The Art of Well-Being

Transcription

1 The Art of Well-Being Physician Wellness Jacques G. LeBlanc MD.,F.R.C.S.C. January 2018

2 What is Wellness?

3 Ayurveda Balancing the Rhythm of Life

4 International Population Health Australia USA India Overweight 62% 69% 72% Diabetes 14% 14% 21% Cardiac Problems 18% 16% 57% Smoking 23% 28% 24% Alcohol 13% 14% 12% WHO stats 2012

5 CALLING Doing something you are good at and like Making life better for people Feeling appreciated and of worth Patient Care is the most Rewarding aspect of our profession.

6 Medicine, A Sense of Calling? Practice of Medicine has long been seen as a calling. A calling is defined as work that is rewarding, that has personal meaning and serve a social purpose, not just getting a pay check Sense of calling is associated with a greater sense of engagement, but a greater sense of responsibility and therefore potential for burnout.

7 Physician Health The Whole Person Physical Mental Emotional Spiritual Professional Life style Environmental Declaration of Alma-Ata: International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September, 1978 The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal

8 The Scope of the Problem

9 Differences between Stress and Burnout Stress is the stimulus Burnout is the behavior

10 Physicians Work Life Issues Burnout Sleep Deprivation Depression Substance abuse: alcohol, cigarettes, food Drug abuse: narcotics, analgesics,

11 What is burnout? Emotional exhaustion: Emotionally overextended, losing enthusiasm. Depersonalization: Negative attitudes. Reduced sense of accomplishment: Work is no longer meaningful. Neglecting needs: Put on back burner. Interpersonal conflict: Less tolerant, anger, not attentive. Psychiatric symptoms: Addictive behaviors, depression, suicide.

12 The majority of people in this room have experienced burnout.

13 Burnout affects physicians at all levels of training Medical School % Residency - 27%-75% depending on specialty Attending Physicians at various stages of career - average 37.9% Burnout During Residency Training: A Literature Review. Waguih William, MD et al 2008 Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population. Tate D. Shanafelt et al. 2012

14 Burnout among Physicians Burnout 45.8% 54.4% Emotional Exhaustion 37.9% 46.9% Depersonalization 29.4% 34.6% Dissatisfied with work-life balance 36.9% 44.5% Shanafelt et al., Arch Int Med ,000 US Physicians survey

15 Why is burnout increasing? Fundamental changes in healthcare Increased volume/demand on providers Rise of EHRs made to improve billing Increased documentation time Altered patient interaction Rising negative views of doctors Duty hours Same amount of work in less time

16 Time demands Increasing bureaucratic tasks Lack of control over schedule Lack of autonomy Workload/intensity Financial strain Unmet personal needs Feeling overwhelmed at work Lack of a voice in important matters Lack of control over practice environment Factors Leading to Burnout

17 Selected Factors related to Burnout Time and bureaucratic pressure Sleep deprivation Addictions Substances abuse Suicide

18 Sleep Deprivation Patients have a right to expect a healthy, alert, responsible, and responsive physician. January 1994 statement by American College of Surgeons Re-approved and re-issued June 2002

19 Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep* Work Hrs/wk Percent Work Hrs/wk % Reporting Serious Medical Errors % Reporting Serious Staff Conflicts 0 < 4 hrs 5-6 hrs > 7 hrs Hours of Sleep 0 *Baldwin and Daugherty, Survey of 3604 PGY1,2 Residents American Academy of Sleep Medicine

20 Myth: If I can just get through the night (on call), I m fine in the morning. Fact: A decline in performance starts after about hours of continued wakefulness. Fact: The period of lowest alertness after being up all night is between 6am and 11am (eg, morning rounds). American Academy of Sleep Medicine

21 Recovery from Sleep Loss Myth: All I need is my usual 5 to 6 hours the night after call and I m fine. Fact: Recovery from on-call sleep loss generally takes 2 nights of extended sleep to restore baseline alertness. Fact: Recovery sleep generally has a higher percentage of deep sleep, which is needed to counteract the effects of sleep loss. American Academy of Sleep Medicine

22 Why Burnout Matters Professional Consequences Increased medical errors/worse patient outcomes Decreased patient satisfaction/less empathy Decreased job satisfaction Difficulty relaxing and having fun Impatience and irritability Decrease professionalism, disruptive behaviors Decreased productivity Absenteism Depression/suicide

23 Why Burnout Matters Personal Consequences Physician satisfaction and safety Disruption to family/divorce 10% higher than pop. Higher rates of Divorce Depression Anxiety Substance abuse Suicide

24 Physician Suicide

25 Clinical Case A 41 yr. old male MD had a long history of self prescribing sedatives to treat anxiety and insomnia. His drug use gradually escalated to the point it was interfering with his work and home life. He tried repeatedly to control his use on his own, but without success. He began seeing a psychiatrist who felt he had a mood disorder, and did not directly address the substance abuse. He began to feel his life was intolerable and discussed suicide with his wife, although he did not disclose a plan. He subsequently died in a hunting accident of a self-inflicted gunshot wound to the head.

26 Physician Suicide Suicide is hard to predict Negating early signs Worsening signs of depression Crippling effects of stigma of mental illness Ill physicians refusing help and treatment Ill physicians afraid of loosing colleagues respect and their job 400 Doctors commit suicide each year (US stats) The equivalent of one medical school is lost each year to suicide Suicide is the 2 nd most common cause of death in medical students More attempts and higher success than average population Male physicians 40% higher Female physicians 130% higher

27 Some 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.

28 Addictions/Substance Abuse 10-15% of health care professionals will misuse substances at one point in their career Alcohol most commonly abused Opioids and stimulants next most common Recreational drugs (marijuana, cocaine) use is less than general population

29 Prevalence US gen pop Doctors Substance Use Disorder 6.2% 6-8% Alcohol Use Disorder 13.5% 14% >800,000 US physicians (75% male) 64,000 will develop SUD 112,000 will experience an Alcohol use disorder Prescription drug use (BDZs, opioids) is higher in doctors than in general population Baldisseri. Impaired health care professional. Crit Care Med 2007 Vol. 35, No. 2 (Suppl.)

30 Substance Use by Physicians Physicians less likely to use cigarettes and illicit substances than the general public Physicians more likely to use alcohol Physicians much more likely to use minor opiates and benzodiazepines Overall, 8% of physicians reported ever having a substance abuse or dependence problem (Hughes, et al. JAMA 1992;267:2333)

31 Physician Use of Opiates and Sedatives Depending on age and gender, 6-23% of physicians had used nonprescribed opiates or sedatives in the past year These substances were used by 1-4% of the general population Most use of these substances by physicians was for self-treatment of symptoms

32 Prognosis Success rates: Doctors have high abstinence rates (74-90%), like airline pilot Mandatory Treatment Frequent Urine Checking Peer Assistance Programs Education & Prevention

33 WHY THE DELAY IN DETECTION? Independence Malignant denial I can take care of myself Knowledge is protective Fear of consequences Conspiracy of silence

34 Denial I noticed if I was stressed, in an emergency situation, or time restricted, I would go into my autopilot mode with my questions. I was less patient and less likely to listen to the patient but just get the information quickly. I flip back into my natural communication of finishing people s sentences and talking over them as opposed to listen.

35 Conclusions Burnout is pervasive and increasing. Burnout results in poor outcomes for patients, doctors, and hospitals. Most of your residents are struggling. Individual approaches (stress management, wellness) are part of the solution. Systemic changes are needed to cope with changing healthcare landscape. Faculty play key roles in recognizing burnout, talking to residents, and knowing resources for treatment.

36 Promote Physician Health Decrease work load Reduce pressure/increase control Establish protected time Establish priorities Resiliency training Improve life style

37 Stimulus and Response Between stimulus and response, there is a space. In that space, is our power to choose our response. In our response lies our growth and our freedom.

38 Recommendations The toolkit for these issues will contain many different tools. There is no one solution but many approaches offer benefit!

39 Medicine Bag for Self Care Building up resilience Self care Organizational role Mindfulness Emotional Intelligence Life style Spirituality

40 Treatment: no pills SELF CARE Professional: balance, priorities, workload Psychological: reflection, mindfulness, relaxation Physical: exercise, sleep, nutrition Social: life balance, family, friends, community engagement

41 First Give to Yourself Sending positive thoughts to oneself May I be happy May I be healthy May I be safe and secure May I live with joy and ease

42 How to Replenish the Tank

43 Resilience Recognizing difficulty, problems, and take appropriate steps Recognizing tiredness, fatigue, sleep deprivation and address it Understanding surroundings, not get angry and react from awareness

44 Definitions Personal Resilience The strength, innate or developed, that enables one to adapt well to extreme stress, including the capacities to: Ability to maintain stability despite adversity Rebound from the deleterious effects of even overwhelming stress It is a process that can be taught or learned Clear boundaries are limiting electronic access, saying no, scheduling time for personnal time/activities

45 4 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

46 TREATMENT OF BURNOUT: PROMOTION OF WELLNESS Individual promotion. Relationships: ensure protected time for significant other and family members; collegial connections. Spiritual practice: personal attentiveness and spiritual aspects of self. Work attitudes: finding meaning in work; limiting work practice control over schedule. Self-care: cultivating personal interests and self-awareness; professional help when needed. Life philosophy: positive outlook, identifying and acting on values, stressing work/home balance.

47 Mindfulness Definition the awareness that emerges through paying attention, on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment Jon Kabat-Zinn, 2003

48 Mindfulness Mindfulness is a skill that gets better with practice.

49 Building Emotional Intelligence Training to practice reflection IN ACTION Alongside practicing reflection ON ACTION Training to be aware how to communicate while communicating.

50 Awe/Astonish Awe is not a luxury We can actively seek out awe We can find awe in the small things Positive emotions have benefits

51 Achieving Success and Wellness Give it time. Give it importance. Give it practice.

52 Wellness Strategies The Organization's Role Be Value Oriented: mission values meet medical profession Promote Physician autonomy Promote adequate Support Services and resources Promote autonomy, flexibility and sense of control Cultivate a collegial and peer support work environment Promote meaning in work Minimize Work-Home Interference: flexibility in child care for women Promote Work-life balance: mentoring, ensuring vacation time Flexible and readily accessible child care Flexibility in scheduling and ready coverage for life events (births, funerals, family emergencies)

53 Thank You for your Attention