P. Bradley Hall, MD Executive Medical Director, West Virginia Medical Professionals Health Program

1. Physician Wellbeing and the PhysiciansHealth Program P. Bradley Hall, MD Executive Medical Director, West Virginia Medical Professionals Health Program Immediate Past-President, Federation of State Physician Health Programs President, West Virginia Society of Addiction Medicine WVU School of Medicine – June 18, 2019

2. Conflict of Interest Disclosures No relevant financial relationships with any commercial interests. Physician Education Grant #G180529

3. Physician Wellbeing and the PHP objectives • Burnout, Wellness & Resilience • Potentially impairing conditions • Substance Abuse, Mental Illness & Co-morbidities • Barriers to detection and assistance • Indicators of potential impairment • Overview of Physician Health Programs • The MESSAGE

4. Special Populations – Safety Sensitive • Examples of Safety Sensitive Workers: • Power company employees, especially in the nuclear power industry. • Defense contractors in selected areas (e.g., missile defense, drone and aircraft manufacture and highly classified weapons systems). • Public servants in the police and fire areas • Special attention must be paid to officers in undercover and drug enforcement • Airline Pilots • Even private pilots must be identified and treated with special attention • Attorneys and Judges • Healthcare workers (Physicians, PAs, nurses, pharmacists and nuclear medicine staff) • Employees of pharmaceutical companies (especially in manufacturing) • Politicians (?)

5. Special Populations – Safety Sensitive The extent of the effect on the public comes from three factors: • The size of the population they affect, • The depth of damage on a single person that arises from potential impairment, and • The amount of public trust that is implied in that worker's occupation. *Fail first isn’t safe

6. Physician Wellbeing and the PHP objectives • Burnout, Wellness & Resilience

7. Finding Balance in the Medical Life Lee Lipsenthal, M.D.

8. Health and Wellbeing Issues * DIS-EASE of HUMAN-NESS 8 Life / Work Balance Satisfaction Lack of joy / unhappiness Stress Distress Burnout Behavioral Health (interpersonal) Mental Health Physical Health Substance Use / Addiction Suicide

9. An example of unhealthy cycle that healthcare professionals may experience PHPs can intervene and help at any point!

10. Stigma Illness resistant God complex Knowledge is not protective Training how and who to ask for help *Education is the key

11. Physician Wellness Shanafelt TD, Sloan JA, Haberman TM. The well being of physicians. Am Med J 2003; 114: 513–17. “Wellness goes beyond merely the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life.”

12. BurnoutAMA / Mayo Clinic – 6,880 physicians surveyed 2011 & 2014 At least one symptom of burnout increased 2011-2014 (45.5-54.4%) Work / Life balance satisfaction declined 2011-2014 (48.5-40.9%) Burnout rates higher for all specialties in 2014 Nearly a dozen specialties increased greater than 10% More prevalent when compared to the general US working population even when adjusted for age, sex, hours and educational level

13. Burnout Emotional exhaustion Loss of meaning in work Feelings of ineffectiveness Depersonalization - viewing people as objects rather than human beings Burnout impacts the quality of care physicians provide and physician turnover.

14. Courtesy: Christine Sinsky, MD

15. Burnout: Demands, Resources, Control Resources Demands Control Personal wellness interventions Workplace interventions

16. Healthy Physicians Give Better Care! Decreased medical errors Increased patient satisfaction Better treatment recommendations Increased treatment adherence Lower malpractice risk Better attitudes toward work Higher team functioning Lower turnover

17. Individual Drivers of Physician Burnout Perfectionism High achievement orientation Difficulty setting boundaries Intellectualization Delay of gratification Compartmentalization Materialism

18. Environmental Drivers of Physician Burnout Workload and time constraints Inefficiencies/frustration (EHR) Lack of autonomy/control Ineffective leadership Mission/values mismatch (loss of meaning) Culture of incivility Perception of fairness and respect Diminished rewards

19. Building Wellness into the Practice Environment Practice Environment Professional Tension Workplace Wellness System Redesign Wellness The way out is to get “all in”

20. How Do You Prevent Burnout? Accept shared responsibility for burnout Elevate personal wellness to a core professional value, starting in medical school Make wellness and satisfaction a quality outcome and incentivize it accordingly Muster the will to address burnout generators and ask for help Create opportunities for peer support and decrease isolation Nurture the brain through meditation and application of mindful practice to clinical work

21. Individual Wellness: Key Targets Awareness Self-Care Resilience Engagement

22. Self-Awareness & Self-Monitoring Recognizing stressed-ness Fatigue & irritability Outside comfort zone Emotional, mental, physical & spiritual “temperature”

23. Self-Regulation & Resilience • Physically • Cognitively • Emotionally • Spiritually

24. Attending To Self Resilience is about wholehearted engagement with and not withdrawal from the often difficult realities of the workplace. Paradoxically the loss of resilience can result from seemingly energy saving measures of withdrawal. The way out is to get all in

25. Resilience The ability of an individual to respond to stress in a healthy, adaptive way such that personal goals are achieved at minimal psychological and physical costs….. the “Bounce-Back”.

26. Burnout Busters • http://www.ama-assn.org/ama/ama-wire/post/beat-burnout-7-signs-physicians-should • http://www.ama-assn.org/ama/ama-wire/post/7-steps-prevent-burnout-practice • http://www.ama-assn.org/ama/ama-wire/post/burnout-busters-boost-satisfaction-personal-life-practice • https://www.stepsforward.org/modules?sort=recent&category=wellbeing • https://www.stepsforward.org/ • http://www.ama-assn.org/ama/pub/physician-resources/physician-health/international-conference-physician-health.page

27. Physician Wellbeing and the PHP objectives • Burnout, Wellness & Resilience • Potentially impairing conditions • Substance Abuse, Mental Illness & Co-morbidities

28. West Virginia Today EPICENTER

29. Education is the Key • Addiction is a chronic relapsing disease • Voluntary versus Involuntary Usage • Addiction – drugs versus alcohol • Addiction stigma • Addiction is non-discriminatory • Addiction is treatable • Addiction recovery is possible • Professional Health Programs Work

30. The Educational Pyramid ALL HEALTH CARE PROVIDERS

31. TODAY Alcohol Use • 140.6 million current users • 16.7 million heavy users • 7.4 million age 12-20 users BINGE ALCOHOL USERS: (30d) • 66.6 million Binge (47.4% of current users) • 1.3 million (5.3%) age 12-17 • 4.5 million (60.7%) age 12-20 2017 NSDUH

32. Alcohol-Impaired Driving Among Adults — United States, 2012 • Alcohol-impaired driving crashes account for approximately one third of all crash fatalities in the United States (1). • In 2013, 10,076 persons died in crashes in which at least one driver had a blood alcohol concentration (BAC) ≥0.08 grams per deciliter (g/dL) MMWR - August 7, 2015 / 64(30);814-817

33. Alcohol Outcome Expectancies and Regrettable Drinking-Related Social Behaviors • Regrettablesocial behaviors were reported by 66.1% of participants, suggesting that they may occur at a much higher rate than more serious drinking-related consequences (e.g. drinking and driving, violence, etc.) Eugene M. Dunne; Elizabeth C. Katz Alcohol Alcohol. 2015;50(4):393-398. 

34. 2017 NSDUH • 14.5 million (5.3%) age 12 or older had AUD • 443 thousand (1.8%) age 12-17 had AUD • 7.5 million (2.8%) age 12 or older had an illicit drug use disorder • 741 thousand (3%) age 12-17 had an illicit drug use disorder

35. 2017 NSDUH Report Illicit <30 days 30.5 Million Adults (11.2%) =1 in 9 Americans!! Marijuana – 26 million (9.6%) Prescription Drugs – 6 million (2.2%) Prescription Pain Relievers –3.2 million (1.2%) Cocaine – 2.2 million (0.8%) Hallucinogens – 1.4 million (0.5%) Inhalants - 0.6 million (0.2%) Methamphetamines – 0.8 million (0.3%) Heroin - 0.5 million (0.2 %)

36. Substance Use Disorders • 19.7 million (7.2%) age 12 or older had an SUD • 13.6 million (6.4%) age 26 or older had an SUD • 5.1 million (14.8%) age 18 -25 had an SUD • 992 thousand (4%) age 12-17 had an SUD In other words… 1 in 25 adolescents, 1 in 7 young adults & 1 in 16 adults age 26 or older …….had an SUD in the past year 2017 NSDUH

37. Mental Illness • 46.6 million (18.9%) age 18 or older had AMI • 11.2 million (4.5%) age 18 or older had SMI • 3.2 million (13.3%) adolescents had MDE • 2.3 million (9.4%) 12-17 with MDE with severe impairment 2017 NSDUH

38. PAST YEAR SUD & MENTAL HEALTH ILLNESS: 2017 SUD & Mental Illness Mental Illness, NO SUD SUD, NO Mental Illness 8.5 Million 18.7 Million w/SUD 46.6 Million w/Mental Illness SAMHSA, NSDUH 2017

39. 2017 NSDUH Report • 8.5 million (3.4%) adults age 18 or older with an SUD had AMI • 3.1 million (1.3%) adults age 18 or older had co-occurring SUD & SMI • 38.1 million (16.7%) adults age 18 or older without SUD had an AMI

40. RECOGNITION: ??? Signs & Behaviors of Potential Impairment Indicating Possible Referral to the Medical Professionals Health Program and “What is that?”

41. Reality • Most chemically dependent physicians are untreated or unrecognized and are still practicing medicine.

42. Illness VS. IMPAIRMENT • FSPHP Public Policy on Illness vs. Impairment Physician illness and impairment exists on a continuum with illness typically predating impairment, often by many years. • Illness is the existence of a disease • Impairment is a functional classification implying the inability of the person affected by disease to perform specific activities www.fsphp.org

43. Addiction & Mental Illness are NON-DISCRIMINATORY & POTENTIALLY IMPAIRING

44. Impairment: “inability to practice with reasonable skill and safety”

45. American Medical Association definition - “IMPAIRMENT” - “the inability to practice medicine with reasonable skill and safety due to: • 1) mental illness • 2) physical illnesses, including but not limited to deterioration through the aging process, or loss of motor skill, or • 3) excessive use or abuse of drugs, including alcohol”

46. Historical Perspective 1953 – FSMB calls for model physician assistance programs 1973 – “The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence” by AMA Council on Mental Health 1980 – almost all state medical societies had authorized or implemented a state PHP and PHPs were communicating. 1990 – Several state Physician Health Program’s organized the Federation of State Physician Health Programs 1995 – FSMB published guidelines for a model Physician Health Program 2004 – Federation of State Physician Health Programs (FSPHP) Guidelines 2011 – American Society of Addiction Medicine 11 Policies on Physician Health 2012 - FSMB updated the guidelines for a model Physician Health Program 2016 – AMA Model Physician Health Program Act (1985 policy revision) 2017 – ACGME – Symposium #3 on Physician Wellbeing 2017 – National Academy of Medicine 2019 – FSPHP updated Guidelines

47. What Is Addiction • Seems So Self Evident • DSM IV/V • Dependence - Physical & Psychological • Negative Effects On Life • Out Of Control • Pattern Of Use

48. The DISEASE OF ADDICTION AND IT’S PROGRESSION

49. What is Addiction?Progressive, Incurable, and Fatal Disease: a Chronic, Relapsing Medical Condition • Progressive- Illness rarely gets better without intervention / treatment. • Incurable- Chronic condition. No such thing as a “cure”. There are no ex-addictsorex-alcoholics. • Fatal- Overdose, car accident, suicide, liver disease, heart disease, homicide • Definition of Addiction: Continuing behavior despite suffering negative consequences as a result of that behavior. www.asam.org = definition of addiction

50. Four “C’s” of Addiction • Involves loss of Control- taking more of the medication than prescribed, taking the medication when pain is well-controlled. • Compulsion -Inability to Cut down on dose despite attempts, promises….can’t stop. • Continued use despite adverse Consequences • Cravings -constant thoughts about (obsession) or intense desire for (compulsion) drug