WELLNESS for EMERGENCY MEDICINE RESIDENTS

1. WELLNESS for EMERGENCY MEDICINE RESIDENTS Lily C. Conrad, MD PhD FACEP ACEP Board of Directors

2. The best interests of patients are served when emergency physicians practice in a fair, equitable and supportive environment

3. Wellness and the Emergency Physician • Reasons for Concern • Burnout Studies • Substance Abuse Data • Attrition Rate

4. Wellness and the Emergency Physician • Major Stressors • Diversity • Diminished Resources • Difficult Patients • Difficult Decisions

5. Why is Wellbeing important? • Career longevity • Happiness and satisfaction

6. Coping Techniques Wellness Strategies • Wellness in the professional environment • Close family and social relationships • Physical fitness • Methods of relaxation and renewal

7. Time management • Balancing • Prioritizing

8. Attitude • Service committment • Vocation - being a healer and helper

9. Wellness and the Emergency Physician • Typical Physician Profile • Perfectionistic • Driven to succeed • Willing to work long and irregular hours • Ideals of individual service and sacrifice

10. Personality and genetics • Adaptation • Know yourself • Expectation vs realistic • Type A

11. Satisfactions and Joys • Making a difference • Teamwork

12. Stress! • Multifactorial • Helping and protecting yourself • Support systems

13. Consequences of Stress • Burnout • Impairment

14. Burnout • Feelings of job dissatisfaction due to work-related stress • Three components • Depersonalization • Diminished sense of achievement • Emotional exhaustion

15. Wellness and the Emergency Physician • Keller and Koenig (1989) • Surveyed 77 Emergency Physicians • 60% Medium to High Emotional Exhaustion • 70% Medium to High Depersonalization • 34% Low Levels of Personal Achievement

16. Wellness and the Emergency Physician • Gallery (1992) • Surveyed 763 Emergency Physicians • 12.4% were likely to leave specialty in one year • 27% were likely to leave in five years • 57% planned to leave specialty in ten years

17. Stress in Residency • Samkoff and Jacques • Reviewed studies on sleep deprivation and fatigue • All revealed deleterious effects on mood and attitude • More errors on repetitive tasks • Deterioration in performance tests requiring prolonged vigilance

18. Stress in Residency • Koran and Litt- 280 house staff • 40%- anxiety or depression impaired their work • 31%- social isolation • 12%- increased use of alcohol or drugs • 46%- concerned that a relationship with a significant other would not survive the residency

19. Stress in Residency • DE Houry, LW Shockley, V Markovchick • Annals of Emergency Medicine • 35 (4): 394-397, 2000

20. Wellness and the Emergency Physician • Physician Impairment • The inability to practice medicine with reasonable skill and safety due to physical and mental illness • Emergency medicine is overrepresented with chemically dependent physicians compared to other specialties

21. Impaired Physicians • Alcohol • Drugs • Mental Illness

22. Symptoms of Impairment • Symptoms • Denial • Compulsion • Progression • Relapse

23. Stages of Dependency • Use: Social functions • Abuse: Using the chemical interferes with life • Addiction: Life interferes with using the drug • Institutionalization/insanity/death or recovery

24. Recovery and Help • State specific programs • Counselling • Confidentiality • Disability

25. Strength • Permission • Boundaries • Trust

26. Life in the Goldfish Bowl • Unique to emergency medicine • Team captain • Interactions with other physicians

27. Wellness and the Emergency Physician • Wellness in the Professional Environment • Adequate physician and support staffing • Input on policies and procedures • Reduction of noise and structural discomforts • Strategies to deal with difficult patients • Shiftwork strategies • Support groups/CISD

28. Frustration and anger • Overcrowding • Admitting • Expectations vs. resources

29. Harassment • Political correctness • EM identity

30. Violence • Toward you and your staff • Society and your patients • Caring for those affected

31. Wellness and the Emergency Physician • The Difficult or Hateful Patient • OBS/Dementia • Language or cultural differences • Hostile patient/borderline personality • Overly dependent • Hypochondriac • Antisocial/self-destructive

32. Wellness and the Emergency Physician • Keys to Dealing with Difficult Patients • Recognize your negative feelings toward the patient and accept them nonjudgementally • Determine that the patient will not make you sick • Set limits for yourself in terms of treatment goals

33. Wellness and the Emergency Physician • Keys to Dealing with Difficult Patients • Set limits for the patient in terms of behavior and expectations for treatment • Share your feelings and concerns with other members of the treatment team • Treat “frequent flyers” with as much consistency as possible

34. Shift work • Circadian rhythms • Scheduling

35. Wellness and the Emergency Physician • Shift Work • Infertility • High rates of drug and alcohol abuse • Chronic hypertension and increased cardiovascular mortality • Increased rates of worker accidents and errors • Increased rates of accidents driving to and from work

36. Wellness and the Emergency Physician • Shift Work • Often cited as the main cause of career dissatisfaction • Chronic fatigue • Chronic sleep disruption and deprivation • Increased rates of depression, mood swings and divorce

37. Wellness and the Emergency Physician • Circadian Principles • 25.1 hr. biologic clock • Temperature cycle correlates well with level of alertness • Temperature “troughs” at 2:00PM and 3:00AM

38. Wellness and the Emergency Physician • Scheduling Strategies • Isolated night shifts • Clockwise rotations • Same shift for extended periods • Older physicians work fewer nights

39. Wellness and the Emergency Physician • Ancillary Measures • Naps, split sleep, anchor sleep • Exposure to bright light • Diet and exercise • Proper sleep environment • Stimulants/Melatonin • Night shift lifestyle • Close contact with family and friends

40. Healthy Lifestyle • Family and friends • Exercise • Diet

41. Wellness and the Emergency Physician • Exercise Prescription • Brisk- raise heart rate to 50-75% of maximum • Sustained- 30-60 min. • Regular- 3-4 times a week • Balance of isometric and isotonic

42. Wellness and the Emergency Physician • Beneficial Effects of a Proper Diet • Lower cholesterol • Weight control • Augment blood pressure control • Lower incidence of certain cancers • Retard the aging process?

43. Wellness and the Emergency Physician • Current Dietary Recommendations • Vitamins • Fiber • Minerals

44. Wellness and the Emergency Physician • Family and Social Relationships • Coombs (1991) reviewed 130 studies on rates of suicide, alcoholism, psychiatric disorder, etc. • Conclusion: “A marital partner who provides mutual companionship and psychic aid buffers individuals against the physical and emotional stresses of life.”

45. Wellness and the Emergency Physician • Physicians and Intimacy: The Barriers • Compulsive personalities

46. Wellness and the Emergency Physician • Adverse Effects of Compulsiveness • Difficulty in relaxing • Reluctance to take vacation • Chronic feelings of “not doing enough” • Difficulty with setting limits • Guilt feelings and the confusion of healthy self-interest with selfishness • Inappropriate sense of responsibility

47. Wellness and the Emergency Physician • The Pattern of Estrangement • Gradual erosion of marital intimacy • Reduction of emotional expressiveness • Absence of meaningful communication • Diminution or cessation of sexual relations • Gradual divergence of interests • Mutual withdrawal

48. Wellness and the Emergency Physician • The Medical Marriage: Maintenance • Key elements are Time and Attention • Devote at least 15-30 min per day to discuss substantive issues • Mutual compromise is necessary and must be openly discussed • Marital therapy may help in developing communication skills

49. Infectious Disease Exposure • Prophylaxis • Prevention

50. Exposures • HIV • Hepatitis B and C • Meningococcus • Pertussis