Corporate Self Care

1. 11/8/2012
Outline
• Background
R2 ‐ Research presentations
• Potential Solutions
• The 2011-12 DOM Intervention Trial
Working towards a policy for parenthood and family/work
• Future Steps
reconciliation during residency training : The initiative of a
residents’ association (E. Desrosiers, J. Hallet)
Feasibility of a job‐specific workers' health surveillance of
hospital physicians (J. Sluiter, M. Ruitenburg, M.‐C. Plat,
M. Frings‐Dresen)
A randomized controlled trial evaluating the effect of facilitated
small group sessions on physician well‐being and job
satisfaction (C. West, L. Dyrbye, J. Sloan, T. Shanafelt)
Ville‐Marie, Friday, Oct. 26, 2012 (11 am‐12:30 pm)
Outline
Background
• Background
• Physician well-being has
• Potential Solutions come under increased
• The 2011-12 DOM Intervention Trial scrutiny in recent years
• Future Steps • Common:
• Burnout
• Low job satisfaction
• High stress
• Low quality of life
Background Consequences of Physician Burnout
• Physician well-being has • Medical errors1-3
come under increased
scrutiny in recent years • Impaired professionalism5,6
• Common: • Reduced patient satisfaction7
• Burnout • Staff turnover and reduced hours8
• Low job satisfaction
• High stress • Depression and suicidal ideation9,10
• Low quality of life
• Affects all stages of
physician training and
practice 1JAMA 296:1071, 2JAMA 304:1173, 3JAMA 302:1294, 4Annals IM 136:358,
5AnnalsSurg 251:995, 6JAMA 306:952, 7Health Psych 12:93, 8JACS
• Affects all specialties
212:421, 9Annals IM 149:334, 10Arch Surg 146:54
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2. 11/8/2012
Outline
Recommendations in the Literature
• Background
• Potential Solutions Choices with regard to work-life balance
• The 2011-12 DOM Intervention Trial Stress management techniques
• Future Steps Spiritual nurturing
Positive life philosophy
Self-care (exercise, health, recognition of place on the
“stress curve”: reflection, mindfulness)
Search for meaning in work
Shanafelt et al., Am J Med 2003; Dyrbye et al., Mayo Clin Proc 2005
Studied Approaches Limitations of the Literature
• SMART program • Interventions to reduce distress and promote well-
being limited by:
• Personal stress reduction training • Small samples
• Uncontrolled studies
• Fostering self-awareness (“mindfulness training”)
• Focus on personal rather than shared responsibility with
• Balint groups organization
• Most interventions on personal time
• Informal Doctoring to Heal physician discussion • Limited and poorly validated outcomes
groups
Outline
An Intriguing Model
• Background
• Krasner et al. reported large effects of a 52-hour
mindfulness training program administered over 1 • Potential Solutions
year • The 2011-12 DOM Intervention Trial
• Markedly improved burnout in all domains
• Improved empathy • Future Steps
• Improved mindfulness
• Results sustained 3 months post-intervention
• Limitations
• No comparative control group
• Volunteer bias
• All participants were primary care providers
• Training occurred after hours and on weekends
Krasner et al., JAMA 2009;302:1284-93.
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3. 11/8/2012
Intervention Trial Intervention Trial
• Develop intervention to promote meaning in work • RCT testing if an established, portable, low-cost curriculum
among Department of Medicine practicing administered during regular work hours can promote meaning
physicians and reduce burnout
• Key driver of physician satisfaction and well-being • Arm A (Intervention):
• meet 90 minutes (12:30-2) every other wk (60 mins protected
• Mechanism to reduce burnout related to work engagement time, ~1% FTE)
• 9 months
• Facilitated curriculum, small groups of 6-8 physicians
• Arm B (Control):
• Receive 60 minutes every other week for
professional/administrative tasks (~1% FTE)
• Outcomes assessed quarterly, 3 months post, 12 months post
(final survey results currently under analysis)
Intervention Trial Intervention Trial
Intervention • Participants:
• Randomization in blocks to match sex and specialty
Volunteers N=37 • 58% men (DOM ~70%)
N=74 • 40% generalists (DOM ~25%)
Control • Prior data suggests generalists and women may have higher
DOM faculty rates of burnout and many other markers of distress.
N=37
N=550 • Small groups constructed to have mix of
generalists/subspecialists and men/women.
Non-
volunteers Current
Practice
N=476
Intervention Trial Intervention Trial
• Intervention broad and varied:
• Expert facilitators • Built on prior literature
• Lead: Jeff Rabatin, MD, MSc • Goals:
• Tim Call, MD • Identify and promote meaning in work
• John Davidson, MD • Foster collegiality and community
• Ada Multari, MD • Share techniques for dealing with challenging professional
• Susan Romanski, MD issues
• Qualitative methods • Identify and share ways to promote personal and
professional satisfaction
• Joan Henriksen Hellyer, RN, PhD
• Learn specific skills: self-reflection, mindfulness, effective
• Facilitator training sessions coping strategies
• Debriefing sessions after each small
group meeting
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4. 11/8/2012
Intervention Trial Intervention Trial
• Topics: 3 Modules • Session structure (60 minutes)
• SELF • BALANCE • Check-in (5 minutes)
• Physician well-being • Personal/professional balance
• Cueing exercise (15 minutes)
• Physician distress • Personal/professional identity
• Meaning in work • Personal/professional relationships • Group discussion (20 minutes)
• Personal resources • Gender and generational differences • Skills and solutions (15 minutes)
• Thriving • Resiliency • Check-out/summary (5 minutes)
• PATIENT
• Patient connectedness
• Barriers to care
• Bad news
• Medical mistakes and errors
• Being present
Intervention Trial Intervention Trial
• Example: Session 12 (Medical mistakes and errors) • 12:30-12:45: Lunch
• 12:45-12:50: Check-in
• Specific Themes to Address: • 12:50-1:05: Prepare the Environment (cueing exercise):
• Experiences of error and reactions from peers/system • Personal reflection/journaling exercise about a personal error
• Impact on physicians • Questions for participants to consider:
• How common are medical errors (i.e., what proportion of
physicians make an error over the course of their career)?
• What factors contribute to errors?
• How do errors affect the physicians who make them?
• 1:05-1:25: Group Discussion:
• Shared reflections
• How common are errors?
• What impacts do they have on physicians?
Intervention Trial Intervention Trial
• 1:25-1:40: Skills/Solutions:
• Main messages: errors are an unavoidable part of human practice, and • 1:40-1:45: Check-out/Summary
they can have major negative impact on physicians – acknowledging
these impacts is a major piece of managing them, even as we strive for a • 1:45-2:00: Travel time
zero-error ideal.
• Resources:
• Note coping strategies suggested in literature, including elements of
• i) Wu article in BMJ, Medical error: the second victim
mindfulness, acknowledge/analyze/improve (see below for suggestions
from literature) • ii) Goldberg article, Coping with errors
• iii) Wears article, Dealing with failure
• 1. Accept responsibility for the mistake. • iv) Rowe article, Doctors’ responses to errors
• 2. Discuss with colleagues. • v) Errors at Mayo: West et al., JAMA 2006 and 2009
• 3. Disclose and apologize to the patient. • vi) 1999 IOM report: To Err is Human
• 4. Conduct an error analysis.
• 5. Make changes in practice or practice setting designed to reduce future
errors.
• 6. Work at local and national levels to change the culture of the medical
profession with regard to the management of medical mistakes.
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5. 11/8/2012
Results – 3 Groups
• Comparison of trial arms with DOM non-study participants,
using data from the annual DOM surveys coordinated by the
PPWB (n=340 responding to both 2010 and 2011 surveys)
• Timing matches baseline and 12 month (3 month post-study) surveys
Results from intervention trial
• Allows “usual care” control arm, control for secular trends
• Analyses adjusted for baseline levels of burnout, etc. to account for
baseline differences across groups
0 3 6 9 12 21
Baseline End Study 3 Month Post 1 Year Post
DOM Survey DOM Survey
Strongly Agree T hat W or k is Meaningful Strongly Agree T hat W or k is Meaningful
100 100
90 Intervention 90 Intervention
80 80 Δ=-6.3
Control Control
%
%
70 Δ=-13.4 70 Δ=-13.4
Non-Study Non-Study
60 DO M 60 DO M
50 50
Baseline 1 year Baseline 1 year
Strongly Agree T hat W or k is Meaningful H igh Emotional Exhaustion
100 p=0.036
50 p=0.007
90 Intervention 40 Intervention
Δ=+6.3 Δ=+4.3
80 Δ=-6.3 30
Control Control
%
%
70 Δ=-13.4 20 Δ=-5.3
Non-Study Δ=-20.4 Non-Study
60 DO M 10 DO M
50 0
Baseline 1 year Baseline 1 year
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6. 11/8/2012
H igh Depersonalization O verall B urnout
50 p=0.03
50 p=0.002
40 Intervention 40 Intervention
Δ=+4.9
30 30
Control Control
%
%
20 20 Δ=-13.8
Non-Study Δ=-25.8 Non-Study
Δ=+2.5
10 Δ=-8.3
DO M 10 DO M
Δ=-13.3
0 0
Baseline 1 year Baseline 1 year
Poor Q O L Conclusions
• A small amount of protected time during the
50 p=0.57 workday resulted in improved meaning from work
and reductions in burnout
40 Intervention • Effects larger in facilitated small group arm than in “free
time” control arm
30
Control
%
Δ=+0.6
20
Δ=-7.3 Non-Study
10
Δ=-15.2 DO M
0
Baseline 1 year
©2010 MFMER | slide-34
Results – 2 Groups M eaning from Work
• Comparison of two intervention arms 70
• Small trial: detectable effect size 0.66 (medium to large) p=0.001
• Assess quarterly longitudinal data
• Broader array of variables, e.g.:
• Full meaning instrument
65
E WS Score
• Full MBI rather than 2-item screen
• SF-8 well-being index Δ=+0.8 Intervention
• Depression screening, empathy, stress, job satisfaction 60
Control
Δ=+2.6
55
0 3 6 9 12 21
Baseline End Study 3 Month Post 1 Year Post
(Pending)
50
B ase line 3 6 9 12 M onth
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7. 11/8/2012
H igh Emotional Exhaustion H igh Depersonalization
50 p=0.61
50 p=0.01
40 40
Δ=-4.0
30 30 Δ=+0.8
Intervention Intervention
%
%
Δ=-19.4
20 Control 20 Control
10 10
Δ=-15.5
0 0
B ase line 3 6 9 12 M onth B ase line 3 6 9 12 M onth
Stress
O verall B urnout 40
p=0.91
30
60
PSS Score
p=0.18 Intervention
20 Δ=-3.1 Control
50 10
Δ=-1.8
40 Δ=-6.5 0
B ase line 3 6 9 12 M onth
Intervention
30 Poor Q O L
%
Δ=-24.7 Control 50
p=0.53
20 40
30
10 Intervention
%
20
Δ=-12.3 Control
0 10
Δ=-4.8
B ase line 3 6 9 12 M onth 0
B ase line 3 6 9 12 M onth
M ental Well-Being Positive Depression Screen
60 50
Conclusions
p=0.14 p=0.32
55
40 • Compared to the unstructured control group, the
Δ=+5.0
facilitated small group intervention improved:
SF-8 Score
30
Δ=+1.2 Intervention Δ=-6.2 Intervention
50
%
Δ=+4.5
Control 20 Control • Meaning from work
45 10 • Depersonalization
40
B ase line 3 6 9 12 M onth
0
B ase line 3 6 9 12 M onth
• No statistically significant improvements in:
• Emotional exhaustion
Empathy Job Satisfaction • Overall burnout
130
p=0.24
5 • QOL
p=0.69
125
Δ=+0.15 • Mental well-being and depressive symptoms
4
JSP E Score
Δ=+1.2 Δ=+0.23 • Empathy
PJSS Score
Intervention
120 Intervention
Δ=+5.0 Control 3
Control
• Stress
115 • Job satisfaction
2
110
B ase line 3 6 9 12 1
• However, the small group intervention outperformed the
M onth B ase line 3 6 9 12 M onth
control in every one of these domains
©2010 MFMER | slide-42
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8. 11/8/2012
Outline
Future Steps
• Background
• Evaluate sustained effects at 12 month post study
• Potential Solutions
• Understand what aspects of intervention are most effective
• The 2011-12 DOM Intervention Trial (and least effective)
• Future Steps • Study other specialty areas and practices
• Build sample size to improve power
• Study other care provider groups
• Study alternative interventions
Mayo DOM
Program on Physician Well-Being Thank You!
• Comments/questions
• Director: Tait Shanafelt, MD
• Associate Directors: • west.colin@mayo.edu
• Lotte Dyrbye, MD, MHPE
• Colin West, MD, PhD
• Statistician: Jeff Sloan, PhD
• Administrator: Tim Burriss
• Administrative Assistant: Kara Kuisle
©2010 MFMER | slide-46
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