September 2016 | San Mateo Physician Magazine by Los Angeles County Medical Association

S a n M at e o C o u n t y

September 2016

Physician

IN S ID E

S A N M AT E O C O U N T Y M E D I C A L A S S O C I AT I O N

Volume 5 Issue 8

Physician Burnout: Healing the Healers

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Physician

EDITORIAL COMMITTEE

Russ Granich, MD , Chair | Judy Chang, MD | Uli Chettipally, MD Sharon Clark, MD | Carri Allen Jones, MD | Edward Morhauser, MD Gurpreet Padam, MD

September 2016 - Volume 5, Issue 8

Sue U. Malone | Executive Director SMCMA LEADERSHIP

Russ Granich, MD | President Alexander Ding, MD | President-Elect Sara Whitehead, MD | Secretary- Treasurer Michael Norris, MD | Immediate Past President Janet Chaikind, MD Uli Chettipally, MD Mamatha Chivukula, MD Paul Jemelian, MD Alex Lakowsky, MD Richard Moore, MD Joshua Parker, MD Xiushui (Mike) Ren, MD Brian Tang, MD Dirk Baumann, MD | AMA Alternate Delgate Scott A. Morrow, MD | Health Officer, County of San Mateo www.SMCMA.org facebook.com/smcma | twitter.com/SMCMedAssoc.

Columns President’s Message: Being Here 2 Russ Granich, MD

Feature Articles Physician Burnout: Burnout Awareness 4 Physician Burnout: Healing the Healers 6

EDITORIAL

San Mateo County Physician is published ten times per year by Physicians News Network (PNN) and the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of PNN or SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

Of Interest Upcoming events, classified ads, index of advertisers

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President’s Message

Being Here I C A N T E L L Y O U E X A C T L Y what is the most

If your mind wanders, acknowledge the thought and get back to the task at hand.

important thing for you to be doing right now. I’m not a mind reader or magician nor do I have any special powers, but it really is straightforward. Every day we make many, many choices. We decide when to wake up, what to eat, what to wear, when to go someplace, etc. At any given moment, what we choose to do is the most important thing for us to be doing at that moment; otherwise, we would be doing something else. So right now, it is reading this article. But you might say, well, I just happened to pick this up and start reading. Could you have done something else, perhaps read an email, get a cup of coffee, or go into an exam room? Of course, but you chose to read this magazine. These choices don’t have to be monumental, but they all stem from our life choices. We decided to become physicians; we decided we wanted a certain lifestyle; we make all sorts of Photo by Scott Buschman decisions, and the choices we make all lead back to what are the most important things in our life. What does this all mean? Immerse yourself in the activity of that moment. Once time passes, it can never be regained, so if you are doing something, then do it; don’t waste your time. In practical matters, this might mean paying attention when someone speaks rather than thinking of the errands you need to run on the way home. Minds wander, that is what the mind does. The ability to totally focus on one thing is extremely difficult and rare to do for more than brief moments. If your mind wanders, acknowledge the thought and get back to the task at hand. This takes practice and practice makes progress. Many religions and belief systems strive to exists only in the moment. Mindfulness is not just the new term of the moment; it is a term often heard for good reason. It is something that has been around for hundreds, perhaps thousands, of years as a manifestation of self-discipline. The term mindfulness comes from Buddhism and the ancient, sacred language of Pali. It also has its counterpart in the sacred language of Hinduism, Sanskrit. I’m oversimplifying this, but the bottom line (my Western mind speaking!) is that our lives would be

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better if we were not off thinking about yesterday or tomorrow, and being present from moment to moment. The West was primarily introduced to mindfulness by Jon Kabat-Zinn, who created the Mindfulness-Based Stress Reduction program in 1979 and has authored many books on the subject. He has taken Buddhist teachings and applied scientific principles to better understand how it all works and the effects on those who have incorporated mindfulness into their lives. Numerous studies show that mindfulness improves the sense of well-being and decreases depression and anxiety. Mindfulness training is used in many environments, from hospitals to sports to prisons to the corporate world and to the U.S. Army, to name just a few. They find that it helps with coping, workplace productivity, decreased violence, etc. Living a mindful existence isnâ&#x20AC;&#x2122;t easy, but just embracing it in small increments of change over time can only help. Practice makes progress. A Harvard publication described the simple exercise of being in a comfortable position and focusing on just one aspect of your breathing. Breathing is a product of the moment. Once you are doing that, expand your focus to other aspects of breathing, like what happens to your abdomen when you breathe in and out. When your mind starts to wander or race, go back to the breathing. The more you do it the faster you will be able to make the transition. Just a few minutes a day. A less structured form of mindfulness is to do an activity in which you can totally immerse yourself and stay in the moment. I have found a couple of things, in a more informal approach that has served me well. First, if I ever feel unhappy or discontented in any situation, I go back to what I wrote about above. I remind myself that I chose to do this, and just that conscious thought changes my perspective. The second, when I am talking with someone and am listening, when I start to notice my mind wander, I go back to what they are saying. I concentrate on them, the thoughts and ideas they are communicating to me. As a physician, when you are with a patient and mindful of them and the moment, you will understand them, better and when they know you are listening, they will be more confident in the care you give them. Give it a test drive; you have nothing to lose and everything to gain.

Numerous studies show that mindfulness improves the sense of well-being and decreases depression and anxiety.

Russ Granich, MD President

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Physician Burnout:

Burnout Awareness FOLLOWING

2015

M AYO

CLINIC

S T U D Y finding that 54.4% of

physicians reported at least one symptom of burnout, a new study finds that full-time physicians

who report worsening burnout or show declining job satisfaction are more likely to reduce the

hours they work. The study, published in Mayo Clinic Proceedings and highlighted in an AMAWire

article earlier this month, indicated the proportion of physicians working less than full time at the Mayo Clinic increased to 16% in 2014, up from 13.5% in 2008. Burned-out doctors are “impaired,” says Mayo Clinic President and CEO John Noseworthy. “They’re at risk for increased medical errors, turnover, and suicide. They are at risk for decreased professionalism, patient satisfaction, and productivity.” Between 2008 and 2014, there was a statistically significant increase in the proportion of men over 55 working less than full time, a jump from 12.6% at the beginning of the study to 17.7% by the end of the study. Women overall were less likely to work full time than men, but their rate did not increase over the study period. In fact, the proportion of women 35 years old or younger who worked less than full time decreased from 29.2% to 11.8% during the study period. “Although the reasons for this trend are unknown, several studies have suggested that the interval of 10 to 20 years after entering practice is a particularly stressful time for physicians, and it is possible that many physicians reduce their workload in response to the distress they experience during this period of their career,” wrote Tait Shanafelt, MD, and colleagues. Dr. Shanafelt is professor of medicine at Mayo Clinic and lead author of the study. In an editorial accompanying the story, Rachel B. Levine, MD, MPH, associate professor of medicine at Johns Hopkins School of Medicine, wrote: “The authors appropriately acknowledge that their study does not provide a complete picture; there are many reasons why physicians may choose to decrease their work effort, and although

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the Shanafelt et al research found an association between burnout and low satisfaction vs decreased effort, causality cannot be fully established. However, their findings provide further compelling evidence that now is the time to address physician burnout and diminished work satisfaction. We are currently facing projected workforce shortages, especially among primary care specialties, at the same time that our population is aging and there is increased demand to care for newly insured patients.” Last year’s Cejka Search survey reported 9 out of 10 physician respondents wanting to change jobs, cut back, or leave medicine. This, along with the longstanding issue of burnout, compounds concerns around the physician shortage, according to an article by Health Leaders Media. “These results have important repercussions for healthcare organizations seeking to maintain a productive and engaged physician workforce,” says Dr. Shanafelt. “Burnout is, in large part, a system issue. Organizational efforts to address the problem must address the drivers of burnout, including problems with excessive workload, inefficiency in the practice environment, loss of flexibility and control over work, and barriers to healthy work-life integration.” The AMA offers several online modules through its STEPS Forward collection of practice improvement strategies to help physicians in practice and physicians in training recognize and address burnout. These modules cover preventing resident and fellow burnout, preventing physician burnout and improving physician resiliency.

Physician Burnout:

Healing Healers the

PRACTICING MEDICINE HAS NEVER BEEN AN EASY CAREER, but todayâ&#x20AC;&#x2122;s healthcare environment has created even greater challenges for physicians, all of which have led to rising physician burnout. While there is a greater awareness of physician and medical student burnout today, the statistics are alarming. Various studies indicate, among other things, that

the physician burnout rate has topped 50% and that doctors are 15 times more likely to burn out compared to professionals in other lines of work. Moreover, 45% of primary care physicians report

that they would quit if they could afford to do so, and the divorce rate among physicians is 10% to 20% greater compared to the general population. The San Mateo County Medical Association, California Medical Association and other groups around the state and country are working hard to address the

issue. In this issue of San Mateo County Physician, we have culled the best expert advice and tips to help physicians understand, identify and manage burnout.

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A personal story The path to burnout About one-third of physicians experience burnout at any given point. Some experts believe that the genesis of negative feelings that doctors experience is multi-fold. High stress levels and dealing with death on a regular basis are two factors that rank high on that list. Physicians are supposed to not only cure but also help heal families when cure is not possible. A lack of control over schedules and time can result in poor sleep patterns, interference with family activities and events, and poor self-care, Elaine Cox, MD, wrote in an article published in US News. For many physicians, setting limits when dealing with sick patients is extremely difficult and often leads to physical and emotional exhaustion, which then translates into cynicism and burnout. Add to that the anguish that comes from living in a litigious society, and doctors are being pushed beyond their limits, she argued. Dr. Cox wrote that the practice of medicine itself may be the main culprit. The pressure starts early. Once the decision is made to pursue a career in medicine, she said, students are expected to excel, sustain long hours and perform while learning to treat patients and be compassionate without getting so emotionally involved that they can’t function. Hence, burnout starts early. According to a recent study, medical students reportedly report a rate of depression that’s 15% to 30% higher than the general population, which can lead to poorer performance, including 6.2 times more medication errors. As healthcare has changed to reflect a business and mission model where doctors are expected to keep up with the latest trends in medicine while watching the financial side, she said, too many physicians become overwhelmed. Yet, even when symptoms of burnout arise, such as fatigue, dissatisfaction and doubt, physicians often hesitate to seek help, for good reason. The fear of losing privileges and their medical licenses when doctors are being treated for substance abuse or depression is a risk too many doctors aren’t willing to take. Consequently, many doctors try to “self-heal” or “self-medicate,” which is usually not a good strategy, Dr. Cox said. Often the help from a colleague out of camaraderie and respect aids in underestimating the severity of the problem.

For one doctor, getting the help he needed to overcome an opiate addiction didn’t come until the state police and DEA sat in his office. Peter Grinspoon, MD, a primary care physician in Boston and instructor at Harvard Medical School, who is also the author of “Free Refills: A Doctor Confronts His Addiction,” wrote an article in the LA Times about his tough journey from losing his medical license to regaining it and now helping other doctors with addiction. Dr. Grinspoon wrote in the article that doctors are prone to drug and alcohol abuse and cited estimated rates of addiction of 10% to 15% among doctors vs. 8% to 10% for the general population. “What appears to account for the difference is physician distress, and in the case of drug abuse, plentiful access,” he wrote. He said in the U.S., practicing medicine has never been easy, but today doctors work longer and faster with less reward, spending as much time battling insurance companies and maintaining electronic medicine as treating patients, which all leads to distress. And when distress is high, he said, humans reach for the relief that’s close – which in the case of doctors translates into a large supply of free samples of pills from drug makers, access to scripts, patients bringing their unused pills into the office, and colleagues willing to write scripts to help, all of which makes prescription drug abuse the obvious choice. He cited a 2013 study in the Journal of Addiction Medicine that revealed that 69% of doctors abused prescription medicine to “relieve stress and physical and emotional pain.” He also finds that addicted doctors rarely seek help out of fear of losing their medical license if they come forward. He feels that if state medical boards, made up of doctors, were enlightened to treat addiction as a disease, not as a crime, it could lead more doctors to come out of their shadows of addiction and avoid disasters such as a DUI or getting charged with a serious crime. Though Physician Health Services offers resources for distressed doctors, signing up voluntarily exposes doctors to punishment by the medical board, given that the board works closely with Physician Health Services, he wrote in the article.

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Dr. Grinspoon said he didn’t make use of Physician Health Services until he served two years of supervised court probation, had lost his medical license, lost his marriage and was out of work. Today, Dr. Grinspoon said he has regained his medical license and was asked to join the Physician Health Services as an associate director, helping other addicted doctors. He said that once doctors get the help they need, they often excel at rehab with a 70% to 80% success rate.

Burnout survey of primary care and ER doctors A recent microsurvey by InCrowd, a provider of real-time data reporting for the medical, healthcare, pharmaceutical/ life sciences industries, found that some 200 primary and emergency care physicians, who have been practicing for 10 or more years, reaffirmed a perceived lack by healthcare facilities or practices to take effective steps to address and prevent physician burnout. Out of 200 respondents, 74% reported more needs to be done to address the issue. Key findings included that 57% of physicians in both fields said they experienced burnout; 37% said they felt frustrated at work a few times weekly, or every day; 58% said they were unsure if they would recommend a career in medicine to a child or family member, or knew if they would; and one ER doctor expressed frustration about losing his autonomy and practicing based on metrics that often aren’t patient-centered, or evidence-based.

Implementing change Dr. Cox said for many doctors, recognizing the need to live a healthy lifestyle in every way, including emotionally, is the first step. Helping to identify a more realistic definition of professional commitment, guiding doctors through exercises on limit-setting and conflict-resolution, and instituting reasonable work hours are good places to start.

He cited a 2013 study in the Journal of Addiction Medicine that revealed that 69% of doctors abused prescription medicine to “relieve stress and physical and emotional pain.”

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For many medical students, entering a career to care for others often means putting their own health and well-being on hold. At UC San Francisco, UCLA and UC San Diego, three of the nation’s top-ranked medical schools for research and primary care, medical students pay the price of experiencing burnout, frustration and emotional exhaustion, according to a recent survey and article published in the Daily Bruin. Almost 50% of medical students surveyed for a 2014 study in the journal Academic Medicine reported experiencing burnout vs. 36% of age-matched college graduates. People who experience burnout are emotionally exhausted and express cynicism and detachment toward patients, according to the 22-item Maslach Burnout Inventory, a scale used to quantify and assess levels of burnout. Burnout among medical students often peaks in their third year of medical school. Susan Rosen, MD, a primary care provider and medical director at UC San Francisco’s Student Health and Counseling, told the Daily Bruin that first- and second-year medical students spend time with each other in large lecture-based classes, study together and talk about their problems. But by the time medical students reach their third-year clinical rotations, stress can reach critical levels, she told the Daily Bruin. Rotations expose students to dozens of clinical specialties and help students gain experience at future careers, but working in different clinics where students face strict hierarchies and are constantly reminded that they rank on the bottom rung combined with less time in the classroom with the familiar group can make students feel isolated.

Sue Jacques, a medical and corporate professionalism consultant based in Calgary, Alberta, recommends the following four decisions that medical practitioners can make today to begin lessening their workload and enhance their satisfaction so they don’t feel burned out, according to an article in Diagnostic Imaging. She calls the decisions the four “D’s”:

The Four “D’s”: Delegate

For many physicians delegating is tough, but vital, Jacques said, to avoid stretching themselves too thin. It starts with delegating tasks to staff or colleagues, but also asking patients to come to the practice prepared with a list of symptoms and requests.

Diversify

Diversifying can mean many things, from setting up a specialty clinic like a flu clinic to planning out schedules, budgets and assigning providers and staff members ahead of time.

Decline

Learning to say no and avoiding overcommitting is often hard for physicians, but warranted.

Decompress

Setting aside time for yourself, family and doing the things you love is as important as treating your patients. Another way to stamp out physician burnout is to change up the work environment. Jacques suggests offloading tasks such as dictating a long patient note or struggling with the EHR by using medical scribes instead. Converting to a concierge or direct-pay practice cuts red tape and allows many physicians to spend more time with patients. Finally, joining a physician organization or group practice can help an economy of scale and, as such, reduce stress.

Resources for help The Physicians’ and Dentists’ Confidential Assistance Line is a phone line for physicians, dentists and their families to get help with problems of alcoholism, drug dependence or mental illness within their families. For Northern California, call 650-756-7787.

While there is greater awareness today of physician burnout, everyone agrees that effective prevention tools are not disseminated widely enough and more needs to be done to promote doctors’ well-being on both an individual and organizational level. The 2015 Association of American Medical Colleges survey, which surveyed fourth-year medical students on their experiences, showed that nearly half, or 46.3%, of 13,886 medical students reported they’ve been publicly embarrassed; 19.5% said they’ve been publicly humiliated; 14.1% reported having been exposed to offensive sexist remarks; and 7.3% reported having been exposed to racially or sexually offensive remarks. Lance Raynor, a mental health provider at UC San Francisco’s Student Health and Counseling, said in the article that constant moving from one hospital to another can block students’ access to care and therapy, resulting in problems like social anxiety and frustration. Some students don’t express their frustration and stress out of fear they are formally diagnosed with a mental illness that may go on their medical records, said Jessica Lloyd, the associate program director for the UCLA pediatric residency program. Students also reported being afraid to take days off and mentioning mental and emotional hardship to their attending physician. The California medical licensure application asks residency applicants to disclose mental illness that could hinder their ability to treat patients, and states that it will decide if a student is eligible for a medical license based on the severity of the condition, according to Lloyd. Students’ stress in thinking about their futures and their lack of time to go to therapy appointments create barriers that aren’t easily fixed, Lloyd added.

“Students’ stress in thinking about their futures and their lack of time to go to therapy appointments create barriers that aren’t easily fixed,”

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Rosen agreed that, at UC San Francisco, students also aren’t comfortable telling their supervisors about their therapy sessions and appointments out of fear it may affect their performance grades and letters of recommendations for residency programs. As part of therapy, Raynor said he’ll assign students to visit landmarks like Coit Tower on top of Telegraph Hill in San Francisco during a weekend to change up the pace. Many medical students have never even toured the city, he said in the article, because they’ve been so focused on their studies. Rosen, who also sees students who complain of burnout, said that when students break their routine long enough, they come back refreshed and ready to go about their studies and clinical work. Burnout and depression among medical students can be prevented if medical schools acknowledge the stigma around mental health issues and work with staff to ensure that medical students are being treated properly.

All three medical schools have existing programs to try to help medical students. At UCSF, the Medical Student Well-Being Program works exclusively with medical students, faculty and staff and offers special evening appointments to accommodate students’ busy schedules. At UC San Diego School of Medicine, an online diagnostic system, called the Healer Education Assessment and Referral Program, seeks out and screens at-risk medical students who may not have the time or energy to travel to the main campus. UCLA David Geffen School of Medicine offers medical students appointments at Counseling and Psychological Services, an on-campus facility, and offers access to a school-affiliated psychologist, according to the article. But medical students reported that more needs to be done to help students cope. Capping resident hours to 80 hours a week, treating medical students with dignity and respect, and not expecting them to know procedures they weren’t taught, were some of the suggested solutions by medical students. Facilitating procedures that would allow for honest communication between physicians and medical students was also mentioned as well as UC medical schools starting a conversation on how to improve and implement programs for mental wellness among students.

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CALIFORNIA MEDICAL ASSOCIATION

PRACTICE MANAGEMENT:

TIP OF THE MONTH

Make sure your billing staff are aware of the prohibitions on balance billing Medi-Medi patients. Both state and federal law provide broad protections to such individuals, and prohibit billing a Medi-Cal patient in most circumstances. Running afoul of these laws can put you at risk of a CMS audit and sanctions. For more information on this topic, see “Ask the Expert: Billing Medi-Medi patients,” free to members at www.cmanet.org/ces.

CMA’s online health law library contains thousands of pages of On-Call documents in hundreds of chapters containing valuable information for physicians and their staff. Access to the library is free to members in the resource library at www.cmanet.org/cma-on-call or by calling CMA’s member help center, (800) 786-4262. Nonmembers can purchase documents for $2 per page.

TROUBLE GETTING PAID? WE CAN HELP! CMA’s Center for Economic Services (CES) is staffed by a team of practice management experts with a combined experience of over 125 years in medical practice operations. Our goal is to empower physician practices by providing resources and guidance to improve the success of your practice. Access to our reimbursement experts is a FREE, members-only benefit. Call (800) 786-4262 or email economicservices@cmanet.org. Meet Your Advocate: Jennifer Williams

Jennifer Williams, who has spent the last 12 years with CMA, currently serves as the Center for Economic Services’ executive assistant, meaning that she’s the first point of contact for practices in need of reimbursement assistance or practice management advice.

A lot of practices think we’re too busy to answer questions or don’t want to ‘bother’ us with what they think is a ‘silly’ question. Please don’t wait to call us. We’re here to Jennifer Williams, CES Executive Assistant help our members; it’s our job.” TO OPT OUT OF FUTURE NOTICES, EMAIL MEMBERSERVICE@CMANET.ORG OR FAX (916) 551-2036. BE SURE TO INCLUDE THE FAX NUMBER YOU WANT REMOVED. S EP T E M B ER 2016 | S A N M AT E O C O U N T Y P H Y S I C I A N 11

IMQ 2016 Medical Staff Conference Registration Is Open! The IMQ 2016 Medical Staff Conference on October 27 at the Embassy Suites SFO (Gateway) Hotel in South San Francisco will deliver the information, solutions and best practices that physicians need to successfully lead their medical staffs. The Conference will tackle some of the difficult decisions that face medical staffs, such as credentialing, granting privileges, proctoring practitioners for remote technology (telemedicine) and privileging policies for the new technology. It also will tackle the difficult issue of the aging physician and how a hospital can best identify, craft and implement policy to appropriately utilize the Well Being Committee to assist with issues surrounding aging physicians. Through examples and discussion, faculty will demonstrate how they can best position the medical staff to modernize quality improvement and update peer review systems. The Conference also will provide an update on Joint Commission standards and discuss standards that are most often found noncompliant. Ashby Wolfe, MD, Chief Medical Officer of CMS Region IX, will discuss CMS initiatives related to patient safety, quality reporting and electronic medical record usage. The conference has been approved for 5.5 AMA PRA Category 1 creditTM as well as 5.5 NAMSS credit. If you are a Physician, Hospital Leader, Medical Staff Director, Credentialing Specialist, or Quality Improvement professional, you want to attend this one day course that addresses the critical challenges facing your medical staff. Early bird rates and CMA member discounts are available. For more information and to register, please visit our website at www.imq.org or contact:

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