Maryland Physician Health Program: Preventing and Treating Physician Burnout

1. Maryland Physician Health ProgramHelping physicians and the medical community for more than 35 years Center for a Healthy Maryland, Inc. MedChi, The Maryland State Medical Society Martin S. Rusinowitz, MD Medical Director, Maryland Professional Rehabilitation Program

2. Why Preventing and Treating Physician Burnout Matters • https://www.youtube.com/watch?v=cDDWvj_q-o8

3. Objective • Understand the prevalence of Burnout amongst physicians • Identify symptoms of Burnout • How to deal with Burnout

4. Physician Health Program (s) Program Philosophy & History “Physicians with substance use and mental health or other problems should not lose their medical licenses (and livelihood) without at least attempting intervention.” • Maryland Physician Rehabilitation Committee established by MedChi in 1978; funded by portion of MedChi dues • Program was established in 1985, with the hiring of professional staff; funded by license fees through the State Board from 1990 to 2004 • Administered by the Center for a Healthy Maryland since July 2004; funded by fees and donations

5. Physician Health Program(s) • Physician Health Programs are in 49 States, Military Branches, and the Veterans Administration • PHP is NOT an “Addiction or Mental Health Treatment Program” • PHP is an intensive, long-term case management and monitoring program designed for Physicians • Participation in the PHP is voluntary • PHP provides education and outreach regarding physician impairment and available services • Services are provided in a private, confidential setting • PHP provides case management facilitates compliance with the rehabilitation plan, and provides on-going monitoring

6. Program Structure • Operated under the Center for a Healthy Maryland, a 501C(3) affiliate of MedChi, the Maryland Medical Society • Maryland Physician Health Committee • Comprised of interested physician colleagues from various specialties (Psychiatry, Neurology, Internal Medicine, General Surgery, ENT, Anesthesiology, Addiction Medicine, Family medicine, etc.) • Provides guidance to the Staff • Staff • 2 Medical Directors; MPHP (psychiatrist), MPRP (neurologist) • Five masters level mental health clinicians • An additional experienced staff with over 30 years of substance abuse expertise

7. Confidentiality • Complies with federal and state laws that ensure the confidentiality of physicians who are participants of the MPHP. • Signed releases obtained from the participants granting permission to release information to other parties. • The Program is separate from the Maryland Board of Physicians.

8. Maryland Medical Practice Act • H.O. 14-404—May reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: • Is guilty of (i) Immoral conduct in practice of medicine; or (ii) Unprofessional conduct in the practice of medicine; [MORAL TURPITUDE; Substance abuse, “DISRUPTIVE BEHAVIOR”] • Is professionally, physically, or mentally incompetent; [Psychiatric or cognitive illness]

9. Maryland Medical Practice Act (Cont.) • Disciplinary actions is possible if these occur while providing professional services: • While under the influence of alcohol • While using any narcotic or controlled dangerous substance as defined in Criminal Law Article, or other drug that is in excess of therapeutic amount or without valid medical indication • Is addicted to, or habitually abuses, any narcotic or controlled dangerous substance as defined in Criminal Law Article • Sells, prescribes, gives away, or administers drugs for illegal or illegitimate medical purposes

10. Additionally, re: Behavioral Issues “The Maryland Board of Physicians (MBP) acknowledges that these behaviors are serious and need to be dealt with accordingly. In some circumstance, certain disruptive behaviors can escalate to the point of threatening patient care, and may be considered “unprofessional conduct” in the practice of medicine. Addressing disruptive behaviors early will improve the physician's function within the healthcare facility and team, and assure the safe, effective delivery of health care services by that physician. The MBP believes that hospitals and facilities which employ physicians have a duty to address potentially dangerous behaviors, and report those issues to the Board of Physicians. The MBP believes that it has the authority to implement penalties afforded in law (fines) against hospitals which have failed to address these issues to the point which these behaviors are eventually ruled to be actionable “unprofessional conduct.”

11. Case #1 58 y.o. general surgeon referred for “anger issues.” Multiple incidents of yelling at staff “when he doesn’t get his way.” Last incidents involved yelling at the cafeteria staff because he was not able to get pancakes after 9:30AM, having been continuously in surgery for the past 24 hours! Another incident involved an “outburst” when his case was bumped from an OR for a “more urgent” one. He was referred to and has been attending an “anger management” course by the hospital but there seemed to be no change in his behavior which was described as “erratic and cyclical.” According to his wife, some of this may have been fueled by his mother’s recent stroke and his best friend falling ill. Irritability has remained a constant and he has been unable to regulate his behavior and avoid conflicts with staff and colleagues.

12. Case #2 35 y.o. highly respected OBGYN with a new born son, and 3 other children all under the age of 6, referred for recent negative outcomes. Husband recently promoted at work and is not able to help with household responsibilities as much as in the past. Her practice recently implemented a new EHR that resulted in spending twice as much time in completing documentation. She described herself as “overwhelmed,” “anxious,” and “unable to sleep,” even when she finds time, unless she takes Ambien. She started with 5mg now takes 10mg. She reports that a “glass or two” of wine helps with sleep. She still complains of being tired and anxious and generally feels that she has to “drag herself through the day.” She started taking Xanax to address anxiety. She sees her situation as hopeless and feels like she’s on “autopilot” and one day simply blends into the next.” She has been getting into more conflicts with nurses due to their “inefficiencies.”

13. BURNOUT • Systematic Causes • Modern healthcare • Societal changes • Business model for the practice of medicine • Individual Characteristics • Personality • Perfectionism • Perseverance

14. Definition • Burnout: “exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration” • Similar to other high stress jobs: law enforcement, military, and air-traffic controllers • “The feeling of being asked to solve a problem without a solution” • “It feels like I’m asked to solve a maze without a solution while on hamster wheel” • Changes in: demeanor, character, overreaction to minor provocations, outbursts, crying, etc. …

15. Is it Burnout or “just” Stress • Burnout—chronic condition—not transient or temporary • Stress—one can recover after the stressful event is over

16. Three Symptoms of Burnout • Emotional exhaustion • Hopeless entrapment response • Learned helplessness • One will stop trying to avoid the negative stimulus and behave as if unable to change the situation, even if there are opportunities to do so • “auto-pilot” syndrome

17. Three Symptoms of Burnout (cont’d) • Depersonalization • Patients are no longer seen as people but tasks • Acting a role that doesn't seem authentic • Emotionally absent • Part of a “defense mechanism” • Empathy become cynical and jaded loss of compassion • “Compassion Fatigue”

18. Three Symptoms of Burnout (cont’d) • Lack of personal accomplishment and meaning • No sense of personal accomplishment or satisfaction from work • Work feels like a “prison sentence” • No self-efficacy • Belief that one has lost the ability to produce effects

19. Common Behavioral Signs • Perfectionism • Obsession with Negative Events • Judging and Labeling • Misplaced Responsibility • Disruptive Behaviors • “I’m the only one who’s trying to save patients”

20. Medicine Has Changed • Technological and scientific changes with more treatment options • Changes in patient and family expectations • Practice of medicine is a “business” • Trust and respect for physicians have eroded amongst the general public • Training of Nurses and other allied health professionals are evolving as is their scope of practice • The practice of medicine is now a “Team Game” and physicians are expected to be managers not just practitioners

21. Physician’s Reactions to Change* • 54% of physicians rate their morale as somewhat or very negative • 37% describe their feelings about the future of the medical profession as positive • 49% often or always experience feelings of burnout • 49% would not recommend medicine as a career to their children • 14% of physicians have the time they need to provide the highest standards of care • 48% of physicians plan to cut-back on hours, retire, take a non-clinical jobs, switch to “concierge” medicine, or take other steps to limit patient contact • 11% of physicians say EHR have improved patient interaction, while 60% say it has detracted from patient interaction • Younger physicians, female physicians, employed physicians and primary care physicians are notably more positive about the current practice environment then older physicians, male physicians, medical specialists and practice owners * The Physicians Foundation--2016 Survey of America’s Physicians

22. MPHP—Individual Approach We do not blame the physician, burnout can/is be caused by the system • Burnt-out physicians are distressed physicians • Distressed physicians are often depressed and unhappy • Distressed physicians are often “disruptive” physicians • Distressed physicians sometimes turn to unhealthy coping mechanisms—alcohol and drugs

23. Typical Physician Personality • Perfectionism • Triad of Compulsivity • Guilt • Exaggerated sense of responsibility • Doubt • Delayed gratification • Survival attitude • “can do anything for 30 days”

24. Physician PersonalityDifferent side of the same coin • Maladaptive • Can’t relax • Can’t allocate time for family • Responsible beyond what you can control • “not doing enough” • Can’t set limits • Selfish vs. healthy self-interest • Can’t take time off • Adaptive • Diagnostic rigor • Through • Commitment • Staying current • Responsibility

25. Solutions/Recommendations • Expectations vs. Reality • Late/Mid Career physicians • Education/Training • Practice of “Modern Medicine” • Change vs. mindset • Accept the situation or change the situation • A higher or same level of accountability as in the past, while autonomy and control has been reduced

26. Solutions/Recommendations (cont’d) • Recognition—acknowledging burnout is not a sign of weakness • But don’t just vent • Action/Changes • Make a commitment/resolve to do something • “Can’t be all things to all people” • Learn to politely and firmly say no

27. Solutions/Recommendations (cont’d) • Create Appropriate Boundaries • Scheduling • Patient Volume • Number of hours worked • “God, grant me the serenity to accept the things I cannot change, change the things I can, and the wisdom to know the difference.”

28. MPHP Experience • Characteristics that often make a great physician may also contribute to burnout • The physician is almost always right • The more “righter” they are the greater the possibility of symptoms of burnout including disruptive behaviors • Aside from “extreme” events, specific events are almost always a reflection of a pattern • Any physician can experience burnout and it does not necessarily indicate a pathology, but it might

29. MPHP Experience (cont’d) • Increase use of coping strategies may be helpful • Being told “it’s your weakness” is not helpful • Important to acknowledge physicians perspectives on changes in “Modern Medicine” • Older physicians have more difficulties with changes • Surgical specialties working in a hospital setting experience more burnout

30. MPHP Perspective • MPHP deals with specific issues or problems of each individual practitioner, NOT systematic causes • We focus on how they can individually deal with causes of Burnout • Burnout can manifest itself as substance abuse, psychiatric distress leading to impairment and “Disruptive Behaviors” • Increasingly, over the past 10 years, MPHP has noticed many “impaired” symptoms are associated with burnout and may have negative consequences with medical licensure

31. For Physicians,… • Private • Confidential • Non-disciplinary • Help • YOU DON’T HAVE BE “IMPAIRED” • ADVOCACY for physicians

32. Program Contacts www.healthymaryland.org phpinfo@medchi.org 800-992-7010 Chair, MPHC-Daniel Nyhan, MD Medical Director, MPHP-Arthur Hildreth, MD Medical Director, MPRP-Martin Rusinowitz, MD Director-Laura Berg, LCSW-C Director of Operations-Michael Llufrio Senior Clinical Manager– Astrid Ashley-Richardson, LMSW Senior Clinical Manager-Matteo Ricci, LCPC Clinical Manager-Syeira Anthony, LMSW Program Assistant-Domenica Stone