Burnout, Stress, and Resilience

Kathi J Kemper, MD, MPH

Director, Center for Integrative Health and
Wellness, OSUMC
Professor, Pediatrics; Nursing; Dietetics
 Learning Objectives

By the conclusion of this presentation,

the participants will be able to:
 Define burnout and its epidemiology
 Describe the feasibility and impact of online
strategies to promote resilience
 Use free online resources to provide mind-body
skills for patients, friends, and colleagues

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3
 Unmanaged Stress makes us

 Sick
 Stupid, anxious,
depressed, forgetful
 Socially awkward
POOR CAREGIVERS

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 What is burnout?
“What started out as important,
meaningful and challenging work
becomes unfulfilling and
meaningless.”
Resilience -> Burnout
1. Energy -> Exhaustion
2. Compassion -> Cynicism
3. Efficacy -> Ineffectiveness

Maslach, et al. Ann Rev Psychol, 2001; 52: 387-422

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Stress versus Burnout:

 STRESS: over-engagement; when emotions

are over-reactive and the demeanor is one of
anxiety or hyperactivity.
 BURNOUT: disengagement; when emotions
are blunted, and the demeanor is one of
depression, detachment, helplessness or
hopelessness.
Burnout in Physicians: A Crisis
U.S. Physicians:
Significantly higher than the general population
38%-60% Burned out vs. 27%

Risks of burnout:
Alcohol/substance abuse
Broken relationships
Poor physical and emotional QOL
Irregular and poor Self-Health Care
Anxiety/Panic/Depression/Suicidal ideation

Suicide in Physicians compared to general population

1.1 to 3.4X in male physicians
2.5 to 5.7X in female physicians

Arch Intern Med. 2012;172(18):1377-1385

JAMA.2003;289:3161-3166
Lancet 2009; 374: 1714–21
JAMA 2002;288:1447-1450
Mayo Clinic Proc 2015;90: 1600-13
 Measuring Burnout
 Maslach Burnout Inventory: 22 items in 3 domains
 2 –item version of MBI (EE, DP); Single question
 Mayo Clinic Physician Well-Being Index (WBI)
During the past month . . . (Yes/No)
1. have you felt burned out from your work?
2. have you worried that your work is hardening you emotionally?
3. have you often been bothered by feeling down, depressed, or hopeless?
4. have you fallen asleep while stopped in traffic or driving?
5. have you felt that all the things you had to do were piling up so high that
you could not overcome them?
6. have you been bothered by emotional problems (such as feeling anxious,
depressed, or irritable)?
7. has your physical health interfered with your ability to do your daily work at
home and/or away from home?

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 Burnout and Engagement

Burnout Engagement

Energetic/
Depleted/
Sustainable Pace
Exhausted
Balanced Work/Life

Distant/
Dedicated/
cynical
Involved, Committed

Discouraged/ Encouraged
Lack of effectiveness, Effective, Recognized,
Depressed Valued

MP Leiter, Acadia University

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 Burnout in Physicians by Specialty

54% of all MD’s with Burnout

-Endemic
-Front-line of care
-Women > Men
-Younger age

2015 Medscape Survey

Shanafelt TD. Mayo Clinc Proc, 2015
 Burnout in Interns

 Block, Wu, et al. Postgrad Med J, 2013

 55/76 medicine interns in 3 programs completed
 47% female; mean age 29 years
 Only 30% reported adherence to all ACGME
requirements
 76% met burnout criteria
 Biggest Risk Factor: being on overnight call
rotation
 Lower burnout, better QOL and relationships,
fewer errors, better communication at sign-
outs/turnovers
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 Burnout: Prevalence, Natural History in
Stanford Pediatric Residents
N = 61

2 classes measured over 3 years of training; 46% with Burnout at some time

Pantaleoni. Acad Med 2014

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 Burnout
High Demands
Lack of Resources
Work Overload Personal Conflict
Diminished:

Control, Coping
Burnout
Exhaustion Cynicism/Depersonalization
Social Support
Diminished Accomplishments and Efficacy
Respect

Fairness Costs*

Autonomy Diminished Organizational Commitment

Consistent Values Turnover and Absenteeism

Physical Illness, Errors

Source: Maslach, Jackson, Leiter 1996

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 Resilience
 Autonomy (perceived control over life)
 Camaraderie (social support; community)
 Opportunity for Excellence
 Being part of something meaningful

Organizations can create a culture of caring,

connection, empowerment, excellence, and meaning
that supports resilience
IT is in organizations’ interest to do so.

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Impact of MD/DO Burnout on Health Care
Patient care:
Compassion reduced; higher hostility
Lower patient satisfaction
Higher incidence of medical errors
Problems with Quality of care, patient safety
Malpractice litigation
Healthcare Systems:
Absenteeism/Presenteeism
Unprofessional behavior
Poorer Quality of care
Productivity
Staff turnover, early retirement, resignation
Causes of Burnout in Physicians
“Death by a Thousand Paper Cuts”

Medscape 2015
 Risks and Strategies to Address Burnout

RISKS STRATEGIES
 High Demands  Reduce duty hours
 Low Control (ACGME rules)
 Low Support  EMR/HER/CBL
 Retreats; parties
 Screening/education
 Exhaustion  Counseling (EAP)
 Frustration  Surveys
Runyan C. Med Educ Online,  Employee Health
2016 – UMass.
 New wellness curricula
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Medscape 2015
 Workplace Culture to Support Engagement

Workload

Values Control

Burnout/
Engaged

Reward
Fairness

Community
*

www.workengagement.com
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 Intentionally Develop a Social Culture of Belonging

 Acknowledgement: say or do
something that acknowledges
another’s presence – “hello” or nod
 Appreciation: thanks for a
contribution of admiration of quality of
contribution; be specific
 Acceptance: welcome a person into
conversation, group, or project
 Accommodation: modify activities or
space to help another person work
more effectively or comfortably

http://workengagement.com/caraway (MP Leiter)

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 Burnout Management/Prevention
Individual Physicians Responsibility
Awareness/education about burnout
Have a plan for work-life balance
Improve self-care and wellness
Address professional priorities; control what you can

Health Care Organizations’ Responsibility

Workplace culture – values, fairness, respect
Address factors affecting wellness and career satisfaction
Physician recognition and intervention strategies
Mentorship – build supportive community
Optimize EHR interface

Health Care Systems’ Responsibility

Larger changes in practice of medicine
Changing business models; resources and control
Support for physicians

JAMA. 2009;301:1155-1164
Burnout and CAM
Desire and confidence
To practice high quality
Compassionate,
Patient-centered care

Yes, feel No, lack confidence

confident and in ability or support
Able to do so to do so

Learn new skills; Burnout

Fulfilling Turn to CAM

practice Change System/ Leave practice

Culture?
 Resilience Strategies: Healthy Habits, Habitat

1) Optimal, nurturing nutrition and avoiding

ingesting toxins (tobacco smoke, excessive
alcohol, misuse of prescription medications)
2) A balance of exercise (30-60 minutes/day) and
sleep (7-9 hours/night)
3) Healthy, supportive relationships with family,
friends, neighbors, colleagues
4) Meaning, purpose, and connection with
something greater than individual self
5) Healthy, supportive physical and psychosocial
environment
6) Mind-body skills for emotional self-regulation
 Training to Promote Resilience and
Compassionate Care?

 Educational
Intervention(s)
 Research Questions

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 Research Questions
 Tools: Burnout and resilience scales exist;
can we measure confidence in calm,
compassionate care? – 1 study
 Conceptual Models
 What is the relationship between the factors
we think are useful to train (mindfulness,
compassion) and outcomes of interest
(burnout, stress, resilience, confidence in
providing compassionate care – 3 studies)
 Process: Impact of cost? Bias in enrollment?
 Impact: Is training feasible/effective? – 3
studies

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 Tool: Compassionate Care
 Cross-sectional survey of 218
health professionals and trainees in
2014
 Confidence in Providing Calm,
Compassionate Care Scale
(CCCS)
 10-item scale
 Scores range 0,100; mean =67
 Cronbach’s alpha 0.87
Correlated with empathy,
compassion, mind-body training,
mind-body practice
Kemper KJ, Gascon G, Mahan JD.
European Journal Integrative Medicine, 2014

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 Conceptual Model: What factors promote
resilience and protect against burnout in
pediatric interns?
• N=45 Pediatric
Emotional  Interns at NCH
Intelligence
• Spring retreat
• Cross-sectional
Self‐ survey
Mindfulness Compassion • Standard
Resilience instruments

Burnout 
(Emotional 
Exhaustion)

Olson K, Kemper K,
Mahan JD. JEBCAM,
2015; Jul;20(3): 192-
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 Model: Factors Associated with Well-being
and Confidence in Providing Compassionate
Care
Variable 1 2 3 4 5 6 7

1 Confidence
in 1 0.91** 0.57 0.75** 0.81** 0.87** -0.92**
Compassionate
Care Scale
2 Compassion-Self 1 0.57 0.83** 0.73* 0.89* -0.79**

3 Flourishing 1 0.78** 0.67* 0.67* -0.62*

4 Mental Health 1 0.57 0.83** -0.78**

5 Mindfulness (CAMS-R) 1 0.59* -0.69*

6 Resilience (Smith, 6-item) 1 -0.88**

7 Stress (PSS) 1

Cross-Sectional survey of OSU Olson K and Kemper K. JEBCAM, 2014;

medical students 19(4): 292-6

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 From models to interventions

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 Two online courses

 HDS: Herbs and Dietary

Supplements Across the
Lifespan (http://herbs-
supplements.osu.edu)
 MBST: Mind-Body Skills
Training for Resilience,
Effectiveness, and Mindfulness
(http://mind-
bodyhealth.osu.edu)
 Both case-centered, evidence-
based; CME&CE available

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 Process: Lower Cost Increases Completion
 905 registrants for 8553 modules over 7
months in Herbs and Dietary Supplements
 847 got free registration for 8344 modules
 Completed 1505 (18%)
 58 paid for 209 modules
 Completed 90 (43%)
 Full price payers completed 62% of
modules they bought
 Margin or Mission?

Kemper KJ, Patel S. JEBCAM, 2015;20(1): 80-1

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 Process: Who Enrolls in MBS vs HDS
training? Preaching to the Choir? No
 Preference Cohort trial
 218 trainees entering graduate
programs or residencies; diverse!
 FREE online elective in HDS or MBS
 NSD between those who chose HDS
vs. MBS in terms of age, gender, stress,
mind-body training or practice,
mindfulness, empathy, compassion or
resilience
 NOT “preaching to choir”; no evidence
of self-selection bias
Kemper KJ, Mo X, Lynn J. JEBCAM,
2015;Apr; 20(2): 98-103

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 Feasibility of MBST

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 Group Online Mindfulness: Proof of Concept
 6 medical students + Family
Medicine intern
 Online http://Palouse.com
mindfulness course, done in a
group weekly for 8 weeks
 6/7 completed at least 4 sessions
 Positive effects on Stress,
Mindfulness, Resilience, and
Confidence in providing Calm,
Compassionate Care
Kemper KJ, Yun J. JEBCAM,
2015; 20(1): 73-5

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 FREE online recordings (for patients)

 Guided Imagery
http://go.osu.edu/guidedimagerypractices
 Mindfulness
http://go.osu.edu/mindfulness
 Heart-Centered Practices
http://go.osu.edu/heartpractices
 Relaxation Response
 http://go.osu.edu/relaxationresponse

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 Online OSU MB-STREAM
 12 modules; 1 hour CME for each
 Topics: Relaxation Response; Mindfulness; Heart-
centered practices (mantram meditation); Guided
Imagery
 Format
 Case
 Self-reflection
 Evidence-based info with hyperlinks
 Link to audio/video guided practice
 Clinical tips & Tools for teaching patients
 Self-reflection
 Resources

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 Process: Is purely online MBS training
feasible? Yes.
 Will health professionals enroll? Which
topics are most popular? Will
participants plan behavior changes in
desired directions?
 693 people enrolled in 1st 4 months
 57% of enrollees completed at least 1
module within 5 months of availability
 91% planned behavior change for self
(49%) or patient care (44%)

Gupta S, Kemper KJ; presented at 2015 PAS

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 Immediate Impact of online MBST? Yes
 Among 513 participants engaging in most
popular modules
 Intro to Stress, Resilience, Relaxation Response
(N=261)
 Autogenic Training (N=250)
 Guided Imagery/Hypnosis for Pain, Insomnia (N=112)
 Intro to Mindfulness (N=112)
 Mindfulness in Daily Life (N=102)
 Pre/post improvements significant for
 Stress (PSS) (P<0.001)
 Mindfulness (MAAS, CAMS-R, FFMQ) (P<0.001)
 Empathy (IRI: ECS, PT) (P=0.01)
 Resilience (Smith) (P<0.01)
Kemper KJ. JEBCAM, 2015; Rao N. JEBCAM, 2016; Kemper
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KJ, JEBCAM, 2016; Rao N, JEBCAM, 2016
 Impact over 12 weeks? Yes

 103 completed pre and post-

training questionnaires
 60 MBS
 43 NOT MBS
 Similar at baseline
 MBS completed median of 3
modules
 12 weeks later: MBS vs. NOT,
significantly better stress,
mindfulness, CCCS scores;
all P<0.01
Kemper KJ, Lynn J, Mahan JD. JEBCAM, 2015; May 11
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 14 month follow-up of 147 MBS participants

All numbers represent Spearman rank-order rho values, and all are significant at P<0.05.
 14 month follow-up of 147 MBS participants

All numbers represent Spearman rank-order rho values, and all are significant at P<0.05.
 Nationwide Children’s Hospital/OSU COM
Short Course Mind-Body Skills Training
 Four 1.5 hr workshops complemented by online MBS training (12 modules); N = 12
 [Mind-Body Skills Training for Resilience, Effectiveness, and Mindfulness (STREAM)
program]
1. Relaxation Response 2. Mindful Body Scan
3. Mindful Breathing 4. Heart-Centered Practices
5. Yoga 6. Ongoing Practice Suggestions
Booster dose: Monthly group meetings/activities; Access to MB STREAM modules
Pre/Post surveys (MBI, PSS, Resilience, 5 Facet Mindfulness, Self-Compassion)
 **Led by 3rd yr Med-Peds resident (Laura Romcevich with Mahan, Kemper)

Early Outcomes: Course worth it! Early Outcomes: Mind/Body Effects

• Online Modules useful = 77% • Stress (Cohen) 19.9->15.4*
• In-person training useful = 88% • Resilience (BRS) 19.3->23.0*
• Time investment worth it = 88% • Burnout (1 item) 2.7->2.3

* = p< 0.05

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 How to access these courses?

 http://mind-
bodyhealth.osu.edu
 > 3100 registrants in 23
months

 http://herbs-
supplements.osu.edu
 >2100 registrants in 26
months

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 Is online MBS training the only answer?

 No, but a helpful start

 Change practice environment
 Support clinicians: Stanford model
 Time Bank for committees, mentoring, covering
others’ shifts
 Exchange for
 Meals delivered to home
 House cleaning
 Errands
 Grant writing assistance

B. Schulte. Washington Post 8/20/2015

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 APPD LEARN: Pediatric Resident Burnout-Resilience
Study Consortium

Objectives:
 Describe the epidemiology and relationships between burnout,
resilience, empathy, and confidence in providing compassionate
care in pediatric and medicine-pediatric (P/M-P) residents.
 Define the natural history of these parameters over time in P/M-P
residents during training.
 Identify modifiable factors that increase or decrease the risk of
developing burnout and promoting positive wellness factors.
 Develop and test different interventions (such as in-person
seminars, on-line mind-body skills training, and individualized
curricula such as global health electives) to affect burnout,
resilience, empathy, compassion and wellness.

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 Pediatric Resident Burnout-Resilience Study Consortium
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 Nationwide Children’s/Ohio State  Medical College Wisconsin

 Seattle Children’s  University of Minnesota
 Duke  University of Pittsburgh
 John Hopkins  Rochester
 Case Western/Rainbow Babies  Chattanooga
 Children’s Mercy (Kansas)  University of Arizona
 Cincinnati Children’s  UCLA
 Cornell  UC San Diego (Rady’s)
 Dayton Children’s  UC Davis
 Montefiore/Einstein  U Illinois
 Lurie Children’s/Northwestern  UT TMC
 Mayo Clinic  U Wisconsin
PIMR Curriculum: 100 Hours in National Pilot
Introduction to Integrative Medicine
 Foundations of IM
 Pediatric Integrative Medicine
 Motivational Interviewing
Self Care
 Burnout & Stress
 Mindfulness in Medicine
 Anti-inflammatory Diet
 Sleep & Exercise
Mind Body
 Integrative Mental Health
 Spirituality & Health Care
 Mind-Body Medicine in Practice
Nutrition & Physical Activity
 Nutrition Fundamentals
 Nutrition Case Studies
 Physical Activity for Children
Dietary Supplements
 Botanical Foundations
 Micronutrients and Supplements
 Vitamins and Minerals
 Common Dietary Supplements
Whole Systems
 TCM, Ayurveda, Naturopathy, Homeopathy
 Manual Medicine
Clinical Focus
 Intake & Treatment Plan, ADHD, Autism,
Immunizations, Environmental Medicine,
Respiratory, Dermatology
PIMR Site Map
 Summary: Build Resilience
 Address workload, resources, control, values,
fairness, reward, community
 Address organizational culture
 Acknowledge
 Appreciate
 Accept
 Accommodate
 Promote individual well-being
 Diet, exercise, sleep, health care, environment
 Mind-Body Skills Training
 More training: time management, self-reflection,
communication skills
 Counseling and support
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 Thank you!

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 Confidence in Compassionate Care Scale
(CCCS)
In what percentage of your patient encounters do
you…
1. … practice being peaceful and focused?
2. … trust your intuition?
3. … use non-drug therapies to help a patient
feel better?

Scoring: 0 = 0; 10% = 1; 20% = 2; 30% = 3;

100% = 10
Plus 7 following questions…

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 Confidence in Compassionate Care Scale
(CCCS)
How confident do you feel today (0 = not confident; 10- very confident)
4. I can be peaceful and focused when my body is quiet and still, and it
is quiet in my environment.
5. I can be peaceful and focused when my body is moving or there is
noise in the background.
6. I regularly practice non-verbal, non-pharmacologic approaches to
calming and reassuring patients.
7. I am confident in being calm, peaceful and focused before and during
patient encounters.
8. I can extend kindness, peace, and compassion to patients.
9. I can extend kindness, peace, and compassion to colleagues.
10. I can extend kindness, peace, and compassion to myself.

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