Practical Tools for Building Clinician Resilience and Reducing Burnout Michelle Dossett, MD, PhD, MPH mdossett@mgh.harvard.edu Darshan Mehta, MD, MPH October 24, 2017
Disclosures We have no relevant financial conflicts of interest MD is funded by K23 AT009218 (NCCIH/NIH)
Outline Burnout and its consequences Resiliency and strategies to promote it Science of mind-body medicine The BHI SMART Program Skills practice Summary and Q&A
What is Burnout? Low Personal Accomplishment the tendency to evaluate oneself negatively. may feel unhappy and dissatisfied with their accomplishments on the job. Emotional Exhaustion emotional resources are depleted, workers feel they are no longer able to give of themselves at a psychological level. Depersonalization negative, cynical attitudes and feelings about one s clients. callous or even dehumanized perception of others. Maslach Burnout Inventory Manual, 1996
Burnout is Epidemic Among Healthcare Professionals ~50% of medical students & internal medicine residents ~54% of attending physicians 37-86% of nurses 21-67% of mental health clinicians higher rates among community social workers than nurses or psychiatrists Dyrbye, Ann Intern Med. 2008 West, JAMA 2011 Shanafelt, Mayo Clin Proc. 2015 Mealer, Depress Anxiety. 2009 Cimiotti, Am J Infect Control. 2012 Dyrbye, NAM Perspectives. 2017 Morse, Adm Policy Ment Health. 2012
Burnout is Associated with anxiety, depression, and suicidal ideation substance use decreased job satisfaction absenteeism, reduction in work hours, and job turnover decreased empathy decreased quality and safety of patient care decreased patient satisfaction Maslach 2001; Shanafelt 2002; Vahey 2004; McCray 2008; Dyrbye 2008; Poghosyan 2010; West 2011; Cimiotti2012; Morse 2012; Green 2014; Shanafelt 2016; Salyers 2017.
Resilience an Antidote A multidimensional construct that refers to the ability to adapt and maintain effective functioning under significant adversity or challenging life conditions. A framework for understanding the adjustment to stress as a dynamic process. Park ER, Psychosomatics, 2013.
Self-Regulation & Resilience It is not enough to recognize that stresses exist, that they are unavoidable, and that they can result in cognitive errors, strong feelings, and moral distress. Clinicians also need to realize the degree to which they have choices about how to address those stresses and self-regulate their own cognitive, emotional, and somatic reactions. Epstein & Krasner, Acad Med. 2013
What Works on the Individual Level? Mind-body approaches Cognitive behavioral techniques Stress-management training Narrative medicine Balint groups Community building Connecting with meaning & purpose in work Shanafelt TD, JAMA, 2017 West CP, Lancet, 2016 Panagiotti M, JAMA Intern Med, 2016 Lee HF, Appl Nurs Res, 2016 Zwack J, Acad Med. 2013
How Do Mind-Body Practices Work? Dusek, Minn Med. 2009
Meditation Changes Brain Structure Regions of the brain affected involve concentration & executive function emotion regulation neurotransmitter release Holzel BK, Psychiatry Res. 2011
Cognitive Changes Associated with Meditation attention working memory functional connectivity within the brain reactivity to negative emotional stimuli metacognitive awareness Chiesa A, Clin Pyschol Rev. 2011; Keng S, Clin Psychol Rev. 2011; Kilpatrick L, Neuroimage, 2011.
Meditation Slows Brain Aging At age 50, the brains of experienced meditators were estimated to be 7.5 years younger than matched controls. For every year over 50, meditators brains were estimated to be an additional 52 days younger. Luders E, Neuroimage. 2016.
Increased Telomerase Activity Reduces Cellular Aging Overall effect size (d) = 0.46; (p = 0.001, 95% CI 0.18, 0.78) Schutte NS, Psychoneuroendocrinology, 2014
Changes in Gene Expression > 1500 differentially regulated genes Decreases in inflammatory pathways Improved insulin utilization Increased ATP synthase/mitochondrial energy production Dusek, PLoS ONE, 2008; Bhasin, PLoS ONE, 2013
Mind-Body Skills Programs Reduce Regehr C, J Nerv Ment Dis. 2014
What is Mindfulness? Paying attention in a particular way: on purpose, in the present moment, and non-judgmentally Kabat-Zinn J. Wherever you go, there you are: Mindfulness meditation in everyday life, 1994
Characteristics of Mindful Practice Active observation of oneself, the patient, and the problem Critical curiosity Courage to see the world as it is rather than as one would have it be Willingness to examine and set aside categories and prejudices Adoption of a beginner s mind Humility to tolerate awareness of one s areas of incompetence Compassion based on insight Presence Epstein RM, JAMA, 1999.
Benefits of Mindful Practice Increased clinician mindfulness is associated with care that is more patient-centered increased patient satisfaction improved outcomes in individuals receiving psychotherapy Beach MC, Ann Fam Med, 2013 Dobkin PL, J Contin Educ Health Prof, 2016 Grepmair L, Psychother Psychosom, 2007
Meditation Traditions in all of the world s cultures Conscious focusing of one s awareness on the breath, a word or phrase, a sound, an image, or sensations Conscious disregard of every day thoughts
Guided Practice
What Did You Notice? Nothing Sleepy Relaxing Anxious Pleasant Restless Thinking about something on your to do list
Tips for Developing a Meditation Practice Find the time(s) of day that work best for your schedule Find a location that works well for you Find a compelling focus to anchor your awareness Start with 5 minutes twice a day and build from there Don t worry about doing it incorrectly or about your mind wandering Find a teacher or group to help support your practice
Hasten Slowly
Minis aka Mini Relaxations A simple way to counter stress throughout the day Use as needed or prophylactically every hour Most effective when used in tandem with a daily meditation practice Can be as simple as 1-2 breaths, a yoga stretch, or as long as 5-10 minutes Couple with a repeated behavior or a visual cue (post-it, screen saver reminder, hand sanitizing)
Mini Even Count or Measured Breathing Inhale slowly through the nose to a count of 4 Hold the breath for a count of 4 Exhale slowly through the nose to a count of 4 Repeat twice more * The number of counts may be increased or decreased, but do not hold the breath to the point of discomfort. Avoid prolonged breath holding if uncontrolled high blood pressure or a serious heart condition.
The Benson-Henry Institute s Stress Management Resiliency Training (SMART) Program adapted from Park ER, Psychosomatics, 2013.
BHI SMART Program Overview adapted from Park ER, Psychosomatics, 2013.
BHI SMART Program Overview adapted from Park ER, Psychosomatics, 2013.
Awareness is the First Step
How Does Stress Affect You? Energy Battery
BHI SMART Program Overview adapted from Park ER, Psychosomatics, 2013.
Adaptive Strategies Social support Healthy Lifestyle Behaviors Sleep Nutrition Physical activity Reappraising and coping Positive perspectives appreciation, humor, acceptance, empathy
Patient experienced an adverse event frown, muscle tension, heart pounding sadness, anxiety, guilt I m a failure. How could I have let this happen? Perfectionism Personalization Acceptance Awareness As a team we did the best we could. How can we learn from this? muscles of face & body relax, heart rate normalizes
The greatest discovery of my generation is that human beings, by changing the inner attitudes of their minds, can change the outer aspects of their lives.it is too bad that more people will not accept this tremendous discovery and begin living with it. William James, 1842-1910
Appreciation We often focus on what is bad or wrong. Purposefully bringing attention to what we appreciate opens the door for more adaptive perspectives. Write down several things per day that you appreciate Write in as much detail as possible Notice the content (self, others, life) Relive each appreciation until you feel the emotion
Metta Meditation: Loving Kindness Meditation Conscious direction of unconditional love, kindness, and compassion to ourselves and other living beings Metta means both gentle and friend Can be used to address negative emotions and feelings such as anger, fear, and loneliness Salzberg S, Loving-Kindness: The Revolutionary Art of Happiness, 2005.
Loving Kindness Meditation Research Increases feelings of social connection and positivity toward novel individuals in practitioners Increases positive emotions and enhances personal resources in veterans with PTSD Decreases self-criticism and depression while increasing selfcompassion Hutcherson, Emotion, 2008 Kearney DJ, Med Care, 2014 Shahar B, Clin Psychol Psychother. 2015
Loving Kindness Meditation Phrases May I be free from danger May I have mental happiness May I have physical happiness May I have ease of well-being
Loving Kindness Meditation Phrases May I be safe May I be happy May I be healthy May I be at peace
Loving Kindness Meditation Sample Format Kindness and compassion directed toward oneself a benefactor or beloved friend a neutral person a difficult person to all sentient beings
Mini - Well Wishing Exercise Mentally repeat the following phrases as you walk into a patient s room or in any challenging situation with a patient, family, or colleague: May you be safe May you be free from suffering May you be happy and at peace
Summary
Place Your Own Oxygen Mask First Self-care and resiliency building is not selfish it is essential for our own well-being and allows us to better care for others. The time investment more than pays for itself.
Integrating Mind-Body Skills Into Daily Life Formal Practice Meditation, body scan, mindful yoga, tai chi, etc Informal Practice Bringing an open, curious attention to any activity Throughout the day, pause briefly to tune in Minis, stretching, appreciation, humor
How to Increase Resilience to Stress Many tools: mind-body, lifestyle, cognitive Involves increasing awareness and choice It is a dynamic process and learned skill
October 25-27, 2018 Annual Mind Body Medicine The Martin Center at Harvard Medical School Register for Online CMEs through the MGH Psychiatry Academy Stress and the Relaxation Response: The Fundamentals of Mind Body Medicine Using Mind Body Techniques in Your Health Care Practice Building Resiliency through Cognitive Reappraisal and Lifestyle Modification Conference 2017 Keynote Speakers Mind Body Medicine Pioneers Jon Kabat-Zinn, PhD & Herbert Benson, MD BHI SMART Certification for Healthcare Practitioners Earn certification to deliver our 8-week Stress Management and Resiliency Training (SMART) program to your patients. We provide training, mentorship and an off-the-shelf, copyrighted curriculum you can use to help your patients buffer stress and decrease anxiety. MD Amy Cuddy, PhD Robert Waldinger, The Power Pose The Science of Happiness