Burnout talk for patients and providers at the Washington Academy of Physician Assistants Spring Conference 2015

1. Burnout Basics
Michael Corsilles, ND, PA-C
WAPA spring recert 2015

2. Chief complaints I hear every day
 I’m tired all day, but when I lay down to sleep it doesn't
come. #tiredbutwired

3.  I get easily irritated at coworkers, friends, patients –
anyone really. #jerk

4.  I initially did well in school and work, but now I think I
developed ADD because I am easily distracted at work
and can’t focus. #squirrel

5.  I’m also gaining weight. But I exercise all. the. time. I
do admit to craving sweets and carbs. Too bad I don’t
crave kale! #sugarisdrugofchoice

6. Note:
This is NOT a talk on
Chronic Fatigue Syndrome

7. Not a talk on
Cushing’s or Addison’s either
 Cushing’s: Excessive cortisol or a
“Cushion” of cortisol
 Addison’s: Aka Adrenal Insufficiency.
No cortisol or adrenal response. Need
to “Add” cortisol.

8. But we all (providers included)
suffer some degree of
Chronic Fatigue Syndrome...

9. It’s called “Burnout”

10. In the beginning... The Adrenals

11. In the end...
the adrenals are burned out

12. The 2 big adrenal hormones
 Norepinephrine (ADRENALIN) is commonly thought of as the
fight-or-flight hormone. Basically, it prepares you for battle.
 CORTISOL increases your appetite and energy level while
toning down your immune system’s allergic and inflammatory
responses. This hormone stimulates the storage and release of
energy in the body, helps the body resist the stressful effects
of infections, trauma, and temperature extremes, and helps
you maintain stable emotions.

13. The cause of Burnout?
Too much fight or flight

14. Do We Really Need the Stress
Hormones? Cortisol and Obesity
 Stress leads to a red alert and sends body into “fight or
flight” mode. Adrenaline and cortisol help mobilize
carbs and fat for quick energy.
 Your body assumes you have just physically exerted
yourself, for example running from a lion, and need to
restock your reserves by eating a lot of carbohydrates or
fatty food that can easily be stored as fat.
 In reality, you are probably still sitting in your car or
at your desk, still fuming and stressed out!

15. Too much cortisol? Think of Cushing’s
Common signs and symptoms involve progressive obesity and skin changes, such as:
 Weight gain and fatty tissue deposits, particularly around the midsection and upper back, in
the face (moon face), and between the shoulders (buffalo hump)
 Pink or purple stretch marks (striae) on the skin of the abdomen, thighs, breasts and arms
 Slow healing
 Acne
 Fatigue
 Muscle weakness
 Depression, anxiety and irritability
 Loss of emotional control
 Cognitive difficulties
 New or worsened high blood pressure
 Glucose intolerance that may lead to diabetes
 Headache

16. Do you have Provider Burnout?
Do you have the following 3 traits?
1. Physical and Emotional Exhaustion:
 You are emotionally drained, depleted and worn out by
work and not able to recover in your non-working hours

17. 2. De-personalization:
The development of a negative, callous and cynical
attitude toward patients and their concerns

18. 3. A Reduced Sense of Personal Accomplishment:
 The tendency to see your work negatively, without
value or meaningless (“what’s the use?”) and see
ourselves as incompetent.
 Source: thehappymd.com by D.Drummond, MD

19. What to do when a patient comes to
you with Burnout?
 I.e., what happens when all workups come back normal?
 If you’re burned out yourself, how are you supposed to
take care of your burned out patients??

21. How to Heal Burnout

22. Coffee creates a fake alarm state
 If you only have the occasional cup
of coffee, your adrenals will be
able to react quickly and capably
to this kind of stimulation.
 But if you are drinking several cups
of coffee each day, you start to
notice a weakened reaction.
 Bottom line: Sorry, you’re in the
wrong city for burnout.

24. Regular exercise and cortisol
 Exercise forces the body to
deviate temporarily from
homeostasis, so it is perceived
as a stress and causes the
release of cortisol.
 But, regular exercise training
will decrease this effect,
causing the body to have a
better response to stress and
require less cortisol release.
 Hill EE1, Zack E, Battaglini C, Viru M, Viru A,
Hackney AC. J Endocrinol Invest. Exercise and
circulating cortisol levels: the intensity threshold
effect. 2008 Jul;31(7):587-91.
http://www.ncbi.nlm.nih.gov/pubmed/18787373

26. Meditation lowers cortisol & slows aging
 Mindfulness meditation lowers
the cortisol levels in the blood
suggesting that it can lower
stress and may decrease the risk
of diseases that arise from stress
such as psychiatric disorder,
peptic ulcer and migraine.
 The more stressed people were,
the shorter their telomeres and
the lower their levels of
telomerase.
 Turakitwanakan W1, Mekseepralard C,
Busarakumtragul P. J Med Assoc Thai. Effects of
mindfulness meditation on serum cortisol of
medical students. 2013 Jan;96 Suppl 1:S90-5.
http://www.ncbi.nlm.nih.gov/pubmed/23724462

27. This is your face on stress

28. Sleep Deprivation
and
Cortisol
Sleep loss affects the resiliency
of the stress response
Note: No sleep also makes us fat!
Leproult, Rachel; Copinschi, Georges; Buxton, Orfeu; Van Cauter, Eve
Sleep: Journal of Sleep Research & Sleep Medicine. Sleep loss results in an
elevation of cortisol levels the next evening. Vol 20(10), Oct 1997, 865-870.
http://psycnet.apa.org/psycinfo/1997-38275-003

30. Laughter and Cortisol
 A Loma Linda 2006 study found that the anticipation of
laughter lowered the levels of stress hormones.
 Also helped mood and immunity: 2 hormones – beta-
endorphins (the family of chemicals that alleviates
depression) and human growth hormone (HGH) – which
helps with immunity when volunteers anticipated
watching a humorous video.
 http://www.the-aps.org/mm/hp/Audiences/Public-
Press/Archive/08/10.html

32. Panax Ginseng enhanced
Cognition
 The 10 minute "cognitive demand" battery comprised a
Serial Threes subtraction task (2 min); a Serial Sevens
subtraction task (2 min); a Rapid Visual Information
Processing task (5 min); and a "mental fatigue" visual
analogue scale. The Panax Ginseng group rocked.
 Reay JL, Kennedy DO, Scholey AB. J Psychopharmacol. Effects of Panax ginseng, consumed with and
without glucose, on blood glucose levels and cognitive performance during sustained 'mentally
demanding' tasks. 2006 Nov;20(6):771-81. Epub 2006 Jan 9.
http://www.ncbi.nlm.nih.gov/pubmed/16401645

33. Holy Basil
 After 6 weeks on Holy Basil, frequent forgetfulness,
sexual problems, exhaustion, and sleep problems
decreased significantly.
Saxena R, 1 Singh R, 2 Kumar P, et.al, Evid Based Complement Alternat Med. Efficacy of an Extract of
Ocimum tenuiflorum (OciBest) in the Management of General Stress: A Double-Blind, Placebo-Controlled
Study. 2012; 2012: 894509. Published online 2011 Oct 3.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185238/

34. Fish oil and stress
 Fish oils reduced indicators of hostility and aggression,
by modulating levels of proinflammatory cytokines or
the neurotransmitter norepinephrine (adrenalin).
 Bradbury J, Myers SP, Oliver C. Nutr J. An adaptogenic role for omega-3 fatty acids in stress; a
randomised placebo controlled double blind intervention study (pilot)2004 Nov 28;3:20.
http://www.ncbi.nlm.nih.gov/pubmed/15566625

35. Ashwagandha and
Cortisol
 The treatment group that was given Ashwagandha root
extract showed a significant reduction in scores on all
the stress-assessment scales on Day 60, relative to the
placebo group.
 Chandrasekhar K, Kapoor J, Anishetty S. Indian J Psychol Med. A prospective, randomized double-blind,
placebo-controlled study of safety and efficacy of a high-concentration full-spectrum extract of
ashwagandha root in reducing stress and anxiety in adults. 2012 Jul;34(3):255-62.
http://www.ncbi.nlm.nih.gov/pubmed/23439798

36. Rhodiola
 Rhodiola extract exerts an anti-fatigue effect that
increases mental performance, particularly the ability
to concentrate, and decreases cortisol response to
awakening stress in burnout patients with fatigue
syndrome.
 Olsson EM, von Schéele B, Panossian AG. Planta Med. A randomised, double-blind, placebo-controlled,
parallel-group study of the standardised extract shr-5 of the roots of Rhodiola rosea in the treatment of
subjects with stress-related fatigue. 2009 Feb;75(2):105-12. doi: 10.1055/s-0028-1088346. Epub 2008
Nov 18. http://www.ncbi.nlm.nih.gov/pubmed/19016404

37. Combo of herbs worked too
 Rhodiola, Schisandra, and Eleutherococcus (Siberian Ginseng)
 Significant difference in attention, speed, and accuracy
between the two treatment groups.
 The subjects in the herbal combo group quickly (two hours)
gained improved attention and increased speed and accuracy
during stressful cognitive tasks, in comparison to placebo.
 Aslanyan G, Amroyan E, Gabrielyan E, Nylander M, Wikman G, Panossian A. Phytomedicine. Double-blind,
placebo-controlled, randomised study of single dose effects of ADAPT-232 on cognitive functions. 2010
Jun;17(7):494-9. doi: 10.1016/j.phymed.2010.02.005. Epub 2010 Apr 5.
http://www.ncbi.nlm.nih.gov/pubmed/20374974

39. Change your Perspective re: Stress
 In order to get companies and employees to take stress
seriously, most trainers/coaches/providers emphasize
that:
 stress is the number 1 health threat in the US; that 70-
90% of provider visits are due to stress-related issue;
and that stress is linked to the 6 leading causes of death
(American Psychological Association).
 This is the wrong approach to treat burnout!
 Harvard Business Review https://hbr.org/2011/02/make-stress-work-for-you

40. We still need stress!

42. It’s All About Your Perspective:
Positive Stress?
 Acute stress – short-lived (not chronic) – primes the brain for
improved performance!
 Positive effects of stress: Research indicates that stress creates
greater mental toughness, deeper relationships, heightened
awareness, new perspectives, a sense of mastery, a greater
appreciation for life, a heightened sense of meaning, and
strengthened priorities.
 http://newscenter.berkeley.edu/2013/04/16/researchers-find-out-why-some-stress-is-good-for-you/

43. Bottom Line
Here’s how to heal burn out for you
and your patients:
 1. Exercise more
2. Eat better
3. Get more sleep
4. Take more vacations
5. Don’t work yourself into the ground.
 Remember this...
No one benefits if you are tired.
Not your patients.
Not your coworkers.
Not your children.
Not your spouse.
Not your sanity!
 Stop the insanity, and rest for crying out loud.
No one benefits when you are tired, particularly you and the results you want to
create.