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Stephen Del Giudice, MD
2019 NH Healthcare Quality and Safety Conference
May 8, 2019
BURNOUT IN HEALTHCARE:
WHY NOW? WHAT’S NEXT?
• Give an overview of burnout in healthcare and how it influences patient safety and satisfaction.
• Discuss some interventions organizations and individuals can use to prevent burnout.
• Define mindfulness and explain how it works to help prevent burnout.
WHAT I’M GOING TO TALK ABOUT TODAY
A Crisis in Health Care: A Call to Action on Physician Burnout
Partnership with the Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute, Ashish K. Jha, MD, MPH Andrew R. Iliff, MA, JD, January 2019
IF YOU READ ONE ARTICLE AFTER THIS TALK, THIS
IS IT
Physician burnout is a public health crisis that urgently
demands action by health care institutions, governing
bodies, and regulatory authorities. If left unaddressed, the
worsening crisis threatens to undermine the very provision
of care, as well as eroding the mental health of physicians
across the country.
CONCLUSION:
Source: Partnership with the Massachusetts Medical Society, Massachusetts Health and Hospital Association,
Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute, Ashish K. Jha, MD, MPH Andrew
R. Iliff, MA, JD, January 2019
• Among physicians, burnout has reached about 50%
• Prevalence of burnout among nurses is estimated to be around one third
• A Medical Group Management Association poll last year revealed burnout among healthcare leaders at 45%
BURNOUT IN HEALTHCARE: HOW BAD IS IT?
SO WHAT IS BURNOUT?
• Loss of enthusiasm at work (emotional
exhaustion)
• Treating people as if they were objects
(depersonalization)
• Having a sense that work is no longer meaningful
(what you do doesn’t really matter)
Some sobering fatigue and burnout statistics regarding nurses*
• 98 percent of hospital nurses said their work is physically and mentally
demanding
• 85 percent noted that their nursing jobs make them fatigued overall
• 63 percent reported that their work has caused nurse burnout
• 44 percent worry their patient care will suffer because they are so tired
• 41 percent have considered changing hospitals during the past year due
to burnout
WHAT NURSES ARE SAYING…
*Source: May 2017 survey by Kronos Incorporated; survey of 257 RNs working in U.S. hospitals
• Too many bureaucratic tasks (e.g. charting, paperwork)
• Spending too many hours at work
• Lack of respect from administrators/employees,
colleagues or staff
• Increasing computerization of practice (EHR)
Source: Medscape National Physician Burnout & Depression Report 2018
WHAT DOCTORS ARE SAYING…
• Conflict with the organization’s mission, vision and values.
• Limited resources and training to perform and complete work
• Lack of appropriate compensation for work.
• Broken promises by the employer.
• Lack of appreciation and recognition.
• The more you have control over what you do and how you do it,
the easier it is to mitigate against burnout.
WHAT HEALTHCARE LEADERS ARE SAYING…
Source: MGMA poll conducted on June 26, 2018, with 1,746 total responses.
Kenneth T. Hertz, FACMPE, principal, MGMA Consulting
• More negative with co-workers, especially when introduced to change
• More callous towards patients; less interested in getting to know them
• Less talkative and cheerful during team meetings or huddles• A lower threshold to become irritable with patients and staff• Making fun of your organization’s leaders and their
commitments to excellence• More self-justification to leave early, show up late, and call in
sick
SOME OF THE WARNING SIGNS OF BURNOUT
THE ELECTRONIC HEALTH RECORD IS OFTEN CITED
AS A CONTRIBUTOR TO BURNOUT IN HEALTHCARE
THE EHR
• Higher turnover rates
• Higher error rates
• Higher absenteeism rates
• Lower morale
• Lower patient satisfaction scores
• Reduction in workforce
WHAT BURNOUT DOES IN THE WORKPLACE
In this large national study, physician burnout, fatigue, and work unit
safety grades were independently associated with major medical
errors. Interventions to reduce rates of medical errors must address
both physician well-being and work unit safety.
REDUCING BURNOUT PROMOTES PATIENT SAFETY
Source: Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors.
Mayo Clinic Proceedings Nov. 2018 Tait Shanafelt, MD et al.
Overall physician burnout doubled the odds of involvement in
patient safety incidents. All three dimensions of physician
burnout—emotional exhaustion, depersonalization, and reduced
personal accomplishment—were linked to involvement in patient
safety incidents.
Source: Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction-A
Systematic Review and Meta-analysis, Maria Panagioti, JAMA Intern Med. 2018;178(10):1317-1331
This meta-analysis provides evidence that physician burnout may jeopardize patient care; reversal of this risk has to be viewed as a fundamental healthcare policy goal across the globe.
Source: Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction-A Systematic Review and Meta-analysis,
Maria Panagioti, JAMA Intern Med. 2018;178(10):1317-1331
BURNOUT AND PATIENT SAFETY
The results of this systematic literature review suggest that there is moderate evidence that burnout is associated with safety-related quality of care.
Source: The Relationship Between Physician Burnout and Quality of Healthcare in Terms of Safety and Acceptability: A Systematic Review,
British Medical Journal 2017:7(6) Carolyn S Dewa
BURNOUT AND PATIENT SAFETY
Overall physician burnout doubled the odds for low patient satisfaction. Depersonalization was linked to a 4.5-fold increased risk. The researchers also found that physicians early in their career have a higher propensity for unprofessionalism.
Source: Association Between Physician Burnout and Patient Safety, Professionalism,
and Patient Satisfaction: A Systematic Review and Meta-analysis, Maria Panagioti,
JAMA Intern Med. 2018;178(10):1317-1331
BURNOUT AND PATIENT SATISFACTION
• Impaired attention and memory• Less attention to detail• Diminished vigilance and cognitive
function• Less effective care team communication• Increased safety lapses• Increased agitation and aggressive
attitudes towards their patients, their work, or their colleagues
CYNICALLY DETACHED:DEPRESSED AND
DANGEROUS
Understanding the business case to reduce burnout and promote
engagement as well as overcoming the misperception that nothing
meaningful can be done are key steps for organizations to begin to take
action. Evidence suggests that improvement is possible, investment is
justified, and return on investment measurable.
Addressing this issue is not only the organization’s ethical responsibility, it is
also the fiscally responsible one.
Source: The Business Case for Investing in Physician Well-being,
Tait Shanafelt, MD; Joel Goh, PhD; Christine Sinsky, MD JAMA Internal Medicine Published online September 25, 2017
Source: Connecting Organizational Culture and Quality of Care in the Hospital: Is Job Burnout the Missing Link?
Montgomery, Anthony & Panagopoulou, Efharis & Kehoe, Ian & Efthymios, Valkanos. (2011). Journal of Health Organization
and Management. 25. 108-23.
• What structural or operational changes will lower stress
at work and prevent burnout?
• What personal changes can make you more resilient at
work?
WHAT CAN YOU DO?
• What can my
organization do to
help me?
• What can I do to
help myself?
NOW WHAT?
• Are individuals who
choose to work in
healthcare more
vulnerable to stress
and burnout, or has the
healthcare system
evolved into a burnout
factory?
QUESTION:
• Excessive workload
• Work inefficiency
• Work-home balance
• Loss of control
• Loss of meaning from work
PRIMARY DRIVERS FOR BURNOUT IN HEALTHCARE
ORGANIZATIONAL: reasonable limits to hours worked,
fair productivity goals, appropriate job role assignments
INDIVIDUAL: consider part-time status, make hard
decisions that balance income and productivity goals with
workplace satisfaction
EXCESSIVE WORKLOAD
ORGANIZATIONAL: optimize electronic medical records,
shift clerical work to non-clinical staff, provide cheerful
assistance to meet regulatory requirements
INDIVIDUAL: prioritize and delegate tasks appropriately,
be open to process improvement recommendations
WORK INEFFICIENCY
ORGANIZATIONAL: support flexible work schedules,
acknowledge when required work tasks cannot be performed
during assigned work hours, reduce clinicians time on the
EHR outside of assigned work hours
INDIVIDUAL: keep your eyes on your North Star: remind
yourself regularly of life priorities and maintain self-care
WORK-HOME BALANCE
ORGANIZATIONAL: promote physician and staff
leadership and shared decision-making, establish work
requirements with employee engagement
INDIVIDUAL: attend resiliency training program and
practice mindfulness
LOSS OF CONTROL
ORGANIZATIONAL: promote core values (walk the talk), offer
peer support, maximize patient time with clinicians, foster
employee communities (commensality), provide professional
development opportunities
INDIVIDUAL: embrace positive attitudes (reframing,
appreciative inquiry), share work experiences with colleagues
(narrative medicine), practice mindfulness
LOSS OF MEANING FROM WORK
SO WHAT IS MINDFULNESS ANYWAY?
“Mindfulness means paying attention in a
particular way, on purpose, in the present
moment, and non-judgmentally.”
(Jon Kabat-Zinn)
• The roots of mindfulness are found in two ancient religions:
• Hinduism, which arose in what is now Pakistan, over 4,000 years ago
• Buddhism, founded around 450 B.C.E. in northern India by Siddhartha Gautama (later referred to as the Buddha)
• After World War II, East and West met:
• The study of comparative religions
• The travel of mediation teachers to the US
• Intellectual leaders in the West study mindfulness
THE HISTORY OF MINDFULNESS IN AMERICA
• Jon Kabat-Zinn started the Mindfulness-Based Stress Reduction (MBSR) program in 1979-U Mass. Medical Center.
• Inspired by MBSR success, Mindfulness-Based Cognitive Therapy (MBCT) developed in the 1990's to treat depression.
• Recently Judson Brewer and others have studied the neuroscience of mindfulness.
• Thousands of years ago, practitioners of mindfulness somehow recognized its transforming power to quiet the mind--now modern science has confirmed their understanding.
OUR HISTORY LESSON (CONTINUED)
• What we call meditation has transformed into a safe, easy, inexpensive way to help treat many of the diseases related to stress (anxiety, depression, insomnia, addiction, chronic pain, hypertension) and other medical conditions.
• Our interest today is how it can help people who work in healthcare manage the expected stress and mental strain of doing this hard work.
MINDFULNESS AS HEALTHCARE
Our study suggests that
mindfulness training produces
an improvement in three
capacities that are key for
successful leadership in the
21st century: resilience, the
capacity for collaboration, and
the ability to lead in complex
conditions.
MINDFULNESS AND LEADERSHIP
Source: How to Bring Mindfulness to Your Company’s Leadership
Megan Reitz, Michael Chaskalson, Harvard Business Review. December 1, 2016
• The leaders in our study became less reactive and more
responsive, which in turn affected many other skills, such
as regulating their emotions, empathizing with others,
focusing more readily on issues at hand, adapting to the
situations they found themselves in, and taking broader
perspectives into account.
• One leader summed up what this meant: “I now have
moments of choice that I didn’t have before.”
MAINTAINING MENTAL EQUILIBRIUM
Source: How to Bring Mindfulness to Your Company’s Leadership
Megan Reitz, Michael Chaskalson, Harvard Business Review. December 1, 2016
Mindfulness weakens
automatically activated
associations
REMEMBER TO LISTEN WHEN YOU LISTEN
Source: Mindfulness Meditation Reduces Implicit Age and Race Bias:
The Role of Reduced Automaticity of Responding
Adam Lueke, Bryan Gibson First Published November 24, 2014 Social
Psychological and Personality Science
The McMindfulness Craze: The Shadow Side of the
Mindfulness Revolution. Jeffrey B. Rubin, Truthout. January
4, 2015
McMindfulness- The Marketing of Well-Being. June13, 2014.
Straight Talk Jeremy D. Safran Ph.D.
• So what is McMindfulness? It’s the
marketing of mindfulness practice as a
commodity that is sold like any other
commodity in our brand culture.
THE RISE OF MCMINDFULNESS
• We know what mindfulness is (sort of).
• We know it can be used to ease mental stress as well as to prevent and treat burnout.
• We know practicing mindfulness improves listening skills and cultivates a responding rather than a reacting mind.
• But how does it work?
LET’S PAUSE HERE
Default Mode Network (DMN)
• Rumination
• Day dreaming
• Mind wandering
Task Positive Network (TPN)
• Attention focused
• Engaged
• Awareness
EVOLUTIONARY BIOLOGY OF THE BRAIN
Default Mode Network
• When our minds have no compelling physical or mental anchor (in the present) we easily slip into this mode.
• We “default” from reality into daydreaming.
• Our thoughts are free floating and unstructured. The roaming mind. Also called the monkey mind. The “movie mind.”
Task Positive Network
• When we concentrate or bring our attention to a physical motion or sensation, or to a specific mental task, we engage TPN, and naturally pull out of the DMN.
• Mutually exclusive operations
• You will always be in one or the other—you cannot be in both modes simultaneously
Default Mode Network….
Task Positive Network….
• The DMN consists of four parts of the brain: amygdala, hippocampus, posterior cingulate cortex (PCC), and medial prefrontal cortex (mPFC)
• The TPN consists of another four neurological structures: insula, somatosensory cortex, anterior cingulate cortex (ACC), and dorsolateral prefrontal cortex (dlPFC)
THE NEUROANATOMY OF CONSCIOUSNESS
• Functional magnetic resonance imaging (fMRI), (records pictures and brain activity) show brain changes occurring when a person is meditating.
• Changes in brain activity, in subjects who have learned to meditate, hold steady even when they’re not meditating.
• During meditation:
• The amygdala is less activated. (Responsible for the response to and memory of emotions, especially fear.)
• The dorsolateral prefrontal cortex is more activated. (Controls executive function and self-regulations skills: working memory, mental flexibility, and self-control including resisting impulsive actions or responses. )
WATCHING THE BRAIN DURING MEDITATION
FUNCTIONAL MRI DURING MEDITATION
• We live in a DMN dominated state of mind when not engaged in
captivating activities
• This can lead to anxiety, depression, and an exaggerated self-referential
view of reality
• The practice of mindfulness and other forms of meditation help to
recalibrate the natural push-and-pull between the DMN and TPN.
• How? Simply by coming back to TPN during activities that frequently
seduce us into DMN.
• Engaging our TPN causes the DMN, and its attendant regrets of the past
(depression) and fear of the future (anxiety) to vanish in an instant.
MINDFULNESS AND THE DMN-TPN BALANCE
• The default mode network, an evolutionary tool that
helped us plan and learn from experience, has reached
unhealthy dominance in a brain with increased mental
capacities
• Neither the DMN or TPN is good or bad; it’s the balance
that counts. Mindfulness keeps the DMN in check and
prevents the overkill of worry and self-blame
MINDFULNESS: REBALANCING THE DMN AND TPN
(“HACKING INTO THE DMN”)
MINDFULNESS HELPS US RESTORE MENTAL
BALANCE
• Today, excessive and compulsive attention to thoughts that arise during the DMN can lead to mental distress: anxiety and depression.
• Mindfulness helps restore the balance between the DMN and the TPN —to keep us sane.
• Training programs
• Books and audio programs
• Apps
GETTING STARTED
• Headspace• 10% Happier • Smiling Mind • Calm • imindfulness • Buddify 2 • Complete Mindfulness • Mindfulness Daily • Simply Being• Stop, Breath, and Think
• Best Way to Start: Today
POPULAR MINDFULNESS APPS
I’ve lived through some terrible things in my life,
some of which actually happened.
WHAT I LEARNED FROM MEDITATION
Mark Twain
Safe and effective patient care
starts with caring for the caregiver.
www.northernskyhealthcareconsultants.com
Stephen Del Giudice, MD
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