Wellness Section Newsletter - April 2007, Vol 11, #2
Julia M. Huber, MD, FACEP
Welcome to the spring edition of the Wellness Section newsletter. First, a bit of spring cleaning: the piece entitled "Lincoln’s Melancholy" which was credited to Richard M. Goldberg, MD, FACEP, also should have been credited to Louise B. Andrew, MD, JD, FACEP, in the previous section newsletter. Our apologies for that oversight.
I hope that this newsletter finds you healthy, balanced, and inspired. If not, why not? Perhaps there is an issue you have been contending with personally and professionally that dovetails with some of the conversations taking place within the Wellness Section, Wellness Committee and among ACEP leaders. I would encourage every member of ACEP to take a look at the email entitled "Future Shock" by Alexander M. Rosenau, DO, FACEP, which we are reprinting here. Wellness may no longer be an issue of interest to just a marginalized few. Let’s hear it for bringing some of these issues forward and center, if anything so we can continue to staff the country’s emergency departments (EDs) with skilled, board certified professionals as well as we can. Our families, our staffs, and our communities need us to be supported as new parents so we remain in our profession, to age as healthily as we can, and overall maintain some sense of balance so we don’t burn out or, in the worst case scenario, commit suicide (SUE-icide?) while being scrutinized during a malpractice suit. If you have no time to read the entire newsletter, then just please open up the piece by Dr. Connie Nichols, "Trial by Trial." It is a personal account of her malpractice case. Her piece was originally submitted to the Section of American Association of Women Emergency Physicians (AAWEP) newsletter, and is reprinted with permission from AAWEP and the author. I think her experience is relevant to ALL of us and is quite sobering. As she writes in her piece, "A trial is the most exquisite form of torture designed for a physician."
Now is the time for us to be moving toward well-being as an organization. I think each of us has the opportunity to contribute to new ACEP policy, and I encourage you to read the notes by Lily Conrad, MD, PhD, FACEP, on areas of focus for the Wellness Committee and Section. Happy Spring!
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Trial by Trial: A Firsthand Account of Being Sued
Connie Nichols, MD, FACEP
We all talk about malpractice legislation, litigation reform and even "what to do once you’ve been sued." But, what happens personally once you’ve been sued? Let me share my story.
First, there was the shock of being served, which occurred during a work shift. Let’s talk about patient safety. In my experience, it became hard to concentrate when my entire ego had just been smashed with a thousand pound subpoena. Then, I looked at the name. Did I even remember this person?
Experts tell us "It isn’t personal." From my experience, it certainly feels personal when your name is on the page of "legalese" next to words like "willingly neglected" and "malfeasance."
We’ve all attended the seminars on "what to do when you are sued." In the abstract it is all well and good. You get served, your insurance company gets you a lawyer or maybe they decide to settle (game over).
Now starts the endless rounds of meetings and paperwork. I saw my chart and thought to myself, "Oh, we were using those charts back then. Why was I so terse in my history of present illness? Boy, we treat this differently than we did then!"
I cringed every time a fancy high bond envelope showed up with my attorney’s firm name on the return address. Large thick bundles of paper showed up containing interrogatories and counter interrogatories. It was still all "boiler plate" stuff, but my name was featured prominently amongst all the pejorative adjectives such as "willingly" "mindlessly" and "negligently."
I began to wonder: what do my colleagues think? (I actually thought twice about telling my spouse…what makes you think anyone tells their colleagues?)
Being sued is the elephant in the room: nobody wants to acknowledge it or even think about it. I had to tell my spouse who was, by the way, the only one to whom I could talk. I just asked for odd days off and hoped that the lawyers didn’t reschedule everything, which happens constantly.
The physician being sued generally meets with his or her lawyer to practice for the deposition. In my case, it was scheduled and rescheduled multiples of times. I thought to myself, "Why did it have to happen at that hospital? The lawyers are 50 miles from home. I hate driving in that city." After oaths are sworn, questions are asked by the plaintiff’s lawyer. With proper coaching from the physician’s lawyer, this part is generally tolerable. It is actually kind of like a trial without a courtroom, jury or judge. The reporter is there to take down every word, and then it’s over.
Next, there will be months, if not years, of waiting. There is nothing for you, the physician, to do as the attorneys are doing all the behind the scenes work. I just filed it away in a little locked box in my brain and only think about it when one of those fancy envelopes shows up in the mail. My kids wondered about my mood. I seemed snappish on some days when I brought in the mail; other times I was sad and even tearful. I told my spouse. He is also an emergency physician so he had a clue.
Does anybody have any idea what kind of mental torture the physician goes through? My case happened in 1998.
What emotions did I feel when I thought about the case?
Doubt: maybe they are right; maybe I did mess up and cause a bad outcome. It’s hard to leave that feeling at home before the next shift.
Anger: how dare they sue me after everything I tried to do- that is if you even remember the patient? It can be years before you are sued.
Frustration: I can’t believe this is taking so long!
I also noticed a change in practice habits: "wow this one kind of reminds me of my malpractice case. Maybe I will do the extra tests and CT scan even though they will probably be negative," I would think to myself. So are doubt, frustration, and anger only applied to the case? It’s hard to remember it’s not personal when these emotions seep out into life at home as well as work. Patients that remind the physician of the malpractice case may end up getting more tests done than necessary.
In my situation, life went on. I didn’t get any fancy envelopes for awhile and was able to let the case slide to the back of my brain until, out of the blue, the lawyer called about court dates. There it was, real and alive; we were having a trial. It was now 8 years after the case occurred. Although most cases don’t take 8 years to come to trial, three postponements will do just that.
A trial is the most exquisite form of torture designed for a physician.
On the first day they picked a jury of people that I hoped could follow the arguments. Court only lasts from 9-1. Lots of paperwork and counter motions get done. I was only there for 4 hours a day. Do I go home, go to work or run away?? How do I spend the time I’m not in court? I studied my copy of the chart and depositions until I felt I could see through them. The commute was a bear. Fortunately, I had friends with whom I did stay.
The next day, after lots of motions, counter motions and passing of papers, the trial got going with opening statements. So, I sat there in my nice clothes and listened to an attorney describe me as the worst doctor to practice medicine in this century. I was presented as stupid, inattentive, careless, and reckless and a disgrace to the practice of medicine, and they had an "expert" to back up that claim! All the time I sat there with my best attentive-but-pleasant face on, while inside I was thinking about how I would love to strangle that weasel with my bare hands. My attorney described me as hard working, caring and that I followed the standard of care rendered by an average emergency physician. Even that comment hurts a little. I always considered myself a little above average. However, "average" is the standard that the plaintiff has to prove the physician has violated. I had to stop thinking so hard and keep my face in order.
Joining the physician in the gallery, since we didn’t sit with the attorney like on "Law and Order," was the patient and family that was suing me. Remember, this is civil, not criminal, law. This scenario, however, is anything but civil, and this is something they don’t talk about in the classes on malpractice. I skillfully learned to avoid eye contact, find a different bathroom to use on breaks and do everything possible not to look at them. This also applied to the jury. I didn’t want to be anywhere near them on breaks. Nothing experienced thus far seemed "civil."
Next, the plaintiff stated the case. In my situation, we listened to an expert--another emergency physician, describe how I egregiously violated the standard of care in this scenario. After the plaintiff attorney put me on the stand to answer questions, the people suing you get to have their say on the stand. My lawyer was polite but firm with them, bringing out all my good points and finding any inconsistencies. Again, I sat there with an attentive but noncommittal face on while other people talk about the thing I have dedicated my life to doing well.
It was hard to remember that this was not personal.
It was now the defendant’s turn. In my situation, a "good" emergency medicine doctor came in and told how I clearly met the standard for an "average emergency physician" (why doesn’t that feel good?) and the jury seemed to get it. I was next on the stand. My attorney led me through the case and everything seemed good. The plaintiff’s attorney then got to take a shot at me. This was so hard. "Listen to the question, don’t be in a hurry to answer" raced around the inside my skull as I tried to listen, answer the question and not try to explain. Even if I did, the plaintiff’s lawyer, whom I thought of as "the weasel" wouldn’t let me. He asked impossibly complex questions to which he required a yes/no answer. Fortunately, my record was reasonably documented, and I don’t remember most of the details. I mostly stated, "I have no independent recollection of this case." It was amazing to me what 8 years, a new ER, building a new home and raising kids did to my memory.
Finally, the time in court was nearly done. I didn’t manage to damn myself on the stand or come across as arrogant. I remembered that statistic about 90% of physicians winning cases. I was completely emotionally exhausted, but maybe I knew I would get through this. I was driving home that night.
After the closing arguments there was nothing to do but listen. My attorney went first. He was wearing his best suit since the trial started. This was day eight. Thank goodness I worked those shifts over the weekend, I thought. My lawyer described the case, summarized the expert testimony and mine. It was looking pretty good and I started to relax. The plaintiff attorney was the last to speak. It seemed to me somehow unfair that he had the last word. He took everything that had been presented over the last few days and twisted it into some horrible tale with me as the monster. He essentially said I lied in my record, I had lied on the stand, that my experts were just protecting a fellow doctor and my attorney skillfully twisted the truth. While the bile rose in my throat I resisted the urge to fling my water bottle at him. The jury was dismissed and I got out of the courtroom as fast as I could. My lawyer caught up to me, hustled me into an unused room and said "Calm down." Right. All the anger I had been squelching now bubbled up and bursted out in a rush of questions laced with profanity. ("How can that *#$&$ say those things about me?? He says I lied!!! He says my chart lied!!! In fact he said our expert lied and even that you lied!!! How can he get away with that?")
I felt violated.
I felt as if I had been physically attacked.
This is the justice system? This is "civil" law??"
Once I calmed down, I understood that his closing was just that, a closing just like any lawyer’s. A day later the jury received its charge from the judge. These instructions were complex but the judge was very clear and they seemed to comprehend. They were sent to deliberate and court was adjourned. Now what? I stood there waiting to be told what to do. I felt numb and nauseated. My lawyer made sure he had my cell number, told me to go home and that he would l call when the verdict was in, or when deliberations were over for the day.
It was assumed I would now I just go home and resume my life.
The call came two hours later. The jury found the case in favor for me. It’s over. I "won."
Somehow, it doesn’t feel like a victory.
Editors Note: Louise B. Andrew, MD, JD, FACEP wanted readers to be aware of the Litigation Stress materials on ACEPs Web site , especially the "So You Have Been Sued" article written by the Medical Legal Committee. An additional resource is MDMentor http://www.mdmentor.com which has many more useful materials and links for folks who find themselves in Connie's situation. It could be lifesaving.
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My Struggle with Shape
Mitchell B. Cordover, MD, FACEP
Alright, I admit it! I’ve become a couch potato! Oh, I can rationalize that I am almost 60 years old and still pretty lean. Still, when I look in the mirror there is no denying that I have developed a little pudge around the middle. Every time I go out to play with my son, I hurt myself. I throw my arm out when I pitch the ball; I twist my back when I reach with a lacrosse stick. I suppose I am in the same boat as many of my colleagues. My life is busy. I have many responsibilities and almost all of them are exercised while I am planted firmly on my derrière. I just know that I must have walked 100 miles per shift until we changed to the electronic medical record. Now it’s a casual sashay to the patient’s room and a promenade back to my seat in front of the computer. Seat is the operative word here.
Well I am certainly not the kind of guy who will let a little thing like getting in shape get past me! I did what any well-organized, well-educated, ambitious (dare I say virile) fellow in my position would do. I sat down in front of a computer and looked up "exercise."
What I found was fascinating! First of all, being in good condition is apparently very very good for you. It’s not just a matter of increasing your HDL, and improving your total peripheral vascular resistance. It improves your attitude, protects you from depression, improves your work performance, and leaves you with more energy at the end of your work day to actually have a life outside of work. (Note to self, after getting in shape, get a life outside of work). So, if it is so wonderful, how come so few people actually are fit? Obesity and poor physical condition in general has become so rampant that they are running public affairs announcements on late-night TV begging people to take a walk for 20 minutes three times a week. I know! I watch them sitting in front of the television at 2 am eating peanut butter sandwiches.
One thing is that we eat that badly. We eat large portions of high fat and high sugar foods because they are more convenient and easier to get. They are also more satisfying! It certainly does not help that your hypothalamus satiety center is specifically tuned to blood sugar and free fatty acids. I like to think that my downfall is baby back ribs. When my wife complains about how unhealthy they are, I remind her that I only eat them twice a year. I tell her that about once a month. But alas, it’s not the monthly transgression that gets us, but the drive-through windows, and the hamburgers, and the daily extra handful of cashews, and the mid-shift Snickers bars. Hype your energy up, you know.
Then there’s the business of exercise. I mean, how much shape do you really need in order to be "in shape." I see the Bow Flex ads and the magazine pictures with young man rippling with arms like knobby tree trunks and six pack abs. But how often in my life would I need to, say, bench press my patients? With the exception of reducing the occasional hip, almost never. But I do need enough muscle mass to keep my metabolism up. Muscle burns calories way better than any other tissue and it helps maintain anaerobic conditioning far better. Aerobic conditioning is essential for good health, and a major contributor to the psychological benefits of being in good condition. But you can’t do it and you can’t maintain it without some muscle mass; to do that you’ve got to do resistance exercise. I need not say that exercise-resistance has been my problem from the first.
In the past, when gripped by this same drive to get in condition, I have gratefully arranged to injure myself early in the process. With any luck, my sore shoulder or swollen knee would keep me out of action until the impulse passed. This time, I have determined to start VERY SLOW. Unless you are already exercising, do not be fooled by the choice between high-weight, low-rep versus low-weight high-rep exercise. Start with low-weight, low-rep workouts. There is some very convincing information coming back into vogue about low weight very slow reps. It is well known that muscle stamina and muscle mass are built disproportionately on the release phase of weighted exercise. Slow smooth flexion, followed by slow smooth release seems to result in very good muscle building with less chance of joint or muscle injury. It allows for, in fact requires, lower weights.
It’s the same with aerobics. This time, I will start with walking. I like an alternating cycle. Walk 20 minutes, nap 20 minutes. Perhaps I’ll carry light hand weights (2 pounders really increase your calorie expenditure without making the first few days a Charlie-horse fest. You probably never need go above 5 pounds. One pound on your feet in the form of ankle weights is said to be equivalent of 5 pounds on your back, but ankle weights can cause knee pain!) The mistake I made last time was trying on my first day to run the stadium steps with a full pack on my back. Thank goodness I sustained a painful groin pull just before I got to the steps. I could’ve had a heart attack!
No, this time it starts slow. Elliptical exercisers claim to be especially easy on one’s joints. I have not found any convincing data to support this, but I’ve tried one and it does comport with my experience. Swimming, spinning and bicycling, Pilates, and a host of other alternatives are proven to be low injury aerobic sports. Unfortunately, the one that seems to be the low tech alternative is running. It is associated with a higher rate of problems like back, foot, and knee pains. Those who do it regularly, however, are really hooked. I envy them their endorphins and I might give it another try once I’m a little warmed up.
I have also determined not to do this alone. The articles suggest that if a trainer, or running partner, or colleague is waiting for you, you are much more likely to show up then if it is just between you and your conscience. In my case, I’ve chosen my wife as my work out buddy. She is far less likely to laugh out loud at my fly weight exertions and she has a stake in my getting in shape. Of course, she also has a stake in my life insurance policy so I’m watching this choice carefully.
Lastly, I will have to find a way to build exercise into my routine. There are always a thousand things that seem more important at the moment than changing clothes and getting sweaty and showering and then dressing again. Exercising just before bed is ill advised. It is far too stimulating. Many people prefer to work out before or after work. Luckily, my work schedule is relatively constant. But I can imagine that if I was changing shifts twice a week, finding just the right time would be more difficult. Most of my partners at work are regular exercisers and if they can find a time so can I. I will try writing it into my schedule. When people call, I won’t be available for that hour. If that ain’t commitment I don’t know what is!
Now if I could just get up from this computer.
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Transplanting the Soul
Shay Bintliff, MD, FACEP
Tentative...yes, that is what life is
from one beat to the next,
until that final encounter.
Knowledgeable professionals mend and medicate
a heart gone bad.
Poets let it die in metaphors of perpetuity.
Once thought a sacrilege to touch,
this oh so vital organ
is subject to the surgeon's meddling,
Defacing, replacing this organ so sacred.
The scalpel falls!
Is the soul's energy now in shutdown?
Has the seat of the soul been
Invaded, removed, and replaced
By those with cardiac paranoia?
"As he thinketh in his heart, so he is"
so sayeth Proverbs.
Where now do we house our emotions?
What is this strange inner hollow,
never here before?
Unknown to the present self.
Can I still touch another's heart?
Or is this the end?
Oh, to feel the resonant beating of my resolve.
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Why Do We Need a Wellness Committee?
Mitchell B. Cordover, MD, FACEP
Let’s agree that wellness is essential for the safe practice of emergency medicine. We’ll take it for granted that it secures or even expands the manpower pool for the safety net of the health care system. It improves the patients’ experiences and it makes our lives nicer. Just preventing burnout, with its ramifications for the mental health of emergency doctors and the well-being of their families, would be enough to certify wellness is a good thing. But, why make it an official task for the American College of Emergency Physicians? Isn’t wellness mostly a matter of being personally cautious with your sleep and keeping your temper with difficult patients? What can our specialty organization do in this arena?
There is no question that some of the burden for maintaining your health and life balance rests squarely on your own shoulders. But certainly not all of that burden and perhaps not most! More than many specialties, emergency medicine is practiced in a highly regulated environment. There is no private practice ED. Emergency departments are regulated, legislated, and carefully scrutinized by hospitals, payers, and the Joint Commission. The very nature of that environment is subject to a "standard of care." More than any other organization, ACEP establishes that standard. Its policies and legislative efforts are taken seriously, and used as a template. ACEP’s interventions with state boards, certifying bodies, and individual facilities on behalf off its members sets precedents for fair practices throughout the United States.
Well and good, but what does this have to do with wellness?
What if your State Board of Medicine decided that depression represented a condition that potentially impaired your ability to practice medicine? Unfortunately, this is not a theoretical question! Such a rule would have a distinctly chilling effect on emergency doctors seeking counseling or medications that could improve their lives and defend their career. A college policy that states propose is that a diagnosis of any mental illness should not be in itself evidence of impairment but that medical performance should be the only relevant measure would be of great benefit. The same would go for recommendations about confidential reporting of alcohol abuse and guidelines for the fair application of due process to physicians who are suspected of abusing substances.
Women are protected in the workplace by law. However, female emergency doctors still face a special and disproportionate burden of family responsibilities, especially in late pregnancy and following childbirth. The ACEP policy titled, Family Leave of Absence, specifically includes mention of the birth or adoption of a child. Widespread use of this recommendation would certainly promote a more balanced family life, and hence improve wellness. It is not a purely personal matter! It is a matter of policy and administrative practice. These are the College’s strong suits.
The same could be said for the special needs of the aging physician. More than producing recommendations about taking the needs of this valuable manpower resource into account, the College could play a leading role in researching what those needs are. Educating emergency administrators about their options to articles, monographs, and policy statements are all within ACEP’s capabilities. The committee’s work in these areas and especially in insuring fair treatment and uniform due process for this most experienced increasingly vulnerable group supports the wisdom of the College putting wellness on its committee agenda.
What if a hospital chose to cut expenses by reducing its security staff, or making them less available to the ED in a timely fashion? Policies regarding physical safety and security would be useful to the emergency doctors in that hospital in their negotiations with administration. When planning expansions of their physical plant or re-examining their security procedures, availability of security staff to the ED would simply be considered the standard. An instructional monograph on safety and security options and architectural requirements would go a long way toward reducing workplace violence in our unpredictable field.
Similarly, there is a recommendation that emergency staff be immunized against influenza when treating patients during an epidemic. What about the coming pandemic? Lobbying for a special stock pile of prophylactic antiviral medications for ED personnel and their families is a wellness measure that can only be done at the organizational level.
There is no greater challenge to wellness in emergency medicine than the problem of scheduling a 24/7 service. The hospital has strong policy language supporting the use of correct circadian scheduling. The ACEP wellness book and articles on its web site provide excellent information on this very personal challenge. But what if the down-to-earth straightforward instructional manual on sleep -- correct scheduling options were available and built into the very curriculum of emergency residency programs? It is a favorite fantasy of mine that EDs would start to compete for the best emergency physicians with the promise of improved scheduling and sensitivity to circadian needs. After all, who would not be tempted to work at a facility with no (or minimal) night shifts? It’s a kind of political and practice environment momentum only possible for an organization with ACEP's size and authority.
Staying fit, maintaining a healthy diet, smoking cessation, stress reduction techniques, these are all central to maintaining wellness and longevity in this field. They are all personal activities (though I would love to see my hospital have a workout room, a better salad bar, a nurse and physician smoking cessation program, and yoga classes). But don’t let the intimate nature of running and meditating mislead you! Wellness is far more than feeling good about work. It is a political, legislative, and policy imperative and worthy of serious attention.
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Well-being Committee Board Liaison Update
Alexander M. Rosenau, DO, FACEP
The Wellness Committee has identified important future shock for ACEP: aging physicians, change of guard to generation x, y and z and the increasing number of physicians whose family obligations stand to impact workplace commitments. This includes the so-called sandwich generation caring for elderly parents and young children, the increasing percentage of female EP’s who will certainly require accommodations for pregnancy and early child care (especially if we are to benefit from their simultaneous practice while meeting obligations of pregnancy and new family) and the number of physicians whose government entitlements may vaporize, leading to a later retirement age.
As a professional society dedicated to the overall health of its members and the profession that they practice, ACEP is the organization in a position to carefully address these issues. As with any policy we will want to consider impact on the individual, seek to avoid painting ourselves into any legal quandaries while crafting policies that bring value to the member.
One route may be for the Wellness Section to suggest a category or set of policies via Council resolution. These would be assigned to the Wellness Committee and then reviewed by the Board. The committee members may have other suggestions for navigating the waters on this.
It's great to have this enthusiastic group recognizing issues that are pertinent to our members’ challenges in this area. Even on a business level the emotional intelligence of ACEP as a group is demonstrated by paying attention to these issues, many of which have the potential to affect the bottom line of EP practices and the College itself.
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Communication with Patients: Four Steps to Problem Solving
Reprinted with the permission of the Texas Medical Association (TMA): 401 West 15th Street, Austin TX 78701 Ph: (800) 880-1300, (512) 370-1300 Copyright 1999-2007 Texas Medical Association. All Rights Reserved. http://www.texmed.org/Template.aspx?id=1603
Although it is directed at medical office staff, the four steps are a good reminder of how to handle the unhappy patient.
When faced with a highly emotional patient, medical office staff members tend to be logical and quote policy as a means of reaching a solution and getting the patient out of the office. Unfortunately, when patients’ emotions are high, their logic is low. So the first task in solving a conflict is to lower the emotional level of the patient so that you can negotiate a reasonable solution. Then, determine the real problem and define an appropriate response rather than resort to a knee-jerk reaction. You can accomplish both tasks by using the following four-step process. It is a very useful tool to work out all kinds of problems, big and small. It also works wonders with family and friends!
- Listen Attentively. Spend several minutes letting the patient tell the whole story without interruption. Be careful not to become defensive, react sarcastically, or appear rushed. Use good eye contact, and take notes, if appropriate. If the patient gets off track, use phrases such as: "Tell me more about …," "Then what happened?" or "How did you feel then?" These phrases invite the patient to continue the story rather than start over at the beginning.
- Show Concern. After the patient has completed the story, show appropriate empathy or understanding for the situation. Use phrases such as: "I can see how you might have gotten that impression of us," "I can see why you’re concerned," or "I’d feel that way, too, if I were in your shoes." You don’t have to agree with the patient’s story or point of view. Simply show understanding for the situation. The benefit of listening and showing empathy is that the patient begins to feel understood and respected as a person, and that usually lessens emotions.
- Clarify Details. The next step is to clarify any details or points in the story that are important to reaching a solution. Focus on those items that give you information and clues about how to approach a situation.
- Respond Assertively. Finally, once you have a clear understanding of both the facts and the emotions of the situation, you can choose an appropriate response. Use an "ideal solution" question such as: "What would you like me to do to solve this problem?" or "What would be your ideal solution to this problem?" The patient may surprise you by suggesting a perfectly acceptable solution. Using the patient’s response as a starting point, negotiate the best possible agreement. Be clear about your policies and possible exceptions, outline the patient’s choices, and work toward a solution.
The purpose of these four steps is to give you a structured way to approach problem solving, a way that is safe, respectful, and productive for you and the patient. This method doesn’t take much time and reduces the stressful emotions to a manageable level.
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Reviewing ACEP Policies Relevant to Emergency Physician Wellness
Lily Conrad, MD, PhD, FACEP, Subcommittee Chair
Eve K. Kaiyala MD, Subcommittee Member
You really have to be well to practice emergency medicine. It is a specialty that requires clear presence of mind and an undistracted attention to the patient. Many of our patients are seriously ill and we are under time pressure to find which ones they are, characterize the problem and intervene. We need the psychological stability, non-judgmental generosity of spirit and a modicum of peace-of-mind to establish a trusting therapeutic relationship with every sort of person within a few minutes. Since physician wellbeing is fundamental and essential, ACEP policies should to be directed at affirming and supporting it, as well as clarifying the College's stance on emergency physician wellness/wellbeing.
This Well-being Subcommittee was directed this year to investigate the presence of emergency physician well-being topics within our ACEP policies. Review of all the ACEP policies reveals serious gaps. We lack formal policy statements, particularly in areas dealing with physical illness and sick leave; aging and the older physician; maternity, paternity; and parenting and family issues. Notably absent are any College policies specifically addressing emergency physician well-being during pregnancy.
The College does maintain a category titled Physician Wellbeing within its Policy Compendium. There are three policies are included under that heading: Emergency Physician Shift Work, Family Leave of Absence, and Physician Impairment.
During our review, we found that a number of ACEP policies, particularly those within the Injury Prevention and Patient Safety headings, do speak generally to wellness - but emergency physicians are distinctly not the focus of these.
Using a breakdown of categories within Emergency Physician Wellness as developed by Mitchell B. Cordover, MD, FACEP, we have listed all those ACEP policies (even remotely) relevant to that Wellness category. Dr. Cordover has divided emergency physician wellness issues into 14 different categories, all of which have been of interest to the Well-being Committee and Wellness Section over the years. (If you would like to check the content or look at any of these policies, be aware: they are listed alphabetically by name, or classified under general groups - such as EP Wellbeing.)
The listings below represent a most liberal and inclusive approach to our College’s current policies. Still, one can see the gaps as noted above.
- Safety and security
Protection from Physical Violence in the ED
Handling of Hazardous materials
Firearm Injury Prevention
Use of Patient Restraints
- Contagion and immunization
Personal Protective Equipment Guidelines for Health Care Facility Staff
Guidelines for Smallpox vaccination for Health Care Workers
Bloodborne Infections in Emergency Medicine
- Circadian stress and scheduling
Emergency Physician Shift Work
- Torts and Litigation Stress
Good Samaritan Protection
Expert Witness Guidelines
- Medical Marriage (Family and parenting management)
Family Leave of Absence
- Relations to patients and staff
Code of Ethics for Emergency Physicians
Emergency Physicians Rights and Responsibilities
Writing Admission Orders
Cultural Competence and Emergency Care
- Aging (limitations, hours, retirement, work alternatives)
Role of the Legacy Emergency Physician in the 21st Century
- Growth, challenge, professional satisfaction
Scholarly Sabbatical Leave for Emergency Medicine Faculty
- Substance abuse, impairment and recovery
Blood Alcohol Concentration and Driving
Legal Sanctions and Rehabilitation for DUI
- Behavior and Psychiatric Disorders
- Fitness and health promotion
Universal Bicycle Helmet Use
Watercraft Safety and Intoxication
Motor Vehicle Safety
- Fair treatment from regulatory bodies (including impairment reporting)
Agreements Restricting the Practice of EM
Compensation Arrangements for Emergency Physicians
Compensation When Services are Mandated
Workforce Diversity in Healthcare Settings
Standardized Physician Credentialing Application
- Physical illness and sick leave
- Patient protection from impaired doctors
Disclosure of Medical Errors
Reporting of Medical Errors
Reviewing the College’s policies with regard to emergency physician well-being raises several issues for the committee.
- What are the areas where we feel it is important for our College to have policies formally on record, regarding emergency physician wellness?
- Which areas of gaps are most important to address promptly, which are lower priority or somewhat already covered?
- Should our committee attempt to draft resolutions or make recommendations to the Board for future policy development?
If the Well-being Committee is interested in considering suggestions for future College policy development, the following are some possibilities derived from the review above.
- Emergency physicians being immunized themselves (eg, stockpiles of appropriate preventive vaccines or prophylactic medications, annual ACEP recommendation about needed vaccines/meds)
- Emergency physician sick time, calling in sick, sick coverage, working when sick
- Emergency physician not smoking, support for stopping smoking for emergency physicians
- Emergency physician obesity, endorsement of general health maintenance by emergency physicians
- ETOH and possibly prescription drugs and the ED doc (eg, min time form ETOH to work, confidential reporting of impairment, due process investigation, and temporary suspension pending rehab, encourage state rehab systems)
- Pregnancy/ adoption during career or residency
- Parenting issues specific to emergency physicians (eg, educational opportunities)
- Aging emergency physicians (eg, accommodations in scheduling, shift length, numbers of shifts, and circadian stress to account for physician age, no mandatory retirement age, but a patient safety standard applied regardless of age)
- Retirement for emergency physicians (eg, provide adequate opportunity for retirement planning and access to and education about it, encouraging financial mechanisms that make such planning feasible)
- Strengthened workplace violence policies (eg confiscation of dangerous objects)
The subcommittee’s work is ongoing and open to comment from the section. We hope that members with a special interest, experience or expertise in one of these areas will read the relevant policy and make suggestions about gaps that can be addressed in the coming session.
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Quality Course at Spring Congress
Angela Franklin, Esq.
Director of Quality and Health IT
American College of Emergency Physicians
If you are an ED administrator, the Quality person, or just a practicing clinical physician or nurse, you are involved in quality to an extent. If you are not practicing quality emergency medicine, you will probably be out of business soon so ignore this brief article. Quality is something we all want to do and it is something our patients demand. So why doesn't quality happen all the time?
The Quality Improvement and Patient Safety Section is offering the first of it’s kind "Quality Course" at his year’s Spring Congress in San Diego on April 25, 2007, from 2:30 to 6:30pm. If you are registered for the Spring Congress, there is no additional charge. Who should take this course? Anyone working in ED quality, new graduates, nurses, and anyone who wants to learn how not to end up on the wrong end of a quality review. There will be four one-hour sessions in the afternoon of day two of the Spring Congress.
The format will be:
- The Case Review
- Data Collection and Analysis
- Fixing Systems to Improve Outcome
- Panel Discussion on Proven Success Stories
The lectures will be case based and practical. We all get plenty of lectures on theory and error reduction. This course is designed to be practical and hands on. When you leave you should be able to design an ED Quality Program or re-tool an already existing one. We have commitments from some of the best and brightest in the College as faculty. Please send along your quality people, nurses, physicians, and mid-level providers. All are welcome.
To register for the course, please contact an ACEP Customer Service Representative at 800.477.2237. You can also leave a message at that number, or send an e-mail to firstname.lastname@example.org. For additional information you may contact Angela Franklin c/o email@example.com
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Core Readings in Wellness for Emergency Physicians
(Note: This is an excellent discussion of burnout in physicians, covering such areas as work and family stressors, personality factors, women physicians, and burnout prevention. The major emphasis is on the need for physicians to be proactive in cultivating personal well-being. This is a life-long endeavor---well-being does not exist in a "steady state." The paper ends by reminding physicians that the deepest values of the profession involve doing no harm, adding that "Doing no harm begins with oneself." --Richard M. Goldberg, MD, FACEP)
Anderson S, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288:1447-1450.
Burnout has been defined as a syndrome of symptoms and signs including emotional exhaustion, a sense of depersonalization in relationships with co-workers and/or patients, and a diminished sense of personal achievement. The syndrome has been associated with impaired job performance, marital difficulties, anxiety, depression, myocardial infarction, and may contribute to alcoholism and drug addiction.1,2 Burnout has been aptly described as "a deterioration of values, dignity, spirit, and will."3 The seeds of burnout may be sown in medical school and post-graduate training, where fatigue and emotional exhaustion are often the norm. By mid-career, the momentum of burnout is maintained by the subtle reinforcement of the esteem and recognition of one’s peers for being a selfless and tireless worker.
Predictors of Work Satisfaction
A study of factors that predict professional satisfaction, organizational commitment and burnout among physicians found that the single most important predictor for these outcomes was a sense of control over the practice environment. Three additional factors – perceived work demands, social support from colleagues and satisfaction with resources – were also critical variables.4 Interestingly, several studies have indicated higher levels of satisfaction and commitment and lower reported levels of burnout among older physicians.4,5 Finally, healthcare organizations exert a strong influence on professional satisfaction in terms of resources and reimbursements provided and degree of control allocated.6
Compulsiveness is a common, if not necessary, characteristic among physicians. Taken to extremes however, the impact on professional, personal and family lives can be devastating. Physicians with excessive compulsiveness have chronic feelings of not doing enough, difficulty setting limits, exaggerated guilt feelings that interfere with the healthy pursuit of pleasure, and the confusion of selfishness with healthy self-interest. A psychology of postponement develops in which physicians habitually delay attention to their significant relationships and other sources of renewal.7 The ability to form nurturing relationships is a major preventative to the burnout syndrome.8,9
By 2010, it is expected that 30% of all physicians and 50% or more of all medical students will be women.10 Studies indicate that female physicians are 60% more likely than male physicians to report signs or symptoms of burnout. The odds of burnout increased in women 12-15% for each additional five hours work per week of more than 40 hours. Female physicians are also more likely to experience sexual harassment from colleagues, patients, or both. They may also have the burden of domestic responsibilities ordinarily not given to male physicians.11
Preventing Physician Burnout
The best means of preventing physician burnout is to promote personal and professional well-being on all levels: Physical, emotional, psychological and spiritual. Physicians are urged to actively take responsibility for their own well-being. Ryff and Singer12 provide an excellent summary of factors that promote positive psychological functioning: Self-acceptance, positive relations with others, autonomy (self-determination), environmental mastery (choosing or creating environments suitable to one’s physical condition), having purpose in life, and fostering personal growth. Specific strategies to prevent burnout are listed below.
- Influence happiness through personal values and choices
- Spending time with family and friends
- Religious or spiritual activity
- Self-care (nutrition, exercise)
- Adopting a healthy philosophical outlook
- A supportive spouse or partner
- Control over environment: Workload
- Finding meaning in work and setting limits
- Having a mentor
- Having adequate administrative support systems
Personal growth and renewal involve not only the time outside of work. Sustainable renewal is possible in all spheres of physician lives including their professional life. One should regard a medical career not merely as a domain of energy expenditure, but also of energy renewal. Physicians can learn to receive support, healing and meaning while giving of themselves each day in their professional lives.
- Maslach C, Leither MP. The truth about burnout. Josey-Bass Publishers; 1997:13-15.
- McCue JD. The effects of stress on physicians in their medical practice. N Engl J Med. 1982;306:458-463.
- Neuwirth ZE. The silent anguish of the healers. Newsweek. 1999;134:79.
- Freeborn DK. Satisfaction, commitment, and psychological well-being among HMO physicians. West J Med. 2001;174:13-18.
- Campbell DA, Sonnad SS, et al. Burnout among American surgeons. Surgery. 2001;130:696-705.
- Suchman AL. The influence of healthcare organizations well-being. West J Med. 2001;174:43-47.
- Gabbard GO, Menninger RW. The psychology of postponement in the medical marriage. JAMA. 1989;261:2378-2381.
- Myers M. Medical marriages. New York, New York. Plenum Medical Book Co.; 1994.
- Warde CE, Moonsinghe K, et al. Marital and parental satisfaction of married physicians with children. J Gen Intern Med. 1999;14:157-165.
- American Medical Women’s Association. Available at: http://www.amwa-doc.org/
- Gautan M. Women in medicine, stresses and solutions. West J Med. 2001;174:37-41.
- Ryff CD, Singer B. Psychological well-being: Meaning, measurement, and implications for psychotherapy research. Psychother Psychosom. 1996;65:14-23.
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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.