This is a topic that is very interesting to me and very important. As Vivek pointed out, I think medicine is the ultimate team sport. He very eloquently talked about the importance of teamwork and a team culture. I believe that APPs have become indispensable to GI. So it's in all of our best interest to build professional satisfaction, do what we can to help with personal satisfaction at home, so that we can have effective teams and deliver the highest quality of care that's possible. I have no disclosures. We'll start off with a polling question. Provider burnout is defined by which of the following? Emotional exhaustion, physical exhaustion, mental exhaustion, or all of the above? Correct, as it is defined by all of the above. Next question, please. Which of the following job stressors could contribute to provider burnout? Role conflict, high levels of workload, time pressures? Perfect. These questions were meant to be straightforward. I think this is a topic that we may not know a lot about, so this was not meant to be tricky to really thinking about the answers other than to begin the process of understanding this potential problem. Our objectives today are understand burnout from the advanced practice provider perspective, understand what's unique from a GI perspective to advanced practice providers as opposed to perhaps an advanced practice provider in internal medicine, and to let you know that there are things we can do both at work and at home to avoid this problem, which we all would like to avoid. So burnout occurs when work, the workload, the stresses of work just become overwhelming and ultimately lead to emotional, physical, and mental exhaustion. As a consequence of these three negative impacts, a chronic condition develops, and I think that's an important piece to understand about burnout. It is chronic. It's not an acute event that lasts an hour. It's a chronic condition that impacts your well-being, so that negatively impacts your professional happiness and your personal happiness. And when that happens, we really lose the ability to care for our patients. And if we lose the ability to care for our patients, we really lose our reason for existing, and that is I think we've all chosen our fields because we want to help. It's almost part of our DNA. We're very passionate about it. Unfortunately, as it relates to non-physicians and, in this case, APPs, we have very little evidence-based data. I found a couple articles that were really more summaries. There are very few articles that are evidence-based to help, but I brought in as much of that data as I could, and there is some data that I pulled in from data on physicians, which tends to be a little bit more robust at this time. There are three pillars of burnout that have been defined, emotional exhaustion, depersonalization, and the saddest one to me is at the end, and that is a low sense of personal accomplishment and self-value. So what is emotional exhaustion? Emotional exhaustion is pretty clear that we really can no longer emotionally handle our work and handle our passion for patient care has gone, and that comes from the constant demand for more work. Since we've come out of the pandemic or are technically coming out of the pandemic, I'm sure all of you are very busy like we are. I don't think the demand for our work is going to decline, so we have this constant demand not only for acceptable amounts of work, but adding more work, having more add-ons, double booking, adding patients over block time that we should not be seeing patients. This leads to us potentially taking work home. We don't get our notes done. We take work home, which I think is a very bad idea, which then extends the workday and starts to impact in a negative way in our personal lives. We have to do more indirect, what I would call indirect clinical work. For example, peer-to-peer work with insurance companies. You have to call to get a CT approved. You speak to somebody. They say they will call you back. You're waiting. You have an hour blocked out, and the call never comes, and there are multiple phone calls, so more indirect clinical work. All of this leads to more work with less time and can lead to emotional exhaustion. Emotional exhaustion can lead to depersonalization, and that's where we see a loss of empathy, a loss of sympathy, a loss of compassion for our patients. We really almost no longer want to take care of patients. We're almost defeated, and we start to view patients as an obstacle. And when we view patients as an obstacle, that train is down the track, and we are on a very bad path. We have chosen our fields to be providers because we want to help. We have a passion to help people. We think it's an honorable and noble goal, and if we reach this point of depersonalization, that's lost. We no longer see patients as an opportunity to heal. Both of those, emotional exhaustion and depersonalization, leads to, again, what to me is the saddest piece and the final piece, and that's a low sense of personal accomplishment and loss of self-value. Every one of you in the audience is highly educated. You've finished nursing school. You've then taken the next, or you've finished a PA program, and so for those who are nurses, you've then taken a next step. You've gotten your master's degree. For those who are PAs, you've completed your ultimate PA degree. You have achieved very high academically. You should have a high sense of accomplishment. You should feel very good about your education process and what you can do. So to think that we no longer feel that we have accomplished so much and that we bring so much value, that is the final and, again, the saddest stage to me. So why does burnout happen, and ultimately how can we avoid it? Well, burnout happens because of job stresses, work engagement, loss of work engagement, and an imbalance between work and family life. So let's take a closer look at each of these. Job stressors. Obviously, we want job stressors to be low, but if we start to see a breakdown of job stressors, it starts with something called hindrance demands, and hindrance demands very simply are challenges and stresses at work that go beyond the normal amount. We all have daily challenges and stresses, but we can manage those. They tend to be limited and simple, but when they become repetitive and they don't seem to go away and they keep building, we then are hindered in our ability or prevented in our ability from achieving our daily work and accomplishing our goals. Some of the variables that can create hindrance demands include role conflict. So, for example, your daily routine, if you're an outpatient provider, is you have 30-minute blocks to see patients, you have a half hour over the lunch hour to perhaps eat and catch up, and then you finish your afternoon. All of a sudden, you're being asked by one of the physicians to come and see a patient with him in the endoscopy center, or you're asked to put on a patient over the noon hour, or now you're asked to take multiple phone calls, and these build up, and now all of a sudden your role is not clearly defined and it's lost. So role overload, by some of the variables I described, can lead to role conflict. So we need to manage our role conflict, understand what our role is, make sure we don't overload our schedule, and understand if we sometimes have to add on or if we have to do a little bit extra in one day, understand what those demands are and make sure there are boundaries and well-defined roles to those demands. So be careful about these hindrance demands. And then there are challenge stressors. We are all challenged every day, and actually, challenges and stress at a low degree can be good. I've got a variceal bleeder in the ER, the patient's really sick, that's a challenge. That actually gets me excited. I can help. I want to help that patient. But when these go awry and these become multiple in a day and they are every day, these then become high levels of stress and lead to high levels of workload, which become a negative. Time pressures. None of us, absolutely none of us, can see five patients in an hour. That's just impossible. We have to be careful about how much time we set for each patient in the clinic, and for those who are at the hospital, how much time we allot for our APPs to make their rounds and see new patients. We have to keep those realistics. We can't keep people at work until 8 o'clock at night. We have to be careful of our time pressures, and we need to clearly define what the responsibility is for all of our providers. Secondly, work engagement. Work engagement is our vigor, our ability to maintain our energy and be happy at our work, and also, again, on those few times when needed to extend that energy. We don't want that to go too far to have a breakdown of vigor where we just can't maintain our excitement and our energy. Dedication, that's our enthusiasm for the patients, our pride in our accomplishments, and maintaining our inspiration to do what I believe is a great honor, and that's to help people with simple problems all the way to some very bad problems. The last one I like the most, because I have never considered that I have a job. I love what I do. I just go do what I love every day, and I don't really consider it work. That's where you absorb yourself in your work, and you lose yourself in your work. You don't even realize you're working. You do something you love, and that allows you to be at your best, to be able to concentrate, to be able to take care of our patients. It's never perfect. I have my moments, but I think the ability to absorb yourself in your work is an important part of work engagement. So we want job stresses to be low. We want work engagement to be high. What we don't want is this. This is Corey, one of our superstar nurse practitioners, who's very angry at the medical record. She's about to throw it out the window, and there I am, smacking my head, saying, Corey, please don't do that. You don't want to pay for the window and the computer. So we want to avoid this, and we want this. This is Stacia, one of our other superstar nurse practitioners. In our group, we all sit in one big office. I'm surrounded by a few nurse practitioners. Behind me, you don't see our espresso machine. During the pandemic, to help us pull us out of our melancholy, we bought a nice espresso machine. And every day, we make it a point for a few of the nurse practitioners and a few of the docs to share a cappuccino or espresso together. I've become the group barista, and unfortunately, over three years, I have about $14 worth of tips. So that's not a very good retirement plan. I show this to be funny a little bit, but I also show this to be serious. We really don't want this. Our ultimate goal is to be this, so we can act as a team and deliver the highest possible care at the highest possible quality. The final piece is work-life balance. The first two variables we talked about were work-related. This variable is a combination of both. We can help at work by keeping job stress low, keeping high work engagement, keeping tension low at work, building that culture that promotes happiness, professional satisfaction, and teamwork. At home, it's a little bit more difficult for us to actually get involved, but by providing a good work environment that typically leads to happiness at home, some of the things we can do at work, job sharing, flexible hours, we'll get more into these things. But the work-life balance is very, very important, and I think probably the trickiest of all. Burnout is a combination of job stresses, work engagement, work-family balance, and unfortunately, a breakdown or failure in all of these or a combination of at least two of these. Hope is not lost. We can foster well-being and resilience, and I think those are two important things to remember. There are personal interventions that can occur. There are institutional interventions that we can implement. Both of these interventions can absolutely lead to improvement, but more importantly, we want to prevent. If we must have improvement because there is burnout, great, but we really want to try to prevent. The key to all of this is communication, communication, communication, and compromise, compromise, compromise. There is no perfect system, but if we work at it, we can create a system that is promoting happiness and teamwork. So what are some personal interventions? Assess the status of your career. Where are you in your career? And what are some of the things you may want to do with your career? For example, are there research opportunities that you can pursue within your practice? Are there teaching opportunities that might create professional satisfaction? So in our practice, we have a local nurse practitioner school, and we only have nurse practitioners in our group. Almost all of the nurse practitioners will have students rotate through and teach on a clinical basis, and some actually teach at the nurse practitioner program. It's okay to say no. That's where communication comes in. That's where compromise comes in. It's good to have boundaries, both from the practice standpoint and the personal standpoint. Follow your passion. Again, be selfish, set some boundaries. From a personal perspective, as you go home, set time for you. Set time for exercise. Set time for reading, if that's what you do. I'm currently learning a new language. Learn a new language. Find your passion. Make sure you get your sleep. Some of my partners, physician partners, meditate. So no matter what you are, physician, APP, find these things that help you be happy at home, and it's okay to be a little selfish about things. As I said, find value in your job, whether that's teaching, research, committee work. Sarah is on one of the ASGE committees. Find committee work within your practice. Join the APP societies. Perhaps become a reviewer at a journal. Find some other things that bring professional help that takes you beyond your average day. Solidify your foundation of support. You can have work friends that may not be your friends outside of work. That sounds mean or negative, but it's not. You can have your work friends where you're friendly at work, you share that cappuccino, you share comments about a book you're reading. Find the family support and find mentorship. Find mentorship at work, whether that is an administrator, a clinical or nurse administrator, a physician, another advanced practice provider. Find mentorship. Take time off. Take time off is so important. We need to spend a few moments on this. I can't tell your practice how to give you time off. I can only tell you how we do it in our practice. We have six full-time nurse practitioners, essentially, and one part-time. She works 40%. So I'll talk about the six full-time nurse practitioners. We have flexible work hours. They all work four days a week. So they have one day off every week to do whatever they need to do to take care of in their personal life, whether that is see the physician, see the dentist, go to the gym, whatever it may be that helps them at home. They all have five weeks or 25 days of vacation in addition to that daily, that weekly day off. They have five days of CME. And in theory, they have five days of personal time. All of our nurse practitioners are female, and five of the six full-time nurse practitioners have young children with working spouses. We don't really hold them to that five days, especially in a time of COVID. So I think this is an area of compromise, and we have to be smart. Be flexible in the personal time off for illness, especially illness of children in the time of COVID and COVID exposures. The bottom line with taking time off and all of this discussion is it is physically and emotionally exhausting to have turnover. When you find really good advanced practice providers like we have in our group, we don't want to lose them. It's really exhausting to have to replace them both physically and emotionally. Some steps the institutions can take. Identify supportive leaders within the institution, good communicators, people that are willing to compromise. Look for leaders that promote health, personal, professional satisfaction, balancing that work, family environment. Look for self-care in your own life, flexible hours for work or job sharing, excellent. Larger institutions, hospitals, universities may offer gym memberships. That's great. And I know you heard me now for the third time. Take time off. Other things that can be done. Supportive staff. It's very important to find supportive staff within the practice to help us offset some of our administrative and clinical burden in our practice. We have a number of people to help us with that. Protected time within your day is very important. All of our nurse practitioners have one half hour of protected time during their day to catch up on records, to make phone calls. That time is never violated. They must have that time. And gain control of scheduling and flexibility in scheduling. No double booking. Limit add-ons. Occasionally they're needed, but it cannot become a routine part of the practice. Again, communicate, communicate, communicate, and compromise. In summary, burnout is real. We want to avoid burnout. We don't want to look at ways we have to correct burnout because that can be difficult. Burnout comes from high job stress, decreased work engagement, and imbalance between work and family life. There are a number of personal and institutional interventions that can occur. And remember, we all have to communicate, communicate, communicate, and compromise, compromise, compromise. We practice, I believe, in what is the ultimate team sport. And avoiding burnout is such an important part of professional and personal satisfaction. For more information, visit www.FEMA.gov

burnout

healthcare

advanced practice providers

gastroenterology

teamwork