covid-19 and burnout in healthcare: two ......darryl anka signs you need to change your mindset you...
TRANSCRIPT
COVID-19 AND BURNOUT IN HEALTHCARE: TWO REALITIES THAT FEED OFF EACH OTHER
HCMS
Naim El-Aswad, MD, FACP
Chief Medical Officer
Vital Signs Vital Skills, L.L.C.
August 26th, 2020
1
Vital Signs Vital Skills, L.L.C.
Live Activity:
Covid-19 and Burnout in Healthcare Two Realities that Feed off Each Other
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS
Policies and standards of the Texas Medical Association, the Accreditation Council for Continuing Medical Education, and the American Medical Association require that speakers and planners for continuing medical education activities disclose any relevant financial relationships they may have with commercial interests whose products, devices or services may be discussed in the content of a CME activity.
The planners/speakers/participants for this activity have NO relevant financial relationships to disclose.
Any new planners, speakers or participants will be verbally disclosed prior to the start of the conference.
2
OUTLINE
Vital Signs Vital Skills, L.L.C.
3
CHALLENGE OF HEALTHCARE
Healthcare
Standards
Burnout and
the healthcare
industry
Knowledge, tools,
skills, and practices
COVID19,
Burnout and the
healthcare
industry
NEW and DIFFERENT
Knowledge, tools,
skills, and practices
Physician/
HCP/HCO
Healthcare
Standards
www.vitalsignsvitalskills.com
4
Physician/
HCP/HCO
SHIFTING LANDSCAPE. MANAGING THE NOW, PREPARING FOR THE FUTURE
1- We have not yet fully figured out how to deal with
the prior landscape
2- Our current landscape keeps changing
a- How do we maintain our balance?
b- How do we successfully navigate it?
c- How do we lead others and make sure they
do not fall?
3- We need to look ahead without stumbling in the
now
a- How do we do that?
b- What do we need and why?
c- What will the road look like later?
d- Will it ever be smooth and somewhat
predictable again?
e- What will be the new norm?www.vitalsignsvitalskills.com
5
HONESTY
6
Vital Signs Vital Skills, L.L.C.
Vital Signs Vital Skills, L.L.C.
7
REFLECTIONS
• Frustration
• Fear
• Anxiety
• Apathy
• Anger
• Exhaustion/fatigue
• Sadness/depression
Vital Signs Vital Skills, L.L.C.
8
WHERE CHANGE NEEDS TO HAPPEN
Vital Signs Vital Skills, L.L.C.
9
Healthcare Environment
Healthcare Organizations
Healthcare Individuals
BURNOUT DEFINITION
10
It is now a DISEASE. (WHO: ICD 11)
“Syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. 3 dimensions:
1- Feelings of energy depletion;
2- Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job;
3- Reduced professional efficacy.
It is an occupational phenomenon.
Vital Signs Vital Skills, L.L.C.
STAGES OF BURNOUT
• According to the psychologists Herbert Freudenberger and Gail North, burnout goes through a 12-stage model:
• Compulsion to prove oneself
• Working hard - with an inability to switch off
• Neglecting basic needs - lack of sleep, lack of healthy eating, lack of social interaction
• Displacement of conflicts - problems are dismissed
• Revision of values - values are skewed, friends and family dismissed, hobbies irrelevant
• Denial of emerging problems
• Withdrawal - social life small or nonexistent
• Odd behavioral changes - changes in behavior obvious to friends and family
• Depersonalization - seeing neither self nor others as valuable
• Inner emptiness
• Depression
• Burnout syndrome - includes mental and physical collapse; medical attention required
BURNOUT CAUSES
Vital Signs Vital Skills, L.L.C.
12
Burnout
Unmet Expectations
Lack of Control
Insufficient Rewards
Leadership
Pressure
Personal characteristics
Purpose and Need
Self-care and wellness
BURNOUT CAUSES
Vital Signs Vital Skills, L.L.C.
13
Burnout
Unmet Expectations
Lack of Control
Insufficient Rewards
What else was
added in the
Covid/Burnout
Realities?
-Lack of PPE
-“Did not sign up for this”
-“Putting our lives at risk”
-Cannot control the public
-Cannot control the virus
-Pay is less, jobs lost
-Risking our loved ones
-Physical, mental, and emotional
separations
EMR
Cog in a wheel
Too many hours at work
Insufficient monetary funds
Emphasis on profits not patients
Severity of illnesses
Acuity of situations
Increase physical, mental and
emotional demands
PURPOSE AND NEED
Engaged: Best MD-
patient
satisfaction/outcome
Vital Signs Vital Skills, L.L.C.
14
E
B
P
C
PURPOSE AND NEED
Vital Signs Vital Skills, L.L.C.
15
Connecting to Purpose
Physician’s Self
Determination Theory:
Empathetically Connected
Clinically Competent
Professionally Autonomous
Behavior
P
Cognition
Emotions
Behavior
P
Cognition
I-THOU I-ITMedical Training
Vital Signs Vital Skills, L.L.C.
16
Emotions
In medical training and
medical practice,
empathy is gradually
eroded and lost. Patients
are viewed as liabilities,
not assets.
COGNITION
Vital Signs Vital Skills, L.L.C.
17
Government
regulations
Insurance
companies
Lawsuits
Feedbacks,
evaluations
Business
demands. Non-
medical
responsibilitiesCognitive
Scarcity
Leads to
counter-
productive
behaviors
and mistakes
Draws cognitive
resources to
urgent demands
Induces
impairments
in other
domains
Behavior
P
COVID-19
Quarantine
Home school
Gathering supplies
Job losses
Economic, political, social
changes
Possibility of getting
infected and infecting
loved ones
BEHAVIOR
• In a single day, residents spent 364.5 minutes (50.6%) of their shift time using computers, compared with 67.8 minutes (9.4%) interacting with patients.
• More and more physicians/nurses are graded based on their bed side manners, not their clinical skills.
• Physicians get evaluated/rewarded on communication and presentation skills rather than clinical performance and outcome
Vital Signs Vital Skills, L.L.C.
18
P
COVID World:
Web-based conferences
Decreased bedside rounding
Decreased patient interactions
Doing our best with little impact
on outcome
“I have never felt so
useless and so needed at the same time”Jewel Jones, MD
PERSONAL CHARACTERISTICS
• Personal characteristics associated with burnout include:
• Being self-critical
• Matching the personality to the specialty
• Engaging in unhelpful coping strategies
• Perfectionism
• Idealism
• Certain personality types can affect positively or negatively
Vital Signs Vital Skills, L.L.C.
Patel S. et al, 2018. Factors Related to Physician Burnout and Its Consequences: A Review. Behavioral Sciences.
19
COVID-19
PRESSURE VERSUS STRESS
Vital Signs Vital Skills, L.L.C.
Pressure is where the outcome is important
to you, it is uncertain, and you are
accountable and judged for the results. You
must deliver the goods or suffer dire
consequences.
Adversely impacts cognitive success,
downgrades behavioral skills, we perform
below our capability, often camouflaged
and is continually increasing.
Weisenger and Pawliw-Fry, (2015) Performing Under Pressure
20
COVID-19
PURPOSE AND NEED
Engaged: Best
physician/patient
satisfaction/outcome
Burnout: Worst MD-
RN/patient
satisfaction/outcome
Vital Signs Vital Skills, L.L.C.
21
E
B
P
C
The “old” world of burnout
and the “new” world of
COVID-19
The New Challenge
of Healthcare: THRIVE
WHERE BURNOUT IMPACTS: PREFRONTAL CORTEX
Vital Signs Vital Skills, L.L.C.
22
From: Stress and Burnout Among Surgeons: Understanding and Managing the Syndrome and Avoiding the Adverse Consequences
Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575Vital Signs Vital Skills, L.L.C.
50 % of MD’s are
burned out
Projections during and postCOVID-19:
More burnout
More moral injury
More will leave the work force
23
BURNOUT AND PHYSICIAN/NURSE PERFORMANCE
• Observation, Reason, Human Understanding, Courage; these make the physician. ~Martin H. Fischer (1879–1962)
• Observation: Disconnected, unrealistic, can’t read clues and “checked out”
• Reason: Decreased ability to analyze, assess and think. Loss of clinical skills, and abilities.
• Human Understanding: Can’t understand or relate to others, loss of empathy
• Courage: Distant, insecure, blaming others, explosive, unpredictable and aggressive
Vital Signs Vital Skills, L.L.C.
24
RELATIONSHIP BETWEEN COVID AND BURNOUT: MAACU EFFECT
Vital Signs Vital Skills, L.L.C.
25
Burnout
PathophysiologyBurnout
Factors
Burnout Signs
and
Symptoms
COVID
MagnifiesAmplifies
Creates
Uncovers
Accelerates
THE IMPACT OF COVID• Created a sense of oneness
• Changed the public view of healthcare providers (Became Heroes)
• Altered our adaptive mechanisms/support systems (Family, exercise, social gatherings, …)
Vital Signs Vital Skills, L.L.C.
26
MAACUBurnout
COVID-19
Focused
Efforts
Burnout
Moral
Injury
MORAL INJURY
Vital Signs Vital Skills, L.L.C.
27
“Moral injury refers to an injury to
an individual's moral conscience
and values resulting from an act of perceived moral transgression,
which produces profound
emotional guilt and shame, and
in some cases also a sense of
betrayal, anger and profound
"moral disorientation“ “
AAA APPROACH
• A: Awareness
• A: ACKNOWLEDGEMENT and ASSESSMENT
• A: ACTION
Vital Signs Vital Skills, L.L.C.
28
Maslach Burnout
Inventory
Mini Z
Mini-Maslach
Several online
BURNOUT AND PHYSICIAN/NURSE PERFORMANCE
• Observation, Reason, Human Understanding, Courage; these make the physician. ~Martin H. Fischer (1879–1962)
• Observation: Disconnected, unrealistic, can’t read clues and “checked out”
• Reason: Decreased ability to analyze, assess and think. Loss of clinical skills, and abilities.
• Human Understanding: Can’t understand or relate to others, loss of empathy
• Courage: Distant, insecure, blaming others, explosive, unpredictable and aggressive
Vital Signs Vital Skills, L.L.C.
29
Intervention
BURNOUT MALIGNANCY MODEL
Environmental and Genetic
FactorsTime
Negative cumulative
Effects
Vital Signs Vital Skills, L.L.C.
30
Lack of defenses and
ability to detect
Intervene:
Resiliency, coping,
EQ/Self-care mindset,
momentum
Use it to our advantage
Develop detection and
defense capabilities:
EQ/Self-care
Positive cumulative CHANGE
CREATE A NEW REALITY
GUIDELINE OF APPROACH
Vital Signs Vital Skills, L.L.C.
31
• “In a battle all you need to make you fight is a little hot blood and the knowledge that it’s more dangerous to lose than to win.” George Bernard Shaw
MINDSET
Vital Signs Vital Skills, L.L.C.
32
“A set of beliefs
or a way of
thinking that
determines one’s
behavior,
outlook, and
mental attitude”
Circumstances
do not
determine state
of being; state of
being determine
circumstancesDarryl Anka
SIGNS YOU NEED TO CHANGE YOUR MINDSET
✓ You continuously focus on what is wrong
✓ You mourn your failures without celebrating your success
✓ You don’t want to face the truth
✓ You get angry when your expectations are not met
✓ You feel unsatisfied or unhappy with everything you have
✓ You are constantly fighting with the ones you care about
✓ You think about what you have to do and not what you get to
do
✓ You see yourself as a victim
✓ You hold on to other people’s dreams
33
Vital Signs Vital Skills, L.L.C.
God, grant me the
serenity to accept the
things I cannot
change, the courage
to change the things I
can, and the wisdom
to know the
difference… Serenity
Prayer
Stephen Covey(1989) The 7 habits of highly effective people: Powerful lessons in personal change.
Vital Signs Vital Skills, L.L.C.
34
CLINICAL PERFORMANCE
Purpose
and
Need
Physician
Physician-Patient Interaction
Decision Making/Interaction/Skills
Engaged Burnout
Emotional Intelligence, Self-care and
Wellness, Resilience, Coaching
Institutional
Political
Social
Governmental
Professional
COVIDVital Signs Vital Skills, L.L.C.
35
DEFINITION OF EMOTIONAL INTELLIGENCE
Understanding
ourselves,
managing
ourselves,
understanding
others, managing
others
www.vitalsignsvitalskills.com
36
EMOTIONAL INTELLIGENCE IN MEDICINE
• Decreasing/diagnosing/preventing Burnout
• Needed for the skills of the 21st century physician
• Needed for personal and professional development
• Needed in the ACGME core competencies
• Tied to physician satisfaction and mission
• Tied to wellness
• Tied to patient satisfaction
• At the core of LEADERSHIP
Vital Signs Vital Skills, L.L.C.
37
WELLNESS AND BURNOUT
Vital Signs Vital Skills, L.L.C.
38
Wellness and
life/work
balance
protect
against and
treat burnout
WITHOUT SELF-CARE AND WELLNESS
• Burnout
• Physician/Nurses/Executives morbidity and mortality
• Patient morbidity and mortality
• Poor leadership
• Healthcare industry failure
Vital Signs Vital Skills, L.L.C.
39
WELLNESS/SELF-CARE40
• Rules of wellness:
• At the heart of wellness: Self-love, Self-compassion, and Self-care
• Four steps to successful wellness:• Deciding (Develop the mindset)
• Taking control
• Taking time
• Creating a habit
Vital Signs Vital Skills, L.L.C.
If you do not make time
for your wellness, you will
be forced to make time
for your illness.
RESILIENCE
Vital Signs Vital Skills, L.L.C.
41
NICHOLSON MCBRIDE RESILIENCE
QUESTIONNAIRE (NMRQ)
• 0-37: A developing level or resilience. Your score indicates that, although you may not always feel at the mercy of events, you would in fact benefit significantly from developing aspects of your behavior.
• 38-43: An established level of resilience. Your score indicates that you may occasionally have tough days when you can’t quite make things go your way, but you rarely feel ready to give up.
• 44-48: A strong level of resilience. Your above average score indicates that you are pretty good at rolling with the punches and you have an impressive track record of turning setbacks into opportunities.
• 49-60: An exceptional level of resilience. Your score indicates that you are very resilient most of the time and rarely fail to bounce back –whatever life throws at you. You believe in making your own luck.
42 Vital Signs Vital Skills, L.L.C.
Resilience Questionnaire Score1. In a difficult spot, I turn at once to what can be done to put
things right.
2. I influence where I can, rather than worrying about what I
can’t influence.
3. I don’t take criticism personally.
4. I generally manage to keep things in perspective.
5. I am calm in a crisis.
6. I’m good at finding solutions to problems.
7. I wouldn’t describe myself as an anxious person.
8. I don’t tend to avoid conflict.
9. I try to control events rather than being a victim of
circumstances.
10. I trust my intuition.
11. I manage my stress levels well.
12. I feel confident and secure in my position.
TOTAL
For each question, score yourself between 1 and 5,
where 1 = strongly disagree and 5 = strongly agree.
COACHING
SUCCESS
Vital Signs Vital Skills, L.L.C.
43
Assessments:
BurnoutEQ
Personality
Resilience
GritOthers
WHERE CHANGE HAPPENS
Vital Signs Vital Skills, L.L.C.
44
Stress/Burnout
Factors
Training
Practice of
medicine
Positive
Emotions/
Mood
Negative
Emotions/Mood
Mindfulness/Wellness/
EI training/Coaching
Hijack, loss of IQ, loss
of will power, Lower
EQ
Problem solving and
creativity
Institutional
Changes/Outside
Factors
Purpose/Need of
medicine
COVID
MAACU
WHERE CHANGE HAPPENS
Vital Signs Vital Skills, L.L.C.
45
TAKE HOME TOOLS, MICRO INITIATIVES
• Mindfulness
• Three good things: Gratitude
• Name it to tame it: Bring the emotions up
• Connect
• Acknowledge goodness
• Highlight positivity
• Share experiences
• Focus on emotional intelligence
• Work on your self-care and wellness
Vital Signs Vital Skills, L.L.C.
46
TIPS TO WORK ON YOUR EMOTIONAL INTELLIGENCE
•ACKNOWLEDGE EMOTIONS!!!!!!• Take an assessment test (EQi, MSCEIT,…). Find out where you are, where you
are strong and where you need help.
• Make a mental memory of your own reactions. Self analyze.
• Few times a day, STOP, and observe your emotions. Listen to your own mind.
• Know your positive and negative triggers. Enhance positive reactions, modify negative reactions.
• Identify the emotion: name it to tame it
Vital Signs Vital Skills, L.L.C.
47
WELLNESS ACTIVITY: WHEEL OF WELLNESS
48
• Use a scale of 0 to 10 (0 being the least and 10 being the most) to write down your personal wellness score for each realm using the wheel below.
• Identify one activity that you can do to improve your score along each realm.
• Set a plan of action to achieve that activity.
• Complete the activity.
Vital Signs Vital Skills, L.L.C.
PLANNING WHAT’S NEXT?
• Identify: Your burnout, your abilities, your assets, your limitations
• Mindset: Decide not only that you SHOULD change, but that you MUST and WILL change
• Enhance: Your EQ, self-care, and resilience
• Plan: With or without a coach, outline a plan of action based on your parameters
• Assess and adjust: “Adapt what is useful, reject what is useless, and add what is specifically your own.” Bruce Lee
Vital Signs Vital Skills, L.L.C.
49
Vital Signs Vital Skills, L.L.C.
50
FOLLOWUP DATA THAT DR. EL-ASWAD SPOKE ABOUT IN THE CENTRAL BRANCH MEETING:51
• HAS DEMONSTRATED THE IMPORTANCE OF FRONT-LINE LEADERSHIP ON THE WELL-BEING AND PROFESSIONAL SATISFACTION OF PHYSICIANS.
• IT OBSERVED THAT LEADERSHIP RATINGS HAD A STRONG ASSOCIATION WITH BURNOUT AND SATISFACTION AT THE LEVEL OF INDIVIDUAL PHYSICIANS...
• FOR EVERY POINT UPWARD ON A 60-POINT SCALE, THERE WAS 9% GREATER STAFF SATISFACTION AND 3.3% LESS BURNOUT.
• AT THE DEPARTMENT AND DIVISION LEVEL, 11% OF THE VARIATION IN BURNOUT AND 47% OF THE VARIATION IN SATISFACTION WITH THE ORGANIZATION WAS EXPLAINED BY THE LEADER INDEX OF THE CHAIRPERSON.”
SHANAFELT, T., ET AL., IMPACT OF ORGANIZATIONAL LEADERSHIP ON PHYSICIAN BURNOUT AND SATISFACTION. MAYO CLINIC PROCEEDINGS. 4/2015 90(4): P. 432-440 4. SWENSEN, S., ET AL.