1. A New Look at What Physician Wellness is and How to Promote It Heather Kirkpatrick, Ph.D. ABPP, MSCP Jodie Eckleberry-Hunt, Ph.D. ABPP

2. Disclosure The presenters have no conflicts of interest to disclose.

3. Objectives Describe multiple dimensions of physician wellness Differentiate between physician burnout and physician wellness Describe methods of promoting physician wellness

4. Plan for our time 1. Brief review of relevant recent work –Importance of physician wellness –Differences from burnout –The need for targeted assessment of physician wellness –What the “well” physician looks like 2. Surveys to consider using 3. How to implement wellness in your training program 4. Wellness activity

5. What is wellness? Vague state of well-being “the quality or state of being in good health, especially as an actively sought goal.” -- (Merriam-Webster) “the quality or state of being healthy in body and mind, especially as the result of deliberate effort.” -- (Dictionary.com)

6. What is wellness? Vague state of well-being “the quality or state of being in good health, especially as an actively sought goal.” -- (Merriam-Webster) “the quality or state of being healthy in body and mind, especially as the result of deliberate effort.” -- (Dictionary.com)

7. Why is Wellness Important in Academic Medicine? It is a critical time in identity development Role models play a key part We teach the ideal and the practical We set the standard

8. PHYSICIAN WELLNESS Background Information—What do we know?

9. Rates of Burnout among Physicians Percentages of results of Maslach Burnout Inventory n= 7288 Shanafelt et al., 2012. Arch Intern Med, 2012 Oct 8; 172(18):1377-85.

10. Shanafelt et al (2013) –Found that spousal satisfaction of physicians report high satisfaction and most associated with time spend with partner each day (vs. other factors) Shanafelt Boone et al( 2012) –45% of practicing physicians report at least 1 symptom of burnout

11. Dyrbye et al, 2012 –Study of 7-item Physician Well-Being Index –Measure of distress in physicians –Tested nationally –Correlated with low quality of life, high fatigue, or recent suicidal ideation

12. Dyrbye et al., 2014 –Studied Medical students Residents/fellows Early career physicians (<5 years) General U.S. population (2 groups) –Grads from 4-year colleges –31-47 year olds who are employed Found burnout highest in residency Trainees more burned out than gen. pop controls Early career physician more burned out than gen pop controls

13. RECENT RESEARCH Wellness programs can make a difference

14. Research Update Olson et al (2014) –Examined role of physical activity and burnout –Survey of internal medicine resident physicians for one month –Residents who were able to meet national physical activity guidelines were less likely to be burned out than their fellow residents

15. Research Update West et al (2014) –Interventional study to promote well- being –Physicians randomly assigned to facilitated small groups 1 hour every 2 weeks vs. control group of unstructured time free from clinical duties –Found 12-month followup effect in decreased depersonalization but not effects on emotional exhaustion which were reduced at 3-months. –Found greater reported empowerment and engagement at work

16. Research Update Sood et al (2014) –Interventional study to promote Stress Management and Resiliency Training –Radiology physicians randomly assigned to one 90-minute group program with 2 followup phone calls vs. 12 week wait list control – Found improved quality of life, mindfulness and reduced stress at 12- week followup compared to controls

17. Research Update Zadeh et al (2012) –10-session wellness program offered to nurses –Satisfaction data collected –Satisfaction was high

18. Research Update Goodman & Schorling (2012) –Offered CE course on mindfulness to 93 practitioners –Met 2.5 hours week + one 7-hour session –MBI given pre- and post-intervention –Significant reduction in burnout found

19. Research Update Saadat et al (2012) –Many residents chose to participate –Randomly assigned to wellness intervention group No treatment but with release time No treatment with regular duties –Beneficial effect with respect to Lower parental stress Increased social support from work Significant reduction in anxiety Decreased use of avoidance coping Decreased use of alcohol

20. Measuring Wellness

21. PHYSICIAN WELLNESS INVENTORY

22. Physician Wellness Methodology 1,985 members of the American Academy of Family Physicians 444 participants (22% response rate) Focused on 310 Full-time Physicians Administered: –Physician Wellness Inventory –Maslach Burnout Inventory –Subjective Happiness Scale –Patient Care Scale Eckleberry-Hunt J., Kirkpatrick, H. et al. Development of the physician wellness inventory (in review).

23. Physician Wellness Inventory 14 items measuring characteristics of wellness specific to physicians 5 point Likert-type scale ranging from Strongly Disagree to Strongly Agree Eckleberry-Hunt J., Kirkpatrick, H. et al. Development of the physician wellness inventory (in review).

24. Maslach Burnout Inventory 22 Items measuring characteristics of burnout 7 point Likert-type scale ranging from Never to Everyday Emotional Exhaustion (High score=Higher distress) Depersonalization (High score= Higher cynicism) Personal Accomplishment (Low score = Feeling of less accomplishment) Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3 rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.

25. Subjective Happiness Scale 4 item global assessment of happiness 7 point Likert type scale ranging from “Not a very happy person” to a “Very happy person” Higher score = more happy Lyubomirsky S, Lepper H. A measure of subjective happiness: Preliminary reliability and construct validation. Social Indicators Research. 1999;46:137- 155.

26. Patient Care Scale 8 item instrument developed based on Firth-Cozens and Greenhalgh categories of stress on patient care 6 point Likert type scale from Never to Everyday Firth-Cozens J, and Greenhalgh J. Doctors’ perceptions of links between stress and lowered clinical care. Soc Sci Med. 1997;44:1017-22.

27. Patient Care Scale Within the last four months: –I have been irritable with patients –I have been impatient with patients –I have taken shortcuts that could negatively impact patient care –I did not follow standard procedures that could have negatively affected the patient care I provided –I made treatment errors not secondary to medical knowledge –I did not listen to a patient’s complaints –I feel guilty about how I treated a patient –I seriously think about leaving the practice of medicine **Cronbach’s Alpha.87 Eckleberry-Hunt J., Kirkpatrick, H. et al. Development of the physician wellness inventory (in review).

28. Demographics of the Study Sample CharacteristicsNo. (% of respondents) (the numbers do not equal 100% due to rounding) Gender Male Female 170 (55) 140 (45) Ethnicity Caucasian African American Hispanic Native American Arabic or Middle Eastern Asian or Pacific Islander Other Missing 249 (80) 11 (4) 8 (3) 1 (0.3) 5 (2) 21 (7) 12 (4) 3 (1) Other demographics collected: Age, Marital Status, Practice Setting

29. Factor Analysis of the Physician Wellness Inventory Three factors found: –Career Purpose –Distress –Cognitive Flexibility Account for 55.41% of the variance

30. Factor One: Career Purpose Factor 1: Career PurposeFactor Loading Working with patients brings me satisfaction..855 My work brings joy to my life..749 Positive patient relationships outweigh negative patient relationships..651 I am generally satisfied with my career choice..619 I feel a spiritual purpose or connection with my life’s work..546 Cronbach’s alpha.83

31. Factor Two: Distress Factor 2: DistressFactor Loading During the past two weeks, my inability to control my distress has negatively affected the care I give patients..780 Over the last month, I have often been bothered by feeling nervous, anxious or on edge..728 During the last two weeks, I have often been bothered by little interest or pleasure in doing things..644 During the past two weeks, I have often been distressed by administrative demands that compete with clinical duties..534 Over the past month, there has been a patient encounter that has distressed me..448 Cronbach’s alpha.756

32. Factor Three: Cognitive Flexibility Factor 3: Cognitive FlexibilityFactor Loadings I am open to new ideas and ways of doing things in the workplace..654 Feeling compassion for others is a regular part of how I work..593 I often see more than one side to an issue..569 I spend time reflecting on things I can improve about myself, my life, and my professional role..466 Cronbach’s alpha.657

33. Physician Wellness Inventory Convergent and Divergent Validity PWI Career Purpose PWI Distress PWI Cognitive Flexibility MBI Emotional Exhaustion -.55.70-.14 MBI Depersonalization -.48.51-.30 MBI Personal Accomplishment.56-.32.30 Subjective Happiness Scale (Total Score).55-.44.29 *all significant at p<.01

34. Wellness Promotion How can you promote Career Purpose and Cognitive Flexibility? How can you decrease Emotional Distress?

35. Wellness Promotion Career Satisfaction –Faculty attitudes affect resident attitudes Wellness for faculty important Assess faculty wellness to increase awareness –Workshops Skill building (finances, relationships, conflict, building spiritual formation) –Support groups with reflection Balint groups Meaning in medicine groups (CommonWeal by Rachel Naomi Remen)

36. Wellness Promotion Cognitive Flexibility –Cognitive behavioral training David Burns Feeling Good Handbook –Mindfulness training Russ Harris The Happiness Trap Jon Kabat-Zinn Ron Epstein’s work –Fun reframing exercises Ball exercise Letter writing Journaling

37. Wellness Promotion Distress –Provide opportunities for normative disclosure of emotion –Create resources List of referral options who are qualified and knowledgeable about medical culture Encourage every resident to have a PCP List of PCPs who will work with residents –Provide opportunities for safe measurement of emotional distress –Be proactive—check in with residents

38. Additional Analyses Includes 439 full and part-time Family Physicians total 70.6% Full-Time 29.4% Part-time 234 Men 205 Female

39. Caucasian 83% Academic Practice 11% Private Practice 66% Both 16% Married 86% Have a PCP 75.6% Mean Age 48.5 Mean Practice Years 17 Additional Analyses

40. t Tests –No gender differences on PWI scales –No gender differences on MBI scales –Children do not make a differences on PWI or MBI scales –No differences between full and part-time status on PWI or MBI scales

41. Additional Analyses: Correlations Career Purpose –Positive correlation with Family Support, Friend Support, Health, Mental Health, Finances, and Workload (p<.01) Distress –Negative correlation with Family Support, Friend Support, Health Mental Health, Finances and Workload (p<.01) Cognitive Flexibility –Positive correlation with Family Support (p<.05), Friend Support Mental Health (p<.01), Finances (p<.05)

42. Additional Analyses: Correlations with PWI Career Purpose Family Support, Friend Support, Health, Mental Health, Finances, and Workload (p<.01)

43. Additional Analyses: Correlations with PWI Distress Family Support, Friend Support, Health, Mental Health, Finances and Workload (p<.01)

44. Additional Analyses: Correlations with PWI Cognitive Flexibility Friend Support, Mental Health (p<.01) Family Support & Finances (p<.05)

45. Additional Analyses: Correlations Patient Care Scale (Higher is Bad) –Negative correlations with Career Purpose, Cognitive Flexibility, and Personal Accomplishment (p<.01) –Positive correlation with Distress, Emotional Exhaustion, and Depersonalization (p<.01) –Negative correlation with Family Support (p<05), Friend Support, Health, Mental Health, Finances, and Workload (p<.01)

46. Additional Analyses: Correlations with Patient Care Scale Worse self- reported Patient Care Distress, Emotional Exhaustion, and Depersonalization (p<.01)

47. Additional Analyses: Correlations with Patient Care Scale Better self- reported Patient Care Career Purpose, Cognitive Flexibility, and Personal Accomplishment (p<.01) Friend Support, Health, Mental Health, Finances, and Workload (p<.01) Family Support (p<05)

48. Additional Analyses: Correlations Emotional Exhaustion –Negative correlation with Family Support, Friend Support, Health, Mental Health, Finances, and Workload (p<.01) Depersonalization –Negative correlation with Family Support, Friend Support, Health, Mental Health, Finances and Workload (p<.01) Personal Accomplishment –Positive correlation with Family Support, Friend Support, Health, Mental Health, Finances and Workload (p<.01)

49. Additional Analyses: Correlations with MBI Emotional Exhaustion Family Support, Friend Support, Health, Mental Health, Finances, and Workload (p<.01)

50. Additional Analyses: Correlations with MBI Depersonalization Family Support, Friend Support, Health, Mental Health, Finances and Workload (p<.01)

51. Additional Analyses: Correlations Personal Accomplishment Family Support, Friend Support, Health, Mental Health, Finances and Workload (p<.01)

52. SURVEY TIME!

53. Scoring the PWI CP 1, 4, 9, 10, 12 Mean: 4.12 SD: 0.66 D 3, 6, 8, 11, 13 Mean: 2.85 SD: 0.83 CF 2, 5, 7, 14 Mean: 4.25 SD: 0.46

54. What the PWI means the meaning of your work Career Purpose (high is good) emotional distress and stress specific to physicians Distress (low is good) open minded-ness and the ability to see different perspectives. Cognitive Flexibility (high is good)

55. USING THE PWI IN YOUR RESIDENCY

56. The Basics How? –PWI available from authors –Administer during time when most residents are already gathered –Or –Administer and have turn in to program coordinator who tracks who has completed and who has not –Consider anonymous reporting

57. The Basics Who? Residents and faculty? –Consider both for more buy-in to the goal of improving wellness for all physicians Who will administer and score? –Concerns about confidentiality –Not the program director –Brainstorm a person who the residents will trust, but can communicate findings to program director and faculty –Consider self-scoring during group activity

58. The Basics When? –At beginning of academic year –Mid-way through academic year –Pre-post intervention –Chose a class to pilot before going residency-wide

59. The Basics Why? –Important to track wellness –Once measureable, is on everyone’s radar –Can attempt to manage Self Program

60. The Basics How? Part 2 –What to do with results? –Can have residents self-score –Communicate scores back to residents for individual feedback? Requires identification –Communicate average scores to program faculty or interventionists

61. WELLNESS ACTIVITY Mindfulness

62. Directions Have your group chose one of the three poems Have one member read it out loud, slowly while others follow along. Read the poem until you hear a word or phrase that touches you, resonates, attracts or even disturbs you. Have someone else in the group read the poem out load again. Consider the word or phrase. Write about that word or phrase for about 5 minutes. Share what thoughts you are willing to share with the group Read the poem out loud a 3 rd time.

63. jeckleberryhunt@att.net hkirkpat@genesys.org