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Physician Well-BeingProtect Against Burnout and Encourage Self-Care

Learning Objectives:
At the end of this activity, you will be able to:
1. Define resiliency in the practice of medicine;
2. Explain how improving resiliency benefits you and your practice;
3. Describe action steps, tools and resources to increase resiliency.
0.5 Credit CME
How will this module help me?

  1. Provides simple, evidence-based solutions to enhance your joy for practicing medicine and to mitigate stress.

  2. Includes action steps, tools, and resources to help you to further improve well-being.

Introduction
What is well-being in the practice of medicine?

Well-being includes the ability to adapt to and bounce back from the stress of the training and/or clinical environment. Physicians who practice well-being are better equipped to handle the many challenges presented in medical training and when providing patient care. As such, they are less likely to experience burnout. Promoting the well-being of physicians translates to benefits for patients and the practice as a whole. You can use or develop both formal and individualized well-being programs for your practice or organization.

Box Section Ref ID

Q&A

  • What is well-being?

    Positive Well-being is the capacity to recover quickly from difficulties, the ability to spring back into shape, or the ability to withstand stress and catastrophe. Generally, resilience improves with age as we are exposed to challenging situations and learn to solve problems. We can also deliberately enhance our well-being and resiliency by learning self-management skills and connecting with the meaning and purpose in our lives.

  • What steps can I take to enhance my well-being?

    Any change in behavior is hard. There are multiple small steps that you can take to help boost your personal well-being.

    These steps range from the basics (such as ensuring adequate nutrition, sleep, and exercise) to more deliberate reflective approaches (such as narrative practices, mindfulness practices, reconnection with purpose and meaning, and peer group interaction).

Six STEPS to managing physician and trainee stress:

Start small. Choose one item from the steps below and spend the next 30 days checking in daily, even if only briefly, to measure your progress. If you don't feel like you're improving, be patient and reassess in a week. If you are making progress, give yourself a pat on the back and keep up the good work. Consider focusing on another item once the previous habit is firmly in place.

  1. Take a deep breath and get organized.

  2. Think about your practice or training from a different perspective.

  3. Think about the big picture.

  4. Find support and guidance in outside groups.

  5. Find meaning outside of work.

  6. Last but not least—don't forget to have fun!

Step 1 Take a deep breath and get organized.

When you decide to focus on your well-being, you have acknowledged that you are looking for solutions to manage stress. Taking a deep breath allows you to diminish the anxiety of beginning a new journey.

Put yourself on your own schedule.

Schedule essential personal responsibilities before you schedule work obligations on your calendar. Your personal schedule may include the number of hours of sleep that are ideal for you, frequency and duration of exercise that you would like to get, downtime strictly for recreation, alone time, and time for attention to nutrition. If you cannot do everything on your schedule, consider prioritizing your activities.

Take stock of your desires, feelings, and actions that may contribute to stress or burnout.

Begin with an initial moral inventory. “Fearless moral inventory” is a phrase used by Alcoholics Anonymous® that means taking stock of your own role in any problematic areas of your life. This exercise is not intended to place blame or be used as an opportunity to judge yourself, but rather to examine how you may unintentionally contribute to your own stress. With this inventory, you can begin to realize how these factors influence your happiness and well-being.

Remember that well-being includes behaviors such as making the time to deal with personal issues. Prioritizing yourself will enable you to address workplace stressors as well. This self-examination should focus on the role of your own emotions, thoughts, or actions in perpetuating feelings of stress or burnout. This is intended to help you find behaviors that are within your power to change.

You may choose to perform this self-evaluation each week, each month, or on an annual basis. The idea is to identify your “thoughts and emotions” and the corresponding “actions” that result. For example, if you wish you had time to meditate but never seem to get around to it, examine the thoughts, emotions, and actions that get in your way. You may find that sadness and feeling a lack of control—the thoughts and emotions—lead to time spent on the internet—the action—which takes up time you would otherwise use to meditate. Another example may be wishing that loved ones would tell you more about their lives—the thoughts and emotions—but you find that you spend limited amounts of time with them and are often preoccupied with other thoughts, and may pay only partial attention to what they are saying—the actions—which results in less meaningful communication than you wish.

Identify and prioritize your values and compare them to how you spend your time.

Start by making a list of the values you hold most dear. Ask yourself what your priorities are at this stage of your life. Priorities will vary from person to person and from stage to stage in your life and career. For instance, at one point in your life, the number one priority may be to get promoted, and at another point, it may be to be the best parent possible. This is why this exercise is worth repeating regularly.

Once you performed this assessment and have a list of core values and priorities, look at how you spend your time, attention, and money. Is there a mismatch between your list of values and your behaviors? It is sometimes useful to look at how you spend every hour in your week and how you spend your income. For example, there is a mismatch if you value a life of human connection, family time, and time outdoors, but spend your days rushing from one patient to the next, getting home too late to talk to your partner, and spend all weekend indoors. Ask yourself if you can delegate tasks so that you have more time to focus on your values and priorities. Are there areas to which you would like to devote more time, attention, or money? Areas where you would like to devote fewer resources?Quiz Ref IDQuiz Ref ID

Box Section Ref ID

Q&A

  • Why does my state of well-being matter?

    There is evidence that stressed, burned-out physicians have:

    • Lower patient satisfaction scores.

    • Higher rates of malpractice lawsuits.

    • Higher likelihood of leaving the profession.13

    • A tendency to make more medical errors.

    • A greater likelihood of exhibiting disruptive behavior.3

    Overall, physicians also have a higher risk of suicide than the general population despite similar risks of depression and anxiety.4 For male physicians, the risk of suicide is up to three times higher than for age-matched non-physician controls. For female physicians, this risk increases to five times that seen with age-matched controls.4

    There is also evidence that medical students are more likely to engage in “dishonest and unprofessional behaviors” when they are feeling depressed or burned out, for example:

    • Reporting a lab exam as pending when they knew it wasn't ordered.

    • Marking a finding as normal on a physical exam when they knew it was omitted.

    • Considering self-prescribing anti-depressants to themselves or a spouse as acceptable behavior.

  • What is physician burnout?

    Physician burnout is defined as “a syndrome encompassing three domains: depersonalization, emotional exhaustion, and a sense of low personal accomplishment.”3

  • How can I tell if I am experiencing burnout?

    A useful self-assessment is to ask yourself: “How often have these statements felt true to me in the last year?”

    • “I feel less enthusiastic about my work than before” (possible emotional exhaustion).

    • “I have become more insensitive toward people since I took this job” or “I have become more callous over time in my current role” (possible depersonalization).

    • “I can't remember why I wanted to become a doctor” (possible loss in sense of purpose).

    If your answer is “more than a few times a year” for any of these statements, you are more likely to fall into the relevant sphere of burnout in a formal assessment. The third domain of burnout, low sense of personal accomplishment, is more difficult to measure and there is no single question that can give insight into this domain.5

    In you are a practicing physician, another option is to use the seven-item Physician Well-Being Index. A score of greater than or equal to four positive answers on the Index correlates with lower mental quality of life, a lack of well-being, and other markers of physician distress. The Index takes very little time to complete and the information obtained from answering the questions may be useful as a personal reference point.6 You may also consider using the validated Mini-Z questionnaire on an organization-wide level to reliably measure staff burnout. Regular measurement and response to burnout should become an institutional best practice—a “vital sign” for organizations.

  • What risk factors are associated with burnout?

    Common risk factors for burnout include:

    • Demanding workloads.

    • Number of nights on call.

    • Having a partner who is also a physician.

    • Raising children.

    • Having recently made a medical error.

    • Being a mid-career practitioner.

    • Work–home conflict.

    • Spending less than 20 percent of time on the most meaningful aspects of your work.

    • Moving to a new environment with little support.

  • What are the common sources of physician and trainee stress in medical practice?

    Physicians are faced with numerous stressors throughout their careers. Some are expected, such as prolonged, intense training and exposure to tragic outcomes during medical practice. Others are the result of the evolving practice environment, including implementation of electronic health records (EHRs) and increasing regulatory demands. Learning resilience gives you the tools to not only appropriately react to these stressors, but helps you develop skills to prevent them from taking a toll on your personal well-being.

    Even changes in your practice that are designed to improve your quality of life can be very stressful, especially those made without your input. It is useful to bolster your individual capacity to cope to make it easier for you to adapt to any changes made on a system-wide level. Learning and utilizing some techniques to foster your own stress tolerance and hedge against burnout will prove useful during times of rapid change.

    Medical training is also stressful. Medical students, residents, and fellows are frequently exposed to loss in the clinical environment, along with stressors outside of the clinical practice as well. Grades, medical school debt, and a disorganized learning environment are often sources of stress for trainees.

Step 2 Think about your practice or training from a different perspective.
Write your individual mission statement.

What do you stand for? Write it down. Each time you are considering doing something, ask yourself whether this action is consistent with your mission statement. This may help you decide whether to agree to do it or not. Many CEOs write their own personal mission statements to guide their decisions.

Write down inspiring patient stories.

Regardless of whether you use a formal or personal approach, writing patient stories as narratives rather than for the medical record is a powerful way to connect with emotions stirred up by patient interaction.

There are formal programs in narrative medicine, such as the one at Columbia University Medical Center. You may find it beneficial to write alone or with a group of peers. Patients should never be named, nor should their stories be identifiable. Do not publish these stories in any form (such as in a magazine or on a blog) without explicit written consent from the patient. This exercise is primarily for your benefit; seek legal advice if you wish to have your work read by a broader audience.

Step 3 Think about the big picture.
Consider the legacy you want to leave behind.

Deciding how you wish to be remembered may help spur changes in the way you currently live. Imagine what a member of your family, a friend, or a coworker might say about you if you move away or at your retirement party.7

Start a gratitude journal.

Write down three items that you are grateful for each day. Examples include seeing the sunrise, a warm smile from a patient, etc. Nothing is too simple for this exercise. Some people like to do this immediately before going to sleep at night, while others prefer to do it first thing in the morning. This easy practice has been shown to increase self-reported happiness and prevent burnout.8

Manage your time and finances

Physicians have extensive training in the practice of medicine, but often have minimal training in managing their own time and finances. It may be worth a course or a consultation with a reliable expert to help hone your skills in these areas. If financial management is a stressor, make an appointment to meet with a local financial advisor.

Develop your spiritual practice.

Having a spiritual practice appears to be protective against burnout.9 Spiritual practices are not necessarily a formal religious practice. For example, you may find that regular time alone in nature serves this purpose.

Step 4 Find support and guidance in outside groups.
Consider a support group.

Many types of group interaction can be beneficial in reducing stress, restoring emotional well-being, and preventing burnout. The general idea is for a group of peers to speak together about the stresses and pleasures of their work. These groups may be peer-led or moderated by a trained facilitator. Examples of groups you may consider include: The American Balint Society, The Center for Mind-Body Medicine, The Institute for Integrative Health Faculty Training in Mind-Body Medicine, and a variety of programs offered by the Center for Courage & Renewal. If none of these groups are available in your area, consider attending training to start your own.

Enlist your peers to provide support.

Health care practitioners are frequently exposed to extremely unsettling events, such as the death of a child, and may be involved in adverse outcomes.

To help physicians cope with these situations, Jo Shapiro, MD, of Brigham and Women's Hospital in Boston, initiated a peer support program for her colleagues. This program consists of a group of physicians trained to provide a sympathetic ear to their distressed colleagues. In the event of an adverse outcome or medical error, peers in the Brigham and Women's Hospital group are available to lend support and direct colleagues to additional resources. This program has helped to transform the culture of secrecy and shame associated with adverse outcomes and provides resources to affected physicians. Numerous hospitals, health systems, and physician groups have created similar peer support programs that lend support and direct colleagues to additional resources.

The Collaborative for Healing and Renewal in Medicine (CHARM) is dedicated to addressing burnout in medical trainees by gathering best practices, promoting investigation of the impact of learner burnout, developing tools for educators to address learners in distress, and advocating for recognition and inclusion of initiatives that foster well-being in this group.

If you are a medical student or are training medical students, consider looking into The Healer's Art program. This program offers curriculum for medical students that focuses on strengthening students' personal values, calling, and service intention. It uses tested principles of adult education, contemplative studies, psychology, formation education, poetry, art, and personal narrative to increase awareness of personal values, increase resilience, and foster professionalism among medical students.

Seek professional help.

Are you one of the many physicians or trainees who do not have their own primary care doctor? If you are concerned about your physical health, find and check in with a primary care doctor. For emotional support and help determining whether any serious mental health issues are present, consider a counselor such as a social worker, psychologist, or psychiatrist.

Most health systems have mental health practitioners who specifically manage health care team members. They are discrete and skilled in the specific challenges that physicians encounter.

Connect with local resources.

Your organization may have a student or employee assistance program that provides free counseling and referrals. You may also explore wellness offerings from your county or state medical society. In addition, most states have a physician health program (PHP). In some states, the PHP is small and primarily handles substance abuse or disruptive behavior by physicians. In other states, offerings include wellness activities like sponsored mindfulness training.

Box Section Ref ID

Q&A

  • Where in the health care ecosystem should burnout be addressed?

    Burnout can be addressed at multiple levels:

    • Individual (addressed in this module).

    • Microsystem (e.g., the office practice, which is addressed in other STEPS Forward™ modules on various aspects of workflow and teamwork).

    • Mesosystem (e.g., the organization or institution).

    • Macrosystem (e.g., the health care system, which is addressed through policy, regulation, research and technology).

    The AMA is working addressing physician burnout at all four levels. This module is focused primarily at the individual level. To learn more about burnout, see the STEPS Forward™ physician burnout module.

Step 5 Find meaning outside of work.

Having a broad perspective of life beyond the medical profession can help buffer the daily challenges of caring for patients.

Volunteer.

Although it may seem counterintuitive to add more to your packed schedule, people who donate their time and expertise in volunteer service often find it easier to attain personal happiness.

Learn something new.

In general, people who choose a career in medicine have a thirst for knowledge and intrinsic curiosity. After many years in practice, the problems that were initially challenging may become routine and less engaging. Consider quenching your thirst by signing up to learn something new. This does not have to be medicine- or career-related.

Take a mindfulness class.

Mindfulness-based stress reduction, or MBSR, is a program developed in 1979 by Jon Kabat-Zinn at the University of Massachusetts Medical School. This secular program is based on meditation, self- and body-awareness, and communication skills. Initially used by patients with chronic diseases and chronic pain, the applications of this program continue to grow. The basic program lasts eight weeks for approximately two hours per week. There are now offshoots for specific issues, such as eating disorders, relapse prevention for substance use, and management of recurrent depression. There is growing literature that mindfulness-based approaches are very useful in mitigating the stress experienced by health care practitioners.1012 In fact, some institutions now have mindfulness courses specifically for health care practitioners.

Connect with your body.

It is healthy and important to find time for regular exercise. However, some specific forms of exercise, such as yoga, tai chi, and qi gong, foster a strong mind-body connection.

Step 6 Last but not least—don't forget to have fun!

Whether you are passionate about gardening, dancing, watching reality TV, or traveling, remember to schedule (and keep) time to enjoy those activities that make you happy.

Conclusion

When you focus on managing the stress of relentless change, it is easy to lose sight of the joy, meaning, and purpose of your profession. Taking small steps devoted to improving your own well-being will help you have a longer, more satisfying career, and reduce your risk of burnout. Improving your personal well-being may also have a positive impact on your team, your family, and all the patients with whom you interact.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Successful completion of this CME activity, which includes participation in the activity and individual assessment of and feedback to the learner, enables the learner to earn up to 0.5 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABP MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Target Audience: This activity is designed to meet the educational needs of practicing physicians, practice administrators, and allied health professionals.

*Disclaimers: Individuals below who are marked with an asterisk contributed towards Version 1 of this learning activity.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, quality improvement and informatics.

Planning Committee:

  • Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, American Medical Association*

  • Marie Brown, MD, MACP, Senior Physician Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association & Associate Professor, Rush Medical College, Rush University Medical Center

  • Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Ashley C. Cummings, MBA, CRCR, CME Program Committee, American Medical Association

  • Rita LePard, CME Program Committee, American Medical Association*

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association*

Content Reviewers:

  • J. James Rohack, MD, FACC, FACP, Senior Advisor and former President, American Medical Association

  • Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Claudia Finkelstein, MDCM, Director of Faculty Wellness Programs, University of Washington School of Medicine*

  • Kathi J. Kemper, MD, MPH, Professor of Pediatrics and Director of the Center for Integrative Health and Wellness, The Ohio State University*

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*

About the AMA Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

ABMS MOC Statement: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Renewal Date: February 22, 2016; May 23, 2019

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