

• Result can be numbness and burnout

(Reference)


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How well do we recognize burnout in ourselves and others?

• This is a challenge• In one study, surgeons self reported burnout

significantly underestimated when evaluated on an instrument like the MBI

• One late clue is often unprofessional behavior• But we do not have good criteria an area for• But we do not have good criteria: an area for

better guidance

Burnout – Consequences

• Self Clinical• Leaving profession early• Substance abuse• Depression• Suicide

• Lower patient satisfaction scores• Association with medical errors

(cause or effect?)


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Gastroenterologists

• Burned out – but less than many other h i i ( f 7288 h i i )physicians (survey of 7288 physicians)

Specialty Rate of Burnout

Emergency Medicine 65%

General Int Med 53%

Overall 46%Overall 46%

Gastroenterology 37%

Peds and Derm 32-35%

MedScape Survey – 24,216 US PhysiciansPhysician Lifestyle Survey, MedScape 2013

Gastroenterologists – ASGE Survey

• Survey of 5,980 members – 8% response• Supplemented with interviews• Compared Interventional GE (IGE) and GE• Burnout higher in junior than senior doctors

– Especially first 3 years– Both in academic and private practice

Keswani et al, Am J Gastroenterol 2011; 106: 1734-40


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Results

Interventional GE – Burnout– Younger – Men– Foreign born– Worked more hours– Fewer leisure hoursFewer leisure hours

3 Areas of Stress – Interventional GIs

• Confidence in their ability• Procedure related stress

– Especially fear of missing malignancy in EUS– Inability to cannulate the bile duct– Misinterpreting fluoroscopic images

• Work-life balance


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Stressors- noninterventional GIs

• Worry about having their endoscopic skills ti dquestioned

• Pressure by nurses to do their procedures more quickly

Complications

A huge contributor to burnout is having a major li ticomplication

The day you stop feeling bad about your complications is the day you quit

Charlie Weems, Seattle surgeon


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Serious Complications + Errors are Inevitable

• Need to take seriously

• Need to learn from our mistakes

• Need to support each other

• Need to forgive ourselves (as we forgive our colleagues)

Malpractice Suits

• Magnifies everything- devastating

• MDs vs Lawyers– Different mindsets- lawyers think differently from

us


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Stress

• Not all studies show work hours contribute to b tburn out

• Stress is another major factor• Some stress is inevitable- how we handle it

makes a difference


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The good news

Th i l h i f it h• There is low hanging fruit here• Early recognition and intervention• Education• Support from peers + seniors• Team with nurses

How Did Surgeons Avoid Burnout?

• Aerobic exercise• Visiting their PCP• Finding meaning in their work• Focusing on what is important• Focusing on work-life balance

Shanafelt et al, Ann Surg 2012; 255: 625-33


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Work Life Balance

Work-life balance is for people who do not like th i ktheir work

“Old Amazon Joke” per New York Times articleMaybe not a joke there?

We Must Control Our Work Schedules

Top 3 factors that contribute to burnout:– Higher number hours worked– Recent work-home conflict– Work-home conflict resolved in favor of work

Control over work schedule predicted better work-life balance


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Solutions

Backup systems for emergencies like the id t h i ht fl t tresidents have, night float, etc

Flexible work hoursReasonable emergency call; schedule day off after? Like airline pilotsPart time workPart time work


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We Cannot Do it All• At least not all at the same time…• Limit what you take on• Limit what you take on

– “exhaustion as a badge of honor”• Plan your day backwards

– Number hours of sleep– Time for self care: exercise, relaxation– Number of hours with friends, family – dinner,

h khomework– Subtract: hours for work

• OK… it won’t work every day but it is a good goal


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A 3 step program

1. Identify and balance professional and l lpersonal goals

2. Identify stressors and shape career path3. Nurture personal wellness strategies

• Adapted from Balch and Shanafelt, Combating Stress and Burnout: a surgical practice, Advances in Surgery 2010; 44: 29-47

Step 1: values and goals

• Identify your personal values• Indentify your professional values• Do they jibe?• Can you integrate them?


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Identify your professional goals

• Why did I choose to become an MD?• Why did I choose to go into GI?• What do I like most about my job?• What 3 things motivate me professionally?• By the end of my career, what 3 things do I

want to have accomplished?• My Steven Covey experience

Integrating work and everything else

• What is my greatest priority in life?– Do I live this way?

• Where am I most irreplaceable?– Home?– Work?– Elsewhere?– Elsewhere?

• What do I want to sacrifice?– Glass and rubber balls


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Integrating (contd)

• What legacy do I want to leave?• How would I change this past year if I could?• What do I fear?

Step 2. Shape your career path and identify stressors

• Enhance work that is personally meaningful to you

• Reshape practice? Give up stressful procedures? Eliminate other things?

• More training? • Reflect with your colleagues• Reflect with your colleagues• Reassess what you enjoy


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What energizes and what drains you?

• Energizer • Drains• Family• Friends• Patients (mostly)• Learning • Teaching

• Non productive committee meetings

• Faculty conflicts• Learned to embrace

conflict but still hard• But no real control

over othersover others

Other People’s Problems

• We want to fix things but we don’t have to fix everythingeverything

• We don’t own other people’s problems

• Listen – don’t reply immediatelyp y y– Chinese saying: pancake has 2 sides, or 3 sides?


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Combat professional burnout: midcareer

• Find your passion• Learn something new

– Clinical?– Teaching?– Leadership?

• For me doing faculty development for the medicalFor me doing faculty development for the medical school

Step 3: nurture personal wellness strategies

Nurture yourself- mentally and physicallyYour relationshipsVacations, hobbiesSleep and eat Protect time for personal reflectionSee your primary care doctorCare for yourself first: oxygen mask on airplane


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Attack your schedule

Take a day off after travelIdentify emergency backup systemsBe realistic but be generousBlock time off, random days or half daysDate nightDecide what time is sacred and honor that

Summary: a 3 step program

1. Identify and balance professional and l lpersonal goals

2. Identify stressors and shape career path3. Nurture personal wellness strategies

• Adapted from Balch and Shanafelt, Combating Stress and Burnout: a surgical practice, Advances in Surgery 2010; 44: 29-47


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Focus Your StrategyThis requires daily attention

• Recognize sources of stress

• Let go of frustrations– What can and cannot be changed

• Two 80% rules

Resilience

• Finding meaning in our work– That we are important– That what we do helps people, not just patients – Mentoring our juniors will be one of our legacies

• Will help us on the days when work doesWill help us on the days when work does overshadow “everything else”


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Someone I knew all too well…“The degree to which you do not believe you have time to spend even

ten minutes sitting quietly is the degree to which you desperately need to spend ten minutes sitting quietly.”

Fahri (2003) Bringing Yoga to Life, Harper Collins, New York

Mindfulness Based Stress Reduction (MBSR)

• Mindfulness is bringing one’s complete tt ti t th t iattention to the present experience on a

moment to moment basis– Nonjudgmental– Conscious awareness– Includes mindful meditation, can include narrative ,

writing and appreciative inquiry


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Mindfulness training

• Primary care physicians trained– Less burnout– Less depression, anxiety and stress– Better communication with patients

– Open trials but no RCTs; looks promisingOpen trials but no RCTs; looks promising

– 2 articles: Beach et al and Fortney et al, Annals Fam Med sept/oct 2013


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Evidence that MBSR works

• Before and after program of primary care docs t i d i i df ltrained in mindfulness

• Significant improvements in well being and patient centered care- short term and sustained

– Krasner et al JAMA 2009; 302: 1284-1293

An epidemic of burnout

Our younger colleagues are at highest riskW d t t t d t th• We need to protect and mentor them

Treatment + Prevention– Renewing our priorities– Taking control of our lives as much as possible– Finding ways to recharge our batteriesg y g– Aligning work and “everything else”


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2 Final Thoughts

“Remember that for each patient, their i it ith i b bl th tvisit with you is probably the most

important event of the day.”–Ron Vender

ACG President 2012-13

“I’ve learned that people will forget

what you said, people will forget p p gwhat you did, but people will never forget how you

made them feel.”

Maya Angelou


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