Stress management techniques for emergency physicians

If you feel exhausted, overwhelmed, tired, and stressed, you’re not alone. Sadly, emergency medicine has the highest rates of burnout of any specialty. A staggering 65% of emergency medicine physicians have self-reported burnout. It can be a challenging role on the front line of medical situations that require fast-moving medical attention and sometimes death.

The stressful situations that Emergency doctors face are unimaginable to the every day person, a bad day in the office compared with one in the hospital...well, there is no comparison. One ER physician recounted that she understood burnout and had some great strategies to manage it. But a stretch of shifts left her sleep-deprived and on the edge of coping. She was stitching up a laceration and stuck herself (so common in sleep deprived doctors), and she knew the patient had a history of drug abuse. She held it together long enough to get back to the workstation, where she cried, unable to hold it together anymore.

Burnout has some scary consequences. Depersonalisation can lead to poorer outcomes for patients, high levels of quitting, three times higher levels of substance abuse and relationship problems.

Understanding burnout in Emergency medicine

ER physicians face numerous factors that could lead to burnout. Working in an emergency department often means encountering patients on their worst days, delivering difficult news while managing complex emotions. These doctors are exposed to a myriad of challenging emotional experiences, acting as sponges for grief and distress. Without proper coping mechanisms, they risk a convergence of depression, guilt, and grief, potentially leading to unhealthy coping patterns.

Symptoms and effects of burnout include:

• Trouble sleeping
• Exhaustion
• Indifference or cynicism
• Frustration and bitterness
• Feeling alienated and isolated
• Mood swings
• Ulcers
• Headaches
• Digestion issues
• Depression

The long-term outcomes could include substance abuse, divorce, physical unwellness, a persistent inability to gain satisfaction from work, and depression or suicide. Burnout is serious, and it’s important that individuals and organisations address it.

Causes of Emergency physician burnout

There are three elements to burnout:

• Emotional exhaustion from relentless work-related demands
• Depersonalisation, with a feeling of distance from the job and patients
• A decreased sense of personal accomplishment or efficacy

These elements are an outcome of a range of causes:

• Malpractice and fear of litigation (In America primarily)
• Sleep deprivation
• Exposure to infectious diseases
• Lack of exercise
• Poor nutrition
• Mortality of patients
• Long hours
• High-stress environments
• Unpredictable workloads
• Pressure for perfection
• No control over workload or type of work each day
• Threats of violence
• Administrative demands
• Shift work

Emergency healthcare roles are highly demanding yet immensely rewarding, offering a dynamic and challenging environment. The nature of work can vary dramatically - from routine cases to managing critical incidents and life-threatening injuries. ER physicians are at the forefront of healthcare, adeptly navigating a wide array of situations. They collaborate with a diverse team of professionals, including nurses and specialists, and provide compassionate care to patients and their families during their most vulnerable moments. This role, while unpredictable, is crucial and deeply valued, making a significant impact on public health and safety.

A few strategies that allow space to process emotions, healthy routines, and the support of colleagues can make a huge difference. While you can’t change the nature of the job, some science-backed techniques may be able to help you manage stress better.

Mindfulness and meditation

Mindfulness and meditation may bring hippies and yoga to mind, but they are both science-based practices, with strong evidence demonstrating their effectiveness. They are practical, don’t take up valuable time, and users can quickly notice differences in their outcomes.

• Meditation is using mental and physical techniques to focus or clear the mind. It’s a practice that enables calmer reactions in day-to-day events. It also can be tremendously helpful in processing the day's events; after a stressful day with patient deaths or where things went wrong, meditation can help you sleep, relax, and prepare for another day.

• Mindfulness is being fully present and aware in a situation, to be cognisant of thoughts, feelings, sensations, and environment in order to be calm in the moment. Imagine the charge nurse tells you there’s a newborn baby in cardiac arrest arriving in four minutes. You can feel the adrenaline rise, your heart pounds, you’re out of practice and panicking. This response can stop you from operating optimally. If you’ve got two minutes, you’ve got time to centre yourself, breathe, and be prepared to save a life.

Both train the brain to function differently. After an eight-week course in mindfulness, imaging showed that participants had more grey matter in the prefrontal cortex, the sensory cortices and insula, the hippocampus, and the cingulate cortex. There was also less grey matter in the amygdala, perhaps explaining the lessened stress response.

Mindfulness and meditation training has resulted in the following outcomes for ER health professionals:

• Less depression, anxiety, burnout
• Were better able to manage work related stress and better emotion regulation
• Improved performance in emergency situations

Neither practice yields benefits immediately; neuroplasticity takes time. But over time and continued practice, the positive outcomes will start to make a difference in individual lives and in the ER environment.

Once the practice and skill have been developed, it’s easy to incorporate, even on the busiest night in the ER. Microhits are when the physician takes 30 seconds to pay attention to their feelings and physical sensations; it can be enough to break patterns and thoughts. It could be as simple as taking a few seconds to feel the physical sensation of washing hands or enjoying the cold air outside while drinking a hot coffee.

More and more ERs and physicians are speaking about its benefits. Whether it’s a four-minute pause at handover or 90-second guided meditation before an incoming situation, it’s a practice that can be made to suit the staff and situation.

For individuals wanting to start, apps include:

• Calm
• Headspace
• 10% happier

Physical activity and burnout prevention

Exercise is vital for a healthy heart and respiratory system, it improves muscle, bone, and functional health, and it reduces the risk of stroke, diabetes, hypertension, depression, and some cancers. Physical activity is also directly correlated with mental wellness and burnout; ER nurses and physicians who exercised experienced less burnout and a higher quality of life overall.

Research shows that despite physicians and nurses being physically exhausted at the end of a shift, an average of only 7333 steps are taken per shift. Adding to this lack of physical activity at work, physicians tend to ignore their personal health with almost no attention paid to regular exercise.

ER staff need to prioritise their physical wellbeing to ensure their mental health. To start a routine, Ben Levine MD, founding Director of the Institute for Exercise and Environmental Medicine (IEEM) at Texas Health Presbyterian Hospital Dallas, recommends:

Finding the motivation to exercise. Is it to lose weight, lower cholesterol, or be able to play with the kids? Find the why. Get moving. Once the motivation is identified, find an activity that fits into the lifestyle. Consider a walk or run a fitness class, or a home workout.

His prescription per week is:

• One day of a long activity of at least an hour. This could be an exercise class, a round of golf, or a bike ride.
• One day of interval training – there are plenty of examples of this on YouTube
• One day of strength training, which could be anything from Pilates to an ER-inspired workout
• Two to three days of moderate activity over 30 minutes

Physicians have offered a range of tips for fitting exercise into often hectic work schedules:

• Make exercise incidental. Walk to work. Take the stairs, not the elevator. Enrol at a gym next to your favourite sushi restaurant. Take the kids to the park and run around with them
• Schedule in exercise so it actually happens. There is always an excuse to not exercise. Be disciplined. Some people like morning workouts, some prefer after work
• At home workouts can be effective and don’t need loads of equipment or great fitness. A yoga mat is enough to start. A skipping rope, weights, exercise bands or a kettlebell can be added later if wanted
• Go HARD. HIIT workouts can be super effective in only 15-30 minutes
• Something is better than nothing
• Exercising outside has multiple benefits; fresh air, vitamin D, or just a break from being inside

Peer support and sharing

The ER is a place where trauma will occur. Healthcare workers will experience high levels of stress as a matter of routine. Whether it’s seeing a young person die, witnessing the grief of surviving relatives, or just the burden of responsibility, it’s a role that is fraught with opportunity for distress. Research shows that peer support groups offer substantial benefits to physicians, with 86% of participants recommending the practice, and improvements in feelings of guilt and depression afterwards. Social media sites also offer places where medical professionals can read news articles, consult colleagues, network, research medical development, share cases and ideas, and vent. These sites include places like Sermo and Hand-N-Hand Peer Support.

Professionals should be talking with each other in person, too; a walk together or a chat over coffee can be helpful to avoid burnout. The hospital could also develop debriefing sessions, especially after traumatic cases or experiences. These give people a chance to reflect on what went well, what could be improved, and how everyone feels.

Building resilience

Resilience is someone’s ability to bounce back after a setback. Within the medical industry, this can look like:

• Understanding that mistakes happen, and being able to address these objectively
• Setting and holding clear personal boundaries
• Embracing and acknowledging own personal limitations
• Seeking professional help when needed, either professionally or emotionally
• A focus on self care and trying to have work-life balance
• Positive personal and professional relationships

The skills and techniques that physicians need to practice to build resilience include:

• Prioritising sleep, exercise, vacations, and practicing spirituality if relevant
• Chatting with supportive professionals about accepting personal limitations, and forgiving errors
• Accepting the demands of the role, and being flexible in response to unexpected demands
• Setting healthy limits in practices
• Prioritising educational needs, which can include reading journals, attending courses, or peer learning
• Nurturing a peer support network across disciplines
• Establishing strong support within family, and allocating time for personal life
• Acknowledging the contribution to the world and the special role a physician has in the lives of others
• Maintain interest in the role, which could mean studying something new

Seeking professional help

Therapy and counselling are vitally important for managing mental health and stress. While everyone benefits from talk therapy, there is much to be gained for those staff working at the frontline of medicine.

However, there is a legitimate fear of consequences that deters many healthcare professionals from seeking help. In the US, 57% of physicians report they would be worried about their job if they sought mental health treatment. This, coupled with discrimination for mental health history, discourages many from seeking the care they need and deserve. Physicians can seek professional help discreetly at a local, national, and international level. Depending on location and attitudes, peers, management team, HR, union, or a wellbeing team may be able to recommend local therapists.

There are a range of options online, which are anonymous:

• Betterhelp
• Talkspace
• Cerebral
• MDLive

Emergency room physicians and the future

The emergency room's fast-paced environment can be challenging, and it's not uncommon for physicians to experience stress and fatigue. Recognising and addressing these challenges is essential for maintaining mental and physical health. Employers and the healthcare industry are increasingly acknowledging the importance of supporting their staff's well-being, focusing on mitigating factors like sleep deprivation, long hours, and emotional strain.

Personal wellness should be a priority for each individual, and it can manifest in various ways. It's important to find the right balance of strategies that work for you. Whether it's seeking peer support, implementing stress-reduction techniques, or consulting with mental health professionals, taking proactive steps can make a significant difference.

If you're feeling the effects of burnout or overwhelming stress, consider exploring the techniques discussed here. Find what resonates with you and begin incorporating positive strategies into your routine. Sharing experiences with colleagues can open up supportive dialogues, fostering a collaborative approach to well-being. Remember, seeking help from therapists or wellness professionals is a strong and positive step towards managing stress and enhancing your quality of life in this demanding but rewarding profession.