Professionalism & Professional Health: Faculty Overview

1. Professionalism & Professional Health:Faculty Overview Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration Associate Professor of Medicine Co-Director & Chair William H. Swiggart, M.S.,LPC/MHSP Assistant in Medicine Co-Director Center for Professional Health, Faculty and Physician Wellness Committee, Vanderbilt University School of Medicine

2. Purpose • To raise awareness of issues related to professionalism and professional health and to provide an overview of key resources in/outside of Vanderbilt.

3. Participant Objectives • List ways to improve your professional health. • Compare and contrast workplace stress and burnout. • Describe distressed behaviors and how to report them. • State resources available for faculty and physicians in/out of Vanderbilt.

4. Agenda • Professional Wellness • Workplace stress, burnout and suicide • Distressed behaviors • Resources • Q&A and Summary

5. Fair Functioning Reduced Productivity Relationships Suffer Fair-Not Functioning Fair-Not Productive Institution & Family Loses High Functioning High Productivity Fair Functioning Decreasing Productivity Coping Mechanisms Risk of MH issues and suicide Faculty vitality Stress & Burnout Professional Health Spectrum

6. Importance & Evidence • MDs suicide > other prof. & gen pop. • One physician per day; PhD – unclear • Grossly underestimated • Little education on topic • 30-60% MD have distress and burnout • Depression/bipolar & substance abuse = suicide risk “Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success.” Cole, Goodrich & Gritz, 2009.

7. Importance & Evidence • Reduced wellness professional lapses • Gender differences: • Females > anxiety, depression, burnout • F>M MD suicides • Reduced use of care by physician • Stigma & anonymity http://www.aamc.org/members/gwims/statistics/stats09/start.htm Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82. (Schindler et al 2006) “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008

8. Professional Wellness • Self-care • Work-place stress Mind, Body and Spirit Balance takes effort, but worth the reward!

9. Professional Wellness Mind Body • Self-care issues: • Sleep • Balanced meals • Physical activity • Socialization • Vacations/down times • Spiritual engagement • Have a physician Soul

10. Work-Place Stress Manage Energy Reduce Distractions Work-place stress: • Manage energy • Reduce distractions • Plan appropriately • Managing failures and successes Planning

11. “The first wealthishealth.”~ Ralph Waldo Emerson

12. Stress & Burnout Stress and burnout occurs for different reasons in different individuals. Work load ≠ level of stress or burnout in all situations. Multifactorial

13. Productive Stress No Prolonged Stress Declining Function Stress & Productivity Prolonged Stress Situational Stress Stressed Burnout Non-Functional

14. Burnout “In the current climate, burnout thrives in the workplace. Burnout is always more likely when there is a major mismatch between the nature of the job and the nature of the person who does the job.” ~Christina Maslach The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

15. Single Gender/sexual orientation ># of children at home Family problems Mid-late career Previous mental health issues (depression) Fatigue & sleep deprivation General dissatisfaction Alcohol and drugs Minority/international Teaching & research demands Potential litigation Risk Factors for Burnout Puddester D. West J Med 2001;174:5-7 Myers MJ West J Med 2001;174:30-33 Gautam M West J Med 2001;174:37-41

16. Work overload Lack of control Insufficient reward Unfairness Breakdown of community Value conflict Six Sources of Burnout Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.”

17. Symptoms of Burnout Chronic exhaustion Cynical and detached Increasingly ineffective at work Leads to: isolation avoidance interpersonal conflicts high turnover Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg 17

18. Protective Factors • Personal: • Tend to self care issues first • Address Maslach’s 6 sources of burnout • Influence happiness through personal values and choices • Adapt a healthy philosophy/outlook • Spend time with family & friends Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):1447-50

19. Protective Factors • A supportive spouse or partner • Engage in religious or spiritual activity • Hobbies • Mentor (s) Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):1447-50

20. Protective Factors • Work: • Address Maslach’s 6 sources of burnout • Gain control over environment & workload • Find meaning in work • Set limits and maintain balance • Have a mentor • Obtain adequate administrative support systems

21. Individual Approach Organizational Approach Starts with person Starts with management Becomes organizational project Becomes group project Connects to organization Connects to people Outcomes affects related mismatches Outcome is a process Preventing & Resolving Burnout Figure 5.1 (pg 80) Maslach, C & Leiter, MP. “The Truth About Burnout: How Organizations Cause Personal Stress and What to do About It.” 1997

22. Case 1: It’s 10:30 PM and you pass your colleague in the hall. She is a 48 yo female physician, recently divorced with one kid. You can tell she was crying. When you ask what is wrong she shapes up and replies, “Nothing really. I am so frustrated with the system!” You offer to talk and she declines. • What are your concerns? • What are her risk factors for stress & burnout?

23. Suicide • “Friends who work with people in medicine need to be aware that, if they see something that concerns them, they need to transmit the message to the powers that be.” Dr. W. Gerald Austen, surgeon-in-chief emeritus Massachusetts General Hospital

24. Case 2: Dr S has struggled for the last year to “fit in.” He often seems emotionless and flat. He has been considered “unsocial” because he does not participate in any of the faculty gatherings. He has missed several deadlines and often calls in sick. His students say he doesn’t teach and is erratic at times. Once on his day off you saw him leaving a bar possibly drunk and on his post call day he was not responding to emails or pages for several hours. Just after the holidays he was found dead after a single vehicle MVA. • What are you concerned with here? • What barriers may play a role in this case?

25. Suicide • “However, hard and stressful work alone does not result in suicide. Those who do commit suicide almost always have significant identifiable underlying mental illnesses, such as major depression and/or bipolar disorders, usually coupled with alcoholism and major drug use.” ~Eugene V. Boisaubin Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressures of Success. Pg 32; 2009

26. Unprofessional behaviors Decreased performance Diverting drugs Unusual pharmacy orders PE signs of either intoxication or withdrawal Isolation & withdrawal from friends Mood changes Overreactions to criticism Long sleeves Frequent restroom stops Asks for extra calls Signs of Addiction Wearing Masks II. 1993 rainbow productions. www.Allanestesia.com

27. Addiction • Residents are more prone (especially anesthesia) than faculty • Increases accidental and intended deaths • Denial, cover-ups, easy access • History of addiction – individual or family • “Tried it just once or twice.” Wearing Masks II. 1993 rainbow productions. www.Allanestesia.com

28. Addiction • >50% residents self-prescribe1 • ETOH most commonly used substance2 • 10% faculty use daily; 9% binge2 • 8% use opiates without MD supervision2 • Recovery can be successful  treatment! 1. Christie et al. 1998 Prescription Drug use and self-prescription among residents. JAMA 280:1253-55) 2. Hughes et al. 1992 Prevalence of substance use among US physicians. JAMA 267:2333-39.

29. “Inaction is NOT an option.”~Dr John Lecky – recovering addicted physicianReport concerns to:SuperiorsPhysician’s Health Program – confidentialWellness Programs – FPWPFPWC Members

31. Case 3: Dr D is an OB/GYN who was fired from one residency program. She joined the faculty 6 mo ago. Since then, she has had five pt and staff generated complaints about her aggressive, loud behavior. In stressful situations, she becomes loud, forceful and rude. She slammed the door after a heated discussion with a nurse in front of a patient. She has also changed OR times without team permission to “take care of VIP patients.” She is quoted as saying, “This is how I get things done.” • What do her behaviors tell us? • Are her behaviors ok if her skills are outstanding?

32. Internal Factors: Alcohol and drug addiction Compulsive behavior around sexual acting out, compulsive gambling, eating, working, etc. Little or no training in conflict resolution, leadership skills, communication and teaching skills Psychiatric disorders Narcissistic personality disorder Depression/bipolar Dementia etc. External Factors: High system demands and low system support Disruptive behavior is reinforced by the system Bully doc gets preferential operating time Masking ineffective managers Failure to act The system fails to provide physician with complaints and/or feedback Life cycle events (i.e. death in the family, children leaving home, divorce, etc.) Distressed Physicians Swiggart, Dewey, Hickson, Finlayson. 4/09

33. Figure 1 Spectrum of Disruptive Behaviors Passive Aggressive Passive Aggressive Chronically late Failure to return calls Inappropriate/ inadequate chart notes Avoiding meetings & individuals Non-participation Ill-prepared, not prepared Inappropriate anger, threats Yelling, publicly degrading team members Intimidating staff, patients, colleagues, etc. Pushing, throwing objects Swearing Outburst of anger & physical abuse Hostile notes, emails Derogatory comments about institution, hospital, group, etc. Inappropriate joking Sexual Harassment Complaining, Blaming Swiggart, Dewey, Hickson, Finlayson. 4/09

34. Distressed Colleagues • Focus on behaviors • Document behaviors • Discuss with leadership • Report in VERITAS • Re-training can be successful

35. Distressed Physicians “This leadership course has brought about change in the way I perceive others and how I am perceived as a professional, husband and father. This intervention should have occurred earlier.” ~CPH participant 07-08

37. Resources

38. Faculty and Physician Wellness Committee (FPWC) Charlene M. Dewey, M.D., M.Ed., FACP (chair)

39. Vanderbilt Internal Resources

40. Vanderbilt Internal Resources • Center for Integrated Health (CIH) • Health Plus • Go for the Gold program • Center for Professional Health Educational Resource web page/on-line classroom (in development) • Dayani center & ortho exercise facility • VERITAS

41. Other Resources • Primary care provider • Centerstone, Elam Center or other private counseling services • Cumblerland Heights & Evelyn Fry for substance use related issues • 1-800-273-TALK: suicide prevention hotline • YMCA/YWCA • State physician health programs

42. Q&A

43. Summary • Good professional health protects both you and your career • Workplace stress and burnout are common in AMC – be aware of the risks and try to prevent it when possible • Seek assistance when needed • Vanderbilt has several resources to assist

44. More Information • Please feel free to contact us: • Charlene.dewey@vanderbilt.edu • Wiliam.swiggart@vanderbilt.edu

45. CPH & FPWC Web Pagehttp://www.mc.vanderbilt.edu/cph CPH FPWC Center for Professional Health * 1107 Oxford House * x6-0678