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SlideShare utilise les cookies pour améliorer les fonctionnalités et les performances, et également pour vous montrer des publicités pertinentes. Si vous continuez à naviguer sur ce site, vous acceptez l’utilisation de cookies. Consultez notre Politique de confidentialité et nos Conditions d’utilisation pour en savoir plus.
The premise is that if a frog is placed in boiling water it will jump out, but if it is placed in cold water and very gradually heated, it will not perceive the danger and be cooked. The story is used as a metaphor for the inability of people to react to significant changes that occur gradually, such as creeping increases in work hours, responsibilities, medical legal stress, emotional exhaustion, etc. Building resilience is the ability to adapt to challenging situations. It’s a more positive approach to conceptualize physician response to stress for well-being.
Burnout is defined by exceeding cutoff levels of either emotional exhaustion or impersonal response towards patients.
Skeptics may consider a physician’s work/life conflict and burnout to be trivial concerns juxtaposed to the immense challenges of patients struggling with cancer. To the contrary, they are prevalent and many physicians and their families suffer because of them, these issues impact patient care, and, these issues have been shown to have importance for oncologists recruitment and retention, hence potentiallly reducing supply of cancer care specialists.
Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443-451.
There are approximately 300-400 physicians who die by suicide per year – this is the equivalent of 3 medical school graduating classes. (Shanafelt, Balch, Arch Surg. 2011
Compared with high school graduates, individuals with MD or DO were at increased risk for burnout, whereas individuals with a BA, masters or professional or doctoral degree other than MD or DO degree, were at lower risk for burnout. Granular differences important but not time in this presentation to get into all of them. Focusing on one cancer increased risk by 320% Gender, age, family structure, type of practice Those oncologists working more hrs/wk, more night call, more weekends, were most dissatisfied with work-life balance
Note that other high stress occupations discuss these topics and having explicit training. We could learn from other domains of professional education (i.e. disaster management, chaplaincy, etc.)
Dr. Beckman, who has been practicing and teaching for years, is a professor of medicine, family medicine, and public health science at the university of rochester school of medicine and dentistry. His commentary reflects upon his daughter’s experience in medical school. Cultural of medicine in which our trainees and their role models work and function day to day.
How do the pieces of the puzzle fit together for you right now?
Imagine a toast to you on your 80th birthday. Write down the words you would like to be remembered for. Plato employs the maxim 'Know Thyself' extensively by having the character of Socrates use it to motivate his dialogues. Plato makes it clear that Socrates is referring to a long-established wisdom. Tait Shanafelt “The oncologist who prioritized personal life may still have a productive academic career and closer relationships with family and friends as compensation for the reduction in academic achievement relative to their colleague. The career paths chosen by these two individuals may be of equal merit with respect to their potential for personal happiness. Dissatisfaction typically arises when a given individual intended to arrive at one destination (or mistakenly believed they could arrive at both) and instead arrived at another.” Important to consciously ask yourself – this is what success looks like to me. Tenure? Being home for dinner 3 nights a week? This may vary over ones’ career and there can be periods of plateau and up ramping. Cali Williams Yost’s book on combining work and life and she walks readers through an exercise whereby time and energy are allocated according to the fact that these are limited resources. Be wary of common roadblocks such as other people’s definitions of success that may or may not be as important to you (prestige, $, advancement & caregiver expectations). Imagine a toast on
Reference Mindfulness Based Stress Reduction for physicians Relaxation practices include deep and calming breathing; progressive muscle relaxation; engaging in pleasurable activities; Listening to music, taking a bath, and other restorative time. Explain difference between restorative activities vs. sitting on the couch
Basic behavioral change model. We use it to advise our patients to lose weight, quit smoking etc. We can follow that ourselves for our own successful self-care/health and sustainable career. Physical well-being A significant challenge faced by residents is attending to their physical well-being in the face of limited resources (time and money are the resources most often is short supply). We encourage you to select a primary care physician. I encourage you to see your doctor yearly and your dentist annually as well. These may have been things that you may have put on hold, but, not is a good time to do this. The strategy of delayed gratification (which many of us have used) is not sustainable over the lifetime of your career. Our wellness program seeks to help you help yourself. Nutrition, exercise, tobacco cessation, etc.
A national survey found that 30% of surgeons had symptoms of depression. (Shanafelt, Balch Ann Surg 2009) Another study showed that 6% of surgeons experienced SI in the preceding 12 months. There are approximately 300-400 physicians who die by suicide per year – this is the equivalent of 3 medical school graduating classes. (Shanafelt, Balch, Arch Surg. 2011)
The workplace has a critical role in actively supporting behaviors of self-care.
These efforts to care for the caretaker are best when they use collaborative approach. This will vary based on each unique setting & individual preferences
Work life fit and wellness
Work-life Fit & Wellness
in Medical Education
Rebecca Guest, MD, MPH
Director, Building Resilience Program; Associate Director, MSK Employee Wellness
Assistant Attending, Dept. of Medicine, Division of Survivorship & Supportive Care
Employee Health & Wellness Services
Memorial Sloan Kettering Cancer Center
August 27, 2015
• Define work-life balance, burnout, work/life fit, wellness
• Show prevalence & importance of physician distress vs.
• Consider the tension that exists between a culture of
productivity and the need for self-care
• Where do we go from here?
- Building resilience
- Work/life fit
- Stress management basics
- Strategies & resources
Physician distress vs. Well-being
Frog in the water – the danger of
the frog boiling
Building resilience – keep stress
from becoming distress
Burnout is an occupational hazard for individuals under constant
pressure or stress over a long period of time. Maslach Burnout
Inventory (MBI-22) A REVERSIBLE STATE
- emotional exhaustion
- physical exhaustion
- a decreased sense of personal accomplishment
- decreased effectiveness
Work-life balance assessed by the item, “My work schedule leaves
me enough time for my personal/family life.”
- Individuals who disagree or strongly disagree considered dissatisfied with
• Wellness. The term is used to capture the complex nature of
physical, mental, and emotional health. It is more that the
absence of disease or distress. For physicians, it includes
success in personal as well as professional life.
Why is work-life dissatisfaction and
• Distress to individual providers & their loved ones
Sleep disturbances and fatigue; Drug and alcohol addiction, physician impairment; careers in
jeopardy; difficult family relationships and divorce; Chronic disease associated with stress (e.g.
cardiovascular) and occupational injury (e.g. sharps BBPE); Depression, anxiety, suicide
• Physician distress associated with suboptimal patient care
Adverse patient events; Increased rate of medical & surgical errors w/ burnout; Poor patient
compliance & lack of patient satisfaction with medical care
• Potentially reducing supply of cancer care specialists*
Dissatisfaction with work-life balance and burnout were the strongest predictors of oncologists’ intent
to reduce clinical work hours and leave their current position
Decreasing interest among medical students in career with poor lifestyle; Change in specialty; Early
retirement among physicians with burnout or work-life conflict
*Coincides with projected shortage of oncologists
Are we an “at risk” group? Yes
• Burnout among med students, resident, new doctors vs. the general population*
• Work-life balance dissatisfaction is common
• Stressful working conditions are an occupational hazard for healthcare providers
• Physicians have a poor record of self-care
• Physician depression and suicide is higher than national averages
*Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to
the general U.S. population. Acad Med. 2014;89(3):443-451.
Facts about physician depression and suicide. American Foundation for Suicide Prevention website.
Rubin R. Recent suicides highlight need to address depression in medical students and residents. JAMA.2014;312(17):1725-
Are we at risk?
• Compared with working US adults, physicians were more likely to have symptoms
of burnout (38% vs. 28%) and to be dissatisfied with work-life balance (40% vs.
• Those oncologists working more hrs/wk, more night call, more weekends, were
most dissatisfied with work-life balance.
• Hours/week in direct patient care most dominant predictor of burnout for both
academic practice (AP) and private practice (PP). PP were less satisfied than AP;
each additional hr/wk imparts greater dissatisfaction.
• Dissatisfaction with balance and burnout associated with intention to leave
• Granular differences (age, gender, children, family structure, type of practice)
Shanafelt TD, et al. Arch Intern Med. 2012
Shanafelt, et al. J Clin Oncol. 2014
Are we at risk?
• One of the tragic paradoxes of burnout and work-life conflict is that those most
susceptible appear to be the most dedicated, conscientious, responsible, and
• Individuals with these traits are often idealistic and have perfectionistic qualities
that may lead them to submerse themselves in their work and devote
themselves to it until they have not enough left to devote to their own self-care.
• Studies show high association with hectic schedule, a strong achievement
orientation, an inability to say no.
GREAT MEANING IN WORK BUT
TOO MUCH OF IT
• Oncologists’ pattern of burnout
prevalence, high career
satisfaction, and low work-life
balance satisfaction is very
similar to surgical specialty
WHERE DO WE GO FROM HERE?
“How can we ensure the wellness of our
future workforce? Sustenance for caregivers
should become a fundamental part of training
and professional development at all levels.”
*American Society of Clinical Oncology, Take Care of Yourself: We Need You, Rebecca S.
Guest and Dean F. Bajorin, JCO, April 10, 2014.
Shouldn’t we have more of a dialogue
on these issues?
• Communication is protective but the topic of burnout and
work-life conflict traditionally has been taboo in medicine
• Identification & use of resources (personal self-care,
workplace wellness, community)
Up-skilling (e.g. mindfulness based stress reduction, communication skills training, a Building
Resilience educational mental health lectureship series)
Mentors, concerned colleagues, EAPC, Family, community, religion…
Physician assistance programs, Employee Health & Wellness when available
Human Resources (i.e. flexible work arrangements, Work/life)
Every physician should have their own personal physician
Burnout & Perceptions about workplace
culture among MSK surgical faculty
• 42% of responders met Maslach Burnout Criteria for burnout; low QOL across 5
domains in 34%
• 32% perceived a great need to change the taboo to discuss distress
• Positive correlations between burnout, low QOL, and modifiable factors
• 58% perceived a low service commitment to prevent burnout
• 90% perceived low support for achieving physical fitness
• 85% failed to use all annual leave and said that the institutional culture does not
encourage use of leave
Guest et al. Cancer surgeons' distress and well-being, I: the tension between a culture of productivity and
the need for self-care. Ann Surg Oncol. 2011.
Guest RS et al. Cancer surgeons' distress and well-being, II: modifiable factors and the potential for
organizational interventions. Ann Surg Oncol. 2011.
Teaching, learning, and practicing
values of professionalism
“How did we learn to push ourselves so much or to ignore self-care to the
point that many of us are experiencing burnout, anxiety, and depression …?
An initial step to understanding the problem should be examining our
current culture of medicine and the environments in which our trainees and
their role models work and function day to day.”*
*Beckman H. The role of medical culture in the journey to resilience. Acad Med. 2015
Academic medicine may be challenged
to reconceptualize traditional work
model so as to include colleagues with
“As increasing numbers of academics seek work-life balance and consider
part-time work as a tool to achieve that balance, academic medicine will be
challenged to develop creative models for integrating successful part-time
physicians, or it will lose that segment of the workforce.”*
Harrison, RA, Gregg, JL. A time for change: An exploration of attitudes toward part-time work in
academic medicine among women internists and their division chiefs. Acad Med. 2009.
What does “balance” mean to you?
- A state of equilibrium
- An equal distribution
- Something used to produce equilibrium
Can we really have balance?
Does Balance = No Stress?
Does “Should have balance = Yet Another Stressor?
Work/Life Fit or Work/Life Management
• Eliminates stigma/rigidity/pressure?
• Less stress?
• Ask yourself, What do I want? What
is my vision of success?
• Identify both personal and
- Become aware of biggest stressors and
priorities for YOU
- Work/life fit is individual and may change over
- What would you like to be remembered for?
Stress Management 101
Aerobic is best;
All exercise is good
Stress Management 101
Cultivate a positive attitude
• Resilient people approach challenges as
opportunities for growth
The attitude that you choose is what you
always have control of
Develop a plan & take steps for
Job satisfaction may be protective
• Get in touch with the meaningfulness of your work.
• Working with cancer patients gives oncologists a unique
perspective that can enrich life.
• Identify what is most rewarding and what is most stressful
about your job. Shape your career & life to maximize
Shanafelt et al. Shaping your career to maximize personal satisfaction in the practice of oncology. J
Clin Oncol. 2006.
Kearney et al. Self-care of Physicians Caring for Patients at the End of Life: Being Connected… a
Key to My Survival. JAMA. 2009.
Ramirez et al. Lancet
Compassion – for self & others
• Work/life conflict and physician distress can be normalized
• Give yourself permission to acknowledge the challenges and
take time/energy to work toward solutions
• Check in with a friend or colleague
Seek professional expertise when
• Do apply your medical judgment.
• Depression, anxiety and alcohol/drug misuse are common
conditions; doctors are not immune.
• You may self-refer to EAPC (meet with a counselor
confidentially to discuss personal issues).
• You may consult with a physician at Employee Health, or,
with your personal doctor.
A Dynamic Tension – the beauty of life’s work
Dynamic tension exists between a culture of productivity, multiple
professional & personal roles, and the need for self-care.
Permission to prioritize your own
psychological & physical health is key
• As physicians, we hold a common determination to provide
the highest standards of care for our patients.
• Those standards should similarly apply to providers
ourselves, personally as well as professionally.
Goal: build an medical culture that
includes caring for the caretaker
Occupational medicine –
culture & physical
leadership buy-in and
Memorial Sloan Kettering Building
• Increasing Transparency – through research, education, discussion
• Lunch & Learn topical lectures (sleep, compassion fatigue, relaxation
• Building Resilience through the Arts (Juilliard, MoMA, etc)
• Team workshops (tailored to needs of service)
• Open door policy / safety net
• Collaborative approach
Employee Health & Wellness Services in Department of Medicine; Office of Faculty Development
GME; Department of Psychiatry & Behavioral Sciences; Social Work; Nursing; Chaplaincy
Employee Assistance Program (EAPC); Survivorship & Integrative Medicine (employee access
to these Services)
Please feel free to contact Rebecca Guest, MD, MPH at firstname.lastname@example.org
• Work/life conflict, burnout, and associated distress are
common and important occupational hazards for physicians.
• Dynamic tension exists between a culture of productivity,
multiple professional & personal roles, and the need for self-
• Educational strategies and resources are identified to build
• Permission to prioritize self-care is key.
*American Society of Clinical Oncology, Take Care of Yourself: We Need You, Rebecca S. Guest and Dean F. Bajorin,
JCO, April 10, 2014.
Resources & References – relevant to
• The AMA Family & Physician Support Program
• The Canadian Medical Association (CMA has very good website/resources)
• The British Medical Association (BMA, The National Clinical Assessment Service)
• The International Physician Health Conference (IPHC)
• Greater New York Hospital Association, GME, Resident Health & Wellness
• The Mayo Clinic Program on Physician Well-being
• Vanderbilt University Faculty & Physician Wellness Program
• Stanford University, Balance in Life program
• Harvard School of Public Health, Center for Work, Health, & Well-being
• CDC – NIOSH WorkLife
• Association for Women In Science (AWIS), Work-Life Satisfaction
Resources available to you at MSK
• Employee Health & Wellness Services (EH&WS)
• Employee Assistance Program Consortium (EAPC)
• MSK Employee Wellness – nutrition/weight loss, exercise/fitness,
tobacco cessation, Active Health, stress management, etc.
• The Building Resilience Program – individualized consultations,
educational lectureship series, Building Resilience through the Arts
• Social Work
• Human Resources - HR business partner
• Integrative Medicine
Resources & References
• Your organizations’ Employee Assistance Program (EAPC)
• Every physician should have a personal physician whose objectivity is not
• Cali Williams Yost, Work+Life: Finding the Fit that’s Right for You and Tweak It:
Make What Matters to You Happen Every Day
• Jon Kabat-Zinn, Wherever you go, there you are – mindfulness meditation in
• Mindfulness meditation
• Stephen R. Covey, First Things First
• Martin E.P. Seligman, Learned Optimism – How to change your mind and your
• Stephan Rechtschaffen, Time Shifting – Creating More Time to Enjoy Your life
Guest R, Bajorin D. Take Care of Yourself: We Need You. J Clin Oncol. 2014 March;32:1-3.
Guest RS, Baser R, Li Y, et al. Cancer surgeons' distress and well-being, I: the tension between a culture of productivity and the need for
self-care. Ann Surg Oncol. 2011;18: 1229-1235.
Guest RS, Baser R, Li Y, et al. Cancer surgeons' distress and well-being, II: modifiable factors and the potential for organizational
interventions. Ann Surg Oncol. 2011;18:1236-42.
Kearney MK, Weininger RB, Vachon MLS, et al. Self-care of Physicians Caring for Patients at the End of Life: Being Connected… a Key
to My Survival. JAMA. 2009. 301:11, 1155-162.
Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general
U.S. population. Acad Med. 2014;89(3):443-451.
Balch CM, Copeland E. Stress and burnout among surgical oncologists: a call for personal wellness and a supportive workplace
environment. Ann Surg Oncol. 2007;14: 3029-3032.
Shanafelt, T, Chung H, White H, Lyckholm LJ. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995–1000.12.
Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US
population. Arch Intern Med. 2012;172(18):1338-85.
Shanafelt TD, Raymond M, Horn L, et al. Oncology fellows’ career plans, expectations, and well-being: do fellows know what they are
getting into? J Clin Oncol. 2014;32:2991-7.
Shanafelt, T: A Career in surgical oncology: Finding meaning, balance, and personal satisfaction. Annals of Surgical Oncology, Feb.
Beckman H. The Role of medical culture in the journey to resilience. Acad Med.2015;90:710-712.
Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and
attitudes among primary care physicians. JAMA. 2009; 302:1284-93.
Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced
physicians. Acad Med. 2013; 88:382-9.
Epstein RM, Krasner MS. Physician resilience: What it means, why it matters, and how to promote it. Acad Med. 2013;88:301-303.
Wallace JE, Lemaire JB, Ghali WA. Physician Wellness: A missing quality indicator. Lancet. 2009;374:1714-1721.
Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M. Future supply and demand for oncologists : challenges to assuring access to
oncology services. J Oncol Pract. 2007; 3:79-86.
Drybye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general
U.S. population. Acad Med. 2014;89:443-451.
Williams, ES, Konrad TR, Scheckler DP. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job
stress, mental and physical health. Health Care Manag Rev. 2001;26:7–19.
Gabbard GO, Menninger RW. The Psychology of postponement in the medical marriage. JAMA. 1989; 261:2378-2381.
Harrison, RA, Gregg, JL. A Time for Change: An exploration of attitudes toward part-time work in academic medicine among women
internists and their division chiefs. Acad Med. 2009;84:80-86.
Salles AS, Liebert CA, Greco, RS. Promoting balance in the lives of resident physicians: A call to action. JAMA Surg. 2015;150(7):607-
Sood A, Prasad K, Schroeder D, et al. Stress management and resilience training among Department of Medicine faculty: a pilot
randomized clinical trial. J Gen Intern Med. 2011 Aug;26(8):858-61.
Facts about physician depression and suicide. American Foundation for Suicide Prevention website. https://www.afsp.org/preventing-
Rubin R. Recent suicides highlight need to address depression in medical students and residents. JAMA.2014;312(17):1725-1727.