American College of Emergency Physicians
July 13, 2021
Core Readings In Wellness for Residents
- Dorevitch S, Forst L. The occupational hazards of emergency physicians. Am J Emerg Med 2000;18:300-311. An excellent overview of the occupational perils of emergency department practice. Discussion includes infectious diseases, radiation exposure, exposure to violence, latex allergy, emotional stress and burnout, and the adverse health effects of shift work.
- Houry DE, Shockley LW, Markovchick V. Wellness issues and the emergency medicine resident. Ann Emerg Med 2000;35:394-397. This is a good article cataloging various aspects of residency training that impact emergency physician wellness. Included are discussions of shift work, chemical dependence, women's issues, interpersonal relationships and personal safety.
- Groves JE. Taking care of the hateful patient. NEJM 1978;298:883-887. An oft-cited article describing four frequently-encountered personality types capable of arousing our negative emotions. Included with each description are recommended strategies for dealing with such patients.
- Carius M. Avoiding "training toxicity" - staying human during residency. Ann Emerg Med 2001;38:596-597. An editorial written by a past president of the American College of Emergency Physicians. Dr. Carius emphasizes the need for lifestyle balance during residency training.
- Milling TJ. Drug and alcohol use in emergency medicine residency: An impaired resident's perspective. Ann Emerg Med 2005;46:148-151. This article details the personal experience of a substance-dependent resident who successfully completed rehabilitation and graduated from an emergency medicine residency program. Emergency medicine residents have higher rates of substance use than residents of other specialties and are more likely to report current use of cocaine and marijuana. Included in the article is a list of resources for dealing with substance abuse.
- Code of ethics for emergency physicians, ACEP Policy Statement, approved by the ACEP Board of Directors, June, 1997; reaffirmed October, 2001. Available at: https://www.acep.org. This is a statement of principle with regard to physician impairment. Important points include using the disease model of chemical dependence, having patient safety as the primary consideration in dealing with physician impairment and the need to support the impaired physician through education, information and collaborative processes.
- Whitehead DC, Thomas H, Slapper DR. A rational approach to shift work in emergency medicine. Ann Emerg Med 1992;21:1250-1258. An excellent introduction to the topic of shift work, this article deals with the physiology of circadian timing and presents strategies for addressing the adverse effects of circadian rhythm disruption.
- Kuhn G. Circadian rhythm, shift work and emergency medicine. Ann Emerg Med 2001;37:88-98. An excellent review of the effect of desynchronosis in the health and productivity of physicians engaged in shift work.
- Whitley TW, Gallery ME, Allison EJ Jr, et al. Factors associated with stress among emergency medicine residents. Ann Emerg Med 1989;18:1157-1161.
The authors report on a survey of 1,100 members of the Emergency Medicine Residents Association. 488 members responded. Subjects were surveyed using measurements of stress and depression. Unmarried residents had high levels of depression, and mean levels of both stress and depression were higher for women residents. It was suggested that spouses may buffer some of the stresses of residency training for both men and women. No significant differences in either stress or depression were found by year of training. - Coran LM, Litt IF. House staff well-being. West J Med 1988;148:97-101.
401 house staff members of a university medical center were surveyed on a variety of wellness-related issues. 40% of respondents indicated that anxiety or depression impaired their performance for a month or more. 12% reported an increased use of alcohol, marijuana, or cocaine, and 7% reported an increase use of sedatives, stimulants or opiates. Married house staff had stronger support systems and less substance abuse, anxiety and depression. Suggestions included establishing faculty and residence support groups. Specific instruction was also recommended in the development of effective coping strategies, including recognition of stressors, time management techniques and techniques of behavior modification and relaxation. - Ziegler JL, Straull WM, Larsen RC. Stress in medical training: Medical staff conference. University of California, San Francisco. West J Med 1985;143:814-819.
The authors present a broad overview of issues relating to stress in medical training. They discuss three major stressors: The consequences of high expectations, the loss of control over one's life, and difficulties with regard to dependency. Stress also results from attempts to adhere to five commonly held myths regarding physicians: Physicians should be all-knowing; uncertainty is a sign of weakness; the patient should always come first; technical excellent will provide satisfaction; and patients, not physicians, need support. Recommendations for stress reduction among house staff include: Recognize stressors; develop effective time-management techniques; modify behavior with respect to active listening and constructive criticism; cultivate social supports; enhance the aesthetic and comfort aspects of work environments; and cultivate relaxation techniques. - Jagger J, Powers RD, Day JS, et al. Epidemiology and prevention of blood and body fluid exposures among emergency department staff. J Emerg Med 1994;12:753-765.
The authors note that emergency department staff are vulnerable to occupational exposure to infectious blood and body fluids (BBF). They also note that universal precautions against such exposure are often ignored in the ED setting. The study involved a survey of all permanent staff in a large public university hospital ED. Respondents were asked to estimate the number of BBF contacts sustained during a one year period of time. The response rate was 85% (N=92). Average exposure rates per staff person per year were as follows: 54.1 intact skin, 1.5 non-intact skin, N.87 (?) mucus membrane BBF contacts. Of the contacts, 94% involved blood, 22% involved emesis or urine and 11% involved saliva. 88% of BBF contacts were to unprotected skin or mucus membranes, either when no barrier was worn or at the gap between glove and sleeve. Most (66%) were distal to the elbow; 13% involved the face. Use of long gloves or another continuous protective barrier from the fingers to the elbow, in addition to increased use of face masks or shields, would markedly reduce the rate of ED BBF contacts with a minimum of inconvenience. - Yehuda R. Post-traumatic stress disorder. NEJM 2002;346:108-114.
The author presents a thorough review of post-traumatic stress disorder (PTSD), a disorder that can affect care givers as well as victims. The discussion involves epidemiologic aspects including prevalence, inciting events and factors that contribute to intensity. Also discussed are the psychological and physiologic aspects of the disorder. Various modalities of treatment are discussed including specialized counseling, both individual and group, and medications. An extensive bibliography is included. - McNamara RM. Physician wellness. An excellent review of several key issues in emergency medicine, including shift work, professional stress, chemical dependency, malpractice stress and stress for women in emergency medicine.
- Birnbaum A, Haughey M. Can you be an EM resident and still experience "wellness"?
A brief but well-written discussion of issues impacting EM resident wellness. Included is a discussion of signs of unhealthy behavior and attitudes, as well as strategies to enhance wellness during residency and beyond. - McNamara RM, Bouzoukis JK, Perina DG. Chemical dependency issues in emergency medical residency programs.
This is a comprehensive, well-referenced primer on chemical dependency issues. It was prepared by the Council of Emergency Medicine Residency Directors (CORD) and is useful for residents as well as program directors. Sections include a general overview, identification of the chemically-dependent physician, management of residents with chemical dependency, legal and practical issues and resources for residents with chemical dependency.
