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Part D: Section D.2
1Part A: Understanding Grief and Loss in Children and Their Families
Maintaining Personal Wellness
Goals of this Session
o Discuss the rewards and challenges of our profession
o Provide a forum to discuss these contrasts
o Learn about adaptive strategies to enhance well being
and develop resiliency in our lives
o Develop an individualized wellness learning plan
Part A: Understanding Grief and Loss in Children and Their Families 2
Objectives
Learners will be able to
o Define wellness and it’s importance for the practicing physician.
o Recognize how a physician’s response to grief and loss may
impact others.
o Identify one’s own responses to grief and loss.
o Learn adaptive strategies both in the moment and long term to
enhance well being and develop resilience.
o Recognize the benefits of good self-care.
o Develop an individualized wellness learning plan.
Part A: Understanding Grief and Loss in Children and Their Families 3
Our Profession as Pediatricians
o We have a rewarding profession in providing service
to our patients.
o Yet, our work in our profession can be challenging
at times.
o We partner with patients and families who
experience suffering.
o The impact of unexpected outcomes, emotions of
family and team, fatigue, and uncertainty can take a
personal toll.
Part A: Understanding Grief and Loss in Children and Their Families 4
Part A: Understanding Grief and Loss in Children and Their Families 5
What are the rewarding aspects of
our profession?
Rewarding Aspects
o Provide a service to others
o Partner with families and patients
o Work as part of a team
o Identify the correct diagnosis
o Help patients to get better
o Help patients/families to adapt/thrive
o Contribute to something greater than self
Part A: Understanding Grief and Loss in Children and Their Families 6
Part A: Understanding Grief and Loss in Children and Their Families 7
What are some of
the challenges?
Challenges
o Patients may not get better
o Situations with high emotions
o Grappling with uncertainty
o Medical errors
o Perfectionism of providers
o Fatigue
o Death of a patient
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Part A: Understanding Grief and Loss in Children and Their Families 9
How are these juxtaposed?
Part A: Understanding Grief and Loss in Children and Their Families 10Part A: Understanding Grief and Loss in Children and Their Families 10
The word patient
comes from the Latin
word “Patiens”
Which means “to suffer”
Part A: Understanding Grief and Loss in Children and Their Families 11Part A: Understanding Grief and Loss in Children and Their Families 11
“In the sufferer, let me see only the human being.”
– Prayer of Maimonides
Part A: Understanding Grief and Loss in Children and Their Families 12
“Set of deep-seated convictions about one’s obligations to
others, especially those in need. Encompassing a spirit of
sincere concern for the centrality of human values in every
aspect of professional activity.”
– Edward Pellegrino, Humanism and the Physician, 1979
Humanism
Part A: Understanding Grief and Loss in Children and Their Families 13
“The practice of medicine combines the life sciences
with humanism. The science and art are not
antagonistic, but supplementary.”
– Robichaud, Bioethics, 2003
Concept of Dual Intelligence
Both science and humanism are essential.
Part A: Understanding Grief and Loss in Children and Their Families 14Part A: Understanding Grief and Loss in Children and Their Families 14
“Humanism is the passion that animates professionalism”
– Jordan Cohen
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Embrace patient suffering
1. Identify multiple perspectives
2. Reflect on how they converge or conflict
3. Choose to act altruistically
Miller and Schmidt. Acad Med, 1999
Part A: Understanding Grief and Loss in Children and Their Families 16
Acknowledging Our Own
Humanism as Providers
Part A: Understanding Grief and Loss in Children and Their Families 17Part A: Understanding Grief and Loss in Children and Their Families 17
Humanism to Self
Acknowledge our
imperfections, fatigue,
mistakes, discomfort with
medical uncertainty
Part A: Understanding Grief and Loss in Children and Their Families
Critical Incidents During
Medical Education
and Practice Affect Us
Part A: Understanding Grief and Loss in Children and Their Families 1818
Part A: Understanding Grief and Loss in Children and Their Families 19
What is an example of a critical incident
that has stayed with you?
Influenced your life?
Examples of Critical Incidents
o Sudden decompensation of a patient
o Unexpected outcome
o Medical error
o Angry parents
o Death of a patient
o Recognizing and coping with uncertainty
o Inability to control outcomes
Part A: Understanding Grief and Loss in Children and Their Families 20
Important to Have Forum for
Discussion of CIs
o Debrief with team, faculty member, colleague or friend
o Address intellectual decision making
o Acknowledge and articulate emotional impact
o Address ways to integrate experiences, rather than
pretend that “it never happened”
o You need to have direct and deliberate dialogue to move
beyond a critical incident
Part A: Understanding Grief and Loss in Children and Their Families 21
Part A: Understanding Grief and Loss in Children and Their Families 22Part A: Understanding Grief and Loss in Children and Their Families 22
Stress!
Part A: Understanding Grief and Loss in Children and Their Families 23
“We have an obligation as educators to share
with learners how we have coped with feelings
of anger, anguish, shame or uncertainty
in caring for patients.”
– Novack DH et al. Acad Med, 1999
Defining Stress
o Stress is the arousal of mind and body in response to
demands made on them.
o Distress results when the arousal is too high or too low.
o Each individual has his/her own zone of positive stress.
Part A: Understanding Grief and Loss in Children and Their Families 24
Factors Associated with
Intern Stress
o Consider programmatic changes to reduce stress:
o Improve sleep quality
o Foster teamwork
o Train in conflict resolution
o Decreasing the number of duty hours may be insufficient to reduce intern fatigue
Part A: Understanding Grief and Loss in Children and Their Families 25
Freisen, 2008
Develop self-awareness regarding stress
o Anticipate stressors
o Interpret stress as a sign or an opportunity
o Believe that you can influence events and reactions
to them
o Talking about feelings and emotions can be healthy
Part A: Understanding Grief and Loss in Children and Their Families 26
Managing Stress: Coping
o You have a choice in how you respond to difficult
situations and emotions
o Learn to respond in a healthy and productive manner
Part A: Understanding Grief and Loss in Children and Their Families 27
Part A: Understanding Grief and Loss in Children and Their Families 28
“There is a form of modern violence to which the idealist
most easily succumbs: activism and overwork. The rush
and pressure of modern life are a form, perhaps the most
common form, of its innate violence.”
– Thomas Merton
“The Violence of Modern Life”
Depressed Residents?
o Study that included 220 residents from 3 large residency
training programs
o 19.6% of residents screened positive for depression
o No significant change with work hour changes
Landrigan CP, 2008
Part A: Understanding Grief and Loss in Children and Their Families 29
Burned out Residents?
o 220 Residents (3 programs)
o Measures:
o Emotional exhaustion
o Depersonalization
o Personal achievement
o Rates of burn out decreased from 75%
to 57% with work hour restrictions
Landrigan 2008
Part A: Understanding Grief and Loss in Children and Their Families 30
What is Burn-Out?
o Emotional exhaustion
o Depersonalization
o Decreased feelings of personal accomplishment
Maslach, C. and Jackson, S. E. 1981
.
Part A: Understanding Grief and Loss in Children and Their Families 31
Burnout is an Occupational Hazard for
Physicians
o Estimates of physician burnout range from 25%-75%.
o Onset is linked to residency training.
o Physicians have a higher rate of depression, anxiety,
substance abuse and suicide when compared to the
general population.
Part A: Understanding Grief and Loss in Children and Their Families 32
Why such a problem?
o Social isolation
o Self-blame for negative outcomes
o Lack of attention to emotional needs
o Inadequate attention to personal medical care
o Strong emotional responses to the care of
complex patients
Eckleberry-Hunt J 2009
Part A: Understanding Grief and Loss in Children and Their Families 33
Why such a problem?
Part A: Understanding Grief and Loss in Children and Their Families 34Part A: Understanding Grief and Loss in Children and Their Families 34
Factors Related to Burnout?
What do you think they would be?
Factors Related to Burnout
o Perfectionism
o Lack of coping skills
o Personal bad habits (smoking and recreational drug use)
o Lack of control over office processes
o Lack of control over schedule
Eckleberry-Hunt, 2009
Part A: Understanding Grief and Loss in Children and Their Families 35
Factors Related to Burnout (continued)
o Difficult and complicated patients
o Poor relationships with colleagues
o Not enough time in the day
o Excessive paperwork
o Regret over chosen career
o Lack of time for self-care
Eckleberry-Hunt, 2009
Part A: Understanding Grief and Loss in Children and Their Families 36
Part A: Understanding Grief and Loss in Children and Their Families 37Part A: Understanding Grief and Loss in Children and Their Families 37
Strongest Factor Association
Pessimism: All three burnout
scales associated with this view
of the world
Emotional Intelligence
o The ability to recognize meanings of emotions
o The ability to reason and problem solve on the basis of emotions
o Enables one to
o perceive emotions
o assimilate emotion-related feelings
o understand the information of those emotions
o and to manage those emotions
Mayer 1999
Part A: Understanding Grief and Loss in Children and Their Families 38
Emotional Intelligence (continued)
o Higher emotional intelligence positively associated with
o More compassionate, empathetic patient care
o More effective coping of pressure and leadership
o Improved teamwork
o Ability to regulate one’s emotional response important in
controlling or minimizing stress and burnout.
o Emotional Intelligence training can include mindfulness
training, mindfulness-based stress reduction or
meditation.
Part A: Understanding Grief and Loss in Children and Their Families 39
Part A: Understanding Grief and Loss in Children and Their Families 40Part A: Understanding Grief and Loss in Children and Their Families 40
Bridge the Continuum
Embrace patient suffering Maintain joy in our work
Part A: Understanding Grief and Loss in Children and Their Families 41Part A: Understanding Grief and Loss in Children and Their Families 41
Need to nourish
ourselves to
maintain our
resilience
Part A: Understanding Grief and Loss in Children and Their Families 42Part A: Understanding Grief and Loss in Children and Their Families 42
Well BeingBeing challenged and thriving in
both personal and professional
life goes beyond the absence of
distress
Literature on Well Being Promotion
o Quill et al. Arch Intern Med, 1990
o Weiner et al. West J Med, 2001
o Shanafelt et al. Am J Med, 2003
o Jones SH. AM J Hospice and Palliative Med, 2005
o Ludwig S, Pediatrics, 2011
o Serwint JR, Acad Pediatr, 2012
Part A: Understanding Grief and Loss in Children and Their Families 43
Strategies to Promote Well Being
o One size does not fit all
o Individual and personal journey
o Each of us must find a strategy that works for us
Part A: Understanding Grief and Loss in Children and Their Families 44
Immediate, In the Moment Strategies
o Develop self insight
o If you become frustrated or worry that you won’t perform
in best way:
- Step away
- Take a few minutes
- Go outside or to bathroom and scream
- Splash water on face
- Take time to rethink strategies
Part A: Understanding Grief and Loss in Children and Their Families 45
Strategies for Immediately
Following an Event
o Walk away to gain some perspective
o Reach out to a colleague to discuss
o Play a favorite song
o Do something nice for yourself
Part A: Understanding Grief and Loss in Children and Their Families 46
Long Term Strategies
o Occupational Strategies
o Approaches to life
o Emotional/cognitive strategies
o Relationships with others
o Spirituality
o Promotion of self care
Part A: Understanding Grief and Loss in Children and Their Families 47
Occupational Strategies
o Honor the training process
o Be gentle with yourself
o Learn to relax
o Develop healthy doctor-patient relationships
o Learn to set limits
o Promote collegiality
o Develop a ritual of transition from work to home
Part A: Understanding Grief and Loss in Children and Their Families 48
Part A: Understanding Grief and Loss in Children and Their Families 49
“There is a form of modern violence to which the idealist
most easily succumbs: activism and overwork. The rush
and pressure of modern life are a form, perhaps the most
common form, of its innate violence.”
- Thomas Merton
“The Violence of Modern Life”
Approaches to Life
o Finding meaning in work
o Maintaining perspective
o Maintaining sense of humor
o Celebrating successes
o Rituals to release tensions of day (e.g. music)
Part A: Understanding Grief and Loss in Children and Their Families 50
Approaches to Life Reflection
o Consider writing or talking about one of these questions:
o Reflect on why you chose a career in medicine.
o What keeps you, as a physician, going?
o Think of a story that inspires you, such as an experience with a
patient , a family, or a colleague.
o Did anything happen this week that touched you or inspired you?
Part A: Understanding Grief and Loss in Children and Their Families 51
Emotional/Cognitive Strategies
o Taking time to grieve losses
o Time for reflection
o Skill in identifying signs of stress and frustration
o Mechanisms to address stress/frustration
Part A: Understanding Grief and Loss in Children and Their Families 52
Relationships with Others
o Connection with family and friends
o Protected time with family and friends
o Permission to say “no”
o Reaching out to others who may be struggling
Part A: Understanding Grief and Loss in Children and Their Families 53
Spirituality
o Belief in something bigger than self
o Contribution to greater good
o May go beyond specific religious beliefs
Part A: Understanding Grief and Loss in Children and Their Families 54
Promoting Well Being (Self-Care)
o Attention to own physical and mental health needs
o Keeping oneself well
o Good nutrition and sleep hygiene
o Relaxation, vacations
o Hobbies, exercise, yoga
Part A: Understanding Grief and Loss in Children and Their Families 55
Develop a Wellness Plan
o To maintain our work as humanistic providers, we must
be nourished ourselves.
o As one develops an ILP for career development, one
should develop an individualized wellness plan.
o Acquiring methods to maintain wellness during residency
may help one adopt life-long strategies.
Part A: Understanding Grief and Loss in Children and Their Families 56
Develop a Wellness Plan (continued)
o Strategies should include:
o Immediate or urgent strategies to incorporate “in the moment”
o After an event occurs
o Long term strategies for prevention
Part A: Understanding Grief and Loss in Children and Their Families 57
Individualized Wellness Plan
Part A: Understanding Grief and Loss in Children and Their Families 58
Strategy Goals
How will
I achieve my
goals?
Indicators of
success
Notes on
progress
(with dates)
Occupational
Strategies
Approaches to Life
Emotional and
cognitive
approaches
Relationships to
others
Spirituality
Promotion of
self-care
Part A: Understanding Grief and Loss in Children and Their Families 59
“The secret of the care of the patient
is caring for oneself while caring
for the patient.”
– Cadib L, 1995
Conclusion
o Our role as pediatricians merges the intellectual and
emotional aspects of patient care.
o While our responsibilities and roles can be rewarding,
they can also be challenging.
o To maintain our resilience, it is essential to develop
strategies for wellness.
o We need active and intentional ways to maintain
personal resilience.
Part A: Understanding Grief and Loss in Children and Their Families 60
Part A: Understanding Grief and Loss in Children and Their Families 61Part A: Understanding Grief and Loss in Children and Their Families 61
Return to the
Meaning of
Our Work
