Are We Healthy? Caring for Ourselves

Linda Blust, MDCenter for Palliative Medicine

“How often do you . . .”

a) Almost Alwaysb) Oftenc) Seldomd) Almost Never

Case

• It’s been a very busy six months. At the request of your supervisor, you have taken on new committee responsibilities in addition to your teaching and clinical/research duties. Your co-workers are beginning to grumble that you’re not available when they need you. Tenure is looming, but you can’t seem to complete the portfolio.

What’s happening?

• Physical Stress• Your working harder with the same amount of

time• Emotional Stress

• You can’t be in two places at once• Spiritual Stress

• Is this really why you choose to do your work?

Intro to Humans: Care and Feeding

• Adequate Sleep: 6-9 hours/day• Nutrition: 1500-1800 kcal/day; balanced• Exercise: Aerobic• Safety

• Injury avoidance• Illness avoidance

• Regular check-ups

Facts

• Direct patient care largest cause of low back injury

in U.S.

• 2/3 docs DO NOT have a PMD

• Sleep deprivation increases work-related errors

• Women encounter a glass ceiling in academia

Strategies

• Recognize physical signs• Irritability• Inattention• Insomnia

• Value your physical health• Sleep when you need • See the Doctor• Etc.

Emotional Health

• Do I get what I need from my job????• Workload• Control• Reward• Community• Fairness• Values

Emotional Health

• Workload• Appropriate number/resources/training

• Control• Empowerment without abandonment

• Reward• Is it meaningful to you?

Emotional Health

• Community/Co-workers• Supportive

• Fairness• Workload/resources/reward

• Values• Organization shares your basic values

Facts

• No job is perfect!!• Know yourself well

• What is essential

• What is intolerable

• What is negotiable

Strategies

• Don’t just sit there, do something!• Identify the problem: name it truthfully!• Plan an intervention: what can I realistically do

about it?• ACT: address problem directly. Remember,

• What is essential• What is negotiable• What is intolerable

Strategies

• Be Creative

• Can I work a different schedule?

• Can I work with different people?

• Can I get different rewards?

Strategies

• Return to beginning

• Why did I choose this?

• Does that reasoning still hold?

• Eyes on the Prize

Caveat Emptor

• Realize the cost of addressing/not addressing the problem• Impaired work performance• Burn-out• Depression

• You may need to explore other options

Spiritual Health

• Does what I do reflect who I am?

• Can I nurture/protect my essential beliefs?

• Does this make sense to me?

Facts

• It is impossible to sustain competence doing

something that “isn’t you”

• Patients/families/coworkers often challenge

our belief systems

• “Crazy-making” will make you crazy

Strategies

• Identify: Be Truthful!

• Plan: Realistically, what can be done?

• Act: Your essential self is at stake: DON’T

IGNORE THIS!

Consequences

• Burnout

• Illness

• Addiction

• Poor work performance

• Unprofessional conduct

• Suicide

What is Burnout?

• Syndrome• Emotional Exhaustion

• Depersonalization/Cynicism

• Sense of Low Personal Accomplishment/

Sense of Inefficacy

Emotional Exhaustion

• “I feel drained. . .”

• Likely a result of high workload and time

pressure

• Precursor to Depersonalization/Cynicism

Depersonalization

• Distance Self from Patients/Clients/co-workers

• Ignore unique qualities of patients/co-workers

• Creation of “other”

• Easier to manage demands

• Protects self from emotional demands of work

Sense of Inefficacy

• “I’m not doing a good job . . .”

• Concurrent with exhaustion/cynicism

• Linked to lack of resources

Stages of Burnout

• Stress Arousal• Energy Conservation• Exhaustion

• Proceed in order• Cycle can be interrupted at any point

Risk Factors

• Individual• demographics, personality, attitudes

• Situational• job, occupation, organization

• Situational Risks More Predictive of Burnout than Individual Risks!!!!!

Demographic Risks

• Young: survival bias?

• Unmarried

• Highly educated

• Gender NOT predictive

Risks: Attitudes

• High job expectations• nature of work• achievement

• Unclear if this correlates with burnout

Individual Risks for Burnout

• Type-A Behavior

• Lack of “Hardiness”• Open to change

• Sense of control

• Involved with daily function

• Low Self Esteem

Poor Work Performance

• Lateness for Work• Needed 3-day weekends• Turning in work late• Resentfulness• Suboptimal performance

• Practice• Attitudes

Addiction

• 10-14% MDs become addicted during career

• Alcohol is primary drug of choice• Addiction is cause for impairment over

70% of the time• We police ourselves and each other

Unprofessional Conduct

• Unprofessional students are THREE TIMES more likely to receive disciplinary action as MDs• Severely irresponsible: odds ratio of 8.5 for

disciplinary action• Severely unable to improve behavior: odds

ratio of 3.1• We police ourselves and each other

Suicide

• Male MDs: relative risk 3.4• Female: 5.7

• Completed suicide = male rate• More likely to die of suicide than other

professionals

Conclusion

• Health has 3 major elements: Don’t ignore any of them!

• Know who you are and what you need• Don’t complain: ACT• Remember, no job is worth your physical,

emotional, or spiritual health.

References• Booth, JV et al. Substance Abuse Among Physicians: A Survey of

Academic Anesthesiology Programs. Anesthesia and Analgesia 2002;95:1024-30.

• Center, C et al. Confronting Depression and Suicide in Physicians: A Consensus Statement. JAMA 2003;289:3161-3167.

• Girdino, DA et al. Controlling Stress and Tension, Allyn & Bacon, Needham Heights MA, 1996.

• Gross, CP et al. Physician, Heal Thyself? Archives of Internal Medicine 2000;160:3209-3214.

• Gundersen, L. Physician Burnout. Annals of Internal Medicine 2001;135:145-148.

References, II

• Maslach, C et al. Job Burnout. Annual Review of Psychology 2001;52:397-422.

• Papadakis, MA et al. Disciplinary Action by Medical Boards and Prior Behavior in Medical School. NEJM;353:2673-2682.

• Shanafelt, TD et al. Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program. Annals of Internal Medicine 2002;136:358-367.

• Texas Medical Association CME website. www.texmed.org/cme/phn/psb/burnout.asp

Case• An elderly man has been transferred to

4NW with a grave prognosis from neurologic injury. Tube feedings were stopped 3 weeks ago, and hydration consists of 120 cc/day from his PCA. He continues to make stool and >1L urine/day. All involved with his care are irritable and angry with the primary care team.

What’s happening?

• Physical stress• Caring for dying patient for 3 weeks

• Emotional stress• Am I doing this right?

• Spiritual stress• Why isn’t he dying????