#CHAIR2016. September 15 17, 2016 The Biltmore Hotel Miami, FL. Sponsored by

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1 #CHAIR2016 September 15 17, 2016 The Biltmore Hotel Miami, FL Sponsored by

2 An Epidemic of Burnout and Increased Risk of Suicide in Medicine: Strategies for Healthcare Providers Douglas Ziedonis, MD, MPH Professor and Chairman, Department of Psychiatry UMass Medical School/UMass Memorial Medical Center President, UMass Memorial Behavioral Health Services Worcester, MA

3 Douglas M. Ziedonis, MD, MPH Disclosures Dr. Ziedonis has no disclosures to report.

4 Thanks Steve Adelman George Abraham Barry Feldman Barbara Grimes-Smith

5 #CHAIR2016 Learning Objective 1 Recognize the risk of burnout and suicide among healthcare providers.

6 #CHAIR2016 Learning Objective 2 Learn to develop a personal and organizational strategy to increase resilience.

7 It s the Economy & Funds Flow.

8 Published May 22, Accessed September 13, 2016.

9 Levitan D. Published February 19, Accessed September 13, 2016.

10 Median Education Debt of Indebted Medical School Graduates, Published Accessed September 13, 2016

11 Burnout Syndrome: What is it? Maslach Burnout Inventory measures 3 main areas: Emotional Exhaustion** measures feelings of being emotionally overextended and exhausted by one's work. Exhaustion is a depletion of emotional energy, distinct from physical exhaustion or mental fatigue. Emotional Exhaustion is a clear signal of distress in emotionally demanding work. Cynicism or Depersonalization measures an unfeeling and impersonal response toward recipients of one's service, care treatment, or instruction. The depersonalization measured by this scale is a problem in careers that value and mandate personal sensitivity to service recipients. Professional Efficacy / Accomplishment measures feelings of competence and successful achievement in one's work. This sense of personal accomplishment emphasizes effectiveness and success in having a beneficial impact on people. Source: Maslach Burnout Inventory. The leading measure of burnout. Christina Maslach, Susan E. Jackson, Michael P. Leiter, Wilmar B. Schaufeli, & Richard L. Schwab.

12 Burnout is Not the Same as Disengagement But They Can Coexist

13 Burnout is Variable Across Tenure, and It s Root Causes Differ

14 Physicians (N = 6880) compared to general population Measures of Burnout (per MBI) & Satisfaction with Work-Life Balance (WLB) Burnout has increased from 46% to 54% WLB satisfaction has decreased from 49% to 41% All specialties are experiencing increased burnout and more WLB dissatisfaction Physicians are faring worse than the general population Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):

15 Burnout Rising in all Specialties Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):

16 Quality of Life Falling in all Specialties Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):

17 Work Life Balance + Burnout: Variations by Specialties Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):

18 Physicians vs. General Public Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):

19 Physician / General Public Burnout Measure Comparisons Shanafelt TD, et al. Mayo Clin Proc. 2015;90(12):

20 Editorial: How Do Dan Ariely, PhD (Professor of Psychology and Behavioral Economics) and William L. Lanier, MD (Editor-in-Chief of the Mayo Clinic Proceedings) Understand the Mounting Burnout Epidemic? Asymmetrical Rewards: Punishment for mistakes is particularly substantial in the medical profession. Loss of Autonomy: Contemporary medicine s escalating oversight and control of how physicians spend their time goes hand in hand with a loss of physician autonomy. Cognitive Scarcity: The need to continuously make consequential decisions creates stress for physicians without time buffers. The problem that needs to be solved: We view the practice of medicine as a production function, a sort of fixing people production line, when, in fact, medicine should be viewed as a research and development activity. Conclusion: The system needs to evolve away from managing physicians time to focusing on long-term health

21 Correlates of Resident Job Satisfaction Online survey results representing 127/227 (56%) of program graduates. Variable Spearman Correlation Coefficient p-value Age Residency class Physical health Emotional health Income Number of jobs Debt burden Work week hours Hours of sleep Number of children Chen C, et al. Rhode Island Medical Journal. 2014;97(10):50-54.

22 Suicide Rates by Profession Rank Profession Odds Ratio 1. Medical Doctors Dentists Police Officers Veterinarians Financial Services Real Estate Agents Electricians Lawyers Farmers Pharmacists 1.29 In general population of the US, the overall prevalence of suicide is 1-2% Tiesman HM. NIOSH Science Blog. Accessed September 13, 2016.

23 US Data (2013) 41,149 known suicides (79% males) 3.7 male completions for each female completion 1,028,725 attempts (25:1 ratio of attempts to completions) 3 female attempts for each male attempt Over 500,000 people annually receive medical care for self-inflicted injuries Top three methods used in suicides: Firearm (52%) Hanging/suffocation (25%) Poisoning (16%) Suicide Facts.

24 Physician Depression and Suicide: An Epidemic? Each year in the US, roughly MDs die by suicide Suicide deaths are 250%-400% higher among female MDs compared to females in other professions In the general population, males complete suicide 4x more often than females among MDs, rate is equal Medical students shave rates of depression 15%-30% higher than the general population MDs have a higher suicide completion to attempt ratio, which may be result of greater knowledge of lethality of drugs and easy access American Foundation for Suicide Prevention website. Accessed September 7, 2016.

25 Depression in Medical School and Residency In one study of 6 medical schools, 1 in 4 students reported clinically significant symptoms of depression Almost 7% had thought of suicide in last 2 weeks 1 29% of residents suffered from significant symptoms of depression 2 Begin with rates similar to general population, but symptoms escalate within a year of starting training 3 Data likely an under-count because suicide not listed on death certificate and not tracked in medical school databases 4 1. Goebert D, et al. Acad Med. 2009;84(2): ; 2. Mata DA, et al. JAMA. 2015;314(22): ; 3. Thielking M Graham J.

26 Stressors Sleep deprivation Competition with peers Criticism from faculty who have little tolerance for ignorance, signs of weakness, or emotional displays Medical education and training are a profoundly dehumanizing experience and it s drilled into you: Do not show your heart or teas to anyone, every again, said Dr. Pamela Wible, family physician and author of a book about physician suicide Graham J.

27 Manifestations of Mental Illness Depressed residents made 6.2x more medication errors than their non-depressed peers Severe irritability and anger resulting in interpersonal conflict Strained professional and personal relationships Inappropriate boundaries with patients, staff or peers Erratic behavior at the office or hospital Bright RP, Krahn L. Current Psychiatry. 2011;10(4): Marked vacillations in energy, creativity, enthusiasm, confidence, productivity Frequent job changes and/or moves Impulsivity or irrationality in decision making or action Diminished or heightened need for sleep Sexually inappropriate comments or behavior Isolation and withdrawal Inconsistency in performance, absenteeism

28 Why are Depression and Mood Disorders Under-recognized and Inadequately Treated in Physicians? Physicians may be reluctant to seek treatment Attempt to diagnose and treat themselves Seek and receive VIP treatment from other health care providers Bright RP, Krahn L. Current Psychiatry. 2011;10(4):16-30.

29 Predictors of Depression in Physicians Difficult relationships with senior doctors, staff, and/or patients Lack of sleep Dealing with death Making mistakes Loneliness 24-hour responsibility Self-criticism Firth-Cozens J. Br J Gen Practice. 1998;48:

30 The 4th AIM Physician Wellness Bodenheimer T, et al. Ann Fam Med. 2014;12:

31 Better Physician Health Promotes Better Health in Patients Compliant physicians enhance patient compliance (screening and immunization) Physicians with better personal health practices counsel patients more (blood pressure and lipids) Providers who share health practices are viewed as more credible and motivating Frank, E. JAMA, 2004;291(5):637.

32 AMA Steps Forward Module 1: Physician Burnout AMA Steps Forward.

33 AMA STEPS Forward Modules Series of modules for practice redesign Among them, one for burnout prevention, another for resiliency

34 AMA Steps Forward Module 2: Improving Resiliency AMA Steps Forward.

35 Some Sweeping Systemic Changes Placing a greater emphasis on identifying emotional intelligence in the medical school admissions process Reorganizing the funding of medical education to diminish burdensome debt for early career physicians Rebalancing the funding and focus of graduate medical education to produce more ambulatory-based primary care physicians and fewer hospital-based specialists Accelerating system migration to value-based care Enhancing the rewards for practicing physicians who focus on health maintenance and primary care Attenuating the macho culture of medicine and restructuring physician worklife, accommodating the influx of working mothers into the profession

36 More Sweeping Systemic Changes Design and implement a coherent and consistent structure for the healthcare system such that it is: Better-led Flatter & less siloed Less beholden to corporate shareholders Less utilization driven More in touch with the everyday, human needs of front-line clinicians

37 Actionable Burnout Countermeasures (ABC) Coaching For patients (health & wellness) For physicians (balance, communication, organization, professionalism) For physician leaders (be coached and learn to coach) Concierge practice (saves PCPs) Fitness centers (on site) Float pools & Time buffers life happens and adds 10% to work volume Lunch (a la Mayo) Financial planning

38 More Actionable Burnout Countermeasures (II) Meaning, Purpose, Spirituality (introducing Dr. Sacra) Recapture the Calling Mindfulness (individual, group, institution) Peer support Balint Groups Finding the Meaning in Medicine dialogues (Florida Hospital) Managing Workplace Complexity discussion groups Schwartz Rounds Salaried positions (a la Mayo) Scribes

39 Individual Coping Strategies Humor Utilize supervision Relaxation time Take care of your body diet; exercise Set boundaries between home and work Avoid isolation involvement in professional organizations

40 MBSR Formal and Informal Practices Formal Practices of Meditation & Gentle Yoga Exercises: Ex: Awareness of Breathing, Sitting Meditation, Slow Walking Meditation, Body-scan, Raisin Exercise (mindful eating), Gentle Yoga Exercises, Mountain / Lake Meditation, Loving-kindness Meditation, etc Informal Practice: Many opportunities all day to enhance awareness Any moment perhaps when you catch yourself being mindless and gently redirect to the present moment Consciously increase awareness to current thoughts, feelings, & body sensations How the weather affects us physically Pleasant experiences & unpleasant experiences Reactivity to stressful situations or events While communicating with others Homework Consider journal / log of your experiences.

41 Call to Action Commit to one small change to provide work-life balance and develop resilience

42 #CHAIR2016 Questions Answers &