Transcript pHYSICAN BURNOUT – UM Residents-Update 11-17-02

PHYSICIAN
BURNOUT
Pepi Granat, MD, November 27, 2002.
What we’ll do in this hour (Please fill
out Evaluation – really helpful for our improvement)

Dimensions of burnout

Brief activity for residents & faculty

Some research in the field

Recent flurry of articles re: residents,
hours,etc

Prevention & treatment

What to do when “bummed out”
PHYSICIAN BURNOUT:
PREVENTION, IDENTIFICATION
(Post DM, Miller K, Strickland C. FP Recertification vol 21, No. 1 Jan 1999)
“Physician burnout syndrome is a
psychological impairment caused by
chronic job-related stress. It is
characterized by emotional exhaustion,
depersonalization, and a diminished sense
of personal accomplishment…..”
Vol. 288 No. 12, September 25, 2002.
JAMA
Linking Evidence and Experience
Mid-Career Burnout in Generalist and Specialist
Physicians
Anderson Spickard, Jr, MD; Steven G. Gabbe, MD; John F. Christensen, PhD
The Silent
Anguish of the
Healers
Burnout Defined

“A state of fatigue or frustration brought
about by devotion to a cause, way of life,
or relationship that failed to produce the
expected reward.” -Freudenberger, 1980
– NOT SIMPLY OVERWORK
– NOT SIMPLY TIREDNESS
– Particularly prevalent in helping professions
Frequent stressors & outcomes






Heavy workload
Long hours
Fatigue
Bureaucratic
interference
Alienation from
families and social
networks
Commercialization of
medicine








Few social
attachments
Inadequacy feelings
Cynicism feelings
Victimization
Disruptive, selfdestructive behavior
Chemical dependency
Depression, anxiety
Suicide
Physician Suicide
Burnout a precursor
 Estimated rate of physician suicides in
1992: 28-40 per 100,000 (vs. nat’l 11.6)
 Physicians adept at disguising intent
 Physicians effective in carrying out intent
 Rate of successful initial suicide attempts
for physicians is exceptionally high: 62%

What is BURNOUT?
First described in 1974: a syndrome
stemming from an inability to conserve
energy and adapt efficiently
 Physical symptoms
 Psychological symptoms
 Behavioral effects

Components of Burnout:
Physiological
Behavioral
Psychological
Spiritual
Physical and Psychological
Symptoms; Behavioral Effects

Physical:
–
–
–
–
–

Muscle tension
Headaches
Tachycardia
Anorexia
Insomnia
Psychological:
–
–
–
–
Depression
Helplessness
Anger
Frustration

Behavioral effects:
– Quickness to anger
– Frustration responses
– Suspiciousness
bordering on paranoia
– Feelings of
omnipotence
Manifestations in Clinical Work








Dreading seeing another patient
Cynicism toward patients
Daydreaming during sessions
Hostility toward patients
Quickness to diagnose or refer out
Blaming patients
Constant complaining to coworkers
Failure to “complain” in appropriate venues
3 DIMENSIONS OF BURNOUT
EMOTIONAL
EXHAUSTION
DEPERSONALIZATION
DIMINISHED FEELINGS
OF PERSONAL
ACCOMPLISHMENT
What causes BURNOUT?
3
major factors:
 Work (overwork, coping with
patients’ problems, administrative
duties)
 Expectation of others
 Personal characteristics
Etiology

Intrapsychic
– Lack of reinforcement contingencies
– Masked narcissism

Systemic/Environmental Factors
Work Environment Stress








Time pressure
Caseload that is excessive in size, scope or intensity
Organizational politics
Non-supportive peers
Excessive paperwork
Unrealistic or unreasonable demands by managed care
Lack of money or resources
Lack of respect from professional colleagues
Self-Induced Stress







Perfectionism
Fear of failure
Self-doubt
Need for approval
Emotional depletion
Unhealthy lifestyle (self-medication, lack of self
care)
Lack of faith (not necessarily religious faith)
Major Life Event-Related Stress








Legal actions taken against you
Major life transitions
Physical or medical problems
Family problems
Economic cutbacks (layoffs, fluctuations in
economy)
Money pressures
Change in job responsibilities
RESIDENCY !!!!!
BUT DON’T FORGET –
IT’S TEMPORARY !!!!!
Some RESIDENCY ISSUES


Work hours petition rejected by OSHA
ACGME voluntary standards supported
– 80 hours/week
– Minimum 10 hrs. between shifts


Burnout said to be linked to overwork & to lead to
suboptimal care (Shanafelt, et al. Annals Int Med.
Sept. 2002)
Some commentators say fewer hours lead to less
competence  burnout (because of poor academic
teaching & inadequate performance). i.e.
suboptimal care leads to burnout (from angst), not
vice versa (Graham, Annals of Internal Med. Oct.
2002)
Stages of burnout

Early Symptoms
– Low energy
– Boredom
– Still productive, but diminished
 Advanced Symptoms
– Poor performance evaluations
– Presence of physical and psychological
symptoms
Prevention
Awareness!
Keeping Your Eye on the Ball
Exercise: Why You Became A
Physician (3 reasons)
Exercise: Assessing Joys &Hardships
(3 joys; 3 hardships)
At this point: Break into groups of 3
(5 minutes)
Negotiate & decide the above &
present to group (5-10 minutes)
Communication not Competence
= most important skill.

Communication skills training for health care
professionals working with cancer patients, their
families and/or carers[Protocol]Fellowes, D;
Wilkinson, S; Moore, P
 Date of Most Recent Update: 9-4-2002
 Date of Most Recent Substantive Update: 1-11-2001
Ramirez AJ, Graham J, Richards MA, Cull A, Gregory
WM, Leaning MS, et al. Burnout and psychiatric disorder
among cancer clinicians. British Journal of Cancer
1995;71(6):1263-9.
Review in progress…….



The Cochrane Database of Systematic
Reviews Volume (Issue 4) 2002
Sex differences in physician
burnout in the United States
and The Netherlands
J Am Med Womens Assoc 2002 Fall;57(4):191-3
Linzer M, McMurray JE, Visser MR, Oort FJ, Smets E, de Haes HC
Separate physician surveys:United States (n=2326)
Netherlands (n=1426
Gender parity in physician burnout in the
Netherlands may be due to fewer work hours and
greater work control of women compared to those in
the United States
Life Satisfaction Among Norwegian
Young Doctors: A Longitudinal Study
Reidar Tyssen, MD, PhD; Per Vaglum, MD, PhD;
Nina T.Grønvold, MD & Øivind Ekeberg, MD, PhD.
Department of Behavioral Sciences in Medicine,
Faculty of Medicine
University of Oslo
Paper presented at International Conference on
Physician Health in Vancouver, B.C, Oct.19, 2002
Preliminary and unpublished data,courtesy of the author.
Results: Comparison of Life Satisfaction
Among Doctors and Comparison Group
Life-satisfaction
Life-satisfaction
Doctors
Controls general population
200
700
600
500
400
100
Frequency
300
200
Std. Dev = 1.01
0
1.0
2.0
3.0
4.0
5.0
6.0
Std. Dev = .98
Mean = 5.2
100
N = 420.00
0
7.0
dissatisfied - satisfied
Mean : 5.2 (1.01)
Mean = 5.6
N = 1627.00
1.0
2.0
3.0
4.0
5.0
6.0
7.0
dissatisfied - satisfied
Mean: 5.6 (0.98)
T-test: t = 7.0, p<0.001
NB!: No gender differences
“Very/extremely satisfied” with
life
%

100
90
80
70
60
50
40
30
20
10
0


Women
Men
Doctors
Controls
1/3 among doctors
1/2 (or more) among
other people
Statistics (doctors
vs. controls):
Chi-Square = 49.3
P<0.001
Dissatisfied with life (any
category)

10

%
Women
Men 
5
0
Doctors
Controls
3.8% (16/420)
among doctors
1.9% (31/1627)
among other people
Chi-square = 5.4
P = 0.03
Conclusion
Young physicians are less satisfied with life than
other people in the society
 Subjective well-being:
- Probably impeding factors: Mental distress
(personality trait), work stress and life stress
- Probably promoting factors: Having a stable
partner, social support, physical training.
 About 30% of the variance is predicted at medical
school level (personality trait & medical school
variables)

Balancing life
Social
relationships
Working
hours
Spare
time
Personal time
& self-care
COPING STRATEGIES
INDIVIDUAL FACTORS-- the physician’s
personality
 ORGANIZATIONAL FACTORS -workplace stressors
 ESTABLISHING PRIORITIES
 FOCUSING ON MOST TROUBLESOME
ISSUES
 SET REALISTIC, ATTAINABLE GOALS

Treatment
Self help
 Therapy
 Psychotropic Medications
 Focus on Spirituality


Resolution to Act!
Barriers to Proper Treatment
Often unrecognized until problem is severe
 Professionals rarely present with burnout
as primary issue
 Embarrassment

SPECIFIC STRATEGIES
Self-help books on stress management
 Specific books for physicians
 Internet resources
 Self-assessment tool: StressMap
 Stress-management workshops
 Individual counseling, especially for selfesteem and identity issues

STRESS-MANAGEMENT
TECHNIQUES




INCREASE SELFAWARENESS
SHARE FEELINGS
AND
RESPONSIBILITES
SELF-CARE
PERSONAL
PHILOSOPHY



EXPLORE HOW
“HEALTHY”
PHYSICIANS DEAL
WITH STRESS
APPRECIATE YOUR
OWN ROLE, DON’T
BLAME OTHERS
CONSIDER ALL
OPTIONS
Strategies to Prevent Physician Burnout
Personal
Influence happiness through personal values and
choices
Spending time with family and friends
Religious or spiritual activity
Self-care (nutrition, exercise)
Adopting a healthy philosophical outlook
A supportive spouse or partner
Work
Control over environment: workload
Finding meaning in work and setting limits
Having a mentor
Having adequate administrative support systems
WHAT TO DO WHEN
“BUMMED-OUT”
“Choose something like a Star”
TRY POETRY
INSPIRATIONAL (“IF”)
OR CALMING(“The Day is
Done”)
The Day is Done… Henry
Wadsworth Longfellow




The day is done, and
the darkness
Falls from the wings
of Night,
As a feather is wafted
downward
From an eagle in his
flight.




I see the lights of the
village
Gleam through the
rain and the mist,
And a feeling of
sadness comes o’er me
That my soul cannot
resist:
The Day is Done




A feeling of sadness
and longing,
That is not akin to
pain,
And resembles sorrow
only
As the mist resembles
the rain.




Come, read to me
some poem,
Some simple and
heartfelt lay,
That shall soothe this
restless feeling,
And banish the
thoughts of day.
The Day is Done




Not from the grand old
masters,
Not from the bards
sublime,
Whose distant
footsteps echo
Through the corridors
of Time.




For, like strains of
martial music,
Their mighty thoughts
suggest
Life’s endless toil and
endeavor;
And tonight I long for
rest.
The Day is Done




Read from some
humbler poet,
Whose songs gushed
from his heart,
As showers from the
clouds of summer,
Or tears from the
eyelids start;




Who through long
days of labor,
And nights devoid of
ease,
Still heard in his soul
the music
Of wonderful
melodies.
The Day is Done




Such songs have
power to quiet
The restless pulse of
care,
And come like the
benediction
That follows after
prayer.




Then read from the
treasured volume
The poem of thy
choice,
And lend to the rhyme
of the poet
The beauty of thy
voice.
The Day is Done
 And
the night shall be filled with
music
 And the cares, that infest the day,
 Shall fold their tents, like the
Arabs,
 And as silently steal away.
IF…. by Rudyard Kipling




If you can keep your
head when all about
you
Are losing theirs and
blaming it on you;
If you can trust
yourself when all men
doubt you,
But make allowance
for their doubting too:




If you can wait and
not be tired by
waiting,
Or, being lied about,
don’t deal in lies,
Or being hated don’t
give way to hating,
And yet don’t look too
good nor talk too wise;
If……..




If you can dream-- and
not make dreams your
master;
If you can think-- and
not make thoughts
your aim,
If you can meet with
Triumph and Disaster
And treat those two
impostors just the




If you can bear to hear
the truth you’ve
spoken
Twisted by knaves to
make a trap for fools,
Or watch the things
you gave your life to
broken,
And stoop, and build
‘em up with worn-out
If…..




If you can make one
heap of all your
winnings
And risk it on one turn
of pitch-and-toss,
And lose, and start
again at your
beginnings,
And never breathe a
word about your loss:




If you can trust your
heart and nerve and
sinew
To serve your turn
long after they are
gone,
And so hold on when
there is nothing in you
Except the Will which
says to them: “Hold
If…..




If you can talk with
crowds and keep your
virtue,
Or walk with Kings-nor lose the common
touch,
If neither foes nor
loving friends can hurt
you,
If all men count with
you, but none too
much:




If you can fill the
unforgiving minute
With sixty seconds’
worth of distance run,
Yours is the Earth, and
everything that’s in it,
And -- which is more - you’ll be a Man, my
son!
What we’ve done this hour(Please fill
out Evaluation – really helpful for our improvement)
 Dimensions
of burnout
 Brief
activity for residents & faculty
 Some
research in the field
 Prevention
 What
& treatment
to do when “bummed out”