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 1. Wellness Definition Importance 2. Issues related to EM residents 3. Promotion of Wellness 4. Resources 5. 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 ones 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 1. Debt / Finances 2. Chemical Dependency 3. Career 4. Interpersonal Relationships 5. 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. 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 Womens 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 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 ones 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-40s

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 physicians Ann Emerg Med. 1991 58-63.

28. 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

29. Factors Associated with Career Longevity in Residency Trained Emergency Physicians Hall, 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 Physicians Hall, 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 Prevents routine and boredom: Diversified career Non-clinical outlets Social opportunities Unique stressors: Time Presentations Committees Research Students/Residents

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 physicians health long term

35. 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. 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 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

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 Daysevenings 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 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

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.orgwww.albertadoctors.org