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11/8/2012                              Outline                                                                            ...
11/8/2012                          Intervention Trial                                           Intervention Trial • Devel...
11/8/2012                                Intervention Trial                                                               ...
11/8/2012                                                                                      Results – 3 Groups         ...
11/8/2012                          H igh Depersonalization                                                                ...
11/8/2012                                                  H igh Emotional Exhaustion                                     ...
11/8/2012                          Outline                                                                 Future Steps• B...
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ColinWestMD FatigueTalk 2012

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ColinWestMD FatigueTalk 2012

  1. 1. 11/8/2012  Outline • Background R2 ‐ Research presentations  • Potential Solutions   • The 2011-12 DOM Intervention TrialWorking towards a policy for parenthood and family/work  • Future Stepsreconciliation 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 1 
  2. 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. 2 
  3. 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 higherDOM faculty rates of burnout and many other markers of distress. N=37N=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 3 
  4. 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. 4 
  5. 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 5 
  6. 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 6 
  7. 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 4JSP 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 7 
  8. 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 8 

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