1. Primary Care Clinician Stress and Psychological flexibility Debra A. Gould MD, MPH Central Washington Family Medicine Residency Program deb.gould@chcw.org Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session # H4a October 18, 2014 Michael J. Aquilino MS Central Washington Family Medicine Residency Program maquilino@chcw.org Patricia Robinson PhD Mountainview Consulting Inc. Patti@Mtnviewconsulting.com

2. Faculty Disclosure We currently have or have had the following relevant financial relationships during the past 12 months: Dr. Gould & Dr. Robinson: Book Royalties - New Harbinger Publications, Inc. Dr. Robinson: - Mountainview Consulting Group, Inc. -Book Royalties - Springer Science + Business Media, LLC - Behavioral Consultation and Primary Care: A Guide to Integrating Services

3. Learning Objectives At the conclusion of this session, the participant will be able to : Use tools to self-assess level of burn-out, sources and magnitude of stress, and level of psychological flexibility Name 6 core psychological processes that support clinician resiliency Describe specific exercises designed to enhance resilience among PCMH team members Develop a personal strategy for building resiliency based on cognitive-behavioral therapy model called Acceptance and Commitment Therapy (ACT)

4. Bibliography / Reference 1.Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD, Acad Med, 2014 Mar;89(3):443-51. doi:10.1097/ACM.0000000000000134. 2.Identifying psychological mechanisms underpinning a cognitive behavioural therapy Intervention for emotional burnout. Lloyd, J., Bond, F. W. & Flaxman, P. E. Lloyd, Apr-Jun 2013, Vol. 27 Issue 2, p181-199. 3.To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice. Lamothe M, Boujut E, Zenasni F, Sultan S. BMC Family Practice 2014, 15:15 doi:10.1186/1471- 2296-15-15. http://www.biomedcentral.com/1471-2296/15/15 4.Not all coping strategies are created equal: a mixed methods study exploring physicians’ self reported coping strategies. Lemaire JB, and Wallace JE, BMC Health Services Research 2010, 10:208, http://www.biomedcentral.com/1472- 6963/10/208 5.Real Behavior in Primary Care; Improving Patient Outcomes and Increasing Job Satisfaction. Robinson PJ, Gould DA, Strosahl KD, New Harbinger Press, Inc., 2010, Oakland California. 6.The Mindful Employee and Effective Employee. Flaxman PE, Bond FW, Livheim F, Hayes SC; New Harbinger Press, Inc., 2013, Oakland California.

5. Learning Assessment Describe self-assessment tools and use them to determine a. level of burn-out, b. sources and magnitude of stress, and c. level of psychological flexibility Describe 6 core psychological processes that support clinician resiliency and specific exercises designed to enhance resilience among PCMH team members

6. Primary Care Home “Adaptive Reserve” Value their role Self-aware Balance and prioritize Manage a practice Support relationships

7. Resilience Burnout Wellness IndividualOrganizational ACT

8. Burnout Symptoms: Emotional Exhaustion Depersonalization Personal Accomplishment Unhealthy coping: Over-eat, drink, work Isolation, Depression, Suicide Leave Profession Relationship Problems

9. Psychological Flexibility “ Learning to be aware and accepting of the pain that comes into our lives and continue to pursue what we value.”

10. Psychological flexibility Be Present Acceptance Defuse Changing Self Resiliency – Core Processes Connect with Values Act on Values MindfulnessValues

11. Tool: PCP Stress Checklist Domains: Interactions with Patients Practice Management Administrative Issues Education / Learning Relationships with Colleagues Balance between Work and the “Rest of Life” Scoring: Higher scores indicates more stress (range 0-100)

12. Tool: Primary Care Provider Acceptance and Action Questionnaire (PCP-AAQ) Measures Psychological Flexibility 20 Items; sum equals total score (range 0-120) Higher indicates greater psychological flexibility.

13. Tool: Values Clarification If you were at your own retirement party, what would you like to hear other people say about what you stood for: 1.Practicing Medicine 2.Relationships with Colleagues 3.Relationships with Family/Friends 4.Personal Health & Well-being

14. My work life is totally consistent with my values My work life is totally inconsistent with my values Studying/ Practicing Medicine Relationships with colleagues Personal Health & Well Being Relationships with Family & Friends Tool: Bulls Eye Values Assessment x x

15. 15 Personal ACTion Plan Value Statement: Action Steps: 1. Practice of Acceptance - 2. Practice of Mindfulness - 3.Practice of Value Consistent Daily Actions - Action Steps: 1. Practice of Acceptance - 2. Practice of Mindfulness - 3.Practice of Value Consistent Daily Actions -

16. Psychological flexibility Be Present “EHR billing” Acceptance “Heavy Hitters” Defuse “Drug Seeker” Changing Self “A Different Doc” How We’ve Done It! Connect with Values “Compassionate Self” Act on Values “3 at 3PM on Friday”

17. ACT Resources Association for Contextual Behavioral Science www.contextualpsychology.org/ www.contextualpsychology.org/ New Harbinger Publications www.newharbinger.com

18. Psychological flexibility Be Present “EHR billing” Acceptance “Heavy Hitters” Defuse “Drug Seeker” Changing Self “A Different Doc” Questions????? Connect with Values “Compassionate Self” Act on Values “3 at 3PM on Friday”

19. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!