Physician wellness is associated with career satisfaction.¹ Compared to other specialties, emergency physicians suffer from high rates of burnout.^2–6 In addition to personal career satisfaction, wellness and resilience are important to maintaining patient safety and quality of care. We demonstrate some important principles of wellness and quality through five case scenarios.

Case 1: No Duty Hours for Attendings

You are recovering from a painful divorce. Although suffering from some depression and sleep deprivation, your financial needs necessitate moonlighting to pay for your kids’ college tuition, and you are working 60–70 hours per week. Colleagues have remarked you are becoming forgetful. On a few occasions, you have forgotten to hand off patients properly to floor providers and lost track of treatments in progress for your ED patients. Who should monitor wellness and quality?

The Accreditation Council for Graduate Medical Education duty hour restrictions were set in place in 2003 and updated in 2011. These guidelines were instituted to enhance patient safety and improve the working conditions and education of resident physicians.^1,2 Unfortunately, there are no restrictions on attending physician duty hours. The lack of regulatory oversight makes it imperative for individual physicians, colleagues, and departments to monitor workload and fatigue.

The primary responsibility lies with the emergency physician. Despite financial pressures, duty to patient safety and quality of care must supersede personal financial interests. The determination of an appropriate workload that allows for rest, exercise, nutrition, and social wellness should be made by the individual physician. At times, if judgment is clouded by personal circumstances, colleagues or medical directors may appropriately discuss these issues with the physician and arrive at a mutually agreeable plan of action.

Case 2: I Never Call in Sick!

After traveling from a busy week at ACEP’s annual meeting, you are scheduled to work three back-to-back shifts. You will only be able to get about three hours of sleep before your next shift, and you are already exhausted. Should you call in sick?

Emergency physicians display a high degree of responsibility to the profession. Many emergency physicians feel such a sense of responsibility and loyalty that they will work while ill, fatigued, or otherwise impaired. Many feel that to shirk such a responsibility would be an undue imposition on already-stressed colleagues.

The solution to this problem must be multifaceted. Insight and prevention are the primary pillars of the solution. Whenever possible, physicians should anticipate stressful schedules and situations and plan accordingly. In this case, it should have been anticipated that an early shift after a trip would not be conducive to wellness and optimal function.

When unforeseen circumstances arise, such as illness or injury, physicians should work together to come to the best solution on a case-by-case basis. Departments should strive to develop a jeopardy call system if feasible. If this is not feasible, such as in a small group, physicians should work together to ensure that physicians are functioning at their best to ensure patient safety and quality of care. This may necessitate trading shifts or working extra shifts to cover for a physician who is not fit for duty.

Case 3: I Smell Alcohol

Dr. A arrives at work late, disheveled, and with alcohol on her breath. What is the duty of the physician she will be relieving?

Emergency physicians routinely interact at shift change. This is an opportunity to interact with each other to ensure fitness for duty. On rare occasions, it may be evident that a colleague is impaired in some way, such as by fatigue, stress, mental health issues, or substance abuse. In such cases, physicians have a duty to work together to support each other and arrive at a plan of action to ensure patient safety. In the short term, a physician who is impaired should not be providing patient care. This may be very uncomfortable to address and may necessitate involvement of the department chair or medical director. A plan of action may include temporary removal from clinical duties, a mental health evaluation, and inpatient or outpatient treatment to ensure physician recovery. Failure to address issues that directly affect patient safety are an abdication of professional responsibility.

Case 4: Caring for the Career

Dr. B, one of your longstanding colleagues, returned from a tour of duty in Iraq within the last year. Lately, he has appeared more quiet and withdrawn and is slower and less interested in his patients. As quality assurance (QA) director, you know he has also had several patient complaints in the last three months with the similar theme of patient dissatisfaction with not receiving opioids for chronic pain. Has he provided a lower quality of care for not “adequately” addressing pain? For lacking empathy? Does your role as QA director give you any additional insights in helping your friend navigate under the circumstances?

Dr. B’s decreased interest in his patients is worrisome and the central issue of this case. This decreased interest may represent a lack of empathy or something else. Physician empathy is a crucial part of interacting with patients. Conversationally, it often provides hope and the shared understanding needed by the patient for healing purposes and provides a meaningful dimension to the medical professional’s work life. If it is potentially missing or coincides with personality changes, it may be indicative of underlying psychiatric issues or substance abuse or dependence. Dr. B should be reminded of any services or resources offered by the department or hospital.

Patient experience of care surrounding opioid analgesics for chronic pain is a challenge we face in emergency medicine. While it’s important to treat pain in all of our patients, best practices recommend against the use of opioids for chronic pain.⁷ Additionally, chronic pain is best managed by a primary care provider, not an emergency physician. Complaints of poor patient experience for this reason should be reviewed, but if some kind of analgesia was provided or recommended, Dr. B has likely adequately addressed the pain complaint. From a quality assurance prospective, patient complaints such as this may offer a useful path to discuss what may be far more substantive and helpful to Dr. B.

Case 5: Physician, to Heal Thyself, First Do No Harm

Dr. C has a high rate of opioid prescriptions and orders in the emergency department. A nurse informs the department chair that she believes he has pocketed some ordered opioids. Who should monitor possible substance abuse and diversion?

Suspected substance abuse and diversion should be directly addressed with Dr. C by his supervisor (eg, department chair) and, perhaps, employee health. If there is concern about substance use before shift or on shift, he should be pulled off the clinical schedule and undergo a fit-for-duty evaluation. In many states, if a physician self-reports abuse to the medical board, the disciplinary action of the board is often more favorable than if the physician is reported by someone else. There are several national groups that facilitate physician rehabilitation and return to the workplace. Normally, an employer may not take action against the employee because the employee has exercised the right to partake in the Family and Medical Leave Act.

(FMLA) for treatment for substance abuse.⁸ However, if the employer has an established policy applied in a nondiscriminatory manner that has been communicated to all employees and that states under certain circumstances an employee may be terminated for substance abuse, pursuant to that policy the employee may be terminated whether or not the employee is presently using leave under the FMLA.

Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio.

Dr. Lall is assistant professor and assistant residency director in the department of emergency medicine at Emory University School of Medicine in Atlanta.

Dr. Wong is an instructior of emergency medicine at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

Dr. Schears is studying social justice and microeconomics at Brandeis University in Waltham, Massachusetts; she is due to graduate in May 2017

References

1. Keeton K, Fenner DE, Johnson TR, et al. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol. 2007;109(4):949-955.
2. Goldberg R, Boss RW, Chan L, et al. Burnout and its correlates in emergency physicians: four years’ experience with a wellness booth. Acad Emerg Med. 1996;3(12):1156-1164.
3. Doan-Wiggins L, Zun L, Cooper MA, et al. Practice satisfaction, occupational stress, and attrition of emergency physicians. Wellness Task Force, Illinois College of Emergency Physicians. Acad Emerg Med. 1995;2(6):556-563.
4. Arora M, Asha S, Chinnappa J, et al. Review article: burnout in emergency medicine physicians. Emerg Med Australas. 2013;25(6):491-495.
5. Keller KL, Koenig WJ. Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med. 1989;18(1):42-47.
6. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.
7. Frieden TR, Houry D. Reducing the risks of relief—the CDC opioid-prescribing guideline. N Engl J Med. 2016;374(16):1501-1504.
8. Code of Federal Regulations-Labor Relations, FMLA, 29 CFR §825.119 (1993).