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Stress is a given in emergency medicine. Shift work, scheduling, risk of exposure to infectious disease, and violence in the emergency department, as well as malpractice litigation and decreasing compensation, can all affect an emergency physician's health and well-being.
"The stresses of emergency medicine are many and cumulative. They can lead to job dissatisfaction, illness and burnout," said Jay A. Kaplan, MD, Medical Director, Studer Group, and Director of Service Excellence for California Emergency Physicians, Oakland, CA.
"Balancing your personal and professional life is the key to avoiding burnout. Think of a scale of one to ten on a seesaw. Place work at one end as a one and your personal life at the other end as a ten. How is your balance? Many emergency physicians will say they're at three. In other words, they're more heavily weighted toward work," said Kaplan.
While dedication to patients and to the medical profession are the hallmarks of a good physician, overwork and the stress that accompanies it can be a recipe for burnout. It's important that emergency physicians identify the sources of stress in their work environment, recognize the effects of that stress and develop strategies to avoid burnout, said Kaplan.
In addition to shift work, scheduling pressures and unpredictable workloads, the practice of emergency medicine poses risks that aren't as common in other specialties, including violence and exposure to infectious disease.
"No other workforce is exposed to as many life-threatening illnesses as often as we are, and often without our knowledge as to when it's occurring. From 6 to 10 percent of the patients seen in your ED may be HIV- or Hepatitis C-positive, and many don't know that they are," said Kaplan.
"Then, of course, there's physician illness and impairment, because doctors do get sick, but we're perfectionists and we don't like to show it. The rate of substance dependence, depression and suicide are substantially higher among physicians than among the general population."
Emergency physicians have no control over either the number or type of people who come into the emergency department during a shift, and this lack of predictability is a major source of stress, especially in an environment where there is constant pressure for perfection, said Kaplan. "The pressure for perfection comes with regard to diagnosis and service-diagnosis because of the risk of malpractice and service because of the risk of a patient complaint at a time when patient satisfaction is very important to hospital administrators."
Both physical and mental problems are common in cases of burnout, including exhaustion, ulcers, depression and mood swings.
"There are emotional cues to burnout. People sometimes have personality changes. We all have our strengths and weaknesses. What happens when people get burned out is that their weaknesses get magnified. It varies from person to person. One person may become sarcastic and edgy, while another may become withdrawn and depressed," said Kaplan.
Among the psychological symptoms of burnout to watch for in yourself and your colleagues:
Involvement and engagement may be replaced by exhaustion, cynicism and indifference.
Patience and compassion may be replaced by anger, bitterness and frustration.
The feeling of being a part of a greater whole may be replaced by alienation and isolation.
"Quite commonly, one physical system is the weakest and the first to be affected by stress. That's why when people get stressed, some get headaches or muscular pain, and others get irritable bowel or another digestive problem," said Kaplan.
The body undergoes a kind of balancing act whereby when a person is stressed, first there is an alarm reaction and a stage of resistance in which the body is fortified enough to resist the stress in one way or another. That's followed by one of two stages-either a stage of recouping, wherein the body has a chance to replenish itself or, if that doesn't happen, then a stage of exhaustion. When people don't have an opportunity to relax and replenish themselves, that's when stress makes them sick.
Studies show that those who set goals for themselves are more satisfied with their work and with their lives. Goal setting is also a strategy for managing stress and avoiding burnout.
"It's important to create a formal renewal investment plan. We're used to thinking this way about our finances, but not our own personal and professional growth and development," said Kaplan. He suggests using the following questions as a basis for setting clear and measurable goals:
What do you want?
Are you getting it?
If yes, how do you plan on keeping it?
If not, how do you plan on getting it?
Personal goals might include making family as high a priority (or higher) as work, scheduling time off, and taking care of yourself. "The goals can be as simple as: How many times do I want to exercise a week? How much sleep do I want to get each day? How many books do I want to read in a month?" he said.
It's important to set goals in such a way that you can measure your progress toward achieving them. For example, a list of professional goals and accomplishments might include the following (concept adapted from the author Tom Peters):
I am known for (2-4 items). By next year at this time, I plan also to be known for (1-2 items)
My current work is provocative and challenging to me in the following (1-3 ways).
New learnings in the last 90 days include (1-3 items).
My public (local/regional/national) "visibility program" consists of (2-4 items).
Important new additions to my computer contacts file in the last 90 days are (2-5 names).
Important relationships nurtured in the last 90 days include (1-3 names).
My principal "resume enhancement activity" for the next 60-90 days is (1 item).
My resume is specifically different from last year at this time in the following (1-3 ways).
Shift work is a major source of physical stress for emergency physicians. "Respect Circadian principles and get proper rest," said Kaplan. Among the methods he recommends:
Set a goal for rest time and stick to it.
Instead of just setting an alarm for when to wake up, set an alarm for when to go to bed.
Avoid alcohol, caffeine and heavy meals close to bedtime.
Enlist the cooperation of family.
If working night shifts and having to sleep during the day, use heavy curtains, white noise, blindfolds or whatever else helps you sleep uninterrupted.
"It's true that you are what you eat, so eat well and regularly. It's also true that exercise is a great drug and flexibility prevents injury, so exercise regularly," said Kaplan. Among the recommended methods:
It's preferable to exercise early in the morning.
For best results, exercise three to five times a week for 30 minutes.
Warm-up and cool-down are essential.
Strength training is important for building lean body mass.
"It's also important to your physical and mental health to have a creative outlet-something you really love to do," said Kaplan. "Seek joy, whether it be through writing, sports, activities with your kids-look for what excites you and go for it."
Colleagues in emergency medicine can have a significant effect on one another's well-being, but maintaining good working relationships in the midst of a chaotic, crisis-ridden atmosphere is challenging. Communicating clearly, treating colleagues and co-workers as partners, and recognizing the contributions of others are key to creating a positive work environment, said Kaplan.
"Communication is a skill that can always be improved. Ask your colleagues for feedback on your communication skills," he said.
Treating colleagues and co-workers as partners means thinking about how we approach each other-how doctors approach other doctors, nurses, clinicians and hospital administrators. "We usually approach each other with demands-I need, I want, I must have," said Kaplan. What if instead you were to think of everyone on staff with whom you interact as an important customer? "So that when you think about someone you work with, the first question you'd ask would be: If I consider this person (or group or department) one of my most important customers, what would I do differently in order to better serve them?" he said.
"In healthcare we have a tendency to take each other for granted and not recognize one another's efforts. I make it a habit at the end of every shift to go around to the people I work with and say thank you, and to be as specific as possible about what I'm thanking them for," said Kaplan. The emergency department is an especially stressful work environment and being supportive of our colleagues and co-workers is vital to helping reduce the effects of that stress.
The best way to avoid burnout is to think carefully about how to manage stress on a daily basis, said Kaplan. "Start with your own self-assessment and formal renewal investment plan. Make your family and yourself a high priority. Take care of your health. And create a positive work environment."
