Primary Care Clinician Stress and Psychological flexibility

Debra A. Gould MD, MPHCentral Washington Family

Medicine Residency Program deb.gould@chcw.org

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session # H4aOctober 18, 2014

Michael J. Aquilino MSCentral Washington Family Medicine Residency Program maquilino@chcw.org

Patricia Robinson PhDMountainview Consulting Inc.Patti@Mtnviewconsulting.com

Faculty Disclosure

We currently have or have had the following relevant financial relationships during the past 12 months:

• Dr. Gould & Dr. Robinson: Book Royalties - New Harbinger Publications, Inc.

• Dr. Robinson:- Mountainview Consulting Group, Inc.- Book Royalties - Springer Science + Business Media,

LLC - Behavioral Consultation and Primary Care: A Guide to Integrating Services

Learning ObjectivesAt the conclusion of this session, the

participant will be able to:

• Use tools to self-assess level of burn-out, sources and magnitude of stress, and level of psychological flexibility

• Name 6 core psychological processes that support clinician resiliency

• Describe specific exercises designed to enhance resilience among PCMH team members

• Develop a personal strategy for building resiliency based on cognitive-behavioral therapy model called Acceptance and Commitment Therapy (ACT)

Bibliography / Reference

1. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD, Acad Med, 2014 Mar;89(3):443-51. doi:10.1097/ACM.0000000000000134.

2. Identifying psychological mechanisms underpinning a cognitive behavioural therapy Intervention for emotional burnout. Lloyd, J., Bond, F. W. & Flaxman, P. E. Lloyd, Apr-Jun 2013, Vol. 27 Issue 2, p181-199.  

3. To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice. Lamothe M, Boujut E, Zenasni F, Sultan S. BMC Family Practice 2014, 15:15 doi:10.1186/1471-2296-15-15. http://www.biomedcentral.com/1471-2296/15/15

4. Not all coping strategies are created equal: a mixed methods study exploring physicians’ self reported coping strategies. Lemaire JB, and Wallace JE, BMC Health Services Research 2010, 10:208, http://www.biomedcentral.com/1472-6963/10/208

5. Real Behavior in Primary Care; Improving Patient Outcomes and Increasing Job Satisfaction. Robinson PJ, Gould DA, Strosahl KD, New Harbinger Press, Inc., 2010, Oakland California.

6. The Mindful Employee and Effective Employee. Flaxman PE, Bond FW, Livheim F, Hayes SC; New Harbinger Press, Inc., 2013, Oakland California.

Learning Assessment

• Describe self-assessment tools and use them to determine a. level of burn-out, b. sources and magnitude of stress, and c. level of psychological flexibility

• Describe 6 core psychological processes that support clinician resiliency and specific exercises designed to enhance resilience among PCMH team members

Primary Care Home

“Adaptive Reserve” • Value their role• Self-aware• Balance and prioritize• Manage a practice• Support relationships

ResilienceBurnout

Wellness

IndividualOrganizational

ACT

Burnout

Symptoms:• Emotional Exhaustion• Depersonalization• Personal

Accomplishment

Unhealthy coping: • Over-eat, drink, work• Isolation, Depression, Suicide• Leave Profession• Relationship Problems

Psychological Flexibility

“Learning to be aware and accepting of the pain that comes into our lives and continue to pursue what we value.”

Psychologicalflexibility

Be Present

Acceptance

Defuse

Changing Self

Resiliency – Core Processes

Connect with Values

Act on Values

Mindfulness Values

Tool: PCP Stress Checklist

Domains:• Interactions with Patients• Practice Management• Administrative Issues• Education / Learning• Relationships with Colleagues• Balance between Work and the

“Rest of Life”Scoring: Higher scores indicates more

stress (range 0-100)

Primary Care Provider Stress Checklist (PCP-SC)

NAME: __________________________________Date: _________________________ Below you will find a list of specific situations that may cause stress for people who work in medical settings. Please rate the extent to which each of the situations is stressful for you at this moment in time. Use the scale below to choose your response. For example, if you believe a situation is highly stressful for you “Highly Stressful,” you would record a 5 in the Response column and if it is “Not Stressful” for you, you would record a 0. To get a picture of what stresses you the most, following the directions for scoring at the bottom of the form.

0 1 2 3 4 5 6

Not Stressful

Very Mild Stress

Mild Stress

Moderate Stress

Greater than

Moderate

Highly Stressful

Extremely Stressful

I. INTERACTIONS WITH PATIENTS Response Stressful Situation 1. Patients who don’t manage their chronic diseases 2. Patients who abuse or are addicted to alcohol or drugs 3. Patients who complain of chronic pain and are seeking narcotics 4. Patients who are angry and demanding. 5. Patients complaining of depression, anxiety and other common psychological

problems. 6. Patients who have unhealthy lifestyles (overeat, under-exercise, over-work) 7. Patients who perpetrate violence or abuse on children, domestic partners,

elderly relatives Total (Sum of 1-7)

II. PRACTICE MANAGEMENT Response Stressful Situation 8. My schedule is too tight to address more than one or two problems 9. Patients wait too long because of office work flow problems. 10. Chart and other important records information is not available 11. Lack of immediate access to information about clinical guidelines 12. Not enough time to address multiple medical and mental health problems in

complex patients 13. Dealing with interruptions and other annoyances during clinic/work day. Total (Sum of 8-13)

Tool: Primary Care Provider Acceptance and Action Questionnaire (PCP-AAQ)

Measures Psychological Flexibility

• 20 Items; sum equals total score (range 0-120)

• Higher indicates greater psychological flexibility.

Tool: Values Clarification

If you were at your own retirement party, what would you like to hear other people say about what you stood for:

1. Practicing Medicine

2. Relationships with Colleagues

3. Relationships with Family/Friends

4. Personal Health & Well-being

My work life is totally consistent with my values

My work life is totally inconsistent

with my values

Studying/ Practicing Medicine

Relationships with

colleagues

Personal Health &

Well Being

Relationships with Family &

Friends

Tool: Bulls Eye Values Assessment

xx

15

Personal ACTion Plan

Value Statement:

Action Steps: 1. Practice of Acceptance -

2. Practice of Mindfulness -

3. Practice of Value Consistent Daily Actions -

Psychologicalflexibility

Be Present“EHR billing”

Acceptance“Heavy Hitters”

Defuse“Drug Seeker”

Changing Self “A Different Doc”

How We’ve Done It!

Connect with Values

“Compassionate Self”

Act on Values“3 at 3PM on Friday”

ACT Resources

Association for Contextual Behavioral Science www.contextualpsychology.org/ New Harbinger Publications www.newharbinger.com

Psychologicalflexibility

Be Present“EHR billing”

Acceptance“Heavy Hitters”

Defuse“Drug Seeker”

Changing Self “A Different Doc”

Questions?????

Connect with Values

“Compassionate Self”

Act on Values“3 at 3PM on Friday”

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!