The Art of Well-Being
PhysicianWellnessJacquesG.LeBlancMD.,F.R.C.S.C.
January2018
What is Wellness?
Ayurveda
BalancingtheRhythmofLife
International Population Health
Australia USA India
Overweight 62% 69% 72%
Diabetes 14% 14% 21%
CardiacProblems 18% 16% 57%
Smoking 23% 28% 24%
Alcohol 13% 14% 12%
WHOstats2012
“ CALLING “
• Doingsomethingyouaregoodatandlike
• Feelingappreciated
andofworth
• Makinglifebetterfor
• peoplePatientCareisthemostRewardingaspectofourprofession.
Medicine, A Sense of Calling?
• PracticeofMedicinehaslongbeenseenasacalling.• Acallingisdefinedasworkthatisrewarding,thathaspersonalmeaningandserveasocialpurpose,notjustgettingapaycheck
• Senseofcallingisassociatedwithagreatersenseofengagement,butagreatersenseofresponsibilityandthereforepotentialforburnout.
Physician Health The Whole Person
• Physical• Mental
• Emotional
• Spiritual
• Professional
• Lifestyle• Environmental
DeclarationofAlma-Ata:InternationalConferenceonPrimaryHealthCare,Alma-Ata,USSR,6-12September,1978TheConferencestronglyreaffirmsthathealth,whichisastateofcompletephysical,mentalandsocialwellbeing,andnotmerelytheabsenceofdiseaseorinfirmity,isafundamentalhumanrightandthattheattainmentofthehighestpossiblelevelofhealthisamostimportantworld-widesocialgoal………
The Scope of the Problem
DifferencesbetweenStressandBurnout
StressisthestimulusBurnoutisthebehavior
Physicians Work Life Issues
• Burnout• SleepDeprivation• Depression• Substanceabuse:alcohol,cigarettes,food• Drugabuse:narcotics,analgesics,
What is burnout?
• Emotionalexhaustion:Emotionallyoverextended,losingenthusiasm.
• Depersonalization:Negativeattitudes.
• Reducedsenseofaccomplishment:Workisnolongermeaningful.
• Neglectingneeds:Puton“backburner”.
• Interpersonalconflict:Lesstolerant,anger,notattentive.
• Psychiatricsymptoms:Addictivebehaviors,depression,suicide.
Themajorityofpeopleinthisroomhaveexperiencedburnout….
Burnout affects physicians at all levels of training
• MedicalSchool-28-45%• Residency-27%-75%dependingonspecialty• AttendingPhysiciansatvariousstagesofcareer-average37.9%
BurnoutDuringResidencyTraining:ALiteratureReview.WaguihWilliam,MDetal2008BurnoutandSatisfactionwithWork-LifeBalanceAmongUSPhysiciansRelativetotheGeneralUSPopulation.TateD.Shanafeltetal.2012
Burnout among Physicians
20112014Burnout45.8%54.4%EmotionalExhaustion37.9%46.9%Depersonalization29.4%34.6%Dissatisfiedwithwork-lifebalance36.9%44.5%
Shanafeltetal.,ArchIntMed2014 7,000USPhysicianssurvey
Why is burnout increasing?
• Fundamentalchangesinhealthcare• Increasedvolume/demandonproviders• RiseofEHRsmadetoimprovebilling
• Increaseddocumentationtime• Alteredpatientinteraction
• Risingnegativeviewsofdoctors• Dutyhours
• Sameamountofworkinlesstime
Factors Leading to Burnout
TimedemandsIncreasingbureaucratictasks
LackofcontroloverscheduleLackofautonomyWorkload/intensityFinancialstrainUnmetpersonalneedsFeelingoverwhelmedatworkLackofavoiceinimportantmattersLackofcontroloverpracticeenvironment
Selected Factors related to Burnout
• Timeandbureaucraticpressure• Sleepdeprivation• Addictions• Substancesabuse• Suicide
Sleep Deprivation
“Patientshavearighttoexpectahealthy,alert,responsible,andresponsivephysician.”
January1994statementbyAmericanCollegeofSurgeonsRe-approvedandre-issuedJune2002
©AmericanAcademyofSleepMedicine
Perc
ent
0
25
50
75
100
Wor
k H
rs/w
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25
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Hours of Sleep< 4 hrs 5-6 hrs > 7 hrs
Work Hrs/wk% Reporting Serious Medical Errors% Reporting Serious Staff Conflicts
*Baldwin and Daugherty, 1998-9 Survey of 3604 PGY1,2 Residents
WorkHours,MedicalErrors,andWorkplaceConflictsbyAverageDailyHoursofSleep*
©AmericanAcademyofSleepMedicine
•Myth:“IfIcanjustgetthroughthe night(oncall),I’mfineinthe morning.”
•Fact:Adeclineinperformance startsafterabout15-16hoursofcontinuedwakefulness.
•Fact:Theperiodoflowest alertnessafterbeingupall nightisbetween6amand 11am(eg,morningrounds).
©AmericanAcademyofSleepMedicine
RecoveryfromSleepLoss
Myth: “All I need is my usual 5 to 6 hours the night after call and I’m fine.”
Fact: Recovery from on-call sleep loss generally takes 2 nights of extended sleep to restore baseline alertness.
Fact: Recovery sleep generally has a higher percentage of deep sleep, which is needed to counteract the effects of sleep loss.
Why Burnout Matters Professional Consequences
• Increasedmedicalerrors/worsepatientoutcomes• Decreasedpatientsatisfaction/lessempathy• Decreasedjobsatisfaction• Difficultyrelaxingandhavingfun• Impatienceandirritability• Decreaseprofessionalism,disruptivebehaviors• Decreasedproductivity• Absenteism• Depression/suicide
Why Burnout Matters Personal Consequences
• Physiciansatisfactionandsafety• Disruptiontofamily/divorce10%higherthanpop.• Higherratesof
• Divorce• Depression• Anxiety• Substanceabuse• Suicide
Physician Suicide
Clinical Case
A41yr.oldmaleMDhadalonghistoryofselfprescribingsedativestotreatanxietyandinsomnia.Hisdrugusegraduallyescalatedtothepointitwasinterferingwithhisworkandhomelife.Hetriedrepeatedlytocontrolhisuseonhisown,butwithoutsuccess.Hebeganseeingapsychiatristwhofelthehadamooddisorder,anddidnotdirectlyaddressthesubstanceabuse.
Hebegantofeelhislifewasintolerableanddiscussedsuicidewithhiswife,althoughhedidnotdiscloseaplan.Hesubsequentlydiedina“huntingaccident”ofaself-inflictedgunshotwoundtothehead.
Physician Suicide• Suicideishardtopredict• Negatingearlysigns• Worseningsignsofdepression• Cripplingeffectsofstigmaofmentalillness• Illphysiciansrefusinghelpandtreatment• Illphysiciansafraidofloosingcolleaguesrespectandtheirjob
• 400Doctorscommitsuicideeachyear(USstats)• Theequivalentofonemedicalschoolislost
eachyeartosuicide• Suicideisthe2ndmostcommoncauseofdeathin
medicalstudents• Moreattemptsandhighersuccessthanaverage
population• Malephysicians–40%higher• Femalephysicians–130%higher
Some Myths
• “I’mtrainedandthereforeinvulnerable.”• “I’veseenworseandhandleditbefore.”• “I’maprofessional,I’msupposedtobeabletohandlethis.”
• “IfIjustfollowtheprotocols,I’llbeOK.”• “I’mokay–Ihavetobe,whoelseisheretohelp?”
• “Ihavetobestrongandshowagoodspiritualwitness.”
Addictions/Substance Abuse
10-15%ofhealthcareprofessionalswillmisusesubstancesatonepointintheircareer
Alcohol–mostcommonlyabusedOpioidsandstimulants–nextmostcommonRecreationaldrugs(marijuana,cocaine)useislessthangeneralpopulation
Prevalence
• >800,000USphysicians(75%male)• 64,000willdevelopSUD• 112,000willexperienceanAlcoholusedisorder
• Prescriptiondruguse(BDZs,opioids)ishigherindoctorsthaningeneralpopulation
Baldisseri.Impairedhealthcareprofessional.CritCareMed2007Vol.35,No.2(Suppl.)
USgenpop DoctorsSubstanceUseDisorder 6.2% 6-8%AlcoholUseDisorder 13.5% 14%
Substance Use by Physicians
• Physicianslesslikelytousecigarettesandillicitsubstancesthanthegeneralpublic
• Physiciansmorelikelytousealcohol• Physiciansmuchmorelikelytouseminoropiatesandbenzodiazepines
• Overall,8%ofphysiciansreportedeverhavingasubstanceabuseordependenceproblem
(Hughes,etal.JAMA1992;267:2333)
Physician Use of Opiates and Sedatives
• Dependingonageandgender,6-23%ofphysicianshadusednon-prescribedopiatesorsedativesinthepastyear
• Thesesubstanceswereusedby1-4%ofthegeneralpopulation• Mostuseofthesesubstancesbyphysicianswasforself-treatmentofsymptoms
Prognosis
Successrates:• Doctorshavehighabstinencerates(74-90%),
likeairlinepilotMandatoryTreatment
• FrequentUrineChecking• PeerAssistancePrograms• Education&Prevention
WHY THE DELAY IN DETECTION?
• Independence• “Malignantdenial”• “Icantakecareofmyself”• “Knowledgeisprotective”• Fearofconsequences• “Conspiracyofsilence”
Denial
“InoticedifIwasstressed,inanemergencysituation,ortimerestricted,Iwouldgointomyautopilotmodewithmyquestions.Iwaslesspatientandlesslikelytolistentothepatientbutjustgettheinformationquickly.Iflipbackintomynaturalcommunicationoffinishingpeople’ssentencesandtalkingoverthemasopposedtolisten.”
Conclusions
• Burnoutispervasiveandincreasing.• Burnoutresultsinpooroutcomesforpatients,doctors,andhospitals.
• Mostofyourresidentsarestruggling.• Individualapproaches(stressmanagement,wellness)arepartofthesolution.
• Systemicchangesareneededtocopewithchanginghealthcarelandscape.
• Facultyplaykeyrolesinrecognizingburnout,talkingtoresidents,andknowingresourcesfortreatment.
Promote Physician Health
• Decreaseworkload• Reducepressure/increasecontrol• Establishprotectedtime• Establishpriorities• Resiliencytraining• Improvelifestyle
Stimulus and Response
“Betweenstimulusandresponse,thereisaspace.Inthatspace,isourpowertochooseourresponse.Inourresponseliesourgrowthandourfreedom.”
Recommendations• Thetoolkitfortheseissueswillcontainmanydifferenttools.
• Thereisnoonesolution…
• …butmanyapproachesofferbenefit!
Medicine Bag for Self Care
• Buildingupresilience• Selfcare• Organizationalrole• Mindfulness• EmotionalIntelligence• Lifestyle• Spirituality
Treatment: no pills
• SELFCARE
• Professional:balance,priorities,workload• Psychological:reflection,mindfulness,relaxation• Physical:exercise,sleep,nutrition• Social:lifebalance,family,friends,communityengagement
First Give to Yourself Sending positive thoughts to oneself
MayIbehappyMayIbehealthyMayIbesafeandsecureMayIlivewithjoyandease
How to Replenish the Tank
Resilience
• Recognizingdifficulty,problems,andtakeappropriatesteps• Recognizingtiredness,fatigue,sleepdeprivationandaddressit• Understandingsurroundings,notgetangryandreactfromawareness
Definitions
PersonalResilience“Thestrength,innateordeveloped,thatenablesonetoadaptwelltoextremestress”,includingthecapacitiesto:
• Abilitytomaintainstabilitydespiteadversity• Reboundfromthedeleteriouseffectsofevenoverwhelmingstress• Itisaprocessthatcanbetaughtorlearned• Clearboundariesarelimitingelectronicaccess,sayingno,schedulingtimeforpersonnaltime/activities
4 Qualities of Resilience
• Remainrelativelysteadyduringlife’sstorms
• Bend,butdon’tbreak
• Rebound,springback
• BecomestrongerinthefaceofadversityOR
laterasaresultofadversity
TREATMENTOFBURNOUT:PROMOTIONOFWELLNESS
• Individualpromotion.• Relationships:ensure“protected”timeforsignificantotherandfamilymembers;collegialconnections.
• Spiritualpractice:personalattentivenessandspiritualaspectsofself.• Workattitudes:findingmeaninginwork;limitingworkpractice–controloverschedule.
• Self-care:cultivatingpersonalinterestsandself-awareness;professionalhelpwhenneeded.
• Lifephilosophy:positiveoutlook,identifyingandactingonvalues,stressingwork/homebalance.
Mindfulness Definition
“theawarenessthatemergesthroughpayingattention,onpurpose,inthepresentmoment,andnon-judgmentallytotheunfoldingofexperiencemomentbymoment”
JonKabat-Zinn,2003
Mindfulness
“Mindfulnessisaskillthatgetsbetterwithpractice.”
Building Emotional Intelligence
“TrainingtopracticereflectionINACTION
AlongsidepracticingreflectionONACTION”
Trainingtobeawarehowtocommunicatewhilecommunicating.
Awe/Astonish
• Aweisnotaluxury• Wecanactivelyseekoutawe• Wecanfindaweinthesmallthings• Positiveemotionshavebenefits
Achieving Success and Wellness
• Giveittime.
• Giveitimportance.
• Giveitpractice.
• BeValueOriented:missionvaluesmeetmedicalprofession• PromotePhysicianautonomy• PromoteadequateSupportServicesandresources• Promoteautonomy,flexibilityandsenseofcontrol• Cultivateacollegialandpeersupportworkenvironment• Promotemeaninginwork• MinimizeWork-HomeInterference:flexibilityinchildcareforwomen• PromoteWork-lifebalance:mentoring,ensuringvacationtime
• Flexibleandreadilyaccessiblechildcare• Flexibilityinschedulingandreadycoverageforlifeevents(births,funerals,familyemergencies)
Wellness Strategies The Organization's Role
Thank You for your Attention