Crisis Intervention for Physicians

1. Crisis Intervention for Physicians • Course overview: syllabus, objectives, online resources, assignments, schedule • Introduction • Crises & your practice • Principles of CI • Symptoms & stages of reaction • Facilitative & supportive behaviors • Next class: Depression & Suicide

2. What are example of crises you expect to encounter in the healthcare profession? • What constitutes a crisis? • Why do people react differently to the same event? • What may create vulnerabilities in otherwise resilient people? • What are the cognitive, emotional, and behavioral indications of stress reaction? • How do these (temporary) impairments require you respond to crisis survivors?

3. The “Set-Up” • caring, dedicated, committed • perfectionism, strong ideals, expectations • like excitement & stimulation • take control, responsibility • must be knowledgeable, expert • occasional helplessness • make critical decisions • very short time pressure • frequent exposure to pain, horror, grief • continual flow of patients • long periods without relief, fatigue • insufficient staffing, equipment

4. “Emergency & medical personnel are the ones who are running toward, what everybody else is running away from”

5. The Stress of Medicine • Although divorce rate is lower than similar professions, “misery” is greater • Suicide rate of physicians is 2-3x higher than non-physicians • Alcoholism rate is as prevalent among physicians as general population; risk of drug addiction is 30-100x • Oncology physician study: 53% emotional exhaustion, 48% low personal accomplishment, 22% depersonalization • Nurses endure 6-12 incidents of physician verbal abuse annually • 35% of physicians have no regular source of health care and are less likely to seek preventive services • Disability claims from physicians have >60% since 1990 • 85% of physicians say family life often/sometimes suffers from the emotional demands of profession

6. Stress of medicine (cont’d) • 54% of office based physicians have experienced a time when they had no more compassion to give • 30% say they would change professions today if they could • Increased threat of malpractice claims (negligence accounts for 2%, but 25-50% of claims are awarded!) • Intrusion of third parties into clinical decision making • 60% of physicians complain of eroding relationship with patients (12 min/patient); peer pressure on those spending more time • 80% of physicians are not fully reimbursed from insurance companies thereby requiring double scheduling and higher case loads • Poor communication and relationship with patients is one of the best predictors of law suits (e.g., Physician Risk Assessment)

7. Physician Stress (cont’d) • 81% said burnout is a significant problem in medicine • 75% patient satisfaction is affected by burnout • 67% burnout poses a problem to group practice • 62% Heavier workload than preferred • 59% unreasonable patient expectations • 59% feel guilty about insufficient time with patients • 58% shows significant signs of exhaustion • 55% family/personal life has suffered • 43% said they were already burned out

8. Being able to respond appropriately to patients is an essential skill to maintaining your practice and value to your facility. Patient satisfaction with and continued use of a physician is related to: • Patient’s familiarity with the physician (sufficient time for acquaintance & self disclosure) • Physician’s knowledge of the patient (case review) • Patient satisfaction with care received (appropriate, timely, knowledgeable, effective) • Patient’s confidence in doctor (knowledgeable, attentive) Family Practice Research Journal, (1993)13(2), 133-147

9. The experience of crisis

10. Stages of Crisis Management Fink’s Crisis Lifecycle Prodromal Risk cues that potential crisis can emerge Crisis breakout Triggering event with resulting damage Resolution Crisis no longer a concern to stakeholders Chronic Lingering effects of crisis Mitroff’s Five Stages of Crisis Management Signal detection Warning signs & efforts to prevent Probing & prevention Search risk factors & reduce potential for damage Damage containment Keep from spreading to uncontaminated areas Recovery Return to normal operations asap Learning Review & critique CM efforts for improvements

11. Ecomap of Stakeholders Primary Effect Secondary (Vicarious) Effect Tertiary Effect

12. Heart Rate & Stress Effects (beats/min) • Above 175 bpm: • irrational fight/flight • freezing • submissive behavior • voiding bladder/bowel • best gross motor skills 220 200 180 160 140 120 100 80 • 175 bpm: • tunnel vision • tunnel hearing • loss of near vision • loss of depth perception • cognitive processing deteriorates • vasoconstriction– reduced bleeding • 145 bpm: • complex motor skills deteriorate • 115-145 bpm-- optimal survival & combat level • complex motor skills • visual reaction time • cognitive reaction time • 115 bpm: • fine motor skills deteriorate • 60-80 bpm: • normal resting heart rate

13. Stress and the Nervous System: Getting stuck in the “on” position • Sympathetic Branch: • acute hearing • visual scanning • pupil dilation • hyperalert • inhibit salivation • faster heart rate • rapid breathing • cold hands • muscle tension • adrenaline rush • liver releases glucose • loss of appetite • slowed digestion • contract sphincters • constipation • Parasympathetic Branch • slower, deeper breathing • slow heart rate • constricts pupil • warm extremities • hunger, digestion • tired, fatigued • relaxed muscles • contract bladder • release sphincters Rebound Reaction

14. Perceptual distortions experienced during extreme stress 83% visual distortions 83% time distortions 69% auditory distortion 67% tunnel vision 67% slow motion 51% diminished sound 18% intensified sound 16% fast motion 16% heightened detail

15. Normal reactions to an abnormal situation (survivors involved in shooting situations) • 58% heightened sense of danger • 49% anger, blaming • 46% sleep difficulties • 45% isolation & withdrawal • 44% flashbacks, intrusive thoughts • 43% emotional numbing • 42% depression • 40% alienation • 40% fear, anxiety • 37% guilt, sorrow, remorse • 34% nightmares • 28% stigmatized • 28% problems with “the system” • 27% family problems • 23% feeling crazy, lose control • 18% sexual difficulties • 14% alcohol/drug abuse About 1/3 have mild or no reaction, 1/3 have moderate reaction, and 1/3 experience a severe reaction

16. Trauma and the Brain Cortical Area “Stream of thought” Subcortical Areas (Limbic System) “Stream of emotions” • Survival emotions • Store/retrieve memory • Obsessional thinking • Hyper-responsiveness • Inhibit evaluation & categorization • Pre-existing personality exaggeration

17. Selye’s General Adaptation Syndrome (GAS): Stages of the stress reaction Alarm Stage Recovery Stage Exhaustion Stage 1 3 2 Normal level of performance Mobilization Faster Stronger Perceptive Hypervigilant “Burnout” Initial shock Confusion Disorientation Slowness Unrealness Fatigue Exhaustion Collapse Illness

18. Duration of Critical Incident Stress Symptoms Emergency Staff Affected (%) No adverse effects 3-10% Acute or delayed reaction with or without help and eventual full recovery 80-85% Continued lifelong PTSD 3-4% Percent

19. Occurrence of PTSD • In 1996 75 Presidentially declared major disasters and 8 • national emergencies occurred in the US • 7% exposed annually to trauma & disaster (17 million • people) • 40-50% of Americans exposed to major trauma during • lifetime; 9% show PTSD, 15% subclinical • 17% of teens in some major cities have PTSD; Children • witness 10-20% of homicides in US • More than 30% of combat veterans have PTSD • 69% of surviving spouses of police officer killed in duty • have diagnosable PTSD

20. Assumptions about Crisis Intervention • Onset, brief period, predictable course, stages, normal reaction to overwhelming situation • Self limiting in 4-8 weeks, adjustment in 2 weeks, best intervention in 24 hours • Immediate reaction or gradual process • Subjective perception of crisis • Risk increases with physical/psychological danger and ratio with coping skills • Some events are critical for nearly everyone • Initial focus on containment, control, and resolution • Active and directive intervener

21. Guiding Principles of Intervention • Proximity--Intervene close or in the setting where crisis occurred to facilitate reintegration • Committment--Be active, involved, directive, available. Give information, set limits, give support, dispel myths, discourage denial, avoid projection. • Concurrence--Link survivor to social supports to share response burden, establish caring relationships, build skills, give feedback, and enhance use of community. • Expectancy-- Emphasize positive, develop hope for constructive outcome, develop access to personal resources, make best of bad situation

22. Listen actively • Use touch cautiously • Assess through interaction • Provide structure • Accept survivor’s viewpoint • Non-judgmental & unconditional acceptance • Elicit problem solving thinking • Focus on strengths • Provide small wins • Set expectations • Link with resources • Coordinate intervention • Reestablish routine • Follow-up Facilitative Behaviors During Crises

23. Positive Outcomes of Crises • Motivation to change • Enhanced creativity, coping & esteem • Higher personal integration • Expanded and tested support system • Outreaching skill building • Second chance resolution • Catalytic effect on family/social system • Survivor advocate