Emergency Physician Wellness

Mark BromleyEmergency Medicine

PGY3

Thanks to Trevor LanghanJames Huffman

Case 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?

ObjectivesObjectives1. Wellness

Definition Importance

2. Issues related to EM residents

3. Promotion of Wellness

4. Resources

5. Practice

““Wellness”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 one’s life.

Perina, DG., http://www.saem.org/publicat/chap12.htm

Why do we care?Why do we care?

Happiness and satisfaction Career longevity

Reasons for Concern:

Lack of personal happiness / fulfillment

Burnout / Attrition

Substance Abuse

Suicide

Relationship problems

Why should the public Why should the public care?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

Emergency Physician Emergency Physician WellnessWellness

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

List 4 major categories of stressors in EM

Within each category list 2 examples

As a resident, what are your greatest sources of

stress?

Do you anticipate these changing as a staff?

Resident WellnessResident Wellness1. Debt / Finances

2. Chemical Dependency

3. Career

4. Interpersonal Relationships

5. Medical Errors

Resident Wellness - Resident Wellness - DebtDebt

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”

Chemical DependenceChemical Dependence

Career StressCareer 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

Career StressCareer Stress USA: formal fellowship certification available for EM

residents in:

Pediatric EM Toxicology Sports Medicine Undersea Medicine Hyperbaric Medicine

Interpersonal RelationshipsInterpersonal Relationships

Interpersonal RelationshipsInterpersonal 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)

Resident WellnessResident Wellness Medical Errors

More common in residency Significant source of stress for all physicians

Women’s Issues “Role Strain” Harassment / discrimination Lack of role models Motherhood

Houry, D., et al. Ann Emerg Med. 2000 (35)

What strategies can we use to mitigate burnout?

Time ManagementTime Management

RelationshipsRelationships

Schedule “Spouse/Partner” time

Schedule family time

Single residents: Hire somebody to help out

Other tipsOther tips

Exercise

Make hobbies a priority

Pleasure reading

Find and cultivate coping mechanisms

Immunization programs: Hep B, Influenza

Report OHS exposures

Universal precautions

Physician WellnessPhysician Wellness2002 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 one’s way of doing things

80% of physicians have 3 of these 5 traits 20% of physicians have 4 of 5

Physician BurnoutPhysician 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-40’s

Physician BurnoutPhysician 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 > # in training at that time

Gallery et al. A study of occupational stress and depression among emergency physicians Ann Emerg Med. 1991 58-63.

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

Factors Associated with Career Longevity in Residency-Trained Emergency Physicians

Hall, K., et al. Annals of EM. 1992 (21) 291-7

Factors Associated with Career Longevity in Residency Factors Associated with Career Longevity in Residency

Trained Emergency PhysiciansTrained Emergency Physicians

Hall, K., Hall, K., et al.et al. Annals of EM. 1992 (21) 291-7 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

Those who left EM were:

Less likely to be board certified (P < 0.001)

More likely to be board certified in another field (P = 0.001)

Less likely to work with residents (P < 0.009)

More likely to report an annual gross income of < $100K/yr (P <0.001)

Factors Associated with Career Longevity in Residency-Trained Emergency Physicians

Hall, K., et al. Annals of EM. 1992 (21) 291-7

Academic EM ParadoxAcademic EM Paradox Academic career provides both protection from burnout and

one of the biggest threats to wellness

Prevents routine and boredom:

Diversified career

Non-clinical outlets

Social opportunities

Unique stressors:

Time

Presentations

Committees

Research

Students/Residents

Shift Work

Shift workShift 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 physician’s health long term

Shift workShift work Physiology:

Forces EP’s to sleep during daytime Body’s 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. 79:5

Smith-Coggins, R., et al. Ann Emerg Med. 2006. Improving Alertness and Performance in Emergency Department Physicians and Nurses: The use of Planned Naps. 48:5

Shift workShift work 1960’s 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

Shift workShift 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

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

Impaired by shiftingImpaired by shifting Task performance

Memory

Multi-tasking

Communication

Skill acquisition and performance

ShedulingSheduling 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

ShiftworkShiftwork 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

Casino ShiftingCasino Shifting

Sleep FactorsSleep Factors Sleep deprivation

Cumulative sleep debt

Circadian factors Sleep phase Shifting design

Sleep disorders Get help

Sleep inertia

StrategiesStrategies 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

Behavioral Behavioral modificationmodification

Adjusting free time expectations

Nutrition

Appropriate training and exercise

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 MVC’s

74% of MVC’s 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

Wellness ResourcesWellness 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

Physician and Family Support Physician and Family Support

Program of the Alberta Medical Program of the Alberta Medical

Assoc.Assoc.

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