Taking Care of Oneself: For Your Self, Your Fellows,

and Your Program

March 13, 2007David F. Giansiracusa, MD

Pain and Palliative Care Service, Department of Neurology

Memorial Sloan-Kettering Cancer Center

Christian T. Sinclair, MD

Fellowship Director, Associate Medical Director

Kansas City Hospice & Palliative Care

Objectives

• Define and recognize burnout in the health care professional

• Optimize a fellowship program to include teaching areas of self-care

• Learn to address situations where self-care has been avoided/ignored

Personal Consequences of Burnout

• Stress, anxiety, anger, depression

• Substance abuse

• Family disruption

• Stress-related health problems

(Maslach 2001)

Job-Related Consequences of Burnout

• Decreased job performance (Parker 1995)

• Reduced commitment to work (Leiter 1998)

• Low career satisfaction (Goldberg 1996, Lemkau 1994)

Clinical Consequences of Burnout

• Prolonged hospital stays

• Patients’ and family members’ preferences for and goals of care are not discussed

• Patient and family feeling a sense of abandonment

• Excessive use of technological interventions

Burnout:Erosion of Engagement

• Vigor: -energy and resilience -increased stamina -persistence in face of difficulties• Dedication: -strong involvement -feelings of enthusiasm and significance -sense of pride and inspiration• Absorption: -pleasure with total immersion

(Maslach 1997)

What Characterizes Burnout?

• Imbalance of professional demands and rewards

• Caused by:– Overwhelming emotional/interpersonal job stress

• Defined by three dimensions:

I- Exhaustion

II- Cynicism

III- Inefficacy (Maslach 2001)

Compassion Fatigue and Burnout in Trainees

• Care for patients with severe illness and suffering

• Have limited relationships with patients and families

• Need to rescue, fix-it

• Difficult communication challenges

Burnout in Trainees

• 76% out of 115 of internal medicine residents met criteria for burnout:

-More likely to self-report suboptimal patient care

-Report of suboptimal care associated only with depersonalization component and in dose-responsive relationship

(Shanafelt 2002)

Burnout in Trainees

• Major depression self-report and screening rates significantly increased

• Career satisfaction strong inverse relationship to burnout

• No significant increased risk of alcohol or substance abuse

(Shanafelt 2002)

Health Care Professionals’ Vulnerability to Burnout

• Work closely with patients and families who are intensely suffering,

In crisis, and often in conflict “Lightening Rod Effect”

• Conversations require time, focus, and emotional and intellectual energy

(Meier 2006)

Our Vulnerability

• Work under institutional pressures:

-workload

-bureaucratic frustrations

-interprofessional conflicts

- “Culture of Medicine” (Meier 2006)

Our Vulnerability

• We may experience feelings of guilt, insecurity, frustration, inadequacy.

(A sense of “not being enough”)• Identification with patient or family

members may heighten our own sense of grief

• Conflicts over goals of care or “agendas” may cause frustration

(Meier 2001)

Workload

Control

Values

Fairness

Community

Reward

Work

The “Match/Mismatch” Theoretical Framework of Burnout:

Of six domains of job:

Mismatch = Burnout

Match = Engagement (Maslach 1997)

Individual and Organizational Interventions

• Individual interventions (coping skills):– may alleviate exhaustion– unlikely to alleviate cynicism, depersonalization and

inefficacy• Need to create a “matched” profile:

– sustainable workload– feelings of choice and control– recognition and reward– supportive work community– fairness and justice– meaningful and valued work.

(Maslach 2001)

Recognizing Burnout/Compassion Fatigue in Oneself

• Wish to avoid work

• Avoidance-rounding

• Feeling sense of anger and frustration towards patients, families, colleagues

• Resisting evaluation for disease progression

• Not communicating serious information

• Over-dependence on technology

So what is Self-Care?

• Strong boundaries– Work versus Life

• Burnout identification

• Physical, emotional, spiritual arenas

Self-Care Activities

• Exercise and nutrition

• Avoid excessive alcohol and caffeine

• Meditation

• Take/make time to laugh/relax with friends

• Enjoy meaningful solitude– walks, reading, writing

• Other hobbies

Returning to Work• Awareness of satisfaction• Finding rewards• Accomplishing renewal• Experience wonder

Satisfaction from Work

• Sense of dealing well with patients, families and staff

• Intellectual stimulation

• Sense of mastery and contribution

• Enjoying adequate resources

• Obtaining professional status

• Limiting demands

Renewal: Professional

• Growth experiences in skill building, self-discovery and networking

∙ Practical Aspects of Palliative Care Conf∙ Palliative Care Education and Practice∙ Educating Physicians in End-of-Life Care∙ Annual Assembly AAHPM∙ Being Here…today.

Renewal: Personal

• “Spirituality and Meaning in Medicine” Conference

• Other organizations offering group discussions, conferences, retreats:∙ “Renew”∙ “Doctor to Heal”

• New outlook• Experiencing how others have dealt with

adversity and illness

Experience the Wonder

• Love in a family• Resilience• Courage• Values • Way patient views his own life and

death

Applied Self-Care: Director/Faculty

• Starts at interview; ends…never

• “Open Door” Policy

• Get in their shoes– Ask them questions about themselves

• Share your own experience

• Be a good example

Applied Self-Care: Director/Faculty

• Scheduled check-in’s (3-4x/year)

• Dismantle the ‘tough it up’ attitude

• Watch for the October-February slump

• Service vs. education

• Connection with other fellows

• Participation in traditions/rituals

Applied Self-Care: Director/Faculty

• Address the ‘affect’ in difficult situations:– death of a patient– identification with a patient or family– challenging patient or family– being “fired” by patient or family

Part of the Curriculum

• Add self-care sessions to weekly talks

• Experiential and knowledge-based

• Planned and spontaneous

• Look to other disciplines for assistance

• Informal debriefings after tough clinical cases

• Talk about other staff

Obstacles

• Faculty or friend?

• Looking for acclaim– Best mentor ever– Best boss ever

• Breaking bad news– Why is feedback harder than death?

• The small fellowship program

Conclusions

• Burnout occurs when self-care is neglected

• Burnout can come from many sources

• Self-care should not be an afterthought

• Self-care can be nurtured:– in your self– in your fellows– In your program

Contact Information

• David F. Giansiracusa, MD– giansird@mskcc.org

• Christian T. Sinclair, MD – csinclair@kchospice.org

References

• Maslach C, Goldberg J. Prevention of burnout: New perspectives. Applied and Preventive Psychology, 7:63-74, 1998

• Zapf D, Seifert C, Schmutte B, Mertini H, Holz M. Emotion work and job stressors and their effects on burnout. Psychology and Health, 16:527-545, 2001

• Zapf D, Holz M. On the positive and negative effects of emotion work in organizations. European Journal of Work and Organizational Psychology, 15:1-28, 2006

References

• Maslach C, Schaufeli WB, Leiter MP. “Job burnout”. Annual Reviews of Psychology. 52:397-422, 2001.

• Maslach C, Leiter MP. The Truth about Burnout, San Francisco: Jossey-Bass, 1997.

• Leiter MP, Maslach C. Preventing Burnout and Building Engagement: A Complete Program for Organizational Renewal, San Francisco: Jossey-Bass, 2000.

• Maslach C, Goldberg J. “Prevention of burnout: new prespectives. Appl. Prev. Psychol. 7:63-74, 1998.

References

• Meier DE, Beresford L. “Preventing burnout”, Journal of Palliative Medicine. 9(5):1045-1048, 2006 (October).

• Zalenski RJ, Raspa R. “Maslow’s hierarchy of needs: A framework for achieving human potential in hospice. Journal of Palliative Medicine. 9(5):1120-1127, 2006 (October)

• Schapira L. “Stress, burnout, and renewal”, Chapter 4. Conversations in Care (www.conversationsincare.com)

References

• Gundersen L. Physician burnout. Ann Intern Med. 135:145-148, 2001.

• Rabow MW, McPhee SJ. Doctoring to heal. West J Med. 174:66-69, 2001.

• Freudenberger H. Staff burn-out. J Soc Issues 30:159-165, 1974.

• Mount BM. Dealing with our losses. J Clin Oncology. 4(7):1127-1134, 1986.

• Remen RN. Recapturing the soul of medicine. West J Med. 174:4-5, 2001.

References

• Meier DE, Back AL, Morrison S. The inner life of physicians and care of the seriously ill. JAMA. 286(23):3007-3014, 2001.

• Jenkins V, Fallowfield L. Can communication skills training alter physicians’ beliefs and behaviors in the clinics? J Clin Onc. 20(3):765-769, 2002.

• Block SD. Psychological considerations, growth, transcendence at the end of life: The art of the possible. JAMA 285:2898-2905, 2001.

• Cassell E. The nature of suffering and the goals of medicine. N Engl J Med. 306:639-645, 1982

References• Shanafelt TD, Bradley KA, Wipf JE, Back AL.

Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 136:358-367, 2002.

• Ramirez AJ, Graham J, Richards MA, et. al. Burnout and psychiatric disorders among cancer clinicians. Br J Cancer 71:1263-9, 1995

• Kilfedder CJ, Power KG, Wells TJ. Burnout in psychiatric nursing. J Adv Nurs 34:383-96, 2001

• Leiter MP, Harvie P, Frizzell C. The correspondence of patient satisfaction and nurse burnout. Soc Sci Med 47:1611-7, 1998

References

• Cherniss C. Beyond Burnout: Helping Teachers, Nurses, Therapists, and Lawyers Recover from Stress and Disillusionment, New York: Routledge, 1995

• Goldberg R, Boss RW, Chan L. et al. Burnout and its correlates in emergency physicians. Acad Emerg Med 3:1156-64, 1996

• Lemkau J, Rafferty J, Gordon R Jr. Burnout and career-choice regret among family practice physicians in early practice. Fam Pract Res J 14:213-22, 1994

References

• Sherman DW. Nurses’ stress and burnout. Amer. J Nursing. 104: 48-56, 2004.

• Redinbaugh EM, Sullivan AM, Block SD et al. Doctors’ emotional reactions to recent death of a patient: cross sectional study of hospital doctors. British Medical Journal 327:1-6, 26 July 2003.

• Rando T. Grief, Dying and Death: clinical interventions for caregivers. Campaign, IL: Research Press, 1984.

References • Figley CR ed. Compassion Fatigue: Coping with

Secondary Traumatic Stress in Those Who Treat the Traumatized. London: Brunner-Routledge, 1995

• Groves JE. Taking care of the hateful patient. N Engl J Med. 298:883-887, 1978

• Novack DH, Suchman AL, Clark W, et al. Calibrating the physician: personal awareness and effective patient care. JAMA.278:502-509, 1997.

• Zuker A. Dissatisfaction with medical practice. N Engl J Med. 350:69-75, 2004.

References

• Eric Cassell. The Nature of Suffering and Goals of Medicine. New York: Oxford Press. 2004.

• James Hallenbeck. Palliative Care Perspectives. New York: Oxford University Presss, 2003.

• Nouwen H. The Wounded Healer, Garden City, NY. Doubleday, 1972.

Suggested Readings

• Ken Wilber, Grace and Grit: Spirituality and Healing in the Life and Death of Treya Killam Wilber, Boston, Shambhala, 2000.

• Wallace Stegner, Crossing to Safety, 1987, Modern Library, 2002.

• Wallace Stegner, All the Little Live Things, Penguin Books, 1967

• Jean Vanier, Becoming Human, Paulist Press, 1999.

• Michael Kearney, Mortally Wounded. New York: Simon and Schuster, 1996

Suggested Readings

• Jean Shinoda Bolen, Close to the Bone, New York: Touchstone, 1996.

• Christine Longaker, Facing Death and Finding Hope: A Guide to the Emotional and Spiritual Care of the Dying, New York: Doubleday, 1997

• David Kuhl, What Dying People Want, New York: PublicAffairs, 2002.

Suggested Reading

• Reynolds Price, A Whole New Life: An Illness and a Healing, Schribner, 2003.

• Christopher Reeves, Still Me, Ballantine Books, 1999.

• Christopher Reeves, Nothing Is Impossible, Ballantine Books, 2004.

• Martha Weinman Lear, Heartsounds, New York: Simon and Schuster, 1980.

Suggested Reading

• Morton Kondrake. Saving Milly, New York: Ballantine Books, 2001.

• Reeve Lindbergh. No More Words: A Journal of My Mother, Anne Morrow Lindbergh, New York: Simon and Schuster, 2001.

• William Bridges. The Way of Transition: Embracing Life’s Most Difficult Moments. Cambridge, MA, Perseus Publishing, 2001.

Suggested Reading

• Ram Dass, Still Here: Embracing Aging, Changing, and Dying, Riverhead Trade, 2001.

• Viktor Frankl, Man’s Search for Meaning, Pocket Publishers, 1971

• Ira Byock. Dying Well: Peace and Possibilities at the End of Life. New York: Riverhead Books, 1997.

• Kotter J. Leading Change, Harvard Business School Press, 1996

Suggested Reading• Bill Bazan. Medicine In Search of Meaning: A

Spiritual Journey for Physicians, Caritas Communications, 1999.

• Kirk Byron Jones. Rest in the Storm: Self-care Strategies for Clergy and Other Caregivers Judson Press, 2001

• The Dalai Lama. The Art of Happiness, Riverhead Books, 1998.

• William Bridges. The Way of Transitions: Embracing Life’s Most Difficult Moments, Perseus Publishing, 2001.

Suggested Reading

• Kubler-Ross E. Death: The Final Stage of Growth, New York: Touchstone, 1975.

• Kabat-Zinn J. Wherever You Go, There You Are. New York: Hyperion, 1994.

• Santorelli S. Heal Thy Self: Lessons on Mindfulness in Medicine, New York: Bell Tower, 1999.

• Arthur W. Frank. The Wounded Storyteller: Body, Illness, and Ethics. University of Chicago Press, 1997.

Suggested Reading

• Brian Sibley. C.S. Lewis through the Shadowlands: The Story of His Life with Joy Davidman, Grand Rapids: Spire, 1999.

• Henri J.M. Nouwen. Our Greatest Gift: A Meditation on Dying and Caring, San Francisco: HarperCollins, 1994.

• Harold S. Kushner. The Lord is My Shepherd: Healing Wisdom of the Twenty-Third Psalm, New York: Anchor Books, 2003.

Suggested Reading

• Daniel Sulmasy. The Healer’s Calling: A Spirituality for Physicians and Other Health Care Professionals. Paulist Press, New York, 1997

• Daniel Sulmasy. The Rebirth of the Clinic: An Introduction to Spirituality in Health Care, Georgetown University Press, 2006

• Arthur W. Frank. The Wounded Storyteller: Body, Illness, and Ethics. Chicago, University of Chicago Press, 1995.

• Milton Lewis. Medicine and Care of the Dying: A Modern History. Oxford University Press. 2006

Suggested Readings• {Risking Everything}, Roger Housden (ed),

New York, Harmony Books, 2003• Jane Kenyon. Let Evening Come (Poems),

Saint Paul: Graywolf Press, 1990.• Jane Kenyon. Otherwise: New and

Selected Poems. Saint Paul: Graywolf Press, 1996.

• Donald Hall. Without. (Poems), New York: Mariner Books, 1998.

• Mary Oliver. West Wind (Poems and Prose Poems), New York: Mariner Books, 1997.

Websites

• www.commonweal.org/ishi/

• www.zenhospice.org

• www.hospitalchaplain.com

• www.erperc.mcw.edu

• www.pallimed.org

“I had never heard of caregiver burnout raised as a possible temporary insanity or diminished capacity defense, so it sort of

caught my fascination a little bit and off we went exploring the idea.”

-David E. Kelley

TV Writer/Producer

“Curing: Making the problem go away. Healing: Giving people the resources to enjoy

life when they cannot make the problem go away.”

__Rabbi Harold Kushner

“There are two ways of

of spreading light;

To be the candle

Or the mirror that reflects it.”

__Edith Wharton

“Be appreciative of your limited

successes, more tolerant of your

limited failures…..I strive to do the very best, but I am pleased with

“good enough”.__J. Andrew Billings

“Man is not destroyed by

suffering alone,

But by suffering without meaning.”

__Viktor Frankl, Man’s Search For Meaning

Look within yourself:

“What is hardest for me in doing my work?”

“What brings me the most joy and meaning in doing my work?”

Pursue a personal quest to find meaning and purpose in life and a relationship to something greater than oneself....

The shift from ourselves to caring for others.

__Michael Kearney, Mortally Wounded

“Healing requires recognition of the human face of each person one sets to heal and of the message that both the healer and the healed share a bond that ties them to each other through their humanity, their mortality, and the God-given spark of grace that lives in each of them.”

__Daniel P. Sulmasy, The Healer’s Calling