Sustaining your practice: Using mindfulness as an everyday tool to promote compassion Cora Collette Breuner, MD, MPH, FAAP Professor Department of Pediatrics  Adolescent Medicine Adjunct Professor Orthopedics and Sports Medicine Seattle Childrens Hospital  University of Washington

Faculty Disclosure Information In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.

Objectives 1.Recognize possible signs of physician burnout. 2. Identify strategies for preventing and addressing burnout.

Definition: Provider Fatigue// Burnout Loss of emotional, mental, and physical energy due to continued job-related stress. Symptoms include: Depersonalization Emotional exhaustion Low personal accomplishment Burnout is more common among physicians than among other professionals.

Burnout and satisfaction with work/life balance among US physicians Burnout among physicians was measured using the Maslach Burnout Inventory (MBI) 45.8% of physicians reported at least one symptom of burnout The MBI has three subscales to evaluate each domain of burnout: Emotional exhaustion Depersonalization Low personal accomplishment Arch Intern Med 2012; DOI:10.1001/archinternmed.2012.3199.

Six in 10 physicians would quit today Doctors are working less, seeing fewer patients, and many would quit if they could, a sweeping survey of 13 575 physicians from across the nation shows. A survey of American’s physicians: practice patterns and perspectives was commissioned by the Physicians Foundation. It is the latest and perhaps the largest and most comprehensive of a number of surveys that have identified wide, deep, and increasing discontent among the nation's physicians regardless of their age, gender, specialty, location, or employment status.

Depression Katherine J Gold MD, MSW, MS, Ananda Sen,PhD, and Thomas L. Schwenk, MD Details on suicide among U.S. physicians: Data from the National Violent Death Reporting System. Gen Hosp Psychiatry 2013 Jan 35 (1) 45-49. Collier R. Physician suicide too often “brushed under the rug”. CMAJ. 2017 Oct 2; 189(39): E1240–E1241.

Why is it happening?

Shortage of physicians "By 2015, the US will be 62 900 doctors short, and the future looks even worse," Archambault said. "By 2025, the estimated shortage of doctors will more than double, as baby boomers require more care. Seeing a doctor in a reasonable amount of time may be a thing of the past, unless meaningful consumer-directed reform is passed soon."

Changing Patient-Physician Interaction EMR distances us from our patients More patient autonomy More focus on patient satisfaction Less focus on provider satisfaction

EMR Time consuming More oversight in the office Redundant Inefficient

Individual issues Entitled (I've worked really hard and got all As)? Anxiety from transition, change, and uncertainty? "Broken contract" Addicted to affirmation—less appreciation shown by patients More deep rooted? “This is not what I signed up for, this is not my calling, these are not my values” Is it because physicians' values are being compromised?

How do we fix it?

Doctors who view medicine as a calling are more satisfied They feel better about caring for patients with complex conditions such as obesity and alcohol addiction than other physicians, research shows. The reasons that drive doctors to practice medicine can have an impact on how satisfied they are caring for patients with challenging conditions, says an Archives of Internal Medicine research letter published online August 27. Researchers analyzed data from a national survey of 1504 primary-care physicians. They found that doctors who see medicine as a calling are more likely than other physicians to be satisfied treating patients who are obese or addicted to nicotine or alcohol.

Interventions Enhance fulfillment Reducing dissatisfiers Focus on the work itself. Do physicians recognize what they find most fulfilling? What does their best work look like? Are they making full use of their knowledge, skills, and innate abilities? Are they growing and developing as human beings? Do they feel that they are making a real difference in the lives of their patients and communities? Reducing dissatisfiers Reduce stressors by cutting back on working hours, relaxing intrusive oversight, and finding ways to lift the burden of "busywork" from the shoulders of physicians. Fair pay

Three Domains of the Stanford Wellness Framework Culture of Wellness: Creation of work environment with a set of normative values, attitudes, and behaviors that promote self care, personal and professional growth, and compassion for colleagues, patients, and self Efficiency of Practice: Value added clinical work accomplished divided by the time and energy spent Personal Resilience: Set of individual skills, behaviors, and attitudes that contribute to personal physical, emotional, and social well-being, including the prevention of burnout ©2016 Stanford Medicine 

Culture of Wellness-Stanford Well MD Culture of Wellness: Creation of work environment with a set of normative values, attitudes, and behaviors that promote self care, personal and professional growth, and compassion for colleagues, patients, and self Ways to Implement: Define professional wellness as a priority Utilize the different survey instruments to regularly assess physician well-being Create a toolkit of interventions such as forums and engagement groups to foster community support Develop a communication platform for physicians to address daily work challenges ©2016 Stanford Medicine 

Efficiency of Practice Efficiency of Practice: Value added clinical work accomplished divided by the time and energy spent Ways to Implement: Re-engineer the way work is done and by whom (ex. EHR documentation) Utilize the Practice Assessment Tool to assess your practice’s current state Undergo a LEAN event Engage clinical and operations leadership teams ©2016 Stanford Medicine 

Personal Resilience Personal Resilience: Set of individual skills, behaviors, and attitudes that contribute to personal physical, emotional, and social well-being, including the prevention of burnout Ways to Implement: Provide assistance for physicians in accomplishing basic life tasks Establish a quiet, refresh, and recharge room for physicians Provide on-site exercise facilities Offer peer support programs and off-site psychological counseling services ©2016 Stanford Medicine 

Institute for Health Care Improvement Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017

Experiential

Grepmair L,et al. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, double-blind, controlled study. Psychother Psychcom. 2007;76(6):332-8.

Experiential

What can you do for your patient/ for yourself? Experiential

Resources Calm, Headspace

AAP Section on Integrative Medicine : SOIM Mission: to support the mission of the AAP "to attain optimal physical, mental, and social health and well being for all infants, children, adolescents, and young adults" by: promoting polices to enhance patient-centered care; integrating evidence-based, safe and effective complementary therapies into high quality pediatric practice; educating clinicians and families; advocating for appropriated payment for safe and effective services; and respectfully collaborating with diverse health professionals dedicated to enhancing the health of infants, children, and adolescents.

Conclusions Burnout is real and has both qualitative and quantitative risks for healthcare delivery and our profession The systemic changes that contributed to this had noble intent but have diminished physician autonomy to such an extent that following the rules and feeling "excessively scrutinized" and avoiding criticism is becoming the chief professional motivation There are many ways to approach this and definitely include institutional and efficiency changes but mindfulness is a proven and thoughtful intervention that may help promote a culture of wellness and personal resilience

Websites https://pediatrics.aappublications.org/content/134/4/830 https://www.ama-assn.org/topics/physician-burnout https://mindfulnessnorthwest.com www.stepsforward.org https://nccih.nih.gov/health/

Questions? Reflections? cora.breuner@seattlechildrens.org (206) 999- 1208

David Whyte - Enough Enough. These few words are enough. If not these words, this breath. If not this breath, this sitting here. This opening to the life we have refused again and again until now. Until now.