Wellness, Stress, and the Impaired Physician

Foundations

Stress is a nonspecific response of the body to any demand that can have both positive and negative effects. Performance may suffer when there is little demand or stress; however, with too much stress, anxiety and exhaustion lead to poor performance ( Fig. e10.1 ). Occupation stress, defined as when the resources of the individual are not sufficient to cope with the demands of the situation, is a leading modern health and safety challenge and is common in the emergency department (ED) setting.

The ED is a highly demanding environment because of around-the-clock patient care in settings where life-threatening illness and injury occur with great frequency, and arrival volumes, patient acuity, and nature of emergencies rapidly and unpredictably shift. Patients frequently arrive in severe pain and anxiety, and care is often affected by language barriers, mental health issues, or many other circumstances presenting challenges in care and communication.

Emergency clinicians deal with death and dying on a daily basis and generally have little time to process emotions because of the continuous demand for patient care. This became more pronounced during the COVID-19 pandemic, when the stress and demand on emergency clinicians became tragically visible.

Personal safety is also a major issue while working in the ED environment where exposure to acts of violence, verbal abuse, and risk of exposure to potentially life-threatening diseases are higher than in other practice settings. In addition to the aforementioned stresses is the expectation of error-free practice and diagnostic certainty, with the constant possibility of human error, a missed diagnosis, and the attendant risk of medical negligence, an ever-present stress for emergency clinicians. The continued focus on the patient experience, with the threat of patient complaint and punitive action related to this, adds to this burden.

The 24/7 nature of emergency medicine also creates unique physiologic stress on the emergency clinician due to changing shifts and its impact on circadian rhythms. Shift work has been shown to lead to poor quality of sleep, fatigue, and mood disturbance; challenges to maintaining relationships; and difficulty coping with the demands of daily life.

Faced with decreased hospital and community resources and growing public demand for emergency services, EDs frequently are stretched beyond capacity by patient load and the boarding of admitted patients. This is further complicated by commonplace workforce shortages, nursing understaffing, and the lack of availability of on-call specialists. These issues have been shown to correlate with poorer patient outcomes and have led to a new culture in which productivity is often viewed as more important than providing safe, compassionate care.

The introduction of electronic medical records (EMRs) has added a new stressor to emergency clinicians. Recent studies suggest that EMRs lead to increased administrative burden (more time charting, performing order entry, etc.) and less face-time with patients, resulting in decreased job satisfaction. ^, The EMR also interferes with physician-nurse collaboration and the fulfilling sense of being part of a team and working together, as communication moves from face-to-face personal interaction to an electronic interface. Communication overload, interruptions, multitasking, and performance-based targets add additional stress to providers in the ED.

Given the high degree and multifactorial nature of occupational stress in the ED, it is not surprising that emergency physicians suffer from high degrees of burnout. Burnout is a work-related syndrome characterized by emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment. The study by Shanafelt and company in 2012 found that emergency physicians had one of the highest rates of burnout when compared to other specialties, with over 60% of emergency physicians reporting one or more characteristic of burnout. Subsequent surveys have demonstrated some improvement in the rate of emergency physician burnout, but over 50% of emergency physicians surveyed in 2017 had symptoms of burnout, which remains above the level of many other specialties. ^,

Compassion fatigue also impacts emergency physicians at a higher rate than their colleagues and can be difficult to differentiate from burnout. Compassion fatigue has been described as burnout plus secondary traumatization. Secondary traumatic stress, which some describe as synonymous with compassion fatigue, is defined as the emotional and physical burden created by the additive trauma of helping others in distress that results in a reduced capacity and interest in being empathetic toward future suffering ( Fig. e10.2 ). ^, Risk factors for emergency clinicians developing compassion fatigue include being in situations where they are a “first responder” or when they share some identity with the people for whom they provide care. Along with leading to decreased empathy, compassion fatigue can also lead to sadness, grief, somatic complaints, detachment, anger, and changes in belief systems, which is similar to posttraumatic stress disorder (PTSD). Studies have shown that compassion fatigue impacts both residents and attending physicians in emergency medicine and may influence the desire of emergency physicians to seek early retirement.

Resilience is defined as the process of adapting well and even thriving in the face of adversity, trauma, or significant stress. Natural personality traits such as optimism and altruism help to support resilience; however, practices such as mindfulness and reflection are also important. Personal resilience may have some protective benefit against burnout, but multiple studies suggest that personal resilience alone is not enough to protect emergency clinicians from the multifactorial issues that create burnout. ^{, ,}

Lack of wellness and resilience of emergency clinicians not only negatively impacts the personal and professional lives of the affected clinicians, but also has a significant impact on quality of care and the health care system as a whole. On the personal level, physicians experiencing burnout have higher rates of problematic alcohol use, distressed relationships, and depression. ^, At the far end of the spectrum of physician lack of wellness is physician impairment. The Federation of State Medical Boards defines an impaired physician as “one who is unable to practice medicine with reasonable skill and safety due to mental or physical illness; due to a condition that adversely affects cognitive, motor, or perceptive skills; or due to substance abuse.” ^, Also of great concern, studies of physicians find burnout to be associated with a nearly 200% greater chance of suicide. It is estimated that over 400 physicians die by suicide each year. As many as 6000 emergency physicians contemplate suicide and 400 attempt suicide each year.

As concerning as the personal consequences of lack of wellness for emergency physicians are, burnout also has been shown to negatively impact quality of care and the patient experience. The presence of burnout leads to a decline in patient safety, and departments with higher burnout levels manifest a deterioration in teamwork and communication which has been shown to correlate with increased patient dissatisfaction and complaints by patients and families. ^, Physicians who are suffering from burnout have also been found to be less likely to follow practice guidelines and to self-report medical errors. ^, Physician burnout is also linked to increased absenteeism, reduced individual productivity, and increased likelihood of changing jobs or leaving the medical profession entirely.

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