Emergency Physician Wellness

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Emergency Physician Wellness

• Mark Bromley
• Emergency Medicine PGY3
• Thanks to
• Trevor Langhan
• James Huffman

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Case

• 30 year old ER resident
• Hard worker loves to say yes
• 2 case reports on the go and a long term research
  project
• 1-2 () extenders per month
• Volunteers for extra admin duties
  RTC/CaRMs/Mentorship
• Nursing staff noting quick temper.
• Spouse concerned
• Wellness issues here? EM in general?

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Objectives

• Wellness
• Definition
• Importance
• Issues related to EM residents
• Promotion of Wellness
• Resources
• Practice

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Wellness

• Wellness describes a state of physical and
  psychological well-being.
• Lum, G., Annals of EM. 1992
• Wellness in EM is defined as those skills,
  attitudes and beliefs that allow one to enjoy
  practicing EM for a long period of time, while at
  the same time allowing balance in ones life.
• Perina, DG., http//www.saem.org/publicat/chap12.h
  tm

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Why do we care?

• Happiness and satisfaction ? Career longevity
• Reasons for Concern
• Lack of personal happiness / fulfillment
• Burnout / Attrition
• Substance Abuse
• Suicide
• Relationship problems

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Why should the public care?

• (1) recruitment and retention of physicians
• World-wide shortage
• Med school and local recruitment
• (2) workplace productivity and efficiency
• Absenteeism, productivity, suspensions
• (3) quality of patient care and patient safety
• Self reporting

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Emergency Physician Wellness

• Emergency Medicine is a relatively young
  specialty
• Early concerns noted regarding
• Stressful work environment
• Unhealthy aspects of EM practice
• Elements could impact on physician wellness and
  career longevity

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List 4 major categories of stressors in EM

• Within each category list 2 examples

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• Diversity of practice
• Shift work
• Surge of patients
• Mass casualties with no notice
• Difficult patients
• Language barrier
• Violent patients
• frequent flyers
• Professional relationships
• fishbowl Medicine
• turf disputes
• Diminished Resources
• Access to diagnostix U/S
• Staffing shortage
• Bed block
• Difficult decisions
• NO code status/history
• Terminating resus in the young
• Occupational hazards

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As a resident, what are your greatest sources of
stress?
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Do you anticipate these changing as a staff?
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Resident Wellness

1. Debt / Finances
2. Chemical Dependency
3. Career
4. Interpersonal Relationships
5. Medical Errors

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Resident Wellness - Debt

• Canadian Association of Interns and Residents
• Jan. 2007 Implications of Medical Resident Debt
  Load
• 5538 Residents at 13 Canadian Universities
• 33 response rate (comparable to other national
  physician surveys)
• 9/10 residents incurred debt during medical
  education
• Average current debt for all residents 158 728
• Median current debt for all residents 135 000
• Average monthly debt payment 1 978
• Monthly salary (after taxes) in AB (PGY-1) 2
  480 Plus call stipend
• 62 of residents agree or strongly agree that
  their financial situation is Extremely Stressful

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Chemical Dependence
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Career Stress

• Jobs
• Extra-training
• (fellowships, academics, research, interest
  groups)
• Timeline
• As previously discussed, can be both a source of
  stress as well as a way to promote wellness

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Career Stress

• USA formal fellowship certification available
  for EM residents in
• Pediatric EM
• Toxicology
• Sports Medicine
• Undersea Medicine
• Hyperbaric Medicine

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Interpersonal Relationships
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Interpersonal Relationships

• Family is one of the most important social
  supports
• Nights, weekends and holidays are usually
  considered family times shifts may/will fall on
  these
• Survey of married, female residents
• Majority believed partner had communication
  difficulties, did not have enough time together
  and had arguments over domestic responsibilities
• Myers, MF. CMAJ. 1986 (134)
• Despite this, married residents experience lower
  levels of occupational stress and depression
• Whitley, TW. Et al. Ann Emerg Med. 1991 (20)

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Resident Wellness

• Medical Errors
• More common in residency
• Significant source of stress for all physicians
• Womens Issues
• Role Strain
• Harassment / discrimination
• Lack of role models
• Motherhood
• Houry, D., et al. Ann Emerg Med. 2000 (35)

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What strategies can we use to mitigate burnout?
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Time Management

• Personal Mission Statement
• Set Realistic Goals
• Personal Planner (organizer)
• Guard your schedule carefully
• Delegation
• Lean to say No
• Use commuting time
• Record TV programs
• Avoid Procrastination
• Understand shift work / circadian rhythms
• Healthful Sleep
• Schedule Down Time

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Relationships

• Schedule Spouse/Partner time
• Schedule family time
• Single residents Hire somebody to help out

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Other tips

• Exercise
• Make hobbies a priority
• Pleasure reading
• Find and cultivate coping mechanisms
• Immunization programs
• Hep B, Influenza
• Report OHS exposures
• Universal precautions

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Physician Wellness

• 2002 AMA/CMA conference on physician health
• Many physicians have compulsive personality
  traits
• Restricted ability to express emotions
• Perfectionism
• Excessive devotion to work
• Chronic self-doubt
• Insistence on ones way of doing things
• 80 of physicians have 3 of these 5 traits
• 20 of physicians have 4 of 5

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Physician Burnout

• Burn-out defined by Freudenberger (1975)
• Feeling of job dissatisfaction caused by
  work-related stress
• Three components
• Depersonalizaion
• Diminished sense of achievement
• Emotional exhaustion
• Burnout ultimately leads to attrition from EM
• True attrition rate hard to know
• Young specialty
• Major stressor (shift work) not felt until EP is
  in mid-40s

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Physician Burnout

• American Medical Association projects annual
  attrition rate of 3 for all physicians (retire,
  death)
• Attrition in Emergency Medicine
• 1350 ACEP docs surveyed
• 56.5 response rate
• Predicts EM attrition of 12/year
• 12 planning to leave in one year, 26.7 in five
  years
• 42.9 planned on seeing pts in 10 years
• leaving gt in training at that time
• Gallery et al. A study of occupational stress and
  depression among emergency physicians Ann Emerg
  Med. 1991 58-63.

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Factors Associated with Career Longevity in
Residency-Trained Emergency Physicians Hall, K.,
et al. Annals of EM. 1992 (21) 291-7

• Retrospective cohort study using a mailed
  questionnaire
• 858 US Residency-trained (1978-1982) EPs
  identified
• 539 respondents (62.8)
• 10 of non-respondents were contacted by
  telephone for demographic comparison (no
  statistical difference found)
• Respondents divided into groups of those who
  continued to practice EM and those who had
  elected to leave the specialty

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Factors Associated with Career Longevity in
Residency Trained Emergency PhysiciansHall, K.,
et al. Annals of EM. 1992 (21) 291-7

• 2-year survival rate 98.5 1.01
• 5-year survival rate 94.4 1.9
• 10-year survival rate 84.1 4.7
• Constant attrition rate 1.6/yr

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• Those who left EM were
• Less likely to be board certified (P lt
  0.001)
• More likely to be board certified in another
  field (P 0.001)
• Less likely to work with residents (P lt 0.009)
• More likely to report an annual gross income of lt
  100K/yr (P lt0.001)

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Factors Associated with Career Longevity in
Residency-Trained Emergency PhysiciansHall, K.,
et al. Annals of EM. 1992 (21) 291-7
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Academic EM Paradox

• Academic career provides both protection from
  burnout and one of the biggest threats to wellness

• Unique stressors
• Time
• Presentations
• Committees
• Research
• Students/Residents

• Prevents routine and boredom
• Diversified career
• Non-clinical outlets
• Social opportunities

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Shift Work
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Shift work

• The ED is always open, 24/7/365 days per year
• Shift work is a fact of life in emergency
  medicine
• Failure to address the issue of shifts will
  compromise the physicians health long term

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Shift work

• Physiology
• Forces EPs to sleep during daytime
• Bodys tuned to wake
• Long-term implications of SW
• Comparable cardiac R/F to smoking one pack per
  day
• Day sleep is shorter than night sleep
• Daytime sleep 2 hours shorter
• Leads to decreased amount of REM sleep
• Irritability and moodiness
• Papp, KK., et al. Academic Medicine. 2004. The
  Effect of Sleep Loss and Fatigue on Resident
  Physicians A multi-institutional, mixed method
  study. 795
• Smith-Coggins, R., et al. Ann Emerg Med. 2006.
  Improving Alertness and Performance in Emergency
  Department Physicians and Nurses The use of
  Planned Naps. 485

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Shift work

• 1960s observed circadian cycle
• Found physiologic functions that ebb and flow
  like sine waves
• Body temperature
• Sleep habits
• Eating habits
• Hormone and gastric secretion
• Bronchial reactivity
• Blood pressure
• Sexual arousal
• Anxiety
• Work performance
• Metabolic rate
• Short-term memory
• Family interactions

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Shift work

• Endogenous mechanisms and exogenous stimuli
  synchronize 25 hour clock with 24 hour rotation
  of earth
• External control (Zeitgeber cues)
• Light/dark
• Timing of meals
• socialization
• Internal locus of control
• Suprachiasmatic nucleus of hypothalamus

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• Associated with immediate and long-term risk to
  well being
• Common complaints
• Disrupted sleep (shorter rest)
• GI distress (increased incidence PUD, duodenitis)
• More likely to eat high sodium/fat diets, drink
  EtOH or caffeine, use tobacco
• IHD risk (increased triglycerides, higher
  incidence of MI)
• Diseases with internal rhythms (DM, asthma)
• Increased incidence of substance abuse, affective
  disorders
• Increased accidents/errors

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Impaired by shifting

• Task performance
• Memory
• Multi-tasking
• Communication
• Skill acquisition and performance

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Sheduling

• Proper scheduling is first step to handling
  shift-work
• Shift length
• Fast vs slow rotation
• Generally accepted is the French method
• Succession of shifts
• Days evenings nights

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Shiftwork

• Clockwise shift rotation (phase delaying) causes
  less strain to system
• Phase advancement more difficult on internal
  clock and rhythms
• Studies have suggested 20 increase in
  productivity in delay vs. advance
• Imagine jetlag
• West bound ? phase delay
• East bound ? phase advancement

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Casino Shifting
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Sleep Factors

• Sleep deprivation
• Cumulative sleep debt
• Circadian factors
• Sleep phase
• Shifting design
• Sleep disorders
• Get help
• Sleep inertia

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Strategies

• Light exposure
• Light suppresses melatonin
• Prepares brain and body for wake state
• Dark seeking
• Dark room for sleep build a cave
• Melatonin
• Sedation high doses
• Phase shifting 3h before sleep
• Strategic napping
• Avoid sedatives

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Behavioral modification

• Adjusting free time expectations
• Nutrition
• Appropriate training and exercise

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• Steele et al. The occupational risk of Motor
  Vehicle Collisions for Emergency Medicine
  Residents. Acad Emerg Med. Oct 1999, 6(10).
  1050-1053.
• N 1554 EM PGY 2-4 (62 response 957)
• Reported 1446 near crashes and 96 MVCs
• 74 of MVCs and 80 of near accidents were on
  drive home after night shift
• Concluded driving home after night shift is a
  significant occupational risk for EM residents

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Wellness Resources

• Physician and Family Support Program of the AMA
  (also Yukon)
• Employee assistance program model
• Toll-free number 24 hours/day
• Callers assessed by trained physicians and
  referred
• Access to counseling sessions

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Physician and Family Support Program of the
Alberta Medical Assoc.

• Toll free 1 877 767 4637
• Web www.albertadoctors.org