Listening so we can Listening so we can HEAR, talking so we can HEAR, talking so we can

be HEARD (or how to be HEARD (or how to avoid burn-out at work avoid burn-out at work

))

Coleen Kivlahan, MD, MSPHColeen Kivlahan, MD, MSPH

CMO Aetna Medicaid CMO Aetna Medicaid ProgramsPrograms

INTRODUCTIONSINTRODUCTIONS

A way to start this morningA way to start this morning► Our initial focus is to take a look at our patients and our work Our initial focus is to take a look at our patients and our work

environments and why they cause us STRESSenvironments and why they cause us STRESS► Then we will take an Then we will take an inward look at ourselvesinward look at ourselves, ,

understanding more about our own beliefs, biases, understanding more about our own beliefs, biases, frustrations in our professional roles.frustrations in our professional roles.

► Finally we will take a BIG Finally we will take a BIG outward lookoutward look -- how WE interact -- how WE interact with others around us, our patients, other staff. with others around us, our patients, other staff.

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

► GOAL FOR TODAY: increase our curiosity!! GOAL FOR TODAY: increase our curiosity!!

ONLY RULES ARE:ONLY RULES ARE:

►Being true to what you believeBeing true to what you believe►Trusting each other as colleaguesTrusting each other as colleagues►Not judging othersNot judging others►Keeping an open heart and mind Keeping an open heart and mind

List YOUR frustrationsList YOUR frustrations with your clinic or our patients with your clinic or our patients►Ok, I will start:Ok, I will start:

People do not call before they cancel or People do not call before they cancel or no showno show

Our patients do not bring in their glucose Our patients do not bring in their glucose records records

There is no privacy hereThere is no privacy here People do not care about their health in People do not care about their health in

the way I would like them to the way I would like them to

What do we believe about our What do we believe about our patients?patients?

►Lifestyles?Lifestyles?►Choices?Choices?►Behaviors?Behaviors?►Priorities?Priorities?►Educational status?Educational status?►Poverty status?Poverty status?►Life outside the clinic for them?Life outside the clinic for them?

FACTSFACTS

Poverty realityPoverty reality

► Increased mortality (more poor people die)Increased mortality (more poor people die)► Severity of illness (more poor people are sicker)Severity of illness (more poor people are sicker)► Violence Exposure (more poor people commit and Violence Exposure (more poor people commit and

are victims of violence) are victims of violence) ► Less health insurance (more poor people have no Less health insurance (more poor people have no

source of care except ER)source of care except ER)► Competing priorities (housing, transportation, food)Competing priorities (housing, transportation, food)► Medication difficulties (access, schedule, disease Medication difficulties (access, schedule, disease

complexity)complexity)► Health care provider reactions (many doctors do Health care provider reactions (many doctors do

not take Medicaid and do not care for the not take Medicaid and do not care for the uninsured; they have biases that lead to provision uninsured; they have biases that lead to provision of poor care)  of poor care)  

Shelter and povertyShelter and poverty

► Federal minimum wage was raised to $6.55 in July ‘08. Federal minimum wage was raised to $6.55 in July ‘08.

► Minimum wage earners can’t afford 1-BR rental unit Minimum wage earners can’t afford 1-BR rental unit anywhere in U.S.  anywhere in U.S.  

► Nationally, the housing wage for a 2-BR rental unit is Nationally, the housing wage for a 2-BR rental unit is $16.31/hour – almost three times federal minimum wage; $16.31/hour – almost three times federal minimum wage; and rising at twice the rate of inflation. In Washington and rising at twice the rate of inflation. In Washington DC, $24.73/hour is needed to rent a 2BDR aptDC, $24.73/hour is needed to rent a 2BDR apt

► On average, 2.5 full time jobs per household are needed On average, 2.5 full time jobs per household are needed to afford a 2-BR unit at fair market rental rate. (2007 to afford a 2-BR unit at fair market rental rate. (2007 data) data)

Cross-cultural FactsCross-cultural Facts

► For many of our patients:For many of our patients: Faith and prayer is a method of healingFaith and prayer is a method of healing They see local and herbal healers at the same They see local and herbal healers at the same

time they see ustime they see us Believe in supernatural forces that hurt or Believe in supernatural forces that hurt or

heal/voodooheal/voodoo Believe in Believe in fatefate or the ‘will of God’ or the ‘will of God’ Believe their families should be involved in all Believe their families should be involved in all

decisionsdecisions Believe foods or weather cause diseaseBelieve foods or weather cause disease Believe that hospitals kill peopleBelieve that hospitals kill people Believe that the ER is better quality careBelieve that the ER is better quality care

DIVING UNDER THE DIVING UNDER THE ‘FACTS’‘FACTS’

Exploring what is known and Exploring what is known and unknown in our patient’s unknown in our patient’s

histories histories

Case presentations: what is Case presentations: what is KNOWN, what is UNKNOWN?KNOWN, what is UNKNOWN?

► 1) 29 year old Egyptian woman working at airport with erratically 1) 29 year old Egyptian woman working at airport with erratically controlled Type I DM. Thin, attentive, bright, brings med and controlled Type I DM. Thin, attentive, bright, brings med and glucose readings, food diary. Anxious.glucose readings, food diary. Anxious. Unknown: Hx of pituitary adenoma on bromocriptine. Wants to be Unknown: Hx of pituitary adenoma on bromocriptine. Wants to be

pregnant, married to her first cousin, only working member of familypregnant, married to her first cousin, only working member of family► 2) 44 year old Latina with uncontrolled Type II DM and obesity. 2) 44 year old Latina with uncontrolled Type II DM and obesity.

Unknown: She will not take glipizide because she believes it makes Unknown: She will not take glipizide because she believes it makes her gain weight, but tells the nurse she takes all her meds, uses her gain weight, but tells the nurse she takes all her meds, uses Advil PM to sleep. Only son died in MVA in December.Advil PM to sleep. Only son died in MVA in December.

► 3) 45 year old El Salvadoran normal weight woman with 3) 45 year old El Salvadoran normal weight woman with uncontrolled HTN on 4 meds. uncontrolled HTN on 4 meds. Unknown: 20 year old son in wheelchair with CP and psychosis; she Unknown: 20 year old son in wheelchair with CP and psychosis; she

is unemployed after 16 years at KMart because she is sole caregiver is unemployed after 16 years at KMart because she is sole caregiver for children for children

► 4) 56 year old Ethiopian man with HTN and angina. 4) 56 year old Ethiopian man with HTN and angina. Unknown: In Ethiopian army, translator for US military, now in US Unknown: In Ethiopian army, translator for US military, now in US

and wife filed restraining order against him for DV. He tells me that 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 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 understand that after 30 years of marriage his wife seems angry all the time. the time.

WHAT IS THE REALITY ABOUT GOING TO THE WHAT IS THE REALITY ABOUT GOING TO THE DOCTOR/APN WHEN YOU HAVE CHRONIC DOCTOR/APN WHEN YOU HAVE CHRONIC

ILLNESSES?ILLNESSES? ►Scared and afraidScared and afraid►ConfusingConfusing►NervousNervous►AngryAngry►Chronic painChronic pain►DenialDenial►Bad newsBad news

What is:What is:

► KNOWN:KNOWN:► AfraidAfraid► Not being fully truthful Not being fully truthful

or revealingor revealing► Guilt or shameGuilt or shame► Hopeless or helplessHopeless or helpless► AngryAngry► In painIn pain► ConfusedConfused

► UNKNOWN:UNKNOWN:► Afraid of WHAT? (us, Afraid of WHAT? (us,

their diseases, family their diseases, family beliefs, dying…)beliefs, dying…)

► What prior health care What prior health care experiences lead them experiences lead them to be not fully revealingto be not fully revealing

► Shame about what? Shame about what? (family secrets, being (family secrets, being immigrant or different, immigrant or different, being sick or helpless)being sick or helpless)

► Angry about what? Angry about what?

PATIENT CHALLENGESPATIENT CHALLENGES

► Poverty is associated with factors that Poverty is associated with factors that increase health care utilization and reduce increase health care utilization and reduce adherence to medical regimensadherence to medical regimens

► There are unique driving forces in poverty: There are unique driving forces in poverty: RelationshipsRelationships SurvivalSurvival EntertainmentEntertainment UNDERLYING FORCES:UNDERLYING FORCES:

►FoodFood►TimeTime►Power/self-management Power/self-management ►DestinyDestiny

PATIENT PATTERNSPATIENT PATTERNS

► Focus on Focus on survival and crisessurvival and crises can increase can increase ‘no show’ rates‘no show’ rates

► Focus on Focus on relationship relationship can increase lack of can increase lack of trust in authoritytrust in authority

► Focus on Focus on destinydestiny can lead to poor self- can lead to poor self-managementmanagement

► Focus on Focus on entertainmententertainment can increase the can increase the likelihood that YOUR goals and the patient’s likelihood that YOUR goals and the patient’s are not in alignment, not sharedare not in alignment, not shared

► Focus on Focus on family and timefamily and time can increase can increase likelihood of not doing effective self-likelihood of not doing effective self-management, self-caremanagement, self-care

10 RULES for s10 RULES for serving low-erving low-income, language-diverse income, language-diverse

populations: populations: 1) create a relationship 1) create a relationship 2) focus on the people2) focus on the people3) reduce the words 3) reduce the words 4) emphasize action 4) emphasize action 5) invite and involve the whole family 5) invite and involve the whole family 6) choose accessible, comfortable program sites to reach where 6) choose accessible, comfortable program sites to reach where

THEY are THEY are 7) choose appropriate times 7) choose appropriate times 8) feature small group activities 8) feature small group activities 9) choose an appropriate length of activities 9) choose an appropriate length of activities 10) spend money on supplies, not paper for education 10) spend money on supplies, not paper for education (Language Sensitive Health Education—Lessons from the Field; (Language Sensitive Health Education—Lessons from the Field;

California Journal of Health Promotion, June 2003; 1(2): 3–12)California Journal of Health Promotion, June 2003; 1(2): 3–12)

► Don’t have poor parents.Don’t have poor parents.► Don’t live in a poor Don’t live in a poor

neighborhood.neighborhood.► Practice not losing your job and Practice not losing your job and

don’t become unemployed.don’t become unemployed.► Don’t be illiterate. Don’t be illiterate. ► Don’t be poor. If you can, stop. If Don’t be poor. If you can, stop. If

you can’t, try not to be poor for you can’t, try not to be poor for too long. (CDC)too long. (CDC)

Tips for Staying Healthy :A Lifestyle/Medical Approach

So WHY are you here?So WHY are you here?

►A job?A job?►A passion?A passion?►Guilt?Guilt?►Care?Care?►Faith?Faith?►Boredom?Boredom?►Commitment?Commitment?

BurnoutBurnout► It is a It is a stress syndromestress syndrome, felt as , felt as emotional emotional

exhaustionexhaustion. . ► Its parameters often have Its parameters often have

somatic (exhaustion, insomnia, GI symptoms, rapid breath)somatic (exhaustion, insomnia, GI symptoms, rapid breath) emotional (sadness and depressed mood, negativism, emotional (sadness and depressed mood, negativism,

decreased creativity and increased cynicism)decreased creativity and increased cynicism) interpersonal manifestations (quickness to anger, interpersonal manifestations (quickness to anger,

defensiveness, edgy and ready to blame others, and a defensiveness, edgy and ready to blame others, and a negative world -view)negative world -view)

► It is often correlated with the process of grief, as a It is often correlated with the process of grief, as a work-life dream is lost. work-life dream is lost.

► Depersonalization of patients and distancingDepersonalization of patients and distancing develop in patient/staff relations and disorganization develop in patient/staff relations and disorganization and ineffectiveness increase. and ineffectiveness increase.

Burnout, cont…Burnout, cont…

► People suffering from burnout seem to People suffering from burnout seem to progressively progressively feel a lack of personal accomplishment in their feel a lack of personal accomplishment in their workwork. .

► Patients are apparently less satisfiedPatients are apparently less satisfied when when receiving care from burned-out physicians and health receiving care from burned-out physicians and health professionals. professionals.

► Staff are less committed and less contributory to the Staff are less committed and less contributory to the continuing success of the practice. continuing success of the practice.

► As the burnout-process progresses burning out As the burnout-process progresses burning out providers prefer to providers prefer to decrease contact with decrease contact with patients/staffpatients/staff, become , become less respectful listenersless respectful listeners, , behave irritablybehave irritably, , order more tests, refer patientsorder more tests, refer patients to others and plan to leave patient care as early as to others and plan to leave patient care as early as possible. possible.

Causes??Causes??

►No single factor causes individual burnout No single factor causes individual burnout ► BUT, the question “Is your personal identity BUT, the question “Is your personal identity

bound up with your work role or professional bound up with your work role or professional identity?” is HIGHLY correlatedidentity?” is HIGHLY correlated

►Merging personal identity with professional Merging personal identity with professional identity blends professional and non-work identity blends professional and non-work roles, usually subverting non-work.roles, usually subverting non-work.

Burnout Risk SurveyBurnout Risk Survey► Are your achievements your self-esteem? Are your achievements your self-esteem? ► Do you tend to withdraw from offers of support? Do you tend to withdraw from offers of support? ► Will you ask for/accept help? Will you ask for/accept help? ► Do you often make excuses, like, “It’s faster to do it myself than to show or tell Do you often make excuses, like, “It’s faster to do it myself than to show or tell

someone? someone? ► Do you always prefer to work alone? Do you always prefer to work alone? ► Do you have a close confidant with whom you feel safe discussing problems? Do you have a close confidant with whom you feel safe discussing problems? ► Do you “externalize” blame? Do you “externalize” blame? ► Are your work relationships asymmetrical? Are you always giving? Are your work relationships asymmetrical? Are you always giving? ► Is your personal identity bound up with your work role or professional Is your personal identity bound up with your work role or professional

identity? identity? ► Do you value commitments to yourself to exercise/relax as much as you value Do you value commitments to yourself to exercise/relax as much as you value

those you make to others? those you make to others? ► Do you often overload yourself—have a difficult time saying “no?” Do you often overload yourself—have a difficult time saying “no?” ► Do you have few opportunities for positive and timely feedback outside of your Do you have few opportunities for positive and timely feedback outside of your

work role? work role? ► Do you abide by the “laws:” “Don’t talk, don’t trust, don’t feel?” 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? 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 Is it hard for you to easily establish warmth with your peers and/or service

(patients/clients) recipients? (patients/clients) recipients? ► Do you feel guilty when you “play” or rest? Do you feel guilty when you “play” or rest? ► Do you get almost all of your needs met by helping others? 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 put other’s needs before or above your own needs? ► Do you often put aside your own needs when someone else needs help?Do you often put aside your own needs when someone else needs help?

Predictors of work stressPredictors of work stress

►Demands of solo practice, long work hours, Demands of solo practice, long work hours, time pressure, and complex patientstime pressure, and complex patients

► Lack of control over schedules, pace of Lack of control over schedules, pace of work, and interruptionswork, and interruptions

► Lack of support for work/life balance from Lack of support for work/life balance from colleagues and/or spousecolleagues and/or spouse

► Isolation due to gender or cultural Isolation due to gender or cultural differencesdifferences

►Work overload and its effect on home lifeWork overload and its effect on home life

BIG risksBIG risks

►At risk earlier in careerAt risk earlier in career►Lack of Life-partnerLack of Life-partner►Attribution of achievement to chance Attribution of achievement to chance

or others rather than one’s own or others rather than one’s own abilitiesabilities

►Passive, defensive approach to stressPassive, defensive approach to stress►Lack of involvement in daily activitiesLack of involvement in daily activities►Lack of sense of control over eventsLack of sense of control over events►Not open to changeNot open to change

SignsSigns

► Stress ArousalStress Arousal: anxiety, irritability, : anxiety, irritability, hypertension, bruxism, insomnia, hypertension, bruxism, insomnia, palpitations, forgetfulness, and headaches. palpitations, forgetfulness, and headaches.

► Energy ConservationEnergy Conservation: Work tardiness, : Work tardiness, procrastination, resentment, morning procrastination, resentment, morning fatigue, social withdrawal, increased alcohol fatigue, social withdrawal, increased alcohol or caffeine consumption, and apathy. or caffeine consumption, and apathy.

► ExhaustionExhaustion: Chronic sadness, depression, : Chronic sadness, depression, chronic heartburn, diarrhea, constipation, chronic heartburn, diarrhea, constipation, chronic mental and physical fatigue, the chronic mental and physical fatigue, the desire to “drop out” of society. desire to “drop out” of society.

Adaptations and Adaptations and ConsequencesConsequences

► Longer Work hours: Longer Work hours: If I work harder, it will If I work harder, it will get better.get better.

►Withdrawal, absenteeism, and reduced Withdrawal, absenteeism, and reduced productivity.productivity.

►Depersonalization: attempt to create Depersonalization: attempt to create distance between self and patients/trainees distance between self and patients/trainees by ignoring the qualities that make them by ignoring the qualities that make them unique individuals. unique individuals.

► Loss of professional boundaries leading to Loss of professional boundaries leading to inappropriate relationships with inappropriate relationships with patients/trainees.patients/trainees.

► Compromised patient care.Compromised patient care.

Maslach Burnout InventoryMaslach Burnout Inventory(CPP, Inc)(CPP, Inc)

Designed for use in health care and other service Designed for use in health care and other service industries. industries.

Evaluates emotional exhaustion, Evaluates emotional exhaustion, depersonalization, and reduced personal depersonalization, and reduced personal accomplishment. accomplishment.

Well-validated; readily available; utilized by Well-validated; readily available; utilized by Physician Worklife Study. Physician Worklife Study.

10-15 minutes to complete. 10-15 minutes to complete. Cost: approximately $1.25 per test, with Cost: approximately $1.25 per test, with

additional fee for scoring key.additional fee for scoring key.

Self Assessment ExerciseSelf Assessment Exercise(Girdin, 1996) (Girdin, 1996)

How often do you . . .a) almost always; b) often; c) seldom; d) How often do you . . .a) almost always; b) often; c) seldom; d) almost never almost never

find yourself with insufficient time to do things you really enjoy? find yourself with insufficient time to do things you really enjoy? wish you had more support/assistance? wish you had more support/assistance? lack sufficient time to complete your work most effectively? lack sufficient time to complete your work most effectively? have difficulty falling asleep because you have too much on your have difficulty falling asleep because you have too much on your

mind? mind? feel people simply expect too much of you? feel people simply expect too much of you? feel overwhelmed? feel overwhelmed? find yourself becoming forgetful or indecisive because you have find yourself becoming forgetful or indecisive because you have

too much on your mind? too much on your mind? consider yourself in a high pressure situation? consider yourself in a high pressure situation? feel you have too much responsibility for one person? feel you have too much responsibility for one person? feel exhausted at the end of the day? feel exhausted at the end of the day?

► Calculate your total score: a) = 4, b) = 3, c) = 2, d) = 1. 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 A total of 25-40 indicates a high stress level that could be

psychologically or physically debilitating. psychologically or physically debilitating.

Additive stressorsAdditive stressors

► Despite the notion that burnout is primarily linked to Despite the notion that burnout is primarily linked to work-related stress, personal life events also work-related stress, personal life events also demonstrated a strong relationship to increased demonstrated a strong relationship to increased professional burnout professional burnout

► In spite of achieving career and financial success, In spite of achieving career and financial success, health professionals are stressed and overworked, health professionals are stressed and overworked, often losing sight of their career goals and personal often losing sight of their career goals and personal ambitions. The resulting frustration, anger, ambitions. The resulting frustration, anger, restlessness, and exhaustion adversely affect the restlessness, and exhaustion adversely affect the quality and costs of patient care.quality and costs of patient care.

► Additional Additional dangers include compassion dangers include compassion fatigue/burnout and vicarious post-traumatic stress fatigue/burnout and vicarious post-traumatic stress disorder in health care settings, especially Medicaid disorder in health care settings, especially Medicaid and the uninsured.and the uninsured.

BIO-BREAK? BIO-BREAK?

RESULT?RESULT?► WE get frustrated and can give upWE get frustrated and can give up► WE begin to believe that our patients are ‘non-WE begin to believe that our patients are ‘non-

compliant’ and they do not value our work, we compliant’ and they do not value our work, we get angry at them or each otherget angry at them or each other

► WE get lost in the complexity of THEIR livesWE get lost in the complexity of THEIR lives► WE make assumptions about their choices and WE make assumptions about their choices and

their behaviorstheir behaviors► WE cannot prioritize what works, what is truly WE cannot prioritize what works, what is truly

impactful action impactful action ► WE implement punitive policies, like three strikes, WE implement punitive policies, like three strikes,

can occur can occur ► Burnout can occur for all of usBurnout can occur for all of us

COUNTERPRODUCTIVE COUNTERPRODUCTIVE STRATEGIESSTRATEGIES

► Our assumptions are wrong at least 50% of Our assumptions are wrong at least 50% of the timethe time

► Scare tactics rarely work for any of usScare tactics rarely work for any of us► Punitive approaches to patient accountability Punitive approaches to patient accountability

have been shown to be just that: punitive for have been shown to be just that: punitive for all of usall of us Yelling at or arguing with patientsYelling at or arguing with patients Belittling or shaming themBelittling or shaming them Implying they are “bad” because they did not Implying they are “bad” because they did not

bring glucose monitors, meds or were not bring glucose monitors, meds or were not “compliant”“compliant”

Rushing people through complex processesRushing people through complex processes Three strikes policiesThree strikes policies

How do we keep the joy How do we keep the joy and wonder in everyday and wonder in everyday

practice?practice?

OUR TASKSOUR TASKS► Resist depersonalizing our patientsResist depersonalizing our patients► Practice empathyPractice empathy► Walk in their shoes; ask What can I do for Walk in their shoes; ask What can I do for

you TODAY? you TODAY? ► Hold them and yourself accountable for what Hold them and yourself accountable for what

we CAN dowe CAN do► STOP talking and listenSTOP talking and listen► Ask patient to repeat your instructions to Ask patient to repeat your instructions to

clarify understandingclarify understanding► Take a BREAK or talk to other staff after clinicTake a BREAK or talk to other staff after clinic► Most importantly, Stay curiousMost importantly, Stay curious

IS THIS POSSIBLE?IS THIS POSSIBLE?

► YOU BET!YOU BET!►Our members/patients deserve our best Our members/patients deserve our best

workwork►We can innovate and measure resultsWe can innovate and measure results►We can focus on the whole person, not their We can focus on the whole person, not their

disease or collection of diseasesdisease or collection of diseases►We can focus on slow and steady steps We can focus on slow and steady steps

toward goals, with patient’s priorities as #1 toward goals, with patient’s priorities as #1 ►We can speak up when things are not We can speak up when things are not

working; and volunteer to fix it!working; and volunteer to fix it!

PROFESSIONAL BURNOUT PROFESSIONAL BURNOUT REDUCTION STRATEGIESREDUCTION STRATEGIES

► CuriosityCuriosity

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

► Adventure (Excitement about the chance to Adventure (Excitement about the chance to get inside the cultures and beliefs of our get inside the cultures and beliefs of our patients)patients)

► Risk-takingRisk-taking► FlexibilityFlexibility► Perspective Perspective

CURIOSITY:CURIOSITY: WONDER WHY? Why is she WONDER WHY? Why is she

angry, why is he angry, why is he uncontrolled on his meds, uncontrolled on his meds, why is this not working, why is this not working,

why am why am II so so engaged/attached? engaged/attached?

STAY OPEN to learning STAY OPEN to learning more, laughing more more, laughing more

RESPECT:RESPECT:respectful deference respectful deference

includes being honest includes being honest with our patients, with our patients,

showing respect for showing respect for their beliefs and culture their beliefs and culture AND decisions; giving AND decisions; giving

information so they can information so they can make decisions make decisions

ADVENTURE:ADVENTURE:if we cannot get excited if we cannot get excited

about learning about about learning about other countries, other other countries, other cultures, other people cultures, other people

and ourselves, it is time and ourselves, it is time to get help or get outto get help or get out

RISK-TAKING:RISK-TAKING:volunteer for a new role; take a volunteer for a new role; take a risk with patients, tell them the risk with patients, tell them the

truth, kindly and with best truth, kindly and with best intent; be fully present and do intent; be fully present and do

not assume you have ANYTHING not assume you have ANYTHING to offer except your skills; tell to offer except your skills; tell your boss that workload, time your boss that workload, time pressure or role conflicts are pressure or role conflicts are

problemsproblems

FLEXIBILITY:FLEXIBILITY:consider new ways of consider new ways of

doing your current job; doing your current job; take some time off; talk take some time off; talk

to colleagues; new to colleagues; new schedules/workloads; schedules/workloads; learn new skills like learn new skills like

mindfulness and mindfulness and meditation meditation

PERSPECTIVE:PERSPECTIVE: the PATIENT is the one the PATIENT is the one

with the problem; balance with the problem; balance empathy and connection empathy and connection with distance; GET A LIFE with distance; GET A LIFE ; try seeing BOTH the ; try seeing BOTH the

sacredness of what we do sacredness of what we do and the small impact we and the small impact we actually ever make on actually ever make on

others’ livesothers’ lives

LEARNLEARN

► LListen with understanding to the patient's isten with understanding to the patient's perception of the problem perception of the problem

► EExplain your perceptions of the problem and your xplain your perceptions of the problem and your strategy for treatment strategy for treatment

► AAcknowledge and discuss the differences and cknowledge and discuss the differences and similarities between these perceptions similarities between these perceptions

► RRecommend treatment while remembering the ecommend treatment while remembering the patient's patient's culturalcultural parameters parameters

► NNegotiate agreement. Understand the patient's egotiate agreement. Understand the patient's explanatory model so medical treatment fits in explanatory model so medical treatment fits in culturalcultural framework framework (Berlin EA, Fowkes WC.1983) (Berlin EA, Fowkes WC.1983) 

Cultural Humility vs Cultural Humility vs CompetenceCompetence

► Humility demands that we self-evaluate how our Humility demands that we self-evaluate how our personal biases may affect care delivery personal biases may affect care delivery

► Humility changes the power imbalances in patient-Humility changes the power imbalances in patient-provider dynamicprovider dynamic

► We become more aware of who uses, and who We become more aware of who uses, and who needs our servicesneeds our services

► We are always learning, every day. We STAY We are always learning, every day. We STAY CURIOUS.CURIOUS.

► The two important paths to cultural competency The two important paths to cultural competency development are development are self-reflectionself-reflection about one’s about one’s cultural identity and beliefs, and cultural identity and beliefs, and experiencesexperiences with with cross-cultural encounters. cross-cultural encounters.

WATCH OUR LANGUAGE:WATCH OUR LANGUAGE:A 72 year old lady who falls and breaks A 72 year old lady who falls and breaks

her hip while sweeping her stepsher hip while sweeping her steps

► You shouldn’t be sweeping steps at your ageYou shouldn’t be sweeping steps at your age► You need to hire someone to do that for youYou need to hire someone to do that for you► Can’t your son help you out?Can’t your son help you out?► Stop worrying about cleaning, let’s take care Stop worrying about cleaning, let’s take care

of your hip, Dearof your hip, Dear► For many people, it can be very scary to For many people, it can be very scary to

break a bone; I wonder what it is like for break a bone; I wonder what it is like for you? What does this mean for you?you? What does this mean for you?

ADHERENCEADHERENCE

► We know it as: Compliance-the obedience of patient We know it as: Compliance-the obedience of patient in following our ordersin following our orders

► By using the word compliant, we assume a power By using the word compliant, we assume a power differential between us and the patient that erodes differential between us and the patient that erodes trust: WE are the doctor, YOU are NOT! We know trust: WE are the doctor, YOU are NOT! We know your body better than YOU do. We know what is your body better than YOU do. We know what is RIGHT for you. If you would JUST do what we say, RIGHT for you. If you would JUST do what we say, you would be better now. you would be better now.

► Adherence relies on RELATIONSHIP, TRUST, Adherence relies on RELATIONSHIP, TRUST, INFORMATION, CHOICE, ACCEPTANCEINFORMATION, CHOICE, ACCEPTANCE

► Adherence implies consensus, a joint or shared Adherence implies consensus, a joint or shared responsibility to the goals we select togetherresponsibility to the goals we select together

► It is an ongoing negotiation!It is an ongoing negotiation!

Active ListeningActive Listening

►Attend and observeAttend and observe ►Resist internal distractionsResist internal distractions ►Suspend judgmentSuspend judgment ►Reflect on the content, feeling and Reflect on the content, feeling and

meaning of what you hearmeaning of what you hear ►Respond as best as you canRespond as best as you can ►““You’re saying ___________.”You’re saying ___________.”  

Four types of protective Four types of protective voicesvoices

► People need to have to ensure that they have People need to have to ensure that they have access to voices that provide: access to voices that provide: Balance (family, partner, hobbies)Balance (family, partner, hobbies) Perspective (humor, distance, silliness)Perspective (humor, distance, silliness) Growth (learning, training) Growth (learning, training) Challenge (new roles, new work, confront imbalance)Challenge (new roles, new work, confront imbalance)Physicians, nurses, and allied health professionals can Physicians, nurses, and allied health professionals can

formulate a formulate a personally-designed self-care protocolpersonally-designed self-care protocol for for themselves. themselves.

► Overcoming Secondary Stress in Medical and Overcoming Secondary Stress in Medical and Nursing Practice: A Guide to Professional Nursing Practice: A Guide to Professional Resilience and Personal Well-Being Resilience and Personal Well-Being by by Robert J. WicksRobert J. Wicks offers an extensive bibliography of offers an extensive bibliography of recent research, clinical papers, and books on recent research, clinical papers, and books on medical-nursing practice and secondary stress. medical-nursing practice and secondary stress.

Homeless (AND the Homeless (AND the uninsured) people are uninsured) people are the the sum totalsum total of our of our

dreams, policies, dreams, policies, intentions, errors, intentions, errors,

omissions, cruelties, and omissions, cruelties, and kindnesses as a society. kindnesses as a society. 

(Peter Marin, sociologist) (Peter Marin, sociologist) 

THANK YOU ALLTHANK YOU ALL