Beyond coping & preventing burnout, to caregiver well-being & growth

Stephen Liben MD

PEI June 2014

 

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Problems in clinicians…

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The Problem

Reaction

1. Avoiding suffering

2. Conflicts with patients and staff

3. Feeling overwhelmed, cognitive traps.

4. Unhappy professionals

5. Burnout, Unacknowledged Grief , Depression

Outcome

1. Not listening

2. Lapses in professionalism

3. Bad Outcomes/Medical errors

4. Unhappy pts & parents.

5. Leaving practice…

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1.What is wrong with me? (Diagnosis)2.What is going to happen to me? (Prognosis)3.What can be done to help me? (Treatment)4.Can you/will you, BE with me?

Will you be there for me even when I feel things are hopeless?

What do patients want when they seek medical care?

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Questions that resonate•How do we sustain & grow in the face of so much suffering that we see?

•What drains us?– Compassion fatigue…

•What energizes us in our work?

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To Not Listen To Listen Mindfully

• Example of not listening – “Why did you have to keep asking me if I knew…?”

• A momentary pause – Listening with awareness to distress

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Challenged: Within & without

• We see others struggle & are affected – Can no more be in the presence of suffering and be unaffected than go

swimming and not get wet.

• We React or Respond – – Compassion– Anger– Non-acceptance

• Can we move from being reactive to being responsive?

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Challenged: Within & without

•Lost in reactive & unhelpful patterns- – Fixing instead of listening---coming to closure too

soon (e.g. kleenex)– Not able to be there for the child and family in front of

me = lack of presence (not being there)

•Reactivity – built in, conditioned, automatic•Responsiveness – a skill we can learn

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Primary Stability

Secondary Stability

Do you turn the motorcycle steering wheel to the right or left if you want to go around a right sided-turn?

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Between Stimulus & Response

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Mindful awareness is not ethically neutral

• Mindfulness cares.

• “Caring attention to the present moment.”

• Intention to not to harm and by the proactive intention to be kind, compassionate, and generous.

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Mindful awareness is simple, but not easy.

• Sometimes it’s easy, sometimes it’s not.

• Gets easier with practice, because you’re developing a habit.

• Mindfulness practice is like building a muscle in the brain: the mindfulness muscle.

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Mindful awareness practice is not just meditation

Mindful awareness exercises :

•Formal Practice– Body scan– Yoga– Mediation

•Informal Practice– Washing hands– Hand touching doorknob.

•In the moment - S.T.O.P.18

Mindful awareness is not synonymous with joy

• The present moment is not always a pleasant moment.

• “Giving up” is not the same as “acceptance” (e.g. unwanted rain)

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Mindful awareness is not passive.

• If you let go a little you will have a little peace; let go a lot you will have a lot of peace; let go completely…

• Caring attention also means that you know when to abandon observing your present moment experience & take action to prevent harm (e.g. abusive situations)

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Mindful awareness is both the means and the end

• Mindfulness, in and of itself, is the goal.

• Wisdom is also the goal.

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Mindful Practice

1. Willingness - Intention

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Mindful Practice

1. Willingness - Intention

2. Know How – Awareness Practices– Formal & Informal methods

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Mindful Practice

1. Willingness - Intention

2. Know How – Awareness practices

3. Effort towards building capacity• “How do you get to Carnegie Hall?”

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Objective To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients.

Design, Setting, and Participants Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo).

Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians Michael S. Krasner, MD; Ronald M. Epstein, MD; Howard Beckman, MD; Anthony L. Suchman, MD, MA; Benjamin Chapman, PhD; Christopher J. Mooney, MA; Timothy E. Quill, MD

JAMA. 2009;302(12):1284-1293. doi:10.1001/jama.2009.1384.

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Main Outcome Measures: Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months.

Conclusions: Participation was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care.

Levels of Knowing

1. Not knowing (ignorance)

2. Knowing = knowledge

3. Realizing – grounded in lived experience

4. Actualizing – bringing the knowing into moment to moment awareness

Example – Universality death27

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Beyond coping…

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3 questions to help dig for the reactive/unconscious subroutines

• Look at difference between intention and the result or outcome. = if there is a difference then reactivity is present. How to get curious about these reactive patterns?

• Ask these 3 questions ;– What do I not notice , – What do I not question,  and – What am I not able to see some humor in…

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ClinicianPerson

Disease

Healing

Curing