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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, November 9, 2015

Towards a better EM Residency: Resident Welfare Programs

Residency (referred as post-graduation in India) can a stressful time for the residents, especially when it comes to much demanding acute care specialties like Acute Medicine, Emergency Medicine and Critical Care. It is a period of enormous personal as well as professional development, when trainees identify themselves with consultants and unknowingly introject many of their qualities and behaviours, making them a part of their own personality. 

As budding physicians residents learn a plenty of new skills, take responsibility for the sick patients and also understand how to communicate with distressed patients and families. They do come across hard situations that they have not dealt with before and if not taken care of at the right time, these issues can have a deeper impact on their working ability and lead to physician impairment and burnout. EM needs a special mention here  because Emergency docs work in the most unexpected and uncertain circumstances. Over years they learn how to converse with all the other services working in different parts of the hospital. They have no other option but to learn and speak the language the other co-specialities understand and then further gauge things as per individual preferences. 

And Emergency Medicine is one such speciality, where your work is almost always cross checked by a "specialist" or one of your colleagues and people judge you based on that without appreciating the kind of circumstances under which you worked. We all know that medicine is not always seen as blacks and whites. Opinions differ many times and there is always a potential for a conflict!

These issues might sound trivial alone but we need look at the bigger picture to really understand how all these minor sounding issues together, can affect the performance and mental health of residents. It is therefore essential to understand the the residents' perspective and look at what problems they are facing on day to day basis and only then we can figure out together on working towards "Resident Wellness" because only healthy (mentally and physically) residents can provide quality care to sick patients.


Here are some key issues with Resident Wellness:
  • Sleep Deprivation
  • Long working hours
  • Difficult Consultants
  • Difficult work relationships (with nurses/colleagues) 
  • Difficult Patients
  • Peer Competition
  • Exposure to infections/ patient mortality
Specific Issues with women:
  • Discrimination (Patients often assume female physicians as nurses!)
  • Lack of female role models
  • Multiple Responsibilities (marriage, family, motherhood)
As a speciality, EM is still in the developmental stages in many parts of the world. Some trainees choose it out of interest and others because they did not match anywhere else! Trainees might also feel that they have nobody around to look up to because hospitals often employ is a single consultant for a 15-20 bedded ED.  

If greater attention is paid towards physicians and residents well-being, it can be associated with better patient care. There are some possible ways out through which we can try and fix these problems. 

Residency Programs should have:
  • Annual Leave Policy
  • Fixed Duty Hours
  • Circadian Scheduling policy (Considering personal preferences)
  • Wellness Workshops (for nursing as well as medical staff)
  • Including wellness in the curriculum
  • Teaching personal safety skills, communication and negotiation 
  • Record all the didactic sessions (Night workers can watch them at their own ease)
  • Department social events (interdepartmental as well as intra-departmental)
For the residency programs, it is frequently not possible to stick to all these measures due to various reasons, and residents also must take some onus to work towards their own wellness by having individual coping mechanisms like:
  • Have a written set of goals for every trimester/semester
  • Have a mentor
  • Always try and think from the other person's perspective
  • Have a fixed time for friends/family
  • Exercise and eat well 
  • Learn to communicate well: This can make or spoil your day!
  • Prioritise and learn to say "no" to a few things
Dealing with other specific issues:
  • Substance Abuse: Encourage self reporting, Speak to the program director
  • Circadian Disruption: Learn the art of working in shifts
  • Litigation: Improve documentation, Know the risk management strategies 
  • Exposure to diseases: Always and Always use PPE
  • Exposure to Mortality: Post death debriefing, Spend time with friends/family and understand that death is part of EM

Key Points:
  • Acknowledge the fact that as an emergency health care providers, you are vulnerable.
  • As residents, work with the residency program to create a healthy learning environment. 
  • Appreciate the opportunities created by the residency programs and make the most out of it.
To keep the body in good health is a duty...otherwise we shall not be able to keep our mind strong and clear - Buddha

Further Reading:
  • Schmitz GR, Clark M, Heron S, et al. Strategies for coping with stress in emergency medicine: Early education is vital. Journal of Emergencies, Trauma, and Shock. 2012;5(1):64-69. doi:10.4103/0974-2700.93117.
  • Schwartz AJ, Black ER, Goldstein MG, et al. Levels and causes of stress among residents. J Med Educ. 1987; 62:744-753.
  • Whitley TW, Gallery ME, Allison ED, et al. Factors associated with stress among emergency medicine residents, Ann Emerg Med. 1989; 18: 1157-1161.
  • Houry D, Shockley L, Markovchick V. Wellness issues and the emergency medicine resident. Ann Emerg Med. 2000;35:394–7.

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