APA Well Being Ambassador Toolkit Challenges and Opportunities

HOW TO USE THIS SLIDE DECK
This slide deck was created by the American Psychiatric Association Workgroup on Physician
Wellbeing and Burnout in January, 2018.
This deck is intended to cover the topic comprehensively. The deck is organized as sections
and lends itself to easy editing. You may edit this slide deck to shorten it or use your own
logo, but may not substantively change the content of the work.
You may present, reproduce, or distribute these slides for non-commercial purposes, but
must acknowledge the APA’s copyright on each slide, “© 2018 American Psychiatric
Association, all rights reserved.”
Please review the accompanying Ambassador Manual which provides further instructions on
how to use this slide deck within your institution. For additional information and resources,
please visit: www.psychiatry.org/burnout
The workgroup was convened by Anita Everett, MD, APA President, 2017-2018.
These slides were developed by:
Carol A. Bernstein, M.D.
Rashi Aggarwal, M.D.
Julie Chilton, M.D.
Matthew L. Goldman, M.D., M.S.
1 © 2018 American Psychiatric Association. All rights reserved.

APA WELLBEING
AMBASSADOR TOOLKIT
Physician Burnout and Depression:
Challenges and Opportunities
January 2018
© 2018 American Psychiatric Association. All rights reserved.

OBJECTIVES
1. Identify key factors contributing to stress, burnout, depression and

suicide among physicians
2. Describe the complex inter-relationships between burnout,
depression and resilience and how these factors may interact with
each other as a result of pressures in the learning environment.
3. Identify different approaches to the problem both at the individual
and systemic levels.
4. Illustrate ways to promote wellbeing and resilience in the medical
culture

AGENDA
This presentation will cover:

• Motivation for addressing physician wellbeing
• Burnout definitions and drivers
• Depression and suicide in physicians
• Resilience and protective factors
• Literature on evidence-based interventions
• Examples of programs and national initiatives
• 6-step plan to implementing interventions at your institution

KEY POINTS
• Burnout is the individual’s response to a systemic problem!

• Burnout needs a systemic organizational response
• Both individual focused and organization focused
interventions can reduce burnout
• Organization based interventions are more effective for
burnout

A CALL TO ACTION
SUMMER 2014

JAMA PSYCHIATRY

THE TIP OF THE ICEBERG
This is NOT a New Problem

AMA CONSENSUS STATEMENT ON
PHYSICIAN WELL-BEING (2003)
• Concluded that the culture of medicine accords low

priority to physician mental health despite evidence
of untreated mood disorders and burden of suicide
• Identified barriers to treatment: discrimination in
licensing, hospital privileges and advancement
• Recommended transforming attitudes and changing
policies

DISCUSS:
WHAT BRINGS YOU AND
YOUR COLLEAGUES TO
DISCUSS THIS ISSUE
TODAY?

BURNOUT 101
BURNOUT: DEFINITIONS
• Emotional depletion: feeling frustrated, tired of going to

work, hard to deal with others at work
• Detachment/cynicism: being less empathic with
patients/others, detached from work, seeing patients as
diagnoses/objects/sources of frustration
• Low personal achievement: experiencing work as
unrewarding, “going through the motions”
• Depersonalization: thoughts and feelings seem unreal or
not belonging to oneself

DRIVERS OF BURNOUT
• Excess stress mediated by long hours, fatigue and

work compression as well as the intensity of work
environment
• Loss of meaning in medicine and patient care:
Decreased support, increased responsibility,
without autonomy and flexibility
• Challenges in institutional cultures: perceived lack
of peer support, lack of professionalism,
disengaged leadership
• Problems with work-life balance

POOR STRESS RESPONSE  BURNOUT
Yerkes-Dodson Curve 1908

GENERAL RISK FACTORS FOR
BURNOUT/DISTRESS
• Sleep deprivation
• High level of work/life conflict
• Work interrupted by personal concerns
• High level of anger, loneliness, or anxiety
• Stress of work relationships
• Anxiety about competency
• Difficulty “unplugging” after work
• Regular use of alcohol and other drugs
Sargent MC, et al. J Bone Joint Surg Am 2009

EFFECTS OF MEDICAL ERRORS ON PHYSICIAN
WELLBEING: “THE SECOND VICTIM”
• Guilt • Loss of confidence
• Shame • Trouble sleeping
• Feelings of inadequacy • Difficulty enjoying leisure
activities and daily life

• Difficulty concentrating
• Depression
• Declining clinical judgment
• Worry about reputation
• Avoidance of some procedures
• ~PTSD
Helo S & Moulton CE, Transl Androl Urol, 2017

EPIDEMIOLOGY OF BURNOUT IN
PHYSICIANS
• Medical students matriculate with BETTER well-

being than their age-group peers
• Early in medical school this reverses
• Poor well-being persists through medical
school and residency into practice:
- National physician burnout rate exceeds 54%
- Affects all specialties, perhaps worst in “front line”
areas of medicine
West C, et al., J Gen Intern Med, 2015

BURNOUT IN TRAINING
• Highly prevalent among medical students, residents

and physicians
– In residents, studies show burnout rates of 41-90%
• Levels rise quickly within the first few months of
residency
• ACGME work hour changes do not appear to have
improved sleep, burnout, depression symptoms or
errors
• Resident distress (e.g. burnout and depression)
associated with perceived medical errors and poorer
patient care
West, CP et al, JAMA 2006; Desai et al, JAMA 2013; Sen S, JAMA
Intern Med 2013

BURNOUT AND WORK-LIFE
BALANCE
Shanafelt,.et.al., Mayo Clinic Proceedings, December 2015

BURNOUT AT CAREER STAGE
Dyrbye et al. Mayo Clinic Proc, 2013

Shanafelt et al Mayo Clin Proc 2015

BURNOUT, DEPRESSION,
AND SUICIDE
BURNOUT, DEPRESSION, AND SUICIDE
ACROSS THE CONTINUUM
Medical Student Resident Early Career < 5yr
Burnout 56% 51% 40%
Depression* 58% 51% 40%
Suicidal Ideation
9.4% 8.1% 6.3%
(last 12 months)
* - Depression screen using 2-item PRIME MD

Dyrbye, Acad Med. 2014;89(3):443

DEPRESSION – DSM-5
• 5 or more of the following symptoms for ≥2 weeks:

– Depressed mood most of the day
– Diminished interest or pleasure
– Significant weight loss or gain
– Insomnia or hypersomnia nearly every day
– Psychomotor agitation or retardation
– Fatigue of loss of energy
– Feelings of worthlessness or excessive guilt
– Diminished ability to concentrate
– Recurrent thoughts of death or suicidal ideation with or without a plan
APA, 2013: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

DEPRESSION DURING INTERNSHIP
Percentage with
Specialty (N=740)
“Depression” (PHQ >10)
• Internal medicine 358 (48.5)
• General surgery 98 (13.3)
• OB/gynecology 42 (5.7)
• Pediatrics 94 (12.7)
• Psychiatry 63 (8.5)
• Emergency medicine 47 (6.3)
• Medicine/pediatrics 19 (2.6)
• Family medicine 19 (2.6)
Sen et al. Arch Gen Psych, 2010

DEPRESSION DURING INTERNSHIP
(CONT.)
• Rate of depression increased dramatically during
internship from 3.9% meeting PHQ-9 criteria (scores
≥10) up to 25.3% at intervals during the year
• Mean PHQ-9 increased from 2.4 to 6.4
• Depression results in increased medical errors and
errors may also cause depression
• Direct association between the number of hours
worked and the risk of depression
• No evidence that depressive symptom score before
internship predicted an increase in work hours

PREDICTORS OF INCREASED DEPRESSIVE
SYMPTOMS DURING INTERNSHIP
Baseline Factors
• Neuroticism
• Personal history of depression
• Lower baseline depressive symptoms
• Female sex
• US medical graduate
• Difficult early family environment
• 5-HTTLPR polymorphism
Within-Internship Factors
• Higher mean work hours
• Perceived medical errors
• Stressful life events

MULTISITE STUDY OF RESIDENT AND
PROGRAM DIRECTOR PERSPECTIVES
• 307 residents across multiple specialties (61% response rate)

• 69% met burnout criteria
• 17% screened positive for depression (PH-Q 9)
• Lack of work/life balance major issue
• Residents reported that more vacation time and increased support
from mid-levels and scribes rather than adverse outcome support and
mentoring would be helpful
• PDs most supportive of on-site childcare, debriefing after adverse
events and formalized peer support as mitigating strategies (PDs also
underestimated burnout rates)
Holmes, et.al., Academic Psychiatry, 41:2, April 2017

SUICIDES AMONG US PHYSICIANS
• National Violent Death Reporting System (NVDRS)

from 2003-2008 across 16 states
• Adults, 18 years or older who died by suicide
• Multiple data sources: death certificates, coroner data,
medical examiner information, toxicology information,
law enforcement reports
• 31,636 victims total
• 203 physicians
Gold, et. al, General Hospital Psychiatry, January 2013

DIFFERENCES IN ASSOCIATED FACTORS IN
PHYSICIAN SUICIDE VS. THE GENERAL POPULATION
• Less likely to have had a recent death of friend/family

• More likely to have had a job problem
• Higher measurable levels of benzodiazepines and
barbiturates
• Older
• Presence of known mental illness
• Major barriers to help-seeking, diagnosis and treatment
due to stigma
Gold, et. al, General Hospital Psychiatry, January 2013

GENDER DISCREPANCIES IN
SUICIDE RATES
• Multiple studies
• Suicide ratio for physicians compared with aged matched
controls in the general population:
– 1.41 times higher for men
– 2.27 times higher for women
Schernhammer E, Colditz G. Am J Psych, 2004

INCIDENCE OF SUICIDE AMONG WHITE MALE
PHYSICIANS, DENTISTS, AND GENERAL POPULATION
Physician Dentist Population

Completed Suicides per 100.000 person years
60
50
40
30
20
10
25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64

0
Occup Med (Lond). 2008. 58 (1): 25-29.
Age Cohort

CAUSES OF DEATH AMONG
RESIDENTS
• 380,000 residents over 14 years from 2000-2014

• 324 died during residency (220 men and 104 women)
• Leading causes: neoplastic disease, followed by suicide and then
accidents
• For men, suicide was the leading cause
• For women, malignancies was the leading cause
• Lower than in age and gender matched controls in the population
• Deaths by suicide higher earlier in training
Yaghmour, et.al. Academic Medicine, July 2017

BARRIERS TO TREATMENT
UTILIZATION OF MENTAL HEALTH SERVICES
AMONG DEPRESSED MEDICAL INTERNS
Reasons for No Treatment:

85.2%
• Lack of time (92%)
90%
• Preference for self-management
80%
(75%)
70%
• Lack of convenient access (62%)
60%
Med & Therapy
• Concerns regarding confidentiality
50%
(57%)
40% Therapy Alone
• Concerns about stigma (52%)
30% No Treatment
• Concerns about cost (50%)
20% 6.7% 8.1%
• Belief that treatment does not work
10%
(25%)
0%
Guille, C. et al. J Grad Med Educ. 2010 Jun; 2(2): 210–214.

BURNOUT IS NOT ONLY BAD FOR
PHYSICIANS, BUT FOR THE BUSINESS
OF MEDICINE AND FOR OUR PATIENTS

BUSINESS CASE FOR PHYSICIAN
WELL-BEING
• Costs Associated with Turnover
– Burnout is a major driver of physician turnover
– Cost to replace a physician is 2-3 times the physicians annual
salary
– Mean cost of replacing a physician=$500,000 to $1,000,000.
• Costs associated with decreased productivity
• Financial risk to organizations long term viability
– Relationship between physician burnout and quality of care, patient safety and
patient satisfaction
Shanafelt TD et al. JAMA Int Med. 2017

PATIENT CARE AND PHYSICIAN
WELL-BEING
• Physicians who care for themselves do a better job of caring for others
– They are less likely to make errors
– Have a higher patient satisfaction
• Habits of practice to promote well-being and resilience need to be
cultivated across the continuum
• A healthy learning environment will lead to improved health care for
all, physicians and patients
Shanafelt TD et al. JAMA Int Med. 2017

POTENTIAL PROTECTIVE
FACTORS
RESILIENCE
• The capacity to bounce back, to withstand
hardship, and to repair yourself
• Positive adaptation in the face of stress or
disruptive change
• Based on a combination of factors:
• Internal attributes (genetics, optimism)
• External (modeling, trauma)
• Skills (problem solving, finding meaning/purpose,
practicing mindfulness)
Wolin 1993, Werner & Smith, 1992

BUILDING RESILIENCE
Br J Gen Pract. 2016 Jul;66(648):e507-15

CAN WE BUILD RESILIENCE?
 Realistic recognition  Hobbies outside medicine

(Overcoming
denial/culture)  Humor
 Exercise, sleep, nutrition  Supportive personal
 Supportive professional relationships
relationships
 Practicing mindfulness
 Boundaries
 Focusing on positive
 Time away from work
emotions like gratitude
 Passion for one’s work and optimism
Swetz, J Palliative Med, 2009

ASSOCIATION BETWEEN A SENSE OF
CALLING AND PHYSICIAN WELLBEING
• 2009-2010 survey, 1504 primary care physicians and 512

psychiatrists
• 42% agreed that medicine is a calling
• Physicians who reported that medicine was a calling may
be experiencing higher levels of career satisfaction and
resilience from burnout
Yoon, et. al., Academic Psychiatry 41.3, April 2017

EVIDENCE-BASED
WELLBEING INTERVENTIONS
FINDING SOLUTIONS TO
COMPLEX PROBLEMS
• Solutions are complex and local to each organization

• Solutions can target a:
– Patient care team
– Division
– Department
– Hospital or academic institution
• There are a few common categories of interventions that
can be used to generate specific local solutions

CONTROLLED INTERVENTIONS TO
REDUCE BURNOUT IN PHYSICIANS
• 20 independent comparisons from 19 studies (1550 physicians)

• Used the emotional exhaustion domain of the Maslach
• Organization-directed interventions are more likely to lead to
reductions in burnout than physician-directed interventions
– Structural changes
– Fostering communication between members of the health care
team
– Cultivating teamwork
• Interventions targeting experienced physicians showed greater
evidence of effectiveness
Panagioti, et.al., JAMA Internal Medicine, December, 2016

META-ANALYSIS OF INTERVENTIONS TO
REDUCE BURNOUT IN PHYSICIANS
• 2617 articles including 15 randomized trials of 716 physicians and 37

cohort studies of 2914 physicians
• 230 articles met criteria for full review
• Most studies reported on changes in burnout domain score
• Both individually-focused and organizational interventions can reduce
burnout
• Both individual and organizational strategies are probably necessary,
but there are no studies to date which include both.
West, et.al., Lancet, November, 2016

WELLBEING INTERVENTIONS:
AN EVIDENCE-BASED FRAMEWORK
A wellbeing plan may include the following types of organizational interventions:
1. Educate and Increase Awareness 5. Ensure Access to Care

– Using these slides! – Confidential, easy to access, available both
– Create a Speaker’s Bureau during and after work hours
– 24-hour emergency phone line
2. Designate Time for Reflection – Online resources with screening tools for
burnout, depression and suicide
– Groups, debrief protocols
6. Improve Workplace Environment
– Review workloads and schedules with
3. Teach Practical Skills physician input, autonomy, flexibility
– Mindfulness, CBT, exercise
– Adequate staffing to reduce admin/clerical
tasks for physicians
4. Build Community – Personnel optimized to work at top of licenses
– Diversity in most meaningful work
– Mentoring and coaching programs 7. Transform Institutional Culture
– Opportunities to socialize at work
Developed by ML Goldman, CA Bernstein, LS Mayer

1. EDUCATE AND INCREASE
AWARENESS
• Offer educational opportunities about:
– Burnout, depression, substance abuse, suicide, and stigma
– Epidemiology of psychiatric illness and comorbidity
– Effectiveness of treatment options for depression and other mental
illnesses
– Sleep hygiene, nutrition, gyms, housing, fun activities
– Both mental and physical health resources
• High-yield venues include:
– Orientation sessions for incoming trainees or employees
– Departmental grand rounds
– Didactic sessions either in training curricula or Graduate Medical
Education (GME) and Continuing Medical Education (CME) settings

1. EDUCATE AND INCREASE
AWARENESS (CONT.)
• Create an electronic resource library or institutional website that
includes online modules and links to well-being resources
• Make information about access to mental health resources visible in
multiple high-traffic areas, where physicians can learn how to access
care without having to draw attention to themselves
• Organize a “Speaker’s Bureau” to include:
– Local “Physician Wellness Champions”
– Staff psychiatrists who are knowledgeable about depression and
suicide
• This is what you are doing as you use this slide deck!

2. DESIGNATE TIME FOR
REFLECTION
• Provide physicians protected time for structured discussion groups
– Membership: ideally 10-15 participants with consistent attendance
– Facilitation: faculty (from psychiatry and/or within each department),
chaplains, peer co-facilitators, etc.
– Structure: follow protocol (e.g. Balint) or allow for open-ended processing
• Disseminate debrief protocols for seminal events (deaths, codes,
errors, etc.)
• Have senior physicians recount medical errors they have made and
how they got through it
• Policies for flexible work scheduling and regularly planned days off for
wellbeing

2. DESIGNATE TIME FOR REFLECTION:
THE EVIDENCE
• 12 studies involved individual-focused interventions

• Interventions included
• Facilitated small group curricula
• Stress management and self-care training
• Communication skills training
• Four of these studies indicated funding or coverage for physicians to
participate during the workday

3. TEACH PRACTICAL SKILLS
• Develop and maintain training in:

– Mindfulness-based stress reduction techniques
– Stress awareness and Cognitive-Behavioral techniques
– Positive psychology
• Facilitate narrative practice and medical humanities
• Arrange physical exercise groups (e.g. yoga classes)

3. TEACH PRACTICAL SKILLS:
THE EVIDENCE
• 12 studies implemented physician-directed interventions
– Interventions included
• Mindfulness-based stress reduction techniques
• Educational interventions targeting
– Physicians’ self confidence
– Communication skills
– Exercise
– A combination of above

4. BUILD COMMUNITY
• Expand structured mentorship and professional development

programs
– Vital for younger physicians who are prone to burnout.
– “Buddy/big sib” programs among trainees help promote camaraderie and informal
support
– Coaching programs between faculty members and trainees or early career
physicians provide opportunities for reflection and support
• Recurring social events and shared community resources (e.g.
childcare)
• Department led team-building activities and funded annual retreats

5. ENSURE ACCESS TO CARE
• Screen for burnout and depression

• Define a clear system for referrals to individual mental health services
• Provide in-house mental health services for physicians
• Develop walk-in well-being center
• Arrange after-hours emergency phone line

EVIDENCE-BASED INTERVENTIONS
FOR DEPRESSION: THERAPY
• Recommended therapies for treatment of acute mild to moderate
depression:
– Cognitive Behavioral Therapy (CBT)
– Interpersonal Psychotherapy (IPT)
– Psychodynamic Therapy
– Problem-Solving Therapy
• Effectiveness varies with skill and training of therapist, but thought to
be equal to medication for mild to moderate depression
• Consider adding medication or adjusting therapy approach if no
response in 4-8 weeks with therapy alone
• If moderate to severe depression, initiate both medication and
therapy
• Therapy may have longer term effects than medication alone after
cessation of treatment
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

EVIDENCE-BASED INTERVENTIONS
FOR DEPRESSION: MEDICATION
• Consider medication if:
– Moderate to severe symptoms
– Prior positive response to antidepressants
– Significant sleep or appetite disturbances
– Agitation
– Patient preference
– Anticipation of need for maintenance therapy
• Antidepressant response rates in clinical trials: 50-75%
• Generally comparable efficacy:
– selective serotonin reuptake inhibitors (SSRIs)
– selective norepinephrine reuptake inhibitors (SNRIs)
– tricyclic antidepressants (TCAs)
– monoamine oxidase inhibitors (MAOIs)
– others (bupropion, nefazodone, trazodone, mirtazapine)
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

WEB-BASED COGNITIVE
BEHAVIORAL THERAPY
• Randomized clinical trial – 119 interns at 2 hospitals, multiple
specialties
• Two groups: wCBT versus attention control (email once/week for 4
weeks with educational information and how to access resources)
• PHQ-9 to assess suicidal ideation at start of internship and 3 month
intervals
• 12% of interns in the wCBT group endorsed suicidal ideation
compared to 21.2% in the control group
Guille, et.al, JAMA Psychiatry, 2015

POSITIVE OUTCOMES FOR TREATMENT OF
SUBSTANCE USE DISORDERS IN PHYSICIANS
• More than 10% US physicians have a substance use disorder

• Physician Health Programs arrange evaluation, referral to treatment,
monitoring and contractual agreement with licensing boards
• With satisfactory treatment and monitoring, majority of physicians
can return to practice
• Success rates of >75% in five-year, longitudinal, large cohort study of
16 state physician programs from 1995-2001
– ~1/3 prescribed an antidepressant for comorbid anxiety or
depression
McLellan et al., BMJ 2008; 337:a2038.

6. IMPROVE WORKPLACE
ENVIRONMENT
• Involve staff in Quality Improvement to address workflow issues
including:
– Health information technology updates to improve user experience
– Physical infrastructure with shared spaces conducive to collaboration and team
building
– Personnel optimized to work at top of licenses (e.g. task shifting)
– Physicians given autonomy to spend at least 20% of day in most meaningful work
• Hold regular meetings with leadership to improve work environment
with follow-up
• Develop a comprehensive strategic plan with operations management
to address workforce issues

6. IMPROVE WORKPLACE ENVIRONMENT:
THE EVIDENCE
• 3 studies examined structural interventions within the work

environment
– Interventions included:
• Shortened attending rotation length
• Various modifications to clinical work processes
• Shortened resident shifts

6. IMPROVE WORKPLACE ENVIRONMENT:
THE EVIDENCE
• 5 studies examined simple workload interventions that focused on

rescheduling hourly shifts and reducing workload.
• 3 Studies tested more extensive organization directed interventions
– Interventions focused on
• Teamwork and leadership,
• Structural changes, and
• Elements of physician interventions such as communication skills training and
mindfulness.

7. TRANSFORM INSTITUTIONAL
CULTURE
• Encourage department chairs and executives to engage in

participatory leadership styles to facilitate a culture of wellbeing
• Promote clear and standardized policies for taking personal days to
care for self, sick coverage, and parental leave
• Establish an institutional Well-Being Committee with broad member
input
• Participate in existing and innovative research studies
• Assess adherence to regulatory guidelines and requirements

TAKEAWAY
– Variety of interventions have been effective in reducing

burnout
– One Size Does Not Fit All
– Solutions are complex and can target a:

• Patient care team
• Division
• Department
• Hospital or academic institution

HOW TO START
IMPLEMENTING
INTERVENTIONS AT YOUR
ORGANIZATION
6-STEP PLAN TO WELLBEING
1. Get Organized For additional resources,

including a how-to manual for
wellbeing ambassadors, visit:
2. Assess Your Needs www.psychiatry.org/burnout
3. Choose Your Priorities

4. Engage Leadership
5. Stay Accountable
6. Anticipate Obstacles

#1: GET ORGANIZED
• Clearly Designated Intervention Group

– Wellbeing Taskforce
and/or
– Wellbeing Committee
– Wellbeing Champions at each
organizational level
Useful Tip: Including junior and

senior colleagues will enrich
your taskforce!

#2: ASSESS YOUR NEEDS
• Assess Your Needs:

– Formal
• Depression screening
• Physician burnout surveys
• Physician satisfaction with work life
– Informal
• Meetings
• Focus groups
• Town halls
• Suggestion boxes
Useful Tip: Acknowledging that

physician burnout is a problem for your
organization can be a good start

#3: CHOOSE YOUR PRIORITIES
• Choose a few interventions based on

– Urgency
– Impact
– Feasibility
• Interventions can be a mix of
– Low-, Medium- or High-resource interventions
– Short- or Long-Term interventions
Useful Tip: There is no perfect universal

solution! Don’t wait for a comprehensive
solution. Just get started.

FRAMEWORK OF INTERVENTIONS
Key components Stage of Intervention
of Well-Being
Initiatives
Preliminary Intermediate Advanced
1. Educate and Presentations at employee Institutional website that includes Established Speaker’s Bureau and
Increase orientation and regularly planned online modules and links to well- curriculum including
Awareness didactics and workshops being resources interdepartmental Grand Rounds
2. Designate Voluntary groups led by peers as Structured, regularly scheduled Policies for flexible work scheduling
Time for needed (e.g. debrief protocols for groups with consistent membership and regularly planned days off
Reflection seminal events) and expert facilitation for wellbeing
3. Teach Health-oriented classes available Facilitated evidence-based Designated time and specified
Practical Skills in the community workshop to teach mindfulness availability for skills groups and
(e.g. yoga, gym, etc.) and CBT skills physical exercise classes
4. Build Recurring social events Structured mentorship and

Department led team-building
Community and shared community professional development programs
activities and funded annual retreats
resources (e.g. childcare) (e.g. peer-to-peer coaching)
5. Ensure Access Employee health insurance that In-house, fully staffed mental health
Internal mental health service that
to Care appropriately covers mental services, including short-term free
provides referrals to the community
health benefits services and 24/7 crisis support
6. Improve Health information technology Physical infrastructure with Personnel optimized to work at top
Workplace updated to improve user shared spaces conducive to of licenses in most meaningful work
Environment experience, with regular feedback collaboration and team building (e.g. task shifting)
7. Transform Institutional wellbeing Department chairs and Innovative policies to maintain

Institutional committee established with executive leadership engaged in wellbeing (e.g. sick coverage,
Culture broad member input culture of wellbeing parental leave)
75 © 2018
Developed by Matthew L. Goldman, MD, MS, Carol A. Bernstein, MD, and Laurel S. Mayer, MD American Psychiatric Association. All rights reserved. Au
#4: ENGAGE LEADERSHIP
• Establish an institutional wellbeing committee charged with rolling out

the goals identified in the needs assessment
• Create a task force with institutional GME to review adherence to
revised ACGME policies
• Compensate for volunteering, teaching, and committee work
• Celebrate team achievements and milestones
• Role model how to voice empathy and concern for colleagues
• Promote effective leadership and hire more leaders who care
Shanafelt TD, Noseworthy JH. Mayo Clin Proc. 2017

#4: ENGAGE LEADERSHIP (CONT.)
• Make the case to executive leadership:

– Improve the patient experience and reduce medical errors
– Improve retention of valued members of the medical staff and prevent resource-
intensive adverse outcomes among physicians (e.g. leave of absence, attrition,
suicide)
– Enhance creativity and flexibility in responding to the challenges of the changing
health care system
– Establish your institution as a leader on an issue of national importance
Shanafelt TD, Noseworthy JH. Mayo Clin Proc. 2017

#5: STAY ACCOUNTABLE
• Accountability
– Communicate the
proposed plans
– Give regular updates
• Include successes, failures and roadblocks
• Assess the impact of your interventions
– Reuse the baseline measures
Useful Tip: Goal alignment and

accountability by themselves can
be wellness intervention

#6: ANTICIPATE OBSTACLES
• Some challenges are likely to arise:

– Limitations of your own energy and resources – don’t burn out on burnout!
– Insufficient mental health services may limit referral options
– Perceived concerns among physicians about repercussions of seeking mental health
treatment on medical licensure
– Stigma
– Tragedy such as the loss of a colleague to suicide
• Be in touch with the members of the APA Workgroup to share your
experiences and seek further assistance whenever needed!

KEY POINTS
• Burnout is the individual’s response to a systemic

problem!
• Burnout needs a systemic organizational response
• Both individual focused and organization focused
interventions can reduce burnout
• Organization based interventions are more
effective for burnout

DISCUSS:
WHAT ARE YOUR GREATEST NEEDS
AND PRIORITIES AT YOUR
INSTITUTION?

EXAMPLES OF
PROGRAMS
MGH – SMART-R CURRICULUM
• Stress Management and Resiliency Training for Residents

• Adapted from Benson Henry Institute’s “Relaxation Response and
Resiliency Program”
• Basic Tenets:
– Relaxation Techniques and Meditation
– Stress Awareness and Cognitive Reframing
– Positive Perspective Taking and Meaning Finding
– During Protected Time
Chaukos, D et al. Acad Psychiatry. 2017

OREGON HEALTH SCIENCES
UNIVERSITY
• Wellness and Suicide Prevention Program (2300 trainees and faculty)
• Two psychologists and 2 psychiatrists (2.4 FTEs)
DESIGN:
• Wellness promotion workshops
• Orientation presentations
• Suicide prevention screening offered
• Resident support groups
• Records stored in encrypted database in secure location – not
documented in EHR
• 85% of expense is for clinicians
• $200,000 estimated start up cost
Ey et al, JGME, 2016

OHSU CONTINUED
Interventions:
• Individual coaching and CBT, mindfulness, brief insight-oriented
treatments
• Psychiatric evaluation and medication management
• Consultation with GME, program leaders and chief residents about
distressed trainees and faculty
• Referrals to the community for fitness for duty, neuropsychological
testing, hospitalization
• 25% increase in utilization of services over 10 years

Ey et al, JGME, 2016
PROGRESS ACROSS
THE CONTINUUM
CURRENT NATIONAL INITIATIVES
(A SAMPLE)
• APA Workgroup on Psychiatrist Wellbeing and Burnout
• Coalition for Physician Accountability
• AMA
• National Academy of Medicine
• AAMC
• FSMB
• Emergency Medicine
• CHARM
• Osteopathic Community
• Nursing Community

ACGME REVISIONS TO CPRS
• Accreditation Council for Graduate Medical Education (ACGME) released new

Common Program Requirements, including section VI.C on Well-Being, effective
7/1/2017:
– Helping residents find meaning in work: protected time with patients; minimizing non-
physician obligations; administrative support; progressive autonomy and flexibility;
enhancement of professional relationships
– Attention to scheduling, work intensity, and work compression
– Evaluating the safety of residents and faculty members in the learning and working
environment
– Establishing policies and programs supporting optimal resident and faculty member well-being,
including the opportunity to attend appointments for personal care, even during working hours
– Attention to and education in resident and faculty member burnout, depression, and substance
abuse in themselves and others; provision of services and resources for care, and tools to
identify symptoms and report them; and availability and access to confidential, affordable
mental health counseling and treatment, including access to urgent and emergent care 24
hours a day, seven days a week.
– Establishing policies and procedures ensuring continuity of patient care in support of patient
and physician safety when residents and faculty members are unable to work, including but not
limited to circumstances related to fatigue, illness, and family emergencies.
http://acgme.org/What-We-Do/Initiatives/Physician-Well-Being

APA WORKGROUP ON
PHYSICIAN WELLBEING AND BURNOUT
• Review prevalence, incidence, causes for burnout, depression and

suicidality and evidence-based interventions
• Develop web portal/app for self assessment, education and resources
• Recommend actions for the APA to take to support and educate other
physicians, including other specialty societies
• Develop an annotated list of assessment tools for burnout and depression
• Disseminate toolkit and this slide deck to provide guidance to:
– Spread awareness at your home institutions with the use of a comprehensive slide deck
and a Speaker’s Bureau;
– Assist your organization in conducting a needs assessment to identify best practices for
advocacy and specific interventions to promote wellbeing within your organization; and
– Gain access to additional resources including a recommended reading list and an
inventory for screening tools.

QUESTIONS?
The APA Workgroup on Physician Wellbeing and Burnout
was convened in 2016 by Anita Everett, MD, APA
President, 2017-2018.
Members: James Lomax, M.D.

Rick Summers, M.D. – Chair Terrance McGill, M.D.
Rashi Aggarwal, M.D. Theresa Miskimen, M.D.
Carol Bernstein, M.D. Steve Moffic, M.D.
Deanna Chaukos, M.D. David Pollack, M.D.
Julie Chilton, M.D. Tony Rostain, M.D.
Kimberly Gordon, M.D. Suzanne Thomas, M.D.
Connie Guille, M.D. Linda Worley, M.D.
Matthew L. Goldman, M.D., M.S. Glenda Wrenn, M.D.

APA Well Being Ambassador Toolkit Challenges and Opportunities

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HOW TO USE THIS SLIDE DECK

1 © 2018 American Psychiatric Association. All rights reserved.

© 2018 American Psychiatric Association. All rights reserved.

1. Identify key factors contributing to stress, burnout, depression and

3 © 2018 American Psychiatric Association. All rights reserved.

This presentation will cover:

4 © 2018 American Psychiatric Association. All rights reserved.

• Burnout is the individual’s response to a systemic problem!

5 © 2018 American Psychiatric Association. All rights reserved.

7 © 2018 American Psychiatric Association. All rights reserved.

8 © 2018 American Psychiatric Association. All rights reserved.

This is NOT a New Problem

• Concluded that the culture of medicine accords low

10 © 2018 American Psychiatric Association. All rights reserved.

13 © 2018 American Psychiatric Association. All rights reserved.

• Emotional depletion: feeling frustrated, tired of going to

15 © 2018 American Psychiatric Association. All rights reserved.

• Excess stress mediated by long hours, fatigue and

16 © 2018 American Psychiatric Association. All rights reserved.

Yerkes-Dodson Curve 1908

17 © 2018 American Psychiatric Association. All rights reserved.

19 © 2018 American Psychiatric Association. All rights reserved.

• Guilt • Loss of confidence

• Shame • Trouble sleeping

• Feelings of inadequacy • Difficulty enjoying leisure

activities and daily life

Helo S & Moulton CE, Transl Androl Urol, 2017

20 © 2018 American Psychiatric Association. All rights reserved.

• Medical students matriculate with BETTER well-

West C, et al., J Gen Intern Med, 2015

21 © 2018 American Psychiatric Association. All rights reserved.

• Highly prevalent among medical students, residents

22 © 2018 American Psychiatric Association. All rights reserved.

Shanafelt,.et.al., Mayo Clinic Proceedings, December 2015

23 © 2018 American Psychiatric Association. All rights reserved.

Dyrbye et al. Mayo Clinic Proc, 2013

24 © 2018 American Psychiatric Association. All rights reserved.

25 © 2018 American Psychiatric Association. All rights reserved.

Medical Student Resident Early Career < 5yr

Burnout 56% 51% 40%

Depression* 58% 51% 40%

* - Depression screen using 2-item PRIME MD

27 © 2018 American Psychiatric Association. All rights reserved.

• 5 or more of the following symptoms for ≥2 weeks:

28 © 2018 American Psychiatric Association. All rights reserved.

Sen et al. Arch Gen Psych, 2010

29 © 2018 American Psychiatric Association. All rights reserved.

30 © 2018 American Psychiatric Association. All rights reserved.

31 © 2018 American Psychiatric Association. All rights reserved.

• 307 residents across multiple specialties (61% response rate)

Holmes, et.al., Academic Psychiatry, 41:2, April 2017

32 © 2018 American Psychiatric Association. All rights reserved.

• National Violent Death Reporting System (NVDRS)

Gold, et. al, General Hospital Psychiatry, January 2013

33 © 2018 American Psychiatric Association. All rights reserved.

• Less likely to have had a recent death of friend/family

Gold, et. al, General Hospital Psychiatry, January 2013

34 © 2018 American Psychiatric Association. All rights reserved.

Schernhammer E, Colditz G. Am J Psych, 2004

35 © 2018 American Psychiatric Association. All rights reserved.

Physician Dentist Population

25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64

36 © 2018 American Psychiatric Association. All rights reserved.

• 380,000 residents over 14 years from 2000-2014