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Provider WellnessProvider Wellness
UCHSC/VAMCUCHSC/VAMCTMC - March 2009TMC - March 2009
Sopheap Na, M.D.Sopheap Na, M.D. Jan McCormack, DMin, BCCJan McCormack, DMin, BCCAssistant Professor of MedicineAssistant Professor of Medicine
VAMCVAMC
Assistant Professor of Chaplaincy and Assistant Professor of Chaplaincy and Pastoral CounsellingPastoral Counselling
Denver SeminaryDenver Seminary
DrivenDriven MotivatedMotivated CompetitiveCompetitive AmbitiousAmbitious DeterminedDetermined High energyHigh energy
Excels at everythingExcels at everything Top of the classTop of the class Type A personalityType A personality High standardsHigh standards AggressiveAggressive High need for controlHigh need for control PerfectionistPerfectionist
Are You?Are You?
Provider Wellness OutlineProvider Wellness Outline
BackgroundBackground
DefinitionsDefinitions
StudiesStudies
InterventionsInterventions
MCAT Scores and GPAs for U.S. Medical Schools by Sex 2000-2007
3.58
3.60
GPA (science)
3.76
3.70
GPA (nonscience)
GPA (total)BSPSVR
3.6410.49.89.9Female
3.6410.810.79.9Male
VR – verbal reasoning PS – political science BS – biological science
www.aamc.org/data/facts/start.htm
Distribution of Total Educational Debt for Medical Students in the United States at Graduation, 2004–2008. AAMC Graduation Questionnaire All School Reports - premedical or college education debt. 2008, 38% of graduates had debt from premedical education (median amount, $20,000). The distribution of the 23% of students with total debt of $200,000 or more was 15% with $200,000 to $249,999 in debt, 6% with $250,000 to $299,999 in debt, and 3% with $300,000 or more in debt (numbers do not sum to 23% due to rounding).R. Steinbrook. Medical Student Debt — Is There a Limit? NEJM 12/18/2008
Mean Tuition and Fees for Medical Schools and Undergraduate Institutions, 1998–1999 to 2008–2009 (Panel A) and Percent Change in Mean Tuition and Fees, the CPI, and Median Physician Compensation, 1998–2008 (Panel B).
Medical school tuition and fees are from the AAMC tuition and fees report; starting in 2004–2005, figures include health insurance as well as tuition and fees. Mean tuition and fees for 2008–2009 were not available.
Tuition and fees at 4-year undergraduate institutions are from the College Board's Annual Survey of Colleges.
Consumer Price Index (CPI) are from the U.S. Department of Labor.
Medical Group Management Association's Physician Compensation and Production Survey
Medical Student Debt — Is There a Limit? Robert Steinbrook, M.D. NEJM 12/18.2008
BackgroundBackground
All physicians Drug and alcoholism 30-100x general population 3x other profession to spend >60 hrs/wk working,
21% 80 hrs/wk, 16% longer hrs 13% F and 20% M physicians episode of
depression Divorce rates 10-20% higher than general
population
$236,383 to replace family practitioner $264,345 to replace general pediatrician
The Resilient Physician. Sotile, WM.
DefinitionsDefinitions
DefinitionsDefinitions
Work addictionWork addiction
Hurrying and staying busy Need to control Perfectionism Difficulty with relationships Work binges Difficulty relaxing and
having fun Impatience and irritability Self-inadequacy Self-neglect
DefinitionsDefinitionsBurnout Burnout
the cost of working too much 1st described in 1970s Triad
1. Emotional exhaustion2. Negative self-esteem, depersonalization
associated w/ work3. Loss of personal satisfaction at work (work
avoidance, unfriendly or irritable behavior, somatic complaints)
Leads to: absenteeism, turnover, cynicism, decreased job satisfaction, friction in personal relationships, depression, substance abuse
Annals July 2001/CPHP 2008
Causes of BurnoutCauses of Burnout
Workload Specialty choice Practice setting Patient
characteristics Sleep deprivation Personality type Methods of dealing
with medical mistakes
Malpractice suits Lack of control over
practice
The Well-Being of Physicians. Am J Med 4/2003
Environment Problems with work-life balance Rising student debt Increasing govt regulations Business aspect of medicine Increase clinical demands Rapidly expanding knowledge base Less time with patients
DefinitionsDefinitionsCompassion Fatigue Affects caregivers only Not the same as “burnout” “A state of tension & preoccupation with
individual or cumulative trauma to clients & manifested in one or more ways:
• Re-experiencing traumatic events of others• Avoidance/numbing of reminders of the events• Persistent “hyper-arousal
“Cost of caring too/so much”• Many costs• Personal Functioning• Professional Functioning
Compassion Fatigue & PTSDCompassion Fatigue & PTSD PTSD symptoms nightmares, avoidance, on
guard, watchful, easily startled, feeling numbed/detached, increased arousal
Many of the same symptoms as PTSD plus• Repeated negative and disturbing thoughts• Feeling bored and irritable; unable to focus• Not feeling satisfied in one’s work—the energy
output and the rewards coming in don’t match• Lack of physical, psychological and emotional
energy• Avoidance which may lead to drastic
escape/flight measures
Personal FunctioningPersonal Functioning
NightmaresDepletedMinimization
Self-harm behaviorsOverwhelmedPerfectionism
Use of negative coping (smoking/substance abuse)
Emotional roller coasterThoughts of self-harm or harm towards others
Accident pronenessHypersensitivityWhirling thoughts
Losing thingsSadness/depressionDisorientation
Hyper startle responseHelplessnessRigidity
HypervigilanceFearApathy
Appetite changesNumbnessTrauma imagery
Sleep disturbancesShutdownPreoccupation w/ trauma
RegressionSurvivor guiltDecreased self-esteem
MoodyAngerLoss of meaning
IrritableGuiltSpaciness
ImpatientAnxietyConfusion/self-doubt
Clingy or withdrawnPowerlessnessDiminished concentration
BehavioralEmotionalCognitive
Compassion FatigueCompassion Fatigue by Figley, p. 184 by Figley, p. 184
Personal FunctioningPersonal Functioning
DizzinessLoneliness
Impaired immune system
Impact on parenting (protective, concern about aggression)
Questioning of prior religious beliefs
Aches and painsIntoleranceAnger at God
Somatic reactionsProjection of anger or blame
Ennui
Breathing difficultiesIsolation from friendsPervasive hopelessness
Rapid heartbeatMistrustLack of self-satisfaction
SwearingDecreased interest in sexQuestioning the meaning of life
ShockWithdrawnLoss of purpose
PhysicalInterpersonalSpiritual
Compassion FatigueCompassion Fatigue by Figley, p. 184 by Figley, p. 184
Professional FunctioningProfessional Functioning
Feelings of incompleteness
Detachment
Lack of appreciationObsession about details
DemoralizationSetting perfectionist standards
ApathyIncrease in mistakes
Negative attitudeAvoidance of job tasks
DissatisfactionLow motivation
Loss of interestDecrease in quantity
Decrease in confidenceDecrease in quality
MoralePerformance of Job Tasks
Compassion FatigueCompassion Fatigue by Figley, p. 184 by Figley, p. 184
DefinitionsDefinitionsAdditivity
home and work stress add to each other or when the benefits of home and work satisfaction create greater well-being
“Universal Vulnerability” Attributes which make caregiver vulnerable…same as
make them excellent caregivers Risk increases if…there are back-to-back “heavy”
cases or other forms of secondary trauma May combine with…caregivers own traumatic past
DefinitionsDefinitions
Personal ResiliencePersonal Resilience “The strength, innate or developed, that enables one to
adapt well to extreme stress”, including the capacities to:
• Optimally function• Maintain sound mental health under adverse circumstances• Rebound from the deleterious effects of even overwhelming
stress Factors
1. Age, sex2. Social class, family dynamics3. Social support, temperament4. Self-efficacy, belief in God/spirituality5. Coping skills
Dr. Glenn Schiraldi, U of Maryland
4 Qualities of Resilience4 Qualities of Resilience
• Remain relatively steady during life’s storms• Bend, but don’t break• Rebound, spring back• Become stronger in the face of adversity
OR later as a result of adversity
Three Components of ResilienceThree Components of Resilience
I.I. Healthy belief systemHealthy belief system• Good self-esteem• Clear thinking under pressure• Basically optimistic & hopeful• Self-confident• Realistic expectations• Flexible• Helpful philosophical/spiritual views
Adapted from the work of Glenn Schiraldi
Three Components of ResilienceThree Components of Resilience
II. Good emotional coping skillsII. Good emotional coping skills• Emotional self-awareness & understanding• Acceptance, use & comfort with a wide• Range of emotions• Managing upsetting emotions appropriately• Empathy skills• Relationship skills
Adapted from the work of Glenn Schiraldi
Three Components of ResilienceThree Components of Resilience
III. Helpful behaviorsIII. Helpful behaviors• Active coping skills• Good social skills• Healthy relationships• Participate in a supportive community• Balanced life: work, play & rest; self & others• Consistent self-care• Good personal & professional boundaries• Active religious/spiritual commitment
Adapted from the work of Glenn Schiraldi
The Role of Spirituality & ReligionThe Role of Spirituality & Religionin Personal Resiliencein Personal Resilience
Having faith allows one to open one’s heart to experience the sacred/holy/ divine
The response to that experience is one of awe, reverence, thankfulness, hope, devotion and gratitude
Allows for a healthy “New Normal”
The Benefits of Faith toThe Benefits of Faith toPersonal ResiliencePersonal Resilience
Meaning & Purpose Hope Connection with others Internal calmness—peace Encouragement Peace/security/sense of safety as one’s faith is lived Values beyond the material & immediate Perspective on suffering & evil (the long view) Reconciliation—self, others, a “Higher Power” Reduced fear of death Less Anger
Why is This Important?Why is This Important?
20 yrs ago “burnout” 30-60% specialist and general practitioners
Canadian National Survey 1998 62% workload too heavy 55% family and personal life suffer 65% limited opportunities to change career
Self-care rarely part of professional training and low on the list of priorities
Denial of own emotions and needs as a survival mechanism
The Well-Being of Physicians. Am J Med 4/2003/ CPHP 2008
Professional EthicsProfessional Ethics AMA Council on Ethical and Judicial Affairs
Based on Code of Medical Ethics, Medline-indexed articles and experts
Policy of the Association 12/2003 Promote overall physician health and wellness Recognizes that effective skills and patient safety are
absolute requirement in the practice of medicine Emphasizes continued need for forethought and
sensitivity in addressing physicians’ health and wellness
Physician Health and Wellness. Occup Med 2006
Studies so far…Studies so far…
Studies so far…Studies so far… Kaiser Physicians-Northwest and Ohio
80% response to survey
Factors predicting professional satisfaction, organizational commitment, and burnout
Sense of control over practice environment = #1 Perceived work demands Social support from colleagues Satisfaction with resources Related to physician age and specialty Pediatricians more satisfied
Satisfaction, commitment, and psychological well-being among HMO physicians. WJM Jan 2001
Studies so far…Studies so far… 304/614 completion - Wisconsin Research Network (WReN)
Survey family systems assessment instrument, life-events checklist, measures of happiness, life satisfaction, emotional functioning, assessment of relationship support, practice stress
Open-ended question “How do you solve dilemmas related to your physical, emotional, and spiritual well-being?”
SPWB (Scale of Psychological Well-Being) 18 item instrument
• well-being, self-acceptance, positive relations with other people, autonomy, environmental mastery, purpose in life, personal growth
A Qualitative Study of Physicians’ own wellness-promotion practices. WJM Jan 2001
Studies so far…Studies so far… 5 primary wellness-promotion practices
Relationships involvement and spending time w/ family/friends/ colleague/community
Religion or spirituality Self-care reading, nutrition, exercise, counselling Work certain practice, limiting practice,
satisfaction/meaning Approaches to life being positive, balance
All correlated with increased SPWB scores
“Approaches to life” associated with highest level of psychological well-being
A Qualitative Study of Physicians’ own wellness-promotion practices. WJM Jan 2001
Studies so farStudies so far…… 44 individuals representative of gender, geographic
location, and practice size
Semi-structured interview and focus groups
Factors affecting positively and negatively the health and well-being of GP
low levels of remuneration time pressures unrealistic community expectations government interference effect on personal life
General practitioner health and well-being. WJM Jan 2001
Cohort study John Hopkins SOM 1948-1964
Predictors of NOT having a regular source of care and association with subsequent preventive services?
77% response 35% no RSOC Internist (OR 3.26), surgeons (OR
2.42), pathologist (OR 5.46) more likely not to have RSOC vs pediatrician
Inversely related to belief that health is determined by health professionals (OR 0.45), related to chance (OR 1.90)
Did predict not being screened: breast, colon, or prostate cancer, influenza vaccine
Physician, Heal Thyself? Archives November 2000
Studies so far…Studies so far…
Special Concerns:Special Concerns:Women and MedicineWomen and Medicine
Before 1960s, 95% physicians = M 2003 – F > M med school applications 2010 – 1/3rd physicians ~5% department chairs, 10% dean, ~15% full professorships Avg $22,000 or less/yr (same hours, practice setting, specialty) All reviewers - more critical of grant proposals by F applicants Less institutional support (funding, admin assistance) 2005 WPC (Women Physician Congress) – 49% experienced
sexual harassment in their careers
Stereotypes – conscious/unconscious survey M med students 30% felt F of childbearing age poses significant risk to optimal
department functioning ~50% agree w/ “women who spend long hours at work were
neglecting their responsibilities to home and family”
Colorado Physician Health Program 2007
Special Concerns:Special Concerns:Women and MedicineWomen and Medicine
F ~8.5 months vs M ~1 month interruption to address child care issues
F:M 85% vs 35% change career plans to accommodate children
F physician 10 yr lower life expectancy vs general population 60% more likely vs M physicians s/sx burnout increases
significantly (1-15%) every 5 hrs over 40hrs/wk 3-4x higher risk suicide vs WM >35 y.o. and 4x rate general F
population. tend to present voluntarily for help less likely to be sued by their patients
Colorado Physician Health Program 2007
Women Physicians’ Health StudyWomen Physicians’ Health Study 2500 grad/year from 1950-1989
age 30-70 y.o. 4500 respondents
84% usually/almost always/always satisfied
31% maybe/probably/definitely not choose to be a physician again
38% maybe, probably or definitely prefer to change their specialty
Age, control work environment, work stress, h/o harassment independent predictors
Strongest association work control and career satisfaction OR 11.3 p<0.001
Career Satisfaction of US Women Physicians WPHS. Arch In Med. July 1999
0%10%20%30%40%50%60%70%80%90%
100%
Sat
isfi
ed
Bei
ng
ap
hys
icia
n
Ch
ang
ing
Sp
ecia
lity
Satisfied
Being aphysician
ChangingSpeciality
Wellness InterventionsWellness Interventions
Some MythsSome Myths
“I’m trained and therefore invulnerable.” “I’ve seen worse and handled it before.” “I’m a professional, I’m supposed to be
able to handle this.” “If I just follow the protocols, I’ll be OK.” “I’m okay – I have to be, who else is
here to help?” “I have to be strong and show a good
spiritual witness.”
Right Brain InterventionsRight Brain Interventions
Be Value Oriented Promote core values of medical profession Involve physicians in organizing/promoting
mission Minimize Work-Home Interference
Flexible and readily accessible child care Flexibility in scheduling and ready coverage for
life events (births, funerals, family emergencies)
Wellness StrategiesThe Organization's Role
Women in Medicine: Stresses and Solutions. EWJM Jan 2001The Well-Being of Physicians. Am J Med. April 2003
The Resilient Physician. Sotile, WM.Physician Health and Wellness. Occup Med. 2006
Promote Work-Life Balance Adequate vacation time Limit overtime expectations Organization sponsored seminars and retreats Mentoring program and periodic sabbaticals
Promote Physician Autonomy Increase ability to influence environment,
participation in practice decisions, flexibility Increase control over schedule
Women in Medicine: Stresses and Solutions. EWJM Jan 2001The Well-Being of Physicians. Am J Med. April 2003
The Resilient Physician. Sotile, WM.Physician Health and Wellness. Occup Med. 2006
Provide adequate Support Services Adequate coverage to allow time off, adequate and
coordinated nursing, secretarial, admin, social work/chaplain support to promote efficient patient care
Supporting peers in identifying physicians in need Establish approp mechanism to detect impairment Intervene in a prompt and supportive fashion
Cultivate a Collegial Work Environment Fosters healthy relationship (retreats, team building,
social gathering, etc)
The Well-Being of Physicians. Am J Med 4/2003
Women in Medicine: Stresses and Solutions. EWJM Jan 2001The Resilient Physician. Sotile, WM.
Wellness StrategiesWellness StrategiesSelf responsibilitiesSelf responsibilities
Relationships “protecting” family time, sense of connection with colleagues,
reflect/share emotional/ existential aspects Categories
I – important and urgent (pressing problems, crises, deadlines, bona fide emergencies)II – important and not urgent (planning, prevention, creativity, building relationships,
enjoying re-energizing leisure-time activities, maintaining increased productivity)
III – not important and urgent (unimportant to you but urgent to someone else)IV – not important and not urgent (frivolous and nonhelpful wastes of time)
The Well-Being of Physicians. Am J Med 4/2003
Women in Medicine: Stresses and Solutions. EWJM Jan 2001The Resilient Physician. Sotile, WM.
Wellness StrategiesWellness StrategiesSelf responsibilitiesSelf responsibilities
Religious Beliefs/Spiritual Practice Personal attentiveness, nurturing of spiritual aspects
Work attitudes Finding meaning in work Actively choosing and limiting medical practice (working part-
time, medical education, research interests, managing schedules)
Life Philosophy Positive outlook, indentifying/acting on values, stressing balance between personal/professional life
Self-Care Practices Cultivating personal interests (reading, exercise, self-
expression activities, adequate sleep, nutrition), seeking professional help (personal physical or psychologic illness, medical care)
The Well-Being of Physicians. Am J Med 4/2003
Women in Medicine: Stresses and Solutions. EWJM Jan 2001The Resilient Physician. Sotile, WM.
Intervention examples…Intervention examples…
DGIM UCali San Fran – 2 hr/month since 1996 (residents, faculty) avg group 6-37/session
Existential and spiritual themes difficult patients, balancing personal/professional
responsibilities, medical mistakes, professional competence, grief, role playing, journal, literature/art, anger, boundaries, compassion, fear, refuge, unmet patient needs, “wounded healer”
>70% attended at least 1 session Strengthen personal and professional identity Increased sense of connectedness with colleagues Specific practice techniques Maintaining balance and promoting well-being
Doctoring to Heal. EWJM Jan 2001
Intervention examples…Intervention examples…
Intervention examples…Intervention examples… Hill Physicians largest IPA (Independent Practice
Association ) 2,200 Northern California gen and specialty physicians
14 hour “Finding Balance in Medical Life” Physicians/significant others 50/session Napa Valley,
$400/spouses free Understanding stresses of a medical practice and how it
diminishes productivity Adverse health ramification of stress Learning/evaluating how personality traits contribute to
stresses Learning tools for managing emotional stress Tools and practices to enhance communication skills Evaluation of individual personality structure
Engendering and Marketing Physician Wellness. GPJ Oct 2004
Intervention examples…Intervention examples…
Medical Board of California Mentor program career development and balancing
personal/professional lives Confidential support groups monthly Annual well-being retreat on company time Fitness center membership Contractual requirement for own PCP Sabbatical program COM program on well-being Flexible scheduling
1. Reluctance to confront colleagues and refer them to appropriate resources
2. Incur licensure actions, shame, or stigmatization
3. Reluctance to think of themselves as needing help
4. Inadequate standards to indentify signs of need, difficulty in ascertaining with confidence this need and available resources
5. ?mandatory disclosure about own personal medical information
Physician Health and Wellness. Occup Med 2006
Limits to wellness interventionsLimits to wellness interventions
1. Provider wellness should be a vital part of medical training and practices.
2. Needs more time, energy, education, and financial commitment to make this happen.
3. Do what you tell your patients to do:• Practice behaving in harmony with your decision• Take care of your physical self (engage in physical
activity throughout the day)• Eat healthy• Live according to your values• Express your feelings• Engage in self-awareness activities• Protect your relationships
In Summary…In Summary…
ReadingsReadings
Broyard A. Intoxicated by My Illness. 1992 Frankl V. Man’s Search for Meaning. 1985 Harper R. On Presence. 1991 Remen RN. Kitchen Table Wisdom. 1996 Roberts, SB. Disaster Spiritual Care. 2008. Williams WC. The Doctor Stories. 1984
ResourcesResources CPHP (Colorado Physician Health Program)
899 Logan St., Suite 410Denver, CO 80203303-860-0122 phone 303-860-7426 fax Monday – Friday 8:30 am. – 4:30 pm.
FSPHP (Federation of State Physician Health Programs)Michele Norbeck, Ex Director, (239) 877-7305Vickie Grosso, Staff Assistant, (312) 464-4574.
CPEP (Center for Personalized Education for Physicians) in-depth evaluation is tailored to the physician’s specialty and
practice, and provides detailed information about clinical competence in the areas of medical knowledge, clinical reasoning, documentation, communications, and cognitive function—while also identifying areas of educational need
BibliographyBibliography Barron, V et al. “Engendering and Marketing Physician Wellness: Creating a
Healthier Delivery System.” Group Practice Journal. October 2004. J. Day, E. Vermilyea, J. Wilkerson and E. Giller. Risking Connections in Faith
Communities. Sidran Press, 2006. George Everly Jr. and James Reese. Psychological Body Armor. Chevron
Publishing,2007. Charles Figley. Compassion Fatigue: Secondary Traumatic Stress Disorders
In Those Who Treat the Traumatized. Routledge, 1995. Frank, et al. “Career Satisfaction of US Women Physicians.” Arch Intern Med.
159;1417-1426. July 1999. Freeborn, DK. “Satisfaction, commitment, and psychological well-being among
HMO physicians.” Western Journal of Medicine (WJM). 174;14-18. January 2001.
Gautman, M. “Women in medicine: stresses and solutions.” WJM. 174;37-41. January, 2001
Gendel, MH. “Physician work stress Part I/II.” CPHP website Gross, CP et al. “Physician, Heal Thyself?” Arch Intern Med. 160;3209-321.
November 2000. Gundersen, DC. “Women in Medicine.” CPHP Newsletter. Gundersen, L. “Physician Burnout.” Annals Int Med. 135;145-148. July 2001. Hartwig, E et al. “General practitioner health and well-being.” WJM. 174;25.
January 2007
BibliographyBibliography Myers, MF et al. “The well-being of physician relationships.” WJM. 174;30-
33. January 2001. Schiraldi, Glen. Post-Traumatic Stress Disorder Sourcebook. Chevron Pub,
2000. Shanafelt, TD et al. “The well-being of physicians.” Am J Medicine. 114;513-
519. April 2003. Shanafelt, TD et al. “Relationship between increased personal well-being and
enhanced empathy among internal medicine residents.” JGIM. 559-564. January 2005.
Spickard, A et al. “Mid-Career Burnout in Generalist and Specialist Physicians.” JAMA. 288;1447-1450. September 2002.
Stamm, B. Hudnall Ed. Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators, 2nd Ed. Chevron Pub,1999.
Steinbrook, R. “Medical Student Debt – Is There a Limit?” NEJM. 359;2629-2637. Dec 2008.
Suchman, AL. “The influence of health care organizations on well-being.” WJM. 174;43- 47. January 2001.
Taub, S et al. “Physician health and wellness.” Occup Med. 56;77-82. 2006. Weiner, EL et al. “A qualitative study of physicians’ won wellness-promotion
practices.” WJM. 174;19-23. January 2001. Visionary Productions Inc. Compassion Fatique: The Stress of Caring Too
Much. PBS Satellite Video Conference June 23, 1994.
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