Wellness Section Newsletter - September 2007, Vol 11, #3
Julia M. Huber, MD, FACEP
Welcome to the early fall Wellness Section Newsletter. This is the final newsletter before Scientific Assembly so here are some updates: the Wellness Section will meet from 4:00 pm to 5:30 pm on Tuesday, October 9. Also, there will be more information in the registration lobby regarding the meditation space ACEP has generously provided for us during the meeting, open to everyone from 6:30 to 7:30 a.m. We are so grateful for their support. I am hoping there will be more discussion at our section meeting about encouraging ACEP to provide other "wellness spaces" for attendees and their family members. Kathy Hall-Boyer has contributed a piece about this with regard to her elderly mother. As an AAWEP member, I have also heard requests for a place for lactating moms to express milk. Please be thinking of other ways that we can bring wellness concepts directly to our colleagues, whether at SA or in our own workplaces, and share these ideas at the section meeting! Thank you all for the opportunity to edit your newsletter, and I look forward to serving as Section Chair this coming year.
This edition favors the expressive aspect of wellness. Many thanks to Hans R. House, MD, FACEP, the editor of the Humanities Section Newsletter, who has shared some contributions from section members Jay Kaplan, MD, FACEP, and Meghann L. Kaiser, MD. I have also included a piece by Sheila H. Steer, MD, FACEP, entitled "The Deepest Struggle" which originally appeared in the June 2007 edition of the AAWEP Section newsletter. Enjoy!
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The Deepest Struggle
Sheila Steer, MD, FACEP
I have had the privilege to practice emergency medicine for nearly 20 years. I have worked in EDs without CT, MRI, nuclear medicine and no ICU. I have worked in tertiary care hospitals with every expensive resource and just enough residents to keep the pace interesting. I have struggled with acceptance of limitations, acknowledgement of the power of the unforeseen and the grace of intuition guiding my hand. So what was different about this day?
He was a full arrest and 54 years old. Witnessed collapse at work. Initial rhythm asystole and despite ALS he remained pulseless, hopeless, scripted. We would not tarry long in the resuscitative waters deemed futile for this patient. Through the doors the EMS angels flew straddling his form-sweating with effort and grim determination to make him "the one," their save, validation of the fight. The patient remained cyanotic, dark, cold with the fates unmoved by the force of good being ground into his chest, his lungs, and his veins.
Routine drugs, routine algorithms, routine regret when cardiac ultrasound confirmed what had been predetermined all along. Pronouncement. Gratitude to the team. A quick prayer for the life lost. And the process continued.
As I opened his wallet I saw a face so young and smiling that it was surreal comparing it to the lifeless form next to me. I leafed through a stack of business cards when I saw it. The familiar medical school logo with a familiar name. My alma mater where I still worked and volunteered and shared meaningful moments with students and staff. The name on the card took me by surprise-it was the name of a friend. A good friend. Same last name as the driver’s license. A pang of pain seared through my gut. Oh sweet Jesus. My friend. His wife.
The routine was so over.
She was at work out of town and was on her way. Her medical school colleagues called me to ask if I could please look out for him. His work had called them. He had a seizure. Did I know if he was alright? Please, I said. Come now. Be here when she arrives. She will need you. I could not tell them more but the smell of death and devastation seeped through the phone lines even as I breathed. They knew.
She arrived. They were huddled in a group in the family room. The room that everyone knows as the "place of awful news." They were gripping hands in a half-circle that reminded me of snow fences against the force and fury of the cold drifts. They were preparing to hear what I was about to say. Preparing to wear the mantle of grief that I was about to bestow upon them. Her face was so trusting and I was about to bury all the hope, the faith and the future she had planned with a few brief words. She had gone to work a wife and come to the ED a widow.
She was incredibly composed. Did he suffer? Did he ask for her? She turned to her friends and said, "Now I want to take you to him so you can meet him. He was so wonderful to me." I was crying as I led her to him. This is an abrogation of nature. I simply do not cry at work. It is not allowed. But the deep regret I felt was for her loss, her shock, her need to be brave for all of us.
A voice whispered, "It is more....." Such an ugly truth. I was incredibly, intolerable, selfishly sad that my name would forever remind her of the worst day of her life. I felt I had taken the best part of her life that day with the words I wish I never had to speak to anyone. I alone spoke the words that destroyed a part of her forever. I hated my job, my responsibility, my professional training, my fancy toys that were impotent, my being on the schedule that day.
She and I have spoken since. She had questions. Some of my answers begat more questions and confusion. She tells me she is comforted I was there. That I was the one to be with him. She knew I was kind. She trusted my knowledge and my compassion. She finds reassurance in my words that he was not able to be revived. He was dead on arrival.
I do not believe in coincidence. I believe I was meant to be the one to transition her through this difficult passage with my part on that day. I believe her husband was meant to break through my shell of routine resuscitations and remember that each death devastates someone. Each survivor I speak to must be given compassion and gentle reassurance that their loved one was not awake, did not suffer, did not ask for them or appear in pain.
The deepest struggle goes on. I must accept my limitations and those of the practice I choose. I must remember that the privilege of being a physician carries an accountability and retrospection that very few other professions demand. I must move forward with the knowledge I have learned and the perspective that will make me more valuable to my future patients. I must accept that devastating events occur in all our lives and I will be associated with a lot of those days for people in my community.
To the good fight.........
Sheila Steer, MD, FACEP
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Memo to the ACEP Board of Directors
The following is a memo sent to the ACEP Board in June of this year. The memo raises concerns regarding a number of issues relating to our aging membership. A policy proposal is also included. Your comments are invited, and should be directed to Richard M. Goldberg, MD, FACEP: email@example.com.
||Board of Directors, American College of Emergency Physicians
||Wellness Section and Wellbeing Committee
Aging EP Subcommittee
||The Aging Emergency Physician
For many members of the American College of Emergency Physicians, issues of aging and retirement are now surfacing. The percentage of members over the age of 50 has increased from 28% to 31% in the past two years.(1) In September of 2005, the Wellbeing Committee formed a subcommittee to promote dialogue and research on the aging emergency physician, particularly with regard to the following questions: 1) are there ways to enhance and prolong the careers of emergency physicians in the latter stages of their professional lives, and 2) what can be done to facilitate the transition of emergency physicians from active practice to retirement?
Toward these ends, the subcommittee has developed the following documents over the past eighteen months for posting on our Section webpage:
- Annotated Bibliography for Physicians in Pre-retirement Years
- Resources For Emergency Physician In Pre-Retirement Years
- The Aging Emergency Physician: Recommended Health Screenings
In November of last year, the subcommittee initiated a randomized survey of 1000 College members over the age of 55 in an effort to identify issues of concern to this population. In responding to the question "What can ACEP do to help members deal with issues regarding retirement and career longevity," the most common answers, in order of frequency could be categorized as follows: 1) provide educational content on retirement-related issues, 2) advocate for senior members with policies that address problems of shift work and work load, 3) conduct additional surveys/studies on the topic of the aging emergency physician.
Not included among these responses, but a particular concern of the subcommittee, is the issue of cognitive decline among senior physicians. A number of recent studies have examined the issue of competence among older practitioners, in view of well-documented age-related declines in abilities relating to memory, reasoning and comprehension. Findings have suggested that older physicians are less likely to be current in their knowledge bases, and less able to incorporate new information into analytic tests. (2-9) Such studies suggest that there may be issues of quality and safety relating to older practitioners that the College should address.
The above concerns would appear to involve the purview of a number of Sections of the College, including Careers in Emergency Medicine, Quality Improvement and Patient Safety, EM Research, Certification Process, EM Practice Management and Health Policy, and Wellness. Accordingly, we recommend that the Board of Directors consider developing a multi-section Task Force on the Aging Emergency Physician, with the following areas of inquiry and responsibility:
- Develop a "primer" for emergency physicians in their pre-retirement years in the form of an educational curriculum, as well as course content suitable for regular presentation at the Scientific Assembly or for a stand-alone conference. Topics should include: strategies for modifying practice work load, health maintenance and screening, emotional aspects of retirement, spousal issues, financial planning (including buy-out agreements and investment strategies), insurance considerations, cognitive decline, and alternative career and volunteer opportunities.
- Research the issue of cognitive decline with respect to means of measuring and monitoring, legal implications, and quality and safety issues.
- Develop a policy recommendation for adoption by the Board addressing specific concerns of senior emergency physicians (sample attached).
- Maintain and regularly update the Annotated Bibliography, Listing of Resources and Recommended Health Screenings currently posted on the Wellness Section Web Page
- Conduct follow-up studies/surveys as might be suggested by results of the subcommittee survey currently being analyzed.
Such a Task Force might report its findings to the Board on a quarterly basis.
- Personal communication: Karen Price, Member Services Representative, American College of Emergency Physicians.
- Budson AE, Price BH. Current Concepts: Memory dysfunction. N Engl J Med. 2005;352:692-699
- Keefover RW. Aging and cognition. Neurolog Clin North Am. 1998;16:635-643
- Eva KW. The aging physician: Changes in cognitive processing and their impact on medical practice. Acad Med. 2002;77:S1-S6.
- Weinberger SE, Duffy FD. Editorial. "Practice Makes Perfect . . . or Does It?" Ann Int Med. 2005;143:302-303.
- Turnbull J, Carbotte R, Hanna E, Norman G, et al. Cognitive difficulty in physicians. Acad Med. 2000;75:177-181.
- Weinberger SE, Duffy FD. Editorial. "Practice Makes Perfect . . . or Does It?" Ann Int Med. 2005;143:302-303.
- Katz JD. Issues of concern for the aging anesthesiologist. Anesthe Analg. 2001;92:1487-92
- Page GG, Bates J, Dyer SM, Vincent DR, Bordage G, et al. Physician- assessment and physician-enhancement programs in Canada. Can Med Assoc J. 1995;153:1723-728.
- Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of healthcare. Ann Int Med. 2005;142:260-273.
- Policy proposal: Emergency Physicians in Pre-retirement Years
POLICY PROPOSAL: EMERGENCY PHYSICIANS IN PRE-RETIREMENT YEAR
The American College of Emergency Physicians recognizes that an increasing percentage of its members are entering retirement or pre-retirement years. In an effort to enhance and prolong the careers of emergency physicians in the latter stages of their professional lives, and to facilitate the transition of emergency physicians from active practice to retirement, the following principles are endorsed:
- Shift work for older emergency physicians should be eliminated or minimized
- Physicians and physician groups should be aware of the need for monitoring clinical competence in older practitioners. This may be accomplished by adoption of requirements for continuing education and certification, periodic chart review, direct proctoring, or a combination of these measures.
- The following alterations to work load should be considered for:
- eight hour shifts
- exchange of clinical for administrative or teaching responsibilities
- scheduling strategies involving lower patient volume and lesser patient acuity
- shortened work week
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Meghann Kaiser, MD
is merely moral chaos
written into the laws of thermodynamics
is more than a divine scorecard
tallying the equation of the cosmos
the Golden Rule
is not so simple as we once believed
and kindness felt, only the probability
of kindness done,
by each of us.
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Wellness Section Member Profile:
Lily C. Conrad MD, PhD, FACEP
Editor’s note: the section member profile is an occasional feature of the newsletter.
Wellness Section member profile: Lily C Conrad MD, PhD, FACEP
My name is Lily Conrad, and I am currently practicing full-time clinical emergency medicine in a teaching hospital in urban Denver with Kaiser Permanente. My actual employer is Colorado Permanente Medical Group, a multi-specialty group of several hundred physicians. My current ED job comes with full benefits such as paid sick time, paid vacation, retirement/pension plan, and specific rules regarding promotion, partnership, work performance and evaluation. This is HIGHLY conducive to my well-being, compared to a "democratic" small group where one works at the whim of those in leadership positions and where, in my experience, one’s contract is not worth the paper it's written on. Also contributing to my well-being at work is the fact that in my group of 30 emergency physicians, ten are women. I'm the oldest and most senior female, which is actually quite nice.
With regard to the Wellbeing Section, it seems like I have always been a member. That's probably not true; it's just that the issues we talk about in Wellness have always been high on my interest list. When I served on the ACEP Board of Directors, I was Board liaison to the Section, which gave me a new view of its activities and role within the College. Then, John Skiendzielewski, MD, FACEP, who served on the ACEP Board with me, developed the "Well Being for Residents" PowerPoint presentation, which he and I then gave many times. John was its original author, then the talk was adopted, adapted and extended. It is now on our ACEP Wellbeing website, and available for anyone to use.
Interestingly, almost all my favorite people in ACEP have been and continue to be Wellbeing Section or Committee members. There are numerous aspect of wellness that interest me professionally. I am most interested in circadian adaptation, scheduling, and also career development and management, especially with an eye toward female-specific issues. Naturally as the years progress, I am developing a keen interest in issues specific to older emergency physicians such as the impact of aging on emergency physicians, and I am also interested in issues regarding emergency physician retirement.
In addition to the professional aspects of wellness that interest me, there are aspects of wellness that I like to focus on personally. I like to stay outdoors: bicycling, running, and skiing. I take as much vacation as I can possibly manage - given that I still have to show up to work full-time.
Of utmost importance is keeping close contact and good relationships with relatives, which means no family fighting, as I have no tolerance for this. Many of you understand why. Just keep in mind your loved ones could be gone in minutes. Here are some other techniques I have applied over the years to keep myself well: Take naps before night shifts. Adopt purposeful attitude management- go with a positive spirit and readiness to be an example of professionalism. Leave home life at home. Make sure home life is good so you can. Appreciate huge mountain views off the back deck, seeing nothing but trees and hills. Focus on spiritual renewal. Commit to service. Focus on gratitude and humility. I also recommend you try the website for Ten Thousand Waves in Santa Fe, New Mexico. Better yet, go.
Some final thoughts about wellness and emergency medicine: If I had it to do over again I would:
- go to work for Kaiser way sooner, a FAIR and safe work environment and forego the brain damage of trying to make partner in a small "democratic" group practice.
- spend even more time with my parents and family, before they're gone - spend the money, spend the time and make the effort because nothing else is as worthwhile or important.
- agitate and advocate even more strongly for male-female parity in opportunity, leadership positions and income within emergency medicine.
- have told them where to shove that extra night shift and gone to the John Mellenkamp concert.
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Wellness on the Web
Richard Goldberg, MD, FACEP
The web has become a rich source of information as well as disinformation on wellness-related issues. Listed below are a number of websites sponsored or endorsed by major wellness organizations. Check out the latest addition to the list: The American College of Lifestyle Medicine!
The American College of Lifestyle Medicine
A newly formed organization whose mission is to present evidence-based information on lifestyle issues. Features publications, slide and power point presentations, references, and a wide collection of web-based lifestyle intervention calculators.
US Department of Agriculture: Food and Nutrition Information Center
Provides information on food guide pyramid and dietary supplements.
Provides self-assessment materials and information on nutrition.
Affiliated with the American Heart Association, provides exercise regimen and diary.
Shape Up America
Provides information about safe weight management, healthy eating, and physical fitness.
A comprehensive resource to other links of health related sites, including preventive medicine.
Alternative Health News Online
Provides news and information on alternative health and preventive medicine
American College of Sports Medicine
Provides information on appropriate amounts of physical activity for health.
American Council on Fitness
Provides information on a wide range of exercise and health issues. Individuals can request the latest fitness news sent directly e-mail.
Your Disease Risk
Provides screening assessments to determine risk for a number of diseases including cancer, heart disease, diabetes, and osteoporosis.
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ACEP for All
Kathy Hall-Boyer, MD, FACEP
Emory University School of Medicine
Department of Emergency Medicine
I have attended ACEP Scientific Assembly off and on for about 20 years; half with my mother. We live across the country from each other so it’s a nice way to spend time together. My mother enjoys learning about the medicines and medical products from Industry Representatives who are very gracious to explain the details. She also goes on the tours while I attend meetings and lectures.
Mom grew up on a chicken farm during the Depression. As valedictorian she got scholarships to several universities, but still could only afford to commute by train. Mom received her degree in Practical Arts and Letters at Boston University in 1942. The degree was intended to help women get good secretarial jobs, and she did. Mom worked at Harvard Business School. A group of the professors started a business in California and recruited my mother. Soon after, she drove across the country and took charge of exports. Mom met my father at a very successful church singles group. About 35 couples from the group married and then met monthly for the next 50 years. They were my extended family growing up. It was after my father died 9 years ago that we started the ACEP get-togethers.
Last year I booked the New Orleans Marriott Romance Package. We were greeted with champagne and chocolate covered strawberries. The included breakfasts allowed us to start each day with a relaxing meal. My mom deserved it. The year before, we stayed at a hotel several blocks from the conference hotel. Walking back from an evening reception, I decided from then on we’d book a hotel near the evening events. At 85, mom was too old to be taking walks with me at night.
One thing that has become apparent to me over the last few years is the lack of chairs in the convention centers. It’s hard for my mother to find a good place to sit while she waits for me. When she was only 80, she could stay on her feet with the best of us. Last year, it became a problem; she just couldn’t find anywhere to sit. Mom decided not to join me in Seattle and instead go see hot air balloons in New Mexico. I will miss her company, but can understand her concerns. How can you assess ahead of time whether there will be enough chairs at a convention center? There must be others who need a chair while waiting for a co-worker, family member, or long lost friend. What about those with disabilities or who’ve aged the 40 years with ACEP? We are a tough group of docs. We work on our feet, forget to eat, and don’t take time to pee. Let’s not keep that attitude when we come to meet. It would be nice to have a comfortable gathering place at each convention center. Just a thought…what do you think?
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Jay Kaplan, MD
|I want to live in that holy place
where souls touch
the caress so soft
|there is no try
|magic as it is meant to be
|just pure joy
|in the instant
|moments to die for
|here and then gone
||leaving a legacy
||of love and honor
|was it a dream
|does it matter
|I have been given a gift
|a sacred reminder
|time is passing
|now is not the time to sleep
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Contributed by Shay Bintliff, MD, FACEP
Do ya love cats??? Here’s a great one. Four men are bragging about how smart their cats were. The first man was an Engineer, the second an Accountant, the third a Chemist and the fourth a County Employee. To show off, the Engineer called his cat, "T-square, do your stuff." T-square pranced over to the desk, took out some paper and pen and drew a circle, a square and a triangle. Then the Accountant said his cat could do better. He called his cat and said, "Spreadsheet, do your stuff." Spreadsheet went to the kitchen and returned with a dozen cookies. He divided them into 4 equal piles of 3 cookies. All agreed that was good. But the Chemist said his cat could do better. He called his cat and said, "Measure, do your stuff." Measure got up, walked to the fridge, took out a quart of milk, got a 10 oz. glass from the cupboard and poured exactly 8 ounces without spilling a drop. All were impressed. Then the three men turned to the County Employee and said, "what can your cat do?" The County Employee called his cat and said, "Coffee Break...do your stuff!" Coffee Break jumped to his feet...ate the cookies...drank the milk...pooped on the paper...claimed he injured his back while doing this...filed a grievance report for unsafe working conditions...put in for Worker's Compensation...and went home for the rest of the day on sick leave...!!!!
Be Well, my friends...Aloha, a hui hou Shay Bintliff
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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.