physician wellness - addiction medicine 2019...oct 27, 2019 · from denial to acceptance to...

Physician Wellness From Denial to Acceptance to Advocacy

David M. Kushner, MDJohn and Jeanne Flesch Professor of Gynecologic Oncology

Vice Chair of Clinical Research, Department of Obstetrics & Gynecology

American Osteopathic Academy of Addiction MedicineOMED 2019

Verbal Disclosure

No Financial Disclosure

No Off-Label Use of Drugs

Pinterest.com

Status Quo

Denial

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=pfsj-l9NICX4aM&tbnid=QGw6KW1KTV5bUM:&ved=0CAUQjRw&url=http://eclecticdad.com/2014/01/30/monty-python-and-the-holy-grail-review/&ei=0Lg6U9uyB8SSiAeExYDABQ&bvm=bv.63934634,d.dGI&psig=AFQjCNHUynWolJD44sbFWSSR_gmgWZrVww&ust=1396443616071869

Stages of dealing with the burnout issue

Elisabeth Kübler-Ross (1926-2004)

On Death and Dying -1969

Denial

Anger

Bargaining

Depression

Acceptance

Bargaining: Duty Hours

1988. ACGME recommended:

1/7 days away from hospital

No more that 1/3 call

Adequate backup for fatigue

Adequate supervision and supervisory communication

1989. Internal Medicine RRC

80 hour limits

1995. Six other specialties implemented duty hours

2003. Common duty hour requirements for all residencies

2011. Updated to include transitions, fatigue mitigation…

www.acgme.org www.osteopathic.org

http://www.acgme.org/

http://www.osteopathic.org/

Bargaining: Definitions

Maslach Burnout Inventory (MBI)

Loera, B. PLOS ONE | DOI:10.1371/journal.pone.0114987 December 12, 2014

7395 Medline Publications

Burnout, professional (MH)

0

100

200

300

400

500

600

1977 1982 1987 1992 1997 2002 2007 2012 2017

# Pub

Updated September 29, 2014

MESH: STRESS, PSYCHOLOGICAL 1983-89, STRESS, PSYCHOLOGIC 1969-72

UW Ob/Gyn FDC 10/16/2014

Addiction Medicine?

Depression (Kubler-Ross Stage)

Increased risk for burned out physicians:

Alcohol/substance abuse

Anxiety/depression/ panic

Broken relationships

Poor physical and emotional QOL

Irregular Health Care habits

Suicidal ideation

Suicide

1.1 to 3.4 in male physicians

2.5 to 5.7 in female physicians

Arch Intern Med. 2012;172(18):1377-1385JAMA.2003;289:3161-3166Lancet 2009; 374: 1714–21JAMA 2002;288:1447-1450

Medscape National Physician Burnout, Depression & Suicide Report 2019

Medscape.com

Acceptance!

Acceptance: Mental & Career Health:Gyn Oncologists

Quality of Life (SF-12)Low Physical Score

Low Mental Score

N=39756 (14%)

91 (23%)

Mental Health(+) Depression screen

Suicidal Ideation (ever)

Panic attacks

CAGE screen (+)-EtOH abuse

Stressed, overwhelmed

Sought psych help w/in 12 mo

Psych medications in past 12 mo

Reluctant to seek help

N=398133 (33%)

49 (13%)

54 (14%)

60 (15%)

168 (42%)

34 (9%)

42 (11%)

178 (45%)

Career SatisfactionPhysician again

Gynecologic Oncologist again

Encourage their child

361/406 (89%)

360/405 (89%)

244/401 (61%)

Reluctance to seek Formal Care

by Gynecologic Oncologists

Variable Odds Ratio 95% C.I. P-value

Burned Out 2.95 1.83-4.78 <0.001

(+) Depression screen 2.52 1.25-5.10 0.010

High CAGE score (EtOH) 2.18 1.15-4.12 0.016

Multivariable analysis of factors associated with reluctance

to seek care:

45% of Gynecologic Oncologists were reluctant to seek formal

medical care for depression, substance abuse (alcohol, drugs,

other), or other mental health issues if it was needed due to

concerns about their medical license.

Local Data Helps

January, 2018Copyright© 2016 Board of Trustees of the Leland Stanford Jr. University. All rights reserved

Local Data Helps

Acceptance

Solutions

Personal Wellness and Resilience:

Having a Plan

Mindfulness **

Resiliency/positive psychology **

Goal clarity/ equilibration **

Mentoring, coaching, communication skills

Energy management (The Energy Project)

Exercise/nutrition

Support network (family/friends)

Awa WL, Pateint Educ Couns 2010 Feb;78(2):184-90.

Burnout prevention: a review of intervention programs.

Mindfulness is…

Paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally

-Jon Kabat-Zinn.

Centering Practice

…We will be more successful in all our

endeavors if we let go of the habit of

running all the time, and take little pauses

to relax and center ourselves.

-Thich Nhat Hanh

…Well-being is a skill

-Richard Davidson, PhD

Misconceptions about

mindfulness

You need to make your mind a blank

You need to be free from thoughts

It takes you to a place of peace and bliss

It is a tool or technique for reducing stress

You will always feel better while you’re practicing

mindfulness

Mindfulness: How?

Pick an app

Calm; Headspace; Breathe; Etc….

Take a class

MBSR; Hospital; etc….

Read a book

Wherever You Go, There You Are; 10% Happier; Joy of

Living; etc…

Join a group

Hospital; Tergar Meditation Community; etc…

Resilience Is….

The long-term ability to survive in and thrive on adversity.

The capacity to be resourceful and creative, to make choices, and to take effective action no matter what’s going on around us.

Med Ed 2012;46:349-356.

Clinical References

1. Based on February 10, 2014, presentation at MidMichigan Health by J. Bryan Sexton, Ph.D.,

Director of Patient Safety Center, Duke University Health System. Research data based on clinical

trials conducted at Duke University with three cohorts: neonatal ICU, internal medicine residents and

patient safety leadership.

2. Seligman, Steen, Park & Petersen (July-August 2005). Positive Psychology Progress; Empirical

Validation of Intervention. American Psychologist.

3. Martin E.P. Seligman (2011). Flourish: A Visionary New Understanding of Happiness and Well-being.

New York, NY: Free Press.

4. “Three Good Things” is also referred to as “The Three Blessings” in some literature.

www.midmichigan.org/3goodthings

34

Multifaceted Approach to Wellness

Personal Wellness


Professional Societies

Training Programs

Hospitals/ Institutions

Insurance Companies

Agencies/ Government

Personal Wellness

A Healthcare Crisis

Medical errors tied to burnout

At least 200,000 deaths/year

$1Trillion impact on US economy

€ 20 Billion economic loss/year in Europe

Career & job dissatisfaction - disability

Sick leave, early retirement, job turnover

Stanford data

$250,000 to replace a physician

$15.5-55.5 million over two years to the organization

Patient dissatisfaction

Ann Surg 2010 Jun;251(6):995-1000 BMJ. 2008 Mar 1;336(7642):488-91Patient Educ Couns. 2010 Feb;78:184-90

A Healthcare Crisis

400

Pranay Sinha & Anna Parini

New York Times

Sept 4, 2014



Training Programs


Insurance Companies


Personal Wellness

UW Health Wellbeing

Committee

Each Chair identified physician representative

3 APPs

3 Residents/Fellows

1 AA & 1 CRNA

SMPH and UW Health Leadership

Easy, Quick Wins

Initial UW Health Initiatives

Remote Scribe Pilots: Contract with M*Modal for remote medical scribe services, involving 100 providers phased in over 18 months (Began 7/19)

Parental Leave: UW Health-funded benefit for the birth, adoption or placement of foster child, providing eligible UWMF physicians 100% of UWMF pay up to $30,000 for a six-week period (Begins 7/1/19)

Physician Leadership Development Program: Cohort-based leadership development program with trainers from the American Association for Physician Leadership (Begins 1/20)

Clinician Collaboration Zones: Dedicated space for physicians and APPs to gather, build community, collaborate and learn (3rd Quarter, FY 20)

Ob/Gyn Provider Wellness Committee

Spotlight on Ob-Gyn

Physician Wellness

Mentoring Matters

Conflict Resolution Skills for

the Clinical Setting

Exploring

Unconscious/Implicit Bias

Increasing Comfort with

Clinical and Translational

Research

Mindfulness in Medicine

and Mindfulness as

Medicine

Avoiding Burnout

EPIC Electronic Medical

Record Optimization

Feedback and Evaluation

in the Clinical Setting

Time Management

Teaching in the Clinical

Setting

Ob/Gyn Provider Wellness Committee

EMPLOYEE RECOGNITION

Section of the Department newsletter devoted getting to know

co-workers

Department-funded social occasions in summer and winter to

thank faculty and staff for service to the department

NEW INITIATIVES

New section of the Department newsletter devoted to wellness

Pilot test of scribes in clinics to ease documentation burden

Cultural change around email to better reinforce working/non-

working hours

Implement “physician as second victim” program to support

provider through challenging or traumatic medical outcomes

Government

Documentation Burden

Medicaid billing, reporting, justification for each test

Facilitate appropriate non-physician delegation

APP and resident documentation

Scribes, RN, clerical staff

Health provider input into future laws/rules

Meaningful use, insurance regulations, MOC, trainings

State licensing boards

Eliminate questions regarding mental health conditions (other than current impairment)

Schanafelt T. JAMA 317:901, 2017



Training Programs


Insurance Companies


Personal Wellness

Wellness Curriculum

Beta test completed at 15 US Fellowships; Dec, 2017

4 modules

Resiliency

Managing Priorities

Empathy & Positivity

Communicating bad news

Full 18-month curriculum

Launch 2020

Annual Meeting Wellness initiatives

Guest speakers – The Energy Project, Tait Shanafelt

Education Forum – The Energy Project

Yoga sessions, fun run, walking challenge

Wellness Zone in Exhibit Hall

Wellness interview break slides

Creative member submissions

AMA's STEPS Forward

https://www.stepsforward.org/


Over 50% of US physicians experience some

sign of burnout. It is estimated that 80% of

burnout is related to organizational factors.

58


What drives burnout and what are the effects?

Burnout is driven by:

• high workloads

• workflow inefficiencies

• increased time spent in documentation

59

• loss of meaning in work

• social isolation at work

• cultural shift from health values to corporate values

Burnout has repercussions at a personal and professional level


What are the effects of burnout on an organization?

Health professional burnout is a threat to the clinical, financial, and reputational success of an institution for quality,

humanitarian, and financial reasons.

60

Quality Humanitarian Financial

Each 1 point increase in burnout correlates with a

3-10% increase in likelihood of physicians

reporting medical errors

Greater rates of dissatisfaction, divorce, drug and alcohol abuse,

and depression

Replacement costs per physician costs between $500,000 to $1 million

* Over $5 million annually


What is the goal?

• Achieve the Quadruple Aim, with the fourth aim of clinician well-being.

• Create a joyful practice environment and create structural elements that support joy, purpose, and meaning in work.

• In return, a more engaged, satisfied workforce will provide better, safer, more compassionate care to patients.

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Nine steps to help clinicians thrive through organizational changes

1. Engage senior leadership

2. Track the business case for well-being

3. Resource a Wellness infrastructure

4. Measure burnout and the predictors of burnout longitudinally

5. Strengthen local leadership

6. Develop interventions and evaluate their impact

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Culture of Wellness


Nine steps to help clinicians thrive through organizational changes

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1.

2. 7. Improve workflow efficiency and maximize power of team-based care

3. 8. Reduce clerical burden and tame the EHR

9. Support the physical and psychosocial health of the workforce

1.

2.

Efficiency of Practice

Personal Resilience


It’s hard to imagine a more critical issue for health care leaders

than combatting burnout and attrition, because our people truly

are our most precious asset—the heart and soul of our

institutions. Moreover, study after study shows that happier

care providers are better care providers, so this is not just a

human resources issue. It’s about quality of care and doing

what’s best for our patients”

“

Paul Rothman, MD

Dean/CEO for John Hopkins Medicine

64


For additional resources, frequently asked questions and implementation support, visit stepsforward.org

65

Formerly: Institute of Medicine (IOM)

https://nam.edu/initiatives/

https://nam.edu/initiatives/

ASAM eLearning: Career & Practice

In Conclusion…



Training Programs


Insurance Companies


Personal Wellness

Thank you for your attention!

“Stop and Smell the Roses”

-Sander A Kushner, DO

physician wellness - addiction medicine 2019...oct 27, 2019 · from denial to acceptance to...

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