PHYSICIANPHYSICIAN

BURNOUTBURNOUTPepi Granat, MD, November 27, 2002.Pepi Granat, MD, November 27, 2002.

What we’ll do in this hour What we’ll do in this hour (Please fill (Please fill out Evaluation – really helpful for our improvement)out Evaluation – really helpful for our improvement)

Dimensions of burnoutDimensions of burnout Brief activity for residents & facultyBrief activity for residents & faculty

Some research in the fieldSome research in the field

Recent flurry of articles re: residents, hours,etcRecent flurry of articles re: residents, hours,etc Prevention & treatmentPrevention & treatment

What to do when “bummed out”What to do when “bummed out”

PHYSICIAN BURNOUT: PHYSICIAN BURNOUT: PREVENTION, IDENTIFICATION PREVENTION, IDENTIFICATION

(Post DM, Miller K, Strickland C. FP Recertification vol 21, No. 1 Jan 1999)(Post DM, Miller K, Strickland C. FP Recertification vol 21, No. 1 Jan 1999)

““Physician burnout syndrome is a Physician burnout syndrome is a psychological impairment caused by psychological impairment caused by chronic job-related stress. It is chronic job-related stress. It is characterized by emotional exhaustion, characterized by emotional exhaustion, depersonalization, and a diminished sense depersonalization, and a diminished sense of personal accomplishment…..”of personal accomplishment…..”

JAMA Vol. 288 No. 12, September 25, 2002.

Linking Evidence and Experience

Mid-Career Burnout in Generalist and Specialist Physicians   

  Anderson Spickard, Jr, MD; Steven G. Gabbe, MD; John F. Christensen, PhD

The Silent Anguish The Silent Anguish

of the Healersof the Healers

Burnout DefinedBurnout Defined

““A state of fatigue or frustration brought A state of fatigue or frustration brought about by devotion to a cause, way of life, about by devotion to a cause, way of life, or relationship that failed to produce the or relationship that failed to produce the expected reward.” -Freudenberger, 1980 expected reward.” -Freudenberger, 1980 – NOT SIMPLY OVERWORKNOT SIMPLY OVERWORK– NOT SIMPLY TIREDNESSNOT SIMPLY TIREDNESS– Particularly prevalent in helping professionsParticularly prevalent in helping professions

Frequent stressors & outcomesFrequent stressors & outcomes

Heavy workloadHeavy workload Long hoursLong hours FatigueFatigue Bureaucratic interferenceBureaucratic interference Alienation from families Alienation from families

and social networksand social networks Commercialization of Commercialization of

medicinemedicine

Few social attachmentsFew social attachments Inadequacy feelingsInadequacy feelings Cynicism feelingsCynicism feelings VictimizationVictimization Disruptive, self-Disruptive, self-

destructive behaviordestructive behavior Chemical dependencyChemical dependency Depression, anxietyDepression, anxiety SuicideSuicide

Physician SuicidePhysician Suicide

Burnout a precursorBurnout a precursor Estimated rate of physician suicides in Estimated rate of physician suicides in

1992: 28-40 per 100,000 (vs. nat’l 11.6)1992: 28-40 per 100,000 (vs. nat’l 11.6) Physicians adept at disguising intentPhysicians adept at disguising intent Physicians effective in carrying out intentPhysicians effective in carrying out intent Rate of successful initial suicide attempts Rate of successful initial suicide attempts

for physicians is exceptionally high: 62%for physicians is exceptionally high: 62%

What is BURNOUT?What is BURNOUT?

First described in 1974: a syndrome First described in 1974: a syndrome stemming from an inability to conserve stemming from an inability to conserve energy and adapt efficientlyenergy and adapt efficiently

Physical symptomsPhysical symptoms Psychological symptomsPsychological symptoms Behavioral effectsBehavioral effects

Components of Burnout: Components of Burnout:

PhysiologicalPhysiologicalBehavioralBehavioral

PsychologicalPsychologicalSpiritualSpiritual

Physical and Psychological Physical and Psychological Symptoms; Behavioral EffectsSymptoms; Behavioral Effects

Physical:Physical:– Muscle tensionMuscle tension– HeadachesHeadaches– TachycardiaTachycardia– AnorexiaAnorexia– InsomniaInsomnia

Psychological:Psychological:– DepressionDepression– HelplessnessHelplessness– AngerAnger– FrustrationFrustration

Behavioral effects:Behavioral effects:– Quickness to angerQuickness to anger– Frustration responsesFrustration responses– Suspiciousness Suspiciousness

bordering on paranoiabordering on paranoia– Feelings of Feelings of

omnipotenceomnipotence

Manifestations in Clinical WorkManifestations in Clinical Work

Dreading seeing another patientDreading seeing another patient Cynicism toward patients Cynicism toward patients Daydreaming during sessionsDaydreaming during sessions Hostility toward patientsHostility toward patients Quickness to diagnose or refer outQuickness to diagnose or refer out Blaming patientsBlaming patients Constant complaining to coworkersConstant complaining to coworkers Failure to “complain” in appropriate venuesFailure to “complain” in appropriate venues

3 DIMENSIONS OF BURNOUT 3 DIMENSIONS OF BURNOUT

EMOTIONAL EXHAUSTIONEMOTIONAL EXHAUSTIONDEPERSONALIZATIONDEPERSONALIZATIONDIMINISHED FEELINGS OF DIMINISHED FEELINGS OF

PERSONAL PERSONAL ACCOMPLISHMENTACCOMPLISHMENT

What causes BURNOUT?What causes BURNOUT?

3 major factors:3 major factors: Work (overwork, coping with Work (overwork, coping with

patients’ problems, administrative patients’ problems, administrative duties)duties)

Expectation of othersExpectation of others Personal characteristicsPersonal characteristics

EtiologyEtiology

Intrapsychic Intrapsychic – Lack of reinforcement contingenciesLack of reinforcement contingencies– Masked narcissismMasked narcissism

Systemic/Environmental FactorsSystemic/Environmental Factors

Work Environment StressWork Environment Stress Time pressureTime pressure Caseload that is excessive in size, scope or intensityCaseload that is excessive in size, scope or intensity Organizational politicsOrganizational politics Non-supportive peersNon-supportive peers Excessive paperworkExcessive paperwork Unrealistic or unreasonable demands by managed careUnrealistic or unreasonable demands by managed care Lack of money or resourcesLack of money or resources Lack of respect from professional colleaguesLack of respect from professional colleagues

Self-Induced StressSelf-Induced Stress

PerfectionismPerfectionism Fear of failureFear of failure Self-doubtSelf-doubt Need for approvalNeed for approval Emotional depletionEmotional depletion Unhealthy lifestyle (self-medication, lack of self Unhealthy lifestyle (self-medication, lack of self

care)care) Lack of faith (not necessarily religious faith)Lack of faith (not necessarily religious faith)

Major Life Event-Related StressMajor Life Event-Related Stress

Legal actions taken against youLegal actions taken against you Major life transitions Major life transitions Physical or medical problemsPhysical or medical problems Family problemsFamily problems Economic cutbacks (layoffs, fluctuations in economy)Economic cutbacks (layoffs, fluctuations in economy) Money pressuresMoney pressures Change in job responsibilitiesChange in job responsibilities RESIDENCY !!!!! BUT DON’T FORGET – RESIDENCY !!!!! BUT DON’T FORGET – IT’S IT’S

TEMPORARY !!!!!TEMPORARY !!!!!

Some RESIDENCY ISSUESSome RESIDENCY ISSUES Work hours petition rejected by OSHAWork hours petition rejected by OSHA ACGME voluntary standards supportedACGME voluntary standards supported

– 80 hours/week80 hours/week– Minimum 10 hrs. between shiftsMinimum 10 hrs. between shifts

Burnout said to be linked to overwork & to lead to suboptimal Burnout said to be linked to overwork & to lead to suboptimal care (Shanafelt, et al. Annals Int Med. Sept. 2002)care (Shanafelt, et al. Annals Int Med. Sept. 2002)

Some commentators say fewer hours lead to less competence Some commentators say fewer hours lead to less competence burnout (because of poor academic teaching & inadequate burnout (because of poor academic teaching & inadequate performance). i.e. suboptimal care leads to burnout (from performance). i.e. suboptimal care leads to burnout (from angst), not vice versa (Graham, Annals of Internal Med. Oct. angst), not vice versa (Graham, Annals of Internal Med. Oct. 2002) 2002)

Stages of burnoutStages of burnout

Early Symptoms Early Symptoms – Low energyLow energy– BoredomBoredom– Still productive, but diminishedStill productive, but diminished

Advanced SymptomsAdvanced Symptoms – Poor performance evaluationsPoor performance evaluations– Presence of physical and psychological Presence of physical and psychological

symptoms symptoms

PreventionPrevention

Awareness!Awareness!

Exercise: Why You Became A Exercise: Why You Became A Physician (3 reasons) Physician (3 reasons) Exercise: Assessing Joys &Hardships Exercise: Assessing Joys &Hardships

(3 joys; 3 hardships)(3 joys; 3 hardships)At this pointAt this point: Break into groups of 3 : Break into groups of 3

((55 minutes) minutes)Negotiate & decide the above & Negotiate & decide the above & present to group (present to group (5-105-10 minutes) minutes)

Keeping Your Eye on the BallKeeping Your Eye on the Ball

Communication not CompetenceCommunication not Competence= most important skill.= most important skill.

The Cochrane Database of Systematic ReviewsThe Cochrane Database of Systematic Reviews Volume (Issue 4)  2002 Volume (Issue 4)  2002

Communication skills training for health care Communication skills training for health care professionals working with cancer patients, their professionals working with cancer patients, their

families and/or carersfamilies and/or carers[Protocol]Fellowes, D; Wilkinson, S; [Protocol]Fellowes, D; Wilkinson, S; Moore, PMoore, P

Date of Most Recent Update: 9-4-2002Date of Most Recent Update: 9-4-2002 Date of Most Recent Substantive Update: 1-11-2001Date of Most Recent Substantive Update: 1-11-2001

Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, et al. Burnout and psychiatric disorder among cancer Leaning MS, et al. Burnout and psychiatric disorder among cancer clinicians. British Journal of Cancer 1995;71(6):1263-9.clinicians. British Journal of Cancer 1995;71(6):1263-9.

Review in progress…….Review in progress…….

Sex differences in physician Sex differences in physician burnout in the United States burnout in the United States and The Netherlandsand The NetherlandsJ Am Med Womens Assoc 2002 Fall;57(4):191-3J Am Med Womens Assoc 2002 Fall;57(4):191-3Linzer M, McMurray JE, Visser MR, Oort FJ, Smets E, de Haes HCLinzer M, McMurray JE, Visser MR, Oort FJ, Smets E, de Haes HC

Separate physician surveys:United States (n=2326)Separate physician surveys:United States (n=2326)Netherlands (n=1426 Netherlands (n=1426

Gender parity in physician burnout in the Gender parity in physician burnout in the Netherlands may be due to fewer work hours and Netherlands may be due to fewer work hours and

greater work control of women compared to those greater work control of women compared to those in the United States in the United States

Life Satisfaction Among Norwegian Life Satisfaction Among Norwegian Young Doctors: A Longitudinal StudyYoung Doctors: A Longitudinal StudyReidar Tyssen, MD, PhD; Per Vaglum, MD, PhD; Reidar Tyssen, MD, PhD; Per Vaglum, MD, PhD;

Nina T.Grønvold, MD & Øivind Ekeberg, MD, PhD.Nina T.Grønvold, MD & Øivind Ekeberg, MD, PhD.Department of Behavioral Sciences in Medicine, Department of Behavioral Sciences in Medicine,

Faculty of Faculty of Medicine University of Medicine University of

OsloOslo

Paper presented at International Conference on Paper presented at International Conference on

Physician Health in Vancouver, B.C, Oct.19, 2002 Physician Health in Vancouver, B.C, Oct.19, 2002

Preliminary and unpublished data,Preliminary and unpublished data,courtesy of the author. courtesy of the author.

Results: Comparison of Life Satisfaction Among Doctors and Comparison Group

dissatisfied - satisfied

7.06.05.04.03.02.01.0

Life-satisfaction

Doctors

Freq

uenc

y

200

100

0

Std. Dev = 1.01

Mean = 5.2

N = 420.00

dissatisfied - satisfied

7.06.05.04.03.02.01.0

Life-satisfaction

Controls general population

Freq

uenc

y

700

600

500

400

300

200

100

0

Std. Dev = .98

Mean = 5.6

N = 1627.00

Mean : 5.2 (1.01) Mean: 5.6 (0.98)

T-test: t = 7.0, p<0.001NB!: No gender differences

““Very/extremely satisfied” with Very/extremely satisfied” with lifelife

0102030405060708090

100

Doctors Controls

WomenMen

1/3 among doctors1/3 among doctors 1/2 (or more) among 1/2 (or more) among

other peopleother people Statistics (doctors Statistics (doctors

vs. controls): vs. controls): Chi-Square = Chi-Square = 49.3 P<0.00149.3 P<0.001

%

Dissatisfied with life (any Dissatisfied with life (any category)category)

0

5

10

Doctors Controls

WomenMen

3.8% (16/420) 3.8% (16/420) among doctorsamong doctors

1.9% (31/1627) 1.9% (31/1627) among other peopleamong other people

Chi-square = 5.4 Chi-square = 5.4 P = 0.03P = 0.03

%

ConclusionConclusion Young physicians are less satisfied with life than other Young physicians are less satisfied with life than other

people in the society people in the society Subjective well-being:Subjective well-being:- Probably impeding factors: - Probably impeding factors: Mental distress (personality Mental distress (personality

trait), work stress and life stresstrait), work stress and life stress- Probably promoting factors: - Probably promoting factors: Having a stable partner, Having a stable partner,

social support, physical training. social support, physical training.

About 30% of the variance is predicted at medical school About 30% of the variance is predicted at medical school level (personality trait & medical school variables)level (personality trait & medical school variables)

Balancing lifeBalancing lifeSocial relationships

Personal time & self-care

Working hours

Spare time

COPING STRATEGIESCOPING STRATEGIES

INDIVIDUAL FACTORS-- the physician’s INDIVIDUAL FACTORS-- the physician’s personalitypersonality

ORGANIZATIONAL FACTORS -- workplace ORGANIZATIONAL FACTORS -- workplace stressorsstressors

ESTABLISHING PRIORITIESESTABLISHING PRIORITIES FOCUSING ON MOST TROUBLESOME FOCUSING ON MOST TROUBLESOME

ISSUESISSUES SET REALISTIC, ATTAINABLE GOALSSET REALISTIC, ATTAINABLE GOALS

TreatmentTreatment

Self helpSelf help TherapyTherapy Psychotropic MedicationsPsychotropic Medications Focus on SpiritualityFocus on Spirituality

Resolution to ActResolution to Act!!

Barriers to Proper Treatment Barriers to Proper Treatment

Often unrecognized until problem is severeOften unrecognized until problem is severe Professionals rarely present with burnout Professionals rarely present with burnout

as primary issueas primary issue Embarrassment Embarrassment

SPECIFIC STRATEGIESSPECIFIC STRATEGIES

Self-help books on stress managementSelf-help books on stress management Specific books for physiciansSpecific books for physicians Internet resourcesInternet resources Self-assessment tool: StressMapSelf-assessment tool: StressMap Stress-management workshopsStress-management workshops Individual counseling, especially for self-Individual counseling, especially for self-

esteem and identity issuesesteem and identity issues

STRESS-MANAGEMENT STRESS-MANAGEMENT TECHNIQUESTECHNIQUES

INCREASE SELF-INCREASE SELF-AWARENESSAWARENESS

SHARE FEELINGS SHARE FEELINGS AND AND RESPONSIBILITESRESPONSIBILITES

SELF-CARESELF-CARE PERSONAL PERSONAL

PHILOSOPHYPHILOSOPHY

EXPLORE HOW EXPLORE HOW “HEALTHY” “HEALTHY” PHYSICIANS DEAL PHYSICIANS DEAL WITH STRESSWITH STRESS

APPRECIATE YOUR APPRECIATE YOUR OWN ROLE, DON’T OWN ROLE, DON’T BLAME OTHERSBLAME OTHERS

CONSIDER ALL CONSIDER ALL OPTIONSOPTIONS

Strategies to Prevent Physician BurnoutStrategies to Prevent Physician Burnout

PersonalPersonal

Influence happiness through personal values and choicesInfluence happiness through personal values and choices

Spending time with family and friendsSpending time with family and friends

Religious or spiritual activityReligious or spiritual activity

Self-care (nutrition, exercise)Self-care (nutrition, exercise)

Adopting a healthy philosophical outlookAdopting a healthy philosophical outlook

A supportive spouse or partnerA supportive spouse or partner

WorkWork

Control over environment: workloadControl over environment: workload

Finding meaning in work and setting limitsFinding meaning in work and setting limits

Having a mentorHaving a mentor

Having adequate administrative support systemsHaving adequate administrative support systems

WHAT TO DO WHEN WHAT TO DO WHEN “BUMMED-OUT”“BUMMED-OUT”

““Choose something like a Star”Choose something like a Star”TRY POETRYTRY POETRY

INSPIRATIONAL (“IF”)INSPIRATIONAL (“IF”)OR CALMING(“The Day is OR CALMING(“The Day is

Done”)Done”)

The Day is Done… Henry The Day is Done… Henry Wadsworth LongfellowWadsworth Longfellow

The day is done, and The day is done, and the darknessthe darkness

Falls from the wings Falls from the wings of Night, of Night,

As a feather is wafted As a feather is wafted downwarddownward

From an eagle in his From an eagle in his flight.flight.

I see the lights of the I see the lights of the villagevillage

Gleam through the Gleam through the rain and the mist,rain and the mist,

And a feeling of And a feeling of sadness comes o’er mesadness comes o’er me

That my soul cannot That my soul cannot resist:resist:

The Day is DoneThe Day is Done

A feeling of sadness A feeling of sadness and longing,and longing,

That is not akin to That is not akin to pain,pain,

And resembles sorrow And resembles sorrow onlyonly

As the mist resembles As the mist resembles the rain.the rain.

Come, read to me Come, read to me some poem,some poem,

Some simple and Some simple and heartfelt lay,heartfelt lay,

That shall soothe this That shall soothe this restless feeling,restless feeling,

And banish the And banish the thoughts of day.thoughts of day.

The Day is DoneThe Day is Done

Not from the grand old Not from the grand old masters,masters,

Not from the bards Not from the bards sublime,sublime,

Whose distant Whose distant footsteps echofootsteps echo

Through the corridors Through the corridors of Time.of Time.

For, like strains of For, like strains of martial music,martial music,

Their mighty thoughts Their mighty thoughts suggest suggest

Life’s endless toil and Life’s endless toil and endeavor;endeavor;

And tonight I long for And tonight I long for rest.rest.

The Day is DoneThe Day is Done

Read from some Read from some humbler poet,humbler poet,

Whose songs gushed Whose songs gushed from his heart,from his heart,

As showers from the As showers from the clouds of summer,clouds of summer,

Or tears from the Or tears from the eyelids start;eyelids start;

Who through long Who through long days of labor,days of labor,

And nights devoid of And nights devoid of ease,ease,

Still heard in his soul Still heard in his soul the music the music

Of wonderful Of wonderful melodies.melodies.

The Day is DoneThe Day is Done

Such songs have Such songs have power to quietpower to quiet

The restless pulse of The restless pulse of care,care,

And come like the And come like the benedictionbenediction

That follows after That follows after prayer.prayer.

Then read from the Then read from the treasured volumetreasured volume

The poem of thy The poem of thy choice,choice,

And lend to the rhyme And lend to the rhyme of the poetof the poet

The beauty of thy The beauty of thy voice.voice.

The Day is DoneThe Day is Done

And the night shall be filled with And the night shall be filled with musicmusic

And the cares, that infest the day,And the cares, that infest the day, Shall fold their tents, like the Shall fold their tents, like the

Arabs,Arabs, And as silently steal away.And as silently steal away.

IF…. by Rudyard KiplingIF…. by Rudyard Kipling

If you can keep your If you can keep your head when all about youhead when all about you

Are losing theirs and Are losing theirs and blaming it on you;blaming it on you;

If you can trust yourself If you can trust yourself when all men doubt when all men doubt you,you,

But make allowance for But make allowance for their doubting too:their doubting too:

If you can wait and not If you can wait and not be tired by waiting,be tired by waiting,

Or, being lied about, Or, being lied about, don’t deal in lies,don’t deal in lies,

Or being hated don’t Or being hated don’t give way to hating,give way to hating,

And yet don’t look too And yet don’t look too good nor talk too wise;good nor talk too wise;

If……..If……..

If you can dream-- and If you can dream-- and not make dreams your not make dreams your master;master;

If you can think-- and not If you can think-- and not make thoughts your aim,make thoughts your aim,

If you can meet with If you can meet with Triumph and DisasterTriumph and Disaster

And treat those two And treat those two impostors just the same:impostors just the same:

If you can bear to hear If you can bear to hear the truth you’ve spokenthe truth you’ve spoken

Twisted by knaves to Twisted by knaves to make a trap for fools,make a trap for fools,

Or watch the things you Or watch the things you gave your life to broken,gave your life to broken,

And stoop, and build And stoop, and build ‘em up with worn-out ‘em up with worn-out tools;tools;

If…..If…..

If you can make one If you can make one heap of all your heap of all your winningswinnings

And risk it on one turn And risk it on one turn of pitch-and-toss,of pitch-and-toss,

And lose, and start again And lose, and start again at your beginnings,at your beginnings,

And never breathe a And never breathe a word about your loss:word about your loss:

If you can trust your If you can trust your heart and nerve and heart and nerve and sinewsinew

To serve your turn long To serve your turn long after they are gone,after they are gone,

And so hold on when And so hold on when there is nothing in youthere is nothing in you

Except the Will which Except the Will which says to them: “Hold on!”says to them: “Hold on!”

If…..If…..

If you can talk with If you can talk with crowds and keep your crowds and keep your virtue,virtue,

Or walk with Kings-- Or walk with Kings-- nor lose the common nor lose the common touch,touch,

If neither foes nor loving If neither foes nor loving friends can hurt you,friends can hurt you,

If all men count with If all men count with you, but none too much:you, but none too much:

If you can fill the If you can fill the unforgiving minuteunforgiving minute

With sixty seconds’ With sixty seconds’ worth of distance run,worth of distance run,

Yours is the Earth, and Yours is the Earth, and everything that’s in it,everything that’s in it,

And -- which is more And -- which is more -- you’ll be a Man, my -- you’ll be a Man, my son!son!

What we’ve done this hourWhat we’ve done this hour(Please (Please fill out Evaluation – really helpful for our fill out Evaluation – really helpful for our improvement)improvement)

Dimensions of burnoutDimensions of burnout

Brief activity for residents & facultyBrief activity for residents & faculty

Some research in the fieldSome research in the field

Prevention & treatmentPrevention & treatment

What to do when “bummed out”What to do when “bummed out”