broken doctors broken systems transcript · 2018-05-15 · broken doctors, broken systems:...

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Broken Doctors, Broken Systems: Clinician Mental Health in Context Eric Levi FRACS. Otolaryngologist Head & Neck Surgeon. Modified from a Plenary Talk at Combined Annual Scientific Congress of the Royal Australasian College of Surgeons and Australian and New Zealand College of Anaesthetists. Sydney, May 2018. @DrEricLevi How do you deliver the best care for your patient? More importantly, how do you deliver the best care for your patient in the context of institutional and individual challenges? The problem of clinician burnout and mental health is well known. As individuals and institutions, we have been grappling with this issue for some time. We have had many interventions with variable successes. Are we thinking correctly around this? I would like to change your mind on this matter. I have no disclosures. I do have a disclaimer. I am not a psychiatrist or a mental health professional. I am a surgeon on the coalface. I have been hit by friendly fire and covered in mud. I would sincerely like to share my thoughts as a front- line worker and offer three possible practical action plans that are not necessarily expensive or extensive to tackle this issue. Doctor wellbeing and doctor suicides are uncomfortable topics for many of us. We are trained to diagnose, treat, gas, tube, stabilise, fix patients. Unlike our colleagues who are GPs and Psychiatrists, we are uncomfortable with this “wishy-washy, touchy-feely” stuff. We know it is important somehow but we don’t know how to approach it. We are not trained to help our colleagues. We don’t know how to respond to a struggling colleague. There is a certain awkwardness when we see our colleagues struggle. We know that there is an elephant in the room but we don’t really know what to do with that elephant. The data is clear and has been covered in many other places. Doctors are struggling, and they are struggling quietly. (National Mental Health Survey of Doctors and Medical Students. October 2013. Beyond Blue.) These are the numbers we know in Australian Doctors in 2013 based on Beyond Blue survey of over 12,000 doctors: 1 in 5 has been diagnosed with or received treatment for depression. 1 in 4 has had suicidal thoughts. And 1 in 50 has attempted suicide. The risk with us looking at these statistics is our cognitive dissociation from this statistic the same way we look at other statistics and say “those numbers are for the patients, not for me.” No, this is our statistic. This is us in this room. This is the state of our health care community. In a typical Surgical or Anaesthetic Department, there will be someone who has had thoughts of suicide and perhaps someone who has attempted suicide. Females are at higher risk, and the specialty hotspots for suicide are GP, ED and anaesthesia. However, it’s not a gender issue because males commit suicide. It’s not an age issue, because consultants commit suicides, not just trainees. I am mindful that there may be some of us struggling with these thoughts this week, or even right now. If that is you, please hear me. You really matter. You really do matter to your community, to us, and to our patients. Please share your burden with a trusted colleague, a GP or a professional mental health worker. Help us help you to be a better doctor for your patient. In view of this elephant in the room, self-care and managing mental health is indispensable. It’s so important that for the first time last year, the World Medical Association has included self-care as part of their Physician’s Pledge on the Declaration of Geneva. The Physician’s Pledge is the modern version of the Hippocratic Oath. In 2017 it begins with: “AS A MEMBER OF THE MEDICAL PROFESSION, I SOLEMNLY

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Page 1: Broken Doctors Broken Systems Transcript · 2018-05-15 · Broken Doctors, Broken Systems: Clinician Mental Health in Context Eric Levi FRACS. Otolaryngologist Head & Neck Surgeon

BrokenDoctors,BrokenSystems:ClinicianMentalHealthinContext

EricLeviFRACS.OtolaryngologistHead&NeckSurgeon.ModifiedfromaPlenaryTalkatCombinedAnnualScientificCongressoftheRoyalAustralasianCollegeofSurgeonsandAustralianandNewZealandCollegeofAnaesthetists.Sydney,May2018.@DrEricLevi

Howdoyoudeliverthebestcareforyourpatient?Moreimportantly,howdoyoudeliverthebestcareforyourpatientinthecontextofinstitutionalandindividualchallenges?Theproblemofclinicianburnoutandmentalhealthiswellknown.Asindividualsandinstitutions,wehavebeengrapplingwiththisissueforsometime.Wehavehadmanyinterventionswithvariablesuccesses.Arewethinkingcorrectlyaroundthis?

Iwouldliketochangeyourmindonthismatter.Ihavenodisclosures.Idohaveadisclaimer.Iamnotapsychiatristoramentalhealthprofessional.Iamasurgeononthecoalface.I

havebeenhitbyfriendlyfireandcoveredinmud.Iwouldsincerelyliketosharemythoughtsasafront-lineworkerandofferthreepossiblepracticalactionplansthatarenotnecessarilyexpensiveorextensivetotacklethisissue.

Doctorwellbeinganddoctorsuicidesareuncomfortabletopicsformanyofus.Wearetrainedtodiagnose,treat,gas,tube,stabilise,fixpatients.UnlikeourcolleagueswhoareGPsandPsychiatrists,weareuncomfortablewiththis“wishy-washy,touchy-feely”stuff.Weknowitisimportantsomehowbutwedon’tknowhowtoapproachit.Wearenottrainedtohelpourcolleagues.Wedon’tknowhowtorespondtoastrugglingcolleague.Thereisacertainawkwardnesswhenweseeourcolleaguesstruggle.

Weknowthatthereisanelephantintheroombutwedon’treallyknowwhattodowiththatelephant.Thedataisclearandhasbeencoveredinmanyotherplaces.Doctorsarestruggling,andtheyarestrugglingquietly.(NationalMentalHealthSurveyofDoctorsandMedicalStudents.October2013.BeyondBlue.)ThesearethenumbersweknowinAustralianDoctorsin2013basedonBeyondBluesurveyofover12,000doctors:1in5hasbeendiagnosedwithorreceivedtreatmentfordepression.1in4hashadsuicidalthoughts.And1in50hasattemptedsuicide.Theriskwithuslookingatthesestatisticsisourcognitive

dissociationfromthisstatisticthesamewaywelookatotherstatisticsandsay“thosenumbersareforthepatients,notforme.”No,thisisourstatistic.Thisisusinthisroom.Thisisthestateofourhealthcarecommunity.InatypicalSurgicalorAnaestheticDepartment,therewillbesomeonewhohashadthoughtsofsuicideandperhapssomeonewhohasattemptedsuicide.Femalesareathigherrisk,andthespecialtyhotspotsforsuicideareGP,EDandanaesthesia.However,it’snotagenderissuebecausemalescommitsuicide.It’snotanageissue,becauseconsultantscommitsuicides,notjusttrainees.Iammindfulthattheremaybesomeofusstrugglingwiththesethoughtsthisweek,orevenrightnow.Ifthatisyou,pleasehearme.Youreallymatter.Youreallydomattertoyourcommunity,tous,andtoourpatients.Pleaseshareyourburdenwithatrustedcolleague,aGPoraprofessionalmentalhealthworker.Helpushelpyoutobeabetterdoctorforyourpatient.

Inviewofthiselephantintheroom,self-careandmanagingmentalhealthisindispensable.It’ssoimportantthatforthefirsttimelastyear,theWorldMedicalAssociationhasincludedself-careaspartoftheirPhysician’sPledgeontheDeclarationofGeneva.ThePhysician’sPledgeisthemodernversionoftheHippocraticOath.In2017itbeginswith:“ASAMEMBEROFTHEMEDICALPROFESSION,ISOLEMNLY

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PLEDGEtodedicatemylifetotheserviceofhumanity”.Andthenfurtherdownthepledgeitsays:“IWILLATTENDTOmyownhealth,well-being,andabilitiesinordertoprovidecareofthehigheststandard”.

Icannotstressenoughtheimportanceofmentalhealthandself-careinourcaringprofession.Thisiswhyresiliencetraining,personalcoaching,havingaGPoraprofessionalmentalhealthworkerareimportantandhavebeenshowntoimprovethewaywedealwithworkplacestresses.Ifyousufferfrommentalillness,gettinggoodtreatmentiscriticaltoyourdeliveringcareofthehigheststandardsforourpatients.

ThebigquestionIwouldliketoposeisthis:Isthatenough?Isresiliencetraining,mindfulness&coachingthesolutiontoourproblems?Forthatparticularelephant,yes.

MayIchangeyourmind?I’dliketosuggestthattheremaybeanotherelephantintheroom?Ifwecallthefirstelephantmentalhealth,canIcallthesecondoneInstitutionalHealth?

IamsureyouknowwhatImeanbyinstitutionalHealth:Workplaceconditions,relationaltoxicity,administrativeintrusions,timepressures,excessiveworkload,resourcelimitations,competitionforjobs,poorjobsatisfaction,poorjobengagement,bullying,harassment,sexism,jobmaldistribution,etc.

Burnout.ThisisAustraliandataagainfromthesameBeyondBlueSurvey.Burnoutisdefinedasapsychologicalstatecharacterisedbyemotionalexhaustion,lowjobefficacyandhighcynicismordepersonalisation,duetochronicoccupationalstressinthecaringprofession.ItisnotaDSM5orICD10mentalillnessdiagnosis.Itisapsychologicalstateduetoworkplacestress.Workplacefactorshavestrongassociationwithburnout.Halfofusareemotionallyexhausted,1in6-7noteffective,andhalf

ofusarehighlycynical.Burned-outdoctorsarebadforpatients,andbadforbusiness.They’reineffective.Theymayordermoreunnecessarytests,takelongertocompletetasks,makemistakes,anddonotdeliverhighstandardsofcare.Howcanyoucareforapatientwhenyouareemotionallyexhaustedandcynical?

Whatistherelationshipbetweenmentalillnessdiagnosisofdepressionandworkplaceillnessofburnout?Wearestillexploringthat.Somesaycausative,otherssayassociative,stillotherssaytheyareoverlappingconditions,andsomesaythey’reessentiallythesamething.Perhapsthey’redifferentconditionsduetotheiraetiologyorcause,butmayresultinasimilarconstellationofsymptoms.Forexample,youcanhavedepressionandnotbeburnedoutbywork.Ontheotherhand,youcanbeabsolutelyburnedoutatworkandnothavetheDSM5diagnosisofmajordepression.Thisiswhysomepeoplefindthatachangeofworkenvironmentresultsinasignificantchangeofemotionalstateandengagementatwork.Thisiswhyadoctorwithdepressionthatiswellmanagedcanbeaneffectiveengagedworkerthatdelivershighstandardsofcare.ThisisexactlywhyweneedtotackletheissueofmandatoryreportinginsomeAustralianstates.Adoctorwithmentalillnessdoesnotequalanunsafedoctor.Adoctorwithmentalillnessmayprovideasafeandefficientcarejustthesameasadoctorwithcardiacorrespiratoryillness.

Thereisanelephantintheroomwe’vecalledmentalhealth.ButthereisanotherelephantsittingonthechestofourcliniciansthatIwouldcallinstitutionalhealth.Howdidwecometothis?Howdidwegetthebestandbrightest,theA-studentsinhighschoolanduniversity,theoneswhoworkedhardthroughschool,medicalschool,specialisttraining,howdidweendupthenwithdoctorswhoareburnedoutandreadytoquitmedicineorquitlifealtogether?

Someofyoumightthink“Oh,justtoughenupprincess.Iusedtodolongerhoursthanyou.”Perhapsthatistrue,butit’snotthedurationbutthequalityoftheworkthathaschangedovertime.Limitingworkhourshavemadenodifferencetoratesofburnout.Ourpatientsaregettingmorecomplex,new

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diagnosesandtreatmentsarebeingdiscoveredeveryday,theadministratorsandlawyersareintrudingourworkspace.Inthepast,dailyworkmayhaveincludedahigherproportionofclinicalwork.Today,muchofourworkisnon-clinical.It’sdataentry,paperwork,organisational,research,etc.Weactuallyspendverylittletimewithpatients.Medicineisnolongerwhatitusedtobe.Youhavetologin27*timesbeforeyouseeapatientandchooseoneof273*algorithmsorprotocolsforyourpatient(*notrealdata).Thelinkbetweenworkplacestressorsandclinicianburnoutisconfirmedthroughseveralstudiesalready.

LastyearIburnedoutspectacularly.IwassnappyandIwasahorriblepersontobewithandworkwith.SolikeagoodGenerationXdoctor,Iwroteablog.ItitledittheDarkSideofDoctoring.TheblogwastriggeredbyasuicidedeathofaBrisbanegastroenterologistbutithitmehardbecauseIwasinadarkplace.Iwrotemostlytopendownmyemotions,butsomehowitwentviralandwasread288,000times.Thatis,morethanaquarterofamillionpeoplehavereadthatblog.AlotofclinicianssimplyidentifiedwiththefeelingsIhad.Thecontentwassimple.Ispokeaboutthe3thingsIlostduringmysurgicaltrainingandmylifeasasurgeon

Firstly:Lossofcontrol.Everydaymylifeisdictatedbyclinics,operatingtheatreandemergencies.Weareslavestoourpagersandoncallroster.EveryyearIgetmovedtodifferenthospitals.EverydayIampressuredtodomore.Iamtoldwheretobe,whattodoandwhotooperateon.

Secondly:Lossofsupport.Iwasstudyinganddidn’tseemyfamily.Imissoutonbirthdays,anniversaries,familyholidays.Ididn’thaveanyonetotalktobecauseeveryonewasbusy.NooneunderstoodthepressuresoftheworkIdo

Andfinally,butmostimportantly,Ihadalossofmeaning.Ilostthepurposeofmyworkbecauseitallbecameaburden.Whatreallymatters,patientcare,islostinthenoiseandbuzy-nessofwork.

Istartedsurgerywiththisideainmind,thatsurgerywasmyIkigai,aJapaneseconcept.WhatIlove,whattheworldneeds,whatIcangetpaidforandwhatI’mgoodat,alloverlappingandIfindmeaningthroughsurgeryatthecentre.Ilostallthat.Thetruthismanyofusinthisroomwouldknowthatsuchisthenoblecallingandpurposeofourwork.Butwelostit.Welostwhatmattered.Butitwasn’tasuddenthing.Itwasalwayssmalllittlethingsduringthedayovermanyyearsthatslowlypushuscloserandclosertotheedge.Thelossofcontrol,thelossofsupport,thelossofmeaning,theexams,theresearchdeadlines,thegenderinequity,thetoxicworkplace,thebullying,theresourcelimitations,everysmallthingbringsusclosertotheedgeofquitting.

Daily,chronic,repetitiveemotionalmicrotrauma.It’sliketheanalogyofthefrogintheboilingwater.Everymicrotraumaweexperienceeverydayisanotherdegreeuponthewatertemperature.Wecan’tkeeptrainingthefrogresilience.Itisnotenough.Weneedtofixtheboilingenvironment.Resilienceisapersonalsolution.Wemustdesigninstitutionalsolutionstoinstitutionalproblems.That’swhyholidaysaren’tenough.Wecan’tjustleavetheroomforabitandhopetheelephantswillgoaway.You’llbebackintheroomandstillfacethesameelephants.

Thegoodnewsisthatwecandosomethingaboutinstitutionalhealth.Butitwilltakeownershipoftheproblemsandcourageousleadershiptowardssolutions.Wemustgofrom“Theychangeortheydie”to“Wechangeorwedie.”Thisisourproblemashealthcarecommunityandweneedtofindpracticalsolutionsourselves.Otherinstitutionsarealreadyaheadinthisjourneyandhavegivenussomeideas:

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ExecutiveLeadershipandPhysicianWell-being:NineOrganizationalStrategiestoPromoteEngagementandReduceBurnout.TaitD.Shanafelt,MD,andJohnH.Noseworthy,MD,CEO.MayoClinProc.2017;92(1):129-146.

Thispaperisamustreadforallofus,whetherornotweareinpositionsofleadership.Itprovidesmultiplepracticalwaysofmeasuringinstitutionalhealthandsuggests9keystrategiesontacklingthisissue.Resiliencetrainingisnumber8.Therestareaimedattheotherelephant.Thesolutionsareabsolutelypractical.Therearemeasurablegoalsforanydepartmentandinstitution.Iimploreyoutoreadthispaperthoroughly.Summarisingitherewillnotdojusticetotheexcellentpaperthatitis.Itprovidesmultiplepracticalmetricsoninstitutionalhealthandpracticalinterventionsonimprovingthosemetrics.Letmereiterate:itisamustread.

ThereisalreadyanationalframeworkonthematterofDoctorsandMentalHealth.TheANZCAhassomeclearplans.TheRACShavemadegreatstridesincreatinganActionPlanforCulturalChangeandLeadershipfromthetop.VariousHospitalsandDepartmentsaroundAustraliaandNewZealandareonactivediscussionaroundthisissue.Iabsolutelybelievethatthereisamomentumalreadyoccurringaroundthisissueandthatweareclosetotippingpoint.Iabsolutelybelievethat.

SowhatcanIdonow?WhatpracticalthingsshouldIdo?

HerecomestheActionPointsandhomework.Pleasethinkcarefullyaboutthese3Csandhowtheyapplytoyou,yourdepartmentandyourhospital.

1. CORE.Findyourcorebusiness.Whatisyourmeaningfulwork?Onewaytocombatburnoutistoensurethatyouaredoingenoughofworkthatyoufindmeaningful.Onefascinatingresearchdoneandexplainedinthesamepaperisthe20%rule.Evidencesuggeststhatdoctorswhospendatleast20%oftheirprofessionaleffortfocusedonthedimensionofworktheyfindmostmeaningfulareatdramaticallylowerriskforburnout(ShanafeltTD,WestCP,SloanJA,etal.Careerfitandburnoutamongacademicfaculty.ArchInternMed.2009;169(10):990-995).Althougheach1%reductionbelowthisthresholdincreasestheriskofburnout,thereisaceilingeffecttothisbenefitat20%(eg,spending50%ofyourtimeinthemostmeaningfulareaisassociatedwithsimilarratesofburnoutas20%).Thissuggeststhatdoctorswillspend80%oftheirtimedoingwhatInstitutionsneedthemtodoprovidedthattheyarespendingatleast20%oftheirtimeintheprofessionalactivitythatmotivatesthem.Thisactivitycouldinvolvecaringforspecifictypesofpatients(eg,thepoor,refugees)orpatientswithagivenhealthcondition(eg,becomingadiseaseexpert)oractivitiessuchaspatienteducation,qualityimprovementwork,communityoutreach,mentorship,teachingstudents/residents,orleadership/administration.Toharnessthisprinciple,youmustknowwhatthat20%activityissoyoucanfacilitateprofessionaldevelopmentinthatdimension.Findyourcoreandmodifyyourworkschedulestomeetthat.

2. CHAMPION.Findachampioninyourdepartment.Youdonothavetohavealeadershippositiontobeinfluentialinyourdepartment.It’samythtothinkthatyouneedtobeaunitLeadertomakeadifference.Findthewelfarechampionsinyourunit.Someonewhocouldbethewelfareofficertoinitiatesomeactionsforyourdepartment.Someonewhocouldkeepaneyeonmeasuringthe

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institutionalhealthoftheunit.Thatpersoncouldbeyouorcouldbeyourcolleague.Tapthemontheshoulderandstartcomingupwithsimplecreativeideastoimprovethehealthoftheteam.UsethatShanafeltpaperasadiscussionprimerastheyhavecuratedandcreatedalistofmeasurableevidencebasedinterventions.Itdoesn’thavetobeexpensiveorextensive.Perhaps,youcanonedayevenformalisetheroleandhaveawellnessofficerineachunitresponsibleforthesematters.Notasocialsecretaryforbeer.Awellnessofficertoimprovethehealthoftheunit.

3. CULTURE.Thisisthebigone.Culturalchangewillrequireadepartmental,collegeandstateaction.Oneofthekeythingsinanyeffectivechangeisleadershipbuy-inandcommitment.Wearenotjusttalkingaboutthedepartmentalhead,buttheCEOortheheadoftheworkforcedepartment.Thiswillrequiresomelonger-termplans,butitisabsolutelypossibleanddoable.ThereisalreadyagoodmomentumandIbelievewearealmostattippingpoint.IcangivemultipleNorthAmericanexamplesofhowtopdownleadershiphasimprovedpatientcareandturnedhospitalsaroundbutIwillquotealocalexample.TheRoyalChildren’sHospitalMelbournehasstartedthisjourneyacoupleofyearsago.TheycameupwithanewClinicianCompact.Severalkeystatementsthatdefinethevaluesoftheorganisationarereiterated,likeapledge.Theystartedatthetoptoincludeallclinicalandadministrativestaff.Thiswastheirwayoftacklinganinstitutionalelephanttochangecultureandtoimprovethecareforeverychild.TheCollegeofSurgeonstoo,havedefinedaculturalchangecampaignwiththe“OperatingwithRespect”initiative.Wehavemomentum.Wecandothistodealwiththeinstitutionalhealthelephant.

NowtheelephantsinyourdepartmentsinMelbourne,AucklandorChristchurcharegoingtolookdifferent.Withthecurrentmomentumthatwealreadyhave,smallchangeswillmakebigdifferences.WecanbeginwithfindingourpersonalCorebusinessandmeaningfulworktoimproveourpersonaljobsatisfactionandefficacy.WecanthenfindChampionsinourdepartmentstoimprovetheunitwelfare.Wecantheninthelonger-termeffectculturalchangewithcollaboration.Dealingwiththeinstitutionalhealthwillgoalongwayinimprovingmentalhealth.Weneedtotacklethementalhealthandinstitutionalhealthelephantsatalllevels.Individualmentalhealthtreatmentapproaches,Departmentalactionplans,Hospitalculturalchangecampaigns,Statewideinitiatives,NationalpoliciesandCollegeleveldirectives.Multifactorialapproachestotheelephants.

Aproverbsays,“Onegenerationplantsthetrees,anothergetstheshade.”Seedhasbeenplanted.Momentumisalreadybuilt.Manyclinicianshavebeenworkinginthisarenaformanyyears.Thisgenerationandthenextwillgettheshade.

Weowethistoourpatients.Ourpatientsmatterandtheydeservementally&physicallyhealthydoctorsandhealthyinstitutions.

MrEricLevi,FRACS,MBBS(Melb),B.Sc,PGDipSurgAnat,MPH&TMSpecialistOtolaryngologist,Head&NeckSurgeonPaediatricENT,Head&Neck,AirwaySurgeon

ericlevi.com@DrEricLevi