The document discusses burnout among healthcare professionals, its causes, and consequences, emphasizing the need for self-care and effective fellowship program optimization. It highlights the vulnerability of caregivers due to emotional stress, workload, and institutional pressures, proposing individual and organizational interventions to combat burnout. The importance of building a supportive work community and promoting self-care activities is also emphasized to enhance professional satisfaction and well-being.

1. Taking Care of Oneself: For Your Self, Your Fellows, and Your Program March 13, 2007 David F. Giansiracusa, MD Pain and Palliative Care Service, Department of Neurology Memorial Sloan-Kettering Cancer Center Christian T. Sinclair, MD Fellowship Director, Associate Medical Director Kansas City Hospice & Palliative Care

2. Objectives Define and recognize burnout in the health care professional Optimize a fellowship program to include teaching areas of self-care Learn to address situations where self-care has been avoided/ignored

3. Personal Consequences of Burnout Stress, anxiety, anger, depression Substance abuse Family disruption Stress-related health problems (Maslach 2001)

4. Job-Related Consequences of Burnout Decreased job performance (Parker 1995) Reduced commitment to work (Leiter 1998) Low career satisfaction (Goldberg 1996, Lemkau 1994)

5. Clinical Consequences of Burnout Prolonged hospital stays Patients’ and family members’ preferences for and goals of care are not discussed Patient and family feeling a sense of abandonment Excessive use of technological interventions

6. Burnout: Erosion of Engagement Vigor: -energy and resilience -increased stamina -persistence in face of difficulties Dedication: -strong involvement -feelings of enthusiasm and significance -sense of pride and inspiration Absorption: -pleasure with total immersion (Maslach 1997 )

7. What Characterizes Burnout? Imbalance of professional demands and rewards Caused by: Overwhelming emotional/interpersonal job stress Defined by three dimensions: I- Exhaustion II- Cynicism III- Inefficacy (Maslach 2001)

8. Compassion Fatigue and Burnout in Trainees Care for patients with severe illness and suffering Have limited relationships with patients and families Need to rescue, fix-it Difficult communication challenges

9. Burnout in Trainees 76% out of 115 of internal medicine residents met criteria for burnout: -More likely to self-report suboptimal patient care -Report of suboptimal care associated only with depersonalization component and in dose-responsive relationship (Shanafelt 2002)

10. Burnout in Trainees Major depression self-report and screening rates  significantly increased Career satisfaction  strong inverse relationship to burnout No significant increased risk of alcohol or substance abuse (Shanafelt 2002)

11. Health Care Professionals’ Vulnerability to Burnout Work closely with patients and families who are intensely suffering, In crisis, and often in conflict  “Lightening Rod Effect” Conversations require time, focus, and emotional and intellectual energy (Meier 2006)

12. Our Vulnerability Work under institutional pressures: -workload -bureaucratic frustrations -interprofessional conflicts - “Culture of Medicine” (Meier 2006)

13. Our Vulnerability We may experience feelings of guilt, insecurity, frustration, inadequacy. ( A sense of “not being enough”) Identification with patient or family members may heighten our own sense of grief Conflicts over goals of care or “agendas” may cause frustration (Meier 2001)

14. Workload Control Values Fairness Community Reward Work

15. The “Match/Mismatch” Theoretical Framework of Burnout: Of six domains of job: Mismatch = Burnout Match = Engagement (Maslach 1997)

16. Individual and Organizational Interventions Individual interventions (coping skills): may alleviate exhaustion unlikely to alleviate cynicism, depersonalization and inefficacy Need to create a “matched” profile: sustainable workload feelings of choice and control recognition and reward supportive work community fairness and justice meaningful and valued work. (Maslach 2001)

17. Recognizing Burnout/Compassion Fatigue in Oneself Wish to avoid work Avoidance-rounding Feeling sense of anger and frustration towards patients, families, colleagues Resisting evaluation for disease progression Not communicating serious information Over-dependence on technology

18. So what is Self-Care? Strong boundaries Work versus Life Burnout identification Physical, emotional, spiritual arenas

19. Self-Care Activities Exercise and nutrition Avoid excessive alcohol and caffeine Meditation Take/make time to laugh/relax with friends Enjoy meaningful solitude walks, reading, writing Other hobbies

20. Returning to Work Awareness of satisfaction Finding rewards Accomplishing renewal Experience wonder

21. Satisfaction from Work Sense of dealing well with patients, families and staff Intellectual stimulation Sense of mastery and contribution Enjoying adequate resources Obtaining professional status Limiting demands

22. Renewal: Professional Growth experiences in skill building, self-discovery and networking Practical Aspects of Palliative Care Conf Palliative Care Education and Practice E ducating Physicians in End-of-Life Care Annual Assembly AAHPM Being Here…today.

23. Renewal: Personal “ Spirituality and Meaning in Medicine” Conference Other organizations offering group discussions, conferences, retreats: ∙ “ Renew” ∙ “ Doctor to Heal” New outlook Experiencing how others have dealt with adversity and illness

24. Experience the Wonder Love in a family Resilience Courage Values Way patient views his own life and death

25. Applied Self-Care: Director/Faculty Starts at interview; ends…never “Open Door” Policy Get in their shoes Ask them questions about themselves Share your own experience Be a good example

26. Applied Self-Care: Director/Faculty Scheduled check-in’s (3-4x/year) Dismantle the ‘tough it up’ attitude Watch for the October-February slump Service vs. education Connection with other fellows Participation in traditions/rituals

27. Applied Self-Care: Director/Faculty Address the ‘affect’ in difficult situations: death of a patient identification with a patient or family challenging patient or family being “fired” by patient or family

28. Part of the Curriculum Add self-care sessions to weekly talks Experiential and knowledge-based Planned and spontaneous Look to other disciplines for assistance Informal debriefings after tough clinical cases Talk about other staff

29. Obstacles Faculty or friend? Looking for acclaim Best mentor ever Best boss ever Breaking bad news Why is feedback harder than death? The small fellowship program

30. Conclusions Burnout occurs when self-care is neglected Burnout can come from many sources Self-care should not be an afterthought Self-care can be nurtured: in your self in your fellows In your program

31. Contact Information David F. Giansiracusa, MD giansird@mskcc.org Christian T. Sinclair, MD [email_address]

32. References Maslach C, Goldberg J. Prevention of burnout: New perspectives. Applied and Preventive Psychology , 7:63-74, 1998 Zapf D, Seifert C, Schmutte B, Mertini H, Holz M. Emotion work and job stressors and their effects on burnout. Psychology and Health, 16:527-545, 2001 Zapf D, Holz M. On the positive and negative effects of emotion work in organizations. European Journal of Work and Organizational Psychology, 15:1-28, 2006

33. References Maslach C, Schaufeli WB, Leiter MP. “Job burnout”. Annual Reviews of Psychology. 52:397-422, 2001. Maslach C, Leiter MP. The Truth about Burnout , San Francisco: Jossey-Bass, 1997. Leiter MP, Maslach C. Preventing Burnout and Building Engagement: A Complete Program for Organizational Renewal , San Francisco: Jossey-Bass, 2000. Maslach C, Goldberg J. “Prevention of burnout: new prespectives. Appl. Prev. Psychol . 7:63-74, 1998.

34. References Meier DE, Beresford L. “Preventing burnout”, Journal of Palliative Medicine . 9(5):1045-1048, 2006 (October). Zalenski RJ, Raspa R. “Maslow’s hierarchy of needs: A framework for achieving human potential in hospice. Journal of Palliative Medicine. 9(5):1120-1127, 2006 (October) Schapira L. “Stress, burnout, and renewal”, Chapter 4. Conversations in Care ( www.conversationsincare.com )

35. References Gundersen L. Physician burnout. Ann Intern Med. 135:145-148, 2001. Rabow MW, McPhee SJ. Doctoring to heal. West J Med. 174:66-69, 2001. Freudenberger H. Staff burn-out. J Soc Issues 30:159-165, 1974. Mount BM. Dealing with our losses. J Clin Oncology . 4(7):1127-1134, 1986. Remen RN. Recapturing the soul of medicine. West J Med. 174:4-5, 2001.

36. References Meier DE, Back AL, Morrison S. The inner life of physicians and care of the seriously ill. JAMA. 286(23):3007-3014, 2001. Jenkins V, Fallowfield L. Can communication skills training alter physicians’ beliefs and behaviors in the clinics? J Clin Onc . 20(3):765-769, 2002. Block SD. Psychological considerations, growth, transcendence at the end of life: The art of the possible. JAMA 285:2898-2905, 2001. Cassell E. The nature of suffering and the goals of medicine. N Engl J Med. 306:639-645, 1982

37. References Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 136:358-367, 2002. Ramirez AJ, Graham J, Richards MA, et. al. Burnout and psychiatric disorders among cancer clinicians. Br J Cancer 71:1263-9, 1995 Kilfedder CJ, Power KG, Wells TJ. Burnout in psychiatric nursing. J Adv Nurs 34:383-96, 2001 Leiter MP, Harvie P, Frizzell C. The correspondence of patient satisfaction and nurse burnout. Soc Sci Med 47:1611-7, 1998

38. References Cherniss C. Beyond Burnout: Helping Teachers, Nurses, Therapists, and Lawyers Recover from Stress and Disillusionment , New York: Routledge, 1995 Goldberg R, Boss RW, Chan L. et al. Burnout and its correlates in emergency physicians. Acad Emerg Med 3:1156-64, 1996 Lemkau J, Rafferty J, Gordon R Jr. Burnout and career-choice regret among family practice physicians in early practice. Fam Pract Res J 14:213-22, 1994

39. References Sherman DW. Nurses’ stress and burnout. Amer. J Nursing. 104: 48-56, 2004. Redinbaugh EM, Sullivan AM, Block SD et al. Doctors’ emotional reactions to recent death of a patient: cross sectional study of hospital doctors. British Medical Journal 327:1-6, 26 July 2003. Rando T. Grief, Dying and Death: clinical interventions for caregivers. Campaign, IL: Research Press, 1984.

40. References Figley CR ed. Compassion Fatigue: Coping with Secondary Traumatic Stress in Those Who Treat the Traumatized. London: Brunner-Routledge, 1995 Groves JE. Taking care of the hateful patient. N Engl J Med . 298:883-887, 1978 Novack DH, Suchman AL, Clark W, et al. Calibrating the physician: personal awareness and effective patient care. JAMA .278:502-509, 1997. Zuker A. Dissatisfaction with medical practice. N Engl J Med . 350:69-75, 2004.

41. References Eric Cassell. The Nature of Suffering and Goals of Medicine. New York: Oxford Press. 2004. James Hallenbeck. Palliative Care Perspectives. New York: Oxford University Presss, 2003. Nouwen H. The Wounded Healer , Garden City, NY. Doubleday, 1972.

42. Suggested Readings Ken Wilber, Grace and Grit: Spirituality and Healing in the Life and Death of Treya Killam Wilber, Boston, Shambhala, 2000. Wallace Stegner, Crossing to Safety , 1987, Modern Library, 2002. Wallace Stegner, All the Little Live Things , Penguin Books, 1967 Jean Vanier, Becoming Human , Paulist Press, 1999. Michael Kearney, Mortally Wounded . New York: Simon and Schuster, 1996

43. Suggested Readings Jean Shinoda Bolen, Close to the Bone , New York: Touchstone, 1996. Christine Longaker, Facing Death and Finding Hope: A Guide to the Emotional and Spiritual Care of the Dying, New York: Doubleday, 1997 David Kuhl, What Dying People Want , New York: PublicAffairs, 2002.

44. Suggested Reading Reynolds Price, A Whole New Life: An Illness and a Healing, Schribner, 2003. Christopher Reeves, Still Me , Ballantine Books, 1999. Christopher Reeves, Nothing Is Impossible, Ballantine Books, 2004. Martha Weinman Lear, Heartsounds, New York: Simon and Schuster, 1980.

45. Suggested Reading Morton Kondrake. Saving Milly , New York: Ballantine Books, 2001. Reeve Lindbergh. No More Words: A Journal of My Mother, Anne Morrow Lindbergh, New York: Simon and Schuster, 2001. William Bridges. The Way of Transition: Embracing Life’s Most Difficult Moments. Cambridge, MA, Perseus Publishing, 2001.

46. Suggested Reading Ram Dass, Still Here: Embracing Aging, Changing, and Dying, Riverhead Trade, 2001. Viktor Frankl, Man’s Search for Meaning , Pocket Publishers, 1971 Ira Byock. Dying Well: Peace and Possibilities at the End of Life. New York: Riverhead Books, 1997. Kotter J. Leading Change , Harvard Business School Press, 1996

47. Suggested Reading Bill Bazan. Medicine In Search of Meaning: A Spiritual Journey for Physicians , Caritas Communications, 1999. Kirk Byron Jones. Rest in the Storm: Self-care Strategies for Clergy and Other Caregivers Judson Press, 2001 The Dalai Lama. The Art of Happiness , Riverhead Books, 1998. William Bridges. The Way of Transitions: Embracing Life’s Most Difficult Moments , Perseus Publishing, 2001.

48. Suggested Reading Kubler-Ross E. Death: The Final Stage of Growth, New York: Touchstone, 1975. Kabat-Zinn J. Wherever You Go, There You Are. New York: Hyperion, 1994. Santorelli S. Heal Thy Self: Lessons on Mindfulness in Medicine, New York: Bell Tower, 1999. Arthur W. Frank. The Wounded Storyteller: Body, Illness, and Ethics . University of Chicago Press, 1997.

49. Suggested Reading Brian Sibley. C.S. Lewis through the Shadowlands: The Story of His Life with Joy Davidman, Grand Rapids: Spire, 1999. Henri J.M. Nouwen. Our Greatest Gift: A Meditation on Dying and Caring, San Francisco: HarperCollins, 1994. Harold S. Kushner. The Lord is My Shepherd: Healing Wisdom of the Twenty-Third Psalm, New York: Anchor Books, 2003.

50. Suggested Reading Daniel Sulmasy. The Healer’s Calling: A Spirituality for Physicians and Other Health Care Professionals. Paulist Press, New York, 1997 Daniel Sulmasy. The Rebirth of the Clinic: An Introduction to Spirituality in Health Care , Georgetown University Press, 2006 Arthur W. Frank. The Wounded Storyteller: Body, Illness, and Ethics . Chicago, University of Chicago Press, 1995. Milton Lewis. Medicine and Care of the Dying: A Modern History . Oxford University Press. 2006

51. Suggested Readings {Risking Everything}, Roger Housden (ed), New York, Harmony Books, 2003 Jane Kenyon. Let Evening Come (Poems), Saint Paul: Graywolf Press, 1990. Jane Kenyon. Otherwise: New and Selected Poems. Saint Paul: Graywolf Press, 1996. Donald Hall. Without. (Poems), New York: Mariner Books, 1998. Mary Oliver. West Wind (Poems and Prose Poems), New York: Mariner Books, 1997.

52. Websites www.commonweal.org/ishi/ www.zenhospice.org www.hospitalchaplain.com www.erperc.mcw.edu www.pallimed.org

53. “ I had never heard of caregiver burnout raised as a possible temporary insanity or diminished capacity defense, so it sort of caught my fascination a little bit and off we went exploring the idea. ” -David E. Kelley TV Writer/Producer

54. “ Curing: Making the problem go away. Healing: Giving people the resources to enjoy life when they cannot make the problem go away.” __Rabbi Harold Kushner

55. “ There are two ways of of spreading light; To be the candle Or the mirror that reflects it.” __Edith Wharton

56. “ Be appreciative of your limited successes, more tolerant of your limited failures…..I strive to do the very best, but I am pleased with “ good enough”. __J. Andrew Billings

57. “ Man is not destroyed by suffering alone, But by suffering without meaning.” __ Viktor Frankl, Man’s Search For Meaning

58. Look within yourself: “ What is hardest for me in doing my work?” “ What brings me the most joy and meaning in doing my work?”

59. Pursue a personal quest to find meaning and purpose in life and a relationship to something greater than oneself.... The shift from ourselves to caring for others. __Michael Kearney, Mortally Wounded

60. “ Healing requires recognition of the human face of each person one sets to heal and of the message that both the healer and the healed share a bond that ties them to each other through their humanity, their mortality, and the God-given spark of grace that lives in each of them.” __Daniel P. Sulmasy, The Healer’s Calling