ACEP Geriatric Emergency Medicine

- [Maura] You'll hear from Katren Tyler, from UC Davis, who's gonna talk about physiologic challenges in emergency medicine. Then we'll have a panel discussion with three individuals talking about the policies or lack thereof that they have at their institutions around age shifts and aging.

- [Man] Take a look at this guy.

- [Maura] And then, and then we'll wrap up with Dr. Binder from Brown.

- [Man] This guy had shoulder length blonde hair.

- [Maura] About physician experiences, and aging. And if you haven't already turned off your microphone, please do.

- [Woman] Or you could pop it out.

- [Maura] This is not a webinar, it is a Zoom link, but it is a Zoom talk that has CME with it, so, please turn off your microphone if you're not speaking, we will have the opportunity for questions. Hopefully our questions, we'll have time to ask them after each talk, but if we don't we'll then just put them all at the end. So importantly, none of the speakers here or planners have any disclosures and Nicole at some point will put into the chat, how to get CME for this talk. Some of you probably are wondering whether we should be having this talk at all, because if you have read anything about the workforce of emergency medicine over the past couple of years, you have heard that in the next eight years, we will have a surplus of emergency physicians. More than 7,000 emergency physician surplus. And as such, you're probably wondering, should we actually even be encouraging longevity in emergency medicine, given this pending surplus? And this is a publication by Dr. Marco and colleagues that did projections of the emergency medicine workforce. It's important to note that they had a number of assumptions about the workforce in the coming years to make this projection. So they had assumptions around emergency physician attrition rates. They had assumptions around growth of residencies and graduating residents and the numbers of encounters that would be seen by NPs and PAs, as well as the growth in ED visits. And there's already some evidence that some of those assumptions maybe incorrect, really challenging to project these assumptions, but this very recent publication from Cameron Gettel and all looked from 2013 to 2019. And they're seeing annual attrition rates of about 5%. Now that's inclusive at temporary and permanent attrition, but already seeing that pre pandemic, we are having attrition rates that exceed the attrition rates that they're estimating in the publication by Dr. Marco and colleagues. So one point where we may not actually have that same surplus and then hard not to remember that at the end of the match this year, we had 7.5% over 2,000 spots, almost 3,000 spots in our residency programs that were unmatched and went to the soap. So some concerns over their projections around the growth of residency spots and graduating residents. And this is all pre pandemic, right? So we don't know what the impact of pandemic will be on our attrition rates, on our ED visits, and on applications going forward. So that's the rebuttal to the global workforce argument about why we should even be having this conversation about longevity, but it's also important to remember these are individual conversations for individual physicians. They're conversations for me, for Dr. Tyler, for Dr. Binder, for all of our panelists, for you, and even for our residents now who are looking forward to hopefully a lifelong career in emergency medicine. And these are conversations that right now impact a large percentage of our workforce. So the median age of emergency physicians in the United States is 50, and 20% of emergency physicians in the United States are over the age of 65. So impacts a lot of our emergency physicians, but also if you're developing policies around older individuals and say night shifts, it's also important to know how many people are gonna be impacted now and in the upcoming decade, and make sure that your policies are addressing the demographic shifts. So the first two parts of this talk are focused on night shifts. Why are we focusing on night shifts? Well, for many of us night shifts get harder as we age. In our 30s, not so hard. In our 40s, a little bit more difficult. I worked the night shift this weekend, I was in rough shape yesterday. And many report, like Mark DeBard in this article or this editorial, "To retire or not?" Then in the 50s and 60s it becomes particularly difficult. So I'm gonna turn over the microphone and the screen to Dr. Katren Tyler. She's gonna talk about physiologic challenges in emergency medicine. She is going to talk specifically about chronotrophy, shift work and aging. So if you don't know, Dr. Tyler, Katren grew up in Australia, so she actually completed two emergency medicine residency programs, one in Australia, one in the US. She has been very active in geriatric emergency medicine, but also very active in wellness. And she actually has a leadership role in her health system around physician wellness.

- [Katren] Thanks so much Maura, I'm very excited to be here this morning. And so I've subtitled my talk "Otherwise known as when did I start hating night shifts," because I think all of us have been on a bit of a path in how we have approached shift work over time. So let me just, yep, alrighty. So I do not have any financial disclosures. As Maura mentioned, I am from Australia. So therefore I am legit allowed to put up pictures of koalas. I am a PGY 30 so I do have a substantially extended exposure to night shift. And I just wanna sort of focus back a little bit on sort of Maslow's Hierarchy of Needs, and this particular diagram is of course, a little bit tongue in cheek with our wifi and battery down the bottom, but I think that, although I did make the mistake of taking my teenagers on a vacation over spring break without wifi. Pro tip, don't do that. But physiologic needs, I think we sometimes overlook the importance of some of these things and how they sort of play into how we feel about ourselves and sort of our life's work. So just a super brief overview of what this talk of, what this very brief overview of a talk is gonna be. I'm gonna talk about the sort of the general burden of shift work, especially night shifts, but not restricted in any way to age. I'm gonna talk a little bit about systems based responses and the shared responsibility, especially what that looks like in some other industries that have tackled this I think a little better than medicine has. What aging and shift work might look like. And then what some possible solutions are, and more importantly, what we at UC Davis chose to do. And just as a side note, there was no night shifts until the Industrial Revolution. Until we had all night lighting there may occasionally have been people who were guarding the carpet, but there were very few people who were actually up all night deliberately. And if I could just ask everybody to mute at the moment, 'cause it's not a webinar, so thanks so much. So the physiologic burden of shift work. So, there's a lot of play in the lay literature about early birds and night owls. And you've probably seen quite a bit of literature about that. This document, I'm going to refer to several times in the talk and it's from the Federal Aviation Authority and it is a circular advisory around fatigue mitigation strategies and sleep in aviation. So I have come to think of sleep as really being, and fatigue management, as really being a patient safety issue. And when I'm talking about fatigue management in medicine, I'm speaking specifically about shift work, about on-call work, extended duration shift work, which is when you have a longer shift, and also some of the condensed work weeks, which is what the nursing staff actually do when they're doing those consecutive 12 hour shifts. And I think that we have sort of undervalued the role of fatigue management and fatigue in general, as a cognitive critical safety process. This study, I have some blown up slides of these images, but this is looking not just at healthcare workers. This is a cross section of the US population. Just looking, the top margin icon is sleep duration, and you can see that most people there are averaging between six and 10 hours. And chronotype. And so I didn't really know that much about what chronotype was before I started looking into this literature, but it turns out that this is actually how they come to describe whether you are a morning person or an evening person. And the measurement that they use is the time of the mid-sleep on weekends. And if you think about when, if you are left to your own devices, you don't have to go to work. You're on vacation. You don't have to get your kids anywhere. You don't have to do anything with the dogs. You don't have to pick up your mother from her doctor's appointment, whatever it is that you normally are very busy with your life doing, it is what time you would choose to go to bed left to your own devices and then what time you would wake up in the morning. And they measure it using the mid-sleep which is halfway through that point. So that you can see that most people are falling between that two to four hours, which is halfway through an eight hours sleep. So they're mostly going to bed between 10 and 11 o'clock at night. So this particular image was really eyeopening for me. So, the first thing is is that there's a lot of natural variation right, in when people's chronotype are. And you can see that some people are going to be awake. You know, some people have a much earlier chronotype, especially as you get older, which means that you want to go to bed earlier and you wanna get up earlier. The thing that was important to me is that when we're in our 20s and 30s which is when we're mostly choosing a career in medicine and choosing which specialty we do, and specifically we're choosing emergency medicine, which has a large component of swing shifts, it's usually when our chronotype is close to being its earliest. So that means that we have a better tolerance for staying up late and then sleeping in late. But over the decades, as you are practicing emergency medicine into your, first into your 40s, and then into your 50s, there's a decline and, well, not really a decline, your chronotype moves earlier, which means that you wanna go to bed earlier, get up earlier. And so that makes it harder to do those later shifts, whatever they look like, and it's particularly hard to do night shifts. So late chronotypes actually very well suited to emergency medicine because as we know, the swing shifts are when the patients come, I just pulled these two completely random emergency department profiles off the internet, but I can guarantee you that all of your emergency departments look like this, the very few patient arrivals overnight, most of the arrivals start picking up around 10 or 11 in the morning and then increase over time and dropping off in the evening. But we're not actually that unusual in that 30% of the United States workforce has alternate rotating or extended shifts that are outside of the 8:00 AM to 6:00 PM range, 12% include night shifts. And as I mentioned, the nursing staff are doing a compressed work week with a 12 hour schedule. So when you add on overtime to what the nurses are doing, that actually becomes quite a burdensome schedule. Morningness what we call early chronotype and so they have a decreased total sleep duration on night shifts, and early chronotype generally does not do well with late shifts or night shifts, are quite difficult. Eveningness is the late chronotype. And those people generally don't do that well with a regular day shift. So like even in non-medicine life, it can be difficult for people with a late chronotype to function with an 8:00 AM to 6:00 PM type schedule. So, evening shifts actually might be protective for those patients, not patients, people with a late chronotype. So just re-emphasize, we're not nocturnal mammals, although I keep this slide in the talk because I do think the bats feet are just so adorable hanging on to the rock. One of the things that happens when we are facing working against our chronotype is that we get this sort of social jet lag. So one way to think about it is, what time is it in the brain? Our circadian asynchrony is what the whole population experiences whenever they travel and also every time we switch to or from daylight saving where there's always some getting used to the time period in the week following the change. For shift workers, it's something that we are painfully familiar with. And this was a study that I just really like this quote, "Physicians feel moodier, drowsier, and more restless after night duty." And I think, certainly, I used to tolerate night shifts fantastic. It was really my preferred shift. And now as I got older, it became something that I had much less tolerance for. So shift workers are often working against their chronotype. We don't allow people to schedule for their chronotype and social jet lag is the misalignment of the biological and social time. So just thinking about what some of the sequelae of shift work are, and again, this is not terribly specific to healthcare because there's remarkably little information about it considering how many hospitals are in operation around the world. So firstly, there's the circadian desynchronization, the sleep disruption, and so the dirty little secret of shift work is the cognitive impairment that I think we have really failed to address in medicine. So these, if you think of these things as sort of stepwise progression, anyway, firstly there's insufficient sleep opportunities.

- [Man] You know how that is? You never know how long those things take.

- [Katren] If you wouldn't just mind muting your call, thanks. Insufficient sleep opportunities. Then there is impaired sleep, then there's fatigue-behavioral symptoms, and then perhaps fatigue-related errors or incidents. And you know, I think-

- [Man] I'm getting that. It'll be good.

- [Katren] Working whilst drunk is illegal and socially discouraged obviously, but in medicine we have this sort of ethos that working while tired is sort of rewarded and revered. And this study came from Australia several years ago, 20 years ago now, looking at blood alcohol versus fatigue, and essentially, people who had been up for 24 hours were just as impaired as if they had a blood alcohol level of 0.1%. So some systemic and institutional solutions. And mostly I have questions here. There's very little evidence of any shared responsibility that I've seen between health systems and their clinicians. And again, this is just bringing up what some of this sort of step-wise error trajectory might look like regarding fatigue management. So first of all, there's this a sleep opportunity and you may or may not be able to take advantage of that. Then there's the actual sleep that you obtain, what your behavioral symptoms are, how cranky you are, are you interacting appropriately or are you not making appropriate choices? Fatigue-related errors, and then finally fatigue-related incidents. This study again, is a meta-analysis looking at shift workers across a wide variety of industries and basically shows that if you take, you know, the risk of a incident is one for a day shift, up here in the breakout box. But it gets progressively higher over time, and it also is more that even over the age of 20, people are less likely to tolerate night shifts and that the risk of an incident also increases with the hours on duty and the shift length. But having a rest break can actually be a bit of a buffer against some of these risk factors. So the consecutive number of shifts, the hours on duty, the shift length and the type of shift can all play a role. And they sort of developed this heat map that essentially, the more shifts you are on, the longer the shifts are, and the less time you have between breaks the more likely you are to make a mistake. Which is not really rocket science when you think about it. So there are some other industries that have started to address some of these fatigue management issues. Trucking, rail and water management have all sort of started to address it. Aviation is what I'm gonna spend the most time on. And manufacturing, I'm not gonna bring up these studies, but actually there are a lot of large industrial plants, particularly in Europe, that have done an excellent job of actually allowing their workers to schedule according to chronotype. This is from that original FAA document that I just showed. And it's important because it shows the impact on not only the period that you are awake, but also the subsequent days. So this is looking at somebody who does a night shift on day two. And so, day one, you can see that they have this, the general window of circadian low, occurs between 2:00 and 6:00 AM. And the secondary window of circadian low is what occurs in the evening when, or late afternoon, sorry, when you wanna have something to eat or a coffee or something, just to get you through the rest of your workday. But you can see that after a night shift, it actually takes somebody a substantial period of time to get back to their baseline. And at day five, they're not actually, well, three days after their night shift, they're not actually back to normal, and this is not, this has nothing to do with age. This is just all comers. So just remembering the window of circadian low, 2:00 to 6:00 AM. So one of the reasons why I'm gonna focus on aviation for most of the rest of this talk is, A, they have the most evidence, and B, their job is similar to ours in that we, the people have an expectation that the decisions that we make at 3:00 AM are gonna be just as good as the decisions that we make at 3:00 PM. And that we are constantly being just the decision makers and we are in fact, the captains of the ship. I'm not gonna read this entire quote out, but basically that the recognition by this pilot in particular, that you know, those long haul flights, where they offer some benefits, they also have significant red eye legs or the equivalent of our night shifts, and that's exhausting. And I really just like this quote that he said just don't use power tools. So again, this flight crew member and member duty and rest requirements actually was published, I think 2019, and I think that this language is something that we don't see very much in healthcare, "whereby both the carrier and the pilot accept responsibility for mitigating fatigue. The carrier provides an environment that permits sufficient sleep and recovery period, and the crewmakers take advantage of that environment. Both parties must meet their respective responsibilities." Familiar to all of you are the three types of fatigue, transient, cumulative, and circadian. And circadian is obviously what happens when you are up all night. I think we've failed to emphasize that fatigue management should be a shared responsibility. Just turning briefly now to clinicians over 50. That is me. There's actually surprisingly little data from healthcare. There's no evidence that we get better at handling shift work as we age. Obviously we've built up strategies and we might have better boundaries around our shift work, but we're not actually physiologically better at doing it. This is from about a decade ago, but it's a flight out from the west coast of the United States to Asia. So about a 15 hour flight looking at how the pilots sleep when they're on their rest breaks. And you can see that the younger pilots woke up 4.2 times per hour, and the older pilots work up 10.5 times per hour. This is from an ICU in France. Couple of things about this study. It's looking at cognitive abilities, working memory, processing speed, perceptual reasoning, and cognitive flexibility. Cognitive flexibility, a higher number is not better, that means that you're making mistakes but you don't recognize them. And basically everything gets worse after a night shift. A couple of things about this study. The ICU staff physicians, their average age is only 38 and everybody in the ICU actually got to have a nap, sometimes up to four hours during their shifts. This study is from healthcare workers in Holland and shows that there seems to be an inflection point above 50 where healthcare workers are not sleeping as well between night shifts compared to younger healthcare workers. And then this study was published a couple of years ago. It's from academic health systems across the country, was published by Stanford. And that as Maura tweeted out, "We're winners," because the discrepancy between our sleep impairment and those of our residents is the least of most of the other specialties. So just something to consider. So when we were thinking of possible solutions in our departments-

- [Maura] Katren, I'm gonna cut you off there.

- [Katren] Okay.

- [Maura] And have you chat at the end about what your solutions are?

- [Katren] Okay.

- [Maura] Does that sound good?

- [Katren] Sounds fine.

- [Maura] Perfect. So we are gonna move on to our panel discussion next, if you have questions for Katren, put them in the chat, she may either answer them in the chat or at the end when we come around. So I am going to quickly share my screen. And I think Nicole is going to be putting up a survey for you as well. So this is actually the ACEP policy statement about physicians in pre-retirement years. And it says that that ACEP encourages physician and physician groups to be mindful of limitations that may accompany the aging process. It has some suggestions on ways that you can accommodate the senior physician or the pre-retirement physician to address biology. And so we'd love to know what your institution has in terms of policies around aging, and answer our surveys. But we are going to move on to our panel discussion. We have three individuals who are gonna talk about night shift policies at their institutions, or whether they have them, and how they pertain to aging. So one of our discussants is Dr. Stephen Meldon. He's the Senior Vice-chairman and the Patient Experience Officer for the Emergency Services Institute, Cleveland Clinic Health System, and is the academic chair of the Department of Emergency Medicine at the Cleveland Clinic. He directs their geriatric ED department and has had leadership roles for National Emergency Medicine staffing groups as well. Dr. Howard Ovens is the Emergency Physician and Chief Medical Strategy Officer of Sinai Health in Toronto, Ontario. He is a full professor in the Department of Family and Community Medicine at the University of Toronto, and a Senior Fellow in the Institute of Health Policy Management and Evaluation. And Paul Chen is the Emergency Medical Director at Brigham and Women's Hospital in the Department of Emergency Medicine. He's an assistant professor at Harvard Medical School and has received a number of awards for his leadership and teaching, including a faculty leadership award at Brigham. He has overseen the revision of the night shift at Brigham and is actually now working with our institution, MGH, as we revisit our policies around shift work and aging. And so each of them is going to speak on what their institution does and why their institution does that. And with that, I am going to first turn it over to Stephen.

- [Stephen] All right. Thank you very much. As I thought about this and reflected on this, the first question I had is, should a group consider this. And I think Katren's answered that question. I think it's really obvious that we really should consider this. So the second thing is really look at your group and I will tell you, we currently do not have a policy. I am working on one now. And the reason was when I first got here, we just had two sites and 25 physicians and they had a policy that you could stop working nights at age 50. So I did a spreadsheet, looked at all the ages, and everybody was in their mid-40s, very little turnover, a lot of longevity here and I said I don't think this is feasible. So we actually held on that and now we're revisiting it since we've a much larger group and 150 physicians. So a couple thoughts is, one, really select your model. And one model we're considering is similar to what we do for vacation. It's based on age and years of service. So if you have a group and you wanna encourage people to stay, that may be one thing to do. The other thing is simply consider, is it graduated? Is it less nights at 55, no nights at 60? And then the third thing we're considering is about are there any penalties or a cost if you will, for the person not to work nights? Like, that might be an additional weekend day or sometimes even financial penalties. I think those are all things to think about. And the biggest thing we do that I think most groups do is that we incentivize staff to pick up nights. There's a significant 10% pay bump for anyone who's full time nights, or picks up nights just out in the regional hospital. So I think those are the thoughts we are currently looking at this, and I was very interested to hear this. I think this is so far a great discussion on this important topic.

- [Maura] Thank you. Moving on to Stephen. Oh, sorry. You just talked! Moving on to Howard Ovens if he wants to unmute and tell us about the policy at his institution and his thoughts on this topic.

- [Howard] Thank you so much for the opportunity to join you from Canada. I'll start with a comment that the Ministry of Health in Ontario has long predicted a glut of emergency physicians. We have a chronic shortage of emergency physicians that just keeps getting worse despite their predictions. And we're really in the midst right now of a crisis in coverage that impacts probably every single emergency department in the province. And that's relevant to the comments I'm going to make, because, as has been alluded to, to have a policy which permits older physicians to opt out of nights requires the right demographic profile in your group. And it really requires some stability and sort of ability to do some long range planning. I also wanna say that, as has been said, I just wanna emphasize that shift work is not normal for anybody and requires all of us to be very deliberate in thinking about our physical and social strategies to maintain wellness, not just on the job, but at home. And yes, it's absolutely true that shift work adaptation declines with age, but there's very wide variation individually on that. And it really also is important in individual circumstances to consider their overall shift load, their personal commitment to those adaptive strategies and their life circumstances outside the work environment. So, all of what I've said means that for the majority of groups in Canada, it's really not possible to provide relief from night shifts on any kind of entitlement basis. The result will be that the burden of nights on the younger staff would become so great that the burnout and loss from the profession would be much worse and it really would not be sustainable. What we've done in my group for a long time is to use financial incentives to make whatever are the most unpopular shifts at a time more covered. And we really adjust, whether it's Christmas Day, we were having trouble covering Christmas. We increased the Christmas bonus dramatically. I started to get complaints from physicians who were angry they didn't get Christmas, they lost out on the opportunity to make the bonus. I was very grateful for those sorts of complaints. We've had a significant night shift premium for at least 25 years. I'm talking about an internal premium, not the system provided premium, but based on our pooled income and internal contract. A night shift's worth about 50% more than a day shift. And as a result, a number of older physicians have opted to do a disproportionate number of nights. They also have reduced their shift load so that they really are trying to meet their target income with the fewest number of shifts possible. And they've managed to thrive for various reasons, both professionally and personally doing that and it's been a net bonus to the rest of the group. Me personally, I'm 67, I still do casino shifts, weekend shifts, late evening shifts. I haven't done the overnight all night shift for about 15 years now. And in a way I think of it as I'm working much less financially remunerative shifts, I'm really paying my colleagues to do my share of nights for me and that works for me very well. And you know, there may be a time when financial incentives will fail, especially if you have some illness or absences from the group and you have to be a little bit more prescriptive, but, I think that the change in life cycle and personal circumstances and the variation in personal physiology mean that we really shouldn't be that prescriptive. We should provide the incentives. And the last thing I'll say is, part of making that strategy work is it's incumbent on all of us to live within our means and come to a point in our careers where I am, where you're working because you want to not because you have to. Thank you.

- [Maura] Thank you, some really important points there. And Paul?

- [Paul] Thanks, Maura, thanks for having me and also for putting this together, such an important topic for us to talk about. So, you know, I'll give a background on our group, and just so people know, because every group is different, the dynamics are different. We're an academic medical center and a group of about 70 faculty that have kind of grown over the years. And even before I came into the organization, there was a move to have doctors over 55 no longer have to work nights. Just a recognition that the nights get tougher as you get older and nod to some of the seniority of those folks as they reached that age. As our group got larger, and many of us have non-clinical responsibilities, you know, there was a recognition that well, nights are difficult for everybody as Dr. Tyler kind of so well demonstrated. And so we wanted to put in a place a system to incentivize the night shifts for folks, but also it has been alluded to provide people with some choice because while generally the chronotype as you get older is that you don't do as well with nights. Some people may fall out of that and wanna continue to work nights. So we wanted to embrace choice. So we actually put basically an incentive for folks that it's basically a 20% incentive. So if you work a nine hour shift, you get 11 hours credit. We asked our existing attending group, if anybody wanted to move to that. And we also started to hire nocturns, people who only worked night shifts. Those are tending to be the younger folks. And, because this is our group, we had to make it basically budget neutral so that we could cover the cost of that incentive within our group and we debated a lot between, is this gonna be money or time? You know, those are ultimately, equivalent, but our group was just more comfortable with time. And so for people who want to reap the benefit of the reduced night shifts, they get hours added on to their kind of annual years that they have to work for the benefit of working less night shifts. We kind of have to redo this every year and get, you know, because our group changes, what's everybody's expected nights and then make a calculation and, you know, attribute these number of nights to the nocturnists and then these number of nights to everybody else. We don't have enough night shift nocturnists to cover every night. So everybody's still working some number of nights, but we do prioritize if you're over 55 and you elect to do so to basically go down to zero nights. They're having to pay for that with hours, but so far it's worked out. And just to give folks a sense, you know, if we didn't have a nocturnists program, like a full time person in our group would work 20 nights a year. They're able to go down to three nights a year and they have to work five or six shifts extra over the course of the year as their payment to reduce those night shifts. You know, our group is changing and so every year we reevaluate what we're doing to make it work for everybody. But so far we've been successful at that.

- [Maura] Amazing. And it's that policy that's started to inform the changes at Mass General from our prior policy to a new policy that's gonna allow people to opt in or out of night shifts, again, with a financial component to it, where, if you opt out, there's a shift of finances to cover those people who have agreed to work, yeah. I think one of the concerns that I've heard raised about this shift at our institution is that it may be more beneficial for those who don't have a lot of loans or, you know, come from wealthier backgrounds, and that they may be more incentivized to pick up shifts or to work night shifts that may be against their chronotype. So that's one of the criticisms that I've heard of this approach. I love something that Katren had in the chat, which is that at her shop, there's actually a 5:00 AM shift, which sounds terrible to most of us probably, but remembering like you're working the night shift and at 6:00 AM everyone has woken up and has decided to come into the ED before they go to work. From a volume perspective that might be amazing, and for people whose chronotrope is such that they're waking up early and earlier with aging, that that might be a shift that's very desirable to an older individual if it matches their time. Phil, do we have some questions in the chat that you wanna to talk about?

- [Phil] Sure, I think some of these, perhaps we've answered either in the chat or through the discussion, but just a couple to sort of pull out. So, "Has anyone dealt with pushback from the union when trying to limit/restrict night shifts based on age?" I think what I've heard is this is a lot of sort of options so sort of giving the option to older physicians, but that was a question I don't know if anyone has comments on that? Any sort of pushback from limiting night shifts for older attendings? Is anyone sort of mandating or requiring? It seems like what I've heard is really sort of giving the option to older adults or to older attendings is sort of the approach.

- [Katren] Of course not-

- [Paul] Obviously we haven't mandated anybody to come off a shift, but we have had attendings that as they are aging, you know, fortunately they've been able to recognize that they probably shouldn't be in the area that gets all of the traumas and the high intensity action, and, we have an urgent care site and some other areas of our ED that are a little bit less intense and we've been able to work with them And it's been kinda mutually beneficial to preferentially schedule them in those areas. We haven't had to deal with any sort of conflict with here we've actually had to take somebody off, yet.

- [Katren] Yeah, and I would reiterate that we are also have not mandated. This is an optout. And I would say that one of the things about being cautious about incentivizing night shifts is that you don't want it so that the physicians are doing it only for the incentives, if you will, because certainly I've, at one of our satellite sites, I took sign out one morning from a much older physician, and actually, I think he would've met the criteria for delirium. Like, he did not know anything really about the patients that he was signing out to me and I thought that was like really pretty scary. So I think, it's a delicate balance. We certainly do not mandate people to, and we have several physicians who are older, who still love doing night shifts and do well at them and others who do not.

- [Maura] And I'm gonna have Phil and Luna put any additional questions, 'cause there's a long chat that they want answered. So if the panelists can look at the chat as we move on to the next part. But worth actually mentioning that there's a recent lawsuit at Yale. It wasn't specific to emergency medicine, but it was about aging physicians and mandating cognitive testing and vision testing. I think it was after the age of 70. And so there was a lawsuit against that. I think it has a temporary stay. And so I think there's the issue of both wanting to make sure that situations are safe for our patients, but also not have age discrimination against our clinicians as well. And recognizing that we all age differently. And in terms of the delirium picture, I know for a fact I've been delirious in residency. So part of it might be aging. Part of it is also, as you mentioned, like the shared responsibility of the institution hours, shifts, to be safe for us. And so we are going to move on to the third part of our talk. And it's important to note that, if you're looking at aging through workforce, shift work isn't the only thing to talk about. It's not just all about night shifts. We should be talking about more than that, the value that older emergency physicians bring to our practice, and other components that we should consider in terms of the value they bring or other things that we need to address as we age. And to that effect, we are going to have Bill Binder talk to us. He is an associate professor of Emergency Medicine at the Warren Alpert Medical School at Brown. He did a residency in internal medicine and then emergency medicine. And then here's here at my institution for a while at MGH, before moving to a medical education startup in Boston, and now he's academic faculty at Brown as the editor in chief of the Rhode Island Medical Journal and has been elected to the Board of Brown Emergency Medicine in 2022. He, if you haven't seen it, had this publication in JACEP Open recently, that's actually from a qualitative study of emergency physicians about their experiences in aging. And he's going to talk about some of the themes that came out of this article and sort of bring our conversation to a more robust conversation. And I think I'm gonna run his slides for him.

- [William] Thank you. Thank you very much, Dr. Kennedy. Appreciate it. Yes, so I was involved in a study. We started this. Basically called, "The age-old question: Physician experience of aging in the Emergency Department." Which you showed that citation. And we actually did a kind of a pilot study using focus groups to which was done at NERDS, the New England Regional Directors Society for using semi-structured questions. And we found a number of emerging themes. We discussed basically the issues surrounding these themes, barriers to solving the issues and then some possible solutions. And so I'll go the next slide. Basically, we found, if I can get the next slide there. Okay, great. Thank you. The senior physician, we talked about really the obvious issues, which are workload demands and nights, which has been brought up today and obviously incredibly important. Other themes that also came up in terms of workload demands, was just the physical impact, are clinical skills equivalent to, and equal to, the demands that are now placed. And we also talked about workload demands and balancing that with financial anxiety and, just the entire workplace culture. The other theme, however, which I think was very important is looking at equity, and basically in social equity and in parity and ageism, it's just trying to find your niche within emergency medicine and how can one age well? We looked at the social policy advances of many of our kind of comrades as we, especially the younger folks, and we really felt like the older physicians wanted some reciprocation. They had fought, at our institution and many other institutions, senior physicians fought for family leave. They fought for wellness for younger physicians and their families. And it was important to see, maybe that this is important for the senior physician as well. Our consensus was that leadership is really important in creating this equity and this should occur both at the national and clinical site level. If you can go to the next slide? We, you know, some of the quotes, and remember this was a qualitative study, it's just really kind of, I think, rang true. We were trying to create a path for everyone. One that even younger physicians will buy into. And that was a very big problem, has been a big problem at our facility where younger physicians just like, didn't get it. They didn't get that they were gonna become older in emergency medicine. And we were trying to create a career "that'll get you to age 65, no matter how old you were. The end goal for a long fruitful career right now, just not designed for that." The only other statements. One was from a friend of mine. It's basically just wellness, and looking at wellness, it's been a theme, but, "isn't wellness the right of all of us as we age?" And this to corollary to that is, "I'd love to drop the usage of the word burnout. Not just talking about burnout, we're really talking about different stages of life, and that's the paradigm that we need to achieve." And that's from a friend of mine at the Brigham. So, can we go to the next slide? So, we then move on to the final. We had really three major themes, which was the workload demands, and the wellness and parity. But the thing that we're really focusing on, what's our value? And what is our value within the emergency department? And truthfully, the data is sparse. You know, there's not a ton of data about older physicians. There's some quantitative work out. Tsugawa in 2017 had a rather seminal study which found that older physicians in low volumes, and this is mostly hospitalists and surgeons, these settings, they have higher mortality outcomes. This actually in larger volume practices, this really evened out, but this one was grabbed onto by the media. I mean, this was all over the news media because just older physicians mean you're gonna die. And that kind of became as in New York Times and every other media outlet you can imagine. The other studies, which Dr. Kennedy mentioned, was the looking at the cognitive studies. This was done at Yale, where they started kind of mandating the cognitive study of the physician over age 30, 70, excuse me. 13% left practice because of this, and then 57% had actually had a false positive. And this is a problem. This is, I think, what has led to that lawsuit. And as again, this is a stay now on this. So, other data regarding senior physicians that has been shown that's actually quantitative, senior physicians might not necessarily have higher efficiency, although in some cases there are, and this is in the emergency medicine literature, but in the ED literature, we're found to use less resources and we use less radiology resources. In terms of better patient outcomes, that's not quite clear, but we certainly do have faster dispositions. Another issue was that recent data showed more a trend towards resilience. And this is in particularly, has been particularly important since the pandemic. Physicians have a higher resilience than the general population and, but they still do have burnout. Burnout is higher, however, in mid-career settings, basically in the 40s to 50s than in senior physicians, and as Dr. Kennedy noted, I had moved over into the business world with the startup and, you know, I was burning out. So I kind of ended up finding an option for myself, but also remained clinically active. So, we did find burnouts certainly occurring in a higher rate, and then yet over 55, it's a little less burnout. And the study by West et al, in AJM network open, which is in 2020, I can post this in a moment, really found that older physicians had a trend towards higher resilience, less burnout. Now, again, this is a selected group. The older physicians are the ones who didn't burn out, the least, you know, practice. So these numbers are better. And then the question comes into what's led to our resilience? There's a Connor Davidson resilience scale is used and just looks at emotional exhaustion and depersonalization. And these scales, you know, found that older emergency physicians in particular, we did pretty well, were actually able to add years to their practice. Now in terms of value, this is important, and has been alluded to, senior physicians will actually, are able to provide some crystallized intelligence. This is the intelligence that occurs between age 40 to 70. You know, you've got tons of practice, you've got experience. This is part of redefining the metrics for a senior physician. We're all based on our RVUs, et cetera, but really crystallized intelligence and just being able to answer the questions that have your younger physicians that you're now possibly mentoring, being able to answer them has been really important and has led to kind of a, both longevity for physicians, and has led to like me, a higher quality experience in a practice. Senior physicians are able to have institutional memory and provide some organizational success. They also have a higher level of commitment to the facility, and that's important in terms of the quality. And we're all always looking at our patient satisfaction metrics. Clinical solutions are important because older physicians really can remember when how to necessarily maybe come to a different outcome to actually come to using different means for solving a problem based, and we see this now, when we all have shortages. we have shortages of bacimycin, and have shortages of lidocaine. We've had shortages of succinylcholine recently. I mean, so we've learned to use from experiential learning, many of the different, really the cannon of the armament area of medicine. From a mentorship standpoint, that's clear that older physicians, senior physicians, are able to offer kind of ways to navigate emergency departments. And, you know, I have been involved not just with medical students, but with some of our younger physicians who just need to figure out how to do life and how to maybe get involved in a research project, how in, in my case, how I navigated not burning out and I actually found my niche. Finally, of course, there's the administrative responsibilities and the perspective after X amount of years in a facility, you get to know everyone and you get to know their personalities and you know, who you can ask. And that's part of the institutional knowledge of who can you ask? Who can you stay away from? So-

- [Man] Unless I actually get sick.

- [Maura] Please mute your lines. Thank you.

- [Man] Yeah,

- [William] No problem

- [Man] Unless you're asymptomatic It could be a lot worse

- [William] In terms of senior physician values in the academic facility, it works out so that we have a scholarship

- [Man] A real hard test it was in 90 days

- [William] As it kinda works with resilience and with a sense of citizenship. Which means-

- [Man] So you're either well or you're not.

- [Maura] Dan Durand, I'm gonna have you mute, please.

- [Man] Something and you're-

- Your facilitator should be able to do that as well. Just to throw that out there.

- [Maura] We've been trying, sometimes it doesn't work.

- [William] All right. Anyway, so these are some of the redefining the metrics of value Not just RVUs, not just how many patients per hour, but actually your scholarship, your citizenship, your mentorship, anything that you can offer to the institutional kinda setting. And that's really where I'd like to go for today. And maybe Dr. Durand would...

- [Maura] Thank you very much. Dr. Durand, if you can mute your phone, that would be great. So I wanna thank all of the panelists. I think we have a little bit of time for a couple of questions. I, Nicole, or Amber, if you can mute that or remove him from the top that would be great. So, one question I have for Katren, which is actually spurned from a interview I heard a few decades ago with George Mitchell, for those of you who may or may not know, he was very much involved in the Northern Ireland peace talks, which as my parents are both from Northern Ireland, so something that was very personal to me and he gave an interview after his book came out, And the very last question of that interview was, "You do a lot of traveling. How do you deal with jet lag?" So this like entire career that he had, and the last question of the interview was about dealing with the jet lag. And so, you know, obviously there's things that we can do structurally to try and improve transitions between shifts or to match chronotype to shift work. But are there other things that we can do to prepare for shifts that might not be our chronotype?

- [Katren] Yeah, so, I mean, I think there's actually one of the things that sort of amazed me when I started researching this was the actual, incredible body of literature about sleep. There's actually more than four high quality journals that are dedicated to sleep, much of which is sort of focused on other industries, almost none of which is focused on healthcare. I mean, and many people have already worked out what some of the specifics are for them. You know, we spent a vast quantity of money on some blockout blinds. I have very fancy, those noise canceling earphones. I do think having us burning up the planet to have your room the right temperature, that you're sleeping in, which certainly in Sacramento in the summer means that the air conditioning is running high. I have a fan, all those other kinds of things. You know, alcohol is a interesting component. Some people find that they're very sensitive to the use of alcohol and same with caffeine. It's a highly individualized response. So I think one of the things that I really sort of came to the conclusion about this is, every person has the responsibility to themselves to figure out really what works for them and try and maximize that as much as you possibly can ahead of a shift that you know is going to be difficult. You know, obviously separate from those systemic responses.

- [Maura] Fabulous. I think one of the key takeaways I'm gonna take from your chat is not just all of the knowledge that you dropped, which we will try and get our slides up online as well for people who want slides. You can also email me. It's mkennedy8@partners.org and I'm happy to get you slides as well. This is recorded, But I like the fatigue management is a system responsibility and that's sort of one of my major takeaways. And I really appreciate that. There was a question from earlier, and if anyone would like to answer it. "When developing a policy or process related to the aging physician, how do you socialize the idea to get buy in from the group?" That might be a good one for Paul to take actually?

- [Paul] Sure. I mean, this is something that is important, not just for aging, but anything you're doing with your group, and there's a little bit of feel and what's the tone of your group. So we'll talk individually to people that we think are important stakeholders and might have input, or who are particularly vocal that you know if you're gonna present this to your entire group, they're all of a sudden gonna stand up and say, and like submarine the whole thing and get it in front. You know, because we're so big, we'll do some of that individually. And then we have a smaller group, like this clinical oversight group where there's a smaller group of attendings that we can run things by and get input to make sure that there's nothing that's gonna be like a deal breaker on this before we announce to everybody else. So, it really depends on your group and how big you are and the dynamics of how you work.

- [Maura] Yeah. Bill, did you wanna say something?

- [William] Yeah, I think, you know, that question is really important how to get buy in. And that is really part of, I think, leadership at the facility and also nationally. The facility, and we found this from our study, that older chairs tended to kind of create the tone that allowed younger physicians to buy into that idea. Younger chairs were a little less inclined to really set the tone for allowing physicians to age gracefully within this field. And so it's not just really socializing it, it's also requires a little bit of maybe advancement by leadership.

- [Maura] Awesome. And with that, we are about to wrap up. I think another takeaway that I think I have from Bill's talk is really about ensuring that when we're talking about wellness, we're talking wellness across the spectrum, and that inputting wellness things, which may be limiting night shifts for older persons, don't become an undue burden on the younger individuals, but similarly, other policies around wellness don't adversely impact the senior physician. So, there's a lot of amazing stuff in the chat. We're gonna, I think we can probably print this off. So, since we've recorded it, we usually can save the chat. We will try and organize some of it 'cause a lot of different policies that people put into the chat and other information that we'll try and put together. And then probably on the ACEP geriatric section, geriatric emergency medicine section website, we'll be able to have a link to this recording, the slides and other material. With that, it is one o'clock. Thank you, everyone for joining us and have a great afternoon. Happy summer.