Professional Health and Wellness for Residents

1. Professional Health and Wellness for Residents Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration Associate Professor of Medicine Co-Director & Chair William H. Swiggart, M.S.,LPC/MHSP Assistant in Medicine Co-Director Center for Professional Health, Faculty and Physician Wellness Committee, Vanderbilt University School of Medicine

2. Reflection • How often and how well do you prioritize your personal and professional health and wellness to the top of your to do list? • How do you manage stress? • Can you list behaviors consistent with burnout?

3. Introduction & Overview • You should document the answers to these questions and modify them as you read this module. Make note of any changes you want to accomplish as a result. • Try to write down 1-2 items you plan to improve on. • This module should take about 30 minutes to complete.

4. Module Goals • Review issues related to professional health and wellness. • Emphasize self-care and managing workplace stress through various cases. • Provide examples residents can use to help prevent burnout and maintain wellness. • Provide an overview of key resources at Vanderbilt.

5. Participant Objectives Upon completion of the module you should be able to: • Identify 2 key areas for maintaining professional health and wellness. • Describe risk factors for burnout and behaviors that result from burnout. • List resources available at Vanderbilt.

6. Agenda • Introduction & overview • Professional health and wellness • Stress and burnout • Self-care tips • Self-awareness and management tips • Case scenarios • Resources • Summary and evaluations

7. Importance • One physician commits suicide every day. • Physicians are subject to stress, depression, anxiety, substance abuse and suicide more than other professionals. • Female physicians are more prone to stress, anxiety and suicide.

8. Importance • This module focuses on how to prevent and manage stress and burnout through maintaining self-care, good coping skills and workplace stress. We want you to be aware of these issues so you can avoid falling prey to stress and burnout both now and throughout your career.

9. “Professional Health and Wellness Starts with YOU!”

10. Professional Health • When stress comes, how will you cope? How will you handle it – the long hours, the sleepless nights and the sacrifice of family and personal issues? • We hope you will learn a few tips from this module to help you survive and thrive through your residency training. • We hope you will build good behaviors and coping mechanisms that you can use throughout your career.

11. Professional Health • How do you define professional health and wellness? What does this mean to you? • We believe professional health and wellness is the physical, mental and spiritual part of you that comes to work everyday to help serve the greater good of the patient and community. • Self care plays a big role, as well as, workplace stress and burnout in your overall physical, mental, emotional and spiritual health. We like to think about this concept as the professional health spectrum.

12. Work & Family Relations Physical Mental Emotional Spiritual Fair Functioning Reduced Productivity Relationships Suffer Fair-Not Functioning Fair-Not Productive Institution & Family Loses High Functioning High Productivity Fair Functioning Decreasing Productivity Burnout Coping Mechanisms Failing Risk of MH issues and suicide No Coping Mechanisms Professionally Healthy & Well Stressed Coping Mechanisms Strong Professional Health & Wellness Spectrum

13. Professional Health • Physicians as a group experience more stress, burnout and depression than the general population and residents are no exception. • 30-60% physicians report experience of distress and burnout • 10% mild, 4% mod-marked depression (twice that of depression in physician pop.) • Increased in younger physicians • Repeated study in 2006 – similar results (Schindler et al 2006) Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82.

14. Professional Health • Residents are also prone to stress, burnout, substance abuse and depressions, the latter two increasing their risk of suicide. • This is due to a variety of reasons including performance anxiety, difficulty adjusting to changes in environment, feelings of isolation, and even difficult relationships with attending physicians and poor examples of professional conduct from supervising faculty members.

15. Stress & Burnout Stress and burnout occurs for different reasons in different individuals. Work load alone does not mean higher levels of stress or burnout. Stress is most likely multifactorial in many situations. Identifying the source is the key to planning a process to reduce stress.

16. Definition - Stress Stress can be defined as: d: a state resulting from a stress; especially: one of bodily or mental tension resulting from factors that tend to alter an existent equilibrium <job-related stress> Webster’s dictionary Stress can be situational or prolonged. When assessing your situation, determine if this is short term or long term. How it affects you and how you adapt to it may be different if it is short term or prolonged.

17. Stress • Short term stress could results from a flat tire on the way to work. You will be more stressed if you are late for clinic and patients are waiting as opposed to if you are on a day off. • Physical, emotional and mental responses will vary. Your response will be more intense in the former example and you may be able to roll with the punches in the latter example. • Short term stress can be good or bad, for example stress during a code – can help you focus or can paralyze you.

18. Productive Stress No Prolonged Stress Declining Function Stress & Productivity Prolonged Stress • Prolonged stress, however, reduces productivity in the long run and can lead to burnout. Situational Stress Stressed Burnout Non-Functional

19. Definition - Burnout Burnout can be defined as: a: exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustrationb: a person suffering from burnout. Webster’s dictionary Prolonged stress can result in burnout. Burnout has effects that can impact you, your colleagues, your family and your ability to cope with stressful situations.

20. Burnout “In the current climate, burnout thrives in the workplace. Burnout is always more likely when there is a major mismatch between the nature of the job and the nature of the person who does the job.” ~Christina Maslach The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

21. Burnout The 6 key areas of mismatch that can lead to burnout include: • Work overload • Lack of control • Insufficient rewards • Breakdown of community • Absence of fairness • Conflicting values The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

22. Burnout Examples include: • Work overload – exhaustion and sleep depravation • Lack of control – being forced to comply; no choice • Insufficient rewards – lack of recognition for your hard work • Breakdown of community – when individuals feel isolated and not in it together • Absence of fairness – when some get privileges while others don’t • Conflicting values – when you believe one thing but the culture of your job opposes that belief. The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

23. Burnout Burnout results in the following symptoms, actions or behaviors: • Emotional exhaustion • Isolation • Avoidance • Feelings of cynicism • Impaired productivity • Interpersonal conflicts • High turnover The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

24. Single Gender/sexual orientation ># of children at home Family problems Mid-late career Previous mental health issues (depression) Fatigue & sleep deprivation General dissatisfaction Alcohol and drugs Minority/international Teaching & research demands Potential litigation Risk Factors for Burnout Puddester D. West J Med 2001;174:5-7; Myers MJ West J Med 2001;174:30-33; Gautam M West J Med 2001;174:37-41

25. Personal: Influence happiness through personal values and choices Spend time with family & friends Engage in religious or spiritual activity Maintain self-care (nutrition & exercise) Adapt a healthy philosophy/outlook A supportive spouse or partner Work: Gain control over environment & workload Find meaning in work Set limits and maintain balance Have a mentor Obtain adequate administrative support systems Protective Factors Spickard, Gabbe & Christensen. JAMA, September 2002:288(12):1447-50

26. Professional Health • Many things are out of your control but there are a few things you can do to help with your ability to cope and deal with the challenges you will face during your training. • Two big categories to think about in maintaining your professional health and wellness include: • Self-care • workplace stress management

27. Self-Care There are seven (7) key areas to focus on in self-care. Self-care issues include: Sleep Balanced and healthy meals Physical activity Socialization Vacations/down times Spiritual engagement Have a physician

28. Self-Care #1: Sleep • These are critical and often challenging to focus on while in training. Keep sleep as your sacred ritual. Get it often and as much as your body needs. Less than 8 hours of sleep makes you prone to medical errors and professionalism lapses. • If you have a family, arrange for older family members to help your spouse and kids during harder rotations or pay baby sitters to sleep over and help with the kids at night so you can sleep uninterrupted.

29. Self-Care #1: Sleep • Be sure to avoid alcoholic beverages. Alcohol interferes with REM sleep and should be avoided if you want a restful night. • Make your sleeping environment conducive to good sleep: cool, dark and comfortable bedding. • On services with a time shift (night float or ER shifts), use block–out shades to prevent the sun from entering the room. This will help create a nighttime for you. These can be purchased at most home stores and can be temporary or permanent. You can also try sleep masks.

30. Self-Care #2: Healthy Eating • Balanced meals and physical activity – doesn’t mean you need a four course meal and 2 hrs a day at the gym. But it does mean you should grab the salad with fruit and vegetables over the fast foods. • Bring healthy, non-perishable snacks that can fit in your white coat pocket just in case you cannot make it to lunch on time. Examples include: fruit (bananas, grapes, apples), vegetables (carrots, celery with peanut butter, broccoli), bars (fiber, energy bars, breakfast), vegetable chips, etc.

31. Self-Care #2: Healthy Eating • When you do have opportunity to sit for a meal, make it a balanced meal with nutrient-rich foods packed with vitamins, minerals and antioxidants. • If you are skipping meals, make sure to get a supplement daily – a standard multiple vitamin will do. • Many residency programs still provide lunch – make this a priority. Schedule activities around your meals. This allows you to get refueled to continue your activities for the rest of the day.

32. Self-Care #3: Physical Activity • You can and should incorporate physical activity into your work day: walk fast between patients; take the stairs and take short walks when you can. • When you do get down time and easier rotations, look for external venues you enjoy – bike riding, swimming, jogging, hiking, etc. • Physical activity helps relieve stress and allows you to feel like you can disconnect from work.

33. Self-Care #3: Physical Activity • For those with a family, include the kids and spouse and make it a family affair. • Place smaller infants and toddlers in a stroller and walk or jog with your spouse. Talk about family topics and avoid talking shop (unless you are both physicians and enjoy sharing the patient care stories with each other.) • Take older kids on bike rides and short runs. • Some gyms such as the YMCA will provide child care; check them in and go work off your stress!

34. Self-Care #4: Socialization • Socialization is important. Whether you like hanging with friends or family, laughing is very important to your overall outlook on life and evidence supports people who laugh more live longer. • Being around other physicians allows for camaraderie and shared understanding. Sometimes, however, you may just want to disconnect and not “talk shop” at all and focus your time on your family or friends. Try to incorporate both aspects of socializing.

35. Self-Care #4: Socialization • If you are married with kids, look for programs with parent night out options or hire a baby sitter at least once a month to allow you and your spouse to have time together. • Also, make sure your love life keeps its steam. Parenting magazines have a variety of articles on this topic. Some range from, “you’ll be tired any way so just do it” to “plan your evening of romance.”

36. Self-Care #4: Socialization • Which ever option you chose, just do it! Intercourse and sharing in a love relationship helps you feel grounded, safe, loved and respected. • It also makes sure you emphasize to your spouse that it is not all about work but it is all about maintaining the love in your relationship. • You both should be equal players in the discussion and set your love making as a priority for your relationship.

37. Self-Care #5: Vacations • A balanced person should seek out and plan their vacations. Allowing your mind and body to rest is important in your ability to cope with stress and challenges as they pop up. • We want to warn you about the “trap” of taking vacation. Many think taking a vacation is harder than not taking vacation because the work piles up or it is worse once they return. They feel “trapped” into staying at work because it is easier. While there may be more emails and stacks of mail when you return, there are ways to handle this and you will be more efficient if you are well rested.

38. Self-Care #5: Vacations • Plan vacations far in advance so patients are not scheduled and coverage is arranged. • Allow one-half to one full day on the front and back ends of the vacation. On the front end, complete outstanding charts, plan meetings for your return, schedule in calendar time for overflow issues and prepare for your trip. On the back end, anticipate activities for the week and plan for the transition by having time to settle back into the work routine.

39. Self-Care #5: Vacation • Avoid having clinical days on the morning you return from a vacation. This allows a little time for urgencies, emergencies and catch up. • If you don’t have this option, try to build in time over the first 1-2 weeks as an hour here and there. • Plan on scanning emails while traveling home – in the airports or in the cab ride home. Do a scan of your emails and prioritize the most important ones into a “must do” file and address these once your return.

40. Self-Care #5: Vacation • If you cannot connect to emails, try creating a “to do list” and/or list of emails to send in a word document. • If you take the blackberry with you, try to limit its use to only while in transport – this allows short periods to address key “must do” issues. If the family is with you, it also sends a strong message that you are there with the family and are focused on them. Plus, can you really disconnect if you stay connected the whole time on vacation?

41. Self-Care #6: Spirituality • However you chose to grow and support your spiritual side, make it part of your routine. Some find strength in formal services while others prefer finding spirituality within themselves and within their family. • Use a variety of resources from self-help books, tapes/CDs, music, yoga, etc. to allow your spirit time to rest, renew and strengthen itself. • A good strong spirit helps you stay motivated and enthusiastic about work even at 2 AM and they wake you about a constipated patient!

42. Self-Care #7: Have a Physician • How many times have we heard the expression, “Physician heal thyself?” Too often, you are almost an impaired physician if you are ill, stressed, depressed, etc. You need a professional to help you focus and keep you on the healing path. • Take time to find a physician so you have access to someone when you need it. You will be more likely to seek assistance when the initial barrier of obtaining a physician is removed.

43. Self-Care #7: Have a Physician • Unfortunately, many physicians do not have their own PCP and try to manage their own physical and mental health issues. This can be very dangerous and very isolating. You need to have a trusted member of the healthcare team to help you see sometimes what you may not or cannot see for yourself. • While stigma may exists around physicians going to the Nth degree before seeking their own care, we feel a balanced physician is one who allows another physician to care for them.

44. Self-Care #7: Have a Physician • But we do caution about the colleague PCP problem. Don’t allow another resident to make you their PCP. Just say no and tell them you care enough for them to seek the care of their own PCP. Never prescribe controlled substances to a peer! Ever! • Most physicians will take extra care to incorporate you into their schedule and most programs have an employee health program that makes sure you have a PCP or health care employee physician to help care for your needs.

45. Self-Care #7: Have a Physician • Make sure you schedule an appointment just to meet your PCP even if just yearly. Hopefully you will remain healthy and strong throughout your training but just in case, you will feel more comfortable seeking help if you can already identify with someone. • This also sets up a good habit. It keeps your health as a priority, not to mention you will have them available if needed.

46. Self-Care #7: Have a Physician • You have no stigma to overcome unless you allow your own fears to rule you. Physicians are human. They have stress. They develop illnesses and having an MD degree does not give you card blanch for living life without stress and illness. • Having a physician allows you a resource that is private, confidential and supportive as well as understanding of the challenges you face. Who else can relate to another physician better than a physician?

47. Self-Care #7: Have a Physician • Mental health issues always seem taboo but that is because we as a culture allow it by perpetuating the idea that only happens to patients. Let’s be real. We will all feel stressed, anxious and near burnout by December of our internship year! Seeking help doesn’t make you less of a doctor, it makes you a better person! • If you already deal with mental health issues, remaining controlled with medication and under the care of a physician will help make sure you stay on top of things.

48. “The first wealthishealth.”~ Ralph Waldo Emerson

49. Work-Place Stress Five (5) key areas to address regarding work-place stress: Be your own self-monitor Manage energy Reduce distractions Plan appropriately Managing failures and successes

50. #1: Be Your Own Self-Monitor • When you start feeling like the individual in these pictures, it is time to get things in check. • Know one can better assess your level of stress than you. • Preventing stress is better than suffering through stress.