Combatting Stress in Surgical Practice

1. Combatting Stress in Surgical Practice Mamta Gautam, MD, MBA, FRCPC, CCPE, CPE, MOT

2. Faculty/Presenter Disclosure • Faculty: Dr. Mamta Gautam • Disclosure: President and CEO, PEAK MD Inc • Relationships with commercial/pharma interests: NONE • Disclosure of commercial support: NONE • Potential for conflict of interest: NONE • Mitigating potential bias: NOT REQUIRED • The content of this discussion is not related to the services of commercial interest. • No therapeutic recommendations for medications will be made.

3. Learning Objectives • What is stress and burnout? • What causes burnout in surgery? • Why should we care? • What can we do about it? • Culture of wellness • Individual Resilience

4. The Practice of Surgery • Surgeons work hard, long hours • Deal with life and death situations • Make personal sacrifices to practice specialty • Endure rigors and length of training • Attract individuals of character and determination who share a code of rules, norms, expectations • A fine line separates dedication from overwork

5. BURNOUT A syndrome of emotional exhaustion, chronic overstress. (Maslach) • Distinct work-related syndrome – demands exceed individual resources • Most likely to occur in jobs that require extensive care of others • Common among practicing physicians • Not a psychiatric diagnosis, but can lead to serious consequences

6. BURNOUT Three stages of burnout: Emotional Exhaustion Depersonalization Reduced Personal Accomplishment

7. Review of Burnout Studies • 2007-8: CMA Survey – 48.6% of Canadian physicians had symptoms • 2017 CMA survey – 28.3% (using 2-item MBI) • In US, according to Medscape: • 2018 – 42-53% of physicians • Highest (52-53%): critical care, ER, neurologists, family physicians, obs/gyns, and internists • Lowest (45%) : plastic surgeons, dermatologists, pathologists, and ophthalmologists

8. Burnout in Surgery • 2009: 40% surgeons had burnout in ACS survey; 30% with depression • 2014: 53% with burnout • Subspecialty – those in frontline specialties (trauma, general surgery) at higher risk • More in private surgeons than in academic practice • Debt load, admin issues, legal issues, pt death Shanafelt, Tait et al

9. Possible Risk Factors • High Workload - demands exceed resources • Incentive Based Pay • Age - inverse relation between age and burnout. Survivor bias. • Gender – higher (2X) in women than men • Children – higher if young children under 21 yo • Spousal support – inverse relation between emotional exhaustion and support from partner

10. Individual Drivers • Intellectual Defenses: Denial, minimization, rationalization, sublimation • Personality traits: perfectionistic, self-critical, guilt, need for control • High expectations of ourselves and others • Sign of weakness; associated sense of shame and guilt • Fear of failure, judgment, exposure • Fear of loss of control, concerns re. future prognosis

11. Cultural Drivers • Attitudes: The patient comes first. Never show weakness or emotion. Tough it out. • Sets high expectations, perfectionism, self denial • Lack of control • Doing things that are not ‘doctoring’ • Concerns dismissed, not taken seriously by colleagues • Unsupportive or judgmental colleagues • Stigma in the culture of medicine

12. Stigma as a Major Challenge “Nowhere is the stigma of mental health greater than within medicine.” M. Gautam, 2008

13. Systems Drivers • Workplace issues: Long hours, frequent call, frustration with administrative burden, paperwork, EMR, feeling undervalued, frustrations with referral networks, difficult patients, medicolegal issues • Challenges in finding work-life balance. • Withdrawal from practice – time away from patients and work, with increasing workloads, • Lack of confidentiality and privacy – loss of autonomy • Regulatory concerns – hospital privileges, practice restrictions, limitations of licensing/privileges • Insurance – discrimination or inability in obtaining insurance

14. Consequences to the Physician • Impaired job performance and Professional Problems • Changing jobs, reducing work hours • Difficulty with Relationships • Physical Illnesses • Addictions • Psychiatric Illnesses – Anxiety, Depression, Suicide

15. Consequences to our Patients • Quality of Care: patient safety and quality of care - increased rates of medical errors, riskier prescribing patterns, and lower patient adherence to chronic disease management plans • Quality of Caring – communication, empathy, patient satisfaction

16. Consequences to the System • Impact on morale and satisfaction • Recruitment and Retention: dissatisfaction, making them more likely to leave clinical practice, retire early • Leadership: Interest, energy and ability to lead changes in the practice or health care system

17. What can we do to prevent burnout? We need to stop blaming doctors and see this as a shared responsibility of: • Individual physicians • Culture in medicine • Healthcare systems

18. Culture of Wellness and Trust • Professionalism • Teamwork • Conflict management • Just culture • Peer support • Error Reduction and Disclosures

19. Emotional Impact of Errors How we react can depend on our background, past experience, degree of impact to patient • Sadness • Shame • Self doubt • Fear • Anger • Isolation

20. Can lead to • More anxiety about making a future error • Less confidence • Less job satisfaction • More sleeplessness • Fear of impact on profession • Burnout, depression • 30%: neg impact on work performance, personal life, collegial relationships

21. Shame loves Perfectionists • Reduce errors, cannot eliminate • Move from Shame/Blame to Share/Care • A&A Rounds • Create a safe culture so can speak up • Learning and growth mindset

22. Resilience after adverse events • Talking about it with a colleague • Disclosure and apology • Forgiveness • Dealing with imperfection • Learning from error to prevent recurrence • Sharing that learning with colleagues and trainees

23. PHYSICIAN RESILIENCE Being prepared for the event Coping with the situation – skills and strategies Bouncing back and growing further

24. THE FIVE C’s of RESILIENCE

25. 1. Control and Confidence One needs a sense of: • Self awareness • Confidence • Control

26. COMMON PERSONALITY TRAITS • Overly conscientious • People pleasing • Sense of Responsibility and Guilt • Unrelenting perfectionism • Need to control others • Chronic self doubts • Uncomfortable with love, approval • Ability to delay gratification

27. FIVE EARLY DANGER SIGNS • Increase in physical problems and illnesses • More problems with relationships • Increase in negative thoughts and feelings • Significant increase in bad habits • Exhaustion

28. Even the healthiest and strongest of us can become unhealthy in an unhealthy environment.

29. 2. Commitment • What initially drew me to this work? • Values clarification exercise • Reflection and Journaling – how is my work meaningful to me? • My best moment at work

30. The Five Balls • Work • Home and Family • Relationships • Friends • Self Care

31. What are your Big Rocks?

32. 3. Caring Connections • We often feel alone and lonely, with our workload and responsibilities • Holding Environment – how would you create this?

33. Relationships in the workplace Create a sense of community – personal touch Emotional Bank Account Add fun to work Use peers/colleagues for support Encourage mentoring Build teams – communicate, resolve conflicts

34. Personal Relationships How do we nurture and support these With our partner? With our children? With our parents and siblings? With our friends?

35. USE SUPPORT SYSTEMS • Have at least one good friend • Friends- good for you physically, emotionally • People who are “good for you” • Pets

36. 4. Calmness • Recognize when you are not calm • Learn skills to manage during that time, eg. errors

37. TAKE REGULAR TIME OFF • Planned : The Tarzan Rule • Unplanned : A Gift of Time

38. RELAXATION TECHNIQUES • Many methods available • Spiritual relaxation, meditation • ‘Rehearse’ for the ‘performance’

39. 5. Care for Self • Take care of yourself first • Make time for yourself • Exercise • Nutrition

40. Healthy sex life • Get your own family doctor • Indulge yourself • Sleep

41. LAUGH MORE OFTEN.

42. FINANCIAL MANAGEMENT • Stick to basic financial principles • Reduce non-deductible debt • Do not overextend financially

43. LET GO OF THE GUILT • Acknowledge it; let go of it • My Rule for Doctors

44. DON’T JUST TRY