Burnout in the ED: Too tired to sleep, too wired to weep?

It is stupid o’clock in the morning. I am wide awake and have been now for two hours. I do not have the excuse of sleep disruption through night shifts because whilst I do work increasingly late clinical shifts, the focus of my efforts is keeping the ships sailing: I am a clinical director (CD).  Ironically, I think that tonight’s insomnia is because I am on holiday from today and I am thinking through what I may not have finished or handed over thoroughly enough. I suppose that this means I am stressed and it got me to thinking about the paper by Yates et al recently published in the EMJ. This is the opening line…

Previous research indicates emergency department (ED) clinicians experience high levels of stress” (1)

So at least I am not alone (I know I am not before you start to worry about me). The paper goes on to compare ED staff to orthopaedic department staff, including nursing and admin colleagues, across a number of measures including the General Health Questionnaire-12, Hospital Anxiety and Depression Scales and the Brief COPE. Their headline message is that ED physicians, but not other ED staff, reported increased psychological distress although clinically significant levels of general psychological distress were above general population levels in all staff groups. Whilst I think there are method  issues with the paper and the results need to be carefully interpreted (and would be better fully reported) it does describe some reasons why I do not need to worry so much and should probably just go to sleep. You can read the full paper by clicking on the abstract below.

 

My real succour came from the coping strategies that were described. Admittedly they did some jiggery-pokery with the Brief COPE classifications in order to describe three “meaningful” strategies:

  1. problem-focused (includes active coping and planning)
  2. adaptive emotion-focused (includes acceptance, seeking emotional support, positive reframing, humour, religion and self-distraction)
  3. maladaptive (includes denial, behavioural disengagement, venting, substance use and self-blame)

I am sure that we can all recognise times when we have used some or all of these ourselves; I certainly can. Importantly, the authors conclude that increased psychological health was associated with the use of problem-focused coping strategies and higher levels of social support at work. This is great news for me (if you believe the results) because I have both now. Over time, more through accident than design, I have developed a problem focussed approach based on the wise words of one Mike Lambert (who was the first Accident and Emergency “Tsar” in the UK) who I heard say that the only way to predict the future of the specialty was to create it. Since then I have done my small part but could only do so  because of the great team here at Virchester (my social support at work). So why couldn’t I sleep?

The problem I think was that whilst I had developed these strategies over time I wasn’t clear how it had happened. More importantly, if there was a route, could I pass it onto my staff to enable them to make the journey quicker than I did? Whilst on one level this was important to me as an individual I did after all have responsibility as a CD  too.

So what else to do at stupid o’clock but open a conversation with Dr Google using the search terms “stress emergency medicine”? On the first page was an article from a geographically disparate group of emergency physicians from the US of A. (2) They assert that awareness of the issue is an important thing and early education of physicians on legitimising  “wellness” is vital. Wellness for them was the opposite of some of the negative aspects of our work:

  • substance abuse
  • circadian disruption
  • sleep deprivation
  • malpractice and fear of litigation
  • exposure to infectious disease and death
  • poor nutrition and access to exercise

Again I recognise all of these – mea culpa – but please don’t tell my mum. Whilst I seem to have near given up alcohol I am still certainly drinking too many caffeine containing drinks. Although we have made strident efforts to change the work patterns of the junior physicians to reduce circadian disruption I have not (yet) managed to do so for my senior team here at Virchester. I certainly can’t guarantee my own sleep soundness as I fail to balance work and life and haven’t yet cracked it for my staff either. We always have some difficult legal issues to contend with and whilst we do (I hope) provide support for our staff during these it remains a pressure. Death…well…is part of life but still comes as a shock for people starting out and as for nutrition and exercise do Haribo Tangtastics and jumping to conclusions count?

I think it is worth saying then that whilst I can (mostly) cope I am a way off providing a clear path for my staff. Maybe I could…no probably not…but maybe…I may sleep on that and get back to you. Night.

Steve J

 

1. Philip J Yates, Elizabeth V Benson, Adrian Harris, et al. An investigation of factors supporting the psychological health of staff in a UK emergency department. Emerg Med J 2012; 29: 533-535.

2. Gillian R Schmitz, Mark Clark, Sheryl Heron, et al. Strategies for coping with stress in emergency medicine; early education is vital. J Emerg Trauma Shock 2012; 5: 64-69.

6 Comments

  1. Henry Morriss (@hrmorriss)

    Yoda speaks. Many a true word he speaks.

    Reply
  2. alig

    I agree wholeheartedly. However, we as EPs LIKE stress. As a trainee, I attended a Leadership training weekend for registrars across the region. Amongst many other topics, most of which our tutors managed to rationalise, not unreasonably, to 2×2 tables, we discussed stress, which they represented using three concentric circles representing “comfortable” {central}, “challenged”, and “stressed” {external} and asked us to indicate where we usually were, most usually, at work. Unsurprisingly, the three EPs in the group placed themselves in the outer ring. Similarly unsurprisingly, the rest of the group {GP trainees, anaesthetists, PH trainees, etc} liked to live in the middle with occasional forays into the periphery.

    I’d argue that our comfort zone was “busy” with a tendency to “chaotic”. By our nature we work in an unpredictable speciality that has huge pressures, emotional, technical, physical and personal. We are a tight knit bunch that rely immensely on trust of our colleagues and an innate need for our team to do the right thing, at all times. You could compare the ED to the Hydra of ancient greek legend in that we are one, but many, and that if you wound one of us, then the other 6 heads will bite you on the arse.

    Personally, I am happy with this situation. I have wonderful colleagues that will cover for me when I am off par, for whatever reason, and will happily take me to task if, and when, my performance would fall short of the paramount standards they set.

    If sleep is a problem, I’d invest in two things. Firstly a sleep app for my smart phone which has improved mine a helluva lot – it was recommended by an intensivist who I didn’t have down as a stress head; secondly, valerian tea. Available for pennies from the supermarket and the only legal thing I know to give sleep, with no hangover, within the hour.

    bw

    AliG

    Reply
  3. Kirsty Challen (@KirstyChallen)

    I seem to remember that leadership course too…..of the 3 EPs, 2 ended up as overall managers of the task and you had to comment via the media – very prescient of them? 😉

    Reply
  4. Janos P Baombe

    Echoes some of my thoughts…
    See/read recent blogs on exhaustion and CRM in the ED!

    http://blogs.bmj.com/emj/2012/08/01/ed-exhausted-doctors/

    http://blogs.bmj.com/emj/2012/05/16/crew-resource-management-in-the-ed/

    Reply
  5. Pingback: What I learnt this week: The signs of burnout #WILTW | The Rolobot Rambles

  6. Pingback: SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust | The Skeptics Guide to Emergency Medicine

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