Emergency Physician Wellness

1. Emergency Physician Wellness Mark Bromley Emergency Medicine PGY3 Thanks to Trevor Langhan James Huffman

2. 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?

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

4. “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

5. Why do we care? • Happiness and satisfaction  Career longevity • Reasons for Concern: • Lack of personal happiness / fulfillment • Burnout / Attrition • Substance Abuse • Suicide • Relationship problems

6. 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

7. 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

8. List 4 major categories of stressors in EM Within each category list 2 examples

9. 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 • Patients • Violence • Relationships • Needles/sharps • ID (SARS, TB, HIV, Hepatitis) • MSK injuries

10. As a resident, what are your greatest sources of stress?

11. Do you anticipate these changing as a staff?

12. Resident Wellness • Debt / Finances • Chemical Dependency • Career • Interpersonal Relationships • Medical Errors

13. 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”

14. Chemical Dependence

15. 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

16. Career Stress • USA: formal fellowship certification available for EM residents in: • Pediatric EM • Toxicology • Sports Medicine • Undersea Medicine • Hyperbaric Medicine

17. Interpersonal Relationships

18. 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)

19. Resident 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)

20. What strategies can we use to mitigate burnout?

21. 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”

22. Relationships • Schedule “Spouse/Partner” time • Schedule family time • Single residents: Hire somebody to help out

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

25. 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 one’s way of doing things • 80% of physicians have 3 of these 5 traits • 20% of physicians have 4 of 5

26. 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-40’s

27. 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 > # in training at that time Gallery et al.A study of occupational stress and depression among emergency physiciansAnn Emerg Med. 1991 58-63.

28. 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

29. 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

30. 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)

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

32. 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

33. Shift Work

34. 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 physician’s health long term

35. Shift 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

36. Shift 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

37. 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

38. 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

39. Impaired by shifting • Task performance • Memory • Multi-tasking • Communication • Skill acquisition and performance

40. 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

41. 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

42. Casino Shifting

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

44. 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

45. Behavioral modification • Adjusting free time expectations • Nutrition • Appropriate training and exercise

46. 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

47. 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

48. Physician and Family Support Program of the Alberta Medical Assoc. • Toll free 1 877 767 4637 • Web: www.albertadoctors.org