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James Ferguson, MD, a family physician in East Islip, N.Y., likes to inject a little humor into his patient encounters. If he has trouble thinking of something funny, he says he can turn to a joke book by the phone in his office hallway. Photo by Amy Sussman / AP Images for American Medical News

How to create a positive practice environment (AAFP scientific assembly)

As demands build and many doctors report burnout, it's critical that physicians use humor and other tools to promote wellness in their practices, experts say.

By Christine S. Moyer — Posted Nov. 12, 2012

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Before seeing a patient, family physician James W. Ferguson, MD, reviews the individual’s medical chart and quickly runs through a few jokes. He’s not trying to perform a stand-up routine for patients. He just wants to make them laugh a little.

“We need some humor in medicine,” said Dr. Ferguson, who has run a solo practice in East Islip, N.Y., for 30 years. “We need to lighten up and show that we’re more than doctors. We’re humans.”

Using humor with patients strengthens the physician-patient relationship, health professionals say. It makes physicians more approachable. And it can relieve patients’ anxiety about the medical visit.

Just as important, incorporating humor can rejuvenate physicians who experience burnout due to the challenges of their job, said Mark Greenawald, MD, associate dean for student affairs at Virginia Tech Carilion School of Medicine in Roanoke.

“Humor relieves some of the pressure [on physicians]. Their work is hard, and the stakes are high,” said Dr. Greenawald, president of the Virginia Academy of Family Physicians.

At a time when demands on primary care physicians are rising and many doctors report experiencing burnout, it’s critical that physicians use humor and other tools to create a positive environment in their practice. That was the message delivered by medical experts at the American Academy of Family Physicians’ annual scientific meeting in Philadelphia Oct. 16-20.

During the meeting, physicians and mental health experts offered doctors guidance on how to weave humor into their day and how to maintain a positive attitude. Several sessions focused on effective ways to manage work-related stress and highlighted steps physicians should take to ensure their own well-being.

“We know there’s a crisis in health care, but there’s also a crisis in our practices,” Dr. Greenawald told colleagues during a session on bringing energy and passion to work. “Many family physicians are experiencing a crisis of burnout, compassion-fatigue and moral distress. Many are thinking of getting out of practice.

“We believe it’s part of our responsibility as leaders in family medicine to do what we can do to help rejuvenate our colleagues. We want to help doctors rekindle their passion for medicine.”

Burnout widespread among doctors

Forty-six percent of physicians experience at least one symptom of serious burnout, such as emotional exhaustion, depersonalization and a low sense of personal accomplishment, according to a June 2011 survey of 7,288 doctors nationwide. The findings were published in the Oct. 8 Archives of Internal Medicine.

Researchers found significant differences in burnout by specialty. Some of the highest rates were among physicians in emergency medicine, general internal medicine and family medicine.

Contributing to the high rate of burnout among doctors are increasing administrative demands, long work hours and concerns about medical liability lawsuits. That discontent can negatively impact the environment in physicians’ practices and hinder patient care, said Stephen P. Bogdewic, PhD, who led a session with Dr. Greenawald on bringing energy and passion to work.

“Doctors are the leaders of their team,” said Bogdewic, professor of family medicine and executive associate dean for faculty affairs and professional development at Indiana University School of Medicine. “In a leadership role, everything that goes on with them influences the health of their practice. If they’re experiencing burnout or feeling depressed, there’s no way they can disguise that completely.”

Such dissatisfaction can make it difficult for doctors to pick up on patients’ subtle cues, such as body language and tone, he said. Those cues can offer insight into medical problems or health concerns the patient might not feel comfortable bringing up during the visit.

Patients also can sense when a doctor is in a bad mood, and that can make them reluctant to share important health information, Dr. Greenawald said.

In those situations, patients “feel like they’re being treated more like problems than people. There’s nothing healing about that at all,” he said.

The key to achieving a positive attitude, even during the most stressful times, is starting the day by thinking about someone or something you are grateful for, said comedian and motivational speaker Steve Rizzo, who spoke at the AAFP meeting.

“You have a choice at that moment to steer your thoughts and emotions in the direction you want them to go,” he said. “You can choose to seize the day or you can let the day seize you.”

People who reflect on things they are grateful for feel better about their lives, are more optimistic about the upcoming week and report fewer physical complaints than those who focus on hassles or events that poorly affected them, said a study of 192 college students. The findings were published in the February 2003 issue of the Journal of Personality and Social Psychology.

Dr. Greenawald refers to this reflective behavior as “choosing your attitude.” He recommends that physicians take a few moments throughout the day to think about the good things in their lives. Doing so can help them put the challenges they face in perspective.

For instance, Dr. Greenawald often reminds himself, “My worst day as a physician is better than the best day of some of my patients.”

He incorporates humor in interactions with patients and colleagues to help lighten the mood and build stronger relationships. Humor does not have to involve telling jokes or being silly. He often makes a funny comment based on an observation.

When an older patient brought his wife to a recent medical visit, Dr. Greenawald asked the man, “Does your wife know you brought your girlfriend to the office today?” The patient smiled, and his wife laughed.

That type of humor “lightens the mood, and then we can dive in and start talking about things that matter,” Dr. Greenawald said. “Patients are more willing to talk openly [when they have] that human connection.”

Laughter enhances a person’s intake of air, which stimulates the heart, lungs and muscles, and increases endorphins released by the brain, according to Mayo Clinic. The result often is reduced feelings of stress.

More research is needed before broad claims can be made about humor’s impact on health outcomes, some medical experts caution.

Doctors can neglect their health

A common mistake physicians make is becoming so consumed with caring for patients and staff that they neglect their own physical, mental and emotional wellness, said U.S. Navy Capt. Mark B. Stephens, MD. Self-neglect impacts not just the individual doctor, but also his or her patients and the office environment, said Dr. Stephens, professor and chair of the Dept. of Family Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md.

For example, burnout in physicians has been linked to poorer quality of care, increased medical errors and decreased ability to express empathy, health professionals say. Personal consequences of burnout include stress-related health conditions, substance abuse and marital problems.

“If you don’t take care of yourself, you will have a hard time taking care of people in the long run,” Dr. Stephens said.

One component to boosting wellness is pausing during natural lulls in the day and thinking about what is going well and what isn’t, he said. Those moments improve self-awareness, which could help physicians identify, for example, when their negative mood needs to be made more positive, Dr. Stephens said. Stepping back to examine the day also can help doctors think of constructive ways to handle conflict.

Dr. Stephens encourages physicians to slow down when they eat, consume more nutrient-rich foods and be more physically active. Each of those simple behaviors not only improves physical health but also can boost happiness, he said.

“The natural elevation in mood and health that is associated with physical activity has been known for a long time and it’s the cheapest, best medicine,” Dr. Stephens said.

He recommends that physicians consider standing while doing administrative work to increase their energy. And he challenges doctors to view their office duties as another important aspect of their job rather than begrudge them.

The mindset of “just getting the work done is a survivalist mode of thinking,” he said. “By embracing the work, it mentally becomes easier to get through some of the chores and mundane aspects of practice that don’t deal with the doctor-patient relationship.”

Dr. Ferguson, the family physician in New York, admits that he has, in some ways, felt dissatisfied. He often has to debate the necessity of a medical test with insurance companies and frequently is pressed for time when caring for older patients who have multiple ailments and medications.

Yet he remains upbeat and tries to ensure that patients and staff have a positive environment at his practice.

“You live in your office,” he said. “You have to make it comfortable.”

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ADDITIONAL INFORMATION

10 ideas to help doctors find happiness

With demands on physicians increasing and burnout on the rise, medical experts offer suggestions on how doctors can lead happier, more fulfilling lives.

  • Pause before reacting to something that bothers you and think about how you could respond to the situation.
  • Develop meaningful connections formed at your job with colleagues and staff.
  • Plan personal and family time and place it on your patient care schedule to help maintain a work-life balance.
  • Learn to say “no” once in a while to requests for your time.
  • Focus on what is working in your life rather than fixating on what’s not working.
  • Laugh with your staff and patients.
  • Spend time doing things that you’re passionate about outside medicine, such as creative writing, photography or playing an instrument.
  • Volunteer with an organization that cares for those who are less fortunate.
  • Stop feeling responsible for patients’ chronic health outcomes. Instead, view yourself as a coach who helps patients improve their health.
  • Ask staff to pick up some of your administrative work so you can spend more time with patients.

Source: Speakers at the American Academy of Family Physicians 2012 Scientific Assembly (link)

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Treatment tips

Here are some patient treatment recommendations and meeting notes from the American Academy of Family Physicians annual scientific assembly.

Ease young patients back into school and sports after concussion. When caring for a child or teenager with concussion symptoms, doctors should tell the family that symptoms typically persist for 7 to 10 days after the incident, said Deepak S. Patel, MD, a family physician and sports medicine doctor at Yorkville (Ill.) Primary Care.During that time, the patient should stay home from school and refrain from physical activity, playing video games, reading, text messaging, watching TV or movies, and working on school assignments.Dr. Patel, who led a session on concussion and minimal brain injury, said such rest should continue until the person is asymptomatic for 24 hours without medication. After patients go 24 hours without symptoms, physicians should ease them back into school and sports, Dr. Patel said. He encourages patients to start with 30 minutes or less of light aerobic, noncontact exercise, such as walking or biking.

If the youth remains symptom-free for another 24 hours, Dr. Patel permits the patient to engage in sport-specific exercise and/or progressive resistance training. The next step often is to allow patients to participate in noncontact drills for practice and resistance training. He examines the patient before determining if the person can start full-contact practice.

If concussion symptoms return, the physician should move the patient back to the previous level of activity, Dr. Patel said. After 24 hours, the doctor can again try to advance the youth to the next step.

Write an exercise prescription for some patients. Physicians should consider talking to each patient about starting or maintaining an exercise routine, said Maj. Christopher W. Bunt, MD, an assistant professor of family medicine at Uniformed Services University. Some people, however, will need more than a short discussion to help them meet physical activity guidelines. In those cases, a physician should write a detailed exercise prescription, said Dr. Bunt, who lead a session on the topic.

To ensure that doctors don’t miss any details when writing the prescription, he recommends that they follow an outline, such as the FITT-PRO (frequency, intensity, type, time and progression) model. The model encourages physicians to detail for patients: the type of physical activity they should engage in; how many days a week they should exercise and at what intensity; the amount of time each week they should commit to the activity; and how the intensity and frequency of exercise should progress over time.

He often encourages patients to start by participating in moderate physical activity one to two days a week. Within six weeks, the goal is for people to partake in more vigorous exercise three to four days a week, Dr. Bunt said.

The 2008 Physical Activity Guidelines for Americans recommend that children take part in 60 minutes or more of exercise each day and that adults engage in at least 150 minutes a week of moderate-intensity physical activity. The guidelines were issued by the Dept. of Health and Human Services.

Assess patients’ lifetime risk of cardiovascular disease. Brian V. Reamy, MD, recommends that doctors use the American Heart Assn.’s Simple 7 measure to identify patients’ lifetime risk of developing cardiovascular-related conditions. Doing so enables physicians to start prevention efforts earlier than if they rely on more common tools that assess an individual’s 10-year risk of developing cardiovascular disease, said Dr. Reamy, who led a session on cardiovascular risk reduction. He is a family physician at the University Health Center on the campus of Walter Reed National Military Medical Center in Bethesda, Md.

When people achieve the Simple 7 measures, they can improve their health, the AHA says. The measures are: Exercise five days a week; maintain a body mass index of 25 kg/m2 or less; eat an optimal diet; don’t smoke; achieve recommended glucose levels; have optimal blood pressure; and have optimal lipid levels.

After assessing these seven measures in patients, physicians should develop individualized treatment plans to help people meet these optimum health goals, Dr. Reamy said.

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External links

American Academy of Family Physicians 2012 Scientific Assembly (link)

“Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Oct. 8 (link)

“Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life,” Journal of Personality and Social Psychology, February 2003 (link)

“Humor and Laughter May Influence Health IV. Humor and Immune Function,” Evidence-Based Complementary and Alternative Medicine, June 2009 (link)

Stress management information from Mayo Clinic (link)

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