Kumu Hendrix, MD Associate Professor Director, Wellness Program Department of Anesthesia MedStar Georgetown University Hospital

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1 Nancy Harazduk, M.Ed, MSW Assistant Professor Director, Mind-Body Medicine Program Georgetown University, School of Medicine Washington, DC Jennifer Pukish, MD Pediatric Anesthesiology Fellow Children s National Medical Center Washington, DC Kumu Hendrix, MD Associate Professor Director, Wellness Program Department of Anesthesia MedStar Georgetown University Hospital

2 Burnout Merriam Webster Dictionary exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration 1974 Fredenberg Occupational health paper burnout syndrome In response to stress, one cascades from a desire to prove one s worth to a state of depression, depersonalization, isolation, and a revision of core values by way of a general neglect for one s own well being. Malach Burnout Inventory Gold standard inventory Emotional Exhaustion, Depersonalization, Decreased sense of accomplishment

3 Stress: Good or Bad? Perception May be beneficial Improve alertness Can add to feeling of success to surmount something difficult Constant and high levels of stress without coping mechanism lead to burnout

4 Studies in Medical Pipeline Burnout and distress starts in medical school Large prospective study, first national survey Shanafelt (2012) among anesthesiology residents showed 41% at high risk for burnout 22% screened positive for depression 5% showed suicidal ideation Burnout associated with: Alcohol and drug abuse Compassion fatigue Depression Problematic relationships Job (dis)satisfaction Suicide Job performance Work load significantly correlates with burnout >70 hours per week

5 Anesthesia and Stress Front line of care access Low control over work, unpredictable work High demand, time sensitive Long work hours Chronic sleep deprivation Fatigue High responsibility Demanding interpersonal relationships Need for sustained vigilance Fear of litigation

6 Perceptions and Prevalence of Stress 90% of Anesthesiologists consider burn out a significant problem Yet 14% have coping strategies to manage it Self perception of burnout is lower than revealed per inventories Hierarchical gradient inversely relates to burnout Job satisfaction is inversely related to burnout Not just a US health care hazard High prevalence suggests systemic problem 50% French ICU physicians 31% Portuguese ICU workers >50% Egyptian Anesthesiologists Females > males Decreased age correlates with higher burnout rates

7 Consequences of Burnout Impaired job performance Lower patient adherence to treatment prescribed by physicians Poor display of empathy Trend to leave practice Patient well-being and physician well-being are highly interconnected

8 Coping Strategies Problem focused strategies Active coping, Instrumental support, Planning Emotion focused strategies Acceptance, Emotional support, Humor, Positive reframing, Religion Dysfunctional coping strategies Behavioral disengagement, Denial, Self-distraction, Self-blame, Substance abuse, Venting

9 Review of Literature Paucity of longitudinal and/or RCT of Cognitive Behavioral or Mindfulness-Based techniques Cognitive Behavioral Therapies identify and modify dysfunctional beliefs that influence responses to stimuli Mindfulness-Based techniques focus on reactions to challenging experiences

10 Interventions to Reduce Burnout A mere 1 hour of online Mindfulness techniques had a great impact on empathy, resilience and stress

11 Mind-Body Medicine Wellness Program for Anesthesia Residents

12 Anesthesia Resident Wellness Program Objectives of the Program To increase self-awareness of emotional, physical, mental social and spiritual aspects of anesthesia residents lives To enhance personal self-care through guided mind-body medicine experiences To foster nonjudgmental, supportive collegial relationships among residents

13 Description of the Resident Wellness Program Two facilitators and eight 1 st year anesthesia residents engage in a 3 year Mind-Body Medicine Wellness Program beginning with: A 2 ½ day off sight retreat to take place 6-8 weeks after the start of residency Residents continue to meet once a month for 2 hours for duration of 3 year residency

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15 Description of Retreat Each resident is interviewed by the facilitators in order to: Learn of the emotional, physical, social and spiritual aspects of their lives To describe the Mind-Body Medicine Wellness program To give them the opportunity to ask any questions regarding the program

16 : Dinner Introductions Morning yoga 5 experiential sessions Closing Description of Retreat Agenda

17 Description of a Session Check in (sharing reflections and insights) A safe environment must be created that adheres to certain guidelines: Confidentiality, respect, compassionate listening, and non-judgment Introduction of a new mind-body medicine skill Guided experiential exercise Process experiential exercise

18 Experiential Exercises Mindfulness Meditation (sitting, walking, eating) Guided Imagery Autogenic Training/biofeedback Journal writing (stream of consciousness dialogue)

19 Retreat Schedule

20 Monthly Follow-up Meetings

21 Room Set-Up Candle Fresh Flowers Chocolate Tingsha Bells Tissues

22 Follow-up Meetings Two facilitators and each resident cohort meet once a month 2 consecutive hours for the remainder of 3 year residency Groups meet from 6:00pm-8:00pm (protected time for residents) Dinner is provided Each group begins with an experiential exercise followed by the group check-in

23 An Intervention: Mindfulness Meditation

24 What is Mindfulness Meditation? Meditation is focusing on one specific thing intentionally and nonjudgmentally in the present moment

25 What is Mindfulness Meditation? The mind is constantly filled with distracting thoughts When we are able to focus on just what is happening in the present moment, our minds cannot be anxious, worried or distressed about other issues

26 What is Mindfulness Meditation? Meditation is about being rather than doing It enables us to slow down and to bring self-awareness and insight into our daily lives so that we can more easily make decisions that are appropriate for us. When our lives are filled with constant doing, meditation can provide periods of stability, clarity, balance, perspective, and inner peace.

27 What is Mindfulness Meditation? Meditation is a process rather than a goal. It is most effective when we: are able to let go of judgment and expectations are open and accepting of whatever happens are gentle and non-judgmental with ourselves let go of trying to do it perfectly trust in ourselves are patient

28 Mindfulness Meditation Method: Assume a comfortable position. Bring your full attention to your breath noticing each inhalation and each exhalation. When thoughts, feelings, sounds or sensations flow through your mind, notice them, accept them and gently bring your attention back to your breath.

29 Benefits of Mindfulness Psychological Benefits: Decreased anxiety Meditation Reduced stress level Decreased depression Lower incidents of irritability and moodiness Improved confidence and concentration Increased peace of mind, optimism and self-worth Improved learning ability and memory

30 Benefits of Mindfulness Meditation Physiological Benefits: Decrease in hypertension Lower heart rate Lower levels of cortisol Strengthened immune system Reduced levels of chronic pain Reduced incidents of headaches

31 Spiritual Benefits: Benefits of Mindfulness Meditation Identifying one s purpose in life Finding meaning in illness Connection with higher aspects of self Connection to other people Connection to Higher Power outside of self

32 General Guidelines for Mindfulness Meditation

33 Mind Body Medicine: A Path to Improved Resiliency During Residency Jennifer Pukish, MD October 23 rd, 2017

34 The MBM Experience CA-1 Year: An Oasis During Clinical Baptism by Fire -Weekend Retreat *Recognition *Meditation *Yoga *Stress Reduction *Relationship Building -Monthly Sessions *Meditation *Check-In *Flexible -Build in Mentorship

35 Relationship Building Connection to other residents Anesthesia residency can be isolating Teams working in tandem Life Goes on Outside the OR Babies Weddings Vacations Family Crises Lifelong Friendships

36 Graduation

37 Personal and Professional Benefits Increased Satisfaction Decreased Stress During Critical Clinical Situations (Stress Management Techniques) Investment in co-residents Introduced more Humanism to our department Mentorship Comradery Normalize dreams outside residency

38 Worth the Time YES!! Does require an investment and support from the department Weekend coverage for the retreat Two hour period once a month

39 Current Practices Learned from MBM What I am like when I am stressed/exhausted/on the verge of burnout Meditation Deep Breathing Confiding in my co-mbm friends

40 Is it right for my program? Existing Burnout and Resiliency Program? An online module is not enough Opportunity to build lifelong (career-long) stress reduction techniques Would you have appreciated a program like MBM during your training? Better performance from residents

41 Experiential Exercise