H I L A R Y M C C L A F F E R T Y , M D , F A A PA M E R I C A N A C A D E M Y O F P E D I A T R I C S

2 0 1 7 P E D I A T R I C S I N T H E 2 1 S T C E N T U R Y

C H I C A G O , I L L I N O I S

S E P T E M B E R 1 5 , 2 0 1 7

Physician Health and Wellness: Creating a Practice Centered on Wellness

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Wellness and Resilience are Multi-Dimensional

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Personal

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Personal

Work culture

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Personal

Culture of Medicine

Work culture

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Personal

Culture of Medicine

Work culture

Positive Progress

The good news…........

Blueprint: Lowering Rates of Burnout

• Sense of personal control• Absence of role conflict• Feeling of being fairly treated • Social support• Appropriate reward (financial, institutional, social)• An alignment of values between individual and workplace• Good leadership

J Appl Psychol. 2008 May;93(3):498-512 Maslach, LeiterAcad Med. 2015 Sep;90(9):1246-50. Jennings, et al.McClafferty 2017

Culture Change: Lead by Example

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“Become Comfortable with Being Uncomfortable”

Shifting the Focus to Wellness

Model your humanityNormalize ‘self care’ in your practice

Actively acquire coping skills to meet practice needs

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Workplace Culture : Desired Outcomes

�Dissolve the culture of silence�Engage colleagues in problem solving�Transparent efforts, reported results �Frame the mission for the bigger cause, i.e.

changing the culture of medicine

J Grad Med Educ. 2011 Dec;3(4):503-10. Billings, et al McClafferty 2016

Culture Change: Build on Positive Progress

Stanford University• Committee for Professional Satisfaction and Support (SCPSS) • Well MD, Wellness Institute

National Academy of Medicine• Action Collaborative on Clinician Wellbeing and Resilience

Association of American Medical Colleges (AAMC)• Wellbeing in Academic MedicineMcClafferty 2017

Culture Change: Build on Positive Progress

American Academy of Pediatrics • Resilience Curriculum, Special Interest Group on Physician Wellness University of Arizona, Center for Integrative Medicine• Physician Wellbeing Course (online)National Pediatric Resident Burnout-Resilience Study Consortium (PRB-RSC)• Best practices, resourcesThe Ohio State University, College of Medicine• Mind-Body Stream (online mindfulness courses)

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Focus on Your Practice

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• Tap into existing resources • Uncover colleague’s hidden expertise and interests• Acquire additional training as a group• Mindfulness Based Stress Reduction (MBSR)• Yoga• Cognitive Based Compassion Training (CBCT)• ‘Enforce’ vacation time, sabbaticals if possible

Focus on Your Practice

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• Network with like-minded colleagues • Acknowledge loss and challenges • (Schwartz Rounds)• Schwartz Center for Compassionate Healthcare• Group wellbeing goals, resident wellbeing

initiatives• Local recreation or retreat opportunities

� Personal Health Habits and Wellness Practices of US Surgeons

� American College of Surgeons Survey (2010)

� n = 7197

Wellness Behaviors are Additive: Annals Surgery 2102

Ann Surg. 2012 Apr;255(4):625-33. Shanafelt, et al

� Ratings of the importance of 16 personal wellness promotion strategies differed for surgeons without burnout (P<0.0001).

� Surgeons placing greater emphasis on finding meaning in work, focusing on what is important in life, maintaining a positive outlook, and embracing a philosophy that stresses work/life balance were less likely to be burned out (P<0.0001)

� A broader collection of wellness promotion measures was needed to move beyond neutral and achieve high well-being. Categories were additive.

Ann Surg. 2012 Apr;255(4):625-33. Shanafelt, et al

Wellness behaviors are additive…,

Modern Physician Resilience

McClafferty 2017 © Arizona (ABOR) 2017

Modern Physician Resilience

McClafferty 2017 © Arizona Board of Regents (ABOR) 2017

Benefits of Mindfulness Training

� Stress reduction� Increased self-awareness� Increased adaptive reserve� Decrease in personal isolation� More thoughtful decision making� Improved listening and attentiveness� Better at addressing patient’s concerns� IMPROVED PATIENT OUTCOMES

JAMA Intern Med. 2014 Apr;174(4):527-33. West CP1, Dyrbye LN2, et al.McClafferty 2017

Well-Being Intervention: Mayo Clinic Rochester

� 74 Internal Medicine Physicians

� 19 x 1 hour biweekly facilitated discussions groups

� Mindfulness� Reflection� Shared experience� Small group learning

JAMA Intern Med. 2014 Apr;174(4):527-33. West CP1, Dyrbye LN2, et al.McClafferty 2017

Well-Being Intervention: Mayo Clinic

Main Outcomes and Measures:

� Burnout � Quality of life � Job satisfaction� Symptoms of depression � Empowerment and engagement in work

JAMA Intern Med. 2014 Apr;174(4):527-33. West CP1, Dyrbye LN2, et al.McClafferty 2017

Well-Being Intervention: Mayo Clinic

Results: 3 month and 12 month follow up

Positive:Improved empowerment and engagement in work p=.04Reduced burnout (decreased depersonalization) p=.004

Unchanged:� Symptoms of depression � Quality of life � Job satisfaction

JAMA Intern Med. 2014 Apr;174(4):527-33. West CP1, Dyrbye LN2, et al.McClafferty 2017

Abbreviated Mindfulness Intervention: U of Wisconsin

Goal: ‘Efficient and Sufficient’ to teach basic mindfulness

Premise: Clinical work is opportunity to practice mindfulness, i.e.,patient is the centering focus:� Pause� Be present� Proceed with recommendations, questions, advice� Mindfully address patient’s needs

Fortney L1, et al. Ann Fam Med. 2013 Sep-Oct;11(5):412-20.McClafferty 2017

Abbreviated Mindfulness Intervention : U of Wisconsin

� 30 Family Medicine Physicians

� Assessed at baseline, day 1, 8 weeks, 9 months post-intervention:

� Burnout� Anxiety� Stress� Resilience� Compassion

McClafferty 2017 Fortney L1, et al. Ann Fam Med. 2013 Sep-Oct;11(5):412-20.

Abbreviated Mindfulness Intervention

Abbreviated version of typical 8-week MBSR program(18 hours versus ~30 hours)

• Facilitated by experienced instructors• Guided sitting meditation• Walking mindfulness• Mindfulness practice 10-20 minutes daily• Audio CD for Practice (Fourteen Essential Practices by Sharon Salzberg)

Fortney L1, et al. Ann Fam Med. 2013 Sep-Oct;11(5):412-20.McClafferty 2017

Abbreviated Mindfulness Intervention

Results:

Decrease from baseline: 1-day 8-week 9-monthEmotional exhaustion p= .046 p=.006 p=.009Depersonalization p=.03 p=.005 p=.005

Increase in personal accomplishment scores at all follow ups p=< .001

Improvement in perceived stress at 9 months p= .002Fortney L1, et al. Ann Fam Med. 2013 Sep-Oct;11(5):412-20.McClafferty 2017

Community at Work Evolves: Mayo Clinic

� Peer support, formal or informal, is critical. � Promotes ‘social resilience’.

Examples tried:• 1-hour protected time every other week• Small group discussions, meaning in work, burnout prevention, skill

building• Colleagues Meeting to Promote and Sustain Satisfaction (COMPASS)

McClafferty 2017 Mayo Clin Proc. Jan 2017;92(1):129-146. Shanafelt, Noseworthy

Culture Change: It Evolves

• Morphed into meal out every 2 weeks with small groups of colleagues (6-7) at restaurant, first 20 minutes discussing meaning and purpose of work.

• Funded by Mayo, 1100/3755 physicians joined.

• Cost effective, improved measures of meaning at work, statistically significant decrease in burnout measures.

McClafferty 2017 Mayo Clin Proc. Jan 2017;92(1):129-146. Shanafelt, Noseworthy

Mindfulness in Practice

• How might you step out of your comfort zone and apply mindfulness at work?

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Thank youHilary McClafferty, MD, FAAP

University of Arizona College of Medicine, Tucson, Arizonahmcclafferty@email.arizona.edu

@DrHMcClafferty

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