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Highly under-estimated problem in Emergency medicine

Stress Management for Emergency Physicians

April 15, 2021

Emergency Physicians as individuals are involved in the acute care of critical patients in a time/resource/space constrained environment and one split second decision of EP can play an instrumental role in outcome of care being given. Our ED had approximately 50000 visits in the last 3 years. Many of our patients are highly valuable human resources of our community, city and country. Thus, sensibility of our decision snowballs into a big impact on the individual, community and country in terms of morbidity, mortality, time, cost, productivity and innumerable abstract factors like physician/ hospital perception, feelings of personal and community well being, and even overall general outlook of the individual. Hence it is absolutely imperative that Emergency physician be fully alert, energetic, non-groggy, and suffer least or no symptoms of avoidable physical, mental and emotional energy drain in order to minimize cognitive, behavioral, motor, concentration and communication lapses during administering patient care. In order to achieve the same, it is necessary to understand the stressors which affect the practice of Emergency Medicine. Residency training in any medical specialty comes with its own set of stressors. Even that needs to be taken into consideration.


A variety of stressors contribute to the potentially unhealthful aspects of EM practice, both during residency training and in practice. These stressors generally relate to four aspects of emergency practice:


1. Difficult patient and professional relationships


2. Diversity of practice elements


3. Diminished resources


4. Difficult decisions full of uncertainty


Residency stress relates to


1. Time demands and work hours


2. Autonomy


3. Balance between personal and professional goals


4. Fear of personal safety and well-being


Consequence: Burned out or Impaired physician


Burnout can be categorized along three general dimensions: emotional exhaustion (feeling emotionally drained by contact with other people), depersonalization (negative feelings toward patients receiving care), and reduced personal accomplishment (the tendency to reflect negatively on your own work). Burnout is of special relevance to physicians because it undermines the integrity of the physician-patient relationship, which is the foundation of medical practice and essential to effective service. People in advanced phases of burnout are likely to experience decreased productivity, less satisfaction with work, higher job turnover, lower self-esteem, more physical symptoms, more troubled family relationships, and a variety of affective changes, such as hostility, anxiety, depersonalization, cynicism, and depression; thus encompassing overall wellbeing and existence itself. Symptoms of burnout are thought to be potential precursors of more severe manifestations of impairment, including alcoholism, drug abuse, and suicide.


The Federation of State Medical Boards, USA, defines an impaired physician as one who is unable to practice medicine with reasonable skill and safety because of a mental illness; a physical illness or condition that adversely affects cognitive, motor, or perceptive skills; or substance abuse. Impairment in a physician colleague often is difficult to detect. The recognition of a pattern of events, rather than a single precipitating incident, may be key to making the diagnosis.


Difficulties that arise in the workplace often are preceded by a history of family difficulties, including frequent arguments, periods of separation, extramarital affairs, and divorce. Frequent job changes (“geographic cure”) and unexplained time intervals between periods of professional employment also may be signs of impairment. A high value usually is placed on maintaining the source of income, and erosion of hospital duties is one of the last things that may be affected.


Patient care responsibilities become neglected, and the impaired physician may exhibit poor medical judgment. The problem may develop during a long period because strong elements of denial are usual among family members and associates as well as in the impaired physician.


The very qualities that characterize medically successful physicians— perfectionism, the drive to succeed, willingness to work long and irregular hours, and ideals of individual service and sacrifice—also may predispose them to neglect their own physical and emotional needs. The formulation of any comprehensive well-ness strategy is based on the concept of lifestyle balance and involves the integration of professional goals and responsibilities with needs for self-care and development. Cultivation of life-style balance involves four basic elements, summarized below.


A. Promote wellness in the professional environment.

  1. General measures
  2. Strategies for shift work
  3. Strategies for managing difficult and violent patients.
  4. Professional support groups.


B. Cultivate close family and social relationships.


C. Develop and maintain physical fitness.


D. Cultivate methods of relaxation and renewal.



a. Prevalence rate of symptoms of SWD in emergency medicine providers in India is 13-27%. Symptoms of SWD occurred more frequently in people who performed shift work and night shift work compared to those who did to work in shifts.(p=0.048).


b. Women are 3 times more likely to have SWD than their male counterparts.(p=0.0416) (OR = 3.006, 95% CI – 1.043-8.665)


c. Shift work disorder is strongly associated with bad sleep hygiene. (p<0.0001 for SHI score >26) Whether shift work leads to bad sleep hygiene practices that results in shift work disorder is subject to further research.


d. Though SWD is associated with higher ESS scores(p=0.015), SWD patients may have normal ESS scores. Having a normal ESS score does not exclude SWD or other sleeping disorders.


e. People with SWD reported lower job satisfaction scores (p=0.037).Despite all the health and sleep problems, (66.5%) majority of the study population report high job satisfaction scores(>3/5), reasons for which are subject to further research.


f. People with SWD are more likely to use sleeping aids.(p=0.0014)(OR= 1.19, 95% CI -1.011-1.405.)


g. Majority (60%) of study population can be said to have a delayed phase sleep cycle(evening type person), thus making them likely to function or perform better in shifts that start later in the day. Whereas the other 40% with early phase cycle(morning type person) may be more suitable for early morning shifts. Even though there is no statistical data to support this, individual should ideally work in whichever shift is best preferable to him/her.


h. Mean age of emergency medicine providers in India is approximately 31 years underlining the fact that it is a young and upcoming specialty.


i. Mean BMI of study population is 26, suggesting most of our study population borders on overweight category.


j. Commonest (>15%) health complaints recorded were fatigue, poor interpersonal relationships, irritability/mood swings, dark circles, weight gain, migraine, depression, irritable bowel, GERD, frequent URTIs among many others.


k. Commonest occupational complaints were argument with coworker, dissatisfied patient, delayed management, inappropriate disposition and clumsiness in fine motor activity.

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