Sally Garhart MD NH Professionals Health Program

Medical Director 603-491-5036

Disclosure I am the medical director of the NHPHP a 501c3 which

receives funding from the NH Board of Medicine through a $15 a year surcharge in license renewal fees and donations from individuals, malpractice insurers and hospital systems. I am paid to work 20 hours a week.

NH PHP

Provides services to the BOM Consultation is free for all MDs, DOs and PAs licensed

in NH Emphasis is on issues affecting the ability to safely

practice medicine because of: Substance abuse – alcohol, drugs, meds Mental Health Disruptive Behavior Health Issues – sleep, apnea, arthritis, vision loss,

Parkinson’s, aging, seizures, communication, dementia or physical limits

Professional Boundary violations (some) Burn out

YES / NO

Are Doctors “Normal” ?? ‣ Perfectionism –essential to medicine, poison to

a human

‣ Abnormal youth, college, young adulthood

‣ Lower “emotional intelligence” EQ

‣ Hyper focus, compulsive – work and play

‣ Workaholic

‣ Focused on science

‣ Minimal free time

‣ Few hobbies and fewer friends

Mental Health issues ANXIETY – MOST COMMON in NHPHP; what if….

Bipolar – over diagnosed in early recovery and under diagnosed if physician “edits” symptoms

Depression

Suicidal – not compatible with patient care

Requires aggressive evaluation and treatment - OOS

PTSD – childhood abuse or military MDs

Burn out, emotional fatigue

Old School vs New School Work comes first

Work til the job is done

Residency call q 3 or 4

Employed by necessity

Loans paid

Kids in college

Is this all there is?

Balanced work-life

Work 8-6, weekends off

Limited residency hours

Employed by choice

High priced loans

No kids or new babies

This is harder than I thought

Long Work Hours Wreak Havoc in MDs’ Personal Lives Medscape 9/23/13

Mayo survey of 90,000 US physicians and partners

27.7 response rate

Median age 55 years; 89% had children

44% reported a work home conflict (WHC) in past 3 wks

WHC most common in younger, female and academic medical centers (due to excessive hours)

MDs with WHC were more likely to have symptoms of burnout or depression, to be considering divorce and to have lower mental and physical quality of life

This used to be the struggle with medical records.

Physician Burnout Estimated to affect 30-40% of physicians

Incr self-reports of medical error, decr in empathy, incr plans to retire early, decr pt satisfaction and adherence

Caused by excessive workloads, call, loss of workplace control and autonomy

+/- features of the ACA may worsen the problem Incr # of patients needing care

Decr financial margins

No pre-existing exclusion

Many “unknowns”

Burnout Personal Problems

Systems Problems

Common themes

Lack of staff due to retirement, illness or someone quit

Months of unused vacation – no coverage

24/7 call

Stuck and unhappy

Too busy to prioritize, exercise or do basic self-care

Treatments Avoidance

Education and focus on self care Exercise, eat right, sleep, turn off electronics early

Schedule pleasurable pursuits and keep the appt

Mindfulness practice Make all activities focused and meaningful

i.e. one thing at a time

Multi-tasking well is a myth!

Not just drag through the day

5 Breath practice

Falling apart Never planned.

It happens too often.

Very tragic.

Should be prevented or treated early but….

Often the doctor needs to go out on medical leave.

Prodrome – ZERO self-care

What happened??

Where is the safety net for a doctor?

Reported Provider Symptoms Not sleeping

High anxiety

Calling out sick; not answering calls / texts / emails

Can’t stop crying

Not eating well – protein bars / coffee

Falling asleep at work; chronically arriving late

Severe burnout

Personality changes – ANGRY, arguing, talking too much, too physical, withdrawn

Can’t make decisions

Symptoms cont’ Office affairs

Way behind in EMR

Positive drug test – pre-placement for illegalsubstance or something self-prescribed

Death – overdose or suicide

Yelling or passive aggressive or both

Overly distracted – my son was just diagnosed with ADHD……

Depression 15-30% rate of depression in medical students and

residents – prob due to isolation and sleep deprivation

Many stop treatment when they move to new city

CAN trial cognitive behavioral skills prior to residency

Physician depression rates equal to the general population.

Depressed residents made 6.2 times more medication errors than non depressed residents.

Predictors of Depression Valliant et all

Difficult work relationships

Lack of sleep

Making mistakes

Loneliness

24 hour responsibility

Self-criticism

Perfectionist traits

PHYSICIAN SUICIDE 400 a year on average in the US

Suicide is cause of 35% of premature US MD deaths

Barriers to care are shame and stigma

Hopelessness/Helplessness

More than 1/3 of physician suicides had hx of prior drug or alcohol problems

Women physicians – highest rate 5.7 X US average

Male physicians – 3.4 X US average

Profile of a high risk physician Silverman, 2000 The Handbook of Physician Health AMA Press

Workaholic white male >50

Female > 45 divorced, single or currently experiencing marital disruption

Concurrent depression, substance abuse or history of risk-taking behavior (particularly high stakes gambling)

Chronic pain or illness

Starting new job after residency or nearing retirement

Increased work demands

Personal losses

Diminished autonomy

Access to lethal means – firearms, meds

Suicide Protective Factors Effective treatment of depressions or substance abuse

With PHP monitoring for alcohol use

Social and family support

Resilience and coping skills

Religious faith

Restricted access to lethal means

Physician Substance Abuse Lifetime rates 1 in 10 (same as general population)

Affects all specialties and ages

Highest incidence in NH: male PCPs age 40-50 and psychiatrists

Anesthesiologists: highest injected drug rate

Most frequent substance is alcohol

Co-occurring diagnoses. Almost 100% have depression

Probably 90% have anxiety

Sentinel Events for substance abuse

DUI - poor judgment vs dependence

Arrested for domestic disturbance

Admission for depression or detox – get a drug test

Admission for a suicide attempt – get a drug test

Suicide

None - because of shame and denial doctors rarely self-report and work hard not to get caught.

“Controlled” heavy drinking for stress relief and to sleep

Recovery Rates in Physicians for chemical dependence 80-90% estimated for those completing 5

years of monitoring 18% unmonitored, general population

Increased by drug testing Identify and treat early relapses

Physicians are highly motivated for success. Treated physicians spread the concept of

improving self care.

How open are most doctors to asking for help? I don’t want to complain.

I am fine. I don’t drink…..

I don’t want anybody to know.

I’d rather be dead than see a psychiatrist.

Psych meds don’t work.

Treatment doesn’t work.

Barriers to effective treatment Fear of social stigma

Time constraints 8-5

Trouble finding a good provider who isn’t a colleague

Concerns about confidentiality

Fear of discrimination by colleagues, work, or BOM

Disgust with the disease and dislike of their patients with the same conditions

Refusal to give up control

Denial of a problem that “I should be able to solve”.

22% of medical students who

screened positive for depression

sought help

42% of students with suicidal ideation

received treatment

Givens JL, Tjia J. Depressed medical students’ use of mental health

services and barriers to use. Acad Med. 2002;77(9):918-921.

Self-treatment Very common

Attempt to treat mood disorder with self-prescribed medications – too short a time, freq dose changes, excessive side-effects

Use alcohol or drugs for mood disorder symptoms.

Dopamine seeking.

No objectivity.

Poor results reinforces theory that TX is hopeless.

Problems with “VIP” treatment Appointments out of the clinic or after hours

“Hypothetical Patient” hall consult

Underestimate the severity of the crisis

Assumptions – particularly on suicide risk

Inadequate “informed consent” because of not wanting to “insult” the doctor patient

Too much latitude – don’t want to interfere with license, ability to practice

DEA issues for prescriptions written without a note

Serious problems Need quick and effective evaluation and triage

Let the doctor talk, tell their story but then don’t get talked out of insisting on treatment.

Don’t just leave it up to the doctor.

Don’t give too many choices.

Refer out for confidentiality – out of state if possible.

Talk to the referral provider so that the doctor can’t change his story.

Remember, Doctors DO LIE.

Education for Burnout Mental health reading and TED talks

Emotional Intelligence – reading and skills

Encourage seeing a PhD therapist

Positive Psychology reading – Flourish, M Seligman

Cognitive Behavioral Therapy

Skills – books, internet: Mood Gym, E Couch

If not for you, then do it for your patients or family

No medications / No med side effects

Multi-day, multi-discipline Eval A “time-out” away from the stressors.

Serious evaluation of multiple issues

Substance abuse

Depression

Learning disabilities

Cognitive dysfunction

Utilizes multiple opinions

Uses “physicians” as the norm for comparison

Very supportive and positive

Outside Coaching Personalized improvement

Behavior oriented, results driven

Emphasis on the positive goals, neutral

Effective for burnout, time management, EMR problems, anger, communication and disruptive issues

Proactive, very acceptable to providers

Improves the bottom line of organizations

Self- Care Sleep – 8 hours a night Hobbies – astronomy, photography,

gardening Sports group (skiing) or team (hockey, golf) Exercise – daily Balance nutrition with real food! Social groups – cooking, bridge Religion **Old friends with long memories** Pets – the bigger the better

Mental Health Diagnoses Do not spare any demographic

Sleep deprivation and overwork severity

Practice prevention Address work hours, stress, alcohol use,

isolation

Seek HELP for both ourselves and our co-workers

Summary Live in the moment.

Speak up for fair work hours and duties.

Don’t wait for retirement to start living.