Who is Going to Heal the Healers? - Bounce Back … is Going to Heal the Healers? Reflections on how...

2016 MMIC. All rights reserved

Who is Going to Heal the Healers?Reflections on how we as leaderscan support our providers

Laurie C. Drill-Mellum, MD, MPHChief Medical Officer Vice President of Patient Safety

December 8, 2016Bounceback Resilience Conference

2016 Constellation. All rights reserved.

Steeped in medicine my whole life

Anthropologist by training Psychologist by nature Emergency Medicine Integrative Medicine Fellow-ship Chief Medical Officer, MMIC Hospice Medical Director

Self-disclosure


Review historical and cultural context for the practice of medicine

Review theories of psychological and behavioral drivers

Review current state of burnout in physicians and the tie to quality, safety, experience, and retention

Review resources for addressing burnout and building resiliency for individuals and organizations

Give examples of programs and tools to address burnout for providers and organizations

Objectives


Curlys one thing


Physician burnout climbs 10% in 3 years,

hits

55%

Burnout is growing (Mayo Clinic research)

Shanafelt, Tait D. et al; http://dx.doi.org/10.1016/j.mayocp.2015.08.023


Burnout by specialty 2014 vs. 2011

Shanafelt, Tait, et al, Mayo Clinic Proceedings: Vol. 90, Issue 12, A1-A36, e129-e141, 1593-1748 2016 MMIC. All rights reserved


Reduced patient satisfaction Increased medical errors Increased malpractice risk Increased hospital mortality rates

Why caring for the healers matters

Burnout and emotional exhaustion

Reduced capacity for empathy

* Journal of Nursing Care Quality April 1996 - Volume 10 - Issue 3 Dugan et al. Stressful nurses: the effect on patient outcomes.** Journal of Applied Psychology, Vol 73(4), Nov 1988, 727-735 Jones et al Stress and medical malpractice: Organizational risk

assessment and intervention.*** Stress and Health Volume 22, Issue 2, pages 131137, April 2006, A proposed physicianpatient cycle model**** AHRQ May 2003, David H Hickam, MD, MPH , The Effect of Health Care Working Conditions on Patient Safety


Relationship of error to risk

Schwappach D., Boluarte T., The emotional impact of medical error involvement on physicians: a call for leadership and organizational accountability. Swiss Med Wkly 2008: 138(1-2):9-15.

Guilt Frustration

Error involvement

Fear

Responses to distress:Burn-out, depression, diminishing empathy

Quality of care,Patient safety


Physician burnout

Positive screen for depression

2011: 38%

2014: 40%

Thoughts of suicide in past year

2011: 6.4%

2014: 6.4%Shanafelt, Tait D., et al. "Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014." Mayo Clinic Proceedings. Vol. 90. No. 12. Elsevier, 2015.


Growth of physicians and administrators19702009

PhysiciansAdministrators

13

3500%

3000%

2500%

2000%

1500%

1000%

500%

0%1970 1975 1980 1985 1990 1995 2000 2005 2009

Source: Bureau of Labor Statistics; NCHS; and Himmelstein/Woolhandler analysis of CPS


Noble intent Duty Special knowledge Beneficent Self-regulating

Era 1: Professionalism, trust, prerogative(Berwick, IHI 2015)

https://www.youtube.com/watch?v=DKK-yFn7e_0

https://www.youtube.com/watch?v=DKK-yFn7e_0


Accountability Scrutiny, inspection, control Measurement Incentive Doubt

Era 2: About money, not trust

Berwick, IHI, 2015


1. Stop excessive measurement

2. Abandon complex incentives

3. Decrease focus on finance

4. Avoid professional prerogative at the expense of the whole

Era 3: The moral era

5. Recommit to improvement science

6. Embrace transparency

7. Protect civility

8. Listen. Really listen

9. Reject greed

Wrong route Ri

ght r

oute

Berwick, IHI, 2015


Its an evolutionPhysician-centered

Patient-centered

People-centered

Metrics/$$-focused


Is there a medical personality?


It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.

William Osler, MD


Mastery Purpose Control

What motivates us?


Edward Deci research

Competence Relatedness Autonomy

Self-determination theory and motivation


Maslows hierarchy of needs

Morality, creativity,

spontaneity,problem solving,lack of prejudice,

acceptance of factsSelf-actualization

Esteem

Social

Safety

Physiological

Self-esteem, confidence, achievement, respect of others, respect by others

Friendship, family, sexual intimacy

Security of: body, employment, resources, morality, the family, health, property

Breathing, food, water, sex, sleep, homeostasis, excretion


Asymmetric Rewards Loss of Autonomy Cognitive Scarcity

Disturbing trends in the practice of medicine


Finding a creative occupation or work with personal meaning

Experiencing love and connection Creating meaning from adversity

Frankl, Victor (1946). Mans Search for Meaning

How do we find meaning?


Recognition and acknowledgementof issue

Motivation to address it (internal v. external)

Tools and resources Accountability

Drill-Mellum theoryof change


Tools and strategies for self-careand resiliency

Good nutrition and sleep Exercise 4-7-8 breathing technique Meditation/mindfulness Gratefulness journal Random acts of kindness Support groups Social connection/

spiritual practice


Engage BOD and Leadership Measure burnout-Dashboard Engage MDs in listening

sessions and supportchampions in the work

Listen-Act-Develop Model Participative Management Measure again

For organizations


Encourage discussion of errors

Create options for flexible schedules

Address challenges with workflow

Address challenges with EHRs

Organizations


AMA STEPS forward program

https://www.stepsforward.org/


1. Establish wellness as a quality indicator.2. Start a wellness committee or choose a wellness

champion.3. Distribute an annual wellness survey.4. Meet regularly with leaders to discuss data and

interventions.5. Initiate selected interventions.6. Repeat the survey to re-evaluate the situation.7. Seek answers within data, refine the interventions and

continue improvements.

7 steps to prevent burnout in your practice

https://www.stepsforward.org


Meta analysis of 19 studies Significant improvement with organization-directedInterventions targeting the work environment(rare) Physician-directed interventions targeting individuals

less impactful, but still small impact Findings supports view that this is not an individual

problem, but a systemic one

Controlled Interventions to Reduce B/O


We can live without religion and meditation, but we cannot survive without human affection.

The Dalai Lama



Build supportive communitiesa. Schwartz roundsb. Balint groupsc. Finding Meaning in

Medicine groups Wellness Rooms Facilitate socialization/connection

Address the need for Tribe


Words of affirmation Quality time Receiving gifts Acts of service Physical touch

Five languages of love


Words of affirmation Quality time Acts of service Tangible gifts Physical touch

Five languages of appreciation


The power of presence


Lets circle back to Chillys story


picture

https://www.mmicgroup.com/pdf/MMIC_Brink%20Magazine_2014%20Fall.pdf


Whats your one thing?


Feed em Water em Provide them with a

chance to rest, to work out, to commune

Care for them Engage them-Listen Seek to understand

Take Home Message:Take care of your peeps!


Books

A Hidden Wholeness: The Journey Toward an Undivided Life by Parker J. Palmer Adverse Events, Stress, and Litigation: A Physicians Guide by Sara Charles, MD Ambiguous Loss: Learning to Live with Unresolved Grief by Pauline Boss, Ph.D. Drive by Daniel Pink Enjoy Every Sandwich and Finding Balance in a Medical Life by Lee Lipsenthal,

M.D. Flourish by Dr. Martin Seligman Healthy Aging by Andrew Weil, M.D. Mans Search for Meaning by Victor Frankl The 5 Love Languages of Love by Gary D. Chapman The 5 Languages of Appreciation in the Workplace by Gary D. Chapman and

Paul E. White The Chemistry of Joy by Henry Emmons, M.D.

References and resources


Links Chillys Story in Brink magazine:

https://www.mmicgroup.com/pdf/MMIC_Brink%20Magazine_2014%20Fall.pdf

Papers A Cluster Randomized Trial of Interventions to Improve Work

Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study; Linzer, Mark et al, presented in part at the Annual Meetings of the Society of General Internal Medicine, San Diego, CA, April 2014.

Disturbing trends in physician burnout and satisfaction with work-life balance. Mayo Clinic Proc.2015;90(12):593-6.

Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014; Shanafelt, Tait D. et al., Mayo Clinic Proceedings , Volume 90 , Issue 12 , 1600 1613.



Institute for Healthcare Improvement. Era three for national health care. Available at : www.ihi.org/resources/Pages/Publications/Era-Three-for-Medicine-Health-Care.aspx.

Meaning and the nature of physicianswork; Rosenthal, D, Verghese, A, NEJM 2016;375:19:1813-15.

Physician Well-Being: Expanding the Triple Aim; Colin P. West, PhD, Journal of general internal medicine : 2016 Feb 26

Physician-organization collaboration reduces physician burnout and promotes engagement: The Mayo Clinic Experience. Jhealthc Manag. 2016;61(12):105-27.

The emotional impact of medical error involvement on physicians: a call for leadership and organizational accountability, Schwappach D., Boluarte T.. Swiss Med Wkly 2008: 138(1-2):9-15.


http://www.ihi.org/resources/Pages/Publications/Era-Three-for-Medicine-Health-Care.aspxhttp://www.unboundmedicine.com/medline/?st=M&journal=J%20Gen%20Intern%20Med


Websites americanbalintsociety.org bluezones.com bouncebackproject.org drweil.com gratefulness.org http://www.mmicgroup.com/resources/well-being-center rishiprograms.org (Finding Meaning in Medicine groups) stepsforward.org theschwartzcenter.org


2016 MMIC All rights reserved

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Who is Going to Heal the Healers?Reflections on how we as leaderscan support our providersSelf-disclosureObjectivesSlide Number 4Curlys one thingCurlys one thingBurnout is growing (Mayo Clinic research)Burnout by specialty 2014 vs. 2011Burnout by specialty 2014 vs. 2011Why caring for the healers mattersRelationship of error to riskPhysician burnoutGrowth of physicians and administrators19702009Era 1: Professionalism, trust, prerogative(Berwick, IHI 2015)Era 2: About money, not trustEra 3: The moral eraIts an evolutionSlide Number 18Is there a medical personality?It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has. William Osler, MDWhat motivates us?Slide Number 22Self-determination theory and motivationSlide Number 24Maslows hierarchy of needsDisturbing trends in the practice of medicineHow do we find meaning?Drill-Mellum theoryof changeTools and strategies for self-careand resiliencyFor organizationsOrganizationsAMA STEPS forward program7 steps to prevent burnout in your practiceControlled Interventions to Reduce B/OSlide Number 35Address the need for TribeSlide Number 37Five languages of loveFive languages of appreciationThe power of presenceThe power of presenceLets circle back to Chillys storySlide Number 43Slide Number 44Take Home Message:Take care of your peeps!Slide Number 46References and resourcesReferences and resourcesReferences and resourcesReferences and resourcesContact me

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