Listening so we can HEAR,

talking so we can be
HEARD (or how to avoid
burn-out at work )

Coleen Kivlahan, MD, MSPH

CMO Aetna Medicaid Programs
INTRODUCTIONS
 A way to start this morning
► Our initial focus is to take a look at our patients and our work
environments and why they cause us STRESS
► Then we will take an inward look at ourselves, understanding more
about our own beliefs, biases, frustrations in our professional roles.

► Finally we will take a BIG outward look -- how WE interact with

others around us, our patients, other staff.

► Not only can we understand our patients and our coworkers better, we
can export these lessons to our other relationships. People who are
happier at home tend to be happier and more productive at work and
vice versa.

► GOAL FOR TODAY: increase our curiosity!!

 ONLY RULES ARE:
►Being true to what you believe
►Trusting each other as colleagues
►Not judging others
►Keeping an open heart and mind
 List YOUR frustrations
with your clinic or our patients
► Ok, I will start:
 People do not call before they cancel or no
show
 Our patients do not bring in their glucose
records
 There is no privacy here
 People do not care about their health in the way
I would like them to
 What do we believe about our
patients?
► Lifestyles?
► Choices?
► Behaviors?
► Priorities?
► Educational status?
► Poverty status?
► Life outside the clinic for them?
FACTS
 Poverty reality
► Increased mortality (more poor people die)
► Severity of illness (more poor people are sicker)
► Violence Exposure (more poor people commit and are
victims of violence)
► Less health insurance (more poor people have no source of
care except ER)
► Competing priorities (housing, transportation, food)
► Medication difficulties (access, schedule, disease
complexity)
► Health care provider reactions (many doctors do not take
Medicaid and do not care for the uninsured; they have
biases that lead to provision of poor care)  
 Shelter and poverty
► Federal minimum wage was raised to $6.55 in July ‘08.

► Minimum wage earners can’t afford 1-BR rental unit

anywhere in U.S.  

► Nationally, the housing wage for a 2-BR rental unit is

$16.31/hour – almost three times federal minimum wage;
and rising at twice the rate of inflation. In Washington DC,
$24.73/hour is needed to rent a 2BDR apt

► On average, 2.5 full time jobs per household are needed to

afford a 2-BR unit at fair market rental rate. (2007 data)
 Cross-cultural Facts
► For many of our patients:
 Faith and prayer is a method of healing
 They see local and herbal healers at the same time
they see us
 Believe in supernatural forces that hurt or
heal/voodoo
 Believe in fate or the ‘will of God’
 Believe their families should be involved in all
decisions
 Believe foods or weather cause disease
 Believe that hospitals kill people
 Believe that the ER is better quality care
DIVING UNDER THE
‘FACTS’
Exploring what is known and
unknown in our patient’s histories
Case presentations: what is KNOWN,
what is UNKNOWN?
► 1) 29 year old Egyptian woman working at airport with erratically
controlled Type I DM. Thin, attentive, bright, brings med and glucose
readings, food diary. Anxious.
 Unknown: Hx of pituitary adenoma on bromocriptine. Wants to be
pregnant, married to her first cousin, only working member of family
► 2) 44 year old Latina with uncontrolled Type II DM and obesity.
 Unknown: She will not take glipizide because she believes it makes her
gain weight, but tells the nurse she takes all her meds, uses Advil PM to
sleep. Only son died in MVA in December.
► 3) 45 year old El Salvadoran normal weight woman with uncontrolled
HTN on 4 meds.
 Unknown: 20 year old son in wheelchair with CP and psychosis; she is
unemployed after 16 years at KMart because she is sole caregiver for
children
► 4) 56 year old Ethiopian man with HTN and angina.
 Unknown: In Ethiopian army, translator for US military, now in US and wife
filed restraining order against him for DV. He tells me that women are
supposed to be quiet and take care of men. He cannot understand that
after 30 years of marriage his wife seems angry all the time.
 WHAT IS THE REALITY ABOUT GOING TO THE
DOCTOR/APN WHEN YOU HAVE CHRONIC
ILLNESSES?
► Scared and afraid
► Confusing
► Nervous
► Angry
► Chronic pain
► Denial
► Bad news
 What is:
► KNOWN: ► UNKNOWN:
► Afraid ► Afraid of WHAT? (us, their
► Not being fully truthful or diseases, family beliefs,
revealing dying…)
► Guilt or shame ► What prior health care
► Hopeless or helpless experiences lead them to
be not fully revealing
► Angry ► Shame about what?
► In pain (family secrets, being
► Confused immigrant or different,
being sick or helpless)
► Angry about what?
 PATIENT CHALLENGES
► Poverty is associated with factors that increase
health care utilization and reduce adherence to
medical regimens
► There are unique driving forces in poverty:
 Relationships
 Survival
 Entertainment
 UNDERLYING FORCES:
► Food
► Time
► Power/self-management
► Destiny
 PATIENT PATTERNS
► Focus on survival and crises can increase ‘no
show’ rates
► Focus on relationship can increase lack of trust
in authority
► Focus on destiny can lead to poor self-
management
► Focus on entertainment can increase the
likelihood that YOUR goals and the patient’s are
not in alignment, not shared
► Focus on family and time can increase likelihood
of not doing effective self-management, self-care
 10 RULES for serving low-income,
language-diverse populations:
1) create a relationship
2) focus on the people
3) reduce the words
4) emphasize action
5) invite and involve the whole family
6) choose accessible, comfortable program sites to reach where THEY are
7) choose appropriate times
8) feature small group activities
9) choose an appropriate length of activities
10) spend money on supplies, not paper for education
(Language Sensitive Health Education—Lessons from the Field; California
Journal of Health Promotion, June 2003; 1(2): 3–12)
 Tips for Staying Healthy :
A Lifestyle/Medical Approach
► Don’t have poor parents.
► Don’t live in a poor neighborhood.
► Practice not losing your job and don’t
become unemployed.
► Don’t be illiterate.
► Don’t be poor. If you can, stop. If
you can’t, try not to be poor for too
long. (CDC)
 So WHY are you here?
►A job?
► A passion?
► Guilt?
► Care?
► Faith?
► Boredom?
► Commitment?
 Burnout
► It is a stress syndrome, felt as emotional exhaustion.
► Its parameters often have
 somatic (exhaustion, insomnia, GI symptoms, rapid breath)
 emotional (sadness and depressed mood, negativism, decreased
creativity and increased cynicism)
 interpersonal manifestations (quickness to anger, defensiveness,
edgy and ready to blame others, and a negative world -view)
► It is often correlated with the process of grief, as a work-
life dream is lost.
► Depersonalization of patients and distancing develop
in patient/staff relations and disorganization and
ineffectiveness increase.
 Burnout, cont…
► People suffering from burnout seem to progressively
feel a lack of personal accomplishment in their
work.
► Patients are apparently less satisfied when receiving
care from burned-out physicians and health professionals.
► Staff are less committed and less contributory to the
continuing success of the practice.
► As the burnout-process progresses burning out providers
prefer to decrease contact with patients/staff,
become less respectful listeners, behave irritably,
order more tests, refer patients to others and plan to
leave patient care as early as possible.
 Causes??
► No single factor causes individual burnout
► BUT, the question “Is your personal identity bound
up with your work role or professional identity?” is
HIGHLY correlated
► Merging personal identity with professional identity
blends professional and non-work roles, usually
subverting non-work.
 Burnout Risk Survey
► Are your achievements your self-esteem?
► Do you tend to withdraw from offers of support?
► Will you ask for/accept help?
► Do you often make excuses, like, “It’s faster to do it myself than to show or tell someone?
► Do you always prefer to work alone?
► Do you have a close confidant with whom you feel safe discussing problems?
► Do you “externalize” blame?
► Are your work relationships asymmetrical? Are you always giving?
► Is your personal identity bound up with your work role or professional identity?
► Do you value commitments to yourself to exercise/relax as much as you value those you
make to others?
► Do you often overload yourself—have a difficult time saying “no?”
► Do you have few opportunities for positive and timely feedback outside of your work role?
► Do you abide by the “laws:” “Don’t talk, don’t trust, don’t feel?”
► Do you easily feel frustrated, sad or angry from your regular work tasks?
► Is it hard for you to easily establish warmth with your peers and/or service
(patients/clients) recipients?
► Do you feel guilty when you “play” or rest?
► Do you get almost all of your needs met by helping others?
► Do you put other’s needs before or above your own needs?
► Do you often put aside your own needs when someone else needs help?
 Predictors of work stress
► Demands of solo practice, long work hours, time
pressure, and complex patients
► Lack of control over schedules, pace of work, and
interruptions
► Lack of support for work/life balance from
colleagues and/or spouse
► Isolation due to gender or cultural differences
► Work overload and its effect on home life
 BIG risks
► At risk earlier in career
► Lack of Life-partner
► Attribution of achievement to chance or
others rather than one’s own abilities
► Passive, defensive approach to stress
► Lack of involvement in daily activities
► Lack of sense of control over events
► Not open to change
 Signs
► Stress Arousal: anxiety, irritability, hypertension,
bruxism, insomnia, palpitations, forgetfulness, and
headaches.
► Energy Conservation: Work tardiness,
procrastination, resentment, morning fatigue,
social withdrawal, increased alcohol or caffeine
consumption, and apathy.
► Exhaustion: Chronic sadness, depression, chronic
heartburn, diarrhea, constipation, chronic mental
and physical fatigue, the desire to “drop out” of
society.
 Adaptations and Consequences
► Longer Work hours: If I work harder, it will get
better.
► Withdrawal, absenteeism, and reduced
productivity.
► Depersonalization: attempt to create distance
between self and patients/trainees by ignoring the
qualities that make them unique individuals.
► Loss of professional boundaries leading to
inappropriate relationships with patients/trainees.
► Compromised patient care.
 Maslach Burnout Inventory
(CPP, Inc)

 Designed for use in health care and other service

industries.
 Evaluates emotional exhaustion, depersonalization, and
reduced personal accomplishment.
 Well-validated; readily available; utilized by Physician
Worklife Study.
 10-15 minutes to complete.
 Cost: approximately $1.25 per test, with additional fee
for scoring key.
 Self Assessment Exercise
(Girdin, 1996)
How often do you . . .a) almost always; b) often; c) seldom; d) almost
never

 find yourself with insufficient time to do things you really enjoy?

 wish you had more support/assistance?
 lack sufficient time to complete your work most effectively?
 have difficulty falling asleep because you have too much on your mind?
 feel people simply expect too much of you?
 feel overwhelmed?
 find yourself becoming forgetful or indecisive because you have too
much on your mind?
 consider yourself in a high pressure situation?
 feel you have too much responsibility for one person?
 feel exhausted at the end of the day?

► Calculate your total score: a) = 4, b) = 3, c) = 2, d) = 1.

► A total of 25-40 indicates a high stress level that could be
psychologically or physically debilitating.
 Additive stressors
► Despite the notion that burnout is primarily linked to work-
related stress, personal life events also demonstrated a
strong relationship to increased professional burnout
► In spite of achieving career and financial success, health
professionals are stressed and overworked, often losing
sight of their career goals and personal ambitions. The
resulting frustration, anger, restlessness, and exhaustion
adversely affect the quality and costs of patient care.
► Additional dangers include compassion fatigue/burnout and
vicarious post-traumatic stress disorder in health care
settings, especially Medicaid and the uninsured.
BIO-BREAK?

 RESULT?
► WE get frustrated and can give up
► WE begin to believe that our patients are ‘non-compliant’
and they do not value our work, we get angry at them
or each other
► WE get lost in the complexity of THEIR lives
► WE make assumptions about their choices and their
behaviors
► WE cannot prioritize what works, what is truly impactful
action
► WE implement punitive policies, like three strikes, can
occur
► Burnout can occur for all of us
COUNTERPRODUCTIVE STRATEGIES
► Our assumptions are wrong at least 50% of the
time
► Scare tactics rarely work for any of us
► Punitive approaches to patient accountability have
been shown to be just that: punitive for all of us
 Yelling at or arguing with patients
 Belittling or shaming them
 Implying they are “bad” because they did not bring
glucose monitors, meds or were not “compliant”
 Rushing people through complex processes
 Three strikes policies
How do we keep the joy
and wonder in everyday
practice?
 OUR TASKS
► Resist depersonalizing our patients
► Practice empathy
► Walk in their shoes; ask What can I do for you
TODAY?
► Hold them and yourself accountable for what we
CAN do
► STOP talking and listen
► Ask patient to repeat your instructions to clarify
understanding
► Take a BREAK or talk to other staff after clinic
► Most importantly, Stay curious
 IS THIS POSSIBLE?
► YOU BET!
► Our members/patients deserve our best work
► We can innovate and measure results
► We can focus on the whole person, not their
disease or collection of diseases
► We can focus on slow and steady steps toward
goals, with patient’s priorities as #1
► We can speak up when things are not working;
and volunteer to fix it!
 PROFESSIONAL BURNOUT
REDUCTION STRATEGIES
► Curiosity

► Respect (from the Latin “respecere” =to LOOK

again)
► Adventure (Excitement about the chance to get
inside the cultures and beliefs of our patients)
► Risk-taking
► Flexibility
► Perspective
 CURIOSITY:
WONDER WHY? Why is she
angry, why is he uncontrolled
on his meds, why is this not
working, why am I so
engaged/attached?
STAY OPEN to learning more,
laughing more
 RESPECT:
respectful deference
includes being honest with
our patients, showing
respect for their beliefs and
culture AND decisions;
giving information so they
can make decisions
 ADVENTURE:
if we cannot get excited
about learning about other
countries, other cultures,
other people and ourselves,
it is time to get help or get
out
 RISK-TAKING:
volunteer for a new role; take a risk
with patients, tell them the truth,
kindly and with best intent; be fully
present and do not assume you have
ANYTHING to offer except your
skills; tell your boss that workload,
time pressure or role conflicts are
problems
 FLEXIBILITY:
consider new ways of doing
your current job; take some
time off; talk to colleagues;
new schedules/workloads;
learn new skills like
mindfulness and meditation
 PERSPECTIVE:
the PATIENT is the one with
the problem; balance empathy
and connection with distance;
GET A LIFE ; try seeing
BOTH the sacredness of what
we do and the small impact
we actually ever make on
others’ lives
 LEARN
► Listen with understanding to the patient's perception of
the problem
► Explain your perceptions of the problem and your strategy
for treatment
► Acknowledge and discuss the differences and similarities
between these perceptions
► Recommend treatment while remembering the patient's
cultural parameters
► Negotiate agreement. Understand the patient's
explanatory model so medical treatment fits in cultural
framework
 (Berlin EA, Fowkes WC.1983) 
Cultural Humility vs Competence
► Humility demands that we self-evaluate how our personal
biases may affect care delivery
► Humility changes the power imbalances in patient-provider
dynamic
► We become more aware of who uses, and who needs our
services
► We are always learning, every day. We STAY CURIOUS.
► The two important paths to cultural competency
development are self-reflection about one’s cultural
identity and beliefs, and experiences with cross-cultural
encounters.
 WATCH OUR LANGUAGE:
A 72 year old lady who falls and breaks her
hip while sweeping her steps

► You shouldn’t be sweeping steps at your age

► You need to hire someone to do that for you
► Can’t your son help you out?
► Stop worrying about cleaning, let’s take care of
your hip, Dear
► For many people, it can be very scary to break a
bone; I wonder what it is like for you? What does
this mean for you?
 ADHERENCE
► We know it as: Compliance-the obedience of patient in
following our orders
► By using the word compliant, we assume a power
differential between us and the patient that erodes trust:
WE are the doctor, YOU are NOT! We know your body
better than YOU do. We know what is RIGHT for you. If you
would JUST do what we say, you would be better now.
► Adherence relies on RELATIONSHIP, TRUST,
INFORMATION, CHOICE, ACCEPTANCE
► Adherence implies consensus, a joint or shared responsibility
to the goals we select together
► It is an ongoing negotiation!
 Active Listening
► Attend and observe
► Resist internal distractions
► Suspend judgment
► Reflect on the content, feeling and
meaning of what you hear
► Respond as best as you can
► “You’re saying ___________.” 
 Four types of protective voices
► People need to have to ensure that they have access to
voices that provide:
 Balance (family, partner, hobbies)
 Perspective (humor, distance, silliness)
 Growth (learning, training)
 Challenge (new roles, new work, confront imbalance)
Physicians, nurses, and allied health professionals can formulate a
personally-designed self-care protocol for themselves.
► Overcoming Secondary Stress in Medical and
Nursing Practice: A Guide to Professional Resilience
and Personal Well-Being by Robert J. Wicks offers an
extensive bibliography of recent research, clinical papers,
and books on medical-nursing practice and secondary
stress.
 Homeless (AND the
uninsured) people are the
sum total of our dreams,
policies, intentions, errors,
omissions, cruelties, and
kindnesses as a society. 
(Peter Marin, sociologist) 
THANK YOU ALL