Burnout: Don t thank me for normal work, a polemic. Joel Zivot, MD, FRCP(C) Associate Professor Emory University

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2 Burnout: Don t thank me for normal work, a polemic Joel Zivot, MD, FRCP(C) Associate Professor Emory University

3 Those are my principles, and if you don t like them well, I have others. Groucho Marx

4 My confession I remain charmed and delighted by the work.

5 Burned out A maladaptive stress response occurring commonly in human service professionals. Occupational burnout Job burnout

6 Burnout is characterized by: Burned out Cynicism Exhaustion Depersonalization Emotional withdrawal Reduced personal accomplishment

7 Work-life balance? Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population Burnout is more common among physicians than among other US workers Physicians at the front line of care access seem to be at greatest risk Shanafelt TD, et al, Arch Int Med Vol 172, No 18, Oct 8, 2012

9 Burnout Inventory Maslach Burnout Inventory (MBI)* Tests for 3 components Emotional exhaustion Depersonalization Reduced personal accomplishment *Maslach, C., Jackson, S. E., Leiter, M. P. (1996)

10 Burnout Inventory Maslach Burnout Inventory (MBI)* 22 Items Divided into 3 subscales Exhaustion Cynicism Inefficacy *Maslach, C., Jackson, S. E., Leiter, M. P. (1996)

11 Burnout Inventory Maslach Burnout Inventory (MBI)* Validity Outside observer corroboration» from a co-worker» From a spouse Independent analysis of job type and burnout» higher rate in jobs with higher caseloads

12 Burnout Inventory Maslach Burnout Inventory (MBI)* Variations MBI educators survey MBI general survey

13 Burnout Inventory Maslach Burnout Inventory (MBI)* limitations Is it really a burnout inventory? Burnout is not a distinct disorder (not in DSM-5, but listed in ICD-10) Burnout is just depression Burnout is just that I don t like my job

14 It didn t answer the question.. Why does work suck sometimes?

15 It didn t answer the question.. Why does work suck sometimes? Why does my life suck sometimes?

16 It didn t answer the question.. Why does work suck sometimes? Why does my life suck sometimes? Maybe I need more work-life balance?

21 Disconnection between the organization and the individual 6 areas workload control reward community fairness values

22 Conflict makes me unhappy.

23 Conflict makes me unhappy. Conflict occurs in the operating room.

24 Conflict makes me unhappy. Conflict occurs in the operating room. What are the origins of conflict?

25 Monkeys know what s fair Capuchin monkeys reject unequal pay.

26 Killer apes Traditional anthropology view (Nature): Dart, Ardrey, Lorenz, Human ancestors were aggressive Aggression and hostility are genetic Humanity retains this aggressive and murderous instinct The Killer Ape

27 Killer apes Traditional social psychology view (Nurture): Berkowitz Frustration aggression hypothesis Role models and authorities

28 Killer apes Nature vs. Nurture Aggression is anti-social Aggression leads to dispersal

29 Individual model Killer apes

30 Individual model: the problem Killer apes Silent on social context. How do families and societies deal with the consequences of aggression? Model does not explain how aggression is controlled. Individual model does not account for civilization.

31 Killer apes In the real world, most aggression occurs among familiar individuals. Aggressor and victim share a past and a future. Need a new model: recognizes that individuals are socially embedded.

32 Great apes are Our family tree

33 Chimps and Humans Primate societies are characterized by cooperation. Chimps and humans show collective intercommunity violence. Often, alliances are formed with 2 or more individuals joining together to defeat a 3rd.

34 Chimps and Humans Power is possessed in the one who can mobilize the most support, not necessarily the one who is strongest. Ubiquitous primate activity of grooming is central to the establishment and maintenance of partnerships.

35 Chimps and Humans Extensive primatology research, both in captivity and in the field, increasingly have made relationships, not the individual, as the unit of analysis.

36 What do we know? Chimps and Humans Primate societies are characterized by co-operation. Reconciliation and appeasement are regular and conspicuous parts of chimp society. Reconciliation involves physical touching, i.e., grooming, kissing, sex, hugging.

37 What do we know? Chimps and Humans Chimps are violent and male dominated. If they new how to handle a firearm, they would surely use them. Are chimps a good model for studies on human aggression?

38 Genus Pan Chimps can t swim Planet of the apes

39 2 pan species, our closest extant relatives Pan troglodytes (common chimp) Pan paniscus (pygmy chimp, bonobo)

40 Highly sexual Pan paniscus (Bonobo) All partner combinations and in a variety of positions.

41 Pan paniscus Matriarchal as opposed to Pan troglodyte which are a male dominated society.

42 Genus Pan Capable of: Altruism Kindness Empathy Romantic love Patience Sensitivity

43 Pan and Human We are half chimp and half bonobo

44 Healthcare Primate Study Thanks to William Bornstein MD, PhD John Fox Fred Sanfilippo MD

45 The Collaborators Joel Zivot MD Frans De Waal PhD Laura Jones PhD

46 Is fighting all bad? Is there a better way to fight?

47 Hockey Violence Rule 46, NHL rule book Fighting must follow certain rules namely Drop gloves and fight bare knuckled. Remove the face shield. Do not use the hockey stick. Do not remove hockey jersey. Non-fighters must go to their bench or defensive zone. Fighting must stop when ordered by official. Fight only during the game. Fight on the ice.

48 Take home message Hockey Violence Strong desire to continue to play. Fighting will not result in grievous bodily harm. Handshake at the end of each game.

49 Hockey Violence The handshake is the physical reconciliation mechanism required to restore civilization and wash away the residue of the conflict. It allows Hockey to be understood as a game, nothing more.

50 Hockey Violence

51 The problem: Role ambiguity Conflicting interests Production pressure Ego Fatigue Fear Oh ya, the sick patient The Operating Room

52 Rules of the game The Operating Room The play can not stop The community is embedded The players have a past and a future

53 The Operating Room A way forward: Allow some argument Mandate reconciliation and it must be soon after the argument. Reconciliation must involve touching (a handshake should suffice). Reconciliation should be seen by others.

54 2 phases Phase 1 Document the problem Understand the problem Phase 2 Create reconciliation mechanism Test the mechanism

55 Before

56 After

57 Balance? Happy at work, unhappy at home Happy at home, unhappy at work Life is all of it

58 Normal work We enter the profession because we want to reduce human suffering We draw satisfaction from the work itself What does it feel like to be thanked?

60 Bring your mind home Mindfulness

61 Take a moment to think about a time when you felt truly appreciated for who you are or for something that you had done You can think of an experience that was meaningful to you

62 You can think about something that someone might do that will make you feel appreciated It can be something very simple

63 Think about the simple or complex things that happen at work that make you feel good at work Perhaps a patient interaction, working in a team, working with a colleague or just feeling supported

64 The simple moments are when we experience the profound Our search for meaning is the search for connection and understanding

65 It is hard in the big machine to find that So many working parts makes it feel isolating and separating Yet we all have good moments that matter and make the difference

66 How can we have more of those?

67 Resilience Resilience is the term we use to recover and bounce back We wonder if resilience is genetic or learned but we know what contributes to resilience

68 Resilience Things like connection, understanding, community, support, hope, encouragement How can we facilitate these things in a large group with many small parts?

69 Nurture the cultural soul Replenishment

70 Nurture the cultural soul Replenishment Facilitate individual connections

71 Nurture the cultural soul Replenishment Facilitate individual connections Nurture the senses

72 Nurture the cultural soul Replenishment Facilitate individual connections Nurture the senses Facilitate personal cognitive growth

73 Burnout is when we are stuck How do we use the life we already have to make us wiser rather than more stuck?

74 The work will always be challenging. That won t change. The occasion of suffering and conflict are inevitable.

75 Think of these challenges as the tools carved by our experiences that direct us where we need to go. Strive to move from burnout to engagement.

76 The last of human freedoms-the ability to choose one s attitude in a given set of circumstances. Viktor E. Frankl, Man s Search for Meaning.

6/29/2018. Chris Searles, MD. I have no financial conflicts of interest to disclose*

6/29/2018. Chris Searles, MD. I have no financial conflicts of interest to disclose* Chris Searles, MD I have no financial conflicts of interest to disclose* 1 Engrossed late and soon in professional cares you may so lay waste that you may find, too late, with hearts given way, that there