Being well while

being a doctor

Shelley Aggarwal MD, MS

Division of Adolescent Medicine

1
Settling in…

- Release
- Balance
- Calm
• What happens in Vegas… ends up on Facebook.
• So, let’s keep it between the team.

Jen Carlson
3 Things and Choice
• #1
• Discuss the concept of stress in
the workplace and how it has
evolved into the wellness
conversation
• Recognizing the signs of professional
exhaustion

• #2
• Discuss some core concepts of
being well: resilience, happiness,
mindfulness
• Practice…

• #3
• Discuss how to pass it on (but
mainly let’s start with taking care of
ourselves)
Stress… in the 20th century
Stress: Fight or Flight – 1915
• Bodily Changes in
Pain, Hunger, Fear
and Rage: An Account
of Recent Researches
into the Function of
Emotional Excitement

• Concept: animals react

to threat by a
discharge in the
Walter Bradford Cannon, M.D.
nervous system
Stress:
General Adaptation Syndrome – 1936
• Diseases of
adaptation: ulcers,
high blood pressure,
arteriosclerosis,
arthritis, kidney
disease, and allergic
reactions.

Hans Selye
Stress: seen and unseen
The Stress System
• Hypothalamic-Pituitary- • Mental Activity Can Lead to
Adrenal Axis
• Increased blood pressure
• Increased heart rate
• Pain and discomfort
• Anxiety
• And on and on…
Brain
Changes in the Brain
• Dendritic remodeling and stress
exposure
• The Hippocampus
• Memory impairment?
• The Pre-Frontal Cortex
• Executive functioning?
• The Amygdala
• Anxiety and hypertrophy
• More to be learned about
the adolescent brain
(Romeo 2006)
(Lupien 2009)
(Romeo 2013)
Stress…good, bad, and chronic
History

From: Constance Ange. Clinician burnout in Contemporary Medicine

Stress
Burnout
Burnout
• What is happening to • “Life is never made
doctors? unbearable by
circumstances, but
only by lack of
meaning and purpose.”
• Viktor Frankl
Burnout…
Burnout…
Physical,
emotional and
mental
exhaustion
caused by
long term
involvement in
emotionally
demanding
situations
Burnout
• Role Overload –
expectations of others
exceed one’s ability to
perform

• Role Conflict – forced to

make a choice about
which demand to satisfy
• ex) child’s soccer game vs.
staying late to see patient
or complete paperwork
Burnout in Healthcare
Definition Contributing Factors

• 3 Dimensions • Professional isolation

• Emotional exhaustion • Working with a difficult
• Feeling low personal population
accomplishment • Long hours with limited
• Depersonalization of the resources
patient • Ambiguous success
• Unreciprocated giving
• Failure to live up to one’s
own expectations
• Personality Variables
The cost of a burned out doc
• Effect on patient care and safety
• Patient medication adherence
• Physician recommended evidence based screening and health
counseling reduced when physicians have poor personal health
• Reduced workplace productivity and efficiency
• Cost of replacing a physician (150-300 K, maybe 1million)

(Wallace, 2009)
Burnout
• Why is it happening • “I swear by Apollo
to doctors? To the Physician and
people who choose to Asclepius and Hygieia
become doctors? and Panaceia and all
the gods and
goddesses, making
them my witnesses,
that I will fulfil
according to my ability
and judgment this oath
and this covenant:”
Hippocratic Oath
Declaration of Geneva of the World Medical
Association: (adopted 1948, amended 1966 and 1983)
• I solemnly pledge myself to consecrate my life to the service of
humanity;
• I will give my teachers the respect and gratitude which is their due;
• I will practice my profession with conscience and dignity;
• The health of my patient will be my first consideration;
• I will respect the secrets which are confided in me, even after the
patient has died;
• I will maintain by all the means in my power, the honor and the noble
traditions of the medical profession;
• My colleagues will be my brothers;
• I will not permit considerations of religion, nationality, race, party
politics or social standing to intervene between my duty and my
patient;
• I will maintain the utmost respect for human life from its beginning
even under threat and I will not use my medical knowledge contrary to
the laws of humanity;
• I make these promises solemnly, freely and upon my honor.
(Nedrow 2012)
Compassion Fatigue (CF)
Definition Contributing Factors

• State of exhaustion and • Helplessness

dysfunction (biologically, • Feeling incapable of
psychologically, and effecting successful patient
socially) as a result of outcomes
prolonged exposure to • Confusion
secondary trauma or a • Isolation
single intensive event • Exhaustion
• Feeling of being
overwhelmed by work
CF – PTSD?
• Most empathetic most • Hyperarousal:
• disturbed sleep, irritability or
likely to experience CF outbursts of anger,
• No quick fix for hypervigilance

traumatized patients • Avoidance:

• “not wanting to go there again”
• Challenging for the and the desire to avoid thoughts,
empathetic provider feelings, and conversations

• Participating in the • Reexperiencing:

patient’s anguish • intrusive thoughts or dreams, and
psychological or physiological
Self care – Doctors are miserable at this
• Less doctor visits for themselves
• Self-prescribe drugs (i.e. will not see a doctor)
• Perceived (??) stigma around seeking help or support

• Willing to work when sick… and expect the same from

colleagues (but not patients)

• Denial and avoidance – physician coping strategies

• Poor record of mutual support and positive feedback in the field
• Protecting the privacy of colleagues
• Doctors are self-reliant, individually driven, achievers who are
industrious and self-sacrificing

(Wallace, 2009)
Heading off the rails…

Emotional Fatigue, insomnia, impaired concentration, somatic

exhaustion symptoms, repeated illness, loss of appetite, anxiety,
depression, anger

Feeling low Loss of enjoyment, pessimism, sarcasm (in excess),

personal isolation, detachment
accomplishment

Depersonalization Apathy, irritability (with staff, trainees, patients), lack of

of the patient productivity
When it’s more?
• 2 weeks or more of persistently diminished mood, loss of
motivation, feelings of guilt or worthlessness
• Persistent social isolation, changes in relationships
• Life interfering anxiety symptoms
• Use of alcohol, non-prescribed medications, illicit
substances
• Sustained decline in function
• Changes in eating patterns or weight loss/gain
• Suicidal thoughts or self-harming behaviors
Conclusion
• Burnout and CF exist • Has anyone ever
and they are taught you how to be
damaging, and well?
therefore we should be • At work

well. • In marriage
• In balanced nutrition
• In life…

• Who taught you? How did

they teach you?
• The impact of modeling
Awareness

Being well
10 commandments of physician wellness
I. Thou shall not expect someone else to reduce your
stress.
II. Though shall not resist change.
III. Thou shall not take thyself in vain.
IV. Remember what is holy to thee.
V. Honor thy limits.
VI. Thou shall not work alone.
VII. Thou shall not kill or take it out on others.
VIII.Thou shall not work harder. Thou shall work
smarter.
IX. Seek to find joy and mastery in thy work.
X. Thou shall continue to learn.
(Krall 2014)
Choice…
• #1: Thou shall not • “Between stimulus and
expect someone else to response, there is a
reduce your stress. space. In that space is
our power to choose
our response. In our
response lies our
growth and our
freedom.”
• Viktor Frankl.
• Man’s Search for
Meaning
Habit
• Common sense and
common action
• Just because we know
what to do doesn’t mean
we do it.

• Tetris

• We are what we
repeatedly do.
Aristotle
Wellness Strategy
Resilience: Self- compassion
• Fear of failure • I am trying… and that
• Fear of inadequacy is good
• Disappointing… • I am a good… parent,
colleagues, friends, friend, sibling,
family colleague, etc.
• I love my family and I
don’t have to show it in
just one way.
-May you be
happy.
-May you be
healthy.
-May you be free
from internal and
external harm.
-May you
experience love, joy,
and wonder just as
it is.
-May you have
ease of the day.
Resilience: Reframing
• The “black cloud” • Language frames our
• Why are all the difficult thoughts and thoughts
patient’s drawn to me? frame our language
Resilience: Appreciation and Gratitude
• Gratitude journal • Deliberately make
• Performing kind acts connections during the
and writing it down day with colleagues
and with patients
• Use humor; look for
something particular or
unusual in the patient’s
room; or notice the
patient’s birth date or
age.
When are we happy?
• When we are in the present.
• When we get what we want AND when we want what we
have.
• When we have slept.
• When we have eaten well and consistently.
• When we have manageable work loads.
• When we have healthy connections to others.
• When we are kind.
• And many more reasons…

(Achor, 2010)
(Hanson, 2009)
Partner up
• 10 seconds
• Discipline
• Resolve
• Strength

• Rejection and pain

• Yawning
How do you increase your happiness?
• https://www.youtube.com/watch?v=RP4abiHdQpc
Duchenne smile vs “say cheese”
• Voluntary and
involuntary contraction
from two muscles:
• The zygomatic major
(raising the corners of
the mouth) and the
orbicularis oculi (raising
the cheeks and
producing crow's feet
around the eyes)
• Limbic system vs. motor
cortex
Mindfulness
• Paying attention on purpose, in the
As a magical cure present moment, and
As enlightenment
nonjudgmentally, to the unfolding of
experience moment to moment.
As a burden…

Jon Kabat-Zinn

• You can use your mind to strengthen

the structure of your brain.

Dan Siegal
Benefits of Meditation
• The primary health benefit • Depression
from meditation practices • Anxiety
appears to be a general shift • Sleep
in the autonomic nervous
system that decreases • Immune Function
sympathetic tone and • Cortisol Levels
increases parasympathetic • Decision Making
tone. • Coping
• As the parasympathetic
system is stimulated, heart
rate and breathing slow,
stress hormones decrease,
blood vessels dilate, and
digestion is facilitated.
PIMR (2016)
The Brain of Meditators
• Hippocampus –
increased gray matter
• Governs learning and
memory
• Decreased in depression
and PTSD
• Amygdala
• Decreased gray matter
• Smaller amygdala
• Participants had less
reported stress
 Brain Training
Anchor
attention with
breath

Return attention
Attention
to the sensation
wanders
of breathing

Choosing the
reaction Notice that
Notice our
- Frustration reaction
attention has
vs. wandered
compassion
Juliet Adams – UK
The Mindful Brain – Physiology

• Gray Matter
• Limbic System
• Autonomic Nervous
System

• Implications for the

adolescent brain

Lazar (2005).
Hutchinson (2008).
Hanson (2009).
Holzel (2011).
Murakami (2012.
Adams (2013).
Seigal (2013). Zeidan (2013).
Sanger (2015).

48
The Practitioner and Health Care
• Interestingly, studies in psychotherapists in training who
received mindfulness training showed an improvement in
the efficacy of their counseling skills in this area as
compared to controls—mirroring the outcomes of
studies showing physicians who have adopted a
healthy lifestyle as more efficacious counselors to
their patients

Grepmair (2007)
Frank (2000)
What does self care look like for you…
• Self-compassion
• Reframing
• Gratitude and appreciation
• Humor
• ? Financial goals
• Time for yourself
• Sleep
• Food
• Aligning with your values
Stanford WellMd: http://wellmd.stanford.edu/.
Faculty and Staff Help Center – 10 Free Counseling Sessions

Pediatric Housestaff: http://peds.stanford.edu/Resident_Life/wellness.html

Resources To Access Information
• SELF-AWARENESS AND SELF-CARE
• Professional Quality of Life Scale
• http://ww
• Institute for the Study of Health and Illness at
Commonweal
• http://www.commonweal.org/ishiw.proqol.org/ProQol_Test.html
• Center for Practitioner Renewal
• http://www.practitionerrenewal.ca
• MINDFULNESS MEDITATION Spirit Rock Meditation Center
• http://spiritrock.org
• University of Massachusetts Medical School Center for
Mindfulness in Medicine, Health Care, and Society
• http://www.umassmed.edu/cfm/mbsr
• REFLECTIVE WRITING Writing and Health
• http://homepage.psy.utexas.edu
/HomePage/Faculty/Pennebaker/home2000/WritingandHealt
h.html
Technology: Apps for stress
• http://www.t2health.org/apps/tactical-breather
• http://www.t2health.org/apps/breathe2relax
• https://itunes.apple.com/us/app/stop-breathe-
think/id778848692?mt=8
• http://www.huffingtonpost.com/david-magone/stress-
meditation-_b_1671435.html
• http://www.marquette.edu/counseling/documents/DeepBreathin
g.pdf
• http://www.youtube.com/watch?v=g3k_-mciE6o
• http://www.marquette.edu/counseling/files/musclerelaxation.mp
3
• http://www.marquette.edu/counseling/files/guidedimagery.mp3
• www.calm.com
Questions…
References
• Adams, J. (2013). What happens in our brain when we practice mindfulness? Retrieved from:
http://mindfulnet.org/page8.htm.
• Achor, S. (2010). The Happiness Advantage: The seven principles of Positive Psychology that fuel success
at work. New York: Random House, Inc.
• Baime, M. (2011). This is Your Brain on Mindfulness. Shambala Sun. Retrieved from:
http://www.nmr.mgh.harvard.edu/~britta/SUN_July11_Baime.pdf
• Casey, B. J., S. Getz and A. Galvan (2008). "The adolescent brain." Dev Rev 28(1): 62-77.
• Gogtay, N., J. N. Giedd, L. Lusk, K. M. Hayashi, D. Greenstein, A. C. Vaituzis, T. F. Nugent, 3rd, D. H.
Herman, L. S. Clasen, A. W. Toga, J. L. Rapoport and P. M. Thompson (2004). "Dynamic mapping of
human cortical development during childhood through early adulthood." Proc Natl Acad Sci U S A 101(21):
8174-8179.
• Grepmair, L., F. Mitterlehner, T. Loew and M. Nickel (2007). "Promotion of mindfulness in psychotherapists
in training: preliminary study." Eur Psychiatry 22(8): 485-489.
• Holzel, B. K., J. Carmody, M. Vangel, C. Congleton, S. M. Yerramsetti, T. Gard and S. W. Lazar (2011).
"Mindfulness practice leads to increases in regional brain gray matter density." Psychiatry Res 191(1): 36-
43.
• Hutcherson, C. A., E. M. Seppala and J. J. Gross (2008). "Loving-kindness meditation increases social
connectedness." Emotion 8(5): 720-724.
• Johnson, S. B. and R. W. Blum (2012). "Stress and the brain: how experiences and exposures across the
life span shape health, development, and learning in adolescence." J Adolesc Health 51(2 Suppl): S1-2.
• Krall, E.J. (2014). “Ten Commandments of Physician Wellness” 12:6-9.
• Lazar, S. W., C. E. Kerr, R. H. Wasserman, J. R. Gray, D. N. Greve, M. T. Treadway, M. McGarvey, B. T.
Quinn, J. A. Dusek, H. Benson, S. L. Rauch, C. I. Moore and B. Fischl (2005). "Meditation experience is
associated with increased cortical thickness." Neuroreport 16(17): 1893-1897.
• Luna, B., D. J. Paulsen, A. Padmanabhan and C. Geier (2013). "Cognitive Control and Motivation." Curr Dir
Psychol Sci 22(2): 94-100.
• Lupien, S. J., B. S. McEwen, M. R. Gunnar and C. Heim (2009). "Effects of stress throughout the lifespan
on the brain, behaviour and cognition." Nat Rev Neurosci 10(6): 434-445.
References
• Murakami, H., T. Nakao, M. Matsunaga, Y. Kasuya, J. Shinoda, J. Yamada and H. Ohira (2012). "The
structure of mindful brain." PLoS One 7(9): e46377.
• Nedrow A., Steckler N.A., Hardman, J., (2013). “Physician Resilience and Burnout: Can you make the
switch.” Fam Prac Man. 25-29.
• Neinstein L, G. C. (2008). Adolescent Health, A Practical Guide. Philadelphia: Lippincott Williams & Wilkins.
• Romeo, R. D. (2013). "Introduction to the special issue on stress and the adolescent brain." Neuroscience
249: 1-2.
• Romeo, R. D. (2013). "The Teenage Brain: The Stress Response and the Adolescent Brain." Curr Dir
Psychol Sci 22(2): 140-145.
• Romeo, R. D. and B. S. McEwen (2006). "Stress and the adolescent brain." Ann N Y Acad Sci 1094: 202-
214.
• Sanger, K. L. and D. Dorjee (2015). "Mindfulness training for adolescents: A neurodevelopmental
perspective on investigating modifications in attention and emotion regulation using event-related brain
potentials." Cogn Affect Behav Neurosci.
• Seigel, D. (2013). the Power and the Purpose of the Teenage Brain. Retrieved from:
http://ibme.info/mindfulness/mindfulness-teen-brain/
• Steinberg, L. (2004). "Risk taking in adolescence: what changes, and why?" Ann N Y Acad Sci 1021: 51-58.
• Steinberg, L., D. Albert, E. Cauffman, M. Banich, S. Graham and J. Woolard (2008). "Age differences in
sensation seeking and impulsivity as indexed by behavior and self-report: evidence for a dual systems
model." Dev Psychol 44(6): 1764-1778.
• Wallace J.E., Lemaire, J.B., Ghlai, W. A., (2009). “Physician Wellness: a missing quality indicator.” 374:
1714-1721.
• Zeidan, F., K. T. Martucci, R. A. Kraft, J. G. McHaffie and R. C. Coghill (2014). "Neural correlates of
mindfulness meditation-related anxiety relief." Soc Cogn Affect Neurosci 9(6): 751-759.
Additional Slides
The Mindful Brain – Physiology
Less aware of
environment and
less aware of space
and time

Attention increases
BUT Pre-frontal cortex
activity (emotional
responses,
planning, decisions, etc.
decreases )

Activate d
- Assign emotional
significance to our
experiences – modify
Changes in limbic system leads to modified activity of nervous
activity of the autonomic nervous system system
Compassion
• Virtue? Moral Tenet? Fundamental to provider-patient
relationship? Role Requirement for a Health Care
Professional?

• Compassion Satisfaction:
• Positive sentiment the provider experiences when able to
empathetically connect and feel a sense of achievement in the
care-providing process
• Positive reinforcement with patient’s improve and belief that
provider has made a positive impact
• Emotionally fulfilled by one’s work in the “human service fields”
Research in cognitive neuroscience
• J. Decety: Physicians
and down regulation of
the pain-empathy
response

• Additional Research
• R. Davidson:
• resilience and stress,
prefrontal cortex vs. limbic
system
Fig. 2. Expertise effects on the cortical responses elicited by the perception of body
parts pricked by a needle and body parts touched by a Q-tip. (a) N110 at FZ. (b) P3 at Cz.
(c) P3 at Pz. The ERP responses are significantly different when the Controls watched
the painful relative to the non-painful stimuli. No significant differences were detected
in the Physicians. Values are expressed as mean±SE (⁎Pb0.01).