Two Sides of the Physician Coin Burnout and Well Being
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23/2/2015 www.medscape.com/viewarticle/839439_print http://www.medscape.com/viewarticle/839439_print 1/5 www.medscape.com February 09, 2015 Editor's Note: The problem of physician burnout has been illuminated by a number of recent studies, including Medscape's 2015 Physician Lifestyle Report, which surveyed approximately 20,000 physicians and asked about severity of burnout, factors contributing to burnout, and its association with a range of other issues, including happiness outside of work, alcohol and marijuana use, and financial status. Burnout is not a new problem, but an emphasis on burnout prevention and physician wellness is a relatively new response. What are the strategies that are protective against burnout? Medscape spoke with Tait D. Shanafelt, MD, a nationally recognized researcher on this topic and program director of the Physician WellBeing program at Mayo Clinic, about prevention, recognition, and interventions for physicians exhibiting signs of burnout. Is Burnout Really on the Rise? Medscape: In our recent survey, we found a 16% increase in the incidence of selfreported burnout in just 2 years. Just under half of the approximately 20,000 physicians who completed our survey indicated that they were experiencing some degree of burnout. That rose to over half of physicians in primary care, emergency medicine, and critical care. How do these results compare with your own research? Dr Shanafelt: The trend that you are reporting is consistent with what we are seeing in national studies. When assessed using validated, fulllength, goldstandard tools, the rates of burnout in primary care, family medicine, and emergency medicine were well above 50% when we reported the national data in 2011. [1] Those rates all increased in the 2014 reassessment that we will soon be reporting. Extensive evidence published over the past decade illustrates that burnout not only is a problem for the individual physician and his or her family, but also has profound effects on quality of care. [2,3] When you consider the rates of burnout that you observed and that we are seeing nationally, I think it indicates that burnout among physicians and nurses is one of the most prevalent and insidious problems undermining the quality of the US healthcare delivery system. Medscape: A recent series of articles we posted about physician suicide garnered hundreds of comments from the tens of thousands of physicians who read it, many noting that they had experienced the suicide of a friend or colleague. Many pointed the finger at factors inherent in physician training, including high levels of competitiveness and punishing work schedules, factors that you also identified in a recently published study of matriculating medical students. [4] A minority, less sympathetic, argued that physicians who succumbed to these pressures probably shouldn't have been in medical school to begin with. Are there medical students who are inherently at higher risk for burnout? Dr Shanafelt: That is a question that I am asked frequently. I think it is misguided to imply that when there is a suicide or a physician leaves the profession, "they were just never cut out for this in the first place." We know that those who are at greatest risk for burnout are those who are the most dedicated and committed to their work. Those are the professionals that are at greatest risk to be consumed by their job and have difficulty drawing healthy boundaries or recognizing work overload. Physician suicide is a substantial and underappreciated problem in both physicians in general and the general public. Physicians' risk for death by suicide is markedly higher than for age and sexmatched professionals in other fields. In one national study of approximately 8000 surgeons, we found that over 6% of US surgeons had thought of killing themselves in the past 12 months. [5] On a practical level, that means that 1 of every 16 of my colleagues that I interact with from day to day has thought of killing themselves in the past year. Two Sides of the Physician Coin: Burnout and Wellbeing Laurie Scudder, DNP, NP, Tait D. Shanafelt, MD
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Sindrome de burnout, Medscape
Transcript of Two Sides of the Physician Coin Burnout and Well Being
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23/2/2015 www.medscape.com/viewarticle/839439_print
http://www.medscape.com/viewarticle/839439_print 1/5
www.medscape.com
February09,2015
Editor'sNote:Theproblemofphysicianburnouthasbeenilluminatedbyanumberofrecentstudies,includingMedscape's2015PhysicianLifestyleReport,whichsurveyedapproximately20,000physiciansandaskedaboutseverityofburnout,factorscontributingtoburnout,anditsassociationwitharangeofotherissues,includinghappinessoutsideofwork,alcoholandmarijuanause,andfinancialstatus.Burnoutisnotanewproblem,butanemphasisonburnoutpreventionandphysicianwellnessisarelativelynewresponse.Whatarethestrategiesthatareprotectiveagainstburnout?MedscapespokewithTaitD.Shanafelt,MD,anationallyrecognizedresearcheronthistopicandprogramdirectorofthePhysicianWellBeingprogramatMayoClinic,aboutprevention,recognition,andinterventionsforphysiciansexhibitingsignsofburnout.
IsBurnoutReallyontheRise?
Medscape:Inourrecentsurvey,wefounda16%increaseintheincidenceofselfreportedburnoutinjust2years.Justunderhalfoftheapproximately20,000physicianswhocompletedoursurveyindicatedthattheywereexperiencingsomedegreeofburnout.Thatrosetooverhalfofphysiciansinprimarycare,emergencymedicine,andcriticalcare.Howdotheseresultscomparewithyourownresearch?
DrShanafelt:Thetrendthatyouarereportingisconsistentwithwhatweareseeinginnationalstudies.Whenassessedusingvalidated,fulllength,goldstandardtools,theratesofburnoutinprimarycare,familymedicine,andemergencymedicinewerewellabove50%whenwereportedthenationaldatain2011.[1]Thoseratesallincreasedinthe2014reassessmentthatwewillsoonbereporting.
Extensiveevidencepublishedoverthepastdecadeillustratesthatburnoutnotonlyisaproblemfortheindividualphysicianandhisorherfamily,butalsohasprofoundeffectsonqualityofcare.[2,3]Whenyouconsidertheratesofburnoutthatyouobservedandthatweareseeingnationally,IthinkitindicatesthatburnoutamongphysiciansandnursesisoneofthemostprevalentandinsidiousproblemsunderminingthequalityoftheUShealthcaredeliverysystem.
Medscape:Arecentseriesofarticleswepostedaboutphysiciansuicidegarneredhundredsofcommentsfromthetensofthousandsofphysicianswhoreadit,manynotingthattheyhadexperiencedthesuicideofafriendorcolleague.Manypointedthefingeratfactorsinherentinphysiciantraining,includinghighlevelsofcompetitivenessandpunishingworkschedules,factorsthatyoualsoidentifiedinarecentlypublishedstudyofmatriculatingmedicalstudents.[4]Aminority,lesssympathetic,arguedthatphysicianswhosuccumbedtothesepressuresprobablyshouldn'thavebeeninmedicalschooltobeginwith.Aretheremedicalstudentswhoareinherentlyathigherriskforburnout?
DrShanafelt:ThatisaquestionthatIamaskedfrequently.Ithinkitismisguidedtoimplythatwhenthereisasuicideoraphysicianleavestheprofession,"theywerejustnevercutoutforthisinthefirstplace."
Weknowthatthosewhoareatgreatestriskforburnoutarethosewhoarethemostdedicatedandcommittedtotheirwork.Thosearetheprofessionalsthatareatgreatestrisktobeconsumedbytheirjobandhavedifficultydrawinghealthyboundariesorrecognizingworkoverload.
Physiciansuicideisasubstantialandunderappreciatedprobleminbothphysiciansingeneralandthegeneralpublic.Physicians'riskfordeathbysuicideismarkedlyhigherthanforageandsexmatchedprofessionalsinotherfields.Inonenationalstudyofapproximately8000surgeons,wefoundthatover6%ofUSsurgeonshadthoughtofkillingthemselvesinthepast12months.[5]Onapracticallevel,thatmeansthat1ofevery16ofmycolleaguesthatIinteractwithfromdaytodayhasthoughtofkillingthemselvesinthepastyear.
TwoSidesofthePhysicianCoin:BurnoutandWellbeingLaurieScudder,DNP,NP,TaitD.Shanafelt,MD
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23/2/2015 www.medscape.com/viewarticle/839439_print
http://www.medscape.com/viewarticle/839439_print 2/5
InthatstudyofUSsurgeons,wefoundthatburnout,aswellasmedicalerrors,wereindependentpredictorsofsuicidalideationafteradjustingfordepression.Theissueofphysiciansuicideisnotlimitedtoan"inherentlyweak"subsetofphysicians.Infact,mostphysicianswouldconsiderourcolleagueswhohavechosentopursuesurgicaldisciplinesashavingsignedupforaparticularlydemandingareaoftheprofessionrelativetowhathavebeencoined"lifestylespecialties"withmorecontainedworkhours.Nophysicianisimmunetotheriskforburnoutanditspotentialrepercussions.
Medscape:Whatistheroleofscreeningtools[6]toidentifyphysiciansindistressorbeusedtoidentifyapplicantstomedicalschoolathigherriskforburnout?Arethesetoolsforusethroughoutaphysician'sprofessionalcareer?
DrShanafelt:Idobelievethatselfassessmenttoolsforphysiciansthatcanprovideindividualizedfeedback,aswellascomparisontonationalbenchmarksforcontext,canbehelpful.OurresearchteamatMayoClinichasspentthelast7yearsdevelopingandvalidatingpreciselysuchinstrumentsinnationalsamplesofphysicians.[6,7]Theabilityofphysicianstoperformselfcalibrationinaconfidentialoranonymousmanner,withlinkstoresourcesatthetimetheyareneeded,wouldbeausefulapproach.
Thehopeisthatsuchtoolswillallowphysicianstomonitorthemselvesatregularintervalsthroughoutthecourseoftheircareers.
Theconceptofapplyingascreeningtoolamongapplicantstomedicalschoolto"weedout"thoseathighriskforburnoutisfraughtwithproblems.First,wehavefoundthatmatriculatingmedicalstudentshavelowerdegreesofburnoutandbettermentalhealthrelatedqualityoflifethancollegegraduatesgoingintootherprofessions.[4]Oncemedicalschoolbegins,however,theirmentalhealthinthesedimensionsdeterioratesandfallsbelowthatoftheirpeersinotherfields.Theavailableresearchsuggeststhatmedicalstudentswithnarcissisticpersonalitytraitsareatlowerriskforburnout.Similarly,individualswiththosequalitiesthosewhoaremorecallousandlessempatheticmaybeatlowerriskforburnout.Neitherofthesetraitsarethequalitieswearetryingtoenrichinthemedicalprofession.Whenwehaveanissuethatisaffectingapproximately50%ofUSphysiciansandwhichmaydisproportionallyaffectthemostdedicatedandcommittedphysicians,itsuggeststhatweneedtolookattheprocessoftrainingandthepracticeenvironment.Thenotionoftryingto"filteroutthoseatrisk"isafundamentallyflawedconcept.
IsOrganizationalChangePartoftheSolution?Medscape:Whilemedicalschoolandresidencyhavebeenfoundtobepeakperiodsofdistress,yourresearchhasillustratedthattheincreasedincidenceofburnout,depression,andsuicidepersistsintoearlycareeryears.[8]
DrShanafelt:Burnoutandattheotherendofthespectrum,physicianwellbeingaremultifacetedandcomplexconstructs.Thefivedriversofburnoutandwellbeinginphysicianscenteraroundworkload,workefficiency,worklifeintegration,autonomy/flexibility/control,andmeaninginthework.Itisimportanttonotethattherearebothindividualandorganizationalfactorsthatcontributetoeachofthesedrivers.
Strategiesfocusedontheindividual,whileimportant,aregoingtogetusonlysofarinaddressingthisproblem.Unfortunately,theenvironmentalandinstitutionalfactorshavebeenlargelyneglectedwhichislikelywhyweseetheratesofburnoutincreasingoverthepast5years.Thephysiciansinthesestudiesarelargelythesameindividuals.Theyhaven'tchangedsomuchoverthepastseveralyearsashasthepracticeenvironment,theworkloadexpectations,andtheefficiencyoftheenvironment.
Medscape:WhataresomeofthestrategiesyouhaveinstitutedatMayothatcanhelptomitigateburnoutanddepressionfortheseearlycareerphysicians?
DrShanafelt:AtMayoClinic,wehavetriedtotakeaverycomprehensiveapproachtothisproblem,framedaround
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thebeliefthataddressingthisissueisthesharedresponsibilityofboththeindividualphysicianandtheorganization.Attheorganizationallevel,whilethereareafewgeneralprinciplesthatcanbebroadlybeneficial(eg,improvingefficiency,givingindividualsflexibility/controloverworktotheextentpossible),manyofthechallengesandsolutionsareuniquetoeachdepartmentorworkunit.Whataradiologistspecificallyneedstoimprovetheworkenvironmentisverydifferentfromwhatwouldbehelpfultoafamilyphysicianorageneralsurgeon.Attheorganizationallevel,itisimportantnottooversimplifytheproblembytryingtocomeupwitha"onesizefitsall"panaceaforalldepartments.Thatapproachoftenmissesthecriticalchangesnecessarytoimprovethepracticeenvironmentinagivendepartment.Thisfactunderscorestheimportanceoflocalleadershiptoaddressthisissue.
Onanindividuallevel,ourresearchteamhasspentalotoftimestudyinghowphysicianscanidentifyandcultivatemeaningintheirworklife.[9,10]Wehavealsoevaluatedthebenefitsofregularstructuredmeetingswithagroupofcolleaguestodiscussthechallengesandvirtuesofphysicianhood.Inrandomizedcontrolledtrials,[11]wehavefoundthatthesegroupscanhelprestorephysicians'senseofmeaningandpassionfortheirworkaswellasreduceburnout.OtherinvestigatorsatMayoClinichavebeenpioneersinevaluatingthebenefitsofmindfulnessbasedstressreductiontrainingforphysiciansandotherhealthcareworkers,whichcanbeahelpfulapproachformany.Ultimately,Ithinkitwillbeimportantforustocreateamenuofeffectiveapproachesforindividualphysicianstocultivatewellbeing,becauseonesizewillnotfitall.
Organizationsmustalsoembracethelargerchallengeofredesigningthepracticeenvironment.Whilemanyorganizationshaveengagedinpracticeredesignwithafocusonenhancingproductivity,fewhaveengagedinredesignwiththegoalofcreatingasustainableandfulfillingworkenvironmentfortheirphysicians,nurses,andotheralliedhealthpersonnel.Thesegoalsdonothavetobemutuallyexclusive.Creatinganenvironmentwherephysiciansandnursesareempoweredtoprovidehighqualityandefficientpatientcare,andalsotoderiveprofessionalsatisfaction,isimportantforthelongtermhealthofthehealthcareorganizationsandthepatientstheycarefor.
Medscape:Whataboutphysiciansnotaffiliatedwithlargermedicalcentersthosecliniciansinsoloorsmallpracticeswithoutresourceslikethephysicianwellbeingprogramthatyouhead?Arepractitionersintheseenvironmentsatthesameriskforburnout?Andwhatarethestrategiesforpreventionthatcanbeimplementedinthesesettings?
DrShanafelt:Physiciansinsoloorsmallgrouppracticeareatriskforburnout,andinmanywaystheyhavetobeevenmoreproactivetomanagethisrisk.Itbeginsbyrecognizingthatburnoutisathreattotheirprofessionalhealthandprioritizingselfcare,cultivatingsustainableworkhabits,andbuildingintimeforrenewalintheirwork.Iftheyrecognizethatthisisimportantandmakeitapriority,thereareresourcestohelpthemsucceed.Thereareanumberofconferencesthatarefocusedonthethemeofselfcare,renewal,addressingburnout,andpromotingresilience.OurresearchteamatMayoClinicisalsotryingtobuildWebbasedtoolsandresourcesaccessibletophysiciansintheirlocalenvironmentoronline.
Physician,HealThyself:WhatAboutIndividualStrategies?Medscape:OnestudyinSpainconcludedthatphysiciansweremorelikelytoseekhelpinprogramsdesignedspecificallyforphysiciansandperceivedtobenonpunitive.[12]Inyourexperience,isselfreferralmorecommonthanreferralbycolleagues?
DrShanafelt:Thesimpleansweristhatphysiciansdonotalwaysaccuratelycalibratetheirlevelofdistress.Inonestudy[7]weconductedincollaborationwiththeAmericanCollegeofSurgeons,webeganbyaskingphysicianstoratetheirwellbeingrelativetophysiciansnationally.Onthenextscreen,physicianscompletedavalidatedwellbeingassessmentwithnationalbenchmarksafterwhichtheyreceivedimmediatefeedback.
Priortotheobjectiveassessment,everybodythoughttheirwellbeingwasatoraboveaverageeventhoseobjectivelybenchmarkedtobeatthebottomendofthewellbeingcontinuumrelativetonationalsamplesofphysicians.
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Itiseasyforphysicianstoassumethat"thesearechallengingtimesallmycolleaguesarestressedouttoo."Thatnarrativecanbeabarriertorecognizingwhenyourlevelofburnoutordistressisstartingtobecomeanoutlier,relativetothegeneralphysicianpopulation.Itisoftennotuntilaphysicianhitsrockbottomthattheyseekhelp.Sometimestheyarefacingpersonallifeissuesandbrokenrelationships,ortheyrecognizethattheyhavelostthejoyintheirworkandarethinkingaboutleavingpracticeorpursuingearlyretirement.Regardless,selfreferralisoftenalateevent.
Unfortunately,mostoftheresourcesandreferralstrategiescurrentlyavailablefocuson"physiciansattheextreme,"whoaredealingwithangermanagementissuesorsubstanceabuseordependence.Theyarethusrelevanttoonlythe1%or2%ofphysiciansdealingwiththoseissuesratherthanthenearly50%ofUSphysiciansdealingwithatleastsomedegreeofburnoutorotherdimensionsofdistress.
Medscape:Whatareyoursuggestionsforphysicians,family,andfriendswhoarewitnessingburnoutinacolleagueorfamilymember?Atwhatpointdoyourecommendreferringacolleagueorfamilymembertoacounselingormentalhealthprogram?
DrShanafelt:IwishIhadasimpleanswer.Althoughthereareanumberofeffortsinthisarea,mostofthemareinrelativelypreliminarystages.Itisfairlycommonforphysiciansearlyintheircareertogetsweptupintheirpracticeandwakeup10yearslatertorealizetheydon'tlikewhattheyaredoinganymore.Familymembersandcolleaguessometimesseethisbeforetheindividualphysicianrecognizesoracknowledgesit.Itisimportantforindividualphysiciansfacingburnouttotakeastepbackandtrulyassesswhattheirprioritiesandvaluesare,bothprofessionallyandpersonally.Theythenneedtoconsiderwhethertheyarestructuringtheirlifeandpracticeinawaythatiscongruentwiththosepersonalandprofessionalvalues,andwhatlifeandpracticewouldlooklikeifitbetteralignedwithwhattheycareabout.Often,smalladjustments,eitheraddressinghowmuchtheyworkorincreasingordecreasingaspecificaspectofwork,canbringbackthejoytheyderivefrompractice.
Mindfulnessbasedstressreductionprogramshavealsobeendevelopedaroundthecountryandareawellestablishedapproachforphysicianstoacquireskillsthatcanhelpthembetternavigatethestressofpractice.Theseapproachesareprobablybestemployedforprevention,howeverprofessionalhelporcounselingistypicallyneededforphysiciansexperiencingsevereburnout.
Itiscertainlypreferabletobeproactiveandcultivateresiliencebeforeburnoutoccurs.Wherewewouldliketoseethingsgo,wherewehavebeentryingtogo,istoincorporateselfrenewalactivities,[9,13]fostercommunityatwork,[11]
andhelpindividualsshapetheirpracticetoenhancemeaning[10,14]ascontinualactivitiesthateveryphysicianisengagedinatalltimesthroughouttheircareer.WeneedprogressalongthatlineifwearegoingtomaketrueinroadsintothisproblemthataffectshalfofUSphysicians.
Medscape:Arethereotherkeymessagesthatyouwouldliketosharewithourreaders?
DrShanafelt:Thereisatremendousneedforadditionalresearchinthisarea.Manyhealthcareorganizationsrecognizetheproblemanditspotentialrepercussionsforqualityofcare,recruitmentandretention,andpatientsatisfaction.Theystruggle,however,withhowbesttorespondinatimeoflimitedresources.Theyneedevidenceregardingthecostandefficacyofinterventionstoreduceburnoutandpromotewellbeingintheirphysicians,nurses,andalliedhealthstaffsothattheycanbeconfidentthattheresourcestheyinvestwillmakeadifferenceandnotbewasted.
Untilwedevelopthatevidence,wearegoingtobeleftwithalotofworkshopsforindividualphysiciansthattellthemto"fixthemselves"bysleepingandexercisingmore,takingmorevacations,and"reducingtheirstress."Thatapproachisjustnotgoingtomakeaseriousorsubstantiveimpactonsuchapervasiveproblemthathasmanyofitsrootsinthepracticeenvironment.Acontinuingfocusonconductingresearchthatprovidesevidenceofhowwecanaddressthisissueattheorganizationandsystemleveliswhereweneedtogo.
References
-
23/2/2015 www.medscape.com/viewarticle/839439_print
http://www.medscape.com/viewarticle/839439_print 5/5
MedscapeFamilyMedicine2015WebMD,LLC
Citethisarticle:TwoSidesofthePhysicianCoin:BurnoutandWellbeing.Medscape.Feb09,2015.
1. ShanafeltTD,BooneS,DyrbyeLN,etal.BurnoutandsatisfactionwithworklifebalanceamongU.S.physiciansrelativetothegeneralU.S.population.ArchInternMed.2012172:13771385.Abstract
2. WestCP,HuschkaMM,NovotnyPJ,etal.Associationofperceivedmedicalerrorswithresidentdistressandempathy:aprospectivelongitudinalstudy.JAMA.2006296:10711078.Abstract
3. ShanafeltTD,BalchCM,BechampsG,etal.BurnoutandmedicalerrorsamongAmericansurgeon.AnnSurg.201025:9951000.
4. BrazeauCM,ShanafeltT,DurningSJ,etal.Distressamongmatriculatingmedicalstudentsrelativetothegeneralpopulation.AcadMed.201489:15201525.Abstract
5. ShanafeltTD,BalchCM,DyrbyeL,etal.Specialreport:suicidalideationamongAmericansurgeons.ArchSurg.2011146:5462.Abstract
6. DyrbyeLN,SateleD,SloanJ,ShanafeltTD.Utilityofabriefscreeningtooltoidentifyphysiciansindistress.JGenInternMed.201328:421427.Abstract
7. ShanafeltTD,KaupsKL,NelsonH,etal.AninteractiveindividualizedinterventiontopromotebehavioralchangetoincreasepersonalwellbeinginUSsurgeons.AnnSurg.2014259:8288.Abstract
8. DyrbyeLN,WestCP,SateleD,etal.BurnoutamongU.S.medicalstudents,residents,andearlycareerphysiciansrelativetothegeneralU.S.population.AcadMed.201489:443451.Abstract
9. ShanafeltTD,SloanJA,HabermanTM.Thewellbeingofphysicians.AmMedJ.2003114:513517.
10. ShanafeltTD,WestCP,SloanJA,etal.Careerfitandburnoutamongacademicfaculty.ArchInternMed.2009169:990995.Abstract
11. WestCP,DyrbyeLN,RabatinJT,etal.Interventiontopromotephysicianwellbeing,jobsatisfaction,andprofessionalism:Arandomizedclinicaltrial.JAMAInternMed.2014174:527533.
12. BraquehaisMD,ValeroS,MatalJL,etal.Promotingvoluntaryhelpseekingamongdoctorswithmentaldisorders.IntJOccupMedEnvironHealth.201427:435443.Abstract
13. ShanafeltTD,OreskovichMR,DyrbyeLN,etal.Avoidingburnout:thepersonalhealthhabitsandwellnesspracticesofUSsurgeons.AnnSurg.2012255:625633.Abstract
14. SinskyCA,WillardGraceR,SchutzbankAM,SinskyTA,MargoliusD,BodenheimerT.Insearchofjoyinpractice:areportof23highfunctioningprimarycarepractices.AnnFamMed.201311:272278.Abstract
