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.

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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.

Constant Jet Lag in Emergency Medicine

Emergency Medicine is high risk speciality that brings a lot of stress with it and maximum burn out rates among its providers. A major reason why people quit EM is due to the rotating shifts. And as we turn older, it gets difficult to cope up with this ever changing shift work schedule. Many of us suffer from this under appreciated problem of shift work disorder. Rather than accepting Shift Work Disorder (SWD) as something that always comes along with EM, we should find out ways and learn how to cope up with it. 

What is Shift Work Disorder?

SWD is clinically recognized condition that develops in some individuals who work at night, start work early in the morning (4am-7am), or work according to a rotating shift schedule. SWD consists of a constant or recurrent pattern of sleep interruption that results in difficulty sleeping when you should sleep or excessive sleepiness when you are supposed to stay awake and alert. 

Problems that might occur with Shift workers:

Medical errors 

Disturbed circadian rhythm

Risk of peptic ulcer disease

Cardiovascular disease
Hypertension

Chronic Fatigue, insomnia

High Divorce rate

Substance abuse and Depression

Immunosuppression

Fertility issues

Poor dietary choices

Thyroid issues

Most circadian rhythms have both an endogenous component (regulated by suprachiasmatic nucleus of the hypothalamus) and an exogenous component. The exogenous component is composed of various time clues called zeitgebers. One of the most powerful zeitgebers is the light/dark cycle (e.g. Sun). Other examples of zeitgebers can be food, television, exercise, caffeine, sports. We can synchronise with these zeitgebers and give the right cues to our body to promote wakefulness/sleep. 

For instance , prior to starting a night shift, exercising OR eating typical breakfast foods OR exposure to bright light gives subtle clues to your body that it is time to get up and start the day. Similarly, having a cup of coffee, bright light exposure and exercising after a night shift is a bad idea!!

Few Strategies for setting up night shifts:

1. If you can work it out, then the best way is to do a stretch of nights for 6-8 weeks once in a year. This way you would need to change your sleep cycle only twice a year (not every week!). No meetings/academic sessions after night shifts.

2. Casino Shifts: With casino shifts, one long night shift is cut into two short shifts, from 10pm-4am and from 4am to 10am. With these shifts the "early risers" turn up for the 4am shift and people who prefer to sleep late in the night leave by 4am. Both these groups can then continue their next day normally without affecting their social liv. Some people like and prefer to work like this.

3. Avoid doing >2-3 nights in a row.

Shift Length: Some physicians prefer shorter shifts (6-8hrs) and some like to stick to the 12hr shifts. With shorter shifts, it is found that physicians are more alert and respond better while with the two 12hr shifts, you get more days off per week. 

Here are some things that we can do to cope up with Shift work:

1. Education and Awareness (For shift workers as well as their families)

2. Individual Strategies

Prior to night shift, To promote wakefullness:

• Make sure you get some sleep during the day time (Never start a night shift in sleep deprivation)
• Exercise in the evening 
• Expose yourself to bright light 
• Having more staff overnight is beneficial
• Have dedicated breaks, with coffee and high protein foods

During night shift, To stay alert 

• Keep your naps short (<30 minutes)
• Stay exposed to bright light
• Have a high carbohydrate/protein snack to keep you awake
• Caffeine (only during the first half of shift)

After night shift, To promote sleep:

• Use sunglasses while travelling back home to avoid bright light exposure
• Use ear plugs/eye protectors, black curtains 
• Make sure that your room temperature is comfortable 
• Keep your kids and pets away to avoid disturbances while you are asleep (Noisy environments cause sleep fragmentation)
• Have a dedicated quiet area to sleep
• Avoid fatty/ spicy food before you sleep
• Avoid early morning caffeine 
• Switch off your phone and try using an answering machine

Shift schedule should be made by someone who understands SWD

ACEP endorses the following principles:

• Scheduling isolated night shifts or relatively long sequences of night shifts is recommended. 
• Overly long shifts or inordinately long stretches of shifts on consecutive days should be avoided whenever possible. In most settings, shifts should last twelve hours or less. Schedulers should take into consideration the total number of hours worked by each practitioner and the intervals of time off between shifts. 
• ACEP strongly recommends that practitioners have regularly scheduled periods of at least 24 hours off work. 
• Rotating shifts in a clockwise manner (day to evening to night) is preferred.
• Night shift workers' schedules must be designed carefully to provide for anchor sleep periods, and those workers' daytime responsibilities should be held to an absolute minimum. 
• Groups should consider various incentives to compensate those working predominantly night shifts. 
• Schedules for emergency physicians should take into account factors such as ED volume, patient acuity levels, non-clinical responsibilities, and individual physician's age. 
• A place to sleep before driving home after night shifts should be provided.

3. Pharmacolgy

To promote sleep:

BZDs (addiction, side effects)

Zolpidem is better than BZDs

Melatonin: take few hours prior to sleep, dose: 0.5-5mg

Stimulants to promote wakefullness:

Modafinil (Dopamine reuptake inhibitor, Also activates Glutamate and inhibits GABA)

Caffeine: Too much leads to agitation, tolerance overtime and withdrawal. Avoid taking caffeine during the second half of your shift.
Energy drinks: Caffeine + sugar 

Key Points

• Educate your family and colleagues about Shift Work Disorder
• Learn how to play with the zeitgebers
• Do not overly on medications
• Consider incentives for those who work the unpopular night shifts 

References:

1.Haney Mallemat - Shift Work Disorder: http://www.emedhome.com/cme_infocus.cfm

2.https://www.acep.org/Clinical---Practice-Management/Emergency-Physician-Shift-Work/

3.Boggild H, Knutsson A. Shift work, risk factors and cardiovascular disease. Scand J Work

Environ Health. 1999;25:85-99.

4.http://www.acep.org/Clinical---Practice-Management/Circadian-Rhythms-and-Shift-Work/

5.http://www.gru.edu/mcg/clerkships/em/documents/shiftwork.pdf

6.http://cjem-online.ca/v15/s1/the-impact-of-“casino-shifts”-on-emergency-physician-productivity