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Emergency Physician Wellness
Mark BromleyEmergency Medicine
PGY3
Thanks to Trevor LanghanJames Huffman
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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?
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ObjectivesObjectives1. Wellness
Definition Importance
2. Issues related to EM residents
3. Promotion of Wellness
4. Resources
5. Practice
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““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
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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
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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
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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
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List 4 major categories of stressors in EM
Within each category list 2 examples
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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 WellnessResident Wellness1. Debt / Finances
2. Chemical Dependency
3. Career
4. Interpersonal Relationships
5. Medical Errors
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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”
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Chemical DependenceChemical Dependence
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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
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Career StressCareer Stress USA: formal fellowship certification available for EM
residents in:
Pediatric EM Toxicology Sports Medicine Undersea Medicine Hyperbaric Medicine
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Interpersonal RelationshipsInterpersonal Relationships
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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)
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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)
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What strategies can we use to mitigate burnout?
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Time ManagementTime Management
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RelationshipsRelationships
Schedule “Spouse/Partner” time
Schedule family time
Single residents: Hire somebody to help out
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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
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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
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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
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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.
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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
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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
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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)
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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
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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
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Shift Work
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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
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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
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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
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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
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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 shiftingImpaired by shifting Task performance
Memory
Multi-tasking
Communication
Skill acquisition and performance
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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
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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
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Casino ShiftingCasino Shifting
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Sleep FactorsSleep Factors Sleep deprivation
Cumulative sleep debt
Circadian factors Sleep phase Shifting design
Sleep disorders Get help
Sleep inertia
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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
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Behavioral Behavioral modificationmodification
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 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
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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
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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