emDocs Wellness: A Growing Issue

Author: Jennifer Robertson, MD, MSEd (Assistant Professor of EM, Emory University) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

Consider the following cases:

1. A 35-year-old male with pneumonia develops sepsis. During one physician’s emergency department (ED) shift, he goes into respiratory failure and arrests. The physician is the only one held liable by administration for this event, even though the ED was known to have inadequate staffing, equipment and training. He is reported to the medical licensing board.
2. A 65-year-old female presents with a chief complaint of a new onset mild headache. Her head computed tomography (CT) scan is normal. Her inflammatory markers, including platelet count, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are normal.  The physician discharges her home with close primary care follow up. A week later, the patient goes blind due to temporal arteritis. She not only sues the physician for malpractice due to misdiagnosis, but she also returns to the ED and verbally accosts the responsible physician.
3. Paramedics bring in a two-year-old female to the pediatric ED at 1am. She is barely responsive, has a large hematoma to the head, and is noted to have scattered bruises on the torso and limbs. She is intubated and sedated for airway protection. Head CT reveals a large intracranial bleed and x-rays reveal several fractures in varying stages of healing. The patient ultimately passes away due to sequelae of child abuse.

Being a physician is not an easy task. While many outsiders may believe that physicians are invincible and lead glamourous lives, these assumptions are not reality. Just like non-physicians, physicians are human and they suffer stresses and ailments that can lead to emotional burnout, mental disorders and poor physical health (1, 2). In fact, studies have shown that physicians suffer from similar rates of mood disorders actually have higher suicide rates than non-physicians (2, 3, 4). Not only do physicians have personal responsibilities and financial burdens such as student loans, but they often work long hours, are underappreciated by patients and employers, and treat complicated patients that occasionally sustain poor outcomes. Many physicians witness patients who have experienced traumatic events on a daily basis including deaths and abuse. Indeed, it has been demonstrated that heavy workloads and job difficulties are considered to be the biggest contributors to physician emotional distress, mental illness and suicide (2, 5).

While research remains ongoing, it has been suggested that poor emotional, mental and physical health in physicians may negatively impact patient care and quality of care in general (1, 6, 7). One emerging area of research is poor emotional well-being or, as others call “burnout”. In general, burnout is a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that occurs in workers who engage with others regularly (7). Most often, burnout develops in employees who work with people who have significant psychological, social or physical problems. With burnout, workers become chronically stressed and eventually feel as though they are unable to provide any more of their own emotional resources to others. Consequently, depersonalization and negative attitudes toward clients can develop (7). Finally, lack of personal accomplishment occurs because eventually, emotional fatigue brings workers to view their work and their accomplishments negatively (7). It has been demonstrated burnout occurs more commonly in physicians than in those with other careers (8). There may be several reasons behind this, and further EMDocs articles will discuss burnout in physicians in more detail. Further articles will also discuss the etiology of burnout, how to measure it, and how to avoid it throughout your career.

Emotional burnout is also closely related to mental health, physical health and personal relationships (7,9, 10, 1l). While depression rates in physicians are similar to those of the general population, suicide risk in physicians is actually higher (2). While there are no exact numbers, it has been estimated that in the United States, doctors commit suicide at a rate of one medical school class per year (12).  Depression in physicians often goes under recognized, but it is a serious issue that must be recognized, treated and prevented.

Post-traumatic-stress disorder (PTSD) is another concerning mental illness that is seen in 5-6% of men in 10-14% of women in the United States (13). However, like depression, PTSD is often not an illness that most would consider to be an issue in physicians (14). While research remains limited in this area, PTSD does seem to occur in physicians (15). In 2005, Mills and Mills published a study on the prevalence  PTSD in emergency medicine resident. Overall, the authors found that 11.9 % of emergency residents met DSM IV criteria for the actual disorder, but 30% met one or more symptom categories of PTSD, including re-experiencing, avoidance and arousal (16).

Finally, physical health may also suffer as a result of job burnout (11, 17). Physicians with proper nutrition tend to also perform better at their jobs, while those with poor nutrision perform more poorly (18). In addition, those who are more physicially active tend to better cognitive performance, lower degrees of job burnout, and less depression (19, 20). Studies have also demonstrated that psychologic stress may lead to acute or chronic inflammation, which may contribute to certain disease states (21). Job burnout has been found to be associated with cardiovascular disease, musculoskeletal disorders, sleep disturbances and even diabetes (9, 11, 17, 21).  Thus, job burnout may not only impact psychologic well-being, but it may actually lead to poor physical health.

What is wellness?

Wellness has been suggested to be the antithesis of burnout (3). While the study of wellness in medicine remains in its early stages, certain methods may deem helpful and will be discussed in future emDocs articles (8, 22). Suggested wellness measures for physicians include regular physical activity, having their own personal physicians, and adequate social support (1, 7, 19). It has been shown that mentally, emotionally and physically healthy physicians provide more empathy toward patients (22). It has also been suggested that wellness measures for physicians should be a measure of healthcare quality (6). This makes sense, since a happy and physically and emotionally healthy physician is likely going to take better care of patients. Hence, overall wellness of physicians is important and should be addressed by all hospital systems, whether community, government-run, or academic.  Further articles will discuss wellness measures as well as the growing crisis in physician burnout and mental health.

References/Further Reading

1. Taub S, Morin K, Goldrich MS, Ray P, Benjamin R. Physician health and wellness. Occupational Medicine. 2006 Mar 1;56(2):77-82.
2. Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: data from the National Violent Death Reporting System. General hospital psychiatry. 2013 Feb 28;35(1):45-9.
3. McClafferty H, Brown OW, Committee on Practice and Ambulatory Medicine. Physician health and wellness. Pediatrics. 2014 Oct 1;134(4):830-5.
4. Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R. Confronting depression and suicide in physicians: a consensus statement. Jama. 2003 Jun 18;289(23):3161-6.
5. Bovier PA, Arigoni F, Schneider M, Gallacchi MB. Relationships between work satisfaction, emotional exhaustion and mental health among Swiss primary care physicians. The European Journal of Public Health. 2009 Apr 29:ckp056.
6. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. The Lancet. 2009 Nov 20;374(9702):1714-21.
7. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. Mountain View, CA: CPP. Inc., and Davies-Black. 1996.
8. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among US medical students, residents, and early career physicians relative to the general US population. Academic Medicine. 2014 Mar 1;89(3):443-51.
9. Melamed S, Shirom A, Toker S, Berliner S, Shapira I. Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions. Psychological bulletin. 2006 May;132(3):327.
10. Ahola K, Honkonen T, Kivimäki M, Virtanen M, Isometsä E, Aromaa A, Lönnqvist J. Contribution of burnout to the association between job strain and depression: the health 2000 study. Journal of occupational and environmental medicine. 2006 Oct 1;48(10):1023-30.
11. Honkonen T, Ahola K, Pertovaara M, Isometsä E, Kalimo R, Nykyri E, Aromaa A, Lönnqvist J. The association between burnout and physical illness in the general population—results from the Finnish Health 2000 Study. Journal of psychosomatic research. 2006 Jul 31;61(1):59-66.
12. Sargent DA, Jensen VW, Petty TA, Raskin H. Preventing physician suicide: The role of family, colleagues, and organized medicine. JAMA. 1977 Jan 10;237(2):143-5.
13. Yehuda R. Post-traumatic stress disorder. New England journal of medicine. 2002 Jan 10;346(2):108-14.
14. Lazarus A. Traumatized by practice: PTSD in physicians. The Journal of medical practice management: MPM. 2013 Dec;30(2):131-4.
15. Wilberforce N, Wilberforce K, Aubrey-Bassler FK. Post-traumatic stress disorder in physicians from an underserviced area. Family practice. 2010 Jun 1;27(3):339-43.
16. Mills LD, Mills TJ. Symptoms of post-traumatic stress disorder among emergency medicine residents. The Journal of emergency medicine. 2005 Jan 31;28(1):1-4.
17. Peterson U, Demerouti E, Bergström G, Samuelsson M, Åsberg M, Nygren Å. Burnout and physical and mental health among Swedish healthcare workers. Journal of advanced nursing. 2008 Apr 1;62(1):84-95.
18. Lemaire JB, Wallace JE, Dinsmore K, Lewin AM, Ghali WA, Roberts D. Physician nutrition and cognition during work hours: effect of a nutrition based intervention. BMC health services research. 2010 Aug 17;10(1):241.
19. Toker S, Shirom A, Shapira I, Berliner S, Melamed S. The association between burnout, depression, anxiety, and inflammation biomarkers: C-reactive protein and fibrinogen in men and women. Journal of occupational health psychology. 2005 Oct;10(4):344.
20. Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects on brain and cognition. Nature reviews neuroscience. 2008 Jan 1;9(1):58-65.
21. Black PH. The inflammatory response is an integral part of the stress response: Implications for atherosclerosis, insulin resistance, type II diabetes and metabolic syndrome X. Brain, behavior, and immunity. 2003 Oct 31;17(5):350-64.
22. Shanafelt TD, West C, Zhao X, Novotny P, Kolars J, Habermann T, Sloan J. Relationship between increased personal well‐being and enhanced empathy among internal medicine residents. Journal of General Internal Medicine. 2005 Jul 1;20(7):559-64.