Category: Wellness

Dx: Burnout

burnout
~ Brenda Varriano, Canada ~ Leave a comment

Author: Brenda Varriano

Guest Author: Jason M White

What is Burnout?

Most of us have experienced some component of Burnout in one shape or another. I know that I myself experienced burnout while preparing for my STEP 1 shelf exam. While I was able to hit my goal, I experienced immense fatigue and mental fogginess for weeks following. Fortunately, I recovered.

For those who are curious if they have experienced Burnout, the AAMC defines and measures it by three indicators: 1) emotional exhaustion associated with work-related stress, 2) feeling of detachment toward patients and 3) a low sense of personal accomplishment. Though I was not in my clinical rotations yet, my feeling of detachment resonated into my personal life and relationships.

Introducing Dr. Jason M White

Dr. Jason M White is an Emergency Medicine physician with over 30 years of clinical experience.  He has almost a decade of experience at the C-suite level as a Chief Medical Officer (CMO). His administrative responsibilities have included Medical Student and Graduate Medical Education, Quality, Physician Relations, Trauma and Emergency Services. His expertise includes Wellness, Patient Safety, Coaching, Leadership Development, and Patient Experience. He is a board certified by the American Board of Emergency Medicine (ABEM) and the Commission of Medical Management. He is a Clinical Assistant Professor in the College of Medicine at Central Michigan University and has over 40 years of experience teaching medical students and residents. It is with great pleasure that I introduce Dr. White to the iEM community to discuss his experience with Burnout.

Figure 2: Dr. Jason White

Q: What is your experience with Burnout?

The relationship between the specially of Emergency Medicine and Burnout goes back for almost half of the century.  When I was in residency 40 years ago, Burnout was already a major topic of discussion.  In fact, we used to joke that our residency program was so advanced that we graduated already “burned out” after just three years of training. 

In addition, you must remember that early in the history of the specialty many practitioners of Emergency Medicine were itinerant Physicians or Physicians from other specialties since there were few accredited Emergency Medicine residency training programs until the late 1970s.

Therefore, much of the longevity and Burnout data at the time was skewed by the presence of Physicians who were transitioning either into or out of their medical careers. I remember seeing data at that time that said that the average emergency physician only practiced for 7 years.

Nonetheless it put the topic of Burnout on the radar screens of the specialty very early on and I believe for this reason became part of the foundation of the curriculum of our specialty and much discussion.

I don’t believe that I personally experienced Burnout during my clinical career.  However, I saw many of my colleagues floundering in the specialty and experiencing Burnout.  In many ways the emergency Physicians are the canaries in the coal mine.  If our work environment is toxic and unhealthy, we may be among the first to demonstrate symptoms.  Much of the emphasis around Burnout has been focused on the individual practitioner which is appropriate.  However, it is an incomplete picture if we don’t also consider the practice environment as a significant component of the problem of Burnout.

Q: What are tactics to avoid Burnout?

I believe that there are several excellent tactics which have had success in helping practitioners to avoid Burnout.  The basics are all about self-care.  We all need to eat healthy, exercise and get an adequate amount of sleep.  However, the specialty of Emergency Medicine, by its very nature, is in direct opposition to those fundamental aspects of self-care.  The hectic, unpredictable pace of the emergency department makes it difficult to eat right or even at all sometimes.  The varied nature of shiftwork and swinging shifts is the enemy of developing good sleep patterns and regular exercise practices.

These foundational factors make it even more important that we understand the factors that contribute to Burnout, the symptoms of Burnout and the ways of preventing, avoiding, and healing from Burnout.

Q: What makes a good Wellness program?

There are as many definitions of Wellness programs as there are Wellness programs. One of the challenges of starting Wellness programs is not everybody has the same definition.  I can’t tell you how many times I would try to discuss developing Wellness programs with hospital administrators, and they would already have their own biases and oversimplifications of what successful programs work.

The conversations would quickly devolve into talks about having New Year’s resolution inspired weight-loss competitions and offering $25.00 gasoline gift cards as incentives.  Or they would quickly default into discussions about yoga classes and barriers to participation and cost. 

Unfortunately, much of the literature around the topic of Wellness has been done in industrial and manufacturing environments where employers may be self-insured and are interested in saving money on their Health Insurance costs by supporting stop-smoking programs or weight-loss programs.

So, the first step is to understand that Health Care providers need a different approach than the manufacturing community. In addition, much of the literature about Burnout in the healthcare environment is anecdotal.  This is what we did, and this is how it worked.  The bias is to report the elements and components of what are perceived as successful programs while never reporting failures.

In addition, the endpoints of success are highly subjective, challenging to reproduce, and often lack sustainability. For these reasons, we need both better design and better execution of the studies about Wellness and it must be focused on the Health Care community.

I believe that a good Wellness Program for Healthcare Providers should include the following elements at a minimum:

  1. Acknowledge that we are all at risk for Burnout.
  2. Educate ourselves about the symptoms of Burnout in ourselves and our colleagues. [see Stages of Burnout]
  3. Preform self-assessments on a regular basis (probably quarterly) to identify at risk areas in our personal lives. [see Gazelle, Wheel of Life]
  4. Educate ourselves on successful strategies to address our at-risk areas and tailor them to our unique situations. [see Being Well in Emergency Medicine: ACEP’s Guide to Investing in Yourself]
  5. Develop a written plan for how we are going to address our at-risk areas.
  6. As leaders, educators, and administrators, we must make the “coal mine” as healthy as possible and create an environment of support and emotional safety. We can also provide resources and advisors to assist practitioners in their self-assessments and creation of their personal Wellness plans.

Q: This last question is for fun. I know the quote below is from your medical school interview. Does it still hold true?

Yes! Absolutely still true! However, I might modify it slightly and change it to: “Because I love medicine, I want to help people, and I want my life’s work to have meaning.

Thank you, Dr. White, for taking to time to share your experiences and research on EM Burnout and physician Wellness. I learnt a lot, and I believe, we are acknowledging what will be a shift in how medicine is practiced over the next few years.

References and Further Reading

Cite this article as: Brenda Varriano, Canada, "Dx: Burnout," in International Emergency Medicine Education Project, January 5, 2022, https://iem-student.org/2022/01/05/dx-burnout/, date accessed: March 24, 2023

Things you should know about wellness and emergency medicine

things you should know about wellness and emergency medicine
~ iEM Education Project Team ~ Leave a comment

In this episode of Coffee Chat With Emergency Medicine Experts, we discussed wellness and emergency medicine for medical students. Dr. Tracy Sanson, Dr. Al’ai Alvarez were the guest speakers of this episode. Dr. Janis Tupesis and Dr. Arif Alper Cevik were the co-hosts of this unique session.

Dr. Sanson and Dr. Alvarez shared their experiences and lessons learned during their career. We believe medical students and junior EM trainees can learn many from this episode.

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Cite this article as: iEM Education Project Team, "Things you should know about wellness and emergency medicine," in International Emergency Medicine Education Project, September 29, 2021, https://iem-student.org/2021/09/29/wellness-and-emergency-medicine/, date accessed: March 24, 2023

The dose makes the poison: Coffee consumption, physiology and health impact

~ Brenda Varriano, Canada ~ Leave a comment

Introduction

As my alarm goes off at 4 am, I dread the day ahead. However, after countless sleepless nights since moving into a new city, I need to wake up early for my M3 orientation. Fortunately, I have caffeine at my disposal. So, reaching for my cup, I became inspired for my next wellness article, “Oh Sweet, Sweet nectar of the Gods.” For this article, I will start by sharing some statistics about coffee, followed by coffee processing, physiology, and, lastly, effects on the body.

In 2020, data from the national coffee association revealed that coffee consumption is up by 5% in the USA since 2015. The average American coffee drinker drinks over 3 cups of coffee a day. With coffee being a stimulant, it is no surprise that it is a favorite among physicians and medical students. Interestingly, one study reported that in-patient physicians were more likely to drink coffee and energy drinks than out-patient-based physicians. During orientation, the surgery director gave a piece of wisdom to the class of 2023. “Drink espresso. Less volume, more caffeine, less need to use the washroom after scrubbing in.”

Coffee Processing and Physiology

Given the high consumption rates of coffee, I want to start by appreciating the tremendous processing it must go through before we consume it. Coffee is derived from the Coffea (genus) shrub; the two most common species being canephora and arabica. First, coffee berries are handpicked, where the flesh is removed, and the seeds are left to ferment and dry. At this stage, the coffee is known as green coffee. Starbucks and other chains have started serving cold brews of coffee at this stage.

Interestingly, green coffee has the highest caffeine content. Second, comes the roasting stage, which impacts the amount of caffeine content and taste of coffee. The longer that coffee is roasted, the more moisture is lost and the less dense it becomes. As coffee is roasted, starches are broken down to simple sugars, high heat causes the breakdown of caffeine, and oils begin to develop. The oils contribute to coffee’s famous aroma. Finally, these beans are ground and brewed as they make their way into our cups. (Note: this is a very brief description, which does not cover decaf coffee)

Coffee is a stimulant, which has unique effects on the human body. Much of this content regarding coffee physiology shall be derived from a review by McLellan et al. 2016 and a sports podcast for those ortho heads: https://www.strongerbyscience.com/caffeine/#Adenosine_antagonism. First, coffee is considered a xanthine derivative with three methyl groups attached (scientific name-1,3,7-trimethylxanthine). This structure is similar to adenosine, explaining coffee’s action as an adenosine antagonist, meaning to inhibit the actions of adenosine at an adenosine receptor (figure 1). There are four adenosine receptors. By inhibiting different subtypes of adenosine receptors, caffeine can cause different effects. For example, adenosine receptors in the brain block the release of serotonin, dopamine, glutamate, and other neurotransmitters (less in the synapse). Caffeine blocks adenosine’s actions, thus increasing the amount of neurotransmitters in the synapse, explaining caffeine’s effects. For example, increased dopamine leads to an increased perception of reward. By altering glutamate levels, caffeine can even alter the seizure threshold. However, it is less straightforward than I am making it to sound since neurotransmitters can cause different effects in different brain regions.

Figure 1: The structure of caffeine vs. adenosine https://www.strongerbyscience.com/caffeine/#Adenosine_antagonism

Peripherally, coffee mainly acts as a sympathetic stimulant, see Figure 2. One mechanism is by stimulating your adrenal glands to secrete catecholamines which act on various organs in the body. Finally, the effects of caffeine vary, depending on individual caffeine metabolism. For example, metabolism differs between naïve or experienced caffeine consumers. Finally, the dose/timing of caffeine intake impacts metabolism. Literature suggests that absorption takes approximately 45 minutes, peak serum caffeine occurs after 15 minutes to 2 hours following ingestion, and finally, half-life ranges from 2.5-4.5 hours.

Figure 2: Impact of Coffee on the body (Van Dam et al., 2020)

Specific Effects

Coffee, while used as a stimulant, impacts our health more than we realize. A recent umbrella review by Poole et al. (2017) looked at the risks and benefits of coffee consumption based on the findings of over 200 meta-analyses. Coffee consumption was analyzed in the following conditions: high vs. Low consumption, any vs. none, and having an extra cup of coffee per day. Overall, coffee consumptions appeared to reduce the risk of all-cause mortality, cardiovascular mortality, and cardiovascular disease. Coffee consumption was also suggested to correlate with a reduced risk of cancer. These findings have been echoed in other studies. For example, a study in 2016 by Liebeskind et al. described the “coffee paradox.” In this study, high rates of coffee consumption were found to have a reduced risk of stroke, even in those who smoked. 

Finally, a recent review published in the New England Journal of Medicine summarizes some of the consistent findings of coffee consumption and its effects on the human body (Van Dam et al., 2020). In the CNS, caffeine:

  1. Reduces fatigue, increases alertness, and improves vigilance (Note: caffeine does not compensate for chronic sleep deprivation!).
  2. Improves pain tolerance.
  3. Increases anxiety when >200 mg is consumed in one sitting or >400 mg is consumed in a day.

Caffeine withdrawal presents with headache, fatigue, and depressed mood 1-2 days after cessation of coffee consumption. Withdrawal effects last between 2-9 days. In addition, coffee toxicity (1.2g or higher) can lead to altered thought and speech, anxiety, insomnia, dysphoria, and cardiovascular toxicity—more on cardiovascular toxicity in peripheral effects. I briefly mention it here, as it is part of the toxicity presentation. 

Peripherally, coffee intake increases epinephrine release by stimulating the adrenal glands and subsequently increases blood pressure transiently, as tolerance develops over time. Coffee intake (non-toxic levels) can reduce the risk of cardiovascular disease (see coffee paradox above). Coffee may potentially improve metabolism and reduce appetite, thus causing minimal effects on weight loss. Coffee may also decrease insulin sensitivity with short-term use (long-term use counteracts these effects). Furthermore, breakdown products of coffee may act as an antioxidant and protect against reactive oxidative species (ROS). Finally, coffee has been reported to reduce the risk of mortality from any cause. 

Conclusion

Coffee is a staple among many households, including our patients. Though used as a stimulant, coffee can have many physiological effects, many being beneficial. However, there can be too much of a good thing. Too much coffee can increase the risk of agitation, anxiety, insomnia, and arrhythmias. Coffee is a tool, but it is our job to use it wisely and educate patients that may be at risk of too much caffeine consumption.

References and Further Reading

  1. de Melo Pereira, G. V., de Carvalho Neto, D. P., Júnior, A. I. M., do Prado, F. G., Pagnoncelli, M. G. B., Karp, S. G., & Soccol, C. R. (2020). Chemical composition and health properties of coffee and coffee by-products. In Advances in food and nutrition research (Vol. 91, pp. 65-96). Academic Press.
  2. International Coffee Organization. The Current State of the Global Coffee Trade. Coffee Trade Stats. (2016). Retrieved from: http://www.ico.org/monthly_coffee_trade_stats.asp.
  3. Kummer, C. (2003). The joy of coffee: the essential guide to buying, brewing, and enjoying. Houghton Mifflin Harcourt.
  4. Liebeskind, D. S., Sanossian, N., Fu, K. A., Wang, H. J., & Arab, L. (2016). The coffee paradox in stroke: Increased consumption linked with fewer strokes. Nutritional neuroscience, 19(9), 406-413.
  5. McLellan, T. M., Caldwell, J. A., & Lieberman, H. R. (2016). A review of caffeine’s effects on cognitive, physical, and occupational performance. Neuroscience & Biobehavioral Reviews, 71, 294-312.
Cite this article as: Brenda Varriano, Canada, "The dose makes the poison: Coffee consumption, physiology and health impact," in International Emergency Medicine Education Project, September 6, 2021, https://iem-student.org/2021/09/06/coffee-consumption/, date accessed: March 24, 2023

Imposter Syndrome In The Medical Field

~ Brenda Varriano, Canada ~ Leave a comment

Authors

Brenda Varriano and Matthew Welch

Part 1: Imposter Syndrome and Current Model (Brenda Varriano)

“You’re a genius.” I am sure many medical students heard this claim. While I am confident my peers are intellectually gifted, I still question my own acceptance. How did I make the cut-off, and do I really belong here?

Much of this self-deprivation stems from the concept of Imposter Syndrome (IS). IS is a psychological pattern in which an individual doubts their skills, talents or accomplishments and has a persistent fear of being exposed as a “fraud.” The concept of IS was first described in an article by Clance and Imes in 1978. However, it is likely that IS had been around before its appearance in the literature. Many highly respected individuals such as Meryl Streep and Albert Einstein have reported experiencing IS. (Buckland, 2017) IS is the opposite of the Dunning-Kruger effect, which is a cognitive bias in which an individual overestimates their ability. While it is possible that some physicians and medical students overestimate their ability, IS is something experienced by most of my peers and my mentors in the ED. Therefore, the goal of this article is to discuss IS, it’s prevalence in the medical field, the current model used to describe it, how it is identified, treated and what we can do at the individual level when there are no other solutions. This article is timed when IS is highest in many US Medical students, when we prepare for our STEP 1 Boards Examination, the most important exam in our medical career. Therefore, I invited my colleague Matthew Welch to co-author this article with me, as we navigate studying and avoid the negative implications of IS.

IS was first described by Clance and Imes in a group of high achieving women (Clance and Imes, 1978). The authors noted that no matter how accomplished these women had become, they mostly expressed feelings of inadequacy, and that they were not deserving of their successes (1978). Research from academic settings has built on the work of Imes and Clance, stating that IS has been associated with certain personality traits (Langford and Clance, 1993). Some of these traits included introversion and trait anxiety (1993). Moreover, IS has been linked to a desire to appear intelligent in front of one’s peers, a propensity to experience shame and is more common in those with a non-supportive family (1993). In a study of 2,612 medical students that attended Jefferson Medical College between 2002-2012; it was found that IS was highly linked to burn out (Villwock et. Al, 2016). Furthermore, there appears to be differences among gender in those who are impacted from IS (2016). Females appear to be more likely to experience IS compared to males, however, there is a high level of burnout in both males and females that suffer from IS (2016). Villwock purports that the reason for burn out in medical students may be due to the environment of a medical school, where shame-based learning, may be a contributor to IS (2016). In such an environment, students experiencing IS may be less likely to participate in medical learning and can experience psychological distress, which may be contributing to burnout (2016). A more recent study has supported findings from Villwock, stating that gender and institutional culture were associated with higher rates of IS, and as a result, led to high rates of burnout among physicians and physicians in training (Gottlieb, 2020).

Figure 1: Clance’s (1985) model of the Imposter Cycle, as depicted in Sakulku & Alexander (2011).

To date, the concept of IS is based around the imposter cycle (Sakulku, 2011), as depicted in figure 1. The imposter cycle describes the theory behind IS, and the futile cycle between accomplishments and feelings of inadequacy. First an individual has a goal, which leads to anxiety, self-doubt and worry. In order to achieve this goal, the individual describes either procrastination or over preparedness. Once achieving the goal, the individual attributes it to luck if they had procrastinated to achieve it or effort if they had over-prepared. Despite the method to achieve the goal, accomplishment of the goal does not result in positive feedback, but leads to feelings of fraudulence, self-doubt, depression and anxiety.

Part 2: Solutions and Pitfalls (Matthew Welch)

My name is Matthew Welch, I am a second-year student at the Central Michigan College of Medicine. I am the first in my family to obtain a college education. Subsequently, the topic of IS is quite personal. In reviewing the literature, it has become apparent that the pitfalls and solutions to IS should be divided into three distinct categories: (1) Personal actions (2) Institutional actions (3) Actions for peers. Table 1 summarizes our findings regarding both the solutions and the pitfalls within each category.

Table 1: A summary of solutions and pitfalls of addressing IS in medical students divided into three categories based on the literature: (1) Personal actions (2) Institutional actions (3) Actions for peers.

Within the category of self, the consensus seems to be that a focus on one’s own mindfulness and emotional regulation can be successful in combating IS. I began a personal mindfulness meditation practice during my M1 year, and my experience aligns with the literature. By practicing mindfulness meditation for 10 minutes daily, I have noticed a dramatic difference in my ability to recognize and soothe my feelings of inadequacy. Beyond my anecdotal experience, research has shown that daily mindful practice leads to a significant reduction in activity within the amygdala, the brain’s stress center (Kral, 2019).

The strengths and weaknesses of institutional contributions to IS is vast. One theme that remains steady among all the literature however, is the effect of transitional periods. For example, IS seems to be higher during periods of transition from one life “chapter” to another. As anyone in medicine can attest, the years of training to become a physician often feel like a series of transitional periods. Beginning in undergraduate education, we transition into preclinical years, followed by clinical years and residency where expectations of our competency are continually increased.  After residency we are independent and expected to have an all-encompassing grasp on the vast information, we spent our entire medical education acquiring. While every step of this path is necessary for educating physicians, softening the harsh transition from one step to the next may be an area to explore solutions to the IS epidemic in medicine.

Finally, the subject of how our behavior affects our peers can be best summarized by a quote from Dr. Edward Hundert, Dean of Medical education at Harvard University;

Hundert likens this to a duck swimming in a swift current. On the water’s surface, the duck sits serenely, floating without effort, while below it is paddling furiously.

Miller, 2020

To help our peers, we must stop masking our own feelings of insecurity with blind confidence. Despite research showing rates of IS in medical students being somewhere in the range of 40% (Villwock, 2016). Any medical student will tell you that number is larger than reality. Moreover, the worst part of IS is the feeling of isolation. Therefore, as medical students, residents, and practicing physicians, we should be willing to admit that we are equally impacted by IS. While I frame this as a personal issue, I also recognize that medical education is designed to breed this behavior. We are constantly told that we are the “best-of-the-best,” and while some schools have moved to pass-fail curriculums, many of us are still continually ranked against our peers, even if inconspicuous in nature. This mentality can have a negative impact on student wellness in the classroom and beyond.

Finally, in the United States, it has only been recently announced that our score on the USMLE Step 1 examination has been altered to a pass fail. For example, previously if you scored below the 96th percentile, specialties such as dermatology/neurosurgery are no longer feasible options. While Brenda and I still must take part in this Hunger Games practice, I am happy that we are the last class to do so. In reducing the burden of the Step 1 examination, I believe we are supporting the mental wellbeing of students. However, IS still exists, and future discussions are warranted to reduce its impact and support the well-being of medical students and physicians at any stage in their career.

Acknowledgments

A special thanks to my colleague Matthew, who worked with me on this paper, which I believe is a particularly important topic in medicine. Please join me for my next article.

References and Further Reading

  • Atherley A, Meeuwissen SNE. Time for change: Overcoming perpetual feelings of inadequacy and silenced struggles in medicine. Med Educ. 2020;54(2):92-94. doi:10.1111/medu.14030Buckland, F. (2018). Feeling like an imposter? You can escape this confidence sapping syndrome. The Guardian, Health and Wellbeing, 1–8.
  • Clance, P. R., & Imes, S. A. (1978). The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice, 15(3), 241–247. https://doi.org/10.1037/h0086006
  • Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine, 81(4), 354–373. https://doi.org/10.1097/00001888-200604000-00009
  • Ingraham, B. L., Lerner, R., Nagai, A. K., & Shepard, J. D. (2001). Letters to the editor. Society, 38(2), A5–A6. https://doi.org/10.1007/s12115-001-1047-0
  • Jensen, D. M. (2018). 肌肉作为内分泌和旁分泌器官 HHS Public Access. Physiology & Behavior, 176(1), 1570–1573. https://doi.org/10.1038/s41395-018-0061-4.
  • Klassen, R. M., & Klassen, J. R. L. (2018). Self-efficacy beliefs of medical students: a critical review. Perspectives on Medical Education, 7(2), 76–82. https://doi.org/10.1007/s40037-018-0411-3
  • Ladonna, K. A., Ginsburg, S., & Watling, C. (2018). “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals about the Imposter Syndrome in Medicine. Academic Medicine, 93(5), 763–768. https://doi.org/10.1097/ACM.0000000000002046
  • Langford, J., & Clance, P. R. (1993). The impostor phenomenon: Recent research findings regarding dynamics, personality and family patterns and their implications for treatment. Psychotherapy, 30(3), 495–501. https://doi.org/10.1037/0033-3204.30.3.495
  • Miller, J. (2020). Tailored for Perfection. Harvard Medicine Magazine, 1–40. https://hms.harvard.edu/magazine/skin/tailored-perfection
  • Sakulku, J. (2019). Impostor Phenomenon. Encyclopedia of Personality and Individual Differences, 1–5. https://doi.org/10.1007/978-3-319-28099-8_2332-1
  • Villwock, J. A., Sobin, L. B., Koester, L. A., & Harris, T. M. (2016). Impostor syndrome and burnout among American medical students: a pilot study. International Journal of Medical Education, 7, 364–369. https://doi.org/10.5116/ijme.5801.eac4
Cite this article as: Brenda Varriano, Canada, "Imposter Syndrome In The Medical Field," in International Emergency Medicine Education Project, July 26, 2021, https://iem-student.org/2021/07/26/imposter-syndrome-in-the-medical-field/, date accessed: March 24, 2023

Recent Blog Posts By Brenda Varriano

Intern Survival Guide – ER Edition

Intern Survival Guide - ER Edition
~ Sumaiya Hafiz, UAE ~ Leave a comment
In some parts of the world, Internships consist of rotating in different departments of a hospital over a period of one or two years depending on the location. In others, interns are first-year Emergency Medicine residents. Whichever country you practice in, an emergency rotation may be mandatory to get the most exposure, and often the most hands-on. Often, junior doctors (including myself)  find ourselves confused and lost as to what is expected of us, and how we can learn and work efficiently in a fast-paced environment such as the ER. It can be overwhelming as you may be expected to know and do a lot of things such as taking a short yet precise history, doing a quick but essential physical exam and performing practical procedures. I’ve gathered some tips from fellow interns and myself, from what we experienced, what we did right, what we could’ve done better and what we wish we knew before starting. These tips may have some points specific to your Emergency Medicine Rotation, but overall can be applied in any department you work in.
  • First things first – Always try to be on time. Try to reach your work a couple of minutes before your shift starts, so you have enough time to wear your PPE and feel comfortable before starting your shift.
  • Know your patients! Unlike other departments, ER does not always have rounds, and you do not know any of the patients beforehand, but it always helps to get a handover from the previous shift, and know if any of the patients have any results, treatment plans or discharges pending, to prevent chaos later on!
  • Always be around, inform your supervising doctor when you want to go for a break, and always volunteer to do more than what you’re asked for. The best way to learn is to make yourself known, ask the nurses to allow you to practice IV Cannulation, Intramuscular injections, anything and everything that goes around the department, remember the ER is the best place to learn.
  • Admit when you feel uncomfortable doing something, or if you’ve done a mistake. This makes you appear trustworthy and everyone respects someone who can own up to their mistake and keeps their patients first.
  • Breath sounds and pulses need to be checked in every patient!
  • Address pain before anything else, if their pain is in control, the patient will be able to answer your questions better.
  • Never think any work is below you, and this is one thing which I admired about ED physicians, you do not need someone to bring the Ultrasound machine to you, you do not need someone to plug in the machine, you do not need someone to place the blood pressure cuff if you can do it yourself. Time is essential, and if you’re the first person seeing the patient, do all that you can to make their care as efficient as possible.
  • Care for patients because you want to, and not for show. Often junior doctors get caught up in the fact that they are being evaluated and try to “look” like the best version of themselves. While it may be true, remember this is the year where you are shaping yourself for the future, and starting off by placing your patients first, doing things for their benefit will not only make it a habit, the right people will always notice and will know when you do things to provide patient-focused care, or when you do them to show that you are providing patient-focused care.
  • Teamwork will help you grow. Not everything in life has to be a competition, try to work with your colleagues, share knowledge, take chances on doing things, learn together, trying to win against everyone else only makes an easier task even more stressful and can endanger lives.
  • Learn the names of the people you work with! In the ER, you may across different people on each and every shift and it may be difficult to remember everyone’s names, but it’s always nice to try, and addressing people by their names instantly makes you more likable and pleasant to work with!
  • Keep track of your patients and make a logbook of all the cases you see and all the procedures you observe/assist in/perform. This not only helps in building your portfolio, but also in going back and reading about the vast variety of cases you must have seen.
  • Always ask yourself what could the differential diagnosis be? How would you treat the patient?
  • Ask questions! No question is worth not asking, clear your doubts. Remember to not ask too much just for the sake of looking interested, but never shy away from asking, you’d be surprised to see how many doctors would be willing to answer your queries.
  • Don’t make up facts and information. If you forgot to ask something in history, admit the mistake, and it’s never too late, you can almost always go back and ask. It’s quite normal to forget when you’re trying to gather a lot of information in a short span of time.
  • Check up on the patients from time to time. The first consultation till the time you hand them the discharge papers or refer them to a specialty shouldn’t be the only time you see the patient. Go in between whenever you get a chance, ask them if they feel better, if they need something. Sometimes just by having someone asking their health and mental wellbeing is just what they need.
  • Take breaks, drink water and know your limits. Do not overwork yourself. Stretching yourself till you break is not a sign of strength.
  • Sleep! Sleep well before every shift. Your sleep cycles will be affected, but sleeping when you can is the best advice you can get.
  • Read! Pick your favorite resource and hold onto it. A page of reading every day can go a long way. The IEM book can be a perfect resource that you can refer to even during your shifts! (https://iem-student.org/2019/04/17/download-now-iem-book-ibook-and-pdf/)
  • Practice as many practical skills as you can. The ER teaches you more than a book can, and instead of looking at pictures, you can actually learn on the job. Practice ultrasound techniques, suturing, ECG interpretation, see as many radiology images as you can, learn to distinguish between what’s normal and what’s not.
  • Last but most important, Enjoy! The ER rotation is usually amongst the best rotations an intern goes through, one where you actually feel like you are a doctor and have an impact on someone’s life! So make the best of it.
If you are a medical student starting your emergency medicine rotation, make sure to read this post for your emergency medicine clerkship, and be a step ahead! https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/  
Cite this article as: Sumaiya Hafiz, UAE, "Intern Survival Guide – ER Edition," in International Emergency Medicine Education Project, May 26, 2021, https://iem-student.org/2021/05/26/intern-survival-guide-er-edition/, date accessed: March 24, 2023

Recent Blog Posts By Sumaiya Hafiz

Coping with an Emotional Crisis

Coping with an Emotional Crisis
~ Sheza Qayyum, Canada ~ Leave a comment

In the ED, we often see patients presenting amid an emotional crisis – whether it’s a panic attack, or a period of extreme anxiety or stress, or a feeling of being overwhelmed. In fact, it is not just patients. We as humans can experience this too, finding ourselves in situations where we feel overwhelmed, unable to deal with our emotions, and not knowing what to do next. For this reason, I wanted to provide some tips on coping with an emotional crisis, that I learned during my psychiatry rotation. In psychiatry, we called these “distress tolerance skills”, which is a component of Dialectical Behavioural Therapy. 

One distress tolerance skill is TIPP – which stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation. 

  1. Temperature: During a crisis, our body may feel hot. So, it can be helpful to come into contact with something COLD. This can include eating/drinking something cold, tapping a cool cloth on yourself, splashing cold water on your skin, standing out in the cold or front of an air conditioner, or holding an ice cube. Whatever is convenient! This will “cool” you down both literally and emotionally.
  2. Intense Exercise: At times, feelings become overwhelming, and you may become full of anxious energy. Performing intense exercise on a daily basis can act as an outlet to release negative emotions and energy and can decrease stress levels. This can be any form of intense exercise, including jogging on the spot, doing jumping jacks, going on a run, or going to the gym. 
  3. Paced Breathing: This is a technique of taking slow, deep breaths. It can heighten performance and concentration while also being a powerful stress reliever with a soothing effect. One way of doing this is box breathing, which actually has evidence for regulating the autonomic nervous system. Here are the steps for box breathing:
    1. Close your eyes. Inhale through your nose while slowly counting to four.
    2. Now, hold your breath inside while counting slowly to four again. Try not to clamp your mouth or nose shut. 
    3. Begin to slowly exhale for 4 seconds.
    4. Now, hold your breath there while counting slowly to four again. 
    5. Repeat these steps multiple times daily, for 5 minutes at a time. 
  4. Progressive Muscle Relaxation: This is a technique that helps to slow down your heart rate and breathing, while also releasing the muscle tension that often accompanies anxious feelings. To perform this, you first tense particular muscle groups in your body, such as clenching your fist, while you slowly inhale. Next, you release this tension, e.g. slowly unclench your fist, while you slowly exhale. 

Focus on what helps you, and encourage patients to focus on what helps them. This may involve identifying problematic ways of coping with anxiety that end up exacerbating anxiety in the long term, such as resorting to alcohol. Other daily things that may be helpful include meditation, yoga, exercise, and getting adequate sleep. Maintaining a routine can be beneficial. Any relaxation exercise of your preference, that helps you be more present in the moment and slow down your thoughts, will help in times of an emotional crisis. Many people find it helpful to keep a journal on a daily basis to collect their thoughts, and to keep up hobbies they enjoy such as sports, hiking, walking, spending time with loved ones, cooking, and so on. I hope you found this blog post helpful, not just for ways to help patients going through an emotional crisis, but yourself too. Feel free to leave a comment below with additional strategies you have found helpful to cope with an emotional crisis!

References and Further Reading

  1. Dialectical Behavior Therapy. (2021). T10: TIPP. Retrieved April 9, 2021, from https://dialecticalbehaviortherapy.com/distress-tolerance/tipp/
  2. GET.gg. (2015). Distress Tolerance. Retrieved April 9, 2021, from https://www.getselfhelp.co.uk/distresstolerance.htm
  3. Scott E & Snyder C. (2019). Tips on How to Cope With a Crisis or Trauma. Verywellmind. Retrieved April 9, 2021, from https://www.verywellmind.com/cope-with-a-crisis-or-trauma-3144525
Cite this article as: Sheza Qayyum, Canada, "Coping with an Emotional Crisis," in International Emergency Medicine Education Project, May 24, 2021, https://iem-student.org/2021/05/24/coping-with-an-emotional-crisis/, date accessed: March 24, 2023

Recent Blog Posts By Sheza Qayyum

Compassion Fatigue in the ER and Beyond: When caring leads to an inability to care

compassion fatigue
~ Brenda Varriano, Canada ~ Leave a comment

That doctor was horrible! How could she be so rude? She’s a doctor after all.

Anonymous

What is Compassion Fatigue?

In December 2020, a relative had just been at the hospital with my grandmother recently diagnosed with pancreatic cancer. The oncologist on site had been described as rude and inattentive to my grandmother’s needs, or so I was told. Due to COVID-19, the number of visitors had been limited in the hospital. Everything I heard regarding the quality of care my grandmother received was through word of mouth. Initially, I was furious. Then, I stopped and pondered the situation, leading to a realization and inspiration for this article. Perhaps the doctor was not as rude as she was made out to be. Perhaps, she was undergoing compassion fatigue, the emotional and physical exhaustion leading to a diminished ability to feel compassion for others. Compassion fatigue is often due to burnout and stress, something which I believe to be more prevalent during the COVID-19 era. However, compassion fatigue is not a new term. I first heard it during my internship with the Emergency Department at Toronto Western this summer. It is only now; I am beginning to see it unfold in real life, and truly understand it. Therefore, for this article, I will discuss compassion fatigue, how to notice it, and how to prevent becoming a victim to burnout.

burn-out army
Figure 1. The Roll Call is an 1874 oil-on-canvas painting by Elizabeth Thompson, Lady Butler. The worn soldiers resonate, what I imagine to be a very burnt-out army of front-line workers during the COVID-19 pandemic.

Compassion Fatigue in the ER and Beyond?

Compassion fatigue is not unique to any one medical specialty; however, it is commonly seen in high-stress specialties where patients are normally sicker and in a more critical condition. In a study of ED nurses (Borges 2019), compassion fatigue was more prevalent in women and decreased with the increasing age of the nurse. Reasons for these trends were that women were more likely to experience their patients’ pain compared to men, and older nurses were more equipped to handle stressful situations compared to younger nurses. Gribben et al. (2019) looked at compassion fatigue in pediatric emergency medicine physicians and found burnout was the highest predicting factor in developing compassion fatigue. Interestingly, this group’s prevalence of compassion fatigue was lower compared to other pediatric specialties that followed patients longitudinally. This may suggest that the greater the relationship with the patient, the greater the impact of developing compassion fatigue; however, only one of the few papers suggested this relationship. In another study. Hooper et al. (2010), assessed compassion fatigue across multiple specialties (nephrology, oncology, intensive care, emergency medicine), and found no significant difference in compassion fatigue among these groups. While there was no statistically significant difference in compassion fatigue in this study, 82% of ER nurses reported moderate to high burnout levels, and 85% of ER nurses reported high levels of compassion fatigue.

Moreover, certain specialties were more likely to report a different adverse experience related to the job. For example, burnout was higher in intensive care doctors, compassion fatigue was higher in oncologists, and healthcare providers in the ER were more likely to report less compassion satisfaction and the pleasure of doing work. Currently, compassion fatigue is becoming a major concern in the era of COVID-19. Ruiz et al. looked at compassion fatigue, burnout, and compassion satisfaction in Spain’s healthcare workers during the COVID-19 pandemic. In this study, physicians reported higher compassion fatigue and burnout scores compared to nurses, who reported higher compassion satisfaction scores, despite reporting similar perceived stress. One explanation for compassion satisfaction in the nurses were their perceived importance during the pandemic.

Model of Compassion Fatigue

Since compassion fatigue is prevalent in medicine, it is important to understand some of the theories behind compassion fatigue and what causes it. Cocker and Joss (2016) provide one example of a model on compassion fatigue.

Model of Compassion Fatigue
Figure 2: Compassion Fatigue Model adapted from Cocker and Joss

This model encompasses many of the concepts cited in the literature regarding compassion fatigue, such as burnout, secondary trauma and compassion satisfaction. Although compassion fatigue is one definition, it is important to fully understand the concepts used in the model by Cocker and Joss (2016), to better our understanding of what compassion fatigue is and it relates to other variables encountered in the healthcare field. Compassion fatigue is the emotional and physical exhaustion, leading to an inability to feel compassion or empathize with another. Compassion Satisfaction is the amount of pleasure derived from being able to do work. Burnout occurs when an individual cannot reach their goals, leading to frustration, loss of morale, and decreased willful efforts. Finally, secondary traumatic stress arises from a rescue-caretaking response and occurs when an individual cannot rescue or save someone from harm, resulting in significant guilt and distress. Compassion fatigue can be caused when there is increased burnout or exposure to secondary trauma. While stressors can be part of the medical career, especially in the ED, compassion fatigue does not always need to become a consequence. Compassion satisfaction can act as a mediator, thus counteracting the negative effects of burnout and secondary trauma. One mechanism for the beneficial role of compassion satisfaction is its importance for building resiliency and transforming negative experiences to positive experiences.

How to Notice and Manage Compassion Fatigue

Given the impact of compassion fatigue on a physician and their ability to care for a patient, it is important to recognize and prevent the development of compassion fatigue. Some studies (Peters et. Al, 2018) acknowledge the need for education on compassion fatigue and suggest that this needs to be implemented at the individual and institutional level. Moreover, it is essential to note that many health professionals are not aware of compassion fatigue (Berg et. Al, 2016). Two inventories which have been used to assess for compassion fatigue in the literature include the Professional Quality of Life Scale and the Holmes-Rahe Life Stress Inventory. Berg describes that while most health professionals have their own individualized ways of dealing with stress, none of the healthcare providers interviewed in his study reported receiving any training in compassion fatigue. Berg mentions that group coping and debrief sessions can be useful strategies to prevent compassion fatigue (Berg et al., 2016; Schmidt et al., 2017). Finally, other institutional strategies may include identifying employees at high risk of compassion fatigue, provision of training to identify and cope with compassion fatigue, the use of workshops to promote self-care and other measures, such as open dialogue, to validate compassion fatigue and the risk it poses to healthcare provider wellbeing (Smith, 2012).

Closing Remarks

Compassion Fatigue is real, and often insidious in the presentation. Unfortunately, the concept of compassion fatigue is not always known, and at times its presence among ourselves and our colleagues can be challenging to identify. I believe that this is a concept which must be discussed, especially with the growing demands on healthcare providers and increasing stress during the COVID-19 pandemic. Sometimes caring can have negative impacts on healthcare providers. So begs the question, who takes care of healthcare providers while they are caring for others. We are not immune to the stress that comes with our job. Importantly, we must find ways to identify and support one another to not diminish our ability to care.

Cite this article as: Brenda Varriano, Canada, "Compassion Fatigue in the ER and Beyond: When caring leads to an inability to care," in International Emergency Medicine Education Project, February 17, 2021, https://iem-student.org/2021/02/17/compassion-fatigue/, date accessed: March 24, 2023

Recent Blog Posts by Brenda Varriano

References and Further Reading

  • Berg, G. M., Harshbarger, J. L., Ahlers-Schmidt, C. R., & Lippoldt, D. (2016). Exposing Compassion Fatigue and Burnout Syndrome in a Trauma Team: A Qualitative Study. Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 23(1), 3–10. https://doi.org/10.1097/JTN.0000000000000172
  • Borges, E., Fonseca, C., Baptista, P., Queirós, C., Baldonedo-Mosteiro, M., & Mosteiro-Diaz, M. P. (2019). Compassion fatigue among nurses working on an adult emergency and urgent care unit. Fadiga por compaixão em enfermeiros de urgência e emergência hospitalar de adultos. Revista latino-americana de enfermagem, 27, e3175. https://doi.org/10.1590/1518-8345.2973.3175
  • Cocker, F., & Joss, N. (2016). Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. International journal of environmental research and public health, 13(6), 618. https://doi.org/10.3390/ijerph13060618
  • Gribben, J. L., MacLean, S. A., Pour, T., Waldman, E. D., & Weintraub, A. S. (2019). A Cross-sectional Analysis of Compassion Fatigue, Burnout, and Compassion Satisfaction in Pediatric Emergency Medicine Physicians in the United States. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 26(7), 732–743. https://doi.org/10.1111/acem.13670
  • Hooper, C., Craig, J., Janvrin, D. R., Wetsel, M. A., & Reimels, E. (2010). Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. Journal of emergency nursing, 36(5), 420–427. https://doi.org/10.1016/j.jen.2009.11.027
  • Peters E. (2018). Compassion fatigue in nursing: A concept analysis. Nursing forum, 53(4), 466–480. https://doi.org/10.1111/nuf.12274
  • Ruiz-Fernández, M. D., Ramos-Pichardo, J. D., Ibáñez-Masero, O., Cabrera-Troya, J., Carmona-Rega, M. I., & Ortega-Galán, Á. M. (2020). Compassion fatigue, burnout, compassion satisfaction and perceived stress in healthcare professionals during the COVID-19 health crisis in Spain. Journal of clinical nursing, 29(21-22), 4321–4330. https://doi.org/10.1111/jocn.15469
  • Schmidt, M., & Haglund, K. (2017). Debrief in Emergency Departments to Improve Compassion Fatigue and Promote Resiliency. Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 24(5), 317–322. https://doi.org/10.1097/JTN.0000000000000315
  • Smith, P. (2012a) Alleviating compassion fatigue before it drags down productivity [PDF]. Long Term Living. http://www.compassionfatigue.org/pages/longtermliving.pdf

Sleep and Shiftwork

sleep and shiftwork
~ Brenda Varriano, Canada ~ Leave a comment

The emergency department is open 24/7, meaning that most ED physicians experience shift work. Shift work means that service is provided around the clock, whether it be night or day. Though shift work is almost always part of the job description for an ED doctor, it may not always favour the wellbeing of the physician. Inspired by a classmate, who adopted the sleep cycle of an ED early on in his M1 year, I wanted to discuss the science of sleep, the impact of shift work and how can we improve sleep hygiene when shift work is part of our job.

Basic Science of Sleep?

Sleep is part of every human being’s existence, as we could not live without it. Even though we have limited recollection of what happens during sleep, the process is quite complex. First, sleep latency is the time needed to fall asleep. Second, sleep is broken down into four stages that we oscillate through 4-5 times a night. The time it takes to go through all stages in a sleep cycle is approximately 90-120 minutes. The four stages we must pass through are called stage 1, stage 2, stage 3 and rapid eye movement (REM) sleep, respectively. Stage 1 through 3 is collectively called non-rapid eye movement sleep (NREM).

Stage 1 is the lightest stage of sleep and the first one we enter from wakefulness and is characterized by theta waves (4-7 Hz) on an EEG. Stage 2 is a deeper sleep and the period where we spend most of our time sleeping. It is characterized by theta waves, sleep spindles and k-complexes. Finally, stage 3 is known as slow-wave sleep, where delta waves predominate the EEG (0-4 Hz). Finally, after the three NREM stages, we enter REM sleep. REM is the deepest stage of sleep, despite the EEG activity being the closest to waking state. It is during REM sleep that we experience vivid dreams and have low muscle tone.

So why is sleep important?

First, there is a growing body of evidence that slow-wave sleep is when we store memories. Therefore, through proper sleep, we can consolidate memories, increasing retention of what we had learned the previous day. Moreover, sleep is important in our ability to regulate our emotions and respond appropriately to different circumstances. In addition, when we get proper sleep, we are more like to be in a positive mood, which can impact our patient interactions. Furthermore, sleep is important in immune regulation and the ability to fight off infection. Finally, sleep helps with muscle recovery and favours protein anabolism (growth). I personally believe that muscle recovery is important given the time spent on one’s feet during an ER shift. This theory of sleep and muscle recovery has been supported in sports medicine literature, and I am intrigued to see if this evidence also existed for ED Physicians and other medical specialities that are more physically demanding.

Shift work in health care workers

So, what happens when we don’t sleep? First, shift work and lack of proper sleep increase levels of fatigue and errors made by health care workers. This can have profound implications on patients, especially in the ED, where the severity of presentation is often greater than in other clinical environments. This is also alarming, given that shift workers tend to have a reduced total amount of sleep. This reduced amount of sleep most commonly impacts stage 2 NREM sleep and REM sleep, thus reducing the quality of sleep, in addition to the duration of sleep. This reduced sleep quality is worse in shift workers on a rotating shift schedule, compared to a nighttime or daytime only worker.

Moreover, in some studies of ER workers, the duration of sleep, especially REM, is less during the day then at night. So even if one believes they are still getting sleep, it may be of reduced quality. Some explanations for this diminished REM sleep during the day is the body’s natural response to a light-dark schedule and the release of melatonin, the sleep hormone. Melatonin is the sleep hormone, which often rises at nighttime when it is time to go to bed. Sunlight inhibits the release of melatonin, signalling our bodies that it is time to be awake. So, even if one tries to sleep in a dark room, the walk home from a shift or exposure to hospital lights may confuse the circadian clock, diminishing sleep quality. Finally, other studies have reported that shiftwork could increase cardiovascular disease risk, blood pressure, increase levels of stress and cause gastrointestinal issues. In women, shiftwork can cause fertility problems, such as premature birth and low-birth-weight infants.

How to combat some of the negative effects of shiftwork

Individual Strategies

There are many things we can do to manage our sleep quality and scheduling. For example, our sleep environment can be adjusted to maximize our sleep quality. Strategies can include the use of earplugs and ensuring a dark room devoid of as much light as possible. Additionally, sunglasses can be worn to and from a night shift, to avoid daylight, which may signal to our body the biological start or end of a day.

Organizational Strategies

While some of the individual strategies may be useful to improve sleep hygiene with a shift work schedule, I also believe that some strategies should be implemented at the institutional level. For example, there is a body of literature which discusses that shifts longer than 12 hours are the most detrimental to sleep quality and a physician’s health. Moreover, the duration and timing of a break during a shift could help reduce some of the symptoms of shift work. Longer breaks during a shift are favoured, though the reasons why the longer breaks are better for sleep hygiene are unknown. Finally, scheduling strategies should be implemented. A paper by Burgess, has suggested that shifts be organized in a clockwise manner. For example, on performs a morning shift, then evening shift and a night shift etc. Moreover, morning shifts should not start earlier than 8:00 A.M. to favour our natural circadian rhythm. Issues with this approach are that multiple physicians work in an emergency department, many with families and different lives, which may prefer different schedules. Another issue is when a physician is sick, and another substitutes in. This could throw off the sleep schedule of both the physician cancelling and substituting the shift. Furthermore, is there an ideal number of days between shifts? Should this change with physician age knowing how melatonin levels decrease and the body becomes less resistant to stressors with ageing. While there are currently no gold standards with sleep regulation and shiftwork, we should at least be aware of why this is important and be mindful of our practices. It is easy to neglect our health in favour of our careers, something I have been all too familiar with and hope to improve.

Conclusion

I would like to end this article with a few comments about sleep. While the published literature may not tell a complete story due to the publication bias, there are a few things we can take away. Sleep is essential for our health and mental wellbeing. Shiftwork cannot be avoided, and, if self-care is not practiced, lack of sleep can have detrimental effects on our body and wellbeing. The impact of shiftwork on everyone can be different. Therefore, individual strategies to advocate for personal health is important. Organizations have a role in fostering an environment that supports good sleep habits and employee health. Finally, medical schools and residency programs should incorporate time to educate students on sleep hygiene and hopefully, inspire students to be agents of change in their own hospitals, thus fostering wellness practices. I look forward to joining you next time while I talk about imposter syndrome in medicine.

References and Further Reading

  • Burgess P. A. (2007). Optimal shift duration and sequence: recommended approach for short-term emergency response activations for public health and emergency management. American journal of public health, 97 Suppl 1(Suppl 1), S88–S92. https://doi.org/10.2105/AJPH.2005.078782
  • Dall’Ora C, Ball J, Recio-Saucedo A, Griffiths P. Characteristics of shift work and their impact on employee performance and wellbeing: A literature review. Int J Nurs Stud. 2016;57:12-27. doi:10.1016/j.ijnurstu.2016.01.007
  • Dattilo M, Antunes HK, Medeiros A, et al. Sleep and muscle recovery: endocrinological and molecular basis for a new and promising hypothesis. Med Hypotheses. 2011;77(2):220-222. doi:10.1016/j.mehy.2011.04.017
  • Gruber R, Cassoff J. The interplay between sleep and emotion regulation: conceptual framework empirical evidence and future directions. Curr Psychiatry Rep. 2014;16(11):500. doi:10.1007/s11920-014-0500-x
  • Halson SL, Juliff LE. Sleep, sport, and the brain. Prog Brain Res. 2017;234:13-31. doi:10.1016/bs.pbr.2017.06.006
  • Ibarra-Coronado EG, Pantaleón-Martínez AM, Velazquéz-Moctezuma J, et al. The Bidirectional Relationship between Sleep and Immunity against Infections. J Immunol Res. 2015;2015:678164. doi:10.1155/2015/678164
  • Kuhn G. Circadian rhythm, shift work, and emergency medicine. Ann Emerg Med. 2001;37(1):88-98. doi:10.1067/mem.2001.111571
  • Marshall L, Helgadóttir H, Mölle M, Born J. Boosting slow oscillations during sleep potentiates memory. Nature. 2006;444(7119):610-613. doi:10.1038/nature05278
  • Paller KA, Voss JL. Memory reactivation and consolidation during sleep. Learn Mem. 2004;11(6):664-670. doi:10.1101/lm.75704
  • Qureshi, S., Karrila, S., & Vanichayobon, S. (2018). Human sleep scoring based on K-Nearest Neighbors. Turkish Journal of Electrical Engineering & Computer Sciences, 26(6), 2802-2818.
  • Sack RL, Lewy AJ, Erb DL, Vollmer WM, Singer CM. Human melatonin production decreases with age. J Pineal Res. 1986;3(4):379-88. doi: 10.1111/j.1600-079x.1986.tb00760.x. PMID: 3783419.
Cite this article as: Brenda Varriano, Canada, "Sleep and Shiftwork," in International Emergency Medicine Education Project, November 30, 2020, https://iem-student.org/2020/11/30/sleep-and-shiftwork/, date accessed: March 24, 2023

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Exercise is Medicine

Exercise is Medicine
~ Brenda Varriano, Canada ~ Leave a comment

Overview

I strongly believe that exercise is medicine. Exercise has been proven to improve cognitive functioning, reduce burnout rates, and support sound mental well-being. However, developing an exercise regimen can be difficult, especially in a demanding academic program such as medicine where time is limited, or after a long shift in the emergency department (ED). Some common barriers to exercise reported in published studies include lack of time and laziness. Though laziness was the term used in these research studies, I prefer fatigue or burnout. Many classmates and colleagues I know, that do not work out, work themselves to the bone, therefore limiting the excess energy available for working out. While I have yet to experience the fatigue of a long ED shift, I have experienced long workdays, and for me, no matter how tired I am, a quick work out can always help me get back into the zone, feel more productive or improve my mood.  

In university students, physical activity has been linked with decreased rates of burn-out, decreased perceived stress, and higher academic performance. As mentioned in my previous post, burnout is not good for physician performance. Burnout can increase the risk of medical errors, and more importantly, reduce the patient-physician experience. Imagine attending an event with a group of friends or colleagues. Would you be drawn to those who are happy, energetic, and lively; or would you rather spend your time with someone who seems so tired and disengaged, someone who keeps asking you to repeat yourself or do not respond to your social cues in an appropriate manner. I would prefer the former, though I have experienced the latter, and do not want to become victim to compassion fatigue because I could not support my own health and wellness. Compassion fatigue, a term I recently learned, is an inability to empathize or show compassion to others due to physical or mental burn out.

Overall, I believe that exercise is important to support one’s health and avoid compassion fatigue or other signs of burnout. However, when it comes to incorporating exercise into your daily routine, there is no one size fits all. The goal of this article is to share three of my favorite styles of exercise, that can be short and effective if done at a proper intensity. At the end of the article, I will have a list of YouTube Channels that provide free workouts, that I am using during COVID-19 as I wait for the gyms to safely open. All these channels have some videos on Tabata, HIIT, and AMRAP training (described below). These can be shared with patients as well, if appropriate, knowing that at times, exercise can be one of the best forms of medicine out there.

Tabata – Named after the Man, the Myth, the Legend

Tabata training is named after the creator, Dr. Izumi Tabata, and his lab, located in Tokyo. Tabata is a specific form of high-intensity interval training. Each exercise (i.e. push-up) is performed for 4 minutes. Within each 4-minute block, the exercise will be performed for 20s with a 10s rest. Overall, the exercise will be performed 8 times in the 4-minute window frame. The workout can be tailored with as many exercises as one wishes. An example of a 16-minute full-body workout can look like the following:

  1. 4 minutes push-ups (20s on – 10s off x8)
  2. 4 minutes of body-weight squats (20s on – 10s off x8)
  3. 4 minutes of sit-ups (20s on – 10s off x8)
  4. 4 minutes of burpees (20s on – 10s off x8)

Don’t forget that exercises always have modifications. For example, if a lunge or squat hurts your knees or your legs are beat after standing in the ED for a long shift, then a wall sit can always be a substitute.

exercise is medicine

HIIT – High-Intensity Interval Training

HIIT often gets mixed up with Tabata training. While they are very similar, HIIT is not as specific as the Tabata framework. HIIT training is similar in which you perform an exercise at a high intensity for a given amount of time followed by a rest period. The rest is important to prevent injury and give your body time to recover from the previous spurt of exercise. There are two ways this can be incorporated:

  1. One exercise at a time (rest in between every single exercise)

For this style of HIIT, you perform one exercise, the work period, and then rest, the rest period. I remember when I used to run or bike, I would start with a 1:2 ratio of work to rest (30 second sprint, 1 minute rest), and slowly work to a 1:1 ratio (30 second sprint, 30 second rest). The example I gave was a form of cardio, but the principles can apply to weights. For example, bicep curl for 2 minutes and rest for 2 minutes. Squat for 30s, rest for 30s.

  1. A series of exercises with rest after the series

In this second form of HIIT, you perform a series of exercises, as shown in the example below, and only rest after completing the entire series. The duration of the exercise time for each exercise is variable, but the entire series is usually the same.

Credit: https://darebee.com/workouts/beginner-hiit-workout.html
Credit: https://darebee.com/workouts/super-hiit-workout.html

AMRAP – As Many Reps as Possible

In AMRAP exercises, you pick one or two exercises and alternate between the two, until the timer tells you it’s time to rest. For example, say you choose squats and lunges (12 reps each) for the exercises, and you pick a 4-minute work period, then you would alternate between 12 squats and 12 lunges until the 4 minutes had passed. You then rest and can repeat with the same two exercises, or two new exercises for as many rounds as you wish. I love this style because you feel like you got an awesome workout in such a short period of time! It was the closest thing I could get to a runner’s high when I couldn’t run, and I could usually do a shorter workout, and feel satisfied. For the timer, I like the website linked below, which allows you to play with the number of intervals and the work/rest periods. The best part is it’s free and provides audio alerts to let you know when the work or rest period is complete. https://fitlb.com/tabata-timer

Here is an example of a workout I put together this summer. After working out, I always found myself to be more productive during the day.

Note: Reverse lunges reduce strain on knee compared to forward. Also, all channels have low impact workout options.

AMRAP #1 (2-minutes each round + 1-minute rest in between; Repeat series #1-8 workout twice)

  1. Air squats
  2. Plank
  3. Reverse lunge left leg
  4. Reverse lunge right leg
  5. Push-ups
  6. Sit-Ups
  7. Calf Raises
  8. Glute bridge

How to increase the intensity of an exercise: 

  1. Increase the number of reps
  2. Increase the speed of an exercise (make sure form is intact)
  3. Add resistance (weights, bands)
  4. Decrease the rest duration
  5. Perform moves that focus on more than one muscle group

Closing Remarks

I hope you learned a bit more about the three styles of exercise described above. They can be done with or without equipment and can be structured based on your goals. I know I would use a quick ten-minute bout of exercise in between a long spurt of studying whenever I would notice my mental fogginess causing careless errors or diminish my quality of work.  

While I encourage exercise as medicine, I also support a healthy mindset; do not hate yourself if you miss a workout, do not hate yourself if a workout is too hard, do not hate yourself if you need to rest. We are all human. Importantly, we are using our time and energy every week in school to study or in the ED to make sure that we can rapidly diagnose, treat and decide what the next steps in a patient care plan are. This takes energy, and so we need to make sure we use exercise to increase our wellbeing, not inch closer to burn out. My mentor, who is an ED physician in Toronto Western, always told me that the moment you don’t have the time or energy to exercise and socialize with loved ones is the moment you are starting to enter burnout territory. 

Finally, inspired by a classmate, I would like my next article to focus on the impact of shiftwork on sleep hygiene and health, in addition to tactics to overcome the detrimental effects of shiftwork on sleep. Send me a message if you want different wellness topics to be discussed. I am always open to feedback. I look forward to learning alongside the iEM community. Happy exercising!

References and Further Reading

  1. Al-Drees A, Abdulghani H, Irshad M, et al. Physical activity and academic achievement among the medical students: A cross-sectional study. Med Teach. 2016;38 Suppl 1:S66-S72. doi:10.3109/0142159X.2016.1142516
  2. Alexandrova-Karamanova, A., Todorova, I., Montgomery, A., Panagopoulou, E., Costa, P., Baban, A., Davas, A., Milosevic, M., & Mijakoski, D. (2016). Burnout and health behaviors in health professionals from seven European countries. International archives of occupational and environmental health, 89(7), 1059–1075. https://doi-org.cmich.idm.oclc.org/10.1007/s00420-016-1143-5
  3. Costa, E. C., Hay, J. L., Kehler, D. S., Boreskie, K. F., Arora, R. C., Umpierre, D., Szwajcer, A., & Duhamel, T. A. (2018). Effects of High-Intensity Interval Training Versus Moderate-Intensity Continuous Training On Blood Pressure in Adults with Pre- to Established Hypertension: A Systematic Review and Meta-Analysis of Randomized Trials. Sports medicine (Auckland, N.Z.), 48(9), 2127–2142. https://doi-org.cmich.idm.oclc.org/10.1007/s40279-018-0944-y
  4. Cuthill, J. A., & Shaw, M. (2019). Questionnaire survey assessing the leisure-time physical activity of hospital doctors and awareness of UK physical activity recommendations. BMJ open sport & exercise medicine, 5(1), e000534. https://doi.org/10.1136/bmjsem-2019-000534
  5. Pereira, E. S., Krause Neto, W., Calefi, A. S., Georgetti, M., Guerreiro, L., Zocoler, C., & Gama, E. F. (2018). Significant Acute Response of Brain-Derived Neurotrophic Factor Following a Session of Extreme Conditioning Program Is Correlated With Volume of Specific Exercise Training in Trained Men. Frontiers in physiology, 9, 823. https://doi-org.cmich.idm.oclc.org/10.3389/fphys.2018.00823
  6. Rao, C. R., Darshan, B., Das, N., Rajan, V., Bhogun, M., & Gupta, A. (2012). Practice of Physical Activity among Future Doctors: A Cross Sectional Analysis. International journal of preventive medicine, 3(5), 365–369.
  7. Vankim, N. A., & Nelson, T. F. (2013). Vigorous physical activity, mental health, perceived stress, and socializing among college students. American journal of health promotion : AJHP, 28(1), 7–15. https://doi-org.cmich.idm.oclc.org/10.4278/ajhp.111101-QUAN-395
  8. Wewege, M., van den Berg, R., Ward, R. E., & Keech, A. (2017). The effects of high-intensity interval training vs. moderate-intensity continuous training on body composition in overweight and obese adults: a systematic review and meta-analysis. Obesity reviews : an official journal of the International Association for the Study of Obesity, 18(6), 635–646. https://doi-org.cmich.idm.oclc.org/10.1111/obr.12532
  9. Wolf MR, Rosenstock JB. Inadequate Sleep and Exercise Associated with Burnout and Depression Among Medical Students. Acad Psychiatry. 2017;41(2):174-179. doi:10.1007/s40596-016-0526-y
Cite this article as: Brenda Varriano, Canada, "Exercise is Medicine," in International Emergency Medicine Education Project, September 28, 2020, https://iem-student.org/2020/09/28/exercise-is-medicine/, date accessed: March 24, 2023

The Importance of Wellness in Medicine – My Story and Introduction to a Series of Blog Posts

wellness in medicine
~ Brenda Varriano, Canada ~ Leave a comment

Either be the light in the room or the mirror that reflects it

Unknown Tweet

I always believe that going to work means putting personal issues aside. As physicians, we have a role to make every patient feel welcome, cared for, and heard. However, being in the ER can be stressful. Not only can stress impact our job performance, but it can increase the burnout rate. So begs the questions; how you handle stress, why is it important and what happens when you lose your main source of stress reduction, is there a back-up plan. For my wellness series, I hope to discuss my own experience of losing my main outlet for stress so you know who I am and why I am writing about this topic, the importance of physical fitness, effective quick workouts for a busy ED lifestyle, and a favorite topic of mine, imposter syndrome. As medical students, aspiring ED physicians or an ED physician, I believe we have a role to protect our own health, so that we may best support our patients. 

As medical students, aspiring ED physicians or an ED physician, I believe we have a role to protect our own health, so that we may best support our patients.

Brenda Varriano Tweet
brenda - who I am

My name is Brenda-Maricela and I have just finished my first year of medical school at Central Michigan University as an international student, having done all prior education in Canada. While, academically, I had performed well in medical school, mentally, I was burnt out. It is not that I was not used to difficult schoolwork, I had graduated from the University of Toronto, where I was quite accustomed to immense workloads, working part-time jobs and juggling extra-curriculars. It was the fact that I had no outlet for my stress.

You see, prior to medical school, my outlet would be running. I was a modern-day Forest Gump. I craved the long runs that would allow me to shake off any stress I was holding onto. The longer the run the better. I was addicted. During my MSc, I was training with the University of Toronto Triathlon club, running road races and trying to win my age group and felt I could face any challenge that crossed my path. However, I would never have anticipated that I would not be able to run for 2 years. 

In the summer of 2018, I recall the moment where I was getting off of a chair at a conference. I felt a twinge in my right knee but thought nothing of it. I had a minor limp, but nothing too severe. A week later the pain grew, and before I knew it, I was in the ER. “I believe you have Patellar Femoral Pain Syndrome,” the doctor told me while reviewing my X-Rays. Patellar Femoral Pain Syndrome (PFPS) is a clinical term to define anterior knee pain, which often shows no structural damage in imaging.

brenda ER

It is most common in female athletes, and given the multifactorial nature, there is no single treatment. However, it often resolves with physical therapy and reducing activity. Reading about PFPS is one thing, experiencing it is a nightmare.

What would I do without running? The most common advice that I had received was to switch to biking and swimming, something which was a lower impact. These strategies worked, but as time had waned on, my knees became worse and soon, even the pool became a source of pain. I was in a rut. I would do anything to get the endorphins, but nothing would suffice. I would do anything to run again, let alone kneel in a yoga class. I saw multiple doctors, physical therapists, chiropractors and each time, I got the same diagnosis and was told it would resolve on its own.

Spring 2019, I got the phone call informing me of my acceptance to medical school. It was something I had dreamed of since I was a little girl. On one hand, I was ecstatic, but on the other hand, I was drained, depressed and couldn’t look at a jogger on the roads without feeling a sinking feeling in my stomach. How on earth was I going to get through medical school? During my undergraduate degree, I had exercising to sharpen my mind and combat stress. I knew medical school would be intense. How would I deal with the stress? What if my knee got worse? I would be in a new country, without friends and family. Would I draw too much attention if I limped, sat all the time, didn’t participate with social outings? I almost wanted to defer a year. However, my father and biggest mentor reminded me that I had managed to get through the application process without my exercises, perhaps studying would be a good distraction.

My father was right about studying being a distractor. At times, I would be so focused on learning the content, that I forgot about the pain. Other times, my brain would be so fried that I needed a distraction. But what could I do? Sitting for so long, my body craved movement, but my knees would be hesitant. During this time, I did educate myself on other exercise styles such as High-Intensity Interval Training (HIIT), or As Many Reps as Possible Workouts (AMRAP), both with weights, and both focusing on the upper body and core. I will discuss the concept of AMRAP and HIIT in my second article, where I talk about quick and effective workouts. I believe that a sound body and mind are critical to perform well and avoid burn out in, school, the ED and beyond. However, the busy lifestyle as a medical student or a physician may make the time a limiting factor. Therefore, short effective workouts may be of use, and I hope to share my research and experiences.

So, while AMRAP and HIIT didn’t replace running, it would provide some mental soundness on days when I felt particularly on edge. Over time my knees improved, and I owe thanks to some wonderful healthcare providers in Michigan. Unfortunately, while volunteering with Special Olympics in November 2019, I got a hockey-related injury to my knees, setting my progress back a few weeks. I was devastated. Mentally, I was fried, emotionally I was drained. However, the schoolwork was still there, and I had to study. So, what did I learn from November 2019 to present? I learned how important mental health and physical wellness is. This has been a topic among peers who lost their gyms due to COVID-19, thus experiencing a loss of an outlet for stress. Personally, I saw the difference that stress made in my productivity, wellbeing and ability to retain information. So, I started exploring different outlets, many of which will be discussed in upcoming articles.

Exercise is still my favorite outlet, and I think it should be a part of a daily regimen. So, for my next two articles, I will discuss different styles of exercises and free resources I discovered on the web, such as timers, YouTube Channels and websites. Following my articles on exercise and fitness, I would like to dive into the science of yoga. I remember being told about traditional meditation, however, I found that my mind was too busy, and ironically, meditation caused me stress. Many of my ED-oriented friends similarly need to keep mentally busy, and one had recommended yoga as an active meditation. This being said, traditional mediation is effective, and my ED mentor loves it. Therefore, meditation will be discussed, most likely through research and interviews with those who have benefited from it. Finally, I intend to write about imposter syndrome. A lack of self-love can be a mental stressor. If we can learn to love and appreciate all that we have accomplished, I believe that the stress will go down. To show some self-love sounds simple but is often something that so many medical students struggle with. I know I question my own acceptance into medical school, being my own worst critic.

To conclude this article, I want to say I am passionate about medicine, and in seeing my colleagues succeed. Given my enthusiasm for exercise, and having done some personal training in the past, I am eager to share all I know. Maybe I’ll be running when I write my next article. If not, I know there are alternatives, and I hope what I share can be of use to my colleagues around the world. As I tell my friends, even if life clips your wings, just know you have all it takes to fly.

References and Further Reading

LaDonna KA, Ginsburg S, Watling C. “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Acad Med. 2018;93(5):763-768. doi:10.1097/ACM.0000000000002046

Moukarzel A, Michelet P, Durand AC, et al. Burnout Syndrome among Emergency Department Staff: Prevalence and Associated Factors. Biomed Res Int. 2019;2019:6462472. Published 2019 Jan 21. doi:10.1155/2019/6462472

Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264-2274. doi:10.1007/s00167-013-2759-6

 

Cite this article as: Brenda Varriano, Canada, "The Importance of Wellness in Medicine – My Story and Introduction to a Series of Blog Posts," in International Emergency Medicine Education Project, August 17, 2020, https://iem-student.org/2020/08/17/the-importance-of-wellness-in-medicine/, date accessed: March 24, 2023

Who Takes Care of You While You Take Care of Others?

Who Takes Care of You While You Take Care of Others
~ Arthur Martins, Brasil ~ Leave a comment

The COVID-19 Pandemic has changed our lives in so many ways that sometimes it is difficult to remember how life was without all these changes. We got used to the “new normal”, which includes a constant concern about contamination, economic crisis, and isolation. When we consider emergency physicians and other healthcare professionals, technical and scientific challenges regarding the pandemic response are also added to the equation.

Recently we completed three months since the first case of COVID-19 in Brazil and, since then, more than 300.000 have been infected and at least 23.000 people have died. These astonishing numbers could be 8 to 10 times higher if it wasn’t for under-notification¹ in countryside areas. The psychological effect of these numbers can be seen every day while people try to cope with the situation, and it may be even more intense in those who are in the frontline of the healthcare system. With this in mind, the question emerges: Who takes care of you while you take care of others?

What are the major psychological symptoms we can expect in healthcare providers three months into the COVID-19 pandemic?

After 3 months of COVID-19, we are not dealing with acute and immediate psychological response anymore; this next phase can be called assimilation, where we already understand better the new workflows, protocols and forms of living. However, we are still in a context of insecurity, fear, and loss of control over things we used to know how to deal with. The major psychological symptoms that are expected and considered to be normal in this context are:2

  • Fear (of getting sick and dying, losing people, being socially stigmatized, being separated from people you care about and transmitting the virus to other people);
  • Stress reactions such as anger, anxiety, confusional states, apathy
  • The recurrent feeling of impotence, irritability, anguish, and sadness;
  • Behavioral changes: changes in appetite and sleep habits, and interpersonal conflicts

Which strategies we can use to minimize these effects?

It’s very important to understand these reactions as being normal reactions in the context we currently live in. However, that doesn’t mean there is nothing we can do to ease them. It’s very important to intervene as early as possible as a way to prevent the chronification of those symptoms and progression to psychological disorders. Here are some strategies that can help2:

  • Recognize these feelings and accept them as real and valid; try to talk about them with people you trust
  • Think back to the strategies and tools you used in moments of crisis in the past. When it comes to dealing with difficulties, everybody has some preferred methods, which were tried and worked. Resume those actions that have worked for you and try to find ways of applying them to this new context
  • Keep your social network active by establishing -even if virtual- contact with family, friends, and colleagues,
  • Avoid watching, reading or listening to news that makes you feel anxious or distressed; look for information only from reliable sources
  • Avoid using alcohol and drugs as coping mechanisms
  • Ask for help if you find your strategies inefficient

There are lots of health professionals who are self-isolating from their families to prevent “bringing the enemy home”. How can self-isolation affect our mental health?

Isolating from family and friends means physically isolating from your support network. It’s relevant, in this context, to understand that physical isolation doesn’t mean affective and emotional isolation. As said before, it’s important to find new ways to be present in people’s lives and keep the social network active. Maintaining these contacts is also a way to ensure that when you leave the hospital and arrive at your rest place, you can actually disconnect from the routine and difficult times by talking to family members and listening about their day, their stories, and so on. In this moment of isolation and fear, we also witness the stigmatization of healthcare professionals3. People can direct their feelings of fear and uncertainty at health professionals, potentially causing behaviors of avoidance, rejection, aggressiveness and violence. If you find yourself in this situation, it’s key to understand that these reactions are not directed towards you personally, but to the global state of insecurity and fear, we are currently living.

Have you seen any changes in the problem-solving and decision-making capabilities of the physicians in the ED due to the stressed environment?

Interpersonal conflict, due to constant changes in protocols and workflows is expected in times of crisis and might be affecting problem-solving and decision-making processes. Here are some strategies to prevent it:

  • Try to maintain a supportive work environment, including designated spaces to eat and rest
  • Have moments to let the team talk about their mental state to help to develop a sense of community
  • Alternate workers between activities of high and low attention and tension, if possible,
  • Recognize effort made and encourage mutual respect among professionals
  • Map and disseminate mental health care actions. Even if most workers will not need individual assistance, knowing that there are services that they can rely on when needed makes them feel supported

Finally, do you have any special tips for emergency physicians who are in the frontline against COVID-19 at this moment?

It’s important to know and to understand when the frequency and intensity of the normal symptoms indicate that you should see a specialized mental health professional.2

  • Persistent symptoms
  • Intense suffering
  • Risk of complications, especially suicidal ideation and substance abuse
  • Significant impairment of social and daily functioning
  • Significant difficulties in family, social or work life
  • Major depression, psychosis, and PTSD are conditions that require specialized attention

We know that healthcare workers bear considerable suffering and symptoms, but usually, this group of people refuses to seek or receive help. Among others, the main reason is that having difficulties to deal with all the emotional demands is -wrongly- seen as a sign of weakness or incompetence. At this moment, it’s more important than ever to understand that we can only take care of others if we, first, take care of ourselves. And taking care of our mental health is as important as our physical health to be at the front lines of COVID-19 response.

Gabriele H. Gomes

Psychologist, current Critical Care & Emergency Psychology Resident at Hospital de Clínicas de Porto Alegre (HCPA)

References and Further Reading (Portuguese only)

  1. https://ciis.fmrp.usp.br/covid19-subnotificacao/
  2. https://www.fiocruzbrasilia.fiocruz.br/wp-content/uploads/2020/04/Sa%c3%bade-Mental-e-Aten%c3%a7%c3%a3o-Psicossocial-na-Pandemia-Covid-19-recomenda%c3%a7%c3%b5es-gerais.pdf
  3. https://www.sbponline.org.br/arquivos/To%CC%81pico_4_Trabalhando_com_profissionais_de_sa%C3%BAde_que_enfrentam_rea%C3%A7%C3%B5es_negativas_das_pessoas_ao_redor_durante_a_COVID-19_No_T%C3%B3pico_4_abordamos_como_entender_e_minimizar_a_estigmatizacao_dos_profissionais_de_sa%C3%BAde1.pdf
  4. https://www.fiocruzbrasilia.fiocruz.br/wp-content/uploads/2020/04/Sa%c3%bade-Mental-e-Aten%c3%a7%c3%a3o-Psicossocial-na-Pandemia-Covid-19-recomenda%c3%a7%c3%b5es-para-gestores.pdf
Cite this article as: Arthur Martins, Brasil, "Who Takes Care of You While You Take Care of Others?," in International Emergency Medicine Education Project, August 5, 2020, https://iem-student.org/2020/08/05/who-takes-care-of-you-while-you-take-care-of-others/, date accessed: March 24, 2023

Why Me? The Story of My Burnout – Part 3

Why Me? The Story of My Burnout - Part 3
~ Jule Santos, Brasil ~ 1 Comment

The story continues from link (Part 2).

I must take a deep breath. I must ask for help.

The Self-Knowledge Path

I could go away and work in another hospital. We have many good hospitals in Brazil. Some even employ emergency physicians who are local graduates. I really could. In truth, there would be no shame if I left the hospital. But I decided to give it one more try.

I just want to make clear that there is no single route back from burnout. It is a multifactorial treatment. You need emotional power. Some you may already have, or you can develop with a mental health specialist’s help. Some you will gather alone, or family and friends will help you to recover if you are lucky enough. Read, talk, discuss, and share with your community. You will never be alone because it is the system that is inflicting moral injury and burning you, and everybody, out.

Each person needs different means and tools to recover. We have to acknowledge that not everybody can afford all of them. Not everybody can pay for a therapist or even leave their work. I was one of the lucky ones. I could.

I promised myself and others that I would get better, and I wouldn’t give up. I felt obliged to improve the system that had harmed me. The system that made me afraid; afraid that I would fail.

It was not easy! It wasn’t “just not thinking about it.” It wasn’t “just a phase.” It wasn’t “just yoga.” It wasn’t “just wanting.” It was more than all the above. It took a long journey of self-knowledge: Who was I? What did I want? How could I achieve that?

Gradually, intertwined with relapses,​ the healing process began. I returned to therapy. Thanks to all support from my amazing friends, -virtual friends, present friends, distant friends- mentors, mentees, students, residents, followers, I was overwhelmed with affection and understanding. There were messages of encouragement everywhere I looked and listened. I did not plan this. It happened organically from across our community, and sometimes unintentionally, as I reached out to others, who always found time to help me.

Kindness can save a life! If you feel so, just go around saying how important people are in your life. I assure you that the kindness and positive comments of these people saved me.

I improved gradually in small steps. With empathy and determination, I took one step after another. Each step led me to find new perspectives. With each small victory​, I felt a small but important​ celebration in my heart​. ​

Yet, I wanted to make sense of it all. How to endure the moral injury? How to continue working here? I desperately needed to make sense of my job.

Why Me?

jule santos

In addition to therapy, I went on leave. I flew away and spent time in Mozambique, an LMIC, with many more difficulties, compared to Brazil. They were just beginning to develop the first emergency medicine residency program, and they had a lot more work to do. They were seemingly starting from scratch, and they had fewer resources than we had in Brazil. I found their enthusiasm and resourcefulness more inspiring than I thought possible.

It wasn’t because I could see how lucky we are in Brazil, but they did their best even though they were aware of their problems. I knew that there was no way that I could give up after seeing them.

I returned to Brazil, where people were eager to work with me. I felt they had missed me. They showed me that I made a difference.

I was fortunate to see my work environment improved. The administration had started to ‘get it,’ and now they cared about what we do. They realized that efficient systems saved money, so they were helping us achieve better care for our patients. Our department was renovated. They hired more people, and we got better medications. It all helped. It felt as though they were listening.

So recovering from burnout not only helped me to accept that problems are a part of the system but also made me realize people make the system. Therefore we can change it to accommodate our needs. Not the contrary. We need to END moral injury by addressing it and demanding solutions! We don’t need to be resilient to it!

In the beginning, I understood that I needed to be ​present​ in all my tasks, but that’s a challenge in the hectic world of emergency medicine. In truth, we are not as good at multitasking as we let ourselves think. However, we get better at prioritizing and scheduling tasks as we develop as clinicians. More importantly, we learn to give each task the proper time and attention it deserves.

As time passed, my most challenging feelings diminished. I redefined my responsibilities and my choices, redefined my motivation, my ambition, my purpose. I adjusted my expectations. I found a new power.

Then, ​gradually​, the love for Emergency Medicine and the energy to become the doctor I aspire came back. However, I still had to face my demons and deal with the most painful side of emergency medicine: Delivering bad news.

“Most of the time, the fact that you care is enough”​ is one of the most effective pieces of advice that I ever received. It helped me relieve the intense pain that I didn’t even know it was there. I still remind others and myself of it regularly.

For example, I dealt with the tragic case of pediatric cardiac arrest, brought in by another medical team. We did CPR over an hour, as this was a very delicate situation with a child. At the debriefing, I was careful with both teams from the other hospital and our own. Although I was worried about having the conversation I did, I was shocked and stunned to hear the reply. The doctor shrugged and said:

– Yeah, right. Can I go now?

He was in a rush. He didn’t even want to hear the debriefing. He didn’t appear to care! The disdain broke my spirit, and the whole team felt the same anger. It made everything harder to cope.

I took a deep breath, thanked the team for all the effort, asked them to prepare the body, and went to the waiting room to talk once again with the father. I had been there a lot of times, talking through everything as we were trying to resuscitate, so he already knew me, and immediately recognized my expression of bad news. I sat next to him and told him everything we did. I was trying to remedy the anguish while allowing time for understanding.

– There was nothing more we could do. I’m so sorry, but he died.

The father stared at the floor for a while.

– My wife is eight months pregnant. What should I do now?

He was in despair. Next came tears. I waited. Present. Then, he looked at me with honest:

– Thank you, doctor, for everything you did.

I will never forget them.

“Most of the time, the fact that you care is enough.”

I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.

Now, when I have to deliver bad news, I try my best to be there and look in the eyes. I patiently wait to make sure until there is no doubt. I don’t try to hide my feelings, ​and I finally feel I’m always telling the truth:

– We are doing everything we can.

I ensure that they know​ we care.​ I make a difference there. My pain eases as theirs alleviates even a little.

“Most of the time, the fact that you care is enough.”

I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.

Finding My Ikigai

ikigai

Ikigai is a Japanese concept that means “a reason for being.” In English, the word roughly means “thing that you live for” or “the reason for which you wake up in the morning.” Each individual’s ikigai is personal and specific to their lives, ​values​ , and ​beliefs​. It reflects the ​inner self​ and faithfully expresses that, while simultaneously creating a mental state​ in which the individual feels at ease.

The thing I like most about ikigai is that it is for everyone. You have to understand yourself to achieve this deeply. Seeking self-knowledge can be the most challenging part.

– Am I doing something that I love?
– Am I doing something that the world needs?
– Am I doing something that I am good at?
– Am I doing something that I can be paid for?

YES!

So, where am I now?

Well, I still love heart attacks! I love the look of amazement of the interns when we save a life. I love the self-satisfaction of the residents when they can do something correctly for the first time. I love how happy the team gets when we can do perfect resuscitation. I love the peculiarities of each patient, their life, culture, and beliefs. I love to learn something new every day. ​And that’s why Emergency Medicine!

I love heart attacks! But when we can't save, when the system fails, when the patient dies but I feel that I softened the pain, even a little bit, by showing that we care, I know I can endure.

And that's why, me.

Why Me? The Story of My Burnout - Part 1
Why Me? The Story of My Burnout - Part 2
Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 3," in International Emergency Medicine Education Project, January 6, 2020, https://iem-student.org/2020/01/06/emergency-medicine-why-me-the-story-of-my-burnout-part-3/, date accessed: March 24, 2023