1. Clinician Wellness - Building Resiliency in Family Medicine Teachers and Trainees Debra A. Gould MD, MPH deb.gould@commhealthcw.org Kirk D. Strosahl PhD Mountainconsult@msn.com Patricia J. Robinson, PhD robinsonpatricia@me.com (Pre-conference Workshop) STFM Annual Conference – Seattle WA April 25, 2012

2. Goals & Objectives teach residents about Resiliency develop a personal strategy for building resiliency based on Acceptance and Commitment Therapy (ACT). learn Self-Assessment – Burnout (MBI), sources and magnitude of Stress (PCP-SC) ) and Psychological flexibility (AAQII). identify 6 core psychological processes that support clinician resiliency learn specific exercises to teach residents effective strategies for coping with the stresses of primary care practice and adaptation to the Patient Centered Medical Home (PCMH).

3. Workshop Outline I.Intro – personal - Deb II.Intro – Burnout epidemiology; Resiliency through Psychological Flexibility (brief model) - Deb III.Burnout - Kirk a.MBI b.PCP-SC IV. Psychological Flexibility, Avoidance, hexaflexes - Deb a. AAQII V. Mindfulness - Patti a.TEAMS b. Sky Metaphor VI. Values - Kirk a.Professional and Personal Values Clarification VII. Bringing it all together ! – Passengers on the Bus - Patti VIII. Self-Compassion – Kirk & Patti a.Video IX. What will you take Home? Professional & Personal Values Assessment & Action Plan - Deb X. Wrap-up –Evaluation & Feedback - Deb

4. CWFM Clinician Wellness Program Goals – burnout education, self-assessments, promote activities & behaviors Core Philosophies –at risk throughout training & career –recognizing & managing risk factors is legitimate core activity of residency –stepped care approach, evidence-based (see handout)

5. Activities –Social integration retreats (Snow day) –Self-discovery workshops (mindfulness) –Clinical Skill Building (Star curriculum) –Individual Assessment & Intervention (MBI, AAQII, PCP-SC) CWFM Clinician Wellness Program

6. value their role self-aware balance and prioritize manage a practice support relationships (Building Physician Resilience. Jensen PM, Trollope-Kumar K, Waters H, Everson J. Can Fam Physician. 2008 May;54(5):722-9.) Resilient Clinicians …

7. Personal & Organizational Resilience Burnout Wellness ( Psychological Flexibility)

8. Psychological flexibility Resiliency - Core Processes Be Present Connect with Values Acceptance Defuse Changing Self Act on Values The ACT Model

9. “Adaptive Reserve” Healthy Relationship Structure Effective Communication Trust Principles for establishing Common Values PCMH (Journey to the Patient- Centered Medical Home: A Qualitative Analysis of the Experiences of Practices in the National Demonstration project. Nutting P, et. Al. Ann Fam Med 2010;8 (Supp1):S45-S55.)

10. The Primary Care Behavioral Health (PCBH) Model in PCMH: fulltime member of PC team consultant to patients, residents, faculty brief interventions to promote psychological flexibility in patients and teaches residents to use these as well ID’s patient populations and develops pathway services that promote skill development in patients and clinicians Teaches & supports ongoing skill development of personal and organizational resiliency 10 (For more information of this model, see Robinson & Reiter, 2007. Behavioral Consultation and Primary Care: A Guide to Integrating Services)

11. Over-eat, drink, work Substance abuse Isolation Depression, Suicide Leave Profession Relationship Problems Burnout 2014

12. Burnout Emotional Exhaustion De-Personalization Personal Accomplishment (Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology. 2001; 52, 397–422. doi:10.1146/annurev.psych.52.1.397.)

13. Psychological Inflexibility Burnout - Core Processes Not “in the room” with patient Forget “Why we went into Medicine” Avoidance of painful Medical Experience Fusion “Difficult Patient” Loss of “Compassionate Clinician” Self Isolate from family, Depression, Etoh

14. Burnout Rates Medical Students – 45% Residents – 27% FP to 75% OB-GYN Attendings – 20% - 65% Limitations of studies – poor response rates, definition of burn-out (EE, DP, PA). 14

15. Burnout – Factors/Consequences Adverse workflowLow MD satisfaction Low control High Stress/Burnout Unfavorable culture Intent to leave MD stress/burn-out Quality of care errors (Linzer et.al, Working Conditions in Primary Care: Physician Reactions and Care Quality. Ann Inter Med 2009;151:28-36.) 15

16. ACT Evidence & Burnout Drug Abuse Counselors ACT vs. Multicultural vs. Bio Education (Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher,G., et al. The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy. 2004;35(4),821–835.) 1 day workshop ACT had Positive impact on Stigma and Burnout scores at 3 mo. f/u (Exercise – MBI)

17. Self-Assessment: Burnout Maslach Burnout Inventory (MBI) – scores LowMeanHigh EE - 27 DP - 10 PA - 40 (Exercise –de-brief)

18. Primary Care Provider – Stress Checklist (PCP-SC) Where are your areas of heaviest stress? I. Interactions with patients II. Practice Management III. Administrative Issues IV. Education/Learning V. Relationships with Colleagues VI. Balance between Work and Life (Exercise PCP- SC)

19. ACT Model (Acceptance and Commitment Therapy) Psychological Flexibility Pain is Inevitable, Suffering is Optional! (AAQ II Exercise)

20. Experiential Avoidance Behavioral Avoidance

21. Psychological flexibility Resiliency - Core Processes Be Present Connect with Values Acceptance Defuse Changing Self Act on Values Mindfulness

22. Psychological flexibility Resiliency - Core Processes Be Present Connect with Values Acceptance Defuse Changing Self Act on Values Values

23. Mindfulness TEAMS (Private Experience) Sensations Thoughts EmotionsAssociationsMemories (TEAMS Exercise)

24. Mindfulness – Noticing Self Clouds = thoughts and feelings (Sky Metaphor Exercise)

25. The Message - Values “Direction in life” Not a goal What’s Important to You in how you live your life?

26. Graduation/Retirement Party Worksheet Instructions: For each of the four life areas listed below, please describe your core values. For example, if you were at your own graduation/retirement party, what would you like to hear other people say about what you “stood for”, the mark you had left... generally, what your behavior over the years demonstrated about your personal beliefs. 1.Studying/Practicing Medicine: 2.Relationships with Colleagues: 3.Relationships with Family/Friends: 4.Personal Health & Well-being:

27. Passengers on the Bus (Exercise)

28. Get Present (Learning to Stay Present) Validate Distress Walk in Their Shoes (Practicing Empathy) See With Soft Eyes (Practice Compassion) Reframing Intentions STAR Model Curriculum (Video)

30. 5. Burnout Prevention and Recovery Plan To help reduce your risk of burnout, please describe specific behaviors you intend to use, when you will use them, and how often for each of the four following skill areas. Try to respond to at least two areas initially and add in more plans later. The more specific is your plan, the more likely it is that you will follow it! Practice of Acceptance: Practice of Mindfulness (i.e., present moment awareness, contacting transcendent of self): Practice of Contact with Personal Values: Practice of Value Consistent Daily Actions:

31. Resident “Self- Management Workshops” - Schedule Beginning of Academic Year: R1 – Orientation: Introduction to Burnout, ACT focus on Values exercise self assessment - MBI, AAQII/PCP-AAQ local resources R2/3 – Reminder about Burnout, ACT focus on Sources of Stress, Mindfulness & Values exercises self assessment - MBI, AAQII/PCP-AAQ, PCP-SCL local resources Mid-Year: R1/R2/R3 – Reminder about Burnout, ACT focus on Sources of Stress, Mindfulness exercises self assessment - MBI, AAQII/PCP-AAQ, PCP-SCL local resources 31

32. Resident Resources CHCW  Employee Assistant Program  Athletic Club corporate membership  Peers  Advisor  Dr. Strosahl – Behavioralist Faculty  Health insurance – health risk assessment,  - Gift certificate for healthy lifestyle choices; massage therapist. Hospital – Physician Wellness Committees Washington State Physicians Health Program - http://www.wphp.org/services http://www.wphp.org/services Community – family, faith community, social interests, Farmer’s Market, Sparkpeople.com – diet & exercise (free) 32

33. Wrap – up Feedback/evaluation forms Thank-you for attending our workshop!!

34. 34 ACT Resources “Association for Contextual Behavioral Science” http://www.contextualpsychology.org/ http://www.contextualpsychology.org/ http://www.newharbingeronline.com/real-behavior-change-in-primary-care.html New Harbinger Publications http://www.newharbinger.comhttp://www.newharbinger.com