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Stehman CR, Testo Z, Gershaw RS, Kellogg AR. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. West J Emerg Med 2019; 20:485-494. [PMID: 31123550 PMCID: PMC6526882 DOI: 10.5811/westjem.2019.4.40970] [Citation(s) in RCA: 171] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 04/03/2019] [Accepted: 04/08/2019] [Indexed: 11/30/2022] Open
Abstract
Each year more than 400 physicians take their lives, likely related to increasing depression and burnout. Burnout—a psychological syndrome featuring emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment—is a disturbingly and increasingly prevalent phenomenon in healthcare, and emergency medicine (EM) in particular. As self-care based solutions have proven unsuccessful, more system-based causes, beyond the control of the individual physicians, have been identified. Such system-based causes include limitations of the electronic health record, long work hours and substantial educational debt, all in a culture of “no mistakes allowed.” Blame and isolation in the face of medical errors and poor outcomes may lead to physician emotional injury, the so-called “second victim” syndrome, which is both a contributor to and consequence of burnout. In addition, emergency physicians (EP) are also particularly affected by the intensity of clinical practice, the higher risk of litigation, and the chronic fatigue of circadian rhythm disruption. Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs. Burned-out physicians are unlikely to seek professional treatment and may attempt to deal with substance abuse, depression and suicidal thoughts alone. This paper reviews the scope of burnout, contributors, and consequences both for medicine in general and for EM in particular.
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Affiliation(s)
- Christine R Stehman
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
| | - Zachary Testo
- University of Massachusetts Medical School-Baystate Health, Department of Emergency Medicine, Springfield, Massachusetts
| | - Rachel S Gershaw
- University of Massachusetts Medical School-Baystate Health, Department of Emergency Medicine, Springfield, Massachusetts
| | - Adam R Kellogg
- University of Massachusetts Medical School-Baystate Health, Department of Emergency Medicine, Springfield, Massachusetts
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Ker K, Edwards PJ, Felix LM, Blackhall K, Roberts I. Caffeine for the prevention of injuries and errors in shift workers. Cochrane Database Syst Rev 2010; 2010:CD008508. [PMID: 20464765 PMCID: PMC4160007 DOI: 10.1002/14651858.cd008508] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Sleepiness leads to a deterioration in performance and attention, and is associated with an increased risk of injury. Jet lag and shift work disorder are circadian rhythm sleep disorders which result in sleepiness and can elevate injury risk. They create a need for individuals to operate at times which are different to those dictated by their circadian rhythms. Consequently there is also a need for interventions to help ensure that these persons can do so safely. Caffeine has a potential role in promoting alertness during times of desired wakefulness in persons with jet lag or shift work disorder, however its effects on injury and error are unclear. OBJECTIVES To assess the effects of caffeine for preventing injuries caused by impaired alertness in persons with jet lag or shift work disorder. SEARCH STRATEGY We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, CINAHL, TRANSPORT (to July 2008); and PubMed databases (to April 2010). We also searched the Internet and checked reference lists of relevant papers. SELECTION CRITERIA Randomised controlled trials investigating the effects of caffeine on injury, error or cognitive performance in people with jet lag or shift work disorder. DATA COLLECTION AND ANALYSIS Two authors independently screened search results and assessed full texts for inclusion. Data were extracted and risk of bias was assessed. Estimates of treatment effect (odds ratio and standardised mean difference (SMD)) and 95% confidence intervals (CI) were calculated and pooled using the fixed-effect model. MAIN RESULTS Thirteen trials were included. None measured an injury outcome. Two trials measured error, and the remaining trials used neuropsychological tests to assess cognitive performance. The trials assessing the impact on errors found that caffeine significantly reduced the number of errors compared to placebo. The pooled effect estimates on performance by cognitive domain suggest that, when compared to placebo, caffeine improved concept formation and reasoning (SMD -0.41; 95% CI -1.04 to 0.23), memory (SMD -1.08; 95% CI -2.07 to -0.09), orientation and attention (SMD -0.55; 95% CI -0.83 to -0.27) and perception (SMD -0.77; 95% CI -1.73 to 0.20); although there was no beneficial effect on verbal functioning and language skills (SMD 0.18; 95% CI -0.50 to 0.87). One trial comparing the effects of caffeine with a nap found that there were significantly less errors made in the caffeine group. Other trials comparing caffeine with other active interventions (for example nap, bright light, modafinil) found no significant differences. There is a high risk of bias for the adequacy of allocation concealment and presence of selective outcome reporting amongst the trials. AUTHORS' CONCLUSIONS Caffeine may be an effective intervention for improving performance in shift workers however, there are no trials from which we can assess its effect on injuries. The results largely originate from studies involving young participants under simulated conditions, and the extent to which the findings are generalisable to older workers and real world shift work is unclear. Based on the current evidence, there is no reason for healthy individuals who already use caffeine within recommended levels to improve their alertness to stop doing so. The assessment of the relative effects of caffeine to other potential countermeasures should be a focus of future research.
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Affiliation(s)
- Katharine Ker
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupRoom 280, North CourtyardKeppel StreetLondonUKWC1E 7HT
| | - Philip James Edwards
- London School of Hygiene & Tropical MedicineDepartment of Epidemiology and Population HealthKeppel StreetLondonUKWC1E 7HT
| | - Lambert M Felix
- London School of Hygiene & Tropical MedicineDepartment of Epidemiology and Population HealthKeppel StreetLondonUKWC1E 7HT
| | - Karen Blackhall
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupRoom 280, North CourtyardKeppel StreetLondonUKWC1E 7HT
| | - Ian Roberts
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupRoom 280, North CourtyardKeppel StreetLondonUKWC1E 7HT
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McBeth BD, McNamara RM, Ankel FK, Mason EJ, Ling LJ, Flottemesch TJ, Asplin BR. Modafinil and zolpidem use by emergency medicine residents. Acad Emerg Med 2009; 16:1311-1317. [PMID: 20053252 DOI: 10.1111/j.1553-2712.2009.00586.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The objective was to assess the prevalence and patterns of modafinil and zolpidem use among emergency medicine (EM) residents and describe side effects resulting from use. METHODS A voluntary, anonymous survey was distributed in February 2006 to EM residents nationally in the context of the national American Board of Emergency Medicine in-training examination. Data regarding frequency and timing of modafinil and zolpidem use were collected, as well as demographic information, reasons for use, side effects, and perceived dependence. RESULTS A total of 133 of 134 residency programs distributed the surveys (99%). The response rate was 56% of the total number of EM residents who took the in-training examination (2,397/4,281). Past modafinil use was reported by 2.4% (57/2,372) of EM residents, with 66.7% (38/57) of those using modafinil having initiated their use during residency. Past zolpidem use was reported by 21.8% (516/2,367) of EM residents, with 15.3% (362/2,367) reporting use in the past year and 9.3% (221/2,367) in the past month. A total of 324 of 516 (62.8%) of zolpidem users initiated use during residency. Side effects were commonly reported by modafinil users (31.0%)-most frequent were palpitations, insomnia, agitation, and restlessness. Zolpidem users reported side effects (22.6%) including drowsiness, dizziness, headache, hallucinations, depression/mood lability, and amnesia. CONCLUSIONS Zolpidem use is common among EM residents, with most users initiating use during residency. Modafinil use is relatively uncommon, although most residents using have also initiated use during residency. Side effects are commonly reported for both of these agents, and long-term safety remains unclear.
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Affiliation(s)
- Brian D McBeth
- From the Department of Emergency Medicine, Regions Hospital (BDM, FKA, EJM, TJF, BRA), St. Paul, MN; the Department of Emergency Medicine, Temple University Medical Center (RMN), Philadelphia, PA; the Department of Emergency Medicine, Hennepin County Medical Center (LJL), Minneapolis, MN. Dr. McBeth is currently with the San Francisco General Hospital, San Francisco, CA. Dr. Mason is currently with the Sacred Heart Hospital, Eau Claire, WI. Dr. Asplin is currently with the Mayo Clinic, Rochester, MN
| | - Robert M McNamara
- From the Department of Emergency Medicine, Regions Hospital (BDM, FKA, EJM, TJF, BRA), St. Paul, MN; the Department of Emergency Medicine, Temple University Medical Center (RMN), Philadelphia, PA; the Department of Emergency Medicine, Hennepin County Medical Center (LJL), Minneapolis, MN. Dr. McBeth is currently with the San Francisco General Hospital, San Francisco, CA. Dr. Mason is currently with the Sacred Heart Hospital, Eau Claire, WI. Dr. Asplin is currently with the Mayo Clinic, Rochester, MN
| | - Felix K Ankel
- From the Department of Emergency Medicine, Regions Hospital (BDM, FKA, EJM, TJF, BRA), St. Paul, MN; the Department of Emergency Medicine, Temple University Medical Center (RMN), Philadelphia, PA; the Department of Emergency Medicine, Hennepin County Medical Center (LJL), Minneapolis, MN. Dr. McBeth is currently with the San Francisco General Hospital, San Francisco, CA. Dr. Mason is currently with the Sacred Heart Hospital, Eau Claire, WI. Dr. Asplin is currently with the Mayo Clinic, Rochester, MN
| | - Emily J Mason
- From the Department of Emergency Medicine, Regions Hospital (BDM, FKA, EJM, TJF, BRA), St. Paul, MN; the Department of Emergency Medicine, Temple University Medical Center (RMN), Philadelphia, PA; the Department of Emergency Medicine, Hennepin County Medical Center (LJL), Minneapolis, MN. Dr. McBeth is currently with the San Francisco General Hospital, San Francisco, CA. Dr. Mason is currently with the Sacred Heart Hospital, Eau Claire, WI. Dr. Asplin is currently with the Mayo Clinic, Rochester, MN
| | - Louis J Ling
- From the Department of Emergency Medicine, Regions Hospital (BDM, FKA, EJM, TJF, BRA), St. Paul, MN; the Department of Emergency Medicine, Temple University Medical Center (RMN), Philadelphia, PA; the Department of Emergency Medicine, Hennepin County Medical Center (LJL), Minneapolis, MN. Dr. McBeth is currently with the San Francisco General Hospital, San Francisco, CA. Dr. Mason is currently with the Sacred Heart Hospital, Eau Claire, WI. Dr. Asplin is currently with the Mayo Clinic, Rochester, MN
| | - Thomas J Flottemesch
- From the Department of Emergency Medicine, Regions Hospital (BDM, FKA, EJM, TJF, BRA), St. Paul, MN; the Department of Emergency Medicine, Temple University Medical Center (RMN), Philadelphia, PA; the Department of Emergency Medicine, Hennepin County Medical Center (LJL), Minneapolis, MN. Dr. McBeth is currently with the San Francisco General Hospital, San Francisco, CA. Dr. Mason is currently with the Sacred Heart Hospital, Eau Claire, WI. Dr. Asplin is currently with the Mayo Clinic, Rochester, MN
| | - Brent R Asplin
- From the Department of Emergency Medicine, Regions Hospital (BDM, FKA, EJM, TJF, BRA), St. Paul, MN; the Department of Emergency Medicine, Temple University Medical Center (RMN), Philadelphia, PA; the Department of Emergency Medicine, Hennepin County Medical Center (LJL), Minneapolis, MN. Dr. McBeth is currently with the San Francisco General Hospital, San Francisco, CA. Dr. Mason is currently with the Sacred Heart Hospital, Eau Claire, WI. Dr. Asplin is currently with the Mayo Clinic, Rochester, MN
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Hanlon JG, Hayter MA, Bould MD, Joo HS, Naik VN. Perceived sleepiness in Canadian anesthesia residents: a national survey. Can J Anaesth 2008; 56:27-34. [PMID: 19247775 DOI: 10.1007/s12630-008-9003-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 10/27/2008] [Accepted: 10/30/2008] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To compare the self-perceived sleepiness of Canadian anesthesia residents providing modified on-call duties (12-16 h) vs. traditional on-call duties (24 h). METHODS A 25-item online survey was distributed to all Canadian anesthesia residents who, at that time, were on anesthesia rotations. The survey assessed resident demographics, perceived work patterns, and sleepiness, as well as their opinions on resident work hour reform. Self-perceived sleepiness was quantified using the validated Epworth sleepiness scale (ESS). RESULTS Three hundred eight of 400 (77%) eligible Canadian anesthesia residents completed the survey. Forty-three percent of residents who worked traditional on-call (duration 24.1 +/- 0.5 h) shifts and 48% of residents who worked modified on-call (duration 15.5 +/- 1.8 h) shifts met ESS criteria for excessive daytime sleepiness. Overall mean ESS scores did not differ significantly between the traditional (9.1 +/- 4.9) and the modified call groups (9.5 +/- 4.8). Residents with an on-call frequency of >or=1:4 days or those who slept <or=2 h while on call perceived themselves as significantly more sleepy (P = 0.045 and P = 0.008, respectively). Six percent of residents admitted to taking "something other than caffeine" to stay awake on call. CONCLUSION Many anesthesia residents do exhibit excessive daytime sleepiness, with a similar incidence for those working within either modified or traditional call systems. Our study suggests that sleepiness may be reduced by scheduling on-call duties no more frequently than one in every five nights and by ensuring that residents sleep more than 2 h while on call.
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Affiliation(s)
- John G Hanlon
- Department of Anesthesia, St Michael's Anesthesia Research into Teaching (SMART), St Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada M5B 1W8
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