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PROMOTING WELLNESS IN YOUR PATIENTS

Dawn C. Buse, PhDDirector of Behavioral Medicine, Montefiore Headache Center

Associate Professor, Department of Neurology

Albert Einstein College of Medicine of Yeshiva University

Assistant Professor, Clinical Health Psychology Doctoral Program

Ferkauf Graduate School of Psychology of Yeshiva University

Disclosures

In the past year I have acted as a consultant and/or received research funding from Allergan, Avanir, Amgen, Biohaven Pharmaceuticals, Eli Lilly and Promeius.

Learning Objectives

� Explain the data on burnout among healthcare

professionals, especially among those who care for patients with chronic pain conditions

� Cite the risk factors and protective factors for burnout

� Describe how to enhance resilience and protective

factors against burnout

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Healthy Lifestyle Habits that Matter in Migraine

� Stress management

� Good Sleep Hygiene, regular routine 7 days per week

� Proper nutrition, hydration, regular meals

� Regular exercise

These healthy habits

� may raise the threshold for migraine

� Are generally inexpensive, free of side effects

� But can be very difficult to maintain motivation

What is stress?

� Walter Canon’s ‘fight-flight’ response in the 1930s

� Hans Selye’s General Adaptation Syndrome in the 1950s

� Richard Lazarus & Susan Folkman’s transactional model in the 1980s

� The psychobiological stress response arises from an imbalance between perceived demands and the perceived personal and social resources of the individual to meet the demands.

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Stress is not inherently negative

Stress is Not Inherently Negative

� Functional response to stimuli necessary for survival

� Enhances performance and engagement in life… in moderation

Notional model of performance in a difficult task: Yerkes and Dodson curve (1908)

Perf

orm

an

ce

Stress (arousal)

–

–

+

+

Rust out

Comfort zone

Peak performance

Wearout

Burnout

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Notional model of emotions that arise from the balance between level of

challenge and a person’s coping ability

Confidence

Challenge

apathyboredom

relaxation

control

engagement,flow

arousal

apprehension,anxiety

worry

high

highlow

low

Too much stress for too long is a problem: Allostasis

� Maintaining stress and adaptive responses over the long term implies high levels of activation of the homeostatic processes

� This causes wear and tear, called 'allostatic load'.� Selye's General Adaptation Syndrome diagram showing the level of endocrine

response mounted:

Resting response

level

Selye H. The stress of life. New York: McGraw Hill; 1956.

Lazarus RS, Folkman S. Stress appraisal and coping. New York: Springer; 1984.

Scientifically proven components of well-being

authentichappiness.com

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Assess, Monitor & Treat (or Refer)…

� Disability and impact

� Quality of life

� Depression and anxiety

Depression and Anxiety Assessment Instruments

PRIME-MDScreens most DSM-IV Axis I

disorders

PHQ-9Depression

GAD-7Anxiety

GAD-4Brief depression and anxiety

screen

• All are available for use and distribution free of charge

• See www.phqscreeners.com for measures, manuals, validation

manuscripts, and versions in multiple language

Motivational Interviewing

Involves:

� RECOGNIZING a problem

� IDENTIFYING the patient’s readiness for change

� TAILORING interventions to the patient’s stage of readiness

for change

Collaborative Guiding*

*To elicit/strengthen motivation for change

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Motivational Interviewing: Strategies For Change

Rollnick et al. Motivational Interviewing in Health Care, 2008.

Show empathy Increase patient trust

Use the patient’s words to help move

towards change

Help patient see discrepancies in their thoughts vs

behaviors

To Motivate Change. . .Use the Motivational 2 x 2

Table

Advantages

Actively managing migraine

NOT actively managing migraine

Disadvant

ages

Actively managing migraine

NOT actively managing migraine

Stages of Change

Prochaska et al. Am Psychol. 1992;47:1102–1114.; Prochaska et al. Health Psychol. 1994;13;39–46.

Precontemplation

Contemplation

Preparation

Action

Maintenance

Decline

P

r

o

g

r

e

s

s

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Cognitive Influences in Migraine: Self-Efficacy

• He/she can successfully engage in a course of action

• Action will produce a desired outcome

Patient’s belief that:

1. Bandura. Psych Rev.1977;84:191–215.; 2 Schwarzer. Self-efficacy: Thought control of action. 1992.; 3. Bandura. Self-efficacy. Encyclopedia of human behavior. 1994.; 4. Bandura. Self-efficacy in changing societies. 1995.

• Managing triggers

• Adhering to treatment regimens

• Coping with pain

• Limiting disability

Individuals possess self-efficacy belief for various behaviors:

How Self-Efficacy Can Influence Migraine

Management

1. French et al. Headache. 2000;40:647–656.; 2. Nestoriuc et al. Pain. 2007;128:111–127.; 3. Nicholson et al. Headache. 2005;45:513–519.; 4. Blanchard et al. Headache Q. 1993;4:259–263.; 5. Holroyd & Martin. In Olesen et al. (eds). The Headaches. 2000.; 6. Smith et al. Headache. 2010;50:600–612.

Predicts response to

combined pharmacologic and behavioral

treatment4-5

Higher self-efficacy leads

to lower disability6

Potential mediator and moderator of

headache treatment

response1-3

Strategies to Enhance Self-Efficacy

Principle for

improvemen

t

Example

Mastery

experience

• Patients keep a diary so they can recognize headache

patterns and track potential triggers

• Ensure that they take their medication early in the course of an attack to demonstrate efficacy

Modeling of

behavior

• Teach patients how to take medication

• Show patients how to complete a diary

Verbal/social

persuasion

Educate patients about an issue related to headache

management (eg, medication adherence, managing

triggers, the importance of daily headache management)

Generalizati

on

Talk with patients about other behaviors they do to

prevent something negative from happening

(eg, using sunscreen, wearing a seatbelt)Nicholson R. Curr Pain Headache Rep. 2010;14:47–54.

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Locus of Control

InternalHealthcare

ProfessionalsFate/Chance

“What can I do

to manage these attacks?”

“You need

to do somethingto manage

these attacks”

“There is

nothing anyonecan do to manage

these attacks”

1. Nicholson et al. Headache. 2007;47:413–426.; 2. Lefcourt. Locus of control: Current trends in theory and research. 1982.; 3. Rotter. Psychological Monographs. 1966;80:609.; 4. Wallston et al. Health Educ Beh. 1978;1:160–170.

Consequences of a Locus of Control

Internal locus of control External locus of control

Are aware of and actively

manage their environment

Do not attempt to

actively manage their situation

Improved management of

triggers such as stress1

Feel “helpless” and/or

“hopeless” about their situation

Value skill development

and achievement reinforcement

Do not develop skills

for headache management

1. Nicholson et al. Headache. 2005;45:1124–1139.; 2. Hudzinsky et al. Headache. 1985;25:1–11.; 3. Nestoriuc et al. Pain. 2007;128:111–127.; 3. Scharff et al. Headache. 1995;35:527–533.; 5. Smith et al. Headache. 2010;50:600–612.

• Better treatment outcomes2-4

• Less disability4

• Less distress5

• Poor treatment outcomes2-4

• More disability4

• More distress5

Strategies to Encourage Internal Locus of Control

Principle for

ImprovementExample

Enhance self efficacy• Keep diary• Formulate realistic plan• Monitor benefits-consequences

Accept what they cannot control

• Genes• Hormones• Weather

Identify current successes • Current behaviors that work

Nicholson R. Curr Pain Headache Rep. 2010;14:47–54.

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Factors Driving Adherence Behaviors

Migraine

ImportantNot

Important

Behavioral

Treatment

of Healthy

Behavior

Effective and

Tolerable (cost,

effort, time, etc)

Adherencevery likely

Address disease

perception

Not Effective

and/or Tolerable

Addressmedication perception

Adherence very unlikely

1. Katic et al. Headache. 2010,50;117-29.; 2 Dunbar-Jacob et al. J Clin Epidemiol. 2001;54:S57-60.; 3. Rainset al. Headache. 2006;46:1395-1403.

Empirically Supported Behavioral Therapies for Migraine

Lifestyle Management

Biofeedback

Cognitive Behavioral Therapy

Relaxation Training

Behavioral Therapies with Emerging Evidence for Migraine

Mindfulness Based Therapies

�Mindfulness Based Stress Reduction (MBSR)

�Mindfulness Based Cognitive Therapy (MBCT)

Acceptance and Commitment

Therapy (ACT)

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Technology options: low touch, low cost, more accesable

� Websites

� Apps

� Wearables

� Smart phones

� Online support groups

“Put on your oxygen mask first before helping those around you.”

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Promoting your own wellness

What is “Burnout”?

� Term coined by Freudenberger in 1974.

� Definition: “increased feelings of emotional exhaustion, an unfeeling and impersonal response toward patients, and dissatisfaction with work accomplishments.”

Freudenberger HJ. Staff burn-out. J Social Issues. 1974;30(1):159–85.

Maslach Burnout Inventory Measures 3 Constructs:

� Emotional Exhaustion: feelings of being emotionally overextended and exhausted by one's work.

� Cynicism or Depersonalization: an unfeeling and impersonal response toward recipients of one's service, care treatment, or instruction.

� Professional Efficacy/Accomplishment: feelings of competence and successful achievement in one's work.

MBI-Human Services Survey (MBI-HSS): The original measure that was designed for professionals in the human services.Christina Maslach & Susan E. Jackson, JOURNAL OF OCCUPATIONAL BEHAVIOUR. Vol. 2.99-113 (1981)

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Burnout Rates by Specialties

Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of

Internal Medicine, Aug. 20, 2012

Satisfaction with Work-Life Balance by Specialty

Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of

Internal Medicine, Aug. 20, 2012

Reasons for Burnout

Cordes CL, Dougherty TW. A review and an integration of research on job burnout. Acad Manage Rev. 1993;18:621-656.

The causes of burnout can be grouped into 3 categories:1. Job characteristics. These include employee-patient

relationships, role conflict, role ambiguity, and role overload.

2. Organizational characteristics. These refer to the extent to which rewards and punishments are linked to job performance.

3. Personal characteristics. These include various sociodemographic variables of the employee, self-efficacy, and social support.

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Burnout Among Healthcare Professionals: A dangerous combination

�HIGH Job Stress and LOW

Personal Autonomy leads to BURNOUT!

Symptoms of Burnout

Table 1. Symptoms of Work Burnout

Physical Behavioral Cognitive/affective

Physical exhaustion Irritability Emotional numbness

Chronic fatigue Anger and resentment Hypersensitivity

Headaches and back pain Alienation Cynicism

Gastrointestinal problems Marital and relationship

difficulties

Apathy

Sleep disturbance Rigid thinking Helplessness and

hopelessness

Muscular tension Self-righteousness Depression

Vulnerability to illness Increased alcohol or drug

use

Overidentification with

patients

Lingering illnesses

Miller D. Stress and burnout among health-care staff working with people affected by HIV. Br J Guid Counc. 1995;23:19-32.

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Recommendations to Reduce or Avoid Burnout for HCPs

1. Set boundaries

2. Take control where possible (self-efficacy)

3. Engage with friends, family and community (social support)

4. Exercise regularly

5. Practice any stress management technique or activity that works for you (during the work day even if very briefly as well as during time away from work)

Sigsbee B, Bernat JL. Physician burnout: A neurologic crisis. Neurology. 2014;83(24):2302-2306.

Sood A, Prasad K, Schroeder D, Varkey P. Stress management and resilience training among Department of Medicine faculty: a pilot randomized clinical trial. J Gen Intern Med. 2011;26(8):858-861

Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with, empathy, and attitudes among primary care

physicians. JAMA. 2009;302:1284–1293

Recommendations to Reduce or Avoid Burnout for HCPs

6. Streamline and triage your commitments.

7. Avoid meaningless tasks and reduce hassle factors

8. Practice gratitude

9. Get enough good quality sleep

10. Enhance resilience

11. Seek professional mental health care and support if stress, depression or anxiety becomes overwhelming

Sigsbee B, Bernat JL. Physician burnout: A neurologic crisis. Neurology. 2014;83(24):2302-2306.

Sood A, Prasad K, Schroeder D, Varkey P. Stress management and resilience training among Department of Medicine faculty: a pilot randomized clinical trial. J Gen Intern Med. 2011;26(8):858-861

Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with, empathy, and attitudes among primary care

physicians. JAMA. 2009;302:1284–1293

Resilience

� Resilience is the capacity to respond to stress in a

healthy way such that goals are achieved at minimal psychological and physical cost.

� Important components include individual, community, and institutional factors.

� See AuthenticHappiness.edu (Martin Seligman, PhD

at UPenn) for strategies and self assessment instruments.

Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013;88(3):301-303.

Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four?

Resilience strategies of experienced physicians. Acad Med. 2013;88(3):382-389.

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Summary

� Stress is common among healthcare professionals.

� Rates of burnout are high among pain expert healthcare professionals… although they also feel appreciated by their patients.

� There are a range of protective and corrective actions that can be taken at the level of 1. the institution and 2. the HCP.

� There are resilience enhancing protective behaviors that HCPs can engage in.

� Remember to take care of yourself so that you can take care of your patients.

Dawn C. Buse, PhDDirector of Behavioral MedicineMontefiore Headache CenterAssociate ProfessorDept of Neurology, Albert Einstein College of MedicineBronx, NYDBuse@Montefiore.orgWebsite: Dawnbuse.comTwitter: @dawnbuse