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Impact of Coping and Communication Skills Program on Physician Burnout, Quality of Life, and Emotional Flooding

Impact of Coping and Communication Skills Program on Physician Burnout, Quality of Life, and... Safety and Health at Work 9 (2018) 381e387 Contents lists available at ScienceDirect Safety and Health at Work journal homepage: www.e-shaw.org Original Article Impact of Coping and Communication Skills Program on Physician Burnout, Quality of Life, and Emotional Flooding 1, 1 2 1 Jennifer K. Penberthy , Dinesh Chhabra , Dallas M. Ducar , Nina Avitabile , 1 1 1 1 3 Morgan Lynch , Surbhi Khanna , Yiqin Xu , Nassima Ait-Daoud , John Schorling Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA Department of Nursing, University of Virginia School of Nursing, Charlottesville, VA, USA Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA art i cle i nfo abstract Article history: Background: Physician behaviors that undermine a culture of safety have gained increasing attention as Received 20 April 2017 health-care organizations strive to create a culture of safety and reduce medical errors. We developed, Received in revised form implemented, and assessed a course to teach physicians skills regarding effective coping and interper- 22 December 2017 sonal communication skills and present our results regarding outcomes. Accepted 26 February 2018 Methods: We examined a professional development program specifically designed to address unpro- Available online 3 March 2018 fessional or distressed behaviors of physicians, and we evaluated the impact on burnout, quality of life, and emotional flooding scores of the physicians. Assessments of burnout, quality of life, and emotional Keywords: flooding were assessed preintervention and postintervention. Coping skills Results: Results demonstrated statistically significant reductions over time in physicians’ emotional Communication flooding and emotional exhaustion (EE). Specifically, using a Wilcoxon Signed-Rank test, results revealed Professional burnout Physicians that flooding scores at follow-up were statistically significantly lower than at baseline, V ¼ 590, p < 0.05, and EE and personal accomplishment distributions were found to significantly deviate from normal as indicated by ShapiroeWilks tests (p < 0.05). A Wilcoxon signed-rank test indicated that EE scores were significantly higher at baseline compared to follow-up 1, V ¼ 285, p < 0.05. Conclusion: We conclude that the physician participants who enrolled in the educational skills training program improved scores on emotional flooding and EE and that this may be indicative of improved skills related to their experiences and learning in the program. These improved skills in physicians may have a positive impact on the overall culture of safety in the health system setting. 2018 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction national survey, 54% of practicing physicians met criteria for burnout [2]. It should be noted that the issue of distress affects Physician behaviors that undermine a culture of safety have nearly every group of physicians ranging from interns [3,4] to gained increasing attention as health-care organizations strive to department chairs [5]. These ever-growing strains, coupled with a create a culture of safety and reduce medical errors. Physicians, competitive and demanding work environment, have led to among other health providers, are experiencing increasing numerous negative psychological consequences including burnout amounts of stress in today’s workforce. They are confronted with and in some cases, suicide [6]. Awareness of distress has resulted in constraints of fewer resources, increasing government regulations, more frequent reports of distress, encouraging many health-care greater patient outcome expectations, and rising student debt [1]. organizations to respond by creating a “healthy work environment”. Also many have expressed dissatisfaction with the decreasing Although this systematic problem has been recognized for years, amount of time allocated to each patient and consider their specialized programs to reduce stress and mitigate burnout levels workload “too heavy”. In a 2014 American Medical Association in physicians are still relatively rare. It is not only important to * Corresponding author. Psychiatry & Neurobehavioral Sciences, PO Box 800623, Department of Psychiatry, Univeristy of Virginia School of Medicine, Charlottesville, VA 22908, USA. E-mail address: jkp2n@virginia.edu (J.K. Penberthy). 2093-7911/$ e see front matter  2018 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC- ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.shaw.2018.02.005 382 Saf Health Work 2018;9:381e387 identify those who suffer within the workplace but also to ensure cause of the recent rise in incidence. If this issue remains unad- the distressed individuals are actively invited to be cared for. The dressed, it will jeopardize the sustainability of health care. importance of this point is made evident in a 2012 study revealing The shortage of nurses in today’s era is a relevant concern in the that 78.3% of the distressed physicians surveyed had not previously rise of unprofessional physician behaviors. Physician behavior has thought about seeking professional help for depression or burnout been cited as a significant factor contributing to nurse dissatisfac- [7]. tion and morale. In a survey conducted in 2001e2002 of 1200 Unprofessional and distressed behaviors among physicians are nurses and physicians, 31% responded that they knew of a nurse unfortunately not uncommon. Disruptive behavior by a physician who had left their hospital because of physicians’ unprofessional has been defined by the Federation of State Medical Boards (2000) behavior, with an average of 2.4 nurses leaving each year for this as “aberrant behavior manifested through personal interaction reason [13]. The same investigators studied the potential impact of with physicians, hospital personnel, health-care professionals, pa- unprofessional behavior in the perioperative setting in an academic tients, family members, or others, which interferes with patient medical center and found that of 244 respondents (46%), including care or could reasonably be expected to interfere with the process physicians, nurses, and other employees, were aware of a potential of delivering quality care.” This can include behavior ranging from adverse event from unprofessional behavior [14]. In a recent survey active verbal abuse, physical threats, and actions to more passive of over 4500 participants (predominantly nurses and doctors) from actions, such as refusing to perform assigned or expected tasks. The 102 hospitals conducted from 2004 to 2007 [11], 94% responded Joint Commission on Accreditation of Healthcare Organizations that unprofessional behavior sometimes, frequently, or constantly (2009) issued a new leadership standard that addresses unprofes- leads to stress and frustration; 89% noted reduced team collabo- sional and inappropriate behaviors, which requires that “the hos- ration; 91% noted reduced communication; and 99% indicated pital/organization has a code of conduct that defines acceptable impaired nurseephysician relationships. In terms of awareness of and unprofessional and inappropriate behaviors” and “leaders the consequences of unprofessional behavior, 67% of respondents create and implement a process for managing unprofessional and thought that unprofessional behavior was linked to adverse events, inappropriate behaviors.” Additionally, as of January 1, 2001, The with 71% of this group believing that such behavior led to errors, Joint Commission also mandated that all hospitals have a process to and 51% believing that such behavior led to reduced patient safety. address physician well-being, separate from disciplinary processes. Furthermore, 18% were aware of a specific adverse event that There are strong links between a physician’s levels of distress occurred directly because of unprofessional behavior. In summary, and their likelihood to display unprofessional behavior. A national unprofessional behavior can violate principles of medical profes- survey reported that US physicians suffer more burnout than other sionalism, undermine morale, decrease retention, decrease effi- American workers [8]. It has also been reported that 46% of all ciency, consume resources, and threaten patient safety [15,16]. physicians responded that they had burnout [9], which speaks to the ubiquity of burnout among physicians. In another survey con- 1.2. Risk factors and patterns of behavior ducted in 2004, 79% of physician executives indicated that prob- lems with physician behavior occurred within their organizations Physicians are under increased stress from working in an envi- more than 3e5 times a year. Disrespect was the most common ronment of declining reimbursement that requires increased pro- behavior noted (83%), but refusal to complete tasks, yelling, and ductivity just to attain financial stability. In addition, there is also insults were also common. Overall, 70% indicated that physician more pressure to practice in specific ways, such as adhering to behavior problems nearly always involve the same physicians, guidelines and pathways that limit physician autonomy. Stress, meaning that modifications to the behavior of a relatively small addiction, psychological suffering, and personality disorders may number of individuals could lead to considerable changes also contribute to unprofessional behavior. Among 38 physicians throughout the whole workforce and work environment [10].Ina referred to a specialized program for unprofessional behavior at survey among veterans health administration hospitals, a national Vanderbilt University, 16% were categorized as having high sub- alliance of more than 1400 not-for-profit hospitals, a total of 77% of jective distress, primarily because of depression and anxiety; 19% respondent health-care workers had witnessed unprofessional had characterological (personality) features, and 61% had normal behavior among physicians. Specialized physicians were found to profiles, based on the Minnesota Multiphasic Personality be more unprofessional, with general surgeons being most Inventory-2 [17]. In some cases, substance use disorders may frequently identified as likely to exhibit unprofessional behavior underlie unprofessional behavior, although the physician execu- (26%), followed by neurosurgeons (20%), cardiovascular surgeons tives in the survey discussed above believed that less than 10% of (13%), and orthopedic surgeons (10%) [11]. These surveys reveal episodes were due to substance abuse [10]. that negative and unprofessional physician behaviors are common Despite the aforementioned consequences of unprofessional to a majority of health-care settings, are usually concentrated to a behaviors, many rationalizations can be construed to justify ac- small number of individuals, and are more common in some spe- tions. Behaviorally unprofessional physicians may rationalize their cialties versus others. Moreover, they also reveal that health-care reactions as natural responses that are based on their commitment settings are in need of an effective maintenance and ideally pre- to their work and their unwillingness to compromise patient care, ventative process to deal with problematic physician behaviors. according to their perceptions, with the lower standards of others [16]. Although holding high standards is appropriate, the responses 1.1. Consequences of these physicians are not appropriate, because they may be adversely affecting the quality of care. Often underlying this stance Distressed or unprofessional behavior among physicians is are compulsive personality traits combined with a lack of linked to a number of negative consequences including: poorer care emotional intelligence. Many physicians exhibit compulsive traits, collaboration, patient dissatisfaction, and increased medical errors. especially what has been called the “compulsive triad” of self- These facets of poor quality health care are strongly linked to doubt, guilt, and an exaggerated sense of self-importance [18]. burnout. A recent meta-analysis of 82 studies revealed that there is Self-doubt often results from having excessively high personal an inverse correlation between burnout and quality of care [12].Itis standards, common in many physicians, that are often so high that therefore important to further investigate the prevalence of un- the standards are difficult, or impossible, to achieve. Given these professional behaviors, their consequences, and to ascertain the high self-expectations, such physicians often impose equally high J.K. Penberthy et al / Physician Burnout 383 standards on others and react strongly if colleagues or staff fails to professionals over a decade ago [21]. Partially in response to the meet them. Among unprofessional physicians, these traits may be data reviewed above and the need for services for distressed and coupled with low emotional intelligence, which refers to how well unprofessional physicians in our own University hospital, the Uni- they understand and are able to regulate themselves (self-aware- versity of Virginia School of Medicine and Health System, we ness and self-regulation) and indicates their ability to read and collaborated with Vanderbilt University Medical Center for Profes- respond appropriately to others (social awareness and relationship sional Health to develop a program to help educate and train phy- management) [19]. Cultivating emotional intelligence requires sicians to improve their coping and interpersonal communication introspection and an understanding of what one is feeling in the skills. This University of Virginia School of Medicine continuing moment to respond appropriately. Lack of these skills can lead to medical education (CME) program is called “Effective Coping and “flooding,” an overwhelming emotional response to a situation Communication Skills (ECCS) for Physicians” and includes 3 initial over which an individual has little control. Flooding is a state of consecutive days of training followed by three follow-up 1-day negative feelings which virtually overwhelm the individual and trainings at 1, 3, and 6 months for a total of up to 48 hours of AMA make lead to irrational behaviors. Flooding has been described as PRA Category 1 Credit(s). Professional practice gaps identified as something akin to being “emotionally high-jacked” in that one’s areas to be addressed through this CME activity/series include: emotions are so strong that they are no longer under the logical physician difficulty in effective interpersonal communica- control of the individual. tiondboth verbal and nonverbal and anger and stress management, including relaxation and mindfulness skills. Other areas include awareness of interpersonal impact on others, including boundary 1.3. Strategies for change issuesdfocusing on professionalism, effective goal setting, and organizational skills with a focus on system-based practices. The modern health-care system may benefit from an increased The University of Virginia Effective Coping and Communication focus on physician well-being and how to achieve and sustain it Skills for Physicians Continuing Medical Education (UVA ECCS CME) within the stressful field of health care, as well as strategies to help course has an emphasis on assessment and feedback to identify transform the health-care system to allow sustained engagement. skill deficits and promote skill enhancement. The course includes Well-being should be considered as more than simply the absence assessments at the onset and at 1-, 3-, and 6-month follow-ups. of distress. Programs teaching mindfulness, effective communica- These assessments will be discussed in more detail below and tion skills, and stress reduction techniques may be key in helping to include a 360 degree evaluation component where the physicians establish a resilience and effective group of health-care workers. In are assessed by team members of their choosing, including other addition to these interventions, longitudinal studies examining physicians, nurses, support staff, and administrators. In this study, both physician distress and well-being are needed to identify and we focus on the self-assessments of emotional flooding, burnout, implement the interventions that have been proven successful. and quality of life. The course materials are provided to the par- Physician engagement in a mindful communication program is ticipants in a binder to keep. The core curriculum components are associated with both short- and long-term physician well-being outlined in Table 1 and include: motivational interviewing strate- and attitudes associated with patient-centered care. This and gies to help clarify ambivalence and advance readiness to change; other mindfulness-based programs for physicians have reduced education and practice of effective interpersonal communication burnout levels [20]. As part of this effort, we developed, imple- skills; education regarding empathy and compassion, including mented, and assessed a course to teach physicians skills regarding interpersonal mindfulness skills; coping skills; stress reduction and effective coping and interpersonal communication skills and mindfulness strategies; cultural awareness skills; anger manage- examined the impact of such on measures of well-being including ment; boundary awareness; and assertiveness training; as well as burnout, quality of life, and emotional flooding tendencies. We strategies to build resilience, reduce vulnerability to burnout, and hypothesized that such training would lead to increased quality of increase self-care. Participants engage in role-play as well as self- life and decreases in scores of burnout and flooding. reflection, discussion, and small group activities. 2. Materials and methods 2.2. Participants The ECCS for Physicians Program is approved to provide Forty-six participants were enrolled into groups of 2e8 physi- continuing medical education and is also approved by the UVA cians who meet together for the course. When the participants Institutional Review Board. A referred individual initially un- arrived for the first day of the program, they were oriented and dergoes a brief phone screen to ensure eligibility, which includes provided an Institutional Review Boardeapproved consent form identifying if there are issues regarding substance abuse, boundary from the University of Virginia for review and signature. Ques- violations, or prescription writing concerns. These issues are not tionnaires were then administered, including basic demographics, addressed in our program and if one or more of these are identified readiness to change scale [22], emotional flooding questionnaire as the primary or a significant concern then the professional is [23], the Professional Quality of Life questionnaire (ProQOL) [24], referred elsewhere. Once the professional is deemed appropriate the Maslach Burnout Inventory (MBI) [25], and the Beck Depression for the program, they are oriented to the program goals and re- Inventory (BDI) [26]. The program then commenced with in- quirements. The course is taught by three senior faculty clinicians, troductions and orientation to the program and materials and who have extensive clinical experience working with professional completion of the assessment materials. Once these were health-care providers. completed, the course didactic and interactive components began. 2.1. Intervention program: description 2.3. Assessments A few university medical centers and schools have created programs to assess and help physicians determined to be demon- Readiness to change: The purpose of a readiness to change as- strating distressed or unprofessional behavior. Vanderbilt Univer- sessments is to analyze the level of preparedness of the person to sity developed a comprehensive assessment program for make changes. The greater the complexity of the proposed change, 384 Saf Health Work 2018;9:381e387 Table 1 change they were in, and how long they had been working to 3-day program agenda. change. We assessed for readiness to change to reduce both their Day 1: (9 am to 5 pm) overall stress and anger. Introduction and welcome Emotional flooding: We assessed emotional flooding using a Orientation to program and materials modified version of Gottman’s flooding scale [23], which was originally designed to use with couples. The scale assesses the Review confidentiality tendency or proneness to flood emotionally in interpersonal situ- Rules of engagement Why you are here: sharing your story of how you got to this program ations and has been associated with unprofessional behavior. Clarification of ambivalence (decisional matrix, identifying emotion) Professional Quality of Life Questionnaire: The ProQOL [24] is Break for lunch the most commonly used measure of the negative and positive Why you are in medicine: sharing your story of how you got to the field of effects of helping others who experience suffering and trauma. The medicine ProQOL consists of subscales for compassion satisfaction, burnout, and compassion fatigue. The journey and goals of a career in medicine: what are your goals? Maslach Burnout Inventory: Burnout was measured using the Identification of key issues/goals for individuals and the group Introduction to effective interpersonal communication skills MBI, a validated 22-item questionnaire considered a standard tool Factors impacting coping and communication (thoughts, emotions, and for measuring burnout. The MBI has 3 subscales to evaluate the behaviors: perception group exercises; interpersonal impact exercises) three domains of burnout: emotional exhaustion (EE), deperson- Assign homework: complete, genogram, interpersonal inventories for alization, and low personal accomplishment (PA). A high score on review on Day 2 Summary, feedback/questions, emotional check-in, and adjourn the EE or depersonalization scales or a low score on PA can be considered a symptom of the burnout syndrome. We considered Day 2: (9 am to 5 pm) participants with a high score using cut-offs for medical pro- Review of assessments fessionals on either the depersonalization and/or EE subscales as having at least one manifestation of professional burnout. Review and genogram homework Beck Depression Inventory: The BDI is a 21-item self-report Introduction to effective communication skills and how they translate measure of attitudes and symptoms frequently displayed by into effective interpersonal interactions and behaviors and goal achievement depressed patients. Respondents rate items on 0 to 3 scales, with The role of empathy higher scores indicating greater depression. Data analysis participants were not always able to attend every Break for lunch Review interpersonal inventories and impact on interactions follow-up session, in which case data were not collected. Addi- tionally, all questionnaires were not given at each visit. Only those Group exercise/role-play stressful situations questionnaires given at both baseline and follow-up 1 data were Stress management: preventing, reducing, and coping with stress analyzed. We used the scores on readiness to change and the BDI to Progressive muscle relaxation (PMR)dgroup exercise Mindfulness trainingdgroup exercise evaluate the characteristics of the physicians at the time they One moment mindfulness initiated the program. Basic descriptive statistics were calculated Assign homework: practice mindfulness exercise or PMR; complete for these assessments. We compared scores on the emotional anger management inventories; cultural awareness materials flooding, Professional Quality of Life, and Maslach Burnout ques- Summary, feedback/questions, emotional check-in, and adjourn tionnaires from time 1 at the beginning of the program to time 2 which was 1 month after the end of the 3-day program. We hy- Day 3: (9 am to 5 pm) pothesized that scores on the emotional flooding scale would be Check-in and review of homework assignments significantly reduced at time 2 when compared to time 1. We hy- The role of cultural and social awareness pothesized that physician burnout scores would be significantly Review of interpersonal boundaries and sexual harassment issues improved from time 1 to time 2. We specifically hypothesized that Anger management and self-controldgroup exercise the scores on the MBI emotional exhaustion and depersonalization Assertiveness trainingdgroup exercises subscales would be significantly reduced from time 1 to time 2, and Role-play interpersonal situations brought in by group membersdrole- play the scores on the personal accomplishment subscale would in- crease significantly. Finally, we hypothesized that on the Profes- Break for lunch Feedback on role-plays and lessons learneddgroup exercise sional Quality of Life assessment, the burnout scores would significantly improve from time 1 to time 2. Analyses were per- Importance of exercise and diet in self-care formed in R 3.2.2 [28] using the g-data, graphics, and stats packages Reducing burnout and improving job satisfaction for calculating statistics, creating plots, and performing analyses Review of resilience [29]. Increasing positive interpersonal and communication skillsdgroup exercise Relapse prevention and maintaining progress 3. Results Summary, feedback/questions, emotional check-in, and completion of postassessment questionnaires Since its inception in 2011, the University of Virginia School of How to claim your CME Medicine’s ECCS program has enrolled 46 medical professionals from many departments at locations from across the United States. CME ¼ continuing medical education. The specialties with the most enrollees have been surgery and obstetrics and gynecology (Table 2). Of the 46 physicians enrolled, 73% were male and 27% female. At the beginning of the program, the greater the importance of understanding whether and where physicians averaged a flooding score 8.7, indicative of a proneness there is readiness for change as this can be critical first for deciding to emotional flooding during conflict, and an average BDI score of 9, whether the person is motivated to work for change. We used a which is classified as within the range of normal ups and downs modified version of the readiness to change questionnaire [27] to and not indicative of significant depression. At baseline, most assess if the participant was working toward change, what stage of physicians were in the action stage of change and had been J.K. Penberthy et al / Physician Burnout 385 Table 2 Physician specialty. Specialty Enrollees Radiology 3 (7%) Radiation oncology 1 (2%) Pediatrics 1 (2%) Surgery (general) 10 (22%) Ophthalmology 1 (2%) Obstetrics and gynecology 6 (13%) Surgery 8 (17%) Urology 1 (2%) Anesthesiology 4 (9%) Internal medicine 3 (7%) Nephrology 1 (2%) Neurology 1 (2%) Hematology and oncology 1 (2%) Cardiology 1 (2%) Emergency medicine 2 (4%) Family medicine 1 (2%) Fig. 1. Average flooding scores over the course of ECCS program. Pathology 1 (2%) ECCS ¼ Effective Coping and Communication Skills. Table 4 attempting to reduce the amount of stress in their life, but for less MBI burnout indices among ECCS enrollees at each visit. than 6 months. Physicians also endorsed being between the Burnout indices Baseline Follow-up 1 Follow-up 2 Follow-up 3 maintenance and action stages of change regarding changing their Emotional exhaustion anger and had been attempting to reduce their angry or acting out 1. Mean score 20.3 19.5 20.5 17.1 behaviors in their life, but with little success. Table 3 provides a 2. Low score 20 (50%) 15 (48%) 10 (43%) 8 (53%) breakdown of stage of readiness to change responses of the 3. Moderate score 7 (17%) 5 (16%) 5 (22%) 3 (20%) physician participants at baseline. 4. High score 13 (33%) 11 (36%) 8 (35%) 4 (27%) Depersonalization 3.1. Emotional flooding 1. Mean score 7.1 7.4 8.3 7.8 2. Low score 24 (60%) 16 (52%) 11 (48%) 8 (53%) Emotional flooding scores were predicted to be significantly 3. Moderate score 7 (18%) 8 (26%) 5 (22%) 3 (20%) decreased as a result of the course. Using the ShapiroeWilk test of 4. High score 9 (22%) 7 (22%) 7 (30%) 4 (27%) normality, we tested the null hypothesis that flooding scores came Personal accomplishment from a normally distributed population; results indicated that the 1. Mean score 39.9 39.9 40.3 41 distribution deviated from normal (p < 0.05). A Wilcoxon Signed- 2. High score 28 (70%) 19 (61%) 15 (65%) 13 (87%) Rank test indicated that flooding scores at baseline were statisti- 3. Moderate score 7 (18%) 8 (26%) 5 (22%) 0 (0%) cally significantly higher than flooding scores at follow-up 1, 4. Low score 5 (12%) 4 (13%) 3 (13%) 2 (13%) V ¼ 590, p < 0.05. Furthermore, flooding scores show an overall MBI missing 5 14 22 30 decreasing trend from each follow-up visit (Fig. 1). ECCS ¼ Effective Coping and Communication Skills; MBI ¼ Maslach Burnout Inventory. 3.2. Burnout * Low, moderate, and high scores calculated using MBI scoring guidelines. We predicted that physician burnout scores would be signifi- cantly improved from the beginning of the course to the first t ¼ 1.65, p > 0.05. Table 4 provides a comprehensive summary of follow-up session. Of particular interest to this program were the MBI scores at each time point. EE and PA submeasures of the MBI, and the burnout submeasure of ProQoL. Both the EE and PA submeasure distributions were found to significantly deviate from normal as indicated by ShapiroeWilks 4. Discussion/conclusion tests (p < 0.05). A Wilcoxon Signed-Rank test indicated that EE scores were significantly higher at baseline compared to follow-up The present study predicted that engagement in the ECCS pro- 1, V ¼ 285, p < 0.05. A Wilcoxon Signed-Rank test indicated that PA gram would teach stress management skills that focused specif- was not significantly improved as a result of the program, ically on reducing emotional arousal, improving interpersonal V ¼ 140.5, p > 0.05. The burnout submeasure distribution of ProQoL communication awareness, and improving self-care skills, thereby was not found to significantly deviate from normal, so a paired t eventually reducing burnout overall, specifically decreasing EE and test was conducted. A paired t test revealed that ProQoL burnout increasing PA. The impact upon outcomes was assessed by scores were not significantly improved as a result of the course, emotional flooding, burnout, and quality of life at work. Our Table 3 Stage of readiness to change (RtC) baseline responses. Readiness to Change Maintenance stage Action stage Preparation stage Contemplation stage Precontemplation stage RtCdstress 21 (46%) 18 (40%) 3 (7%) 1 (2%) 2 (4%) RtCdanger 28 (62%) 15 (33%) 1 (2%) 0 (0%) 1 (2%) 386 Saf Health Work 2018;9:381e387 hypotheses were partially supported, in that engagement in the of assessments to a reasonable amount, there were still multiple program appears to result in a significant decrease in EE scores and and possibly redundant questions. The hypothesis of this current significantly sustained decrease in average flooding scores. program was that gains in emotional regulation and effective self- The reduction in flooding may represent a change in self- management would result in improved functioning as evidenced control, self-awareness, and emotional intelligence. Negative on emotional flooding measures and measures of burnout and affectivity, anger, emotion regulation, and emotional expressivity quality of life. We found some support for this but are not able to have all been associated with flooding and observed in those with make conclusive summaries or link actions to outcomes directly. compulsive personality traits [30]. The reduction in flooding scores The present study has only partially revealed the impact of teaching indicates increased emotional awareness. This result may have such skills to clinicians exhibiting unprofessional behavior. Future occurred due to the nature of the intervention, an opportunity to research should be conducted to explore the temporal relationship focus on self-care, and interpersonal communication awareness. between teaching stress reduction and burnout amelioration; and Simply attending group-based therapeutic interventions can be the role of improving mood and mindful awareness in this rela- insightful for those who rarely confront their own behavior. Spe- tionship. Finally, further research should directly measure how cifically, for those with compulsive personality traits, awareness of programs such as ECCS impact institutional factors relevant to the dynamic nature of modern health care may allow for one to flooding and burnout, as this has the potential to reveal how in- break free from rigid perceptions and cognitively reframe their dividual and interpersonal changes impact larger occupational situations. This cognitive reframing may allow one to reassess their systems as a whole. own reactions and to effectively practice emotional control when Further research is needed to ascertain what role a reduction in flooding occurs and keep impulses in check. In a health-care flooding and, thereby, an increase in emotional control and environment, unprofessional behavior can undermine morale, improvement in both interpersonal communication awareness and while also decreasing collaboration, retention, and patient safety. self-awareness have on burnout. There is a complex interaction While unprofessional behavior is correlated with burnout, the between individual, interpersonal, and institutional factors, which relationship between the two is unknown. What is known is that remains unclear. We do not yet understand which of the three di- three categories of causes of burnout exist: individual, interper- mensions has the greatest importance nor do we know how one sonal, and institutional [31]. Increased emotional control and self- affects the other. Specifically, additional research regarding the awareness would likely affect one’s perception and relationship impact of programs such as ECCS, among populations of clinicians with others. Moreover, it is likely that gains in both of these do- with unprofessional behavior, is likely to reveal how teaching these mains could result in a decrease in all three causes of burnout. If an skills can reduce burnout overall. In regard to this population, individual experiences changes in their ability to cope with additional research investigating the long-term effects of this stressful situations (decreased flooding), this can foster improved program on burnout and flooding may have the potential to reveal interpersonal relations and even affect the institution as a whole. a relationship between the two. Additional research should also be EE decreased significantly as a result of the intervention, which directed to colleagues of unprofessional clinicians to ascertain the may indicate that this intervention has particular success in wide-reaching impact of such programs. attending to emotions and altering one’s perception of said emo- tions. This measure examines feelings of being emotionally over- Conflicts of interest extended and exhausted by one’swork [32]. These results illustrate that the reduction of flooding may not simply be due to emotional The authors have no conflict of interest. control but further evidence of internalizing the teachings of this program and cognitively reframing one’s relationship with one’s References reactions. Importantly, significant changes were not observed in the PA submeasure of MBI. It could be hypothesized that PA is more [1] Privitera MR, Rosenstein AH, Plessow F, LoCastro TM. 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Psychological climate and individual factors as ante- [22] Nigg CR, Burbank P, Padula C, Dufresne R, Rossi JS, Velicer WF, Laforge RG, cedents of work outcomes. Eur J Work Organ Psychol 2008;17:33e54. Prochaska JO. Stages of change across ten health risk behaviors for older [34] Parker CP, Baltes BB, Young SA, Huff JW, Altmann RA, Lacost HA, Roberts JE. adults. Gerontologist 1999;39:473e82. Relationships between psychological climate perceptions and work out- [23] Gottman JM. The roles of conflict engagement, escalation, and avoidance in comes: a meta-analytic review. J Organ Behav 2003;24:389e416. marital interaction: a longitudinal view of five types of couples. J Consult Clin [35] Bedi A, Courcy F, Paquet M, Harvey S. Interpersonal aggression and burnout: Psychol 1993;61:6e15. the mediating role of psychological climate. Stress Health 2013;29:350e9. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Safety and Health at Work Pubmed Central

Impact of Coping and Communication Skills Program on Physician Burnout, Quality of Life, and Emotional Flooding

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Safety and Health at Work 9 (2018) 381e387 Contents lists available at ScienceDirect Safety and Health at Work journal homepage: www.e-shaw.org Original Article Impact of Coping and Communication Skills Program on Physician Burnout, Quality of Life, and Emotional Flooding 1, 1 2 1 Jennifer K. Penberthy , Dinesh Chhabra , Dallas M. Ducar , Nina Avitabile , 1 1 1 1 3 Morgan Lynch , Surbhi Khanna , Yiqin Xu , Nassima Ait-Daoud , John Schorling Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA Department of Nursing, University of Virginia School of Nursing, Charlottesville, VA, USA Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA art i cle i nfo abstract Article history: Background: Physician behaviors that undermine a culture of safety have gained increasing attention as Received 20 April 2017 health-care organizations strive to create a culture of safety and reduce medical errors. We developed, Received in revised form implemented, and assessed a course to teach physicians skills regarding effective coping and interper- 22 December 2017 sonal communication skills and present our results regarding outcomes. Accepted 26 February 2018 Methods: We examined a professional development program specifically designed to address unpro- Available online 3 March 2018 fessional or distressed behaviors of physicians, and we evaluated the impact on burnout, quality of life, and emotional flooding scores of the physicians. Assessments of burnout, quality of life, and emotional Keywords: flooding were assessed preintervention and postintervention. Coping skills Results: Results demonstrated statistically significant reductions over time in physicians’ emotional Communication flooding and emotional exhaustion (EE). Specifically, using a Wilcoxon Signed-Rank test, results revealed Professional burnout Physicians that flooding scores at follow-up were statistically significantly lower than at baseline, V ¼ 590, p < 0.05, and EE and personal accomplishment distributions were found to significantly deviate from normal as indicated by ShapiroeWilks tests (p < 0.05). A Wilcoxon signed-rank test indicated that EE scores were significantly higher at baseline compared to follow-up 1, V ¼ 285, p < 0.05. Conclusion: We conclude that the physician participants who enrolled in the educational skills training program improved scores on emotional flooding and EE and that this may be indicative of improved skills related to their experiences and learning in the program. These improved skills in physicians may have a positive impact on the overall culture of safety in the health system setting. 2018 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction national survey, 54% of practicing physicians met criteria for burnout [2]. It should be noted that the issue of distress affects Physician behaviors that undermine a culture of safety have nearly every group of physicians ranging from interns [3,4] to gained increasing attention as health-care organizations strive to department chairs [5]. These ever-growing strains, coupled with a create a culture of safety and reduce medical errors. Physicians, competitive and demanding work environment, have led to among other health providers, are experiencing increasing numerous negative psychological consequences including burnout amounts of stress in today’s workforce. They are confronted with and in some cases, suicide [6]. Awareness of distress has resulted in constraints of fewer resources, increasing government regulations, more frequent reports of distress, encouraging many health-care greater patient outcome expectations, and rising student debt [1]. organizations to respond by creating a “healthy work environment”. Also many have expressed dissatisfaction with the decreasing Although this systematic problem has been recognized for years, amount of time allocated to each patient and consider their specialized programs to reduce stress and mitigate burnout levels workload “too heavy”. In a 2014 American Medical Association in physicians are still relatively rare. It is not only important to * Corresponding author. Psychiatry & Neurobehavioral Sciences, PO Box 800623, Department of Psychiatry, Univeristy of Virginia School of Medicine, Charlottesville, VA 22908, USA. E-mail address: jkp2n@virginia.edu (J.K. Penberthy). 2093-7911/$ e see front matter  2018 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC- ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.shaw.2018.02.005 382 Saf Health Work 2018;9:381e387 identify those who suffer within the workplace but also to ensure cause of the recent rise in incidence. If this issue remains unad- the distressed individuals are actively invited to be cared for. The dressed, it will jeopardize the sustainability of health care. importance of this point is made evident in a 2012 study revealing The shortage of nurses in today’s era is a relevant concern in the that 78.3% of the distressed physicians surveyed had not previously rise of unprofessional physician behaviors. Physician behavior has thought about seeking professional help for depression or burnout been cited as a significant factor contributing to nurse dissatisfac- [7]. tion and morale. In a survey conducted in 2001e2002 of 1200 Unprofessional and distressed behaviors among physicians are nurses and physicians, 31% responded that they knew of a nurse unfortunately not uncommon. Disruptive behavior by a physician who had left their hospital because of physicians’ unprofessional has been defined by the Federation of State Medical Boards (2000) behavior, with an average of 2.4 nurses leaving each year for this as “aberrant behavior manifested through personal interaction reason [13]. The same investigators studied the potential impact of with physicians, hospital personnel, health-care professionals, pa- unprofessional behavior in the perioperative setting in an academic tients, family members, or others, which interferes with patient medical center and found that of 244 respondents (46%), including care or could reasonably be expected to interfere with the process physicians, nurses, and other employees, were aware of a potential of delivering quality care.” This can include behavior ranging from adverse event from unprofessional behavior [14]. In a recent survey active verbal abuse, physical threats, and actions to more passive of over 4500 participants (predominantly nurses and doctors) from actions, such as refusing to perform assigned or expected tasks. The 102 hospitals conducted from 2004 to 2007 [11], 94% responded Joint Commission on Accreditation of Healthcare Organizations that unprofessional behavior sometimes, frequently, or constantly (2009) issued a new leadership standard that addresses unprofes- leads to stress and frustration; 89% noted reduced team collabo- sional and inappropriate behaviors, which requires that “the hos- ration; 91% noted reduced communication; and 99% indicated pital/organization has a code of conduct that defines acceptable impaired nurseephysician relationships. In terms of awareness of and unprofessional and inappropriate behaviors” and “leaders the consequences of unprofessional behavior, 67% of respondents create and implement a process for managing unprofessional and thought that unprofessional behavior was linked to adverse events, inappropriate behaviors.” Additionally, as of January 1, 2001, The with 71% of this group believing that such behavior led to errors, Joint Commission also mandated that all hospitals have a process to and 51% believing that such behavior led to reduced patient safety. address physician well-being, separate from disciplinary processes. Furthermore, 18% were aware of a specific adverse event that There are strong links between a physician’s levels of distress occurred directly because of unprofessional behavior. In summary, and their likelihood to display unprofessional behavior. A national unprofessional behavior can violate principles of medical profes- survey reported that US physicians suffer more burnout than other sionalism, undermine morale, decrease retention, decrease effi- American workers [8]. It has also been reported that 46% of all ciency, consume resources, and threaten patient safety [15,16]. physicians responded that they had burnout [9], which speaks to the ubiquity of burnout among physicians. In another survey con- 1.2. Risk factors and patterns of behavior ducted in 2004, 79% of physician executives indicated that prob- lems with physician behavior occurred within their organizations Physicians are under increased stress from working in an envi- more than 3e5 times a year. Disrespect was the most common ronment of declining reimbursement that requires increased pro- behavior noted (83%), but refusal to complete tasks, yelling, and ductivity just to attain financial stability. In addition, there is also insults were also common. Overall, 70% indicated that physician more pressure to practice in specific ways, such as adhering to behavior problems nearly always involve the same physicians, guidelines and pathways that limit physician autonomy. Stress, meaning that modifications to the behavior of a relatively small addiction, psychological suffering, and personality disorders may number of individuals could lead to considerable changes also contribute to unprofessional behavior. Among 38 physicians throughout the whole workforce and work environment [10].Ina referred to a specialized program for unprofessional behavior at survey among veterans health administration hospitals, a national Vanderbilt University, 16% were categorized as having high sub- alliance of more than 1400 not-for-profit hospitals, a total of 77% of jective distress, primarily because of depression and anxiety; 19% respondent health-care workers had witnessed unprofessional had characterological (personality) features, and 61% had normal behavior among physicians. Specialized physicians were found to profiles, based on the Minnesota Multiphasic Personality be more unprofessional, with general surgeons being most Inventory-2 [17]. In some cases, substance use disorders may frequently identified as likely to exhibit unprofessional behavior underlie unprofessional behavior, although the physician execu- (26%), followed by neurosurgeons (20%), cardiovascular surgeons tives in the survey discussed above believed that less than 10% of (13%), and orthopedic surgeons (10%) [11]. These surveys reveal episodes were due to substance abuse [10]. that negative and unprofessional physician behaviors are common Despite the aforementioned consequences of unprofessional to a majority of health-care settings, are usually concentrated to a behaviors, many rationalizations can be construed to justify ac- small number of individuals, and are more common in some spe- tions. Behaviorally unprofessional physicians may rationalize their cialties versus others. Moreover, they also reveal that health-care reactions as natural responses that are based on their commitment settings are in need of an effective maintenance and ideally pre- to their work and their unwillingness to compromise patient care, ventative process to deal with problematic physician behaviors. according to their perceptions, with the lower standards of others [16]. Although holding high standards is appropriate, the responses 1.1. Consequences of these physicians are not appropriate, because they may be adversely affecting the quality of care. Often underlying this stance Distressed or unprofessional behavior among physicians is are compulsive personality traits combined with a lack of linked to a number of negative consequences including: poorer care emotional intelligence. Many physicians exhibit compulsive traits, collaboration, patient dissatisfaction, and increased medical errors. especially what has been called the “compulsive triad” of self- These facets of poor quality health care are strongly linked to doubt, guilt, and an exaggerated sense of self-importance [18]. burnout. A recent meta-analysis of 82 studies revealed that there is Self-doubt often results from having excessively high personal an inverse correlation between burnout and quality of care [12].Itis standards, common in many physicians, that are often so high that therefore important to further investigate the prevalence of un- the standards are difficult, or impossible, to achieve. Given these professional behaviors, their consequences, and to ascertain the high self-expectations, such physicians often impose equally high J.K. Penberthy et al / Physician Burnout 383 standards on others and react strongly if colleagues or staff fails to professionals over a decade ago [21]. Partially in response to the meet them. Among unprofessional physicians, these traits may be data reviewed above and the need for services for distressed and coupled with low emotional intelligence, which refers to how well unprofessional physicians in our own University hospital, the Uni- they understand and are able to regulate themselves (self-aware- versity of Virginia School of Medicine and Health System, we ness and self-regulation) and indicates their ability to read and collaborated with Vanderbilt University Medical Center for Profes- respond appropriately to others (social awareness and relationship sional Health to develop a program to help educate and train phy- management) [19]. Cultivating emotional intelligence requires sicians to improve their coping and interpersonal communication introspection and an understanding of what one is feeling in the skills. This University of Virginia School of Medicine continuing moment to respond appropriately. Lack of these skills can lead to medical education (CME) program is called “Effective Coping and “flooding,” an overwhelming emotional response to a situation Communication Skills (ECCS) for Physicians” and includes 3 initial over which an individual has little control. Flooding is a state of consecutive days of training followed by three follow-up 1-day negative feelings which virtually overwhelm the individual and trainings at 1, 3, and 6 months for a total of up to 48 hours of AMA make lead to irrational behaviors. Flooding has been described as PRA Category 1 Credit(s). Professional practice gaps identified as something akin to being “emotionally high-jacked” in that one’s areas to be addressed through this CME activity/series include: emotions are so strong that they are no longer under the logical physician difficulty in effective interpersonal communica- control of the individual. tiondboth verbal and nonverbal and anger and stress management, including relaxation and mindfulness skills. Other areas include awareness of interpersonal impact on others, including boundary 1.3. Strategies for change issuesdfocusing on professionalism, effective goal setting, and organizational skills with a focus on system-based practices. The modern health-care system may benefit from an increased The University of Virginia Effective Coping and Communication focus on physician well-being and how to achieve and sustain it Skills for Physicians Continuing Medical Education (UVA ECCS CME) within the stressful field of health care, as well as strategies to help course has an emphasis on assessment and feedback to identify transform the health-care system to allow sustained engagement. skill deficits and promote skill enhancement. The course includes Well-being should be considered as more than simply the absence assessments at the onset and at 1-, 3-, and 6-month follow-ups. of distress. Programs teaching mindfulness, effective communica- These assessments will be discussed in more detail below and tion skills, and stress reduction techniques may be key in helping to include a 360 degree evaluation component where the physicians establish a resilience and effective group of health-care workers. In are assessed by team members of their choosing, including other addition to these interventions, longitudinal studies examining physicians, nurses, support staff, and administrators. In this study, both physician distress and well-being are needed to identify and we focus on the self-assessments of emotional flooding, burnout, implement the interventions that have been proven successful. and quality of life. The course materials are provided to the par- Physician engagement in a mindful communication program is ticipants in a binder to keep. The core curriculum components are associated with both short- and long-term physician well-being outlined in Table 1 and include: motivational interviewing strate- and attitudes associated with patient-centered care. This and gies to help clarify ambivalence and advance readiness to change; other mindfulness-based programs for physicians have reduced education and practice of effective interpersonal communication burnout levels [20]. As part of this effort, we developed, imple- skills; education regarding empathy and compassion, including mented, and assessed a course to teach physicians skills regarding interpersonal mindfulness skills; coping skills; stress reduction and effective coping and interpersonal communication skills and mindfulness strategies; cultural awareness skills; anger manage- examined the impact of such on measures of well-being including ment; boundary awareness; and assertiveness training; as well as burnout, quality of life, and emotional flooding tendencies. We strategies to build resilience, reduce vulnerability to burnout, and hypothesized that such training would lead to increased quality of increase self-care. Participants engage in role-play as well as self- life and decreases in scores of burnout and flooding. reflection, discussion, and small group activities. 2. Materials and methods 2.2. Participants The ECCS for Physicians Program is approved to provide Forty-six participants were enrolled into groups of 2e8 physi- continuing medical education and is also approved by the UVA cians who meet together for the course. When the participants Institutional Review Board. A referred individual initially un- arrived for the first day of the program, they were oriented and dergoes a brief phone screen to ensure eligibility, which includes provided an Institutional Review Boardeapproved consent form identifying if there are issues regarding substance abuse, boundary from the University of Virginia for review and signature. Ques- violations, or prescription writing concerns. These issues are not tionnaires were then administered, including basic demographics, addressed in our program and if one or more of these are identified readiness to change scale [22], emotional flooding questionnaire as the primary or a significant concern then the professional is [23], the Professional Quality of Life questionnaire (ProQOL) [24], referred elsewhere. Once the professional is deemed appropriate the Maslach Burnout Inventory (MBI) [25], and the Beck Depression for the program, they are oriented to the program goals and re- Inventory (BDI) [26]. The program then commenced with in- quirements. The course is taught by three senior faculty clinicians, troductions and orientation to the program and materials and who have extensive clinical experience working with professional completion of the assessment materials. Once these were health-care providers. completed, the course didactic and interactive components began. 2.1. Intervention program: description 2.3. Assessments A few university medical centers and schools have created programs to assess and help physicians determined to be demon- Readiness to change: The purpose of a readiness to change as- strating distressed or unprofessional behavior. Vanderbilt Univer- sessments is to analyze the level of preparedness of the person to sity developed a comprehensive assessment program for make changes. The greater the complexity of the proposed change, 384 Saf Health Work 2018;9:381e387 Table 1 change they were in, and how long they had been working to 3-day program agenda. change. We assessed for readiness to change to reduce both their Day 1: (9 am to 5 pm) overall stress and anger. Introduction and welcome Emotional flooding: We assessed emotional flooding using a Orientation to program and materials modified version of Gottman’s flooding scale [23], which was originally designed to use with couples. The scale assesses the Review confidentiality tendency or proneness to flood emotionally in interpersonal situ- Rules of engagement Why you are here: sharing your story of how you got to this program ations and has been associated with unprofessional behavior. Clarification of ambivalence (decisional matrix, identifying emotion) Professional Quality of Life Questionnaire: The ProQOL [24] is Break for lunch the most commonly used measure of the negative and positive Why you are in medicine: sharing your story of how you got to the field of effects of helping others who experience suffering and trauma. The medicine ProQOL consists of subscales for compassion satisfaction, burnout, and compassion fatigue. The journey and goals of a career in medicine: what are your goals? Maslach Burnout Inventory: Burnout was measured using the Identification of key issues/goals for individuals and the group Introduction to effective interpersonal communication skills MBI, a validated 22-item questionnaire considered a standard tool Factors impacting coping and communication (thoughts, emotions, and for measuring burnout. The MBI has 3 subscales to evaluate the behaviors: perception group exercises; interpersonal impact exercises) three domains of burnout: emotional exhaustion (EE), deperson- Assign homework: complete, genogram, interpersonal inventories for alization, and low personal accomplishment (PA). A high score on review on Day 2 Summary, feedback/questions, emotional check-in, and adjourn the EE or depersonalization scales or a low score on PA can be considered a symptom of the burnout syndrome. We considered Day 2: (9 am to 5 pm) participants with a high score using cut-offs for medical pro- Review of assessments fessionals on either the depersonalization and/or EE subscales as having at least one manifestation of professional burnout. Review and genogram homework Beck Depression Inventory: The BDI is a 21-item self-report Introduction to effective communication skills and how they translate measure of attitudes and symptoms frequently displayed by into effective interpersonal interactions and behaviors and goal achievement depressed patients. Respondents rate items on 0 to 3 scales, with The role of empathy higher scores indicating greater depression. Data analysis participants were not always able to attend every Break for lunch Review interpersonal inventories and impact on interactions follow-up session, in which case data were not collected. Addi- tionally, all questionnaires were not given at each visit. Only those Group exercise/role-play stressful situations questionnaires given at both baseline and follow-up 1 data were Stress management: preventing, reducing, and coping with stress analyzed. We used the scores on readiness to change and the BDI to Progressive muscle relaxation (PMR)dgroup exercise Mindfulness trainingdgroup exercise evaluate the characteristics of the physicians at the time they One moment mindfulness initiated the program. Basic descriptive statistics were calculated Assign homework: practice mindfulness exercise or PMR; complete for these assessments. We compared scores on the emotional anger management inventories; cultural awareness materials flooding, Professional Quality of Life, and Maslach Burnout ques- Summary, feedback/questions, emotional check-in, and adjourn tionnaires from time 1 at the beginning of the program to time 2 which was 1 month after the end of the 3-day program. We hy- Day 3: (9 am to 5 pm) pothesized that scores on the emotional flooding scale would be Check-in and review of homework assignments significantly reduced at time 2 when compared to time 1. We hy- The role of cultural and social awareness pothesized that physician burnout scores would be significantly Review of interpersonal boundaries and sexual harassment issues improved from time 1 to time 2. We specifically hypothesized that Anger management and self-controldgroup exercise the scores on the MBI emotional exhaustion and depersonalization Assertiveness trainingdgroup exercises subscales would be significantly reduced from time 1 to time 2, and Role-play interpersonal situations brought in by group membersdrole- play the scores on the personal accomplishment subscale would in- crease significantly. Finally, we hypothesized that on the Profes- Break for lunch Feedback on role-plays and lessons learneddgroup exercise sional Quality of Life assessment, the burnout scores would significantly improve from time 1 to time 2. Analyses were per- Importance of exercise and diet in self-care formed in R 3.2.2 [28] using the g-data, graphics, and stats packages Reducing burnout and improving job satisfaction for calculating statistics, creating plots, and performing analyses Review of resilience [29]. Increasing positive interpersonal and communication skillsdgroup exercise Relapse prevention and maintaining progress 3. Results Summary, feedback/questions, emotional check-in, and completion of postassessment questionnaires Since its inception in 2011, the University of Virginia School of How to claim your CME Medicine’s ECCS program has enrolled 46 medical professionals from many departments at locations from across the United States. CME ¼ continuing medical education. The specialties with the most enrollees have been surgery and obstetrics and gynecology (Table 2). Of the 46 physicians enrolled, 73% were male and 27% female. At the beginning of the program, the greater the importance of understanding whether and where physicians averaged a flooding score 8.7, indicative of a proneness there is readiness for change as this can be critical first for deciding to emotional flooding during conflict, and an average BDI score of 9, whether the person is motivated to work for change. We used a which is classified as within the range of normal ups and downs modified version of the readiness to change questionnaire [27] to and not indicative of significant depression. At baseline, most assess if the participant was working toward change, what stage of physicians were in the action stage of change and had been J.K. Penberthy et al / Physician Burnout 385 Table 2 Physician specialty. Specialty Enrollees Radiology 3 (7%) Radiation oncology 1 (2%) Pediatrics 1 (2%) Surgery (general) 10 (22%) Ophthalmology 1 (2%) Obstetrics and gynecology 6 (13%) Surgery 8 (17%) Urology 1 (2%) Anesthesiology 4 (9%) Internal medicine 3 (7%) Nephrology 1 (2%) Neurology 1 (2%) Hematology and oncology 1 (2%) Cardiology 1 (2%) Emergency medicine 2 (4%) Family medicine 1 (2%) Fig. 1. Average flooding scores over the course of ECCS program. Pathology 1 (2%) ECCS ¼ Effective Coping and Communication Skills. Table 4 attempting to reduce the amount of stress in their life, but for less MBI burnout indices among ECCS enrollees at each visit. than 6 months. Physicians also endorsed being between the Burnout indices Baseline Follow-up 1 Follow-up 2 Follow-up 3 maintenance and action stages of change regarding changing their Emotional exhaustion anger and had been attempting to reduce their angry or acting out 1. Mean score 20.3 19.5 20.5 17.1 behaviors in their life, but with little success. Table 3 provides a 2. Low score 20 (50%) 15 (48%) 10 (43%) 8 (53%) breakdown of stage of readiness to change responses of the 3. Moderate score 7 (17%) 5 (16%) 5 (22%) 3 (20%) physician participants at baseline. 4. High score 13 (33%) 11 (36%) 8 (35%) 4 (27%) Depersonalization 3.1. Emotional flooding 1. Mean score 7.1 7.4 8.3 7.8 2. Low score 24 (60%) 16 (52%) 11 (48%) 8 (53%) Emotional flooding scores were predicted to be significantly 3. Moderate score 7 (18%) 8 (26%) 5 (22%) 3 (20%) decreased as a result of the course. Using the ShapiroeWilk test of 4. High score 9 (22%) 7 (22%) 7 (30%) 4 (27%) normality, we tested the null hypothesis that flooding scores came Personal accomplishment from a normally distributed population; results indicated that the 1. Mean score 39.9 39.9 40.3 41 distribution deviated from normal (p < 0.05). A Wilcoxon Signed- 2. High score 28 (70%) 19 (61%) 15 (65%) 13 (87%) Rank test indicated that flooding scores at baseline were statisti- 3. Moderate score 7 (18%) 8 (26%) 5 (22%) 0 (0%) cally significantly higher than flooding scores at follow-up 1, 4. Low score 5 (12%) 4 (13%) 3 (13%) 2 (13%) V ¼ 590, p < 0.05. Furthermore, flooding scores show an overall MBI missing 5 14 22 30 decreasing trend from each follow-up visit (Fig. 1). ECCS ¼ Effective Coping and Communication Skills; MBI ¼ Maslach Burnout Inventory. 3.2. Burnout * Low, moderate, and high scores calculated using MBI scoring guidelines. We predicted that physician burnout scores would be signifi- cantly improved from the beginning of the course to the first t ¼ 1.65, p > 0.05. Table 4 provides a comprehensive summary of follow-up session. Of particular interest to this program were the MBI scores at each time point. EE and PA submeasures of the MBI, and the burnout submeasure of ProQoL. Both the EE and PA submeasure distributions were found to significantly deviate from normal as indicated by ShapiroeWilks 4. Discussion/conclusion tests (p < 0.05). A Wilcoxon Signed-Rank test indicated that EE scores were significantly higher at baseline compared to follow-up The present study predicted that engagement in the ECCS pro- 1, V ¼ 285, p < 0.05. A Wilcoxon Signed-Rank test indicated that PA gram would teach stress management skills that focused specif- was not significantly improved as a result of the program, ically on reducing emotional arousal, improving interpersonal V ¼ 140.5, p > 0.05. The burnout submeasure distribution of ProQoL communication awareness, and improving self-care skills, thereby was not found to significantly deviate from normal, so a paired t eventually reducing burnout overall, specifically decreasing EE and test was conducted. A paired t test revealed that ProQoL burnout increasing PA. The impact upon outcomes was assessed by scores were not significantly improved as a result of the course, emotional flooding, burnout, and quality of life at work. Our Table 3 Stage of readiness to change (RtC) baseline responses. Readiness to Change Maintenance stage Action stage Preparation stage Contemplation stage Precontemplation stage RtCdstress 21 (46%) 18 (40%) 3 (7%) 1 (2%) 2 (4%) RtCdanger 28 (62%) 15 (33%) 1 (2%) 0 (0%) 1 (2%) 386 Saf Health Work 2018;9:381e387 hypotheses were partially supported, in that engagement in the of assessments to a reasonable amount, there were still multiple program appears to result in a significant decrease in EE scores and and possibly redundant questions. The hypothesis of this current significantly sustained decrease in average flooding scores. program was that gains in emotional regulation and effective self- The reduction in flooding may represent a change in self- management would result in improved functioning as evidenced control, self-awareness, and emotional intelligence. Negative on emotional flooding measures and measures of burnout and affectivity, anger, emotion regulation, and emotional expressivity quality of life. We found some support for this but are not able to have all been associated with flooding and observed in those with make conclusive summaries or link actions to outcomes directly. compulsive personality traits [30]. The reduction in flooding scores The present study has only partially revealed the impact of teaching indicates increased emotional awareness. This result may have such skills to clinicians exhibiting unprofessional behavior. Future occurred due to the nature of the intervention, an opportunity to research should be conducted to explore the temporal relationship focus on self-care, and interpersonal communication awareness. between teaching stress reduction and burnout amelioration; and Simply attending group-based therapeutic interventions can be the role of improving mood and mindful awareness in this rela- insightful for those who rarely confront their own behavior. Spe- tionship. Finally, further research should directly measure how cifically, for those with compulsive personality traits, awareness of programs such as ECCS impact institutional factors relevant to the dynamic nature of modern health care may allow for one to flooding and burnout, as this has the potential to reveal how in- break free from rigid perceptions and cognitively reframe their dividual and interpersonal changes impact larger occupational situations. This cognitive reframing may allow one to reassess their systems as a whole. own reactions and to effectively practice emotional control when Further research is needed to ascertain what role a reduction in flooding occurs and keep impulses in check. In a health-care flooding and, thereby, an increase in emotional control and environment, unprofessional behavior can undermine morale, improvement in both interpersonal communication awareness and while also decreasing collaboration, retention, and patient safety. self-awareness have on burnout. There is a complex interaction While unprofessional behavior is correlated with burnout, the between individual, interpersonal, and institutional factors, which relationship between the two is unknown. What is known is that remains unclear. We do not yet understand which of the three di- three categories of causes of burnout exist: individual, interper- mensions has the greatest importance nor do we know how one sonal, and institutional [31]. Increased emotional control and self- affects the other. Specifically, additional research regarding the awareness would likely affect one’s perception and relationship impact of programs such as ECCS, among populations of clinicians with others. Moreover, it is likely that gains in both of these do- with unprofessional behavior, is likely to reveal how teaching these mains could result in a decrease in all three causes of burnout. If an skills can reduce burnout overall. In regard to this population, individual experiences changes in their ability to cope with additional research investigating the long-term effects of this stressful situations (decreased flooding), this can foster improved program on burnout and flooding may have the potential to reveal interpersonal relations and even affect the institution as a whole. a relationship between the two. Additional research should also be EE decreased significantly as a result of the intervention, which directed to colleagues of unprofessional clinicians to ascertain the may indicate that this intervention has particular success in wide-reaching impact of such programs. attending to emotions and altering one’s perception of said emo- tions. This measure examines feelings of being emotionally over- Conflicts of interest extended and exhausted by one’swork [32]. These results illustrate that the reduction of flooding may not simply be due to emotional The authors have no conflict of interest. control but further evidence of internalizing the teachings of this program and cognitively reframing one’s relationship with one’s References reactions. Importantly, significant changes were not observed in the PA submeasure of MBI. It could be hypothesized that PA is more [1] Privitera MR, Rosenstein AH, Plessow F, LoCastro TM. 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Journal

Safety and Health at Work – Pubmed Central

Published: Mar 3, 2018

References

  • Physician burnout and occupational stress: an inconvenient truth with unintended consequences
    Privitera
  • Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014
    Shanafelt
  • Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns
    Rosen
  • Burnout among US medical students, residents, and early career physicians relative to the general US population
    Dyrbye
  • Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention
    Gabbe
  • Taking their own lives – the high rate of physician suicide
    Schernhammer
  • Why don't academic physicians seek needed professional help for psychological distress?
    Fridner
  • Burnout and satisfaction with work-life balance among US physicians relative to the general US population
    Shanafelt
  • Physician burnout: it just keeps getting worse
    Peckham
  • Poll results: doctors' unprofessional behavior disturbs physician leaders
    Weber
  • A survey of the impact of unprofessional behaviors and communication defects on patient safety
    Rosenstein
  • The relationship between professional burnout and quality and safety in healthcare: a meta-analysis
    Salyers
  • Nurse-physician relationships: impact on nurse satisfaction and retention
    Rosenstein
  • Impact and implications of unprofessional behavior in the perioperative arena
    Rosenstein
  • Problem doctors: is there a system-level solution?
    Leape
  • Physicians' “unprofessional” behavior: consequences for medical quality and safety
    Pfifferling
  • Problematic physicians: a comparison of personality profiles by offence type
    Roback
  • Mid-career burnout in generalist and specialist physicians
    Spickard