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Burnout and Post-Traumatic Stress Has Reached Epidemic Proportions

Posted on Thu, Jun 22, 2017
Burnout and Post-Traumatic Stress Has Reached Epidemic Proportions

By Jane Sullivan, Ph.D.

Epidemic is the term currently used to describe the increased incidence of both burnout and post-traumatic stress disorder (PTSD) in emergency physicians. It’s difficult to know if calls to action to address this epidemic have been responded to with any successful intervention. So perhaps the statistics will continue to be astounding:
 

  • 300 to 400 physicians commit suicide a year
  • 52 percent of emergency physicians report being burnt out
  • 60 percent of midcareer doctors have been involved in lawsuits
  • 10 to 15 percent of all doctors have issues with substance abuse during their careers
  • 80 percent of physicians state that they believe that the medical profession is on the decline

PTSD

Post-Traumatic Stress Disorder (PTSD) is a trauma and stress related disorder that may develop after exposure to an event or ordeal in which death, severe physical harm or violence occurred or was threatened, according to Psychology Today. Witnessing the pain and suffering of patients who are impacted by traumatic events such as mass shootings, car accidents, suicides, opiate overdoses and terminal illnesses can erode the barriers that help protect physicians from incapacitating, overwhelming emotions. It is, however, the inability to access emotions and the lack of support to express genuine and understandable grief that may set the foundation for the symptoms of PTSD.

The Symptoms of PTSD

The symptoms of PTSD are usually quite demonstrable — flashbacks, nightmares, startle responses that can last for months and can become debilitating. Treatment options exist for those medical providers suffering from PTSD, and most organizations are sympathetic to and supportive of providing help.

Burnout

Recognizing burnout may be more elusive. The term “burnout” suggests that one was on fire at some point, but now the fire is gone. Christine Maslach, who has done significant work on burnout, defines it as, “an erosion of the soul caused by a deterioration of ones values, dignity, spirit and will.”

The Symptoms of Burnout

The symptoms of burnout are varied and refer to a change in a person’s behavior and personality. They include:
 
  • Loss of a sense of personal satisfaction, accomplishment and meaning
  • Isolation from friends and family
  • Increase in cynicism and sarcasm (patients become stereotyped)
  • Appetite changes – weight gain, weight loss
  • Loss of interest in favorite activities
  • Depersonalization
  • Robotic actions
  • Fatigued before the day begins
  • Increased alcohol and/or drug use
  • Change in demeanor
  • Overreaction to minor incidents
  • Angry outbursts
  • Increased rate of divorce
  • Loss of empathy
  • Disengagement from patients, profession and other providers

The factors contributing to burnout are numerous and somewhat predictable. They include:
 
  • Societal and patient expectations for medical “perfection” (no mistakes)
  • Personal physician expectation of “perfection” (personal cost of mistake)
  • Too much output, not enough input
  • Pressure to see more patients
  • Medical malpractice creates defensive medicine
  • Focus on the negative
  • Repeat narcotic-seeking patients, drunk patients in the ED
  • Emergency physicians becoming “social workers”
  • Loss of autonomy
  • Increased scrutiny, e.g., physicians judged by quality measures, documentation, chart reviews, peer reviews
  • Standardized medicine
  • Repetition of patients who may appear to be willfully self-destructive or neglectful, with expectations that doctors will “fix them” (“Same stuff, different day”)
  • Decreasing public respect for the medical profession
  • Increasing reliance on technology by patients
  • The impact of night shifts on sleep patterns
  • Disillusionment in medicine, whereby idealism becomes disappointment and dissatisfaction
  • “Destination sickness”; You’ve “arrived,” but now what?
  • Decreasing trust between doctor and patient and increased distance
  • Adversarial relationship with administration
  • Years of ongoing litigation, which generates guilt and, worse, profound shame
  • Shame for failing to live up to one’s image
  • Repetitive grief with no space to grieve
  • Constant stress, fear of making a mistake

Given the impact of burnout on physician behavior, higher medical errors, suicide and lower quality of care, it would seem imperative to understand the causes of burnout and generate concrete actions to address the “epidemic.” However, there are barriers and challenges that exist in addressing both PTSD and burnout which impacts mobilizing treatment interventions.

First, medical organizations and administrators whose focus is on the financial bottom line may believe that it’s more cost effective to replace a “hurting” physician than invest in supporting that physician. Individual physicians, who view themselves as heroic and strong, may have difficulty admitting to their own pain and need for help. Peers who witness other doctors with the symptoms of PTSD or burnout are reluctant to talk with their fellow providers about what they are witnessing, perhaps because of a concern about what the reaction may be. In addition, there may be fear of acknowledging a potentially debilitating distress because of the medical licensing board’s question: “Have you ever had a medical condition or been treated for a problem that could hinder or impair your ability to provide patient care?”

Identifying and Treating Burnout and PTSD

Although some organizations do attempt to assess how their physicians are doing by surveying clinicians, such surveys typically have only about a 40 percent response rate. It will, therefore, take vigilance on the part of peers, fellow practitioners and medical directors (who may themselves be burning out) to be observant of physician behavior and attitudes. Engaged physicians maybe the ideal, but identifying and supporting those physicians struggling with PTSD and burnout needs to be a more immediate goal.

Treatment of both burnout and PTSD is the responsibility of all involved. There are many support systems available to help individual physicians in their struggles, such as the American Medical Association and The HappyMD.com.

As Nietzsche said, “Physician, heal thyself: then wilt thou also heal thy patient.”

Peer groups provide safe, non-judgmental environments to address issues of mistakes, guilt, shame, disengagement, anger and all of those emotions that impact physicians’ attitudes and behaviors. Knowing one is not alone can be very helpful. Staff meetings could include some of these topics for general discussion. Hospital administrations can advertise their commitment to not only helping identify those physicians struggling with the cost of their profession, but also their investment in support activities. In fact, several large hospital systems have hired professionals trained in physician health and well-being to provide care, both proactively and reactively.

If burnout and PTSD in healthcare is indeed at epidemic levels, it will take mobilizing all of the resources necessary to respond adequately. The cost is too high to continue to ignore this issue.

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Jane M. Sullivan, Ph.D., is an adjunct professor at Albert Einstein College of Medicine, Bronx, N.Y.; Yeshiva University, New York City; and Fairleigh Dickinson University, Teaneck, N.J., teaching courses on conflict resolution and family dynamics. Much of Dr. Sullivan’s recent professional work has been on leadership development, generational transitions and supporting effective and productive interpersonal communication in organizations. Dr. Sullivan has been a guest speaker on topics such as emotional intelligence, burnout, dynamics within family business, conflict resolution, effective communication and gender differences. She has written several articles on topics related to interpersonal dynamics in business.

References:
Danielle Ofri, M.D. What Doctors Feel: How Emotions Affect the Practice of Medicine, Beacon Press, Boston, 2013.
Tom Murphy, M.D. Physician Burnout: A Guide to Recognition and Recovery, Aloha Publishing, 2015.
Joseph S. Bujak, M.D. Inside the Physician Mind: Finding Common Ground with Doctors, ACHE Management Series, Health Administration Press, 2008.
Burnout: Emergency Medicine Hit Hardest, J. Duncan Moore, Jr., Health Leaders Media
Physician Burnout: Why It’s not a Fair Fight (blog article), Dike Drummond, The Happy MD.com
Physician Burnout: It Just Keeps Getting Worse, Medscape, Carol Peckham

Resources:
Whole Health Medicine Institute
Lissa Rankin, M.D. – Self Healing Kit
 

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James Rhee, M.D., Honored as 2017 Emergency Physician of the Year

Posted on Thu, May 25, 2017
James Rhee, M.D., Honored as 2017 Emergency Physician of the Year

James Rhee M.D., FACMT, FACEP, FAAEM, medical director at Corona Regional Medical Center in Corona, Calif., received Envision Physician Services’ 2017 Emergency Medicine Physician of the Year award.

“I am thrilled to be selected as one of Envision Physician Services’ Physicians of the Year,” Rhee said. “I would like to acknowledge the dedicated team members at Corona Regional Medical Center whom I am proud to work alongside every day. We constantly strive for excellence and, in our short time together, have built a strong foundation for which we provide quality, patient-centered care.”

“Dr. Rhee took over as the director of the emergency room at a time when there was a need for strong physician leadership and a change in culture,” said Mark Uffer, chief executive officer at Corona Regional Medical Center. “He has helped recruit a stable core of providers that demonstrates daily the commitment to quality care and service. We find him to be a calm and calculating director who is committed to the vision of our administration and the values required to be the hospital of first choice in the market."

In his two years at the facility, Rhee has applied his clinical expertise and strong leadership skills to improve operational efficiency and enhance the patient experience. Within 11 months, he helped reduce the amount of time between patients’ arrival and consultation with a physician from 70 minutes to 27 minutes. Since implementing Lean principles to improve patient flow and experience, he has been asked to consult Corona Regional Medical Center’s partnering hospitals in Las Vegas.

“Dr. Rhee’s dedication to his team members and the patients he serves is unparalleled,” said Thom Mayer, M.D., regional chief executive officer for Envision Physician Services. “Through his strong leadership abilities, evidence-based practices and commitment to excellence, he has been able to implement substantial and far-reaching improvements in the clinical operations and employee culture at Corona Regional Medical Center. In a word, Dr. Rhee is an exemplary physician.”

Rhee was presented with the award during the Envision Physician Services 2017 Annual Leadership Conference held in Las Vegas April 18-20. In addition to honoring the year’s top emergency medicine physician, the organization recognizes leading physicians in hospital medicine, radiology and acute surgery.

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Specialty Training Program for APPs Wins Award for Innovation

Posted on Thu, May 18, 2017
Specialty Training Program for APPs Wins Award for Innovation

A new program is empowering emergency department advanced practice providers (APPs) to practice at the top of their license, which is helping enhance the delivery of care and improve productivity, job satisfaction and clinician turnover rates at collaborating Envision Physician Services facilities.

Lynden Pelbath, PA-C, MBA, regional director of APP services at Envision Physician Services, and Adam Brown, M.D., MBA, regional medical director at Envision Physician Services, developed the APP Skills, Training, Experience and Professional Credential (STEP) program. They are the recipients of Envision Physician Services’ prestigious 2017 Genesis Cup award.

“I am honored to receive the recognition and proud to have the opportunity to promote the successful development of APP programs,” Pelbath said. “Nurse practitioners, physician assistants and other advanced practice providers are essential to the healthcare system. When we perform the initial evaluation and advanced treatment on high-acuity patients presenting to the emergency department, we lessen the burden on physicians, improve operational efficiency and enhance the patient-caregiver experience.”

The Genesis Cup is an award for healthcare innovation presented each year by Envision Physician Services. Pelbath and Brown presented their award-winning APP STEP program, which prepares APPs to become expert emergency medicine caregivers, at the Envision Physician Services 2017 Annual Leadership Conference held in Las Vegas April 18-20.

In the emergency department, there are wide variances in APPs’ experience and capabilities. APP STEP is minimizing that gap. Providers first undergo a skills assessment for placement in one of the program’s three stages. Then, with the appropriate education and training, they advance through the program. In addition to leveraging on-site experience, the program requires advanced certification and continuing medical education training.

Together, Pelbath and Brown launched the pilot program at the beginning of 2015 at Sentara Northern Virginia Medical Center in Woodbridge, Va. Initially, nine APPs who primarily triaged and tended to patients with mild ailments and minor injuries participated in the program. Currently 21 APPS are providing the same level of care and are working in the intermediate care, acute care and observation units. Pelbath and Brown have since implemented the program in five additional Envision Physician Services sites throughout the north division with more than 50 APPs participating.

“We are committed to supporting our providers and equipping them with the tools they need to provide quality care,” Brown said. “APP STEP is easy to implement in all sites and hospital departments, and we find that our partnering facilities experience improved productivity and patient outcomes. I am extremely proud of what we have been able to accomplish and look forward to broadening the reach of the program.”

The Genesis Cup program recognizes and celebrates the creativity and innovation of everyday physicians as part of the company’s ongoing pursuit to improve the delivery of patient care. In addition to recognizing the inventor/innovator, the Genesis Cup acknowledges those involved in the initiative and the regional office supporting such endeavors.

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Emergency Physician’s Photography Featured at New Smithsonian Exhibition

Posted on Wed, Apr 12, 2017
Emergency Physician’s Photography Featured at New Smithsonian Exhibition

Envision physician Jeff Gusky, MD, FACEP, lives two lives: one as an emergency physician and the other as a National Geographic photographer, explorer and now television host. His photographs and discoveries have been featured in media and museums around the world – and even on Broadway.

Dr. Gusky, who is an emergency physician at Emergis ER locations in Dallas and Fort Worth, was fortunate to find and photograph a hidden world of World War I, modern underground cities beneath the former trenches in France that once housed tens of thousands of troops at any given time. They were equipped with electricity, railways, telecommunications and the infrastructure of a modern city. One site is more than 25 miles underground in one place, another housed 24,000 troops underground and had a 700-bed hospital. Almost all of these findings are beneath private farmland and unknown to the outside world, even today. Now in complete darkness are thousands of messages that soldiers left behind: notes to loved ones, museum-quality art and inscriptions, names and addresses – a hidden world frozen in time.

The 100-year anniversary of the United States entering World War I was last week. On April 6, an 18-month exhibition of Dr. Gusky’s work opened at The Smithsonian National Air and Space Museum in Washington, D.C. More than 13 million people are expected to visit the exhibition. This short video, which is part of the exhibition, underscores the connection between emergency medicine, art and exploration.

“My mission as an explorer and artist is identical to my mission in the ER: to help people see and avoid danger,” explains Dr. Gusky. “I strive to inspire hope about the future among ordinary citizens by encouraging people to ask questions about modern life we have forgotten how to ask and by helping to create a language for us to talk about how technology and life in cities affects conscience.”

He made his debut as a television host March 13 on the Smithsonian Channel when the documentary titled “Americans Underground: Secret City of WWI” aired.

Dr. Gusky’s career as an explorer and artist began on a bleak day in December 1995 at the former Nazi concentration camp Plazow, just outside Cracow, Poland. Acting on a hunch while visiting a memorial near the camp’s entrance, he climbed a nearby hill in knee-deep snow. Approaching the top, a barbed wire fence came into view surrounding a Nazi-era compound: an abandoned building with prison-bar windows next to a set of ovens, ashes still present. In the dim light and silence, Dr. Gusky experienced a strong sense that unspeakable acts of barbarism once occurred there. Guided by intuition, he began photographing what he felt, the same method he uses today.
 
Since that day, Dr. Gusky has been on a quest to understand why mass murder and terrorism still threatens us. Exploring places in Poland, Belgium, France, Moldova, Ukraine, Transnistria and Romania, where millions of innocent people have been slaughtered in modern times, he has discovered a common thread to every modern mass murder.
 
“Technology and the inhuman scale of modern life endangers us by making us feel like machines and by disabling our moral compass,” Dr. Gusky said. “My work seeks to help communicate the looming human emergency caused by compromises we make that diminish our humanness.”
 
Dr. Gusky’s first year of medical school at the University of Washington was spent in Alaska as part of the WAMI (Washington, Alaska, Montana and Idaho) Program, created to inspire students to become country doctors. After graduation, he combined his love of flying and rural medicine and used his plane to reach remote hospital emergency rooms on short notice throughout Texas and Oklahoma. Since 1991, he has taught trauma skills to other physicians as an instructor in the Advanced Trauma Life Support program. He is a member of Alpha Omega Alpha and a fellow of the American College of Emergency Physicians.
 
He has published three books, and frequently posts new photographs and videos on his website and social media channels. Several other television productions are in the pipeline.

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