RECOGNITION AND PREVENTION OF BURNOUT – YOURS AND THEIRS

1. RECOGNITION AND PREVENTION OF BURNOUT –YOURS AND THEIRS Rebecca P. McAlister, M.D. Washington University School of Medicine

2. EDUCATIONAL OBJECTIVES • This presentation will discuss the syndrome of burnout, its causes and effects. We will examine how it may affect residents, attending physicians, other health professionals and support staff, and ourselves. Strategies for identification and prevention will be reviewed.

3. BURNOUT DEFINED • “A PROLONGED RESPONSE TO CHRONIC EMOTIONAL AND INTERPERSONAL STRESSORS ON THE JOB” • DEFINED BY THREE DIMENSIONS • EXHAUSTION • CYNICISM • INEFFICACY

4. EXHAUSTION • BASIC INDIVIDUAL STRESS DIMENSION • FEELINGS OF BEING OVEREXTENDED • FEELING DEPLETED OF EMOTIONAL AND PHYSICAL RESOURCES • PROMPTS DISTANCING ONESELF TO COPE WITH WORK OVERLOAD

5. CYNICISM DEPERSONALIZATION • A NEGATIVE, CALLOUS, OR EXCESSIVELY DETACHED RESPONSE TO VARIOUS ASPECTS OF THE JOB • DISTANCE ONESELF BY ACTIVELY IGNORING PERSONAL QUALITIES

6. INEFFICACY • THE SELF EVALUATION COMPONENT • FEELINGS OF INCOMPETENCE, LACK OF ACHIEVEMENT AND PRODUCTIVITY AT WORK • SEEMS TO ARISE FROM A LACK OF RELEVANT RESOURCES

7. ROOTS IN 1970’S • FOCUSED ON CARE GIVING AND SERVICE OCCUPATIONS • CORE OF THE JOB WAS RELATIONSHIP BETWEEN PROVIDER AND RECIPIENT • HEALTH CARE PROFESSIONALS, SOCIAL WORKERS, TEACHERS

8. MASLACH BURNOUT INVENTORY • MASLACH & JACKSON DEVELOPED MBI IN 1981 • MBI-HUMAN SERVICES SURVEY • MBI-HSS • MBI-EDUCATORS SURVEY - MBI-ES • MBI-GENERAL SURVEY – MBI-GS • SUBSCALES • EMOTIONAL EXHAUSTION • DEPERSONALIZATION • REDUCED PERSONAL ACCOMPLISHMENT

9. EFFECTS OF BURNOUT • JOB PERFORMANCE • ABSENTEEISM • JOB TURNOVER • LOWER PRODUCTIVITY / EFFECTIVENESS • “CONTAGIOUS” • HEALTH • STRESS RELATED HEALTH OUTCOMES • NEUROTICISM • NEGATIVE MENTAL HEALTH EFFECTS • ?spectrum with depression

10. WHERE DOES BURNOUT OCCUR? • JOB CHARACTERISTICS • OCCUPATIONAL CHARACTERISTICS • ORGANIZATIONAL CHARACTERISTICS

11. JOB CHARACTERISTICS • WORK OVERLOAD AND TIME PRESSURE • ROLE CONFLICT / AMBIGUITY • SEVERITY OF CLIENTS PROBLEMS • ABSENCE OF JOB RESOURCES • LACK OF SOCIAL SUPPORT • LACK OF SUPERVISOR SUPPORT • LACK OF FEEDBACK • LACK OF CONTROL / DECISION MAKING

12. OCCUPATIONAL CHARACTERISTICS • FOCUSED ON HUMAN SERVICES AND EDUCATION • REQUIREMENT TO EXPRESS OR SUPPRESS EMOTIONS ON THE JOB • REQUIREMENT TO BE EMOTIONALLY EMPATHETIC

13. ORGANIZATIONAL CHARACTERISTICS • RULES THAT VIOLATE BASIC EXPECTATIONS OF FAIRNESS / EQUITY • VIOLATION OF THE PSYCHOLOGICAL CONTRACT (WHAT EMPLOYER IS OBLIGED TO PROVIDE FOR RECIPROCAL WORK EXCHANGED)

14. WHO IS AT RISK? • ? LESS THAN AGE 30 OR 40 • ? FEMALE (MALES MORE CYNICAL) • ?UNMARRIED, ESP. SINGLE • HIGHER LEVEL OF EDUCATION • EXTERNAL FOCUS OF CONTROL • PASSIVE / DEFENSIVE COPING • POOR SELF ESTEEM • NEUROTICISM / TYPE “A” BEHAVIOR • “DISORGANIZED” PERSONALITY

15. THE PEOPLE YOU WORK WITH • PHYSICIANS IN GENERAL / OBGYNs • RESIDENTS IN TRAINING • STUDIES IN PGY-1s • Acad Med 2006;81:82-5 • HEALTH PROFESSIONALS / EDUCATORS / SUPPORT STAFF

16. BURNOUT IN PHYSICIANS • 25 – 60% MEET MBI CRITERIA FOR BURNOUT • CAN LEAD TO INCREASED MEDICAL ERROR (SELF REPORTED V. OBSERVED) • DISSATISFACTION AND DISTRESS INCREASE COSTS TO SYSTEM • $240K – 260K TO REPLACE PRIMARY CARE PHYSICIAN

17. CAREER SATISFACTION IN OBGYN PHYSICIANS

18. CAREER SATISFACTION WORK-LIFE BALANCE BURNOUT Keeton K, et al. ObstetGynec April 2007 OBGYNs more personal accomplishment and work/life balance than general surgeons More career satisfaction than general internists

19. BURNOUT IN OBGYN CHAIRS • 88% MODERATE BURNOUT • 4% HIGH BURNOUT • HIGH EMOTIONAL EXHAUSTION • MODERATE – HIGH DEPERSONALIZATION • HIGH PERSONAL ACCOMPLISHMENT • GABBE, AM J OBSTET GYNECOL 2002

20. STRESS / BURNOUT IN RESIDENCY • 76% INTERNAL MEDICINE RESIDENTS MET CRITERIA FOR BURNOUT • ASSOCIATED WITH SELF REPORTED SUBOPTIMAL PATIENT CARE • SHANAFELT, ET AL, ANN INTERN MED, 2002 • OBGYN RESIDENTS • 9X MORE LIKELY TO LACK EFFECTIVE COPING MECHANISMS • 14X MORE COMMON MALADAPTIVE STRESS SCORES • SCHNEIDER, ET AL, AM J OBSTET GYNECOL 2002

21. BURNOUT AND DEPRESSION • FAHRENKOPF et al (BMJ 2012) surveyed 123 Peds residents with MBI & Harvard nat’l depression screening day scale • 75% burnout, 20% depression (of which 96% also burned out)

22. BURNOUT AND DEPRESSION • Burnout- no increase observed errors, increased reported errors, diff. concentrating • Depressed- 6X increased observed errors, difficulty concentrating, poor health (few on antidepressants) • Not assoc with age, sex, PGY, logged sleep or work hours

23. THREE LIKELY BURNOUT SCENARIOS • PGY4 overheard making derogatory remarks about clinic patients • PGY1 tells PD he/she is considering transferring to Dermatology • OBGYN PD had poor internal review. DIO said “terrible data collection.” He/she yells at coordinator who promptly quits.

24. BUILDING JOB ENGAGEMENT • BURNOUT IS THE EROSION OF ENGAGEMENT WITH THE JOB • RELATED TO JOB DEMANDS • ENGAGEMENT CHARACTERIZED BY ENERGY, INVOLVEMENT, EFFICACY • RELATED TO JOB RESOURCES

25. Loss of Control in the Practice of Medicine • Frequently part of patient encounters • Difficult encounters, noncompliance, end-of-life care, uncertainty/ambiguity in dx/mx • Institutional and systemic factors • Lack of control over work environment, team vs. captain, “limit the territory” • Need to identify constructive ways to respond to lack of control

26. EXAMPLES OF TRAINING IN COPING MECHANISMS • Reflection /critical incident journaling • Peer group discussions • Balint training • Mindful emotion regulation • Positive vs. Negative Assertion vs. Yielding • Journal of Graduate Medical Education Dec 2009

27. TEACHING /CHANGING THE INDIVIDUAL • PEOPLE CAN LEARN NEW COPING SKILLS • ?CAN PEOPLE APPLY THIS TO THE WORKPLACE? • CAN REDUCE EXHAUSTION, LITTLE CHANGE IN CYNICISM, INEFFICACY

28. ORGANIZATIONAL CHANGE • MUCH MORE DIFFICULT BUT LIKELY MOST EFFECTIVE • EXPAND RANGE OF WORK OPTIONS • PEOPLE TOLERATE GREATER WORK LOADS IF FEEL REWARDED/VALUED • BUILD SENSE OF FAIRNESS /EQUITY • EMPOWER WITH SENSE OF CONTROL

29. STEPS TO PROMOTE ENGAGEMENT PERSONAL WELLNESS • EXERCISE, COUNSELING, TX PSYCH DZ ORGANIZATIONAL ENVIRONMENT • CHOICES, FEEDBACK, FAIRNESS, CULTURE CHANGE PROMOTING WELLNESS IN THOSE YOU WORK WITH

30. IT’S A BALANCING ACT “If all of the knowledge and advice about how to beat burnout could be summed up in one word, that word would be balance-balance between giving and getting, balance between stress and calm, balance between work and home.” • Maslach 1982