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Burnout and Post-Traumatic Stress Has Reached Epidemic Proportions

Posted on Thu, Jun 22, 2017
Burnout and Post-Traumatic Stress Has Reached Epidemic Proportions

By Jane Sullivan, Ph.D.

Epidemic is the term currently used to describe the increased incidence of both burnout and post-traumatic stress disorder (PTSD) in emergency physicians. It’s difficult to know if calls to action to address this epidemic have been responded to with any successful intervention. So perhaps the statistics will continue to be astounding:
 

  • 300 to 400 physicians commit suicide a year
  • 52 percent of emergency physicians report being burnt out
  • 60 percent of midcareer doctors have been involved in lawsuits
  • 10 to 15 percent of all doctors have issues with substance abuse during their careers
  • 80 percent of physicians state that they believe that the medical profession is on the decline

PTSD

Post-Traumatic Stress Disorder (PTSD) is a trauma and stress related disorder that may develop after exposure to an event or ordeal in which death, severe physical harm or violence occurred or was threatened, according to Psychology Today. Witnessing the pain and suffering of patients who are impacted by traumatic events such as mass shootings, car accidents, suicides, opiate overdoses and terminal illnesses can erode the barriers that help protect physicians from incapacitating, overwhelming emotions. It is, however, the inability to access emotions and the lack of support to express genuine and understandable grief that may set the foundation for the symptoms of PTSD.

The Symptoms of PTSD

The symptoms of PTSD are usually quite demonstrable — flashbacks, nightmares, startle responses that can last for months and can become debilitating. Treatment options exist for those medical providers suffering from PTSD, and most organizations are sympathetic to and supportive of providing help.

Burnout

Recognizing burnout may be more elusive. The term “burnout” suggests that one was on fire at some point, but now the fire is gone. Christine Maslach, who has done significant work on burnout, defines it as, “an erosion of the soul caused by a deterioration of ones values, dignity, spirit and will.”

The Symptoms of Burnout

The symptoms of burnout are varied and refer to a change in a person’s behavior and personality. They include:
 
  • Loss of a sense of personal satisfaction, accomplishment and meaning
  • Isolation from friends and family
  • Increase in cynicism and sarcasm (patients become stereotyped)
  • Appetite changes – weight gain, weight loss
  • Loss of interest in favorite activities
  • Depersonalization
  • Robotic actions
  • Fatigued before the day begins
  • Increased alcohol and/or drug use
  • Change in demeanor
  • Overreaction to minor incidents
  • Angry outbursts
  • Increased rate of divorce
  • Loss of empathy
  • Disengagement from patients, profession and other providers

The factors contributing to burnout are numerous and somewhat predictable. They include:
 
  • Societal and patient expectations for medical “perfection” (no mistakes)
  • Personal physician expectation of “perfection” (personal cost of mistake)
  • Too much output, not enough input
  • Pressure to see more patients
  • Medical malpractice creates defensive medicine
  • Focus on the negative
  • Repeat narcotic-seeking patients, drunk patients in the ED
  • Emergency physicians becoming “social workers”
  • Loss of autonomy
  • Increased scrutiny, e.g., physicians judged by quality measures, documentation, chart reviews, peer reviews
  • Standardized medicine
  • Repetition of patients who may appear to be willfully self-destructive or neglectful, with expectations that doctors will “fix them” (“Same stuff, different day”)
  • Decreasing public respect for the medical profession
  • Increasing reliance on technology by patients
  • The impact of night shifts on sleep patterns
  • Disillusionment in medicine, whereby idealism becomes disappointment and dissatisfaction
  • “Destination sickness”; You’ve “arrived,” but now what?
  • Decreasing trust between doctor and patient and increased distance
  • Adversarial relationship with administration
  • Years of ongoing litigation, which generates guilt and, worse, profound shame
  • Shame for failing to live up to one’s image
  • Repetitive grief with no space to grieve
  • Constant stress, fear of making a mistake

Given the impact of burnout on physician behavior, higher medical errors, suicide and lower quality of care, it would seem imperative to understand the causes of burnout and generate concrete actions to address the “epidemic.” However, there are barriers and challenges that exist in addressing both PTSD and burnout which impacts mobilizing treatment interventions.

First, medical organizations and administrators whose focus is on the financial bottom line may believe that it’s more cost effective to replace a “hurting” physician than invest in supporting that physician. Individual physicians, who view themselves as heroic and strong, may have difficulty admitting to their own pain and need for help. Peers who witness other doctors with the symptoms of PTSD or burnout are reluctant to talk with their fellow providers about what they are witnessing, perhaps because of a concern about what the reaction may be. In addition, there may be fear of acknowledging a potentially debilitating distress because of the medical licensing board’s question: “Have you ever had a medical condition or been treated for a problem that could hinder or impair your ability to provide patient care?”

Identifying and Treating Burnout and PTSD

Although some organizations do attempt to assess how their physicians are doing by surveying clinicians, such surveys typically have only about a 40 percent response rate. It will, therefore, take vigilance on the part of peers, fellow practitioners and medical directors (who may themselves be burning out) to be observant of physician behavior and attitudes. Engaged physicians maybe the ideal, but identifying and supporting those physicians struggling with PTSD and burnout needs to be a more immediate goal.

Treatment of both burnout and PTSD is the responsibility of all involved. There are many support systems available to help individual physicians in their struggles, such as the American Medical Association and The HappyMD.com.

As Nietzsche said, “Physician, heal thyself: then wilt thou also heal thy patient.”

Peer groups provide safe, non-judgmental environments to address issues of mistakes, guilt, shame, disengagement, anger and all of those emotions that impact physicians’ attitudes and behaviors. Knowing one is not alone can be very helpful. Staff meetings could include some of these topics for general discussion. Hospital administrations can advertise their commitment to not only helping identify those physicians struggling with the cost of their profession, but also their investment in support activities. In fact, several large hospital systems have hired professionals trained in physician health and well-being to provide care, both proactively and reactively.

If burnout and PTSD in healthcare is indeed at epidemic levels, it will take mobilizing all of the resources necessary to respond adequately. The cost is too high to continue to ignore this issue.

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Jane M. Sullivan, Ph.D., is an adjunct professor at Albert Einstein College of Medicine, Bronx, N.Y.; Yeshiva University, New York City; and Fairleigh Dickinson University, Teaneck, N.J., teaching courses on conflict resolution and family dynamics. Much of Dr. Sullivan’s recent professional work has been on leadership development, generational transitions and supporting effective and productive interpersonal communication in organizations. Dr. Sullivan has been a guest speaker on topics such as emotional intelligence, burnout, dynamics within family business, conflict resolution, effective communication and gender differences. She has written several articles on topics related to interpersonal dynamics in business.

References:
Danielle Ofri, M.D. What Doctors Feel: How Emotions Affect the Practice of Medicine, Beacon Press, Boston, 2013.
Tom Murphy, M.D. Physician Burnout: A Guide to Recognition and Recovery, Aloha Publishing, 2015.
Joseph S. Bujak, M.D. Inside the Physician Mind: Finding Common Ground with Doctors, ACHE Management Series, Health Administration Press, 2008.
Burnout: Emergency Medicine Hit Hardest, J. Duncan Moore, Jr., Health Leaders Media
Physician Burnout: Why It’s not a Fair Fight (blog article), Dike Drummond, The Happy MD.com
Physician Burnout: It Just Keeps Getting Worse, Medscape, Carol Peckham

Resources:
Whole Health Medicine Institute
Lissa Rankin, M.D. – Self Healing Kit
 

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6 Strategies for the Organized Mind

Posted on Mon, Apr 10, 2017
6 Strategies for the Organized Mind

Healthcare professionals have mastered the art of multi-tasking. But, the skill that has long been valued is now seen as a liability, especially with the new and increased focus on high-quality, error-free care. This was the premise of a keynote address titled, “The Organized Mind and Information Overload,” that Daniel Levitin, Ph.D., recently delivered. Dr. Levitin is a James McGill Professor of psychology, behavioral neuroscience and music at McGill University in Montreal. He is also the author of several books including the No. 1 best-seller, “The Organized Mind: Thinking Straight in the Age of Information Overload.”

Dr. Levitin told attendees that information overload often causes mistakes and that it can lead to deadly consequences in the hospital. Taking a cue from other industries that have pioneered efforts in safety and high reliability, such as aviation and heavy machinery, researchers are now studying the causes and effects of interruptions and distractions in the clinic.

It is easy to understand the potential impact interruptions have on patient safety. A 2005 study conducted by Alvarez and Correra of a hospital intensive care unit (ICU) identified 838 interruptions in 24 hours for an attending staff of nine physicians. The study identified two types of interruptions – turn-taking interruptions (where the person speaking is interrupted by the person he or she is speaking to) and breaking into a conversation interruptions (a third person interrupts a conversation that is occurring between two people). People tend to interrupt because they feel they need to know something immediately.

A 2010 study of ICU nurses by Anthony identified 75 interruptions during medication preparation in an eight-hour shift. Recognizing the potential for medication errors, the hospital placed red tape around the central medication area and the medication prep cart, designating the space as a “no interruption zone.” Medication errors fell by 50 percent as a result of this proactive intervention.

Dr. Levitin led the audience through six major themes that appear to be getting worse in the hospital setting. First, he discussed the Myth of Multi-Tasking. “The brain simply doesn’t work that way,” he explained. “When presented with a task, a project file opens in the cortex. As additional tasks or interruptions occur, new project files are opened. As the brain shifts from one thing to another, you are not fully engaged in any one thing. You deplete your neuro resources every time you switch because switching releases cortisol that causes interference in a variety of ways – increased heart rate, elevated blood pressure and disrupted digestive system. All of these can contribute to foggy thinking, sort of like being drunk, but you aren’t aware of it.”

“Uni-taskers” get more done, are more creative and produce higher quality work output than multi-taskers,” Dr. Levitin said. Other industries recognize this phenomenon and have instituted policies to mitigate it. For example, pilots cannot have unnecessary conversations below 10,000 feet. This rule enables them to focus solely on critical conversations with one another and with air traffic control. Air traffic controllers are required to take a break after working two hours. Likewise, to stay fresh and focused, translators at the United Nations cannot work more than 90 minutes consecutively.

The second theme was the Importance of Naps and Breaks. Dr. Levitin said we don’t fully understand why a 15-minute break if done correctly, can hit the “neuro reset” button in the brain. He cited research that identified the default mode network comprised of the central executive mode and daydreaming or mind-wandering mode. The central executive mode keeps you on-task and fully focused so that everything goes right. There is a distinct set of neuro circuits that are involved in this state. When you are in the daydreaming or mind-wandering mode, your thoughts are loosely connected from one moment to the next. This is the mode of the brain in which spent glucose is restored. It is also the most creative mode and one that enables us to think and solve problems. People do many things to enter this mode such as listening to music, immersing themselves in nature or going for a walk. In this mode, your mind wanders non-linearly making connections between things that normally don’t go together and, as a result, making solutions more apparent. Snacking during the day is also beneficial in restoring glucose. Dr. Levitin encouraged attendees to incorporate 10 to 15 minutes of mind-wandering a day while working in the Emergency Department (E.D.).
 
Decision Fatigue was the third major theme. Researchers have recently discovered a network of neurons that help people make decisions. The network does not distinguish between important and unimportant decisions. This information is valuable because it can help us govern the ways we schedule our brain power and make decisions during the day. He cited an example of judges, who in a recent study, were shown to make better decisions just after beginning work in the morning or right after lunch. The quality of their decision making declines as time passes between meals. So, if you’re innocent, you want a court case early in the morning or just after lunch. If you’re guilty, you want your case heard late in the afternoon. “Your mother was right,” Dr. Levitin said. “If you have an important decision to make, sleep on it and make it the next day.” He acknowledged that everyone has to make dozens of decisions each day. “But, you have the luxury to know that some decisions will be better than others, depending on the time of day. In some cases, it may be best to consult another colleague who is fresher regarding decisions that have to be made.”
 
The fourth major theme he highlighted was Externalizing Your Memory. “Writing things down reduces the burden of having to remember them,” he explained. “We tend to think our memories are better than they are. Memory is fallible, so it’s best to put things out in the world, so they don’t have to stay in your brain.” David Allen, an efficiency guru, says writing things down on note cards is a mind-clearing exercise. Studies have shown that people who write things down remember them better than those that type them. Use the environment to remind you of things you need to do. Set up a system to remind you where you put things – keys, wallet and/or telephone. Put a bowl by the door to provide a consistent location to place these items. If you check into a hotel room, experts recommend spreading a white hand towel out on a nightstand to designate a place to put your room key, wallet, phone, etc. Dr. Levitin described transactional memory systems as shared information structures. “People who are most effective and have the most power in organizations aren’t necessarily ones who know everything, but they do know the people to call to get the information. These people are extensions of memory because they help the other person keep track of all of the information.”

Managing Channels of Communication was the fifth major theme. “In this era of connectivity, we must figure out ways to manage how people reach us,” he said. “We have to train people in our social networks about how we want to be reached and when. There are truly a limited number of people who need to reach us immediately. Using a second email address for urgent communication is one way to manage contact. The worst thing to do first thing in the morning is to open up email. Every email requires us to make a decision. Before you’ve really done anything meaningful, you’ve already depleted your decision-making capacity.”
 
Dr. Levitin wrapped up his presentation with the sixth major theme – Ways to Handle Information Overload Better. “This really is the age of information overload,” he told the audience. “Every day of last year, Americans took in five times as much information as they did in all of 1986. That’s the equivalent of reading 175 newspapers cover to cover daily. In fact, we have created more information in the last four years than in all of human history before. Specialization has created a glut of information. Consider that last year 2,000 papers were published on the visual system of the squid. For every hour of YouTube video you watch, there are 12,000 additional hours of video being uploaded.”

How severe is the problem of overload and how does it exacerbate the number of decisions we have to make? In 1976, the average grocery store stocked 9,000 unique items. Today, more than 40,000 unique items populate grocery store shelves. Why is this important? Decision making has a neurobiological cost associated with it.
 
Bringing the topic back to the E.D., Dr. Levitin advised attendees to have a serious conversation about collaboration and record keeping. “We can talk faster than we can write,” he said. “Remember when physicians used the Dictaphone to capture their notes? Now we all have this capability on our smartphones. That’s why there has been an explosion of voice to data conversion programs. Developers are currently perfecting automated data entry into the patient record. No interruption zones are a great idea, as are mandatory short breaks that allow for mind wandering. Checklists provide an important avenue for externalizing memory. Examples include surgical checklists, palliative care checklists, medication administration checklists, etc. They reduce the stress of multi-tasking. Finally, I urge you to consider implanting gatekeepers – human or mechanical – to take extraneous calls and messages that create interruptions. These gatekeepers will protect your time and will help put into priority what will come into your sphere of decision making.”

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Securing Physician Resources: A Business Case for Outsourcing

Posted on Mon, Apr 03, 2017
Securing Physician Resources: A Business Case for Outsourcing

As hospital and health system CEOs continue to see their organizations’ bottom lines being squeezed by a confluence of factors – declining reimbursement, demand for enhanced value from patients and payers, heightened focus on improving the quality of care and the overall patient experience – they are turning to a variety of tactics. One of the leading strategies is outsourcing for physician resources.

While outsourcing isn’t a new phenomenon, it’s taken on increased importance, especially as a way of decreasing costs, strengthening alignment with physicians and supporting efforts to improve patient care and operational efficiencies. Physicians also are seeking shelter from the growing financial and regulatory pressures bombarding their private practices. They are turning to employment arrangements with healthcare organizations (HCOs) via outsourcing companies or direct contracts with hospitals and health systems, many of which are beginning to offer the support of outsourced management services.

HCOs first dipped their toes into the outsourcing pool by contracting out their support services including environmental services and food services. Clinical outsourcing began more than 40 years ago when emergency medicine became a medical specialty. Today, the top five most commonly outsourced patient care services include dialysis, anesthesia, diagnostic imaging, hospitalist staffing and emergency department staffing1. In 2012, some 35 percent of all outsourcing agreements fell into this category, and the trend has remained steady over the past few years2.

How the Changing Environment Is Impacting Outsourcing

There’s no doubt the whirlwind of change that is engulfing hospitals is pushing them to look outside of their own walls for relief. Hospitals are being driven by a near-desperate need to reduce operating costs to cope with lower reimbursement rates, so they are increasingly turning to outside contractors.

Contributing to the historic changes taking place in the healthcare environment is the changing face of the physician workforce. In 2014, the Physicians Foundation conducted the Survey of America’s Physicians: Practice Patterns and Perspectives. More than 20,000 physicians responded to the survey, which found that there is a crisis in private practice with a strong migration toward the hospital employment model. The survey showed that solo practice volume dropped from 24 percent in 2012 to 17 percent in 2014. It pointed out the following challenges remaining in private practice – the administrative burden; the lack of access to capital; and the need to have communication with other physicians, physician groups and hospitals through large, expensive electronic medical records (EMR) systems.

What’s In It for Hospitals That Choose to Outsource?

How can an HCO determine whether to outsource services or keep them in-house? The Healthcare Financial Management Association offers these key questions to ask before making a final decision:
 

  • What barriers has your hospital encountered to achieving your business objectives? Why is outsourcing likely to solve a problem?
  • What are the sources, anticipated financial benefits, and true costs of outsourcing the function? Will outsourcing provide access to lower-cost computer capabilities? Will it provide lower labor and benefits costs (and if so, how will that be accomplished)?
  • What impact will outsourcing have on hospital employees? Will outsourcing provide additional benefits, better leadership, or more training? Will the outsourcing decision be viewed as a positive step or one that has to be “sold” within the organization?
  • How will outsourcing improve patient service and satisfaction?
  • With hospitals typically being one of the largest employers in a community, how will outsourcing affect the broader community?

Not only are an increasing number of healthcare organizations choosing to outsource staffing or practice management services in clinical areas, many are now realizing the incremental value of seeking one outside partner for several service lines. There are many reasons for this trend, including reduced physician recruitment and retention costs, improved operational efficiencies, strengthened alignment between HCO and physicians, accelerated development of physician leadership and improved clinical quality and outcomes.

“A hospital may be stuck, for example, on how to improve management of pneumonia patients,” says Francisco Loya, MD, chief executive officer of EmCare Hospital Medicine. “A local group of physicians only has a local perspective of the market. We have the advantage of working with hundreds of hospitals and health systems across the country, so we can identify best practices at similar size organizations and share those with our hospital partner or local practice. Because of our structure, we can immediately implement practice changes and monitor performance for achieving the desired outcomes.”

Other benefits of outsourcing include:
  • Access to resources
  • Better hospital-physician alignment
  • Leadership development opportunities
  • Improved metrics
  • Continuity of care/integrated services

EmCare and our parent company, Envision Healthcare, are changing the face of healthcare by pioneering solutions that increase the quality and experience of care while simultaneously reducing costs. By marrying our leading hospital-based physician group with the largest EMS and medical transportation organization (AMR) and launching a cutting-edge mobile integrated healthcare organization focused on post-acute care and intervention (Evolution Health), we are positioned to be on the leading edge, driving solutions for the future-state of healthcare.

Hospitals continue to seek opportunities to work with strong partners to protect their bottom line. Outsourcing physician resources offers benefits to patients, physicians and HCOs. Outsourcing has become an important thread woven into America’s delivery of healthcare and will continue to help hospitals and health systems achieve sustainable improved performance.

To learn more about outsourcing, download EmCare’s recent whitepaper on the topic.

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