Physician burnout is a widespread problem affecting over half of physicians. It can begin in medical school and residency training and persist throughout a physician's career. Burnout leads to negative consequences like medical errors, impaired mental health, and lower quality of patient care. Both individual-level strategies like stress management and mindfulness as well as organizational interventions around workload, work-life balance, and promoting meaning in work can help address physician burnout. Addressing this crisis requires efforts at both the individual physician and health system levels.

1. Bill M Wooten, PhD - 2018
billmwooten@gmai.com
Resilience
in Physicians
Foster stress hardiness and protect against physician burnout

2. “Rest is the conversation between what we love
to do and how we love to be. Rest is the essence
of giving and receiving; an act of remembering,
imaginatively and intellectually but also
physiologically and physically.
To rest is to give up on the already exhausted
will as the prime motivator of endeavor, with its
endless outward need to reward itself through
established goals.
To rest is to give up on worrying and fretting and
the sense that there is something wrong with
the world unless we are there to put it right; to
rest is to fall back literally or figuratively from
outer targets and shift the goal not to an inner
static bull’s eye, an imagined state of perfect
stillness, but to an inner state of natural
exchange.”
David Whyte
1

3. The Problem
◦ One-third to one-half of physicians meet burnout criteria, leading to very real suffering
among physicians and their families.3 Women physicians are 1.6 times as likely as men to
report burnout, with lack of work control being a strong predictor of burnout in women
but not men.
◦ Burnout can begin during medical training or even before. In a recent large study
conducted by the Mayo Clinic, 53 percent of medical students had symptoms of
burnout.9 This burnout was associated with self-reported unprofessional conduct and
less altruistic professional values among medical students at the seven U.S. medical
schools included in the study.
2

4. If Every Fifth Physician Is Affected by Burnout,
What About the Other Four?
3
Physicians’ health matters, not only to the
physicians themselves but also to their
patients.
Mental health is an important component of
overall health, and research shows that
approximately 15% to 20% of physicians will
have mental health problems at some point
in their careers.
Julika Zwack, PhD, and Jochen Schweitzer, PhD (2012)

5. Background
Physician well-being has come under increased scrutiny
in recent years
Common:
◦ Burnout
◦ Low job satisfaction
◦ High stress
◦ Low quality of life
Affects all stages of physician training and practice
Affects all specialties
4

6. 5
“Burnout makes it nearly impossible for individuals to provide
compassionate care for their patients.”
Steven Lockman, MD, Senior Medical Director, Neurosciences, Orthopedics and Rehabilitation Service Line/Chief, Physical Medicine and Rehabilitation
Hennepin County Medical Center, Minneapolis, MN

7. Brief Summary of Epidemiology
•Medical students matriculate with BETTER well-being than their age-group peers
•Early in medical school, this reverses
•Poor well-being persists through medical school and residency into practice:
• National physician burnout rate exceeds 54%
• Affects all specialties, perhaps worst in “front line” areas of medicine
• >500,000 physicians burned out at any given time
6

8. Burnout among Practicing Physicians
National Data (Shanafelt et al., Arch Intern Med 2012; Mayo Clin Proc 2016)
2011 2016
Burnout: 45.8% 54.4%
Emotional exhaustion: 37.9% 46.9%
Depersonalization: 29.4% 34.6%
Dissatisfied with work-life balance:
36.9% 44.5%
7

9. Figure 1
Mayo Clinic Proceedings 2015 90, 1600-1613DOI: (10.1016/j.mayocp.2015.08.023)
Copyright © 2015 Mayo Foundation for Medical Education and Research Terms and Conditions
8

10. Physician Distress: Key Drivers
Excessive workload
Inefficient work environment, inadequate support
Problems with work-life integration
Loss autonomy/flexibility/control
Loss of values and meaning in work
9

11. Consequences of Physician Burnout
Medical errors1-3
Impaired professionalism4-6
Reduced patient satisfaction7
Staff turnover and reduced hours8,12
Depression and suicidal ideation9,10
Motor vehicle crashes and near-misses11
1JAMA 296:1071, 2JAMA 304:1173, 3JAMA 302:1294, 4Annals IM 136:358, 5Annals Surg
251:995, 6JAMA 306:952, 7Health Psych 12:93, 8JACS 212:421, 9Annals IM 149:334,
10Arch Surg 146:54, 11Mayo Clin Proc 2012, 12Mayo Clin Proc 2016
10

12. Breaking News!
•A new illness runs rampant in our communities!
•Affects 54% of certain parts of the population, a risk 2x that of the
rest of the population!
• ~500,000 people
• Prevalence comparable to that of lung cancer
•Affects students and our most highly educated and trained
individuals!
11

13. Breaking News!
Among those affected:
◦ More professional errors, impaired professionalism, reduced patient satisfaction,
increased job turnover and reduced hours, higher rates of depression and suicidal
ideation, more motor vehicle crashes and near-misses, lower standardized test scores,
etc.
◦ The group affected most is also more likely to complete suicides when affected.
12

14. What is this epidemic?
•An infectious disease?
• Get the CDC involved ASAP!
• Figure out the triggers and transmission patterns!
• Develop effective prevention and treatment options!
•A chronic cardiovascular condition?
• Rally the Surgeon General and the AMA!
• Educate the public to prevent this problem!
• Establish public health programs for support!
•A zombie apocalypse?
13

15. What is this epidemic?
BURNOUT
14

16. A Public Health Crisis!
Individual or System Problem?
Burnout in U.S. alone:
>40,000 Medical Students
>60,000 Residents and Fellows
>490,000 Physicians
Plus other health care and biomedical science
professionals
15

17. Individual Strategies
•Identify Values
◦ Debunk myth of delayed gratification
◦ What matters to you most (integrate values)
◦ Integrate personal and professional life
•Optimize meaning in work
◦ Flow
◦ Choose/focus practice
•Nurture personal wellness activities
◦ Calibrate distress level
◦ Self-care (exercise, sleep, regular medical care)
◦ Relationships (connect w/ colleagues; personal)
◦ Religious/spiritual practice
◦ Mindfulness
◦ Personal interests (hobbies)
16

18. Delayed Gratification: Life on Hold?
50% residents report “Survival Attitude” - life on hold
until the completion of residency
37% practicing oncologists report “Looking forward to
retirement” is an essential “wellness promotion
strategy”
Many physicians may maintain strategy of delayed
gratification throughout their entire career
Shanafelt, J Sup Oncology 3:157
17

19. Individual Strategies
Recognition of distress:
•Medical Student Well-Being Index (Dyrbye 2010, 2011)
•Physician Well-Being Index (Dyrbye 2013, 2014)
• Simple online 7-item instruments evaluating multiple dimensions of distress, with strong validity evidence
and national benchmarks from large samples of medical students, residents, and practicing physicians
• Evidence that physicians do not reliably self-assess their own distress
• Feedback from self-reported Index responses can prompt intention to respond to distress
•Suicide Prevention and Depression Awareness Program (Moutier 2012)
• Anonymous confidential Web-based screening
•AMA STEPSForward modules
• Mini Z instrument (AMA, Linzer 2015): 10-item survey
18

20. Physician Well-Being Index
https://www.mededwebs.com/well-
being-index
19

21. Physician Well-Being Index
https://www.mededwebs.com/well-being-index
20

22. Individual Strategies
Risk of exclusively individual focus:
•Deepen cynicism through perceived message that physicians must “toughen up” to
cope with a toxic working environment, rather than addressing the toxic working
environment itself.
•Sydney Morning Herald, July 5, 2017:
• “The ‘con’ of building resilience has left junior doctors vulnerable to mental
illness and suicide by ignoring the systemic failures of the medical profession …”
• “ … the current focus on building resilience ignored the deleterious culture of
medicine and dangerous working conditions to which junior doctors (are)
subjected.”
21

23. What Can Organizations Do?
•Be value oriented
◦ Promote values of the medical profession
◦ Congruence between values and expectations
•Provide adequate resources (efficiency)
◦ Organization and work unit level
•Promote autonomy
◦ Flexibility, input, sense control
•Promote work-home integration
•Promote meaning in work
22

24. ©2010 MFMER | slide-23
Mayo RCT #1 (2012)
A small amount of protected time during the workday resulted in improved meaning from work
and reductions in burnout
◦ Effects larger in facilitated small group arm than in “free time” control arm, particularly in
promoting meaning and reducing depersonalization.
◦ Follow-up study data found sustained benefits at 1 year after the close of the study.
West et al., JAMA Intern Med
2014:174:527-33
23

25. ©2010 MFMER | slide-24
Mayo RCT #2 (2014)
Compared to the wait-listed control group, the small group topic-oriented discussion intervention
improved:
◦ Depersonalization
◦ Personal accomplishment
◦ Overall QOL
◦ Depression
◦ Meaning from work
◦ Social isolation at work
◦ Job satisfaction
◦ Likelihood of leaving in next 2 years
Initial intervention shows benefit with sustained changes over subsequent 6 months.
Physician Engagement Groups funded by Mayo
◦ http://peg.mayo.edu West et al. J Gen Intern Med.
2015;30:S89.
24

26. ©2010 MFMER | slide-25
Mayo RCT #2 (2014)
Sample Discussion Topics:
Meaning in work/job satisfaction
◦ Specific experiences
◦ Think about one of your most satisfying days at work over the last month. What made this day so
professionally satisfying? Share with your colleagues.
Teamwork/Social support/Collegiality/Relationships/Work-life balance and integration
◦ Relationships and support
◦ Brainstorm ways to promote collegiality in your hallway or work unit.
Personal strengths/Problem solving/Coping/Resources for thriving and flourishing
◦ Choose one stressor that you can control, come up with 2 concrete ways you can reduce it, and
commit to trying 1 approach within the next week.
West et al. J Gen Intern Med.
2015;30:S89.
25

27. Physician Well-Being: Approach
Summary
Individual Organizational
Workload
Work Efficiency/
Support
Work-Life
Integration/
Balance
Autonomy/
Flexibility/
Control
Meaning/Values
26

28. Physician Well-Being: Approach
Summary
Individual Organizational
Workload Part-time status Productivity targets
Duty Hour Requirements
Integrated career development
Work Efficiency/
Support
Efficiency/Skills Training EMR (+/-?)
Staff support
Work-Life
Integration/
Balance
Self-care
Mindfulness
Meeting schedules
Off-hours clinics
Curricula during work hours
Financial support/counseling
Autonomy/
Flexibility/
Control
Stress management/Resiliency
Mindfulness
Engagement
Physician engagement
Meaning/Values Positive psychology
Reflection/self-awareness
Mindfulness
Small group approaches
Core values
Protect time with patients
Promote community
Work/learning climate
27

29. Figure 2
Mayo Clinic Proceedings 2017 92, 129-146DOI: (10.1016/j.mayocp.2016.10.004)
Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions
Shanafelt TD, Noseworthy JH. Mayo Clin
Proc. 2017;92:129-46.
28

30. Recommendations
Doctors have a professional obligation to act.
◦ Physician distress is a threat to their profession
◦ It is unprofessional to allow this to continue
◦ Evolve definition of professionalism? (West 2007)
◦ SHARED RESPONSIBILITY
Distress must be assessed.
◦ Metric of institutional performance
◦ Part of the “dashboard”
◦ Can be both anonymous/confidential and actionable
29

31. Recommendations
The toolkit for these issues will contain many different
tools.
There is no one solution …
… but many approaches offer benefit!
30

32. 46.9%
31

33. If you can remain perfectly calm in traffic…
If you see others succeed without a tinge of
jealousy,
If you can love everyone around you
unconditionally,
If you can always be cheerful just where you
are
You are probably …
32

34. A dog . . .
33

35. Keys for Resilient Living
1. Rewrite your negative scripts
2. Choose the path to become stress hardy rather than stressed
out
3. Develop the ability to view life through the eyes of others
4. Learn to communicate effectively: listen, learn and influence
5. Accept yourself and others
6. Make connections and display compassion
7. Learn to deal effectively with mistakes
8. Learn to deal well with success in building islands of
competence
9. Develop self-discipline and self-control
10. Learn the lessons of resilience: Maintain a resilient lifestyle
34

36. So what is your level of awareness of
what is occurring in the present,
simply, what is taking place?
35

37. Obstacles that Prevent Progress
1. A lack of awareness of the role negative scripts play in your life
2. Insisting that others must change first
3. Being overwhelmed by the stress of everyday life
4. Giving up.
36

38. Become the Author of Your Life
1. Identify negative scripts in your life and assume responsibility to change them
2. Define short- and long-term goals related to the particular issue at hand
3. Consider new scripts or plans of action that accord with your goals
4. Select from these new scripts the one that you believe has the greatest probability for
success. This step also requires considering criteria for assessing the success of the new step
5. Anticipate the possible obstacles that might interfere with reaching your goal and consider
how these obstacles might be handled
6. Put the new script into action and assess its effectiveness
7. Change your goals, scripts, or approach if they prove unsuccessful
37

39. Choosing the Path to Become Stress Hardy
Are you committed to the important things in your life?
Do you view difficult situations, mistakes, and problems as challenges to learn from?
Do you practice personal contral?
38

40. The Lessons of Resilience: Maintaining a
Resilient Lifestyle Daily
Exercising Resilience on a Daily Basis
1. Have I truly listened during the past day and attempted to understand the viewpoints of others?
2. How have I related to others? Have I practiced empathy and respect?
3. How have I responded to stress, mistakes, and setbacks? If I am not happy with my response, what will
I do differently next time?
4. In what areas did I do well? How do I maintain or reproduce these positive behaviors tomorrow?
39

41. The Lessons of Resilience: Maintaining a
Resilient Lifestyle Long-Term
Guiding Principles for the Long-Term
◦ Revisit the principles of a resilient mindset
◦ Periodically assess your progress in terms of leading a resilient lifestyle
◦ Do not wait for other people to change first for you to achieve your goals and happiness
◦ Articulate and evaluate short- and long-term goals that are realistic, achievable and in concert with your
values
◦ Anticipate mistakes and setbacks. Be prepared with a backup plan.
◦ Relish your accomplishments.
◦ Develop and maintain connections with people, ideas, causes, and your spirituality
40

42. “Everything Is Waiting for You”
Your great mistake is to act the drama as if you were alone. As if life
were a progressive and cunning crime with no witness to the tiny
hidden transgressions. To feel abandoned is to deny the intimacy of
your surroundings.
Surely, even you, at times, have felt the grand array; the swelling
presence, and the chorus, crowing out your solo voice. You must
note the way the soap dish enables you, or the window latch grants
you freedom. Alertness is the hidden discipline of familiarity.
The stairs are your mentor of things to come, the doors have always
been thereto frighten you and invite you, and the tiny speaker in the
phone is your dream-ladder to divinity. Put down the weight of your
aloneness and ease into the conversation. The kettle is singing even
as it pours you a drink, the cooking pots have left their arrogant
aloofness and seen the good in you at last. All the birds and
creatures of the world are unutterably themselves. Everything is
waiting for you.
David Whyte
41

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