“Doctor, Your Life is Calling”

1. “Doctor, Your Life is Calling” Work Overload, Burnout, and Empathy: The Struggle to Maintain Work-Life Balance in Psychiatric Practice Steven Pflanz, Lt Col, USAF, MC, FS Chief, AF Suicide Prevention Program Senior Psychiatry Policy Analyst AF Medical Operations Agency

2. Presenter Disclosure Information AOOP Meeting April 14-15, 2007 • No commercial products or services will be discussed in this presentation. • No off-label or investigational use of any medical device or pharmaceutical agent will be discussed in this presentation. • I have no commercial affiliations or financial relationships to disclose

3. References • Willcock SM et al. Burnout and psychiatric morbidity in new medical graduates. Medical Journal of Australia, 181(7):357-360, 2004. • Zuger A. Dissatisfaction with medical practice, NEJM, 350:69-75, 2004. • Landon RF et al. Changes in career satisfaction among primary care and specialist physicians, 1997-2001. JAMA 289(4):442-449, 2003. • Spickard A et al. Mid-Career burnout in generalist and specialist physicians. JAMA 288(12):1447-1450, 2002 • Stress at Work, NIOSH Publication 99-101

4. References • Pflanz, SE. Psychiatric illness and the workplace. Military Medicine 164 (6): 401-406, 1999. • Pflanz, SE. Occupational stress & psychiatric illness in the military. Military Medicine 166 (6): 457-462, 2001. • Pflanz SE, Sonnek S. Work stress & emotional health in the military. Military Medicine 167(11); 2002. • Pflanz SE, Ogle AD. Job stress, depression, work performance and perceptions of supervisors in military personnel. Military Medicine 171 (9): 861-865, 2006.

5. Objectives • Explain the relationships between work overload and empathy, job performance, emotional health • Describe the negative consequences of supervisor and employee burnout in the workplace • Discuss the deleterious effects of psychiatrist work overload on the therapeutic relationship • Recognize the importance of addressing healthy work-life balance in the treatment of patients suffering from work stress

6. Overview • Work overload related to job stress & burnout • Job demands often exceed work hours • Navigating mismatch is major developmental task • Often resolved by working longer hours and neglecting other needs, with ultimately negative consequences • Negotiating work-life balance often the goal of therapy • Work overload amongst psychiatrists can adversely impact care

7. Agenda • Work Stress • Burnout • Physician Issues • Prevention

8. “Whether I shall turn out to be the hero of my own life, or whether that station will be held by anybody else, these pages must show.” • Charles Dickens, David Copperfield, page 1

9. “Engrossed late and soon in professional cares … you may so lay waste that you may find, too late, with hearts given way, that there is no place in your habit-stricken souls for those gentler influences that make life worth living.” • Sir William Osler

13. Case #1 • Physician newly out of residency • High patient volume • New parent s/p 4 months • Hard to leave baby at daycare • Spouse frequently away from home • Functioning as single parent

14. Case #1 • Initial presentation with depression • Prescribed Prozac • Two weeks later, reports anxiety and panic • Klonopin added • 4 days convalescent leave • Credentials question • Returned to work without incident

15. U.S. Sources of Stress

16. Job Stress • Job stress results when: • Requirements of the job do not match the capabilities, resources, or needs of the worker • Role demands of work conflict directly with role demands of other life domains • Work function often preserved until end

17. Work Stress in America • 10%, Schilling & Brackbill, 1987 • 40%, Northwestern National Life, 1992 • 23%, McCarroll et al, 1993 • 26%, Families & Work Institute, 1997 • 29%, Yale University, 1997 • 80%, American Institute of Stress, 2000 • 65%, Integra, 2000 • 60%, Pflanz, 2001 • 26%, Pflanz & Sonnek, 2002 • 33%, DoD, 2005 • 27%, Pflanz & Ogle, 2006 • 55%, ComPsych Corporation, 2006 • 32%, Mental Health America 2006

18. Work Stress in America • ¼ of employees view job as #1 life stressor • ¾ of employees believe work is more stressful than a generation ago • ½ of employees report working 12-hour days and/or skipping lunch because of the stress of job demands • 12% report calling in sick due to job stress

19. Work Stress in America • Work stress costs industry at least $150 billion per year in lost productivity and disability claims • Health care expenditures 50% greater for workers with high job stress • Problems at work are more strongly associated with health complaints than any other life stressor

20. Increasing Work Hours • Average work week is now 47 hours • 20% work 49 hours per week • Increased 8% in past generation • From 1990 to 2000, increased by extra week per year • Americans work one month more per year than Japanese and three months more than Germans

21. 2006 ComPsych Corporation Survey • 55% of workers had high levels of stress with extreme fatigue and feeling out of control • 42% had constant but manageable stress • Top three work stressors: • People issues • Workload • Work-life balance.

22. DoD 2005 Survey ofHealth-Related Behaviors • More military personnel rate their work (32.5%) as very stressful than their personal lives (18.9%) • More military personnel report that work stress (10%) was significantly impairing their duty performance than family stress (4.7%)

23. Sources of Job Stress • Inadequate staffing: 39% (n=127) • Work overload: 33% (n=107) • Long work hours: 30% (n=98) • Work conflicts with family: 23% (n=74) • Missile field duty: 19% (n=62) • Deployments: 10% (n=31) • Military disciplinary action: 9% (n=28) • Conflict with supervisors: 8% (n=26) • Miscellaneous comments: 15% (n=50)

24. Costs to the Workplace • Decreased productivity • Increased workforce turnover • Higher rates of absenteeism • More accidents • Lower morale • Increased interpersonal conflict • Physical and psychological health problems • Direct Treatment costs • Workers’ Compensation and disability claims

25. Costs to the Employee • Distress & suffering • Illness • Disability • Instability • Change in finances • Loss of self-esteem • Loss of identity

26. Work Climate & Job Stress • Work climate related to job satisfaction, job stress, health status, & absenteeism • Greater psychiatric morbidity and poorer physical health associated with: • High job stress • Long work hours • Low autonomy and control

27. Burnout • Emotional fatigue • Detachment • Depersonalization • Cynicism • Perceived professional ineffectiveness • Loss of career satisfaction

28. Irritability Fatigue Sleep disturbance Poor concentration Impaired performance Loss of creativity Absenteeism Job dissatisfaction Low morale Dreading going to work Feeling overwhelmed Feeling ineffective Increased negativity Decreased pleasure Hopelessness Social isolation Headaches Upset stomach Depression Anxiety Marital problems Substance misuse Symptoms

29. Risk Factors • Organizational culture that reinforces saying yes or discourages saying no • Lack of participation of workers in decision-making • Unclear job expectations • Too much responsibility • Poor organizational communication • Dysfunctional interpersonal dynamics • Lack of workplace social support

30. Risk Factors • Mismatch in values • Poor job fit • Extremes of activity • Monotony • Work Overload • Job insecurity or lack of career growth • Environmental concerns • Compulsive personality traits

31. Consequences of Burnout • Decreased capacity to regulate reaction to stress • Increased acting out • Loss of empathy • Supervisors • Lose objectivity • Overindulgent or overprotective • Unduly harsh or punitive • Employees • Fewer organizational citizenship behaviors

32. Medical Career Issues • Rewarding profession with many benefits • Demanding profession with many stressors • Growing frustration amongst physicians • Autonomy very important to physicians • Physician job satisfaction strongly linked to a feeling of control over one’s practice and work

33. Physician Pressures • High self-expectations • High expectations of others • Poor limit setting • Strong reinforcement for service before self • Often possess compulsive personality traits • Chronic self-neglect in pursuit of work • Leadership roles reshuffle priorities

34. Burnout & Countertransference • Over-identification with patient • Anger towards or dislike of patients • Lack of empathy • Depersonalization • Sense of inefficacy or incompetence • Acting out in therapy or other boundary violations

35. Burnout Prevention • Work towards healthy work-life balance • Promote personal and professional well-being • Physical, Emotional, Psychological, Social, and Spiritual • Physician well-being associated with: • Physician productivity • Physician, staff, and patient satisfaction • Patient safety

36. Organizational Actions • Healthy working conditions • Recognition for good performance • Opportunities for career development • Organizational culture that values individual workers • Management actions and policies that are consistent with organizational values • Employee input into design of workplace practices

37. Personal Actions • Influence happiness through choices • Know yourself and accept your limitations • Learn to lean on others – ask for help • Spend time with family and friends • Healthy philosophical outlook • Supportive relationships at home and at work • Identify a mentor

38. Personal Actions • Pick what’s important and do that first • Set limits with work and at work • Learn how to say no sometimes • Avoid sacrificing personal time for work • Your schedule and time are important, too • Find meaning in work • Find something to recharge your energy

39. Personal Actions • Self care before caring for others • Blow off steam with someone you trust • Get plenty of sleep • Exercise regularly • Watch your diet • Recreation • Take time off • Get professional treatment, when necessary

40. Adapt or Get Sick • Being overwhelmed by role demands or role conflict will wear you down eventually • Make choices or change the rules • Your goals, your hours, buy services • Lower your standards, if necessary • Recognize when close enough is good enough • Understand that not every problem can be solved

41. Ask Yourself: • What roles are essential? • What roles are key to one’s identity? • Is this really what I want to be doing? • Recognize the difference between idealized and realistic role expectations • Give up non-essential responsibilities

42. Reducing Workload • Salary • Career consequences • Loss of security • Personal perceptions • Perceptions of others • Career satisfaction • Change practices or switch specialties

43. Case #2 • Top performer • Long job hours • Missed quota for several months • Hostile response from supervisor • Loss of confidence • Vicious cycle ensued

44. Case #2 • Presented with symptoms of depression • Initial job modifications (decreased hours) • Suicide attempt • Further job modifications • Decreased hours and no recruiting duties • Not placed on convalescent leave • Returned to primary military career field • Pt felt less desperate, reducing suicidal ideation

45. Questions? steven.pflanz@pentagon.af.mil