H I L A R Y M C C L A F F E R T Y , M D , F A A PA M E R I C A N A C A D E M Y O F P E D I A T R I C S

2 0 1 7 P E D I A T R I C S I N T H E 2 1 S T C E N T U R Y

C H I C A G O , I L L I N O I S

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The Culture of Health Care: Are We Making Ourselves Unwell?

McClafferty 2017

Faculty Non-Disclosure Information

In the past 12 months, I have had no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of

commercial services discussed in this CME activity.

I do not intend to discuss an unapproved/investigative use of a commercial

product/device in the presentation.

McClafferty 2017

Goals

1. Convey my sense of urgency.

2. Acknowledge complexity, and the short and long term impact of the culture we create.

3. Emphasize our connections, common mission.

4. Highlight opportunities to lead change.

5. Provide tools & resources for your immediate use.

McClafferty 2017

2017: Where is the Burnout Research Leading?

• The toll is significant. • At least 50% of physicians experience professional

burnout.• Between 2011 and 2014 burnout increased in all

medical specialties in the US.• Systems level, sustainable approaches are needed.

Mayo Clin Proc. Jan 2017;92(1):129-146. Shanafelt, NoseworthyMcClafferty 2017

Burnout Myths

� Too expensive to fix.

� Addressing burnout interferes with our organizational goals.

� Focusing on the individual physician is adequate to prevent or remedy burnout.

Mayo Clin Proc. Jan 2017;92(1):129-146. Shanafelt, NoseworthyMcClafferty 2017

Burnout Facts

� Acknowledgement is key.

� The stigma must lift before progress can be made.

� Candid, repeated dialogue with administration develops trust.

� Standardized benchmarks must be developed and measured.

Mayo Clin Proc. Jan 2017;92(1):129-146. Shanafelt, NoseworthyMcClafferty 2017

Are We Making Ourselves Unwell?

McClafferty 2017

Wellness, the Opposite of…

Burnout: the feeling of being overextended and depleted of one’s emotional and physical resources.

Early predictors of job burnout and engagement. Maslach C, Leiter MP. J Appl Psychol. 2008 May;93(3):498-512.

� Emotional Exhaustion� Depersonalization� Loss of a Feeling of Personal Accomplishment

McClafferty 2017

Yerkes-Dodson Curve (1908)

McClafferty 2017 Yerkes RM, Dodson JD (1908) The relation of strength of stimulus to rapidity of habit formation. J C0mparative Neurology and Psychology 18:459-482

Positive Trait In Exaggerated Form

Altruism Loss of sense of self, martyr

Compassion Compassion fatigue, loss of empathy, depression

Perfectionism Compulsiveness, self doubt, imposter syndrome

Competitiveness Isolation, alienation of peers

Resiliency Sense of invincibility, unsustainable pace, exhaustion

High Achievers Workaholic, burnout

Positive Traits or Risk Factors?

McClafferty 2017

Taking Stock: a Snapshot

Wheel of Life Exercise

McClafferty 2017

Wheel of Life

Co-Active Coaching (2nd ed.) © 2007 by Laura Whitworth, Karen Kimsey-House, Henry Kimsey-House, and Phillips Sandahl.McClafferty 2017

Wheel of Life Exercise

Co-Active Coaching (2nd ed.) © 2007 by Laura Whitworth, Karen Kimsey-House, Henry Kimsey-House, and Phillips Sandahl.McClafferty 2017

Where Are You?

• Take a moment for self-reflection.

• Ask yourself, what is going well?

• Where can you identify a strength?

• How do you cultivate this strength?McClafferty 2017

Wheel of Life

Co-Active Coaching (2nd ed.) © 2007 by Laura Whitworth, Karen Kimsey-House, Henry Kimsey-House, and Phillips Sandahl.McClafferty 2017

Why Do We Care?

Strengths *Healthy Resilience

McClafferty 2017

Emotional Resilience

Psychol Rep. 2016 May 18. pii: 0033294116649707.

Resilience: The ability to generate positive emotion and to recover from negative emotion is a modifiable factor

closely linked to burnout.

The ability to ‘bounce back’ after being psychologically challenged

McClafferty 2017

Resilience is:

• Teachable

• Learnable

• Measurable

McClafferty 2017

Common Traits of Resilient People

� Strong social connections � Emotional awareness � Strong sense of purpose � Openness to challenges � Flexibility, openness to

change � An internal locus of control � Identifying as a survivor,

not a victim

� Able to set reasonable goals � Able to ask for help � Take good care of themselves � Sense of optimism

Stress in America: Paying with Our Health. American Psychological Association, 2015McClafferty 2017

Common Traits of Resilient People

� Strong social connections � Emotional awareness � Strong sense of purpose � Openness to challenges � Flexibility, openness to

change � An internal locus of control � Identifying as a survivor,

not a victim

� Able to set reasonable goals � Able to ask for help � Take good care of themselves � Sense of optimism

Stress in America: Paying with Our Health. American Psychological Association, 2015McClafferty 2017

Resilience Associations in Physicians

• Sense of humor • Higher levels of intelligence• Attention to consistent exercise, healthy

nutrition, rest, play, relationships, and coping skills

• Spirituality/organized faith community• Most powerful predictor for physicians:

maintaining caring connection with others

Wayne/Mary Sotile- http://www.sotile.com/advice_articles.php?articleMcClafferty 2017

Healthy Resilience

Why should we care?

McClafferty 2017

Sobering Statistics

� Nearly half of all medical students report feelings of burnout by the third year of training.

� Strong associations have been identified between burnout and suicidal ideation.

J Grad Med Educ. 2014 Mar;6(1):78-84. Dyrbye et al McClafferty 2017

National Pediatric Trainee Data

Pediatric Resident Burnout - Resilience Study Consortium

McClafferty 2017 https://pedsresresilience.com

Pediatric Resident Burnout - Resilience Consortium

• Describe the epidemiology and relationships between burnout, resilience, empathy and confidence in providing compassionate care by pediatric and medicine-pediatric residents

• Test interventions that positively impact burnout, resilience, empathy, compassion and wellness and generate evidence that may be useful in addressing similar concerns in all residents and fellows.

McClafferty 2017 https://pedsresresilience.com

McClafferty 2017

Pediatric Resident Burnout and Resilience Consortium PHASE 1- 1693/2723 (62%) Residents, 34 Institutions

https://pedsresresilience.com

Professional’s Mental Health

Stigma, Stoicism, Consequences

J Grad Med Educ. 2014 Mar;6(1):78-84. Dyrbye et alMcClafferty 2017

• Competency• Professionalism• Quality of patient care• Career satisfaction • Substance abuse • Self prescribing• Motor vehicle accidents

Male physician: Relative risk ratio 1.4 to general male population

Female Physician: Relative risk ratio 2.27 to general female population.

300-400 medical students and physicians complete suicide annually, equivalent to 2 average sized medical school classes.

At the Extreme: Physician Suicide

Moutier et al, Acad Med. 2012 Mar;87(3):320-6.McClafferty 2017

Recognizing External Stressors

• Chronic elevated stress• Patient care demands, EMR• Environmental and infectious

exposures, excessive light, noise• Chronic fatigue, sleep disruption• Time constraints, strained

relationships – personal and professional

• Lack of exercise• Frequent exposure to conflict, yet

lack of conflict resolution training• Erratic meals, poor quality nutrition• Deferred gratification• Unprocessed emotional or spiritual

needs – grief, trauma exposure

McClafferty 2017

Immune system to brain signaling: neuropsychopharmacological implications. Capuron L, Miller AH. Pharmacol Ther. 2011 May;130(2):226-38. Epub 2011 Feb 17. Review.

Internal Effects of Stress: Highly

Pro-inflammatory.

McClafferty 2017

McClafferty 2017

Long working hours and risk of coronary heart disease and stroke: a systematic review and meta-analysis of published and

unpublished data for 603,838 individuals.

Lancet. 2015 Aug 19. pii: S0140-6736(15)60295-1. Kivimäki, et al.

McClafferty 2017 Lancet. 2015 Aug 19. pii: S0140-6736(15)60295-1. Kivimäki, et al

Leadership is a Critical Predictive Factor, Distinct From:

• Salary • Culture• Specialty • Personality conflicts • Workload expectations • Strategic direction of the organization • Opportunities for professional development

Impact of organizational leadership on physician burnout and satisfaction Mayo Clin Proc. 2015 Apr;90(4):432-40. Shanafelt, et al.McClafferty 2017

Barriers to Seeking Help

� Denial

� Distortion

� Defensiveness

� Deference

“I’m fine”

“I’m the only one struggling”

“I’m worried about practice andlicense implications”

Subordinate in a culture that frownson weakness

Mayo Clin Proc. 2015 Apr;90(4):432-40. Shanafelt, et al.McClafferty 2017

Our Collective Goal Today

Mayo Clin Proc. 2015 Apr;90(4):432-40. Shanafelt, et al.McClafferty 2017

“If you do not change direction,

you might end up where you are heading.”

Lao Tzu

In Summary:

• Heighten awareness of the culture we have created.• Recognize the cost of unmitigated stress.• Build on your existing strengths. • Identify personal and professional obstacles to wellness.• Remain open-minded and identify useful resources. • Attitudes are changing, time to dispel the culture of silence.

McClafferty 2017

1. Create urgency

2. Form a powerful coalition

3. Create a vision for change

4. Communicate the vision

5. Empower action

6. Create quick wins

7. Build on the change

8. Make it stick

Creating the climate for change

Engaging & enabling the organization

Implementing & sustaining for change

Dr. John P. KotterProfessor EmeritusHarvard BusinessSchool8 Steps to LeadingChange

McClafferty 2017 Harvard Business School http://www.hbs.edu/

Thank youHilary McClafferty, MD, FAAP

University of Arizona, College of Medicine Tucson, Arizona

hmcclafferty@email.arizona.edu

McClafferty 2017