Self-care for ER Physicians: Practical Strategies to reduce physician stress and burnout

I found the following discussion of practical strategies on ER physician self-care by Golberg and Barnosky (2009) very interesting. My signature program of physician coaching promotes many of them.

The maintenance of wellness is critical in achieving a satisfying and productive career as a competent emergency physician. Wellness can be defined as the optimal state of health and well-being achieved through the active prevention of illness. Emergency medicine as a specialty was still in its formative years when concerns first surfaced regarding the stressful and potentially unhealthful aspects of practice in this specialty and the impact such stressors could have on wellness and career longevity. Although experience has shown that large numbers of emergency physicians enjoy long and fulfilling careers, questions remain about how best to cope with the demands and stresses associated with the practice of emergency medicine.

This chapter presents an overview of wellness issues facing the emergency physician, divided into three main sections: major stressors, physician burnout and impairment, and strategies for promoting wellness in emergency practice…

Here’s my synopsis of the article:

Sources of Major stressors in ER medicine

Major stressors in ER medicine, according to Goldberg and Barnosky, derive from difficult relationships with patients and professionals, the diversity in ER medicine, limited resources, and hard decisions. These stressors can overwhelm ER physicians, causing them to be less satisfied and productive. This “burnout” syndrome can cause low self-esteem, troubles with family and other relationships, depression, anxiety, cynicism, and even hostility. Frank physician impairment, in the form of mental illness, alcoholism, or chemical and other addictions, is an extreme consequence of excessive stressors on ER physicians.

ER physicians can neglect own physical and emotional needs

Doctors in general may be particularly vulnerable to some types of stressors due to adjustments they have made to survive training and be successful physicians – perfectionism, drive, resignation to long and irregular hours, commitment to service and sacrifice. So ER physicians committed to self-care should keep in mind that they are by nature disposed to neglecting their own physical and emotional needs.

Elements of Self-care

ER physicians who want to be more satisfied and content should: (1) promote wellness in their professional environment (2) maintain connections with family and friends, (3) stay fit, and (4) practice relaxation and renewal.

Promoting wellness in the professional environment requires having adequate physician and staff support for the patient load; having the adequate input through departmental policies and procedures; having good relationships with other physicians and staff; and reducing discomfort associated with noise, light, crowding, patient waiting times. Meeting such goals may require use of a physician executive coach.

A number of strategies for coping with the impact of shiftwork can help reduce this major cause of dissatisfaction among emergency room physicians and the adverse effects on physical and emotional health (mood swings, depression, drug and alcohol abuse, altered immune system, hypertension, increased cardiovascular mortality, infertility in women, divorce, and work related accidents and errors [Kuhn, 2001; Silbergleit, 2002]). These include:

  • Promoting regular sleep patterns by working the same shift as much as possible and rewarding physicians willing to work night shifts for extended periods
  • Working isolated night shifts and working with minimal circadian disruptions
  • Having one physician commit to an extended night schedule with isolated nights
    off. (Thomas schedule for groups)
  • Arranging shift rotations in a clockwise fashion that provide for 1-month minimum commitments per rotation.
  • Discouraging 12-hour shifts
  • Sleeping in a dark room and minimizing disruptions
  • Having physicians who cannot maintain consistent sleep patterns consider strategies such as anchor sleeping, split sleep periods, or napping
  • Starting awake periods with a high-protein meal and consuming complex carbohydrates toward bedtime.
  • Avoiding caffeine and high-calorie, high-fat snack food prior to sleep.
  • Promoting accommodating to new shifts by using bright light (>10,000 lux) for 2 hours after arising.
  • Avoiding a day shift lifestyle that involves working night shifts.
  • Exercising regularly.

Connection with family friends –  The ability to develop and sustain close relationships is high on the author’s list of strategies for balancing the lifestyle. Thus, they recommend:

  • a genuine relationship with a caring, emotionally expressive spouse or significant other
  • protected time with spouse and other family members
  • communicating consciously with others through active listening and open expression of feelings

Physical fitness –  ER physicians should not be excused from regular, vigorous aerobic exercise similar to those recommended by American Heart Association Guidelines (Fletcher et al., 1996):

  • aerobic exercise (repetitive use of large muscle groups) 3 to 6 times per week for at least 30 minutes
  • strength-developing (resistance training) at least twice per week (8 to 10 exercises of major muscle groups) involving one or two sets of 8 to 12 repetitions of each sufficient to increase the heart rate to at least 50% the maximum recommended

Relaxation and renewal – To reduce stress, authors recommend that ER physicians embrace a practice of relaxation though:

  • prayer
  • Zen
  • yoga
  • transcendental meditation
  • autogenic training, or
  • progressive relaxation

Finally, ER physicians should commit to regular renewal (e.g., through spiritual and other forms of retreat, vacations, hobbies) to counter the effects of their extreme work ethic, which include a tendency to lose emotional resilience.

Selected references

Fletcher GF, et al: Statement on exercise: Benefits and recommendations for physical activity programs for all Americans: A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation 1996; 94:857.

Goldberg R, Barnosky AR. Wellness, Stress, and the Impaired Physician. In:
Marx JA, Hockberger RS, Walls RM, et al (Eds). Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th ed, Vol 1, ch 203. Philadelphia: Mosby, 2009. Available by clicking here. (Accessed March 26, 2012)

Kuhn G. Circadian rhythm, shift work, and emergency medicine. Ann Emerg Med 2001; 37:88.

Silbergleit R. Shift work and physician performance. Ann Emerg Med 2002; 39:349.

2 Comments

  1. Elbert M. Belk

    Do you have any recommendation or literature that supports limiting physician hours (I am an ER doc), length of shift, avoidance of night shifts after age 45, or anything along that line?

  2. Hi Elbert,

    Yes, I do. Let me select some for you.

    DH

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