Session 9 farnan the patient with complex chronic pain
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This document discusses physician wellness and burnout. It notes that physicians are prone to qualities like perfectionism and compulsiveness that can lead to overwork, neglect of health, and relationship issues. Chronic stress from heavy workloads can cause emotional exhaustion, reduced personal accomplishment, and depersonalization among physicians. Maintaining balance, prioritizing relationships and self-care, practicing in a supportive culture, and finding meaning outside of work are important for physician wellness and preventing burnout.
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Session 9 farnan the patient with complex chronic pain
1. The Foundation for Medical Excellence
Vancouver
March 8 2014
Dr. Paul A. Farnan
farnan@mail.ubc.ca
2. Physicians – Qualities and Vulnerabilities
The House of Medicine
Acute V Chronic Illnesses
Pain Patients at Risk?
Clinicians at Risk?
Stress, Burnout, Mental Health
Staying well
4. • Competitive, Controlling, Perfectionistic
• We ultimately start to assimilate the values,
attitudes of the profession
• OverWork is the norm
• Blurred boundaries
• Neglect health and relationships
• ‘Psychology of Postponement’
5. Work in the House of Medicine
Judging ourselves by what we do rather than by
who we are
Work is placed in an exhalted position because it
is important to be successful or to be seen to be
successful by our peers
Work can become a state of mind rather than a job
Work starts to control our lives
6. Postpone Gratification
Attention to the needs of marriage is regularly
postponed
Assume that delay will not jeopardize quality of
relationship
Preference for work
Psychology of avoidance
To escape emotional intimacy
Gabbard & Menninger 1989
7. We admit the Respectable
but conceal the Darker side
• Passion for work
• Non-stop schedules
• Obsession for work
• Shows us in a good light
and glorifies ‘workaholism’
• Also perpetuates the myth
that it brings only positive
outcomes
• Anxiety
• Depression
• Chronic Fatigue
• Family Tensions
• Relationship Strains
• Life has become
unmanageable
• Loss of Control
• ‘No Time’
10. Patient with CCP
Complex
Unhappy
Have not responded or are made worse by
pharmacotherapy
Attempted rescue by MD makes it worse
Solutions are largely non-medical
11. Dysfunctional/alcoholic family of origin
Emotionally traumatized
Past episode of SUD
Stimulus augmenters - deficit in hedonic tone
Lack effective coping skills
Dependent traits
Problems with relationships
Savage 1991
13. Stress is the automatic non-specific response
of the human organism to any change or
demand.
Stress is a particular relationship between the
person and the environment that is appraised
by the person as taxing or exceeding his or
her resources and endangering his or her
well-being.
The response is mediated by the autonomic
nervous system.
14. Acute & Chronic Stress
Acute Stress: the threat is immediate and the
need to respond is instantaneous.. Adrenaline
and noradrenaline of the adrenal gland
Chronic Stress: the threat is prolonged and
unabated, and it usually involves the presence in
the blood of cortisol.
15. Freudenberger – occupational exhaustion in those
in the helping professions
(1980) “a state of fatigue or frustration brought
about by devotion to a cause, way of life, or
relationship that failed to produce the expected
reward”
Not just physical tiredness – it is an erosion of the
soul in people with ideals and commitment
16. 1. Emotional Exhaustion – feeling emotionally
overrun/exhausted by one’s work – little left to give
1. Reduced Personal Accomplishment – perception
of clinical ineffectiveness, dissatisfaction with
achievement
1. Depersonalization – Becoming distant and cynical,
view others as objects, avoidance of people. Negative
attitude towards others and self
Maslach
18. Read the twenty-five statements below and grade
how much each one pertains to you, using the
following scale:
1 = never true;
2 = sometimes true;
3 = often true; and
4 = always true.
When you are finished, add the numbers in the
blanks for your total score.
Chained to the desk – A Guidebook for Workaholics
Bryan E. Robinson, Ph.D.
20. 20
Physician at Risk
Strong relationship with patient
Unresolved rescue fantasies
The ‘special patient’
Inability to set limits
Overconfidence
Denial about possibility of boundary issues
21. Medical profession does not encourage physicians to
admit health vulnerabilities or seek help
- Levine & Bryant, 2000
‘Illness doesn’t belong to us. It belongs to them, the
patients. Doctors need to be taught to be ill. We need
permission to be ill and to acknowledge that we are
not superhuman’
McKevitt C, Morgan M.
Illness doesn’t belong to us
J R Soc Med 1997;90: 491 -495
22. Suboptimal attention to self-
wellness by MDs
'..ignorance, indifference and
carelessness of physicians towards their
own health'
Physicians neglect to have physical
examinations and procrastinate when
seeking medical treatment
23. Physician Wellness
'Wellness goes beyond merely the absence of
distress and includes being challenged,
thriving, and achieving success in various
aspects of personal and professional life’
24. 'Building Physician
Resilience'
1) Attitudes and Perspectives
2) Balance and Prioritization
3) Practice Management Style
4) Supportive Relations
Can Fam Physician 2008;54:722 9
25. Physicians – Qualities and Vulnerabilities
The House of Medicine
Acute V Chronic Illness
Pain Patients at Risk?
Physicians at Risk?
Stress, Burnout, Mental Health
Staying well
“The fool, with all his other thoughts, has this also: he is
always getting ready to live.”
- Epicurus, 341-270 BC
26. Once I get....I will be happy
Success does not precede Happiness
‘The areas that contributed most to doctor’s
happiness with their lives as physicians
seem to focus on the people they work
with, the people they live with, and most of
all the people for whom they provide
medical care’.
Relationships #1
28. Physicians and Intimate
Relationships
• “In many physicians, the character armour that
enables them to do their daily work becomes
hypertrophied and is carried from the workplace
into the home”
• “Hence, giving and receiving love in the medical
‘marriage’ becomes a challenge”
29. Family
Psychological effects of work & family shows
that the psychological health of the family has
important implications for the morale, stability
and productivity of the workplace
30. 'Worklife Balance'
'Family Relationships are central to workers
attitudes and behaviours at work'
No matter what level of professional success
we may enjoy, we are unlikely to feel fulfilled
if our personal lives are in a shambles!
31. Burnout - 6 Category
Framework
Workload(Too much work. Not enough resources)
Control(Micromanagement, Lack of influence,
Accountability without power)
Reward(not enough acknowledgement or
satisfaction)
Community(Isolation, Conflict, Disrespect)
Fairness( Discrimination, Favouritism)
Values(Ethical Conflicts, Meaningless Tasks)
Maslach & Leiter
32. Principles of Faculty
Satisfaction and Work-Life
Balance
Meaningful Work
Challenges commensurate with Skills, Interests,
and Resources
Opportunities for Professional Development
A Culture that cultivates Professionalism and
Professional Satisfaction
Autonomy and Flexible Scheduling
A Culture that Values and Encourages Life
outside of Work
A Culture of Wellness
Shanafelt, Dec 2008 Mayo Clinic
Medical School/Residency/Practice etc
Our apprenticeship model
Learn not only skills but Behaviours
Dedication to work viewed as positive trait
Emphasizes material gain through hard work
Glorify professionals who put aside family duties to work long hours
Encourages unbalanced & out of control work
Unable to slow down or to nurture ourselves (and loved ones)
Emphasis on material gain through hard work
Revere professionals who put aside family duties
Encourages unbalanced & out of control work
Assumptions that we are immune to emotional or physical ill-health
Unable to slow down or to nurture ourselves
Difficulty asking for help
Pain has an effect on physical and emotional behaviour
Pain Behaviour is an interesting social communication
This is to point out a few keys to stress management.
Acute stress is catecholamine driven
Each catecholamine burst effects the body for up to 60 minutes
Chronic stresses are re-occurring smaller events which cause release of catecholamines and cortisol
Physicians tend to enjoy the ‘rush’ of acute events, but don’t handle chronic events well at all
The pay-off for self-sacrifice never materializes
Feelings of betrayal and disillusionment with medicine