HARISH K. GAGNEJA: Thank you, again. Those who stuck around here for the last talk, I think they're all in need for ethics CME, right?

[LAUGHING]

Those of you who know me in this say, you are talking about how to prevent burnout, balancing work and personal life? You? [INAUDIBLE] he's [INAUDIBLE] workaholic. About five, six years ago, I was at a ACG meeting-- American College of Gastroenterology meeting-- six, seven years ago, seven years ago, in Seattle. And at that time, ACG president, Christina Surawicz, she's from Seattle. The main theme of the meeting on the presidential lecturers was burnout, physician burnout, that was going on at that time, really starting to take off.

I'm sitting there. I'm like, you know what, I have that symptom. [LAUGHS] It's going to be a problem If I continue what I'm doing. I did some soul searching at that point and then changed the ways around. And I couldn't be happier. That's how I got involved in how to burn out, because a lot of my personal journey in that.

So goals of today will be, define what-work life balance is, define burnout and the scope of the burnout, discuss a few interventions to deal with the burnout, and some tips. I was showing this when I made this to my daughter, and my daughter was like, you're being too preachy. I'm like, I'm not being preachy, I'm just [LAUGHS] giving some tips.

So work-life balance is a term used to describe the balance between workplace obligations and personal responsibility. That's all it is, right? But it is very difficult to balance. It's a skill. But balance is key to life. This is my favorite, favorite quote from the Dalai Lama. Very deep.

Man, because he sacrifices his health in order to make money. Then, he sacrifices money to recuperate his health. And then, he's so anxious about the future that he does not enjoy the present. The result being that he does not live in the present or the future. He lives as if he is never going to die. And when he dies, he never really lived. It's very deep.

So that's my quote. This is all work and no play makes Jack a dull boy. But all play and no work makes Jack it really dull and poor boy.

[LAUGHING]

My dad passed away about six years ago. He was a very simple man, very simple. He's very, very-- he had advice for me. He said, I know that you want to become a great doctor. You really want to do well financially. And you also are a good family person. So you want to spend time with your kids and family. He says pick any two.

If you're a great doctor, spending a lot of time with the patients, doing well financially, you're probably not home most of the time. If you're doing well financially, very well, good family person, you probably are rushing through your work and not doing what needs to be done for your patients. If you're a great doctor and are with your kids all the time and with family, whatever time you need to spend, then you're probably not doing that well financially, by today's day of free investment.

So he was-- he had this a sense of life. And those three things, he told me that, I'm like, dad, yeah, I to do my best that I can. So when we talk about work-life balance, it's a work-life triangle. It's really not work and life. There's three different things going on in our lives.

The most important thing, the top of the triangle, is self care. If you are not there, it doesn't matter if it's work or life or birth, nothing's going to happen. So it's very, very important. You are the most important person in your life. With that, I mean there's physical health, mental health, emotional health, intellectual, spiritual, whatever you going to call it.

At your work, you have one angle of the triangle, on side of the triangle, which is patients, your patients, your procedures, your management of the practice. Or if you're in an employed practice, then management, which controls you. Professional development, competition, finances, and otherwise, your significant others, children, partners, friends, all.

So it's very important to strike a balance in all three, but most important is, again, the top of the triangle. There's some myths in work-life balance. People think that work-life balance is 50-50. 50% work, 50% life. Is it really 50-50? Is really 70-30? Is it really 80-20? It really is whatever works for you. Because there's a finite amount of time and intellectual resources you have. You have to allocate those to your personal or professional goals. That may change day to day. Today you may be able to spend the whole day with your family. Tomorrow, you may have to have a very long day, maybe you work until 7, 8 PM. It all depends.

Balance is really what works for you. It is not 50/50. Whatever works for you, makes you happy, that is what work-life balance is, really. If you start doing this, oh, I want to allot so many resources to my work, so many resources to my personal life, that's very unrewarding, unrealistic, not going to happen. So the right balance is very important. Right balance for today may not be the right balance for tomorrow. So there's no perfect one size fits all. That's very important to understand.

More important is that, rather than, I think, doing that, whatever you achieve, you enjoy that achievement. That's more important. It's not like I achieve something, now I'm going to move on to next, move on to next, move on to next. Why don't you enjoy that and then do whatever else needs to be done? What I see is people-- one thing after the other, one thing after the other. So they enjoy their achievements. That's more important than 50-50 or 70-20, or 90-30 or whatever it is.

Myth number two. Women desire more work life balance than men. Pick any two.

[LAUGHING]

So CareerBuilder survey showed that one third of men will say that they'll stay home if they can do as well financially as if your spouse is working. So there's no gender difference, really. Myth number three, work-life balance is synonymous with work-family balance or family support. You have to very careful in this, because this assumes that people with no families, single people, you can-- and there's some lawsuits, there's some discrimination lawsuits happening on this point only. That I'm discriminated against because I was the only one single woman. Somebody has to go. Their kid is sick. This is-- so doing more work than other person, but on the same salary.

[LAUGHING]

So moving on to burnout. So that was work-life balance. So what is burnout? Burnout is a condition marked by emotional exhaustion, basically meaning just, I just can't do it anymore. Little sense of personal accomplishment. Doesn't matter how hard I try, how I do it, I just can't do it. I just can't get it done. Depersonalization, that is a big, big thing which is happening in medicine. I'm not in control. I'm a cog in the wheel. That is the problem.

So what's happening with burnout is, it leads to decreased effectiveness at work. So top five reasons for physician burnout from last year's Medscape physician survey, which is about 17,000 physicians took part in the survey. Increased bureaucracy and regulatory demands, increased computerization of the practice, decreasing reimbursements, spending too many hours at work, and feeling like just a cog in the wheel. Just a cog in the wheel and EMR are the two biggest ones.

Competition, individual career ambitions, dealing with difficult patients, changes in family roles, talk of malpractice, MOC-- hopefully that will go away for Texas soon. [LAUGHING]

Gender doesn't matter, male or female. But late age is little bit less. Middle career is more prone. Same thing, specialty, primary care surgery, surgeon specialty, internal medicine-- again, middle career is a little bit more prone to burnout. Even the popular media is picking up on this theme. And this was Wall Street Journal, American doctors are unhappy, and it's hurting patients.

So when that happened, burnout-- physicians would burnout, they're at higher risk of substance abuse, mental health issues. They will leave the practice. Some relationship issues, a lot of other things. There have been increased reporting of motor vehicular crashes and near misses because they're thinking something, doing something in the car, and--

There's a study by Shanafelt. Shanafelt has done a lot of work in physician burnout. He's from Mayo clinic. And if you get Mayo Clinic Proceedings, every second, every third, you will see something on physician burnout, where they have studied something at Mayo Clinic. They've done a lot of work on that.

So prevalence of burnout the United States 45.8%. That's a very high number. Emotional exhaustion, 27.9%. And depersonalization, 29.4%. And this study was from 2012. The latest numbers are four, five points higher than these numbers. So it's 50% now, really. Here's a study from 2015, we were talking about. So now it's 54% of physicians experience at least one symptom and burnout, 10% increase since 2011. So during this period, from 11 to 15, 7.5% increase in the physicians who experienced a symptom of burnout.

Association between burnout and changes in professional work effort-- burned out physicians basically are going to leave, that's what this study said. Two years, three years, so there is a decrease in FTEs in physicians who burnout. That's my CPR.

[LAUGHING]

So if you look at it, burnout is a continuous, burnout resilience. We want to live in this part of the continuum and not in this part of the continuum. That's what our interventions are looking for, will do-- bring you from one side to the other side. So does mindfulness training in physicians work? Yes. Physicians who received training in mindfulness techniques show a marked improvement in symptoms of burnout.

Multiple studies have shown either long term or even short term interventions that both work. The pioneer work was done by Ronald Epstein. If you haven't yet, the book he published is called, "Attending." It just released, I think, early this year or last year. Very, very good book read. Ronald Epstein has done a lot of work on burnout. And this study was from University of Rochester. 12 month training-- what it did was 8 weekly 2.5 hour sessions of mindfulness training and then one eight hour seminar between sessions 6 and 7.

So then followed this with 10 monthly sessions, of 2.5 hours each, of self awareness, dealing with unpleasant emotions, and so on-- conflict resolution, meditation, and yoga. Every physician, 100%, who participated in this intensive mindfulness training, they reported significant decrease in burnout symptoms. And you can also do it in smaller sessions, not very intense like that.

This was a 30 physician study. 14 hour weekend course, Friday and Saturday. Then they gave a audio series and training website, which is 10 to 20 minutes each day. All participants achieved significant reduction in symptoms of burnout. And when they re-looked at it, it was maintained for nine months afterwards, as well.

I like that a lot. It's coming up. One is coming up in two weeks, right?

[LAUGHING]

So having learned what is work-life balance, what is burnout, what we can do to burn out to get out of that. We need to change our statement. Instead of, I have a stressful life, I will learn how to come back on track and live a balanced life without stress. That should be the mantra. Let's get us some tips. That's what my daughter said, you're being preachy, dad. But I want to say it anyway.

So plan and prioritize, be SMART. SMART is specific goals, measurable goals, attainable. Be realistic. Realistic is very, very important, realistic. And be timely. It's all about flexibility, structure, tools, and resources. If you have not utilized mid-levels, I can tell you my life is much simpler because of Brittany sitting right there.

Really, I mean, I have taken so much time off, because I was going through all this and can take so much time off. And she makes everything running, everything kicking. I can tell you how I do my vacations. When I go on vacation, I don't-- people say you got off completely. I don't. Because when I come back, then I'm more stressed. Because that didn't work for me.

So what I do is, I do one hour in the morning, when everybody else is sleeping. I'm just going to log in. I get my remote, log in, we text back and forth a few things. It doesn't matter where I am in the world-- and take care of whatever needs taken care of. And after that, my mind is free. This works for me, that my mind is free. And then, before I go to bed, sometime I log in, sometimes I don't. But usually one hour in the morning, that gives me plenty.

And she knows, OK, 24 hours I can get an answer for this question. And of course, in an emergency, my partners are here. So that's what I said-- flexibility, structure, tools, and resources. That's all your partners, your mid-level. So laptop remote access, that's very, very important. And flexible hour, this really gives you that time. It works for me.

I think, more important, is priorities than anything else. If you have a priority, what happens is sometimes, when I'm dictating my charts in the office, the phone is sitting right there. And then, oh, something comes up. Notifications all day long, these days. Something comes up, look at a notification. Then you get distracted. Not doing the right thing, right time, right-- I'm not doing that, because I'm getting distracted.

So I just say, OK, my phone is away for two hours. If you don't hear from me, if you text me for two hours, that means I'm really dictating or doing something. I'm not looking at the phone. I don't do that. I clear two hours at a stretch, don't look at it, and dictate what I need to do and then look at the phone and answer them. If you keep on going back and forth, it really wastes a lot of time. And really, you don't accomplish much.

Delegation-- I'm still working on this. [LAUGHS] It's hard, but it's system important. If you delegate more, then you have more time for yourself. Somebody once said, perfection is the enemy of excellence. Think about it. Sometimes, we try to do so much, everything so perfect, even if it's excellent, we just get so riled up on everything else, that we really don't accomplish much. It's very, very important in that. Think about it.

Again, I said, prioritize your schedule. Stephen Covey said, but to schedule your priorities is more important. This is controversial. A lot of people often say, OK. I said, bring some of your home to work, as well as some of your work to home. People say, hey, I'm done at 5:00, I'm done at 5:00. Yeah, it was true 10 years ago when your charts were at the office. And that's not true anymore. Your EMR is not done. Nothing is finished. You can't-- so you've got to figure out how you handle this, right?

So I can tell you my story. When my kids were young, I had to be at their school functions, wherever I needed to be. I finished work, picked up charts in a bag, and run home. Go to school, go to game, whatever, after that. Come home, eat, now they're going to bed, and I'm doing my work afterwards. So that's how it worked at that time. Now, I can-- kids are gone-- now I can spend a little time. And my wife is in school, as well.

So as I said before, it is not one size fits all. It's whatever works for you. That's the most important thing. And now, I take my work at home. At night, she's studying. I'm just doing my EMR. We're sitting together, but we're just doing stuff. And now they have some bills to pay or some things to do, fighting with maybe Dish Network or Time Warner or something. So I'll bring those bills to-- it happens, right? I mean, let's face it. So I bring those bills. At lunchtime, I just call them and say, hey, why are you charging me this? [LAUGHS] So bring some of your home to work and work to home. I think it's very important.

There are a lot of resources available. There are tons, tons. YouTube is-- I mean, everything you can find on YouTube, on goal setting, prioritizing activities-- Harvard Business Review has lot of videos on-- I've watched a lot of those. They have all that free, actually, on YouTube. You can watch a lot of this stuff. One on one training sessions, you can do.

Seminars. Travis County Medical Society, actually, is going to roll out a program for physicians, it's a physician wellness program, just looking at this. So the specifics are being worked out right now. In about the next three to six months, the program will be rolled out for physicians, to help them with one on one training, to help prevent burnout.

So again, if you have a good structure in place, good support system-- and I am lucky that I do-- then you can really find time off for long weekends, for four days, just go out, have fun. This is just a few of our trips we took as a family.

Reward yourself, something you are working extra. The reward can be big or small. Hey, I want to buy those nice shoes. I finished what I needed to do, I want to buy them. It doesn't matter, right? At work or at home, whenever you do it, you just deserve it. You deserve it. That also gives you ever more motivation to work something else.

[LAUGHING]

Dream on. Dream on.

[LAUGHING]

As I said before, you are the most important person. You are the one. So health is wealth. Eat well, sleep well, exercise, regular medical checkups. We are very bad as physicians. We're the worst at medical checkups. Good desk, good chair. And then nothing wrong with buying a good, comfortable car. We spend so much time in the car, going back and forth. There's nothing wrong in doing that. Don't feel guilty, that oh my god, I'm spending so much money. Hey, that's what it is.

I'm still working on this. I'm getting much better, but I'm still working on this. Very important. I'm also working on this. I used to be a very big procrastinator. [LAUGHS] So that's me right there.

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And that's my clock.

[LAUGHING]

I sent my polyp slides last night at 11:00 PM, I think. But I had them, I just wanted to spruce them up, so that's me. I'm still working on it.

[LAUGHING]

Avoid getting pulled from different directions. I'm getting much better at this than I used to be. Now I'm like, OK, let me do this. Then, I'll do whatever I want to do. This is very, very important. That causes more stress.

Be passionate and enthusiastic. Mix with positive people. See opportunity, not obstacles. Again, this is the preachy part, which my daughter was talking about. An important thing to remember is this, there's two techniques, actually. Which is very important, people. That's what I learned from watching a lot of videos and stuff.

One is a positive self talk. If you're always saying, ah, I'm not-- If you're talking positive to yourself, that' one technique. Second is, visualize your goal, where you're going. And once you achieve that, reward yourself and enjoy that. That's important. Some days I feel that.

[LAUGHING]

That's my mantra. I really, really feel that any type of work, anything you do, if you're doing it as your passion, you're doing a quality product out there. And you have integrity, then you're doing everything when nobody else is watching. That's what your integrity is. Now, I think nothing can fail you. Do great work is loving what do you do. That's what it is. Passion, quality, integrity.

Enjoy the journey. Be true to yourself. Enrich yourself socially, culturally, intellectually. Again, I said, there's a study which showed that if you attend your professional meetings, that prevents burnout. I go to three, four meetings a year. It's nothing bad. It's just you're getting you out of the daily routine from work. And you're learning something new, and you're meeting people. You're talking to people.

It really is-- it works very therapeutically for me. I go to four meeting a year. Every-- I have not missed Digestive Disease Week conference in 19 years. I go every year.

Small things. Very small, little things. Go for a walk. Watch a comedy. Just take a long bath. Sip a glass of wine. Meet some friends for a get together. Shopping. Sometimes shopping is hot. I love that. [LAUGHS] Some photography. I know that doctor Pfleger is one of the biggest-- I love your photos. It's really, really, really good. Yoga, meditation, anything. Take a bubble bath. Or even, you know, people say, oh, there's a family inside of me, but light scented candles. That's good. Why not? [LAUGHS]

Make a list of what you're thankful for. Out of this, I'll pick a glass of wine. [LAUGHS] So that's little tips, but now I know there's some-- the organizations you work for or you work with, I think it's very important for their organizations to help in that regard. If they really want to prevent future burnout, what's very important is to promote value of the profession and of the organizations you work for.

Organizations you work for should provide adequate resources, efficient good work at all unit level, effectiveness at all levels. Dream team. That's my concept dream team. That's I was talking earlier about. I'm really fortunate and really thankful for the administration at my hospital, where they really listened to my concerns, provided me all the equipment, everything that I needed to do. And I have everything in one location now. I don't have to run around all over town to do things.

I think that really, if you look at it, parents burnout, because now I'm OK. I'm happy going back and forth to my office from the hospital. It's important. People you work with and that the organization is really behind you, that's really important.

So this was a intervention trial again, published in JAMA. Two different things happened. Organization said, OK, one do is, we'll give you 90 minutes every other week with 60 Minutes of protected time for nine months. Or you just get 60 minutes every other week, just don't do nothing, just protect your time and see. And when it looked at both of these groups, they had a decrease in symptoms of burnout. It worked in both groups. But in the group, which was a little bit intervention, which is 90 minutes meeting together, it worked a better. So I think organizations can help, administrators listening.

A lot of different places have programs. University of Rochester, Mayo Clinic, Stanford has three of the prominent ones. There's some resources, a mindful practice. That's, so you know, the Rochester one. Then there is a-- for physician well being is one. There's action learning, it's a very good one. The Happy MD was started by a physician. He also puts together some of the retreats for physicians. That's a good one.

And then Chopra yoga, they do well-being. And you know Deepak Chopra. And San Diego is the head office, but they're in different places. They have very good four, five days retreats. Really, really nice.

So at the end of the day, your competitors can copy your work, your style, your procedure, but no one can copy your passion, your sincerity, and your honesty. If you hold on to them firmly, the world is yours. Follow your principles. That's all I'm going to say. That's my formula. It says work hard, play harder, and pray hard.

[LAUGHING]

Now you have identified what's important. You're making it happen. You're in control, and you are enjoying every step of it. Thank you.