Download - Two Sides of the Physician Coin Burnout and Well Being

23/2/2015 www.medscape.com/viewarticle/839439_print

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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



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



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.



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



MedscapeFamilyMedicine2015WebMD,LLC

Citethisarticle:TwoSidesofthePhysicianCoin:BurnoutandWellbeing.Medscape.Feb09,2015.

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