Physician Health and Wellness Workshop Fusion Session PDF

5. Define and assess physician disruptive behavior. 6. Define and apply mindfulness to stress management and physician wellness. 7. Recognize prevention and intervention strategies and ways to access help.  Professional Standards of Heal...

5. Define and assess physician disruptive behavior. 6. Define and apply mindfulness to stress management and physician wellness. 7. Recognize prevention and intervention strategies and ways to access help.  Professional Standards of Health and Wellness Read below to learn about health and wellness definitions. Health Definition Wellness Definition “Health is a state of complete physical, “Wellness is an active process of becoming mental and social well-being and not merely aware of and making choices toward a the absence of disease or infirmity.” more successful existence.” Reference: World Health Organization Reference: National Wellness Institute Image Transcript  8 Dimensions of Wellness Emotional Financial Intellectual Spiritual Occupational  Physical Environmental Social AMA Code of Ethics When physician health or wellness is compromised, so may the safety and effectiveness of the medical care provided. To preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness, broadly construed as preventing or treating acute or chronic Maintain personal diseases, including mental illness, disabilities, and health and wellness occupational stress. Seeking appropriate help as needed, including help in addressing substance abuse. Physicians should not practice if their ability to do so safely is impaired by the use of a controlled substance, alcohol, other chemical agent, or a health condition. Physicians who are impaired are deserving of thoughtful, compassionate care. Physicians are ethically obligated to: (a) Intervene in a timely manner to ensure that impaired colleagues cease practicing and receive appropriate Act on behalf of assistance from a physician health program. (b) Report impaired colleagues impaired colleagues in keeping with ethics guidance and applicable law. (c) Assist recovered colleagues when they resume patient care. (d) Collectively, physicians have an obligation to ensure that their colleagues are able to provide safe and effective care. The medical professional should safeguard the public and themselves against physicians deficient in moral character or professional competence. Physicians should observe all laws, uphold the dignity and honor of the profession, and Protect society accept its self-imposed disciplines. They should expose,  without hesitation, the illegal or unethical conduct of fellow members of the profession. Society permits medicine to set standards of ethical and professional conduct for physicians. In return, medicine is expected to hold physicians accountable for meeting those Self-Regulate standards and to address lapses in professional conduct when Profession they occur. Collectively, physicians have an obligation to ensure that colleagues are able to provide safe and effective care, which includes promoting health and wellness among physicians.  Challenges and Their Consequences Click through the interactive below to review training and career stressors.       Interactive Transcript  Competition Ongoing assessment Residency match Unrealistic expectations Work More workload, less time Long hours Patients as stressors EMRs Bureaucracy (insurance/ health policy changes/ reimbursement stress) Service Orientation Intense sense of responsibility Patient before self Lifestyle Stressors Sleep deprivation Medical school debt Neglect of personal relationships Emotions Coping with death, grief Fear of being sued Loss of sense of control  Personality Risk Factors Personality Strengths Neuroticism Positive indicators: worry, guilt, low-stress Emotional Intelligence tolerance Ability to have a good relationship Passive, defensive coping with others “Low extraversion” (Introversion) Personality problem or culture problem? Potential Consequences The findings from a meta-analysis of 47 studies, including more than 42,000 physicians, showed that physician burnout doubled the risk of adverse patient safety incidents. Read the image below to learn more about patient care, physician health, and the health care system. Image Transcript  Physician Health and Wellness Patient Care Lower care quality Medical errors Longer recovery times Lower patient satisfaction Health Care System  Reduced physician productivity Increased physician turnover less patient access Increased costs Physician Health Substance abuse Depression/suicidal ideation Poor self-care Motor vehicle crashes  Understanding Burnout What is Burnout? Dr. Christina Maslach's Quote “erosion of the soul caused by deterioration of one’s values, dignity, and spirit” -- Dr. Christina Maslach, creator of Maslach Burnout Inventory Click on the tabs below to learn more about how burnout is measured, burnout in medicine, and a culture of burnout. Maslach Burnout Inventory – Most common instrument, 35+ years of use – 3 Factors: * Recent research raises questions about psychometric properties, e.g., less valid with depressed individuals. 1. Emotional Exhaustion: Lost Energy. Emotionally overextended by one's work; drained, “used up,” unable to restore oneself between activities, and energy spirals downward. Distinct from physical exhaustion or mental fatigue. 2. Depersonalization/Cynicism: Lost Enthusiasm. Feel hardened or callous in  response to patients. Marked by cynicism, sarcasm, feeling “put upon” by patients, and needing to vent about patients or job. Also called “compassion fatigue.” 3. Lack of Accomplishment/Inefficacy: Lost Confidence. Doubt the meaning and quality one’s work, “What’s the use?” According to the 2020 Medscape National Physician Burnout & Suicide Report: Based on more than 15,000 physicians in over 29 specialties, “42% of physicians reported that they are burned out, down from 46% five years ago.” (Kane, 2020) In a more recent survey by Medscape: Based on more than 5000 US physicians, “64% of US physicians said their burnout intensified during the COVID-19 crisis. Also, 25% of US respondents said they were considering early retirement and another 12% were considering leaving medicine for another career.” (Frellick, 2020) Moral injury Understaffed Social injustice Racism Sexism Do you... Cover up vulnerability? Isolate your feelings? Lie about how you’re doing? Avoid asking for help? Brag about how overworked you are? Worry if you are not overworked? Cover up self-care? Cover up your joy? Feel superior when you are miserable? Then, you could be experiencing burnout.  Depression, Suicide, and Substance Abuse Click on the tabs below to learn more about depression and physician suicide. Prevalence Predictors Medical students – 2-5 times more Difficult relationships with senior likely to have depression than the doctors, staff, and/or patients general population; prevalence Lack of sleep range: 9%-56%. Dealing with death Residents – NIH study ( JAMA. Making mistakes/litigation 2015 Dec 8; 314(22): 2373–2383.) 24-hour responsibility found a prevalence of 21–43%. Self-criticism Resident depression is associated Loneliness with 6x more medication errors. (BMJ. 2008 Mar 1; 336(7642): 488–491.) Lifetime rates: women physicians - 39%; compared to 30% in age- matched women with PhD’s male physicians - 13%; likely an underestimate due to limited self-reporting  400 MD suicides per year in the U.S. (more than a doctor a day.) More than double the rate of the general population. Male physicians: 70% higher than aged-matched males in the general population. Female physicians: 250-400% higher than in age-matched females. Same or higher rate than male physicians. Risk factors: The profession itself Being a female physician Suffering from untreated or inadequately treated depression + knowledge of and access to lethal means. Substance abuse Experiencing malpractice litigation “And when she became so overworked and despondent that she was unable to move, do you know what she was worried about? Her job. She was worried that she would lose her medical license, or be ostracized by her colleagues, because she was suffering due to her work on the front lines of the COVID19 crisis. She was afraid to get help, because she was worried it would end the career that she had spent her entire life working for. At the time, we thought her fears were unfounded. What we learned after her death is that licensing boards throughout the country require disclosure by physicians of current or past mental health care (in some cases at any level), hospitals require disclosure for credentialing, and seeking mental health care is considered a sign of weakness amongst many medical professionals. Lorna had no prior mental health issues (known or suspected), she had no history of depression or anxiety. But after she died, we learned that in the United States, 400  physicians die each year by suicide. We learned that female physicians die by suicide at a rate higher than their male counterparts. And we learned that the specialty of emergency medicine has one of the highest suicide rates of all medical specialties.” Quote taken from: https://drlornabreen.org/about-lorna/ (https://drlornabreen.org/about-lorna/)  Impaired and Disruptive Providers Click on the tabs below to learn more about physician substance use, loss of function, physician impairment, physicians with disruptive behaviors, and the spectrum of disruptive behaviors. Recreational drugs (e.g., Overall, substance use marijuana, cocaine) is Men > women likely to disorders rates similar to lower general public, but… abuse substances;alcohol the general population use disorder among Opioid use 5x higher female doctors > general (10-15%) than among the general female population public Anesthesiologists usually Higher rates: ER comprise 25% of Lowest rates: Pediatrics, Medicine, Psychiatry, physicians being treated for Pathology, Radiology, Anesthesiology, Family substance use disorder OB/Gynecology Practice, solo practitioners (SUD), the highest rate of opiate use disorders Review the image below to learn more about the loss of function progression.  Loss of Function Progress Used primarily to refer to substance- related disorders, also encompasses unaddressed physical or mental impairment that reduces a physician’s ability to undertake professional activities competently and safely. Disruptive behavior: Personal conduct*, whether verbal or physical, that threatens to affect patient care negatively. This includes conduct that interferes with one’s ability to work with other health care team members. Constructive criticism/ difficult feedback that is offered in good faith with the aim of  improving patient care should not be construed as disruptive behavior. Note A single episode of disruptive behavior does not render a physician a disruptive physician. Click on the interactive to learn more about passive, passive-aggressive, and aggressive behaviors.   Interactive Transcript  Passive Chronically late Failure to return calls Inappropriate/Inadequate chart notes  Avoiding meetings and individuals Non-participation Ill-prepared, not prepared Unavailability for professional matters Passive-Aggressive Intentional miscommunication Hotile notes, emails Derogatory comments about institutions, hospitals, group, etc. Inappropriate joking Blaming Speaking in a low or muffled voice Condescending language or tone Impatience with questions Malicious gossip Racial, gender, sexual, or religious slurs "Jokes" about a person's personal appearance Sarcasm Aggressive Yelling Foul and abusive language Threatening gestures Public criticism of coworkers Insults and shaming others Intimidation Invading one's space Slamming down objects Physically aggressive or assaultive behavior  Prevention, Intervention, and Getting Help Need Help? Your personal physician- do not self-treat! What To Do? Psychiatrist Psychologist Therapist Counselor Clergy Where To Go? Self-help/ Support groups: Meaning in Medicine Physician Wellness Committee Litigation Stress Committee Click on the tabs below to learn more about physician health programs, inappropriate behaviors by other health professionals, restoring joy to practice, what is mindfulness, and self- awareness. Federation of State Physician Health Programs, Inc. The mission of the Federation of State Physician Health Programs, Inc. (FSPHP) is to support physician health programs in improving the health of medical professionals, thereby contributing to quality patient care. For any physician who is concerned about a colleague, regardless of the relationship, the key step is to call the regional PHP (www.fsphp.org) to request guidance anonymously. All 50 states are separate from state medical boards. The approach is non-punitive and focuses on rehabilitation, not discipline. Allows physicians to seek help without jeopardizing their license. Fellowship and support of peers. Link to recovery support (International Doctors in  AA or Caduceus Meetings). Individualized treatment contract, typically 5 years. Do not provide treatment or drug testing (expense born by MD/patients themselves). Key Concept If you are aware of unprofessional conduct by another physician and do nothing, you are as liable as they are. Ethical Priorities: 1. A separate offender from patient contact. 2. Report offense to designated authority. 3. Facilitate rehabilitation through counsel and/or referral. Considerations: Assure patient safety Assure physician safety (relates back to #1) Assure follow-up: consult, refer, report Job Satisfaction Repels Burnout! Programs Offered in Medical School Learn about the dark side of “The Healer’s Art”: honoring loss, medical values -> Shift the culture grief, restoring “awe in medicine” Be Mindful & Self-Aware Mindfulness-Based Stress Ask What Works & Be Grateful Reduction (MBSR) Groups: Build & Rely on Your Community teaching mindfulness, self- Set boundaries at home and work compassion and emotional- regulation skills. Mind-Body Skills Groups: teaching mindfulness skills, fostering self-awareness and openness (here at RUSM!)  “…The awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally.” --Jon Kabat-Zinn Mindfulness According to Self-Awareness Theory (Duval & Wicklund, 1972): You are not your thoughts (or feelings, sensations, or drives), and you have the power to influence how they affect you. You are an entity observing your thoughts (feelings, sensations, and drives). People with strong self-awareness are honest with themselves and can reassess their values, assumptions, and behaviors. Answer the question below and then check your answer. A 33-year-old physician has been reported to administrators for his constant complaining and sarcastic remarks to staff. He has also been heard in the clinic’s breakroom laughing about a colleagues' personal appearance. These behaviors illustrate what type of disruptive behaviors?  Passive-Aggressive  Aggressive  Assertive  Passive  Check Transcript  A 33-year-old physician has been reported to administrators for his constant complaining and sarcastic remarks to staff. He has also been heard in the clinic’s breakroom laughing about a colleagues' personal appearance. These behaviors illustrate what type of disruptive behaviors? Aggressive Assertive Passive Passive-Aggressive  Check-In: How Are You Doing? “While jobs are sustenance, careers are altars upon which all else is sacrificed.” --Cassady Rosenblum  Questions to ask yourself: This is your house, which rooms do you inhabit? What rooms would you add? Image Transcript  Emotional Financial Intellectual Spiritual Occupational Physical Environmental Social Read the image below to learn more about a wellness house. Image Transcript  Example of a Wellness House What are 3 "rooms" in your life? *Renovations always in progress You Meta Writing Home Art Parenting Friends and Family Marriage Nothing World Dr. appointments Exercise  Body Food Entertainment Activism Food Feelings Spirituality Read the image below to learn more about the puzzle of life. Image Transcript  Puzzle of Life "LIVSPUSSEL": The puzzle of life (Swedish) Environment Arts/Music Home Travel/Adventure Reading Writing Entertainment Sports Cooking Leisure Work/School Relationships Mind Spirit Emotions Body Activism Nature Collecting Religion Philosophy Politics Traditions Technology Gaming Money Designs Hobbies Charity Artronomy Family Partner Children Friends Advisors Animals Plants Community Social Media