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PHYSICIANPHYSICIAN
BURNOUTBURNOUTPepi Granat, MD, November 27, 2002.Pepi Granat, MD, November 27, 2002.
What we’ll do in this hour What we’ll do in this hour (Please fill (Please fill out Evaluation – really helpful for our improvement)out Evaluation – really helpful for our improvement)
Dimensions of burnoutDimensions of burnout Brief activity for residents & facultyBrief activity for residents & faculty
Some research in the fieldSome research in the field
Recent flurry of articles re: residents, hours,etcRecent flurry of articles re: residents, hours,etc Prevention & treatmentPrevention & treatment
What to do when “bummed out”What to do when “bummed out”
PHYSICIAN BURNOUT: PHYSICIAN BURNOUT: PREVENTION, IDENTIFICATION PREVENTION, IDENTIFICATION
(Post DM, Miller K, Strickland C. FP Recertification vol 21, No. 1 Jan 1999)(Post DM, Miller K, Strickland C. FP Recertification vol 21, No. 1 Jan 1999)
““Physician burnout syndrome is a Physician burnout syndrome is a psychological impairment caused by psychological impairment caused by chronic job-related stress. It is chronic job-related stress. It is characterized by emotional exhaustion, characterized by emotional exhaustion, depersonalization, and a diminished sense depersonalization, and a diminished sense of personal accomplishment…..”of personal accomplishment…..”
JAMA Vol. 288 No. 12, September 25, 2002.
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 The Silent Anguish
of the Healersof the Healers
Burnout DefinedBurnout Defined
““A state of fatigue or frustration brought A state of fatigue or frustration brought about by devotion to a cause, way of life, about by devotion to a cause, way of life, or relationship that failed to produce the or relationship that failed to produce the expected reward.” -Freudenberger, 1980 expected reward.” -Freudenberger, 1980 – NOT SIMPLY OVERWORKNOT SIMPLY OVERWORK– NOT SIMPLY TIREDNESSNOT SIMPLY TIREDNESS– Particularly prevalent in helping professionsParticularly prevalent in helping professions
Frequent stressors & outcomesFrequent stressors & outcomes
Heavy workloadHeavy workload Long hoursLong hours FatigueFatigue Bureaucratic interferenceBureaucratic interference Alienation from families Alienation from families
and social networksand social networks Commercialization of Commercialization of
medicinemedicine
Few social attachmentsFew social attachments Inadequacy feelingsInadequacy feelings Cynicism feelingsCynicism feelings VictimizationVictimization Disruptive, self-Disruptive, self-
destructive behaviordestructive behavior Chemical dependencyChemical dependency Depression, anxietyDepression, anxiety SuicideSuicide
Physician SuicidePhysician Suicide
Burnout a precursorBurnout a precursor Estimated rate of physician suicides in Estimated rate of physician suicides in
1992: 28-40 per 100,000 (vs. nat’l 11.6)1992: 28-40 per 100,000 (vs. nat’l 11.6) Physicians adept at disguising intentPhysicians adept at disguising intent Physicians effective in carrying out intentPhysicians effective in carrying out intent Rate of successful initial suicide attempts Rate of successful initial suicide attempts
for physicians is exceptionally high: 62%for physicians is exceptionally high: 62%
What is BURNOUT?What is BURNOUT?
First described in 1974: a syndrome First described in 1974: a syndrome stemming from an inability to conserve stemming from an inability to conserve energy and adapt efficientlyenergy and adapt efficiently
Physical symptomsPhysical symptoms Psychological symptomsPsychological symptoms Behavioral effectsBehavioral effects
Components of Burnout: Components of Burnout:
PhysiologicalPhysiologicalBehavioralBehavioral
PsychologicalPsychologicalSpiritualSpiritual
Physical and Psychological Physical and Psychological Symptoms; Behavioral EffectsSymptoms; Behavioral Effects
Physical:Physical:– Muscle tensionMuscle tension– HeadachesHeadaches– TachycardiaTachycardia– AnorexiaAnorexia– InsomniaInsomnia
Psychological:Psychological:– DepressionDepression– HelplessnessHelplessness– AngerAnger– FrustrationFrustration
Behavioral effects:Behavioral effects:– Quickness to angerQuickness to anger– Frustration responsesFrustration responses– Suspiciousness Suspiciousness
bordering on paranoiabordering on paranoia– Feelings of Feelings of
omnipotenceomnipotence
Manifestations in Clinical WorkManifestations in Clinical Work
Dreading seeing another patientDreading seeing another patient Cynicism toward patients Cynicism toward patients Daydreaming during sessionsDaydreaming during sessions Hostility toward patientsHostility toward patients Quickness to diagnose or refer outQuickness to diagnose or refer out Blaming patientsBlaming patients Constant complaining to coworkersConstant complaining to coworkers Failure to “complain” in appropriate venuesFailure to “complain” in appropriate venues
3 DIMENSIONS OF BURNOUT 3 DIMENSIONS OF BURNOUT
EMOTIONAL EXHAUSTIONEMOTIONAL EXHAUSTIONDEPERSONALIZATIONDEPERSONALIZATIONDIMINISHED FEELINGS OF DIMINISHED FEELINGS OF
PERSONAL PERSONAL ACCOMPLISHMENTACCOMPLISHMENT
What causes BURNOUT?What causes BURNOUT?
3 major factors:3 major factors: Work (overwork, coping with Work (overwork, coping with
patients’ problems, administrative patients’ problems, administrative duties)duties)
Expectation of othersExpectation of others Personal characteristicsPersonal characteristics
EtiologyEtiology
Intrapsychic Intrapsychic – Lack of reinforcement contingenciesLack of reinforcement contingencies– Masked narcissismMasked narcissism
Systemic/Environmental FactorsSystemic/Environmental Factors
Work Environment StressWork Environment Stress Time pressureTime pressure Caseload that is excessive in size, scope or intensityCaseload that is excessive in size, scope or intensity Organizational politicsOrganizational politics Non-supportive peersNon-supportive peers Excessive paperworkExcessive paperwork Unrealistic or unreasonable demands by managed careUnrealistic or unreasonable demands by managed care Lack of money or resourcesLack of money or resources Lack of respect from professional colleaguesLack of respect from professional colleagues
Self-Induced StressSelf-Induced Stress
PerfectionismPerfectionism Fear of failureFear of failure Self-doubtSelf-doubt Need for approvalNeed for approval Emotional depletionEmotional depletion Unhealthy lifestyle (self-medication, lack of self Unhealthy lifestyle (self-medication, lack of self
care)care) Lack of faith (not necessarily religious faith)Lack of faith (not necessarily religious faith)
Major Life Event-Related StressMajor Life Event-Related Stress
Legal actions taken against youLegal actions taken against you Major life transitions Major life transitions Physical or medical problemsPhysical or medical problems Family problemsFamily problems Economic cutbacks (layoffs, fluctuations in economy)Economic cutbacks (layoffs, fluctuations in economy) Money pressuresMoney pressures Change in job responsibilitiesChange in job responsibilities RESIDENCY !!!!! BUT DON’T FORGET – RESIDENCY !!!!! BUT DON’T FORGET – IT’S IT’S
TEMPORARY !!!!!TEMPORARY !!!!!
Some RESIDENCY ISSUESSome RESIDENCY ISSUES Work hours petition rejected by OSHAWork hours petition rejected by OSHA ACGME voluntary standards supportedACGME voluntary standards supported
– 80 hours/week80 hours/week– Minimum 10 hrs. between shiftsMinimum 10 hrs. between shifts
Burnout said to be linked to overwork & to lead to suboptimal Burnout said to be linked to overwork & to lead to suboptimal care (Shanafelt, et al. Annals Int Med. Sept. 2002)care (Shanafelt, et al. Annals Int Med. Sept. 2002)
Some commentators say fewer hours lead to less competence Some commentators say fewer hours lead to less competence burnout (because of poor academic teaching & inadequate burnout (because of poor academic teaching & inadequate performance). i.e. suboptimal care leads to burnout (from performance). i.e. suboptimal care leads to burnout (from angst), not vice versa (Graham, Annals of Internal Med. Oct. angst), not vice versa (Graham, Annals of Internal Med. Oct. 2002) 2002)
Stages of burnoutStages of burnout
Early Symptoms Early Symptoms – Low energyLow energy– BoredomBoredom– Still productive, but diminishedStill productive, but diminished
Advanced SymptomsAdvanced Symptoms – Poor performance evaluationsPoor performance evaluations– Presence of physical and psychological Presence of physical and psychological
symptoms symptoms
PreventionPrevention
Awareness!Awareness!
Exercise: Why You Became A Exercise: Why You Became A Physician (3 reasons) Physician (3 reasons) Exercise: Assessing Joys &Hardships Exercise: Assessing Joys &Hardships
(3 joys; 3 hardships)(3 joys; 3 hardships)At this pointAt this point: Break into groups of 3 : Break into groups of 3
((55 minutes) minutes)Negotiate & decide the above & Negotiate & decide the above & present to group (present to group (5-105-10 minutes) minutes)
Keeping Your Eye on the BallKeeping Your Eye on the Ball
Communication not CompetenceCommunication not Competence= most important skill.= most important skill.
The Cochrane Database of Systematic ReviewsThe Cochrane Database of Systematic Reviews Volume (Issue 4) 2002 Volume (Issue 4) 2002
Communication skills training for health care Communication skills training for health care professionals working with cancer patients, their professionals working with cancer patients, their
families and/or carersfamilies and/or carers[Protocol]Fellowes, D; Wilkinson, S; [Protocol]Fellowes, D; Wilkinson, S; Moore, PMoore, P
Date of Most Recent Update: 9-4-2002Date of Most Recent Update: 9-4-2002 Date of Most Recent Substantive Update: 1-11-2001Date of Most Recent Substantive Update: 1-11-2001
Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, et al. Burnout and psychiatric disorder among cancer Leaning MS, et al. Burnout and psychiatric disorder among cancer clinicians. British Journal of Cancer 1995;71(6):1263-9.clinicians. British Journal of Cancer 1995;71(6):1263-9.
Review in progress…….Review in progress…….
Sex differences in physician Sex differences in physician burnout in the United States burnout in the United States and The Netherlandsand The NetherlandsJ Am Med Womens Assoc 2002 Fall;57(4):191-3J Am Med Womens Assoc 2002 Fall;57(4):191-3Linzer M, McMurray JE, Visser MR, Oort FJ, Smets E, de Haes HCLinzer M, McMurray JE, Visser MR, Oort FJ, Smets E, de Haes HC
Separate physician surveys:United States (n=2326)Separate physician surveys:United States (n=2326)Netherlands (n=1426 Netherlands (n=1426
Gender parity in physician burnout in the Gender parity in physician burnout in the Netherlands may be due to fewer work hours and Netherlands may be due to fewer work hours and
greater work control of women compared to those greater work control of women compared to those in the United States in the United States
Life Satisfaction Among Norwegian Life Satisfaction Among Norwegian Young Doctors: A Longitudinal StudyYoung Doctors: A Longitudinal StudyReidar Tyssen, MD, PhD; Per Vaglum, MD, PhD; Reidar Tyssen, MD, PhD; Per Vaglum, MD, PhD;
Nina T.Grønvold, MD & Øivind Ekeberg, MD, PhD.Nina T.Grønvold, MD & Øivind Ekeberg, MD, PhD.Department of Behavioral Sciences in Medicine, Department of Behavioral Sciences in Medicine,
Faculty of Faculty of Medicine University of Medicine University of
OsloOslo
Paper presented at International Conference on Paper presented at International Conference on
Physician Health in Vancouver, B.C, Oct.19, 2002 Physician Health in Vancouver, B.C, Oct.19, 2002
Preliminary and unpublished data,Preliminary and unpublished data,courtesy of the author. courtesy of the author.
Results: Comparison of Life Satisfaction Among Doctors and Comparison Group
dissatisfied - satisfied
7.06.05.04.03.02.01.0
Life-satisfaction
Doctors
Freq
uenc
y
200
100
0
Std. Dev = 1.01
Mean = 5.2
N = 420.00
dissatisfied - satisfied
7.06.05.04.03.02.01.0
Life-satisfaction
Controls general population
Freq
uenc
y
700
600
500
400
300
200
100
0
Std. Dev = .98
Mean = 5.6
N = 1627.00
Mean : 5.2 (1.01) Mean: 5.6 (0.98)
T-test: t = 7.0, p<0.001NB!: No gender differences
““Very/extremely satisfied” with Very/extremely satisfied” with lifelife
0102030405060708090
100
Doctors Controls
WomenMen
1/3 among doctors1/3 among doctors 1/2 (or more) among 1/2 (or more) among
other peopleother people Statistics (doctors Statistics (doctors
vs. controls): vs. controls): Chi-Square = Chi-Square = 49.3 P<0.00149.3 P<0.001
%
Dissatisfied with life (any Dissatisfied with life (any category)category)
0
5
10
Doctors Controls
WomenMen
3.8% (16/420) 3.8% (16/420) among doctorsamong doctors
1.9% (31/1627) 1.9% (31/1627) among other peopleamong other people
Chi-square = 5.4 Chi-square = 5.4 P = 0.03P = 0.03
%
ConclusionConclusion Young physicians are less satisfied with life than other Young physicians are less satisfied with life than other
people in the society people in the society Subjective well-being:Subjective well-being:- Probably impeding factors: - Probably impeding factors: Mental distress (personality Mental distress (personality
trait), work stress and life stresstrait), work stress and life stress- Probably promoting factors: - Probably promoting factors: Having a stable partner, Having a stable partner,
social support, physical training. social support, physical training.
About 30% of the variance is predicted at medical school About 30% of the variance is predicted at medical school level (personality trait & medical school variables)level (personality trait & medical school variables)
Balancing lifeBalancing lifeSocial relationships
Personal time & self-care
Working hours
Spare time
COPING STRATEGIESCOPING STRATEGIES
INDIVIDUAL FACTORS-- the physician’s INDIVIDUAL FACTORS-- the physician’s personalitypersonality
ORGANIZATIONAL FACTORS -- workplace ORGANIZATIONAL FACTORS -- workplace stressorsstressors
ESTABLISHING PRIORITIESESTABLISHING PRIORITIES FOCUSING ON MOST TROUBLESOME FOCUSING ON MOST TROUBLESOME
ISSUESISSUES SET REALISTIC, ATTAINABLE GOALSSET REALISTIC, ATTAINABLE GOALS
TreatmentTreatment
Self helpSelf help TherapyTherapy Psychotropic MedicationsPsychotropic Medications Focus on SpiritualityFocus on Spirituality
Resolution to ActResolution to Act!!
Barriers to Proper Treatment Barriers to Proper Treatment
Often unrecognized until problem is severeOften unrecognized until problem is severe Professionals rarely present with burnout Professionals rarely present with burnout
as primary issueas primary issue Embarrassment Embarrassment
SPECIFIC STRATEGIESSPECIFIC STRATEGIES
Self-help books on stress managementSelf-help books on stress management Specific books for physiciansSpecific books for physicians Internet resourcesInternet resources Self-assessment tool: StressMapSelf-assessment tool: StressMap Stress-management workshopsStress-management workshops Individual counseling, especially for self-Individual counseling, especially for self-
esteem and identity issuesesteem and identity issues
STRESS-MANAGEMENT STRESS-MANAGEMENT TECHNIQUESTECHNIQUES
INCREASE SELF-INCREASE SELF-AWARENESSAWARENESS
SHARE FEELINGS SHARE FEELINGS AND AND RESPONSIBILITESRESPONSIBILITES
SELF-CARESELF-CARE PERSONAL PERSONAL
PHILOSOPHYPHILOSOPHY
EXPLORE HOW EXPLORE HOW “HEALTHY” “HEALTHY” PHYSICIANS DEAL PHYSICIANS DEAL WITH STRESSWITH STRESS
APPRECIATE YOUR APPRECIATE YOUR OWN ROLE, DON’T OWN ROLE, DON’T BLAME OTHERSBLAME OTHERS
CONSIDER ALL CONSIDER ALL OPTIONSOPTIONS
Strategies to Prevent Physician BurnoutStrategies to Prevent Physician Burnout
PersonalPersonal
Influence happiness through personal values and choicesInfluence happiness through personal values and choices
Spending time with family and friendsSpending time with family and friends
Religious or spiritual activityReligious or spiritual activity
Self-care (nutrition, exercise)Self-care (nutrition, exercise)
Adopting a healthy philosophical outlookAdopting a healthy philosophical outlook
A supportive spouse or partnerA supportive spouse or partner
WorkWork
Control over environment: workloadControl over environment: workload
Finding meaning in work and setting limitsFinding meaning in work and setting limits
Having a mentorHaving a mentor
Having adequate administrative support systemsHaving adequate administrative support systems
WHAT TO DO WHEN WHAT TO DO WHEN “BUMMED-OUT”“BUMMED-OUT”
““Choose something like a Star”Choose something like a Star”TRY POETRYTRY POETRY
INSPIRATIONAL (“IF”)INSPIRATIONAL (“IF”)OR CALMING(“The Day is OR CALMING(“The Day is
Done”)Done”)
The Day is Done… Henry The Day is Done… Henry Wadsworth LongfellowWadsworth Longfellow
The day is done, and The day is done, and the darknessthe darkness
Falls from the wings Falls from the wings of Night, of Night,
As a feather is wafted As a feather is wafted downwarddownward
From an eagle in his From an eagle in his flight.flight.
I see the lights of the I see the lights of the villagevillage
Gleam through the Gleam through the rain and the mist,rain and the mist,
And a feeling of And a feeling of sadness comes o’er mesadness comes o’er me
That my soul cannot That my soul cannot resist:resist:
The Day is DoneThe Day is Done
A feeling of sadness A feeling of sadness and longing,and longing,
That is not akin to That is not akin to pain,pain,
And resembles sorrow And resembles sorrow onlyonly
As the mist resembles As the mist resembles the rain.the rain.
Come, read to me Come, read to me some poem,some poem,
Some simple and Some simple and heartfelt lay,heartfelt lay,
That shall soothe this That shall soothe this restless feeling,restless feeling,
And banish the And banish the thoughts of day.thoughts of day.
The Day is DoneThe Day is Done
Not from the grand old Not from the grand old masters,masters,
Not from the bards Not from the bards sublime,sublime,
Whose distant Whose distant footsteps echofootsteps echo
Through the corridors Through the corridors of Time.of Time.
For, like strains of For, like strains of martial music,martial music,
Their mighty thoughts Their mighty thoughts suggest suggest
Life’s endless toil and Life’s endless toil and endeavor;endeavor;
And tonight I long for And tonight I long for rest.rest.
The Day is DoneThe Day is Done
Read from some Read from some humbler poet,humbler poet,
Whose songs gushed Whose songs gushed from his heart,from his heart,
As showers from the As showers from the clouds of summer,clouds of summer,
Or tears from the Or tears from the eyelids start;eyelids start;
Who through long Who through long days of labor,days of labor,
And nights devoid of And nights devoid of ease,ease,
Still heard in his soul Still heard in his soul the music the music
Of wonderful Of wonderful melodies.melodies.
The Day is DoneThe Day is Done
Such songs have Such songs have power to quietpower to quiet
The restless pulse of The restless pulse of care,care,
And come like the And come like the benedictionbenediction
That follows after That follows after prayer.prayer.
Then read from the Then read from the treasured volumetreasured volume
The poem of thy The poem of thy choice,choice,
And lend to the rhyme And lend to the rhyme of the poetof the poet
The beauty of thy The beauty of thy voice.voice.
The Day is DoneThe Day is Done
And the night shall be filled with And the night shall be filled with musicmusic
And the cares, that infest the day,And the cares, that infest the day, Shall fold their tents, like the Shall fold their tents, like the
Arabs,Arabs, And as silently steal away.And as silently steal away.
IF…. by Rudyard KiplingIF…. by Rudyard Kipling
If you can keep your If you can keep your head when all about youhead when all about you
Are losing theirs and Are losing theirs and blaming it on you;blaming it on you;
If you can trust yourself If you can trust yourself when all men doubt when all men doubt you,you,
But make allowance for But make allowance for their doubting too:their doubting too:
If you can wait and not If you can wait and not be tired by waiting,be tired by waiting,
Or, being lied about, Or, being lied about, don’t deal in lies,don’t deal in lies,
Or being hated don’t Or being hated don’t give way to hating,give way to hating,
And yet don’t look too And yet don’t look too good nor talk too wise;good nor talk too wise;
If……..If……..
If you can dream-- and If you can dream-- and not make dreams your not make dreams your master;master;
If you can think-- and not If you can think-- and not make thoughts your aim,make thoughts your aim,
If you can meet with If you can meet with Triumph and DisasterTriumph and Disaster
And treat those two And treat those two impostors just the same:impostors just the same:
If you can bear to hear If you can bear to hear the truth you’ve spokenthe truth you’ve spoken
Twisted by knaves to Twisted by knaves to make a trap for fools,make a trap for fools,
Or watch the things you Or watch the things you gave your life to broken,gave your life to broken,
And stoop, and build And stoop, and build ‘em up with worn-out ‘em up with worn-out tools;tools;
If…..If…..
If you can make one If you can make one heap of all your heap of all your winningswinnings
And risk it on one turn And risk it on one turn of pitch-and-toss,of pitch-and-toss,
And lose, and start again And lose, and start again at your beginnings,at your beginnings,
And never breathe a And never breathe a word about your loss:word about your loss:
If you can trust your If you can trust your heart and nerve and heart and nerve and sinewsinew
To serve your turn long To serve your turn long after they are gone,after they are gone,
And so hold on when And so hold on when there is nothing in youthere is nothing in you
Except the Will which Except the Will which says to them: “Hold on!”says to them: “Hold on!”
If…..If…..
If you can talk with If you can talk with crowds and keep your crowds and keep your virtue,virtue,
Or walk with Kings-- Or walk with Kings-- nor lose the common nor lose the common touch,touch,
If neither foes nor loving If neither foes nor loving friends can hurt you,friends can hurt you,
If all men count with If all men count with you, but none too much:you, but none too much:
If you can fill the If you can fill the unforgiving minuteunforgiving minute
With sixty seconds’ With sixty seconds’ worth of distance run,worth of distance run,
Yours is the Earth, and Yours is the Earth, and everything that’s in it,everything that’s in it,
And -- which is more And -- which is more -- you’ll be a Man, my -- you’ll be a Man, my son!son!
What we’ve done this hourWhat we’ve done this hour(Please (Please fill out Evaluation – really helpful for our fill out Evaluation – really helpful for our improvement)improvement)
Dimensions of burnoutDimensions of burnout
Brief activity for residents & facultyBrief activity for residents & faculty
Some research in the fieldSome research in the field
Prevention & treatmentPrevention & treatment
What to do when “bummed out”What to do when “bummed out”