The Physician in Distress

SYM05: The Physician in Distress

Moderator(s): Julie E. Adams, MD

Faculty: Carrie Barron, MD, Felicity Fishman, MD, Donald H. Lee, MD, and Scott D. Lifchez, MD, FACS

Session Handouts Friday, October 02, 2020

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

SYM05: The Physician in Distress

Session Chair: Julie E. Adams, MD

Faculty: Carrie Barron, MD, Felicity Fishman, MD, Donald H. Lee, MD snd Scott D. Lifchez, MD, FACS

ASSH 2020 Virtual Annual Meeting October 2, 2020

• Burnout is real • Burnout is widespread – 50% of physicians and 32% of hand surgeons endorsing symptoms of “burnout” – Symptoms: workplace disruption, anxiety, failed coping skills and work avoidance

• Manifestations: cynicism, substance use, disruptive behavior, maladaptive coping strategies

• The alternative: becoming resilient, developing coping skills, seeing the glass half full, being a resource

3 Program

• Burnout and Cynicism, Interrupted – Donald Lee MD • Resources for Reaching the Disruptive Physician – Lissie Fishman MD • Finding Joy in Everyday Life – Carrie Barron MD • Nature vs Nurture: Addressing Environmental Concerns – Julie Adams MD • Self Care and Resilience – Scott Lifchez MD

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DISCLOSURES

Donald H. Lee, MD

Royalty: Zimmer-Biomet Elsevier

Burnout and Cynicism, Interrupted

Symposium 05 The Physician in Distress Oct. 2, 2020

2016: 2017: 2018: 11-14-16: 6:30 pm 5-10-17: 7:25 pm 2018: 8-6-18: 9 pm 11-15-16: 7 pm 5-12-17: 5:56 pm 8-14-18: 1 am 1-10-18: 9:00 pm 11-21-16: 6:55 pm 6-8-17: 10:30 pm 8-20-18: 6:45 pm 1-15-18: 7:05 pm 12-12-16: 8:50 6-9-17: 6:30 pm 8-24-18: 6:40 pm 2-14-18: 7:15 pm 12-12-16: 11:50 pm 6-12-17: 7:25 pm 9-7-18: 7:30 pm 3-26-18: 8:20 pm 12-19-16: 8:19 pm 6-29-17: 8:10 pm 9-19-18: 9:57 pm 3-28/18: 6:30 pm 12-20-16: 11:20 pm 7-3-17: 3 am 9-24-18: 7:35 pm 4-3-18: 6:40 pm 12-30-16: 10:10 pm 7-12-17: 7:32 pm 9-26-18: 11:44 pm 4-11-19: 10:55 pm 7-15-17: 8:30 pm 10-1-18: 7:55 pm 4-16-18: 6:15. MCE 7-18-17: 11:59 pm 10-3-18: 6:45 pm 4-18-18: 6:50 MCE 2017: 7-21-17: 12:45 am 10-7-18: 12:51 am 5-16-18: 7:30 pm 1-4-17: 9:45 pm 7-28-17: 7:14 pm My experience with burnout 10-8-18: 8:50 pm 5-25-18: 4 am 1-16-17: 7:15 pm 8-6-17: 10:52 pm 10-19-18: 9:45 pm 5-30-18: 6:30 pm 1-22-17: 6:pm 8-11-17: 9:02 pm 10-26-18: 12:15 am Late cases in OR 6-9-18: 2:20 am 1-23-17: 7:50 pm 8-16-17: 7:05 pm 11-2-18: 9 00 pm 6-10-18: 10:30 pm 1-25-17: 8 pm 8-23-17: 9:30 pm 11-7-18: 8:33 pm 6-11-18 12:50 am 1-30-17: : 7:24 pm 8-24-17: 10:08 pm 11-12-18: 10:10 pm 6-12-18: 9:25 pm 2-13-17 : 8:36 pm 8-28-17: 10:47 pm 11-14-18: 10:26 pm 6-13-18: 10:35 pm 2-15-17: 8:05 pm 8-30-17: 8:05 pm 11-15-18: 6:25 pm 6-15-18: 2:07 am 2-20-17: 7:50 pm 8-31-17: 7:30 pm 11-19-18: 8:25 pm 6-16-18: 9:10 pm 3-29-17: 9:30pm 9-27-17: 8:45 pm 11-27-18: 7:55 pm 7-3-18: 7:53 pm 3-30-17: 9:30pm 10-16-17: 7:25 pm 11-30-18: 6:30 pm, 7-16-18: 8:35 pm 3-31-17: 6:30 pm 10-25-17: 10:10 pm 12-5-18: 7:15 pm 7-19-18: 7:45 pm 4-10-17: 11:18 pm 10-27-17: 6:05 pm 12-22-18: 9:07 pm 7-20-18: 3;30 am 4-17-17: 7:58 pm 11-15-17: 7:45 pm 12-26-18: 10 pm 4-19-17: 11:15 pm 12-5-17: 6:51 pm 1-7-19: 9:40 pm 4-26-17: 10:30 pm 12-6-17: 8:10 pm 12-20-17: 8:45 pm

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Late Cases in OR

2:20am • Moved to a new surgery center • Block time: 1-2 rooms at surgery center / twice a week 10:30 pm 12:50 am 9:25 pm 10:35 pm 2:07 am 9:10 pm ➔ 1 room main OR • All other cases are scheduled as add-on cases • 50 – 60 cases / month • No support from leadership

Burnout

• Herbert Freudenberger • American psychologist • Coined “burnout” – 1970’s • State of mental and physical exhaustion caused by one’s professional life

Burnout

• Emotional exhaustion – constantly trying to live up to your own demands/expectations and those of job, family, and friends • Depersonalization – decreased capacity for compassion, empathy, and caring dwindles • Low sense of personal accomplishment – “nothing I do matters”

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Burnout

• Consequence of a work situation • Batting their head against the wall day after day and year after year • Health care professionals are prone • Expectation level is dramatically opposed to reality and the person persists in trying to reach that expectation, trouble is on the way

44% physicians burned out

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Highest rates: Urology, Neurology, PM&R Orthopedics: 38%, Plastics: 36%

Why are physicians (professionals) burned out?

• Workload and its intensity, time demands, and complexity • Lack of control of establishing and following day to day priorities • Insufficient reward and the accompanying feelings of continually having to do more with less • The feeling of community in which relationships become impersonal, and teamwork is undermined • The absence of fairness in which trust, openness, and respect are not present; • Conflicting values, in which choices that are made by management often conflict with their mission and core values Leiter and Maslach, 1997

Why are physicians burned out? • Uncertainty created by the ever-changing landscape of healthcare • A lack of control over their future • Highly stressful jobs • Bureaucratic pressure that interferes with optimal care • Time constraints that keep them from forming meaningful patient relationships • Salary concerns (evaluated by RVU’s) • Feeling of being stuck in a career that they no longer enjoy • Burdened with massive education debt, mortgages, and other expenses • Many physicians are not receiving the feedback or coaching on how to meet these performance standards or metrics

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How to deal with burnout How to improve oneself

What is currently working for me?

1) Lifelong learning Invest in your mind Mindset Continued learning Bibliotherapy Self-examination (self-awareness) Constantly changing 2) Align yourself with something larger than yourself Have goals

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What is currently working for me?

3) Become engaged 4) Take time to develop relationships 5) Control stressors 6) Take time for yourself Get rest / sleep / exercise Develop outside interests (hobbies) Constantly changing Take time off

1. Lifelong Learning

• Invest in your mind as well as body • Always be learning, acquiring knowledge, and seeking wisdom • When the student is ready the teacher appears

Grit

• Grit: combination of passion and perseverance • May be unrelated or inversely related to measures of talent

From: TED Talks

• Fixed mindset • Growth mindset- belief that the ability to learn is not fixed

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Bibliotherapy • Cognitive behavioral therapy - cognition is a thought or perception - change cognitive distortions and behaviors, by improving emotional regulation, and development of coping strategies • Bibliotherapy – reading therapy self-help books, positive psychology • Self-help seems to be a key to recovery whether or not you receive therapy • Constant on-going process Jamison and Scogin Journal of Consulting and Clinical Psychology The outcome of cognitive bibliotherapy with depressed adults

Audio Programs: Audible.com

What type of learner are you?

• Visual • Aural (auditory) • Verbal • Physical (kinesthetic)

Books

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Audio Programs: Podcasts

Apps

Read about burnout

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Self Examination

• self reflection

Self Examination

From: TEDx Mile High

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2. Align yourself with something larger

• Meaning is the secret to happiness (Martin Seligman) • Have your life aligned with something bigger than yourself, more likely to live a fuller life • May be something spiritual or the mission of leaving a meaningful legacy

Meaning: Vicktor Frankl • Life is never made unbearable by circumstances, but only by lack of meaning or purpose • Logotherapy – the search for the meaning in life is the primary motivational force in human beings

He who has a Why to live for Austrian Neurologist and Psychologist can bear almost any How Friedrich Nietzsche

Meaning: Vicktor Frankl

• “Life is not primarily a quest for pleasure, or a quest for power, but a quest for meaning.” “Forces beyond your control can take away everything you possess except one thing, your freedom to choose how you will respond to the situation. You cannot control what happens to you in life, but you can control what you will feel and do about what happens to you.”

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Goals • Goals - realistic and meaningful for personal achievement • Goals - difficult but realistic • Goals achieved with little effort • seldom appreciated • give little personal satisfaction • frequently not worthwhile • What are your goals in life • What do you plan for your own personal legacy?

Priorities: • Family what are • Faith yours? • Friends

Priorities

Terry Canale, MD Past President of AAOS

“I have lived my life to regret that I have spent too much time on my career to the neglect of my family”

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Define happiness for you Aristotle: Eudaimonia – human flourishing Happiness is the joy we feel striving after our potential.

From: TEDx Bloomington

3. Become Engaged

• No person was ever honored for what he received. Honor has been the reward for what he gave. Calvin Coolidge

Become Engaged

• Local charity work • Local and national organizations

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4. Foster relationships and friendships Have mentors and be a mentor 2008 Gallup Poll: People happiest on days when they’d spend 6 to 7 hours socializing

John Wooden: You cannot live a perfect day without doing something for someone without the thought of repayment

5. Control Stressors

• Analyze frustrating situations come up with ways to solve or lessen them • Manage expectations to minimize frustrations • Break the cycle of relativity Stop comparing yourself to others • Control rumination, self criticism (toxic) • Have self-compassion – regularly take time to feel gratitude • Identify triggers • If we do not create and control our environment, our environment creates and controls us

Get a Scribe

• Try new things • Wellness task force • Scribes • Standing desks • Friday socials

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Change habits • Habits • important role in creating an atmosphere of growth • help us make consistent, reliable progress • Help us do better • By mindfully choosing our habits we harness the power of mindlessness

Change habits

• Habit loop: • a cue, a routine, and a reward • To change a habit • keep the cue, replace the routine, and keep the reward.

6. Take Time for Yourself Get rest / sleep / exercise • Habitual ‘sleep credit’ associated with higher emotional intelligence and better mental health • Sleep deprivation consistent with mild prefontal lobe dysfunction • 7-9 hrs sleep recommended shorter or longer associated with increased morbidity or mortality • Sleep new information is consolidated and stored in memory brain clears harmful toxins during sleep may reduce risk of Alzheimer’s

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What is your definition of success?

What is your definition of success? • Success is peace of mind that is the direct result of self- satisfaction in knowing that you did your best to become the best that you are capable of becoming. John Wooden

Sense of Purpose

• Physicians • have great purpose • do worthwhile work • make a difference • appreciate the difference

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Thank you for your time

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DISCLOSURES

Felicity Fishman, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

Bullying in Hand Surgery

Felicity Fishman, MD Associate Professor, Loyola University Medical Center Shriners Hospital for Children- Chicago ASSH Annual Meeting, 2020

Overview • Definition of Bullying

• Prevalence of Bullying in medicine

• Why is bullying a problem in medicine?

• How do we eliminate bullying?

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What is Bullying?

Systematic abuse of power that is defined as aggressive behavior or intentional harm-doing by peers that is carried out repeatedly and involves an imbalance of power, either actual or perceived, between the victim and the bully

What is Bullying? • Any interaction that consists of repetitive intimidation, harassment, humiliation, aggression, emotional abuse or psychologic mistreatment

• Most common form of abuse is verbal

• Characterized by threatening, humiliating or intimidating actions or words

Types of Bullying • Verbal

• Intimidation

• Work performance → work sabotage, taking credit for ideas

• Retaliatory → false accusations in response to bullying being reported

• Institutional → workplace accepts, allows and encourages bullying → unrealistic production goals, forced overtime, singling out those that can’t keep up

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Who are the Bullies? • 70% ♂︎, 30% ♀︎ • Both male and female bullies more likely to target women

• 61% comes from bosses or supervisors

• 33% comes from co-workers

• Superior physician, administrator, colleagues, RNs

Who are the Bullies?

• Managers/Superiors → abuse of power, including negative performance reviews that aren’t justified, threats of firing/demotion, denying time off

• Colleagues → gossip, work sabotage, criticism

Who are the Bullies?

• 71% of targets of disruptive behavior are bullied by those who outranked them in the hierarchy

• 68% of nurses and 47% of physicians reported witnessing disruptive behavior

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Bullying vs. Discrimination/Harassment

• Discrimination → adverse action taken against a person because of a protected characteristic or activity

• Harassment → person is treated poorly because of a protected characteristic or activity

• Bullying → repeated unreasonable behavior that creates risk to health and safety but behavior is not because of a protected characteristic or activity

Bullying vs. Discrimination/Harassment • Discrimination and Harassment are unlawful • Federal and State laws cover workplace discrimination and harassment

• Bullying is not unlawful in most states • Definition of bullying is wide and broad – hard to come to agreement on exactly what constitutes bullying behavior

Why is Bullying a problem in Surgery?

Workplace Bullying Institute (WBI) -2014: • Bullying occurs more frequently in environments that: • Are stressful or change frequently • Have heavy workloads • Have unclear polices about employee behavior • Have poor employee communication and relationships • Have more employees who are bored or worried about job security

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• Surgeons value hierarchy

• Other specialties are afraid of surgeons

• Unspoken code of silence • Loathe to speak up against colleagues for fear or retaliation

• Bullying can be invisible → verbal or psychological in nature

• Trainees are common targets of bullying • Perpetrator recognizes signs of weakness

• High stakes environment

• Trainees and faculty emulate bullying behavior • Especially if bully is perceived as influential and successful

Why does Surgery have a Bullying problem?

• Bully may be motivated by a desire to improve colleague/trainee’s performance → Intentions are irrelevant

• Bullying used as teaching tool despite studies demonstrating these are dysfunctional and harmful • Harsh pimping & asking humiliating questions

• Educators protected by the established hierarchy of academic authority

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• Evaluated workplace bullying in general surgery trainees and attendings in Australia

• Study found much higher rate of bullying in medicine than in other workplaces in Australia

• 47 % of respondents reported bullying

• 68% reported witnessing bullying

• Attendings were the most common source of bullying

• Only 18% of victims made a formal complaint

Why does bullying persist? • Banduras Social Learning Theory → learn aggression and bad behavior from watching role models • Normalize bad behavior

• Bully is often established recognized figure in their specialty → behavior goes unreported & then perpetuates

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Why does bullying persist? • No state or federal statues against bullying

• Few institutions have direct policies against bullying • most have antiharassment and antidiscrimination mandates for protected classes • Bullying is 4 x more prevalent than illegal discrimination

Healthy Workplace Bill

• No federal legislation

• Purple states have HWB

• Blue states have training mandates

Examples of Bullying • Persistent attempts to belittle & undermine one’s work • Excessive performance monitoring/criticism • Humiliation in front of colleagues • Destructive innuendo and sarcasm • Making inappropriate jokes or persistent teasing • Withholding necessary information • Setting impossible deadlines • Physical violence

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Examples of Bullying

• M&M conference • Medical Errors can be used as learning opportunities not opportunities for shame

• Academic conference with humiliation used as a learning tactic

• Workload expectations • Demanding productivity with unrealistic expectations

Examples of Bullying: Bullying of RNs

• Most bullying is not flagrant → not a tantrum in operating room

• Passive → not answering pages/phone calls, subtle condescension, aggressive/sarcastic HuffPost.com remarks

Examples of Bullying: Bullying of RNs

• Sets off a chain: • MDs bully RN, RN bully other RN, attendings bully residents, experienced nurses bully interns

• Problem for patient safety → can ↑ medical errors Jamesclear.com

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What is the Effect of Bullying in Surgery? • Bullying associated with suboptimal health and poor job satisfaction, frequent job change and absenteeism • affects patient safety and treatment outcomes • Higher rate of medical errors • Associated with anxiety and depression

• Bullying makes the victim feel a loss of control in their environment

• Bullying can bring about a profound sense of shame

Medical Students

• 50% of med students report their self confidence ↓ during medical school • Partially due to bullying and feelings of shame

• 2017- ACGME revised a section of program requirements to address well being “more directly and comprehensively”

What is Shame? • Shame is a painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging • Shame makes one feel inferior – creates a desire to hide or disappear • Link between shame and depression

• Doctors are particularly vulnerable to shame → self selected towards perfectionism • Can feel shame when criticized (bullied) or if they don’t meet ideal standard

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How do we cope with the Bullying problem in Surgery?

National Level • Legislation → Healthy Workplace Bill

• March 2008 → NY passed bill establishing cause of action for employees who are subjected to abusive work environment

• 2009 → Joint Commission included requirements that leaders create protocols for managing disruptive behaviors and that they maintain a culture of safety & quality

National Level • Feb 2008 → Center for American Nurses adopted a statement on Lateral Violence and Workplace Bullying

• 75th Annual Congress of American College of Health Care executives→ speaker called for coordinated organizational action by healthcare leaders and mangers → the human aspects of QI

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Potential Litigation • 3% of targets of bullying file lawsuits

• April 2008 – Raess v Doescher (Indiana Supreme Court) → hospital employee awarded $325,000 after accusing a prominent heart surgeon of bullying him

• Growing body of literature attests to link between disruptive physician behavior and risk of malpractice litigation

Professional Societies

• Historic tolerance of disruptive behavior has led to a culture in which people are hesitant to address unprofessional behavior

• Need AAOS/ASPS to potentially develop comprehensive position statement on disruptive physician behavior and bullying

Workplace Changes • Healthcare leaders and managers must view workplace bullying from legal point of view and from perspectives of organized labor and ethics

• WBI claims that only the institution or the employer has the power to effectively stop bullying • Leaders should empower victims to speak up

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Workplace Changes • Hospital could adopt standards of professional behavior • Need to be applied uniformly

• Offending parties should be required to undergo civility training

• Possible revoking of hospital privileges

Individual Changes: Healthcare Leaders • Be aware of the workplace scenarios that breed bullying • Excessive workload • Role conflict and ambiguity • Lack of coworker support • Competitive work environment

• Hard to simply impose bureaucratically → Change the Culture

Individual Changes: Healthcare Leaders

• Change needs to start at top due to the hierarchical nature of hospitals

• Create a culture of openness, honesty, respect and cooperation

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Individual Changes: Educator • Empathy → encouraging a culture of kindness and respect

• Reframe failure as learning • De-villainize M&M conference

• Constructive feedback is more effective than destructive feedback • Constructive Feedback : Specific, considerate and does not attribute poor performance to internal causes

• Destructive Feedback: focuses on self rather than actions

Individual Changes: Victim of Bullying

• Part of shame resilience occurs by first addressing that shame exists for all • Shame is the result of feeling alone, powerless and isolated

• Solutions: EMPATHY • being able to see the world as others see it • being non-judgmental • understanding another person’s feelings • communicating understanding of that person’s feelings

Individual Changes: Victim of Bullying • Useful steps when one feels shame after failure or error

Robertson et al, 2019

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Individual Changes: Victim of Bullying

• Speak up!

• Report bullying to help break the cycle

Success.com

General Recommendations to Eliminate Bullying • Adopt a policy of zero tolerance for disruptive behavior & bullying and enforce it consistently

• Create culture that focuses on attaining goals by enabling individuals and groups to maximize their potential

• Recognize and reward behaviors that demonstrate collaboration, respect and high regard for interpersonal ethics

Summary • Bullying is more prevalent in medicine and especially in surgical fields, than most of us are aware

• Continues to be under-reported → perpetuates the problem

• Cultural changes necessary to break the cycle

• Consider changes that can be made on all levels: national, healthcare leaders, educators, personal

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Thank you! • Any questions?

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DISCLOSURE

Carrie Barron, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

A Vital, Inclusive Health Ecosystem

Finding Joy in Everyday Life: 11 Tips From Positive Psychology

Carrie Barron, MD Director of Creativity for Resilience Associate Professor of Medical Education Dell Medical School

A Vital, Inclusive Health Ecosystem

No Disclosures

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A Vital, Inclusive Health Ecosystem

Positive Psychology Positive Psychology is the scientific study of the strengths that enable individuals and communities to thrive. The field is founded on the belief that people want to lead meaningful and fulfilling lives, to cultivate what is best within themselves, and to enhance their experiences of love, work, and play.

A Vital, Inclusive Health Ecosystem

Tip #1: Principles of Positive Psychology Positive Emotion Engagement Relationships Meaning Accomplishment PERMA

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A Vital, Inclusive Health Ecosystem Tip #2: Character

Definition: Mental and moral qualities of an individual

“Character is higher than intellect.” RW Emerson

Working out of your strengths for FLOW

Virtue and authenticity are rewarding

A Vital, Inclusive Health Ecosystem

Tip #3: Intrinsic Motivation

Self Determination: Competence, relatedness, autonomy

These self-states foster and protect intrinsic motivation

Optimal growth and well-being

A Vital, Inclusive Health Ecosystem Tip #4: Human Connection

Mentors and role models

People who care for us and for whom we care

Relationships are number one

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A Vital, Inclusive Health Ecosystem Tip #5 : Creativity

Divergent and convergent thought

Spontaneous experience

Culture as prescription

A Vital, Inclusive Health Ecosystem

Tip #6: Altruism

Greater well-being, happiness, health and longevity

Emotional and behavioral compassion for the well-lived life

Unless one is overwhelmed by tasks

A Vital, Inclusive Health Ecosystem Tip #7: Nature

Boosts mood

Decreases anxiety

Improves cognitive performance

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A Vital, Inclusive Health Ecosystem Tip #8: Gratitude

“Gratitude blocks toxic emotions, such as envy, resentment, regret and depression, which can destroy our happiness.” — Robert Emmons

Keep a journal

A Vital, Inclusive Health Ecosystem Tip #9: Choosing Our Response

A Vital, Inclusive Health Ecosystem Tip #10 Self-reliance

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A Vital, Inclusive Health Ecosystem Tip #11:The Little Things

What does it for you?

Pets, gardens, playlists, baking, crafting, sports, films…..

6 Nature vs Nurture: Addressing Environmental Concerns in Wellness

Julie E. Adams MD Professor Of Orthopedic Surgery

ASSH 2020 Virtual Annual Meeting

[email protected] 1

DISCLOSURES

Julie E. Adams, MD

Royalty: Zimmer Biomet Intellectual Property: Zimmer Biomet Arthrex

Other speakers have spoken

• About changing yourself • About changing your attitude • About changing or confronting others

• But what if it’s the environment? • What if we have a responsibility to our colleagues, our support staff, our patients, ourselves...to change the environment? Or our response to the environment?

3 Organizational culture and factors

• When one feels one isn’t contributing or making a difference • When one feels one’s efforts are not appreciated • Role conflict • Work overload • Lack of predictable / clear expectations

• Brown, LW, Quick, JC, Environmental Influences on Individual Burnout and a Preventive Approach for Organizations, Journal of Applied Biobehavioral Research, 2013, 18, 2, pp. 104–121.

Social Construct Contributors to Burnout in Medicine • The EMR – Pushing buttons – Focus on machine not patient – Documentation not caring • The rat race – Case numbers – RVU numbers – Start to see patients as a number not a person 5

Social Construct Contributors to Burnout in Medicine • Depersonalization – “Provider” not “physician” or surgeon – Shift labor – “traumatologist” “hospitalist” “laborist” • Lack of respect for medical professionals • Lack of predictability

6 So what can be done?

• The EMR – Scribes – Dot phrases – Automation – A domino effect !

Make the EMR work for you! Dot phrases

Pic of my dot phrases

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The Rat Race / Depersonalization

• Breather • Connection with patients / people • Reminder of why you chose this • See yourself, your family, your loved ones in your patients • Consider if your environment is aligned with your goals and your personality • Consider employment that supports your values • Consider volunteerism • Uphold the values that give our profession respect! • Do everything in our power to remind the public why we are hand surgeons!

Institutional Strategies: Develop strategies to care for each other • RAST/ FAST – Mayo initiative. Almost impossible to get an appointment, at a time that works for you, as a physician. Separate office facilitates. • Erlanger Doctor’s dining room – Safe space to grab a snack, coffee or meet with colleagues – Results in developing relationships – C suite frequently is found there – and actively engages! • Consider a survey of your attending’s / faculty’s /residents thoughts – You may find low hanging fruit of what “really” matters to these individuals – May identify systemic issues that are previously not recognized!

13 Institutional Strategies: UTCOM Survey of residents/ faculty

• Do you think actions can /should be taken to improve wellness? • If so, what 3 things would you suggest to improve job/ general wellbeing • What things keep you up at night or do you find most annoying?

Short survey + write in answers = not a burden, allows creativity, and anonymity = “tell what you really think / how you really feel”

Institutional Strategies: Survey of residents/ faculty • RESULTS: Specific – Discrete actionable items • The big things are big – but your survey takers get that and don’t expect an easy fix for all that ails US medical systems • But the small things may help- and are often do-able! • Example- residents would like streamlined communication strategies to/from nursing and to/from attendings, and want to make sure they have access to snacks on call

Institutional Strategies: Survey of residents/ faculty • RESULTS: • Example: Faculty and residents want to be respected and valued and want fairness and transparency – little things like simple measures of recognition or a cup of coffee go a long way • Example: Can we repurpose existing un-used space for gym/ workout, meditation room? Can we gain access to walking trails, university gym, fitness classes on or nearly on campus?

16 Institutional Strategies* • Physician / Surgeon Autonomy / Control – Customizing scheduling / work options • Work Efficiency – MA training programs to decrease turnover and increase efficiency – Making the EMR work for, not against, you • Encouragement of and by physician leaders – Acknowledgement and thanks • Fairness and transparency – Group meetings to discuss – focus on clinical not administrative issues – Clear guideposts on promotions, resource allocation • Mentorship programs for more junior surgeons by senior surgeons * The MOST effective means of reducing burden of burnout (Maslach et al Ann Rev Psy 2001) Dunn et al J Gen Intern Med 2007; Choong et al ANZ J Surg 2013; Daniels et al. JAAOS 2016

But what can I do ?

TEAM US

• You may not have a large leadership role in your institution. • BUT as a surgeon, you are a team leader! • Remind the team of the “why” • Burnout is less if its not just a rat race, and there is a big “why” that we can all buy into

19 TEAM US

• Reach out • Get to know your staff • Develop a relationship with them – Its hard to dislike someone you know and are interested in – They will work for you if they know you work for them • Rejoice in their successes, help them through disappointments • Praise in public, correct in private • Even your “least favorites” • In the meantime, you will not just be the boss or the doc, you will become part of the team

Other strategies – manipulate your environment! • Know your triggers and mitigate / avoid them – and develop strategies of your own! – News / Media – Toxic people / situations – Develop a sense of humor / sympathy with interactions with toxic people – Meetings that could be emails

• Know yourself and how you unwind – Introvert? Extrovert? • Set clear boundaries • Be creative with manipulating your environment and with whom you choose to surround yourself

Although you can exert some (minimal) changes in your environment... – you can choose how you react to the environment – You can choose what you take home from that environment – You can choose when you think about that environment – You can choose to leave that environment

• Have a life. Make sure it is outside of work. • Have a passion. Make sure it is not work. • Have a hobby. Make sure it is not work.

22 Thank You !

[email protected]

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DISCLOSURES

Scott D. Lifchez, MD, FACS

Ownership Interests: Co-founder and equity holder of EduMD, LLC, an educational assessment company that makes the Operative Entrustability Assessment surgical assessment tool.

SYM-05: The Physician In Distress Self-Care and Resilience Scott D Lifchez, MD, FACS

Outline Slide • The Problem with Burnout • Resilience • Self-care • Mindfulness • Self-compassion • Relationships • Going Forward

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Burnout Is

• Emotional exhaustion, depersonalization • Decreased sense of personal accomplishment due to work-related stress • Consequences: • Fatigue • Inefficiency • Errors • Suicide

Burnout Among Physicians

• 2014 Shannefelt (6880 physicians): • 54.4% met criteria for burnout (10% from 2011) • Much higher than general population • 2009 ACS (7905 surgeons) • >40% met criteria • 2000 Physician Work Life Study • Burnout symptoms 60% more frequent among women physicians http://www.newdiaspora.com/dr-burnout/

Maslach Burnout Inventory • Burnout (section A) • <17: Low-level burnout • 18-29: Moderate burnout • >30: High-level burnout

• Depersonalization (section B) • <5: Low-level burnout • 6-11: Moderate burnout • >12: High-level burnout

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Maslach Burnout Inventory • Personal Achievement (section C) • <33: High-level burnout

• 34-39: Moderate burnout

• >40: Low-level burnout

Resilience • Ability to recover from stressful situations and negative events • Become stronger in the process • Increase strategies/skills for dealing with future stressful/negative events https://www.cio.com/article/3268390/7-ways-to-bounce-back-from-a-career-setback.html

Dimensions of Resilience

http://cronkitehhh.jmc.asu.edu/wp-content/uploads/2015/09/Resilience-Circle-Intersection.png

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Attitudes that Promote Resilience • Acceptance and realism • Self-awareness and reflexivity • Active engagement with the downside(s) of the medical profession • Accepting personal boundaries • Recognizing when change is necessary • Creating inner distance by taking an observer perspective • Appreciating the good things • Interest in the person behind the symptom https://climatechange.lta.org/resilience-projects/

Activities that Promote Resilience

• Leisure-time activity • Limitation of working hours • Build relationships with family, • Ritualized time-out periods friends, and colleagues • Supervision, coaching, • Discuss and come to terms with psychotherapy limits of one’s own skills as related • Cultivate non-work hobbies to errors/complications • Prioritization of basic needs • Personal reflection and goal setting • Spirituality • Talking about job-related stress with • Adapted from: Zwack J, Schweitzer J. If every fifth physician family and friends is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med • Cultivate one’s own professionalism 2013 Mar;88(3):382-9.

System Efforts to Promote Resilience • Medical school curricula • U Rochester SOM “Mindful Practice” seminars started in 2007 • Workshops for physicians in practice • Self-awareness • Resilience • Support groups • Counseling services • Challenges • Cost (Money, time spent) • Variable in delivery • Limited data on effectiveness • Epstein RM, Krasner MS. Physician resilience: what it means, why it https://startshining.com/bend-but-dont-break-2/ matters, and how to promote it. Acad Med. 2013 Mar;88(3):301-3.

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What is Self-Care

• Commitment to nurturing wellness • Personal • Professional • Dimensions • Physical • Emotional • Psychological • Spiritual http://stagingd7.chinarosewellness.com/retreats/resized- • Siegel TR, Nagengast AK. Mitigating Burnout. Surg Clin North Am. balancing-rocks-shutterstock_530429059/ 2019 Oct; 99(5): 1029-1035.

Mindfulness

https://www.livingmorefully.com/blogs/what-is-mindfulness

Being Present

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Research on Mindfulness • Regular practice: • Decrease anxiety, depression, anger, worry and stress • Increase joyfulness, gratitude, hopefulness, satisfaction w life • Positive effects mindfulness practice • Psoriasis, Type 2 DM, RA, ADHD • Training in mindfulness reduces resident stress and burnout better than providing equal amount of free time as time spent in mindfulness training program. • Irelanda MI, Cloughb B, Gillc K, Langand F, O'Connord A, Spencer L. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Medical Teacher 2017; 39(4): 409–414.

Self-Compassion • Self-Esteem • Global evaluation of self-worth • Contingent outside factures • May be harmful if decreased or elevated • May promote denigration of others to promote self-perception • Self-compassion • Accepting oneself as is • Including flaws, without judgement • Mindfulness is a component of this • Combats false instinct self-criticism required for self-improvement • Self is attacker and attacked • Germer CK, Neff KD. Self-compassion in clinical practice. J Clin Psychol. 2013 Aug;69(8):856-67.

Effects on Stress Response

Stress Response Stress Response Self-Compassion Turned Inward

Fight Self-Criticism Self-Kindness

Flight Isolation Common Humanity

Freeze Rumination Mindfulness

Neff K and Germer C, The Mindful Self-Compassion Workbook, 2018.

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Relationships w Self & Others

• Pay attention to your social relationships • Identify supportive relationships • Notice where you find energy • Notice where you feel like you give more energy than you receive • Give yourself permission to say no • Self-care is not selfish

So (Now) What?... • Resilience protects us when negative events happen • Some people have better tendencies/traits • CAN be taught/practiced/improved • Self-care is a primary way to improve resilience • Physical/emotional/spiritual • Mindfulness • Self-compassion vs self-esteem https://blog.caregiverasia.com/keep-calm-and-be-mindful

Some Light Reading

• Epstein RM, Krasner MS. Physician Resilience: What It Means, Why It Matters, and How to Promote It. Acad Med 2013; 88(3): 301-303. • Germer CK, Neff KD. Self-compassion in clinical practice. J Clin Psychol. 2013 Aug;69(8):856-67. • Irelanda MI, Cloughb B, Gillc K, Langand F, O'Connord A, Spencer L. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Medical Teacher 2017; 39(4): 409–414. • Sargent MC, Sotile W, Sotile MO, et al. Managing stress in the orthopaedic family: avoiding burnout, achieving resilience. J Bone Joint Surg Am 2011;93:e40. • Siegel TR, Nagengast AK. Mitigating Burnout. Surg Clin North Am. 2019 Oct; 99(5): 1029-1035. • de Vibe M, Solhaug I, Tyssen R, Friborg O, Rosenvinge JH, Sørlie T, Bjørndal A. Mindfulness training for stress management: a randomised controlled study of medical and psychology students. BMC Med Educ. 2013; 13: 107. • West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057): 2272-2281. • Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med 2013 Mar; 88(3):382-9.

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THANK YOU