Physician-based approaches to burnout: How little we know

Dr. Jillian Horton, BA MA MD FRCPC (Internal Medicine)

Associate Chair, Professionalism and Diversity, Department of Internal medicine

Director, Allan Klass Health Humanities Program and Learner Wellness

Assistant Director, Manitoba Practice Assessment Program

Max Rady College of Medicine, Rady Faculty of Health Sciences

www.dreamstime.com

No conflicts to declare.

Burnout is:

“Emotional exhaustion, depersonalization, and diminished sense of personal accomplishment, primarily driven by workplace stressors.”

Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. Palo Alto CA: Consulting Psychologists Press; 1996.

http://www.clker.com/clipart-burnt-match.html

Burnout has personal consequences

Lower work satisfaction

Disruption to personal relationships

Substance misuse

Depression and suicide

-Wurm W, Vogel K, Holl A, et. Al. Depression-burnout in physicians. PLoS One. 2016; 11(3):e0149913.

Burnout has patient consequences

Increase in medical errors

Reduced quality of patient care

Lower patient satisfaction

-Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010; 251(6): 995-1000

Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008; 336 (7642): 488-491.

Burnout has organizational consequences

Decreased productivity

High job turnover

Early retirement

-Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. B<C Health Serv Res. 2014; 14: 325

“Organizational factors* remain the primary drivers of burnout.”

Shanafelt, T, Noseworthy, John H. Executive Leadership and Pysician Well-being: Nine organizational strategies to promote engagement and Reduce Burnout. Mayo Clinic Proceedings. Jan 2017, Vol 92(1), pp. 129-146

Burnout cannot be dealt with by individual alone

Problem with health care organization

Problem with working environment

Problem with organizational culture

-Montgomery A. The inevitability of physician burnout: implications for interventions. Burnout Research. 2014; 1(1): 50-56

“Casting the issue as a personal problem can lead individual physicians to pursue solutions that are personally beneficial but detrimental to the organization and society.”

-Shanafelt, T, Noseworthy, John H. Executive Leadership and Pysician Well-being: Nine organizational strategies to promote engagement and Reduce Burnout. Mayo Clinic Proceedings. Jan 2017, Vol 92(1), pp. 129-146

Change at organizational level(ie work environment interventions)

Change at individual level(ie mindfulness, self-compassion, behavioral training)

Lown M, Lewith G, Simon C, Peters D. Resilience: what it is, why do we need it, and can it help us? Br J Gen Practice. 2015; 65(639):e708-e710

Physician Interventions

Horton, J and Chomichuk, GMB. Medicine. 2017

“Human freedom involves our capacity to pause between the stimulus and response and, in that pause, to choose the one response toward which we wish to throw our weight….”

-Rollo May, The Courage to Create. WW Norton, 1994.

There are physician-directedinterventions associated with small, significant reductions in burnout in controlled* trials…

Panagioti, M, Panagopoulou, E. Controlled Interventions to Reduce Burnout in Physicians: A systematic review and meta-analysis. JAMA Internal Med. 2017;177(2):195-205.

System AND individual interventions

RCTs, non-RCTs, controlled before-after, interrupted time

2322 articles * 19 articles

12 were MD-directed interventions

*No intervention, no burnout outcome, mixed

sample <70%, uncontrolled before/ after

The “physician-directed” interventions:

Mindfulness meditation

Communication/ behavioral skills

Empathy, self-compassion, self-examination

Exercise w. accountability

Panagioti, M, Panagopoulou, E. Controlled Interventions to Reduce Burnout in Physicians: A systematic review and meta-analysis. JAMA Internal Med. 2017;177(2):195-205.

Organizational and physician-directed interventions showed small, significant reductions in burnout

Standardized mean difference –0.29, 95% CI, -0.42 to -0.16 (equals improvement by 3 points on MBI)

Results:

Organization-directed interventions were more effective: SMD 0.45, 95% CI, -0.62 to -0.28

Physician-directed interventions:SMD 0.18, 95% CI, -0.32 to -0.03

. Panagioti, M, Panagopoulou, E. Controlled Interventions to Reduce Burnout in Physicians: A systematic review and meta-analysis. JAMA Internal Med. 2017;177(2):195-205.

West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281

System and individual interventions

2617 52 made final cut

20/ 52 were physician-directed interventions.

Most were RCTs or OS.

“Physician-directed” interventions:

Small group curricula; “belonging”intervention

Stress-management and self-care

Communication training

Mindfulness

West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281

Organizational and physician-directed interventions showed small, significant reductions in burnout

Overall burnout decreased from 54% to 44% (95% CI 5-14)

If you could apply this result to 2014 national data for US physicians, that 10% reduction would represent an 18% RRR in burnout

West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281

Results were similar for individual-focused and organizational interventions.

West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281

For Physician-directed interventions:

“Results generally suggest sustained or even augmented benefits for many months after completion…but finding not universal.”

http://clipart-library.com/pictures-of-syringe.html

West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281

“No specific interventions are better than are others…

…both strategies are probably necessary. However, their combination has not been studied.”

West, MD, Dyrbye, L, Erwin, P, Shanafelt. Interventions to prevent and reduce burnout: a systematic review and metanalysis. The Lancet. Vol 388, Issue 10057, 5-11, November 2016, 2272-2281

THE BOTTOM LINE:

“…we should not wait for perfect understanding before acting; too much is at stake.”

Epstein, RM, Privitera, M. Doing something about physician burnout. The Lancet. Vol. 388, Issue 10057, 5-11. November 2016.

THE BOTTOM LINE:

Don’t just sit there…do something !

https://www.aldacenter.org/medical/immersionPhoto: Jillian Horton

https://www.narrativemedicine.org

http://www.ronaldepstein.com

Krasner, Michael S ; Epstein, R et al. Association of an Educational Program in Mindful Communication with Burnout, Empathy and Attitudes among Primary Care Physicians. JAMA, 23 September 2009, Vol.302(12), pp.1284-1293

Improvements in mindfulness: raw score change 8.9%, 95% CI, 7.0-10.8)

Reductions in burnout: -6.8; 95% CI-4.8 to -8.8

Improvements in mindfulness* were correlated with improvements all measured outcomes

Evidence has linked each 1 point deterioration in burnout scores with an increased likelihood of reduction in FTE in the following 12 months.*

*Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clinic Proc 2016; 91: 422-31

Bringing it home:

Burnout has individual and organizational remedies

Literature says: use dual approach, but much uncertainty in terms of best practice

Bringing it home…

A wide variety of individual interventions have some support in the literature

Even small improvements in burnout scale scores can help with attrition (and with other things too)

For more information on Mindful Practice Programs :

Mindful Practice Courses through Compassion Project at SBGH (next one April 13)

http://www.chcm-ccsm.ca/compassion-project/spring-2019-programming/event-series/mindful-practice/

Burnout – carrying on the conversation:

Internal Medicine Grand Rounds, May 14, 08:00

Theatre A, BMS, Bannatyne Campus, Rady FHS

Dr. Tait Shanafelt, Director, Well MD Centre

Associate Dean, Stanford School of Medicine

Jillian.Horton@umanitoba.ca

Dr. Jillian Horton, BA MA MD FRCPC (Internal Medicine)

Associate Chair, Professionalism and Diversity, Department of Internal medicine

Director, Allan Klass Health Humanities Program and Learner Wellness

Assistant Director, Manitoba Practice Assessment Program

Max Rady College of Medicine, Rady Faculty of Health Sciences

The Mindful Practice Program, University of Rochester

“Before and after” study*

70 primary care MDs (invited all 871 in area)

8-week intensive (2.5h/week, 7 hr retreat) followed by 10-month maintenance phase (2.5h/month)

-Krasner, MS, Epstein, RM, Beckman, H et al. Association of an educational program in mindful communication with burnout, empathy and attitudes among primary care physicians. JAMA. 302 (2009), 1284-1293

*Mercer SL, DeVinney BJ et al. Study designs for effectiveness and translation research: identifying trade-offs. Am. J. Prev. Med. 2007; 33(2): 139-154

Leading drivers of burnout

Excessive workload

Imbalance between job demands and skills

Lack of job control

Prolonged work stress

-Linzer M, Visser MR, Oort FJ, Smets EM, McMurray JE, de Haes HC; Society of General Internal Meidcine(SGIM) Career Satisfaction Study Group (CSSG). Predicting and preventing physician burnout: results from the Uited States and the Netherlands. Am J Med. 2001; 111(2): 170-175