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Provider Wellness

UCHSC/VAMC TMC - March 2009. Provider Wellness. Sopheap Na, M.D. Jan McCormack, DMin, BCC. Assistant Professor of Medicine VAMC. Assistant Professor of Chaplaincy and Pastoral Counselling Denver Seminary. Are You?. Driven Motivated Competitive Ambitious Determined High energy.

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Provider Wellness

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  1. UCHSC/VAMC TMC - March 2009 Provider Wellness Sopheap Na, M.D.Jan McCormack, DMin, BCC Assistant Professor of Medicine VAMC Assistant Professor of Chaplaincy and Pastoral Counselling Denver Seminary

  2. Are You? • Driven • Motivated • Competitive • Ambitious • Determined • High energy • Excels at everything • Top of the class • Type A personality • High standards • Aggressive • High need for control • Perfectionist

  3. Provider Wellness Outline Background Definitions Studies Interventions

  4. VR PS BS GPA (science)‏ GPA (nonscience)‏ GPA (total)‏ Male 9.9 10.7 10.8 3.60 3.70 3.64 Female 9.9 9.8 10.4 3.58 3.76 3.64 MCAT Scores and GPAs for U.S. Medical Schools by Sex 2000-2007 VR – verbal reasoning PS – political science BS – biological science www.aamc.org/data/facts/start.htm

  5. Distribution of Total Educational Debt for Medical Students in the United States at Graduation, 2004–2008. AAMC Graduation Questionnaire All School Reports - premedical or college education debt. 2008, 38% of graduates had debt from premedical education (median amount, $20,000). The distribution of the 23% of students with total debt of $200,000 or more was 15% with $200,000 to $249,999 in debt, 6% with $250,000 to $299,999 in debt, and 3% with $300,000 or more in debt (numbers do not sum to 23% due to rounding). R. Steinbrook. Medical Student Debt — Is There a Limit? NEJM 12/18/2008

  6. Mean Tuition and Fees for Medical Schools and Undergraduate Institutions, 1998–1999 to 2008–2009 (Panel A) and Percent Change in Mean Tuition and Fees, the CPI, and Median Physician Compensation, 1998–2008 (Panel B). Medical school tuition and fees are from the AAMC tuition and fees report; starting in 2004–2005, figures include health insurance as well as tuition and fees. Mean tuition and fees for 2008–2009 were not available. Tuition and fees at 4-year undergraduate institutions are from the College Board's Annual Survey of Colleges. Consumer Price Index (CPI) are from the U.S. Department of Labor. Medical Group Management Association's Physician Compensation and Production Survey Medical Student Debt — Is There a Limit?Robert Steinbrook, M.D. NEJM 12/18.2008

  7. Background • All physicians • Drug and alcoholism  30-100x general population • 3x other profession to spend >60 hrs/wk working, 21% 80 hrs/wk, 16% longer hrs • 13% F and 20% M physicians  episode of depression • Divorce rates  10-20% higher than general population • $236,383 to replace family practitioner • $264,345 to replace general pediatrician The Resilient Physician. Sotile, WM.

  8. Definitions

  9. Definitions Work addiction • Hurrying and staying busy • Need to control • Perfectionism • Difficulty with relationships • Work binges • Difficulty relaxing and having fun • Impatience and irritability • Self-inadequacy • Self-neglect

  10. Definitions Burnout • the cost of working too much • 1st described in 1970s • Triad • Emotional exhaustion • Negative self-esteem, depersonalization associated w/ work • Loss of personal satisfaction at work (work avoidance, unfriendly or irritable behavior, somatic complaints) • Leads to: absenteeism, turnover, cynicism, decreased job satisfaction, friction in personal relationships, depression, substance abuse Annals July 2001/CPHP 2008

  11. Causes of Burnout • Workload • Specialty choice • Practice setting • Patient characteristics • Sleep deprivation • Personality type • Methods of dealing with medical mistakes • Malpractice suits • Lack of control over practice • Environment • Problems with work-life balance • Rising student debt • Increasing govt regulations • Business aspect of medicine • Increase clinical demands • Rapidly expanding knowledge base • Less time with patients The Well-Being of Physicians. Am J Med 4/2003

  12. Definitions Compassion Fatigue • Affects caregivers only • Not the same as “burnout” • “A state of tension & preoccupation with individual or cumulative trauma to clients & manifested in one or more ways: • Re-experiencing traumatic events of others • Avoidance/numbing of reminders of the events • Persistent “hyper-arousal • “Cost of caring too/so much” • Many costs • Personal Functioning • Professional Functioning

  13. Compassion Fatigue & PTSD • PTSD symptoms nightmares, avoidance, on guard, watchful, easily startled, feeling numbed/detached, increased arousal • Many of the same symptoms as PTSD plus • Repeated negative and disturbing thoughts • Feeling bored and irritable; unable to focus • Not feeling satisfied in one’s work—the energy output and the rewards coming in don’t match • Lack of physical, psychological and emotional energy • Avoidance which may lead to drastic escape/flight measures

  14. Cognitive Emotional Behavioral Diminished concentration Powerlessness Clingy or withdrawn Confusion/self-doubt Anxiety Impatient Spaciness Guilt Irritable Loss of meaning Anger Moody Decreased self-esteem Survivor guilt Regression Preoccupation w/ trauma Shutdown Sleep disturbances Trauma imagery Numbness Appetite changes Apathy Fear Hypervigilance Rigidity Helplessness Hyper startle response Disorientation Sadness/depression Losing things Whirling thoughts Hypersensitivity Accident proneness Thoughts of self-harm or harm towards others Emotional roller coaster Use of negative coping (smoking/substance abuse)‏ Perfectionism Overwhelmed Self-harm behaviors Minimization Depleted Nightmares Personal Functioning Compassion Fatigue by Figley, p. 184

  15. Spiritual Interpersonal Physical Loss of purpose Withdrawn Shock Questioning the meaning of life Decreased interest in sex Swearing Lack of self-satisfaction Mistrust Rapid heartbeat Pervasive hopelessness Isolation from friends Breathing difficulties Ennui Projection of anger or blame Somatic reactions Anger at God Intolerance Aches and pains Questioning of prior religious beliefs Impact on parenting (protective, concern about aggression) Impaired immune system Loneliness Dizziness Personal Functioning Compassion Fatigue by Figley, p. 184

  16. Performance of Job Tasks Morale Decrease in quality Decrease in confidence Decrease in quantity Loss of interest Low motivation Dissatisfaction Avoidance of job tasks Negative attitude Increase in mistakes Apathy Setting perfectionist standards Demoralization Obsession about details Lack of appreciation Detachment Feelings of incompleteness Professional Functioning Compassion Fatigue by Figley, p. 184

  17. Definitions Additivity • home and work stress add to each other or when the benefits of home and work satisfaction create greater well-being “Universal Vulnerability” • Attributes which make caregiver vulnerable…same as make them excellent caregivers • Risk increases if…there are back-to-back “heavy” cases or other forms of secondary trauma • May combine with…caregivers own traumatic past

  18. Definitions Personal Resilience • “The strength, innate or developed, that enables one to adapt well to extreme stress”, including the capacities to: • Optimally function • Maintain sound mental health under adverse circumstances • Rebound from the deleterious effects of even overwhelming stress • Factors • Age, sex • Social class, family dynamics • Social support, temperament • Self-efficacy, belief in God/spirituality • Coping skills Dr. Glenn Schiraldi, U of Maryland

  19. 4 Qualities of Resilience • Remain relatively steady during life’s storms • Bend, but don’t break • Rebound, spring back • Become stronger in the face of adversity OR later as a result of adversity

  20. Three Components of Resilience I. Healthy belief system • Good self-esteem • Clear thinking under pressure • Basically optimistic & hopeful • Self-confident • Realistic expectations • Flexible • Helpful philosophical/spiritual views Adapted from the work of Glenn Schiraldi

  21. Three Components of Resilience II. Good emotional coping skills • Emotional self-awareness & understanding • Acceptance, use & comfort with a wide • Range of emotions • Managing upsetting emotions appropriately • Empathy skills • Relationship skills Adapted from the work of Glenn Schiraldi

  22. Three Components of Resilience III. Helpful behaviors • Active coping skills • Good social skills • Healthy relationships • Participate in a supportive community • Balanced life: work, play & rest; self & others • Consistent self-care • Good personal & professional boundaries • Active religious/spiritual commitment Adapted from the work of Glenn Schiraldi

  23. The Role of Spirituality & Religionin Personal Resilience • Having faith allows one to open one’s heart to experience the sacred/holy/ divine • The response to that experience is one of awe, reverence, thankfulness, hope, devotion and gratitude • Allows for a healthy “New Normal”

  24. The Benefits of Faith toPersonal Resilience • Meaning & Purpose • Hope • Connection with others • Internal calmness—peace • Encouragement • Peace/security/sense of safety as one’s faith is lived • Values beyond the material & immediate • Perspective on suffering & evil (the long view)‏ • Reconciliation—self, others, a “Higher Power” • Reduced fear of death • Less Anger

  25. Why is This Important? • 20 yrs ago  “burnout”  30-60% specialist and general practitioners • Canadian National Survey 1998 • 62% workload too heavy • 55% family and personal life suffer • 65% limited opportunities to change career • Self-care  rarely part of professional training and low on the list of priorities • Denial of own emotions and needs as a survival mechanism The Well-Being of Physicians. Am J Med 4/2003/ CPHP 2008

  26. Professional Ethics • AMA Council on Ethical and Judicial Affairs • Based on Code of Medical Ethics, Medline-indexed articles and experts • Policy of the Association 12/2003 • Promote overall physician health and wellness • Recognizes that effective skills and patient safety are absolute requirement in the practice of medicine • Emphasizes continued need for forethought and sensitivity in addressing physicians’ health and wellness Physician Health and Wellness. Occup Med 2006

  27. Studies so far…

  28. Studies so far… • Kaiser Physicians-Northwest and Ohio • 80% response to survey • Factors predicting professional satisfaction, organizational commitment, and burnout • Sense of control over practice environment = #1 • Perceived work demands • Social support from colleagues • Satisfaction with resources • Related to physician age and specialty • Pediatricians  more satisfied Satisfaction, commitment, and psychological well-being among HMO physicians. WJM Jan 2001

  29. Studies so far… • 304/614 completion - Wisconsin Research Network (WReN) • Survey  family systems assessment instrument, life-events checklist, measures of happiness, life satisfaction, emotional functioning, assessment of relationship support, practice stress • Open-ended question  “How do you solve dilemmas related to your physical, emotional, and spiritual well-being?” • SPWB (Scale of Psychological Well-Being)  18 item instrument • well-being, self-acceptance, positive relations with other people, autonomy, environmental mastery, purpose in life, personal growth A Qualitative Study of Physicians’ own wellness-promotion practices. WJM Jan 2001

  30. Studies so far… • 5 primary wellness-promotion practices • Relationships  involvement and spending time w/ family/friends/ colleague/community • Religion or spirituality • Self-care  reading, nutrition, exercise, counselling • Work  certain practice, limiting practice, satisfaction/meaning • Approaches to life  being positive, balance • All correlated with increased SPWB scores • “Approaches to life”  associated with highest level of psychological well-being A Qualitative Study of Physicians’ own wellness-promotion practices. WJM Jan 2001

  31. Studies so far… • 44 individuals  representative of gender, geographic location, and practice size • Semi-structured interview and focus groups • Factors affecting positively and negatively the health and well-being of GP • low levels of remuneration • time pressures • unrealistic community expectations • government interference • effect on personal life General practitioner health and well-being. WJM Jan 2001

  32. Studies so far… • Cohort study  John Hopkins SOM 1948-1964 • Predictors of NOT having a regular source of care and association with subsequent preventive services? • 77% response  35% no RSOC • Internist (OR 3.26), surgeons (OR 2.42), pathologist (OR 5.46)  more likely not to have RSOC vs pediatrician • Inversely related to belief that health is determined by health professionals (OR 0.45), related to chance (OR 1.90) • Did predict not being screened: breast, colon, or prostate cancer, influenza vaccine Physician, Heal Thyself? Archives November 2000

  33. Special Concerns:Women and Medicine • Before 1960s, 95% physicians = M • 2003 – F > M  med school applications • 2010 – 1/3rd physicians • ~5% department chairs, 10% dean, ~15% full professorships • Avg $22,000 or less/yr (same hours, practice setting, specialty) • All reviewers - more critical of grant proposals by F applicants • Less institutional support (funding, admin assistance)‏ • 2005 WPC (Women Physician Congress) – 49% experienced sexual harassment in their careers • Stereotypes – conscious/unconscious  survey M med students • 30% felt F of childbearing age poses significant risk to optimal department functioning • ~50% agree w/ “women who spend long hours at work were neglecting their responsibilities to home and family” Colorado Physician Health Program 2007

  34. Special Concerns:Women and Medicine • F ~8.5 months vs M ~1 month  interruption to address child care issues • F:M 85% vs 35% change career plans to accommodate children • F physician • 10 yr lower life expectancy vs general population • 60% more likely vs M physicians  s/sx burnout increases significantly (1-15%) every 5 hrs over 40hrs/wk • 3-4x higher risk suicide vs WM >35 y.o. and 4x rate general F population. • tend to present voluntarily for help • less likely to be sued by their patients Colorado Physician Health Program 2007

  35. Women Physicians’ Health Study • 2500 grad/year from 1950-1989 age 30-70 y.o.  4500 respondents • 84% usually/almost always/always satisfied • 31% maybe/probably/definitely not choose to be a physician again • 38% maybe, probably or definitely prefer to change their specialty • Age, control work environment, work stress, h/o harassment  independent predictors • Strongest association  work control and career satisfaction  OR 11.3 p<0.001 Career Satisfaction of US Women Physicians WPHS. Arch In Med. July 1999

  36. Wellness Interventions

  37. Some Myths • “I’m trained and therefore invulnerable.” • “I’ve seen worse and handled it before.” • “I’m a professional, I’m supposed to be able to handle this.” • “If I just follow the protocols, I’ll be OK.” • “I’m okay – I have to be, who else is here to help?” • “I have to be strong and show a good spiritual witness.”

  38. Right Brain Interventions

  39. Wellness Strategies The Organization's Role • Be Value Oriented • Promote core values of medical profession • Involve physicians in organizing/promoting mission • Minimize Work-Home Interference • Flexible and readily accessible child care • Flexibility in scheduling and ready coverage for life events (births, funerals, family emergencies) Women in Medicine: Stresses and Solutions. EWJM Jan 2001 The Well-Being of Physicians. Am J Med. April 2003 The Resilient Physician. Sotile, WM. Physician Health and Wellness. Occup Med. 2006

  40. Promote Work-Life Balance • Adequate vacation time • Limit overtime expectations • Organization sponsored seminars and retreats • Mentoring program and periodic sabbaticals • Promote Physician Autonomy • Increase ability to influence environment, participation in practice decisions, flexibility • Increase control over schedule Women in Medicine: Stresses and Solutions. EWJM Jan 2001 The Well-Being of Physicians. Am J Med. April 2003 The Resilient Physician. Sotile, WM. Physician Health and Wellness. Occup Med. 2006

  41. Provide adequate Support Services • Adequate coverage to allow time off, adequate and coordinated nursing, secretarial, admin, social work/chaplain support to promote efficient patient care • Supporting peers in identifying physicians in need • Establish approp mechanism to detect impairment • Intervene in a prompt and supportive fashion • Cultivate a Collegial Work Environment • Fosters healthy relationship (retreats, team building, social gathering, etc) The Well-Being of Physicians. Am J Med 4/2003 Women in Medicine: Stresses and Solutions. EWJM Jan 2001 The Resilient Physician. Sotile, WM.

  42. Wellness StrategiesSelf responsibilities • Relationships • “protecting” family time, sense of connection with colleagues, reflect/share emotional/ existential aspects • Categories I – important and urgent (pressing problems, crises, deadlines, bona fide emergencies) II – important and not urgent (planning, prevention, creativity, building relationships, enjoying re-energizing leisure-time activities, maintaining increased productivity) III – not important and urgent (unimportant to you but urgent to someone else)‏ IV – not important and not urgent (frivolous and nonhelpful wastes of time) The Well-Being of Physicians. Am J Med 4/2003 Women in Medicine: Stresses and Solutions. EWJM Jan 2001 The Resilient Physician. Sotile, WM.

  43. Wellness StrategiesSelf responsibilities • Religious Beliefs/Spiritual Practice • Personal attentiveness, nurturing of spiritual aspects • Work attitudes • Finding meaning in work • Actively choosing and limiting medical practice (working part-time, medical education, research interests, managing schedules) • Life Philosophy • Positive outlook, indentifying/acting on values, stressing balance between personal/professional life • Self-Care Practices • Cultivating personal interests (reading, exercise, self-expression activities, adequate sleep, nutrition), seeking professional help (personal physical or psychologic illness, medical care) The Well-Being of Physicians. Am J Med 4/2003 Women in Medicine: Stresses and Solutions. EWJM Jan 2001 The Resilient Physician. Sotile, WM.

  44. Intervention examples…

  45. Intervention examples… • DGIM UCali San Fran – 2 hr/month since 1996 (residents, faculty)  avg group 6-37/session • Existential and spiritual themes • difficult patients, balancing personal/professional responsibilities, medical mistakes, professional competence, grief, role playing, journal, literature/art, anger, boundaries, compassion, fear, refuge, unmet patient needs, “wounded healer” • >70% attended at least 1 session • Strengthen personal and professional identity • Increased sense of connectedness with colleagues • Specific practice techniques • Maintaining balance and promoting well-being Doctoring to Heal. EWJM Jan 2001

  46. Intervention examples… • Hill Physicians largest IPA (Independent Practice Association ) 2,200 Northern California gen and specialty physicians • 14 hour “Finding Balance in Medical Life” • Physicians/significant others  50/session  Napa Valley, $400/spouses free • Understanding stresses of a medical practice and how it diminishes productivity • Adverse health ramification of stress • Learning/evaluating how personality traits contribute to stresses • Learning tools for managing emotional stress • Tools and practices to enhance communication skills • Evaluation of individual personality structure Engendering and Marketing Physician Wellness. GPJ Oct 2004

  47. Intervention examples… Medical Board of California • Mentor program  career development and balancing personal/professional lives • Confidential support groups monthly • Annual well-being retreat on company time • Fitness center membership • Contractual requirement for own PCP • Sabbatical program • COM program on well-being • Flexible scheduling

  48. Limits to wellness interventions • Reluctance to confront colleagues and refer them to appropriate resources • Incur licensure actions, shame, or stigmatization • Reluctance to think of themselves as needing help • Inadequate standards to indentify signs of need, difficulty in ascertaining with confidence this need and available resources • ?mandatory disclosure about own personal medical information Physician Health and Wellness. Occup Med 2006

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