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Professionalism & Professional Health: Faculty Overview Charlene M. Dewey, M. D. , M. Ed. Professionalism & Professional Health: Faculty Overview Charlene M. Dewey, M. D. , M. Ed. , FACP Associate Professor of Medical Education and Administration Associate Professor of Medicine Co-Director & Chair William H. Swiggart, M. S. , LPC/MHSP Assistant in Medicine Co-Director Center for Professional Health, Faculty and Physician Wellness Committee, Vanderbilt University School of Medicine

Purpose • To raise awareness of issues related to professionalism and professional health and Purpose • To raise awareness of issues related to professionalism and professional health and to provide an overview of key resources in/outside of Vanderbilt.

Participant Objectives 1. List ways to improve your professional health. 2. Compare and contrast Participant Objectives 1. List ways to improve your professional health. 2. Compare and contrast workplace stress and burnout. 3. Describe distressed behaviors and how to report them. 4. State resources available for faculty and physicians in/out of Vanderbilt.

Agenda 1. 2. 3. 4. 5. Professional Wellness Workplace stress, burnout and suicide Distressed Agenda 1. 2. 3. 4. 5. Professional Wellness Workplace stress, burnout and suicide Distressed behaviors Resources Q&A and Summary

Professional Health Spectrum High Functioning High Productivity Faculty vitality Fair Functioning Decreasing Productivity Stress Professional Health Spectrum High Functioning High Productivity Faculty vitality Fair Functioning Decreasing Productivity Stress & Burnout Fair Functioning Reduced Productivity Relationships Suffer Coping Mechanisms Fair-Not Functioning Fair-Not Productive Institution & Family Loses Risk of MH issues and suicide

Importance & Evidence • • • MDs suicide > other prof. & gen pop. Importance & Evidence • • • MDs suicide > other prof. & gen pop. One physician per day; Ph. D – unclear Grossly underestimated Little education on topic 30 -60% MD have distress and burnout Depression/bipolar & substance abuse = suicide risk “Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success. ” Cole, Goodrich & Gritz, 2009.

Importance & Evidence • Reduced wellness professional lapses • Gender differences: • Females > Importance & Evidence • Reduced wellness professional lapses • Gender differences: • Females > anxiety, depression, burnout • F>M MD suicides • Reduced use of care by physician • Stigma & anonymity http: //www. aamc. org/members/gwims/statistics/stats 09/start. htm Lin et al. 1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19): 2775 -82. (Schindler et al 2006) “High physician suicide rates suggest lack of treatment for depression. ” - MD Consult News June 11, 2008

Professional Wellness 1. Self-care 2. Work-place stress Mind, Body and Spirit Balance takes effort, Professional Wellness 1. Self-care 2. Work-place stress Mind, Body and Spirit Balance takes effort, but worth the reward!

Professional Wellness • Self-care issues: – Sleep – Balanced meals – Physical activity – Professional Wellness • Self-care issues: – Sleep – Balanced meals – Physical activity – Socialization – Vacations/down times – Spiritual engagement – Have a physician Mind Soul Body

Work-Place Stress Work-place stress: Manage Reduce – Manage energy Energy. Distractions – Reduce distractions Work-Place Stress Work-place stress: Manage Reduce – Manage energy Energy. Distractions – Reduce distractions Planning – Plan appropriately – Managing failures and successes

“The first wealth is health. ” ~ Ralph Waldo Emerson “The first wealth is health. ” ~ Ralph Waldo Emerson

Stress & Burnout • Stress and burnout occurs for different reasons in different individuals. Stress & Burnout • Stress and burnout occurs for different reasons in different individuals. • Work load ≠ level of stress or burnout in all situations. • Multifactorial

Stress & Productivity No Prolonged Stress De e cli iv t ni c ng Stress & Productivity No Prolonged Stress De e cli iv t ni c ng du ess Fu ro tr nc P S t Situational Stress ion Stressed Burnout Non-Functional

Burnout “In the current climate, burnout thrives in the workplace. Burnout is always more Burnout “In the current climate, burnout thrives in the workplace. Burnout is always more likely when there is a major mismatch between the nature of the job and the nature of the person who does the job. ” ~Christina Maslach The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

Risk Factors for Burnout • • • Single Gender/sexual orientation ># of children at Risk Factors for Burnout • • • Single Gender/sexual orientation ># of children at home Family problems Mid-late career Previous mental health issues (depression) • Fatigue & sleep deprivation • • General dissatisfaction Alcohol and drugs Minority/international Teaching & research demands • Potential litigation Puddester D. West J Med 2001; 174: 5 -7 Myers MJ West J Med 2001; 174: 30 -33 Gautam M West J Med 2001; 174: 37 -41

Six Sources of Burnout 1. Work overload 2. Lack of control 3. Insufficient reward Six Sources of Burnout 1. Work overload 2. Lack of control 3. Insufficient reward 4. Unfairness 5. Breakdown of community 6. Value conflict Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. ”

Symptoms of Burnout 1. Chronic exhaustion 2. Cynical and detached 3. Increasingly ineffective at Symptoms of Burnout 1. Chronic exhaustion 2. Cynical and detached 3. Increasingly ineffective at work 4. Leads to: 1. 2. 3. 4. isolation avoidance interpersonal conflicts high turnover Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. ” pg 17

Protective Factors • Personal: – Tend to self care issues first – Address Maslach’s Protective Factors • Personal: – Tend to self care issues first – Address Maslach’s 6 sources of burnout – Influence happiness through personal values and choices – Adapt a healthy philosophy/outlook – Spend time with family & friends Spickard, Gabbe & Christensen. JAMA, September 2002: 288(12): 1447 -50

Protective Factors – A supportive spouse or partner – Engage in religious or spiritual Protective Factors – A supportive spouse or partner – Engage in religious or spiritual activity – Hobbies – Mentor (s) Spickard, Gabbe & Christensen. JAMA, September 2002: 288(12): 1447 -50

Protective Factors • Work: – Address Maslach’s 6 sources of burnout – Gain control Protective Factors • Work: – Address Maslach’s 6 sources of burnout – Gain control over environment & workload – Find meaning in work – Set limits and maintain balance – Have a mentor – Obtain adequate administrative support systems

Preventing & Resolving Burnout Individual Approach Organizational Approach Starts with person Starts with management Preventing & Resolving Burnout Individual Approach Organizational Approach Starts with person Starts with management Becomes group project Becomes organizational project Connects to organization Connects to people Outcomes affects related mismatches Outcome is a process Figure 5. 1 (pg 80) Maslach, C & Leiter, MP. “The Truth About Burnout: How Organizations Cause Personal Stress and What to do About It. ” 1997

Case 1: It’s 10: 30 PM and you pass your colleague in the hall. Case 1: It’s 10: 30 PM and you pass your colleague in the hall. She is a 48 yo female physician, recently divorced with one kid. You can tell she was crying. When you ask what is wrong she shapes up and replies, “Nothing really. I am so frustrated with the system!” You offer to talk and she declines. • What are your concerns? • What are her risk factors for stress & burnout?

Suicide • “Friends who work with people in medicine need to be aware that, Suicide • “Friends who work with people in medicine need to be aware that, if they see something that concerns them, they need to transmit the message to the powers that be. ” Dr. W. Gerald Austen, surgeon-in-chief emeritus Massachusetts General Hospital

Case 2: Dr S has struggled for the last year to “fit in. ” Case 2: Dr S has struggled for the last year to “fit in. ” He often seems emotionless and flat. He has been considered “unsocial” because he does not participate in any of the faculty gatherings. He has missed several deadlines and often calls in sick. His students say he doesn’t teach and is erratic at times. Once on his day off you saw him leaving a bar possibly drunk and on his post call day he was not responding to emails or pages for several hours. Just after the holidays he was found dead after a single vehicle MVA. • What are you concerned with here? • What barriers may play a role in this case?

Suicide • “However, hard and stressful work alone does not result in suicide. Those Suicide • “However, hard and stressful work alone does not result in suicide. Those who do commit suicide almost always have significant identifiable underlying mental illnesses, such as major depression and/or bipolar disorders, usually coupled with alcoholism and major drug use. ” ~Eugene V. Boisaubin Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressures of Success. Pg 32; 2009

Signs of Addiction • Unprofessional behaviors • Decreased performance • Diverting drugs • Unusual Signs of Addiction • Unprofessional behaviors • Decreased performance • Diverting drugs • Unusual pharmacy orders • PE signs of either intoxication or withdrawal • Isolation & withdrawal from friends • Mood changes • Overreactions to criticism • Long sleeves • Frequent restroom stops • Asks for extra calls Wearing Masks II. 1993 rainbow productions. www. Allanestesia. com

Addiction • Residents are more prone (especially anesthesia) than faculty • Increases accidental and Addiction • Residents are more prone (especially anesthesia) than faculty • Increases accidental and intended deaths • Denial, cover-ups, easy access • History of addiction – individual or family • “Tried it just once or twice. ” Wearing Masks II. 1993 rainbow productions. www. Allanestesia. com

Addiction • • • >50% residents self-prescribe 1 ETOH most commonly used substance 2 Addiction • • • >50% residents self-prescribe 1 ETOH most commonly used substance 2 10% faculty use daily; 9% binge 2 8% use opiates without MD supervision 2 Recovery can be successful treatment! 1. Christie et al. 1998 Prescription Drug use and self-prescription among residents. JAMA 280: 1253 -55) 2. Hughes et al. 1992 Prevalence of substance use among US physicians. JAMA 267: 2333 -39.

“Inaction is NOT an option. ” ~Dr John Lecky – recovering addicted physician Report “Inaction is NOT an option. ” ~Dr John Lecky – recovering addicted physician Report concerns to: Superiors Physician’s Health Program – confidential Wellness Programs – FPWP FPWC Members

Case 3: Dr D is an OB/GYN who was fired from one residency program. Case 3: Dr D is an OB/GYN who was fired from one residency program. She joined the faculty 6 mo ago. Since then, she has had five pt and staff generated complaints about her aggressive, loud behavior. In stressful situations, she becomes loud, forceful and rude. She slammed the door after a heated discussion with a nurse in front of a patient. She has also changed OR times without team permission to “take care of VIP patients. ” She is quoted as saying, “This is how I get things done. ” • What do her behaviors tell us? • Are her behaviors ok if her skills are outstanding?

Distressed Physicians • Internal Factors: – Alcohol and drug addiction – Compulsive behavior around Distressed Physicians • Internal Factors: – Alcohol and drug addiction – Compulsive behavior around sexual acting out, compulsive gambling, eating, working, etc. – Little or no training in conflict resolution, leadership skills, communication and teaching skills – Psychiatric disorders • Narcissistic personality disorder • Depression/bipolar • Dementia etc. Swiggart, Dewey, Hickson, Finlayson. 4/09 • External Factors: – High system demands and low system support – Disruptive behavior is reinforced by the system – Bully doc gets preferential operating time – Masking ineffective managers – Failure to act – The system fails to provide physician with complaints and/or feedback – Life cycle events (i. e. death in the family, children leaving home, divorce, etc. )

Figure 1 Spectrum of Disruptive Behaviors Aggressive Inappropriate anger, threats Yelling, publicly degrading team Figure 1 Spectrum of Disruptive Behaviors Aggressive Inappropriate anger, threats Yelling, publicly degrading team members Intimidating staff, patients, colleagues, etc. Pushing, throwing objects Swearing Outburst of anger & physical abuse Swiggart, Dewey, Hickson, Finlayson. 4/09 Passive Aggressive Chronically late Hostile notes, emails Failure to return calls Derogatory comments about institution, hospital, group, etc. Inappropriate/ inadequate chart notes Inappropriate joking Sexual Harassment Complaining, Blaming Avoiding meetings & individuals Non-participation Ill-prepared, not prepared

Distressed Colleagues • • • Focus on behaviors Document behaviors Discuss with leadership Report Distressed Colleagues • • • Focus on behaviors Document behaviors Discuss with leadership Report in VERITAS Re-training can be successful

Distressed Physicians “This leadership course has brought about change in the way I perceive Distressed Physicians “This leadership course has brought about change in the way I perceive others and how I am perceived as a professional, husband father. This intervention should have occurred earlier. ” ~CPH participant 07 -08

Resources Resources

Faculty and Physician Wellness Committee (FPWC) Rahn K. Bailey, M. D. – MMC Chad Faculty and Physician Wellness Committee (FPWC) Rahn K. Bailey, M. D. – MMC Chad Boomershine, M. D. Donald W. Brady, M. D. Ildiko Csiki, M. D. (resident) Larry Churchill, Ph. D. Roy Elam, M. D. A. J. Reid Finlayson, M. D. Kimberly Garcia, M. D. (resident) Stephan Heckers, M. D. Gerald B. Hickson, M. D. Jerry Jaboin, M. D. (resident) Tracy Jackson, M. D. Peter Martin, M. D. Jeanette J. Norden, Ph. D. James O’Neill, Jr. , M. D. Paul W. Ragan, M. D. David S. Raiford, M. D. Scott M. Rodgers, M. D. Debbie Smith, M. A. William Swiggart, M. S. , LPC/MHSP Donna Seger, M. D. Anderson Spickard, Jr. , M. D. Mary Yarbrough, M. D. , MPH Charlene M. Dewey, M. D. , M. Ed. , FACP (chair)

Vanderbilt Internal Resources Abbrev. Program Focus Contact Number FPWC Faculty and Physician Wellness Committee Vanderbilt Internal Resources Abbrev. Program Focus Contact Number FPWC Faculty and Physician Wellness Committee All issues of professional health Charlene Dewey x 6 -0678 FPWP Faculty and Physician Wellness Program – Work/Life Connections EAP Treatment of faculty and employees Mary Yarbrough X 6 -1327 CPH Center for Professional Health Training physicians Bill Swiggart x 6 -0678 VCAP Vanderbilt Comprehensive Assessment Program for Professionals Fit for duty assessments and treatment Reid Finlayson X 2 -4567 CPPA Center for Patient and Professional Advocacy Identification and assistance Jerry Hickson X 3 -4500

Vanderbilt Internal Resources • • Center for Integrated Health (CIH) Health Plus Go for Vanderbilt Internal Resources • • Center for Integrated Health (CIH) Health Plus Go for the Gold program Center for Professional Health Educational Resource web page/on-line classroom (in development) • Dayani center & ortho exercise facility • VERITAS

Other Resources • Primary care provider • Centerstone, Elam Center or other private counseling Other Resources • Primary care provider • Centerstone, Elam Center or other private counseling services • Cumblerland Heights & Evelyn Fry for substance use related issues • 1 -800 -273 -TALK: suicide prevention hotline • YMCA/YWCA • State physician health programs

Q&A Q&A

Summary • Good professional health protects both you and your career • Workplace stress Summary • Good professional health protects both you and your career • Workplace stress and burnout are common in AMC – be aware of the risks and try to prevent it when possible • Seek assistance when needed • Vanderbilt has several resources to assist

More Information • Please feel free to contact us: – Charlene. dewey@vanderbilt. edu – More Information • Please feel free to contact us: – Charlene. [email protected] edu – Wiliam. [email protected] edu

CPH & FPWC Web Page http: //www. mc. vanderbilt. edu/cph CPH FPWC Center for CPH & FPWC Web Page http: //www. mc. vanderbilt. edu/cph CPH FPWC Center for Professional Health * 1107 Oxford House * x 6 -0678