EM Mindset: Occupational Wellness

Author: Elise Lovell, MD (@Elise_Lovell, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center, Clinical Associate Professor University of Illinois at Chicago) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Burnout, the triad of emotional exhaustion, depersonalization, and low personal accomplishment, is common in physicians, and its incidence is rising.  As of 2017, nearly 60% of emergency physicians feel burned out.  Emergency medicine is number one for burnout among specialties surveyed.^1,2 Burnout has significant career implications, as it increases the likelihood of medical error, decreases career satisfaction and longevity, and is associated with physical and mental illness and substance abuse.

Wellness is not simply the absence of burnout.  Wellness requires active, ongoing, lifelong effort.  A holistic approach to wellness crosses six commonly cited dimensions: Social, Spiritual, Occupational, Physical, Emotional, and Intellectual.³ 

Why focus on Occupational Wellness?

We spend a lot of time at work.  We all started this journey with a feeling of purpose, meaning, gratitude, and excitement.  With every patient, we have the chance to care, with some, the chance to cure, and occasionally, the chance to save a life.  Somewhere along the way though, “work-life balance” became the buzz-phrase.  This implies a tension between work (bad) and life (good) that needs to be resolved in order to find happiness.  Instead, consider the concept of “work-life integration.”  This has caught on in the business world, where technology blurs the boundaries of office and home, and working remotely is increasingly common.  There is a more humanistic interpretation of work-life integration, which promotes the synergies between all components of life, including our work.  If our work is meaningful and brings joy, then time in the hospital, and contributing to rewarding medical activities outside of the hospital (EMS, education, community engagement), feed our spirit instead of causing frustration and the fear of missing out.⁴

It’s recognized that a number of systems issues contribute to physician burnout: bureaucracy, loss of autonomy, the EHR, and feeling undervalued or diminished by administration.  Reclaiming autonomy and control of your workplace by becoming involved in operations, quality improvement, or through creating hospital initiatives to provide physician recognition and emotional support, can all improve occupational wellness.

But let’s dig deeper, to personal factors that chip away at our occupational wellness and impact the depersonalization component of burnout – the psychological withdrawal from relationships, and the development of a negative, cynical, and callous attitude, otherwise known as compassion/empathy fatigue.

In other words, how do we retain our humanism as physicians?

I. Patients are not the enemy. The twisting of the doctor/patient relationship into an adversarial battle was epitomized by the anger and resentment of The House of God, written by author and psychiatrist Stephen Bergman.⁵ Unfortunately, belittling patients for coming to the ED too early or too late, or for not having the health literacy or access to care to use the ED “appropriately,” continues today. We don’t realize how much we have learned (just try having a truly medical conversation with a non-medical friend), and we lose sight of the crucial role of the ED safety net.  Over the past three decades, Bergman has been committed to speaking about “Staying Human in Health Care.”  He emphasizes the power of connection, both in medicine and in personal relationships; empathy; speaking up against wrongs in the medical system; and nurturing a global sense of community.

II. Who is your compassion role-model? Seek out the Tiggers at work. Who seems to consistently keep a positive outlook, speak warmly of their patients, and express gratitude for being a doctor?  Learn their secrets.  Some tips I’ve taken away: bring a sandwich or a warm blanket to a patient or family member – it’s an exchange of humanity.  Ask the elderly couple how long they’ve been married, and see them light up.  Include a question about a patient’s job during a social history.  Use touch to connect and express respect – shake everyone’s hand in the room. Sometimes humor is the best medicine; a well-placed joke goes a long way towards calming anxiety.  In the charting room or on the phone, refer to patients by name, not room number or diagnosis.  Higher physician empathy scores and the attempt by doctors to take into account the perspective of the patient have been associated with decreased levels of burnout.⁶

III. Foster Social Resilience.  Resilience is the ability to adapt in healthy ways to adversity, to act and react with optimism; bouncing back from setbacks or failure.  Resilience is closely tied to wellness.  It requires self-knowledge, flexibility, motivation, and especially relationships.  Social resilience is the capacity of a group to endure stress in a positive way, through bonding and reliance.  Beyond our personal connections, we talk of our “tribe” of emergency physicians.  Trusting ourselves to be vulnerable to share bad cases, doubts, and errors makes us stronger.⁴ After a medical error, positive coping mechanisms include talking about the event, personal forgiveness, acknowledging imperfection, and teaching about the mistake – all strategies facilitated by strong social resilience.⁷ In a study of perceived medical error, personal distress and decreased empathy were associated with increased future risk of medical error, suggesting a cyclic nature to distress, empathy, and error.⁸  Reach out, and nurture your relationships.

IV. Read. Anything by Abraham Verghese, Atul Gawande, Jerome Groopman, Sherwin Nuland. Consider a medical humanism book club, even if it has a membership of two.

V. Journal. Start by reading “How to Tell a Mother Her Child Is Dead,” by emergency physician Naomi Rosenberg, published in the New York Times in 2016.⁹ Narrative medicine is not just about writing, but about learning how better to listen to and understand our patients and each other.  As Dr. Rita Charon, founder of the initial narrative medicine program at Columbia University states, “Narrative medicine is a deep kind of training in not just how to write, but also how to hear, how to listen, and how to receive what the patient is telling you so that you comprehend it more fully.”¹⁰ Often, a visit to the ED is an experience a patient and family will never forget.  We are an active witness, and reflecting and sharing stories provides an invaluable opportunity for reflection.

VI. Identify your Bias. Malcolm Gladwell’s book Blink¹¹ discussed the concept of implicit, or unconscious bias, as a determinant in our decision-making. While nearly all of us would deny conscious feelings of bias or racism, the majority of people, including physicians, hold unconscious attitudes about social groups.  These develop over time through exposure to media, advertising, life experiences, and cultural messages and stereotyping.  In turn, unconscious bias influences our behaviors, and in physicians, our clinical decision-making.  Implicit bias in physicians has been associated with decreased patient satisfaction, and with disparities in providing analgesia to both pediatric and adult patients, appropriate care for ACS based on racial/ethnic group, and referral for knee arthroplasty based on gender.¹²

Another way to be a more humanistic physician, and to decrease judgment and improve care, is to mitigate our unconscious biases.  Simply identifying bias has been shown to improve it.  The Implicit Associate Test,¹³ created by Harvard psychologists, is a quick online tool to measure implicit attitudes across a variety of domains.  Other strategies to decrease implicit bias include seeking out positive exemplars of a group, either in your personal or professional life, in order to change the messages that are being internalized.  Individuating requires a conscious effort to prioritize specifics about a patient over social category information such as race or gender when making clinical decisions.  Perspective-taking, or the attempt to look at a situation from the patient’s point of view, has also been demonstrated to lead to less biased care.¹²

Conclusions

Building occupational wellness involves seeking connection with your patients and colleagues, fostering empathy, learning to share stories, and developing resilience to react in a healthy way to medical error, loss, and stress.  Learn from authors and senior clinicians who are well into this journey, and from friends and trainees who are just starting out.  Identify and mitigate your implicit bias and judgment.  Engage with your medical system to build autonomy and a sense of value.  Through work-life integration, create a lifelong approach to self-care, and sustained joy and satisfaction as an emergency physician.

References / Further Reading

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.
2. Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout
3. National Wellness Institute http://www.nationalwellness.org/?page=Six_Dimensions
4. The Missing Link: Connection Is the Key to Resilience in Medical Education. McKenna KM, Hashimoto DA, Maguire MS, Bynum WE. Acad Med 2016;91:1197-1199.
5. Shem, Samuel. The House of God. New York City, NY: Random House, Inc., 1978.
6. To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice. Lamothe M, Boujut E, Zenasni F, Sultan S. BMC Family Practice 2014, 15:15.
7. Wisdom in Medicine: What Helps Physicians After a Medical Error? Plews-Ogan M et al.  Acad Med 2016;91:233-241.
8. Association of Perceived Medical Errors with Resident Distress and Empathy. A Prospective Longitudinal Study.  West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, Shanafelt TD.  JAMA 2006;296:1071-1078.
9. https://www.nytimes.com/2016/09/04/opinion/sunday/how-to-tell-a-mother-her-child-is-dead.html?_r=0
10. Special Report: Who Lives, Who Dies, Who Tells Your Story? The Magic of Narrative Medicine in the ED. Shaw G. Emergency Medicine News: January 2017 – Volume 39 – Issue 1 – p 20–21
11. Gladwell, Malcolm. Blink: The Power of Thinking Without Thinking.  New York City, NY:  Little, Brown and Company, 2005.
12. Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities.  Chapman EN, Kaatz A, Carnes M. J Gen Intern Med 28(11):1504-10.
13. Project Implicit: https://implicit.harvard.edu/implicit/takeatest.html