So...you want to be an opinion leader? Try this succinct and practical approach.

Every summer, Vitalsmarts hosts a fantastic three day event in Utah for trainers across the world.  It is a great to time to catch up with like-minded people, most of which are busily working hard to change the world for the better.

Today's pre-conference workshop, part of the REACH Labs, focused on how individuals can consider how they can best influence change.  Social scientist David Maxwell, one of the authors of the bestselling books Crucial Conversations, Crucial Conversations, Influencer, and Change Anything, took our group through an experiential process.

We looked at our professional challenges from the perspective of becoming an opinion leader and change agent...in the world of physician health that raises all sorts of factors revolving around motivation (our own motivation to care for ourselves and each other, the motivation of those people around us to compel us towards healthy behaviours, and the non-human aspects of physician health such as safe working conditions/policies and procedures/rewards and consequences) and ability (our skills to care for ourselves and others, the skills of the people around us to help or hinder us, and the skills of the system to join us in a journey of sustainability).  

If you are struggling with a change issue and are curious how you can influence the opinions of those around you then I suggest you read Influencer:  The New Science of Leading Change.  Maxwell et al take a massive amount of research data and translate evidence into a succinct and practical tool of change.

Doesn't succinct and practical sound tempting?

Connection: Whatworks4me.org

Shout out to Drs. Steve Adelman, Eddie Phillips, Diane Shannon, & Frank Fortin who are editors of the What works for me blog.  Jointly sponsored by the Massachusetts Medical Society and the Institute of Lifestyle Medicine, physicians are encouraged to share their stories and experiences and use the blog to demonstrate their best practices.

The editors write:

"What works for you? What do you do at home, at work, and in the community, to keep your personal batteries fully charged? What personal and professional practices keep you engaged and excited, when you are “on duty” and when you are “off duty?”

Please submit a 300-600 word account of what works for you. Try to dig beneath the surface a bit and reveal the “why” behind your passion. Consider including a patient anecdote (disguised and de-identified) to make your story come alive. Do patients know what works for you? How have they reacted?"

What works for me shares stories of creativity, music, exercise and nutrition, mutual support and reflection...all fresh from the lived experience of colleagues.

Well worth both reading...and contributing.

Celebration Saturdays: Dr. Helen Ward - Innovator in Forensic Psychiatry

Colleague Dr. Helen Ward has won the College of Physician's and Surgeon's prestigious Council Award - a well deserved honour.

Dr. Ward is a highly regarded educator, clinician, and colleague. Her innovative application of best practices in serving the needs of society's most mentally ill has been recognized by her peers across Ontario.

The CPSO press release reads:

The Council Award recognizes physicians who have demonstrated excellence in eight physician roles. These roles include the physician as a scientist, a scholar and a health advocate, among others.

Dr. Ward is clinical director of the Royal Ottawa Mental Health Centre’s 46-bed forensic psychiatry unit where she supervises 10 psychiatrists, in addition to carrying a caseload of 12 to 16 inpatients, as well as 250 outpatients.

She was instrumental in spearheading the creation of the Mental Health Court in Ottawa. The collaborative program - between the Crown, judges and defence lawyers – is designed to help offenders with serious mental illness such as manic depression, severe anxiety, schizophrenia, bipolar disorder and dementia get easier and faster access to treatment, and at the same time, determine their capacity for criminal behaviour or to face trial.

Dr. Ward is a tireless advocate for the mentally ill. She has spoken at international conferences on the subject of mental health courts to promote this approach in other jurisdictions. She has also testified before the Canadian Senate on this topic, as well as the potential negative consequences of a DNA bank for offenders found not criminally responsible on criminal charges.

In presenting the award, Council member Dr. Andrew Falconer said, “Dr. Ward’s patients are fortunate to have her as their physician. With her compassion and commitment, she serves as a role model for us all.”

The CPSO Council congratulates Dr. Ward for her dedication to the profession and to her patients.

A real role model - congratulations!

Connection: Dr. Sara Taylor's Physician Health Anthology Project

Shout out to fellow Canadian physician, Dr. Sara Taylor, who has a beautiful blog on health and wellness.

A colleague recently sent me a link one of Dr. Taylor's posts - she is recruiting physician-authors to contribute to a unique anthology on physician health:

"My vision for the anthology:

I have spent a lot of time considering avenues whereby I can inspire other physicians to recognize the potential for burnout in their own lives and how they can remain well. The delivery is the tricky part, but what better way than for other physicians to tell their own story and present actionable ideas toward well-being. My vision is a personal story, followed by actionable ideas, from a physician in every province and territory across Canada. I am seeking nonexclusive rights to your story with the main goal to be a part of something publishable, exposure as a writer and creatively unique. I will be responsible for the costs incurred with editing and publishing.

Given up to three quarters of physicians have experienced a form of burnout, we all have a story to tell. My hope is to unveil stories where physicians have discovered the importance of self-care and improved well-being, or are continuing their journey toward wellness and away from burnout. Some stories may include ideas to enhance work-life balance, find passion in your work, build resiliency and rediscover your overall purpose. I welcome your creative expression.

Dates to consider & guidelines:

I will accept submissions until September 30, 2014. Each submission will represent a chapter in the book. I do plan to contribute to the book in the introduction and ending. I do not want to put a number on creativity, but a rough guideline would be 2,000 to 3,000 words. You can break it up as you see fit, keeping additional characters anonymous. If you wish to include references and resources, please add them at the end of your submission. Please submit your document as either a Word or Pages attachment to your email with the subject title “Anthology”.

You will be notified by October 31, 2014 if your submission is accepted.

For your time and efforts, if your piece is accepted, I would like to offer you a $100.00 honorarium along with a copy of the book when it is available."

There have been similar anthologies produced in other countries, but I believe this will be a Canadian first.  

Congratulations to Dr. Taylor for leading this effort!

Saturday Celebration: 48% of doctors are organ donors - are you?

In 2012,  15 people died waiting for a heart, 62 waiting for a liver, 69 waiting for lungs, and 84 waiting for a kidney. That is a lot of individuals, families, and communities affected by painful losses that might be avoided.

In Ontario, only 24% of the population has stepped up to be an organ donor.  While this may seem superficially selfish (and it is), most people simply haven't given serious thought to donating their organs/tissues at dead.  In fact, most people don't think about their death at all - our culture is remarkably uncomfortable with death and dying.

48% of Ontario's physicians, a population that is quite familiar with death and dying, are identified as donors.  Women physicians and younger doctors were more likely to donate than their male and/or more senior colleagues.

That commitment - and that reflection of some of the complexities of mortality - is worth celebrating.  Those numbers, however, need to seriously improve.

Join me in giving to others after
death.  After all, what are you going to with your organs or tissues when you're gone?

Go grab your health card, find two minutes, and become a donor.  Your gift can make a huge difference to 8 patients (and their families...and their communities...and our collective future).

Samuel Shem - (now) 36 years after the House of God

Samuel Shem's House of God told a stark and painful tale of the harm done to physicians (and patients) by their training system and workplace culture.  Dr. Roy Basch, a new intern, quickly learns the 13 laws that permeate the workplace of the "House of God":

• Gomers don't die
• Gomers go to ground
• At a cardiac arrest, the first procedure is to take your own pulse
• The patient is the one with the disease
• Placement comes first
• There is no body cavity that cannot be reached with a #14 needle and a good strong arm
• Age + BUN=Lasix dose
• They can always hurt you more
• The only good admission is a dead admission
• If you don't take a temperature you can't find a fever
• Show me a medical resident who only triples my work and I will kiss his feet
• If the radiology resident and the medical student both see a lesion on the CXR there can be no lesion there
• The delivery of good medical care is to do as much nothing as possible

(Shem, S. House of God Richard Marek Publishers, Inc., New York, 1978)

On twitter this week, Dr. Shem's 2012 article in The Atlantic made the rounds again - not quite sure why - but seemed to be in response to a number of discussions about physician health and evolution of medical training.  In that great discussion piece, he added 4 "laws", which are worth the read (much more in his article):

• Connection comes first
• Learn empathy. 
• Speak up
• Learn your trade, in the world

These align nicely with the themes raised in Return to The House of God: Medical Resident Education 1978–2008 which I reviewed for the Canadian Medical Association Journal in 2009.  I was most struck by an essay by American scholar Dr. Kenneth Ludmerer and his recommendations for postgraduate medical education:

• residents need to see patients in more depth, not more quantity 
• residents need to be relieved of noneducational work that can be done by others
• educational opportunities afforded to residents must improve in quality (content, delivery, evaluation), and 
• programs need to respond better to the emotional needs of trainees and promote their health and sustainability

36 years after introducing Dr. Basch to the world, Dr. Shem continues to influence. Curious if he influenced you?

Self-Regulation: Key Cornerstone of Doctor's Well-Being

My good friend and colleague, Christopher Simon, will shortly complete (as far as I can tell) Canada's first Ph.D. focused on physician health and well-being.  His postgraduate research is now in the first phase of publication and his data will be of interest to anyone with interest in health-professional sustainability and well-being.

His first paper was released this week, and looked carefully at the link between physicians' self-regulation (i.e., effective management of thoughts, emotions and behaviours, and ability to cope with adversity) and perceived psychological well-being.  As a child psychiatrist, I often help children/youth/families improve and enhance their self-regulatory skills and can't help but understand how these skills are important to all adults, including physicians.

Chris found that there was a strong relationship between self-regulation capacity and the dimensions of "purpose in life" and "environmental mastery", which he concluded suggests that physicians who effectively self-manage may be better able to preserve a sense of purpose and an adequate work-life balance in their daily life.

I've observed that when a physician has either lost their sense of purpose or had it taken away (e.g., clinical restructuring, illness/impairment) they are particularly vulnerable to burnout.  Typically, physicians will work even harder to maintain a sense of service fulfilment or life purpose which only makes things worse.

Self-regulation skills can be taught and/or enhanced.  Psychotherapy, psychoeducation, coaching, and reflection (e.g., mindfulness) can be helpful strategies.  In addition, self-regulation skills apply to a whole host of homeostatic variables such as the ability to attend to exercise, sleep, nutrition, hydration, social connection, and to more complex behaviours such as delaying gratification, managing frustration, and monitoring impulses.  

These skills can also be innate and perhaps screened for as part of application to medical school or a postgraduate education program.  I'm not suggesting poor self-regulation skills should preclude the opportunity to study and practice medicine, but it does seem reasonable to offer skill-enhancing opportunities to those who may have vulnerabilities in this area.

Chris notes that our work is only going to get more complex and suggests that enhancement of self-regulation skills of physicians will not only be of value to themselves, but also for the patients that they serve.

"Grit" - A New Marker for Residents at Risk of Attrition?

 I wasn't aware that attrition from general surgery residencies has hovered around 20% for nearly a decade.  This has a number of natural consequences on the health human resource planning, access to surgical care, and the ability of training programs to function properly.  In addition, transitioning residency programs is not a simple task and brings a great deal of stress to the trainee and their family.

In a multisite study across twelve general surgery programs, investigators evaluated "grit" - a novel character trait they defined as passion and perseverance for long-term goals, and explored how it could be a marker and potential risk factor for resident attrition.

Interestingly, of the residents that left their training programs, all had "below-median grit."  However, the limited sample size, compounded with the low attrition rate in this particular sample, resulted in low power and limited statistical significance.

The study also looked at key resident support strategies and found that having access to family, spending time with friends outside of residency, supportive co-residents, and formal mentorship  seemed to improve "grit" and reduce attrition.

Be interesting to see the study on a larger scale and see how valuable "grit" may turn out to be for surgery and, perhaps, across disciplines.

Saturday Celebration: KickAss Canadian Dr. Samantha Nutt

There is no shortage of interesting, innovative, and fun physicians in our community and I don't think we acknowledge them enough.

I am delighted to link to a really neat site - KickAss Canadians.  Designed by Amanda Sage, the blog shares stories of very real Canadians doing remarkable work.

Please enjoy her story on Dr. Samantha Nutt - it starts: "Quite simply, Dr. Samantha Nutt is extraordinary. She’s the epitome of a Kickass Canadian: true to herself (and unafraid to speak the truth); endlessly strong; and both inspiring and inspired. She’s also generous, brilliant and a key instigator of positive change—for Canada and the world."

Who will protect us from ourselves? Hmmm, us of course.

University of Toronto Internal Medicine Resident Dr Michael Fralick and CMAJ Senior Associate Editor Dr. Ken Flegel teamed up to write a powerful editorial this week.

"Physician burnout:  Who will protect us from ourselves" suggested physicians focus on mindfulness, take time away from work, apply principles of behaviour-modification, use their common-sense (e.g., exercise, healthy eating), and apply lessons from the business world (e.g., ending company email at the end of the day or eliminating email altogether) to minimize their risk of burnout.

Burnout seems to be a much more complex issue, however.  After all, physicians are not victims of their own vulnerabilities.  Rather, they are highly successful and competent architects of their own success.  Indeed, The Canadian Physician Health Survey found that doctors work hard to promote their own good physical health:

- only 5% reported poor physical health that interfered with practice

- only 8% were obese

- only 3% smoked cigarettes

- only 1% consumed 5 drinks or more on a regular basis

- doctors averaged 4.7 hours of exercise per week and 

- they ate fruits and vegetables 4.8 times a day.

Fralick and Flegel's nod to mindfulness is a wise one.  The literature is full of solid studies showing very positive links between mindfulness and physical/mental health gains for physicians.  Even the New York Times has blogged about mindfulness and emphasized its value for all.  

Their suggestion of implementing lessons from the world of industry is more thought provoking. But reducing or ending email (or other such digital intrusions or work extensions) may not be enough.  And duty hour regulation is an issue that has mainly focused on the training years of the physician life cycle.  The natural consequences for practicing physicians is largely unknown, and there is emerging evidence that regulated hours has a negative effect on trainees. 

Perhaps, as noted in the editorial, looking the commitments made by and expectations put on physicians for their "off-duty" time is more critical.  After all, that is when research is done, forms completed, teaching offered & meetings attended - and all largely done in a volunteer capacity.  Doubtful Volkswagen, the Bank of Montreal, Goldman Sachs Group Inc, and other corporations would have these sorts of relationships with their contractors or senior employees.  Why is this expected in medicine?

Protecting physicians from burnout will require a deeper, much deeper, approach.  Screening for and enhancing skills of resiliency, de-stigmatizing stress and mental illnesses, having rapid access to prevention and promotion programs, building highly functional teams of clinical excellence, practicing principles of appropriate human resource management, and ensuring health-workplaces are themselves modelling best practices of both work and health are critical components of change.

These principles of self-advocacy can be implemented by physicians themselves.  Indeed, if one looks at new constructs of training (e.g., CanMEDs 2015) they will be.  The future seems rather bright.

What do you do to advocate for your own health and wellness?

When to stop: Normal Cognitive Decline Amongst Aging Physicians

The Newfoundland and Labrador Medical Association hosted its first physician-health retreat, Safe Harbour,  this past weekend.  One of the attendees pulled me aside and shared their concern about their memory, concentration, and processing speed.  I suggested they talk with their family physician and see if a formal assessment by a neuropsychologist was in order.

Which led me to wondering about the aging population of physicians in Canada and how the profession will address this question on a systematic basis.  Drs. Lee and Weston looked at this issue in detail in the Canadian Family Physician in 2012.  Their observations were sobering:  by 2026, 20% of Canadian doctors will be over 65 years old and it is expected that 13% will develop dementia and another 20% will have mild cognitive impairment.  About 1/3 of physicians with competency concerns are likely to have moderate to severe cognitive impairment and physicians tend to have minimal insight into their own cognitive decline.

Lee and Weston took a thoughtful approach in giving advice to physicians like the one I met in Newfoundland - consider slowing down the pace of practice, take concerns raised by others about cognitive ability or competency seriously, take one's own concerns about cognition very seriously, maintain a healthy lifestyle, and plan for one's own retirement.

This is going to be an increasingly common issue in Canada - is it for you?

How heart-healthy is your cardiologist? Turns out they may not know, either.

Whenever I reflect on my adventures in Italy, I tend to remember how healthy everyone seemed to be.  Life was savoured and enjoyed.  Food was fresh, thoughtfully prepared, usually local, and full of flavour.  And everyone seemed active and in good shape.

I was surprised when I read the SOCRATES (Survey on Cardiac Risk Profile and Lifestyle Habits in a Cohort of Italian Cardiologists) study published late last fall.  Over 5000 cardiologists were contacted to complete a survey that evaluated their lifestyle habits, medication use, cardiovascular risk factors, and personal characteristics.

What did the investigators discover?  Almost 50% of the group was living with a major cardiovascular risk factor (e.g., diabetes, high cholesterol, hypertension) and almost 30% had two or more risk factors.  Only 22% were free of risk.

Interestingly, 90% of the cardiologists identified that they were living without major risk to their cardiac health.  Given that the majority of those studied identified as overweight/obese, sedentary, highly stressed, and did not take cardioprotective agents, the authors wondered to what degree to cardiologists have insight into their own heart-health.

Any cardiologists care to comment?  Is this a geographically-bound phenomena or are there other factors involved?

Avoiding Burnout in First Year Residents: "It really isn't that hard" - Dr. Elisabeth Paice

In Medicine, exciting things happen in July.  Perhaps the best is the opportunity to welcome all of our new residents to our postgraduate programs and join them in the journey of advanced training.  These are hard working, innovative, and dedicated colleagues who will help advance health and wellness around the world and it is in our collective interest to support them on that journey.

Last July, the UK published one of their first - and most shocking - studies on resident burnout.  Block et al uncovered that 76% of their first year residents met criteria for burnout.  Furthermore, residents with burnout were more likely to make clinically significant errors and described the quality of care they provided as less than satisfactory.

Dr. Eisabeth Paice, a well-known global leader in health-workplace health and wellness, made a great observation in follow up to the UK study:

"It really isn't that hard to take effective steps to reduce burnout. For a start, we can avoid work schedules that institutionalise sleep deprivation. We can ensure ready access to approachable and reliable supervisors who understand the full extent and critical importance of their roles. And we can make sure that all clinical professionals, including the new doctor, are working in well-functioning teams. None of this should be seen as an optional extra or ‘nice to do’. These steps are critical for the health and safety of new doctors and their patients, today and tomorrow."

And this July, Batra et al. have released a longitudinal study of resident burnout citing rates between 41-76% across disciplines.  Clearly, the time for hard work is here.  

What does your program do to promote sleep, quality supervision, and high-functioning teamwork?

A RCT proving an intervention to promote physician-health is effective? I'll take two.

JAMA published a great RCT a few weeks ago that just rose to the top of my to-read list.  RCT's in physician health are few and far between, and the Mayo clinic designed and implemented a very interesting study.

The intervention saw 19 biweekly facilitated physician discussion groups that reflected on elements of mindfulness, reflection, shared experience and small group learning for 9 months.  The institution helped - significantly - by providing 1 hour of paid protected time for the participants.

And what did everyone get for their 19 hours of investment?

• empowerment and work engagement increased (p=.04)
• improvement was sustained at 12 months (p=.03)
• work felt more meaningful (p=.04)
• rates of depersonalization, emotional exhaustion, and burnout decreased significantly (p=.03, .007, .002 respectively)

The fact that the intervention lasted at the one-year mark is particularly intriguing.  Hopefully, West et al., will follow this cohort long term.  He has also done research on rates of burnout amongst physicians in practice and those in training that set the stage for this useful RCT.

How much is that burnout in the window?

Burnout rates among Canadian physicians have been well-established for many years and appear to be in the range of 40-45%.

This raises a number of important questions, such as:

• how can burnout be prevented? 
• what methods of intervention work best? 
• what can the individual physician do to minimize or recover from burnout?  
• what is the role of the practice environment?  
• and how does this affect patient care in a socialized health care system?

A new study has just released the annual economic cost of physician burnout in Canada.  The total cost was $213.1 million, with $185.2 million due to early retirement and $27.9 million due to reduced clinical hours.  In terms of specialty of impact, family physicians accounted for 58.8% of the costs, with surgeons (24.6%) and other specialists (16.6%) following suit.

This is important data in our socialized health care system.  

Medical associations in Canada have already made investments in their  Physician Health Programs but such investments are targeted, rightfully, at services for ill or impaired physicians.  Funding for prevention and promotion programs has been hard to come by.

As physician health services continue to grow and evolve, targeted funding for promotion/prevention services seems appropriate.  This needs to involve a number of stakeholders in the system - Medical Schools, Residency Training Programs, Health Authorities, Provincial/Territorial Governments, and the nation's Medical Associations.

After all, wouldn't a few hundred million more dollars for patient care be worth such investment?