Metro Health – University of Michigan Health Physician Burnout David Berg DO Emergency Medicine Metro Health – University of Michigan Health January 2018

Financial disclosures None

Objectives Define burnout as it relates to the practicing physician Provide a history and current update of physician wellness and how it is integrated into the current medical education system. Discuss the extent, major contributing factors, and consequences of the burned out physician Provide resources and diagnostic tools for recognition of clinical burnout

Scary Statistics A study by Shanafelt and colleagues studied two groups of physicians from 2011 to 2014 Using the MBI, 3310 physicians surveyed in 2011, 45.5% had at least one symptom of burnout In 2014, 54.4% of 3680 physicians surveyed

Scary Statistics Physicians in front line specialties (Emergency Medicine, Internal Medicine, and Family Medicine) are at greatest risk Female physicians are 1.6 times as likely to experience burnout than men

Scary Statistics Burnout is not just unique to physicians. A study completed by McHugh MD et al. found that 34% of nurses working in the hospital and 37% of nurses working the in nursing homes experienced burnout.

What is Burnout? Webster defines burnout as: “exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration” Physical, emotional and mental exhaustion caused by long term involvement in emotionally demanding situations

What is Burnout? Truthfully is Difficult to define There is a huge literature base, many authors put their own spin on it, and it means different things to different people at different times Cristina Maslach, Professor of Psychology at the University of California at Berkley, had created the Maslach Burnout Inventory

Maslach Burnout Inventory Defines burnout as: “an erosion of the soul caused by deterioration of one’s values, dignity, and spirit.” This Inventory model goes on to explain 3 components of burnout that are now widely used to define the burnout syndrome.

3 components of Burnout Emotional exhaustion or loss of passion for one’s work Depersonalization, or treating patients as objects 3. Sense that your work is no longer meaningful

History From: Constance Ange. Clinician burnout in Contemporary Medicine

How ACGME is getting involved A task force was utilized to update Section VI of the Common program requirements The revision was completed in February 2017 and most of these requirenments went into effect in July 2017

How ACGME is getting involved The Learning and Working Environment Patient Safety, Quality Improvement, Supervision, and Accountability Professionalism Well-Being Fatigue Mitigation Clinical Responsibilities, Teamwork, and Transitions of Care Clinical Experience and Education

Welcome to 2018!!! As the landscape of medicine changes and physicians continue to strive to provide safe, cost effective, quality care consider these daily obstacles Try to make varied patient clinical presentations fit within the constraints of the EHR Learn workarounds to maneuver through unfriendly EHR user interfaces Hunch over keyboards performing data entry that could be done by others or by cognitive support Click boxes to prove to CMS their meaningful use of the EHR Hassle with payers over prior authorization issues Pick the right diagnostic code from the 10-fold increase in choices following ICD-10 Answer questions coming in through the EHR’s patient portal

Welcome to 2018!!! Check state opioid databases prior to prescribing narcotic pain meds Ensure they are conforming with multiple quality measures to ensure maximal reimbursement in 2019 through MACRA Explain to patients that the testing and treatment that Google recommended for their symptoms is not in their best interests Get translators or language lines into the exam room for increasingly diverse patient populations Learn virtual visits and figure out how to get paid for them Spend thousands of dollars and hundreds of hours on maintenance of certification, performing tasks and taking tests to prove they are current and competent

Medscape Lifestyle Report 2017: Race Ethnicity, Bias and Burnout More than 14,000 physicians from 30 specialties responded to this survey Burnout rates have been trending upwards since 2013 (from overall 40% from the first survey to overall 51%) Severity of burnout is not consistent with burnout rates

Medscape lifestyle report 2017

Medscape lifestyle report 2017

Respondents were asked to rate the severity of their burnout on a scale of 1 to 7 where 1 equals “it does not interfere with my life” to 7 “it is so severe that I’m thinking of leaving medicine altogether’. Of note, ER and primary care physcians did not have the highest rates of burnout severity.

Consequences of Burnout Professionally 1. Decreased patient satisfaction 2. Increased medical errors 3. Increased litigation Personally 1. Increased rates of depression 2. Increased rates of substance abuse 3. Decreased quality of interpersonal relationships 4. Increased rates of early retirement

Medscape lifestyle report 2017

Medscape lifestyle report 2017

Scoring the MBI Section A: Burnout Burnout (or depressive anxiety syndrome): Testifies to fatigue at the very idea of work, chronic fatigue, trouble sleeping, physical problems. For the MBI, as well as for most authors, “exhaustion would be the key component of the syndrome.” Unlike depression, the problems disappear outside work. Total 17 or less: Low-level burnout Total between 18 and 29 inclusive: Moderate burnout Total over 30: High-level burnout

Scoring the MBI Section B: Depersonalization “Depersonalization” (or loss of empathy): Rather a “dehumanization” in interpersonal relations. The notion of detachment is excessive, leading to cynicism with negative attitudes with regard to patients or colleagues, feeling of guilt, avoidance of social contacts and withdrawing into oneself. The professional blocks the empathy he can show to his patients and/or colleagues. Total 5 or less: Low-level burnout Total between 6 and 11 inclusive: Moderate burnout Total of 12 and greater: High-level burnout

Scoring the MBI Section C: Personal Achievement The reduction of personal achievement: The individual assesses himself negatively, feels he is unable to move the situation forward. This component represents the demotivating effects of a difficult, repetitive situation leading to failure despite efforts. The person begins to doubt his genuine abilities to accomplish things. This aspect is a consequence of the first two. Total 33 or less: High-level burnout Total between 34 and 39 inclusive: Moderate burnout Total greater than 40: Low-level burnout A high score in the first two sections and a low score in the last section may indicate burnout. Note : Different people react to stress and burnout differently. This test is not intended to be a scientific analysis or assessment. The information is not designed to diagnose or treat your stress or symptoms of burnout. Consult your medical doctor, counselor or mental health professional if you feel that you need help regarding stress management or dealing with burnout.

Self care – Not the physicians’ strength Less doctor visits for themselves Self-prescribe drugs (i.e. will not see a doctor) Perceived (??) stigma around seeking help or support Willing to work when sick… and expect the same from colleagues (but not patients) Denial and avoidance – physician coping strategies Poor record of mutual support and positive feedback in the field Protecting the privacy of colleagues Doctors are self-reliant, individually driven, achievers who are industrious and self-sacrificing

What does self care look like for you… Self-compassion Reframing Gratitude and appreciation Humor ? Financial goals Time for yourself Sleep Food Aligning with your values

Resources for Physician Wellness Did you know????? Metro Health has its own resources for physician wellness available through the metronet!!

Resources for Physician Wellness http://wellmd.stanford.edu/ https://www.thehappymd.com https://www.aafp.org – Physician Health First www.acgme.org/what-we-do/initiatives/physician-well-being

References Harley, Phil; Beating Burnout: Physician Heal Thyself: A guide for busy, tired and stressed doctors. CreateSpace Independent Publishing Platform, 2016. Gergen-Barnett, Katherine, “In Pursuit of the Fourth Aim in Health Care: The Joy of Practice,” Med Clin North Am. 2017 Sep;101(5):1031-1040. Stultz, Tara, “Would You Do It All Over Again?” Medical Economics, Oct. 22, 2010. Dechant, Paul, “Stop Piling on Physicians : The Last Straw of Burnout”, KevinMD.com, Aug. 6, 2017 C. Maslach, S.E. Jackson, M.P. Leiter (Eds.), Maslach Burnout Inventory manual (3rd ed.), Consulting Psychologists Press (1996)