Session #: Period 3, Track H3
October 27, 2011
4:15-5PM
Promoting Provider Resiliency in
the Primary Care Medical Home
Debra A. Gould MD, MPH [email protected]
Central Washington Family Medicine Residency Program,
Yakima, Washington
Associate Clinical Professor, University of Washington, Seattle
Patricia J. Robinson PhD [email protected]
Mountainview Consulting Group, Inc. patriciarobinsonphd.com
Healthcare Consultant and Trainer, Yakima, WA
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
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Faculty Disclosure
• We currently have the following relevant financial
relationships during the past 12 months:
• New Harbinger Publications – Co-Authors
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Need/Practice Gap & Supporting Resources
What is the scientific basis for this talk?
• Burnout in Primary Care Clinicians is a current reality
Working conditions in primary care: physician reactions and care quality.
Linzer M, et. Al. MEMO (Minimizing Error, Maximizing Outcome)
Investigators. Ann Intern Med. 2009 Jul 7;151(1):28-36, W6-9.
• PCMH requires “Adaptive Reserve” for successful
practice transformation
Journey to the Patient- Centered Medical Home: A Qualitative Analysis of
the Experiences of
Practices in the National Demonstration project.
Nutting P, et. Al. Ann Fam Med 2010;8(Supp
1):S45-S55.
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Need/Practice Gap & Supporting Resources
What is the scientific basis for this talk?
• Resiliency is a dynamic, evolving process of positive
attitudes and effective strategies
Building Physician Resilience. Jensen PM, Trollope-Kumar K, Waters H,
Everson J.Can Fam Physician. 2008 May;54(5):722-9.
• Resilient clinicians are needed for primary care
practice who: value the their role, are self-aware, can
balance and prioritize, manage a practice and,
support relationships
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Objectives
• Provide a summary of research concerning resiliency
and burnout in primary care providers and primary care
residents
• Use the Primary Care Provider Stress Checklist to
determine sources and magnitude of stress
• Use the Primary Care Provider Acceptance and
Action Questionnaire to obtain an estimate of
psychological flexibility
• Identify Core Processes that support Provider
Flexibility in responding the to stresses of practice in
today's primary care medical home
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Expected Outcome
“By using self-assessment tools and learning about the
core processes of psychological flexibility, primary care
clinicians and trainees will become more self-aware
and flexible in dealing with the personal and
professional stresses of primary care and practice
transformation.”
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Learning Assessment
A learning assessment is required for CE credit.
1. Based on your PCP-SC scoring, what specific
stress area do you want to work on?
2. Of the six core processes of psychological
flexibility, which one would you like to learn
more about to help you cope with your
specific stress area?
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Burnout - Definition
“Insidious changes in attitudes, moods and behaviors
that have consequences on personal and
professional life.”
 Emotional exhaustion
 Depersonalization
 Personal Accomplishment
(Maslach Burnout Inventory)
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Burnout Rates
• Medical Students – 45%
• Residents – 27% FP to 75% OB-GYN
• Attendings – 20% - 65%
Limitations of studies – poor response rates,
definition of burn-out (EE, DP, PA).
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Burnout – Factors/Consequences
Adverse workflow
Low control
Unfavorable culture
Low MD satisfaction
High Stress/Burnout
Intent to leave
Some work conditions associated with lower quality &
more errors but findings inconsistent across work
condition & diagnosis.
MD stress/burn-out
Quality of care errors
Linzer et.al, Working Conditions in Primary Care: Physician
Reactions and Care Quality. Ann Inter Med 2009;151:28-36.
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Burnout in Primary Care – Why Care?

Substance abuse

Over-eating, over-drinking, over-working

Depression/isolation

Suicide

Leave profession

Leave current position/job

Relationship problems work

Relationship problems at home
.
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PCMH- “A Relationship Centered Approach”
1. “Adaptive Reserve” for successful practice
transformation - dealing with Constant Change !
 Healthy Relationship Structure
 Effective Communication
 Trust
 Principles for establishing Common Values
2. Aligned Management Model
3. Facilitative Leadership – empower staff, respect for all
staff, shared responsibility
Journey to the Patient- Centered Medical Home: A Qualitative
Analysis of the Experiences of Practices in the National
Demonstration project. Nutting P, et. Al. Ann Fam Med 2010;8
(Supp1):S45-S55.
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Primary Care Provider – Stress Checklist
(PCP-SC)*
Where are your areas of heaviest stress?
I. Interactions with patients
II. Practice Management
III. Administrative Issues
IV. Education/Learning
V. Relationships with Colleagues
VI. Balance between Work and Life
Available on-line
http://www.newharbingeronline.com/real-behavior-change-in-primary-care.html
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PCP Stress (PCPs A, B, C, D, E)
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PCP Stress: Interactions with Patients
Top 3: Chronic Pain, Angry Demanding, Alc / Drugs
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Physician Resiliency
• Attitudes and Perspectives – valuing physician role,
maintaining interest, developing self-awareness, accepting
personal limitation
• Balance and Prioritization – setting limits, taking effective
approaches to CME, honoring thyself
• Practice management - sound business mngmt, good staff,
effective practice arrangements
• Supportive relations – positive personal relationships,
effective professional relationships and good communication
Building Physician Resilience. Jensen PM, Trollope-Kumar K, Waters H, Everson J.
Can Fam Physician. 2008 May;54(5):722-9.
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Psychological Flexibility
(Model of Acceptance and Commitment Therapy)
Pain is inevitable, suffering isn’t!
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Psychological Flexibility
Learning to be aware and accepting of the pain
that comes into our lives while continuing to
pursue what we value.
Primary Care Provider – Action & Acceptance
Questionnaire (PCP-AAQ)
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What Can I do to become more
Psychologically Flexible?
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TEAMS (Our Private Experience)
Emotions
Associations
Memories
Thoughts
Sensations
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Core Processes – Psychological Flexibility
Experience Present
Moment
Accept TEAMS
Connection with
Values
Flexibility
Step back from
TEAMS (Defusion)
Value Consistent
Action
Use Observer Self
To See Limiting Self-stories
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Resident “Self- Management Workshops” - Schedule
Beginning of Academic Year:
•R1 - Introduction to Burnout, ACT model with focus on Values
exercises
 self assessment - MBI, AAQII/PCP-AAQ
 local resources
•R2/3 – Reminder about Burnout, ACT model with focus on Sources
of Stress, Mindfulness & Values exercises
 self assessment - MBI, AAQII/PCP-AAQ, PCP-SCL
 local resources
Mid-Year:
•R1/R2/R3 – Reminder about Burnout, ACT model with focus on
Sources of Stress, Mindfulness exercises
 self assessment - MBI, AAQII/PCP-AAQ, PCP-SCL
 local resources
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Resident Resources
CHCW
 Employee Assistant Program
 Athletic Club corporate membership
 Peers
 Advisor
 Dr. Strosahl – Behavioralist Faculty
 Health insurance – health risk assessment,
 - Gift certificate for healthy lifestyle choices; massage
therapist.
Hospital – Physician Wellness Committees
Washington State Physicians Health Program http://www.wphp.org/services
Community – family, faith community, social interests,
Farmer’s Market, Sparkpeople.com – diet & exercise
(free)
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ACT Resources
New Harbinger Publications http://www.newharbinger.com
“Association for Contextual Behavioral Science”
http://www.contextualpsychology.org/
http://www.newharbingeronline.com/real-behavior-change-in-primary-care.html
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Learning Assessment
A learning assessment is required for CE credit.
1. Based on your PCP-SC scoring, what specific
stress area do you want to work on?
2. Of the six core processes of psychological
flexibility, which one would you like to learn
more about to help you cope with your
specific stress area?
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Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!
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