Physician Burnout(2) - Charles Samenow, MD

Addressing Physician Burnout:
How to Keep Sane When Things
Seem Insane
Charles P. Samenow, MD, MPH
Department of Psychiatry
George Washington University
Goals
•  To describe physician burnout
•  To understand the etiologies, risk factors,
and consequences of burnout
•  To explore personal, occupational and
cultural changes that might prevent burnout
Vanderbilt Center
for
Professional Health
Continuing Medical Education Courses
Prescribing Controlled Drugs©
Maintaining Proper Boundaries©
Program for Distressed Physicians©
www.mc.vanderbilt.edu/cph
Context
•  Physicians are leaving medicine at higher rates.
•  Physicians are less likely to recommend medicine
as a career to others.
•  Thirty percent of physicians say they would
change their profession if they could. (Hippocrates.
April 1994:32-33)
•  Physicians are working harder for less money.
•  Increasing paperwork and less time with patients
•  Increasing malpractice insurance premiums
“Engrossed late and soon in professional
cares… you may so lay waste that you may
find, too late, with hearts given way, that there
is no place in your habit-stricken souls for
those gentler influences which make life
worth living.”
Sir William Osler, 1899
What Is Burnout?
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Emotional Exhaustion
Cynicism
Ineffectiveness
Depersonalization of
relationships
Spickard Jr., WA, Gabbe, S, Christenesen, J. Mid-career burnout in generalist and
specialist physicians: definitions, risk factors and prevention. JAMA. 2002;288
(12):1447-50.
Prevalence
•  25 - 60% of practicing physicians
Maslach Burnout Inventory
•  A 22-item inventory designed to measure three
aspects of burnout: –  emotional exhaustion: “I feel emotionally drained from
my work”
–  Depersonalization: “I’ve become more callous towards
people since I have taken this job.”
–  lack of personal accomplishment: “I feel I am positively
influencing people’s lives through this work.”
Why do we care?
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Sleep disturbances and fatigue
Irritability, anxiety and depression
Marital dysfunction
Myocardial Infarction
Alcohol and drug addiction
Impaired job performance (physician error)
Physician turnover
Spectrum of Functioning
Healthy
Burnout
Disruptive
Impaired
Misuse
Abuse
Dependence
Burnout and Patient Care
•  Physicians who report burnout
–  write more prescriptions
–  order more tests for their patients
–  have less compliant patients
–  have less satisfied patients.
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(Gunderson, L. Physician burnout, Annals of Intern Med, 2001;135(2):146-48,
Soc Sci Med. 1980;14A:495-9, Health Psychology. 1993;12:93-102, Med
Care. 1994;32:745-54)
Risk Factors -- Developmental
•  Childhood: Valliant’s longitudinal study of
male physicians
•  By caregiving, some physicians give to
patients the “love” and attention that they
may not have received.
Risk Factors -- Personality
•  compulsive triad (Gabbard): doubt, guilt, and
exaggerated sense of responsibility.
•  Rigidity
•  Stubbornness
•  Inability to delegate
•  Excessive devotion to work
•  Perfectionism
Risk Factors
•  Familial: Supportive marriage may be a
protective factor.
•  Environmental (Kaiser): less control = less
satisfaction, leadership and management,
administrative policies and procedures, and
organizational culture.
•  Gender: Women > Men
•  Age: Midcareer > early or late career
Well functioning
hospital system
Hospital/Clinic
Partially
functioning
system
Totally inadequate
hospital/clinic
function
Physician
MD with good skills;
team player; emotional
intelligence; knows
conflict resolution
Periodic anger
outbursts; poor team
player
Narcissistic traits;
recurrent anger outbursts;
generally frustrated;
passive aggressive; nurses
take brunt of anger
Perfect Storm:
Individual Pathology + Institutional Pathology
Capitalweather.com
Evolution of a Physician
Alice in Wonderland
There was nothing so VERY remarkable in that; nor did Alice think it
so VERY much out of the way to hear the Rabbit say to itself,
`Oh dear! Oh dear! I shall be late!'
(when she thought it over afterwards, it occurred to her that she ought
to have wondered at this, but at the time it all seemed quite natural);
But when the Rabbit actually TOOK A WATCH OUT OF ITS
WAISTCOAT- POCKET, and looked at it, and then hurried on, Alice
started to her feet, for it flashed across her mind that she had never
before seen a rabbit with either a waistcoat-pocket, or a watch to take
out of it, and burning with curiosity, she ran across the field after it,
and fortunately was just in time to see it pop down a large rabbit-hole
under the hedge.
(Lewis Carroll)
In another moment down went Alice after it, never once
considering how in the world she was to get out again.
The rabbit-hole went straight on like a tunnel for some way, and
then dipped suddenly down, so suddenly that Alice had not a
moment to think about stopping herself before she found herself
falling down a very deep well.
Evolution of Physicians
Family of Origin
Age 18
Conspiracy of Role Models
College
Medical
School
Residency
Licensed
Qualified
Certified
PTSD
MD
Stress Across the Lifespan
•  Medical Students: adjustment to the medical school
environment, perceived ethical and professional dilemmas, firsttime exposure to death and human suffering, student abuse,
personal life events, and educational debt. •  Residents: sleep deprivation, student loan debts, extended duty
hours, a lack of time for personal life, and efforts to find a job at
the completion of training.
•  Practicing physicians: malpractice suits, their degree of
autonomy, reimbursement issues, and challenges related to
office management.
•  Other sources of distress are similar at all stages of a career,
including encounters with patient death and suffering, medical
errors, fatigue, and challenges in balancing personal and
professional lives.
How Do Distress and Well-being Relate to Medical Student
Empathy? A Multicenter Study
Journal of General Internal Medicine 2007;22:177–183
Burnout in GW Class of ‘04 & ‘05
• Overall 41% indicated burnout in at least one category.
• Combining scores for both the high and medium terciles
• 69% emotional exhaustion
• 49% depersonalization
• 33% personal accomplishment.
Change in Mood and Empathy
during Internship
•  Elevated baseline vigor, energy and empathy compared to
same age peers
•  After 5 months, interns were significantly more angry,
fatigued, and depressed and had decreased empathic
concern
•  There was no improvement by the end of the internship
year.
Bellini L et al. Variation of mood and empathy during internship. JAMA. 2002; 287:
3143-3146.
Burnout and Resident Physicians
•  Recent study of internal medicine residents-76% met the
criteria for burnout. Burned out residents said they were
more likely to discharge patients early to make their work
manageable, did not fully discuss treatment options or
answer a patient’s questions, and made more medical
errors
•  50% said they rendered suboptimal care at least monthly
compared with 21% of residents who did not experience
burnout
(Shanafelt KA et al, Burnout and self-reported patient care in an internal
medicine residency program, Annals of Internal Medicine 2002;136:356-367)
Residents and Burnout
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Meta-analysis of published articles (n = 15)
Cross sectional, small, methodological problems
All specialties and international
Associated with depression and problems with
clinical care (subjective).
•  Sleep deprivation did not increase burnout, work
hour restrictions did not improve it!
•  Not strong enough to make causal explanations or
use demographic date to predict risk
Thomas, 2004 (JAMA)
Residents and Burnout
•  Prevention includes:
–  Restoring meaning
–  Facilitating social interactions
–  Increasing resident work control
–  Separating work from home life
Women and Burnout: The Good,
the Bad and the Ugly
Women and Medicine
•  Females more satisfied with specialty and
colleague relationships but less satisfied
with autonomy, relationship with
community, pay and resources (McMurray,
2000).
•  Female physicians had more complex
psychosocial patients, needed more time,
and made less money
Women and Medicine
•  Female physicians twice as likely to experience
stress and burnout compared to male counterparts
(Horner-Ibler, 2005)
•  More complex cases, more at odds with
organization
•  Canada: women had more group practices, lower
salaries, and double loads -- work + family
(Williams, 1990)
•  Resident Meta-analysis did not support higher
burnout in women.
Women and Medicine
•  More likely to experience harassment and
discrimination (example: pregnancy).
Women and Medicine
•  Female suicide rate equals that of males
among physicians (General population:
Males 4X > Females).
Women and Medicine: The Good
•  More naturally seek balance
•  Smoke less, drink moderate, and attend to
health screenings (Frank, 1998).
•  May be setting limits and serving as role
models to change culture of medicine
“If I stay at home with my baby, I
feel guilty about leaving my
patients unattended. But when I
am with my patients, I feel like a
bad mother who is neglecting her
child. It’s a no-win situation.”
(Myers and Gabbard, 2008)
Preventing Burnout -- Individual
•  The patient has the ultimate responsibility in
maintaining their health.
•  Take control of your work environment (hours) as
much as you can (Capacity - Load = Margin)
•  Have a rich personal, spiritual, emotional, and
community life outside of work
•  Have your own PCP
Preventing Burnout -Institutional Factors
•  Intrinsic Factors vs. Extrinsic Factors Rewarded
•  Physician Wellness Committee, Support Groups,
Retreats
•  Establish a Mentor Program
•  Offer benefits -- health clubs
•  Involve physicians in leadership decisions
•  Flexible scheduling for critical family events
•  Include physician health in curriculum
Preventing Burnout -- Training
•  Rachel Remen:
–  Finding Meaning
–  Restoring Sense of Service
Resources
•  Medical Society of DC (Barbara Allen)
–  www.msdc.org
•  Center for Professional Health
–  www.mc.vanderbilt.edu/cph