Wellness Week January 23 – 27, 2023

It’s CAEP Wellness Week 2023!

It seems to have rolled around again very quickly… and yet very slowly too. We had some internal debate about what would be best for this week. We didn’t want to paint the current situation with toxic positivity, and we also recognized that speaking of “doom and gloom” all the time doesn’t make us feel better.

Many of us felt that self-compassion has really been key our mindsets right now, and so the content this week mirrors the 3 elements of self-compassion that have been described by Dr. Kristen Neff.

• mindfulness: acknowledgement of the current emotional state with honesty
• common humanity: recognising that we are not in this alone
• self-kindness: “being warm and understanding toward ourselves when we suffer, fail, or feel inadequate, rather than ignoring our pain or flagellating ourselves with self-criticism.”1

So, what we have for you this week is: a discussion of where we are right now, what is happening in EM internationally, and finally, because we are emerg docs, both Wednesday National Grand Rounds, and the final day post will include practical activities to help cultivate hope and energy. National Grand Rounds free! The topic is Shame Resilience for Emergency Physicians, with Dawn Lim presenting & Sara Gray moderating. Don’t let the word “resilience” scare you off. This is a talk full of thoughtful messages and practical take-aways!

What is going well?

“Now is a great time to live in the place you always wanted to. Staff emergency medicine positions are available for the taking across Canada (and, in fact, across the world). Departments will welcome you with open arms.

The public (and the rest of the hospital) have never been so aware of the role of the emergency department. I don’t remember being thanked by so many patients before. My neighbours finally seem to understand I work during holidays and nights. Nonemergency physicians tell me they find it hard to visit our department. Maybe, finally, other people get what happens in emergency medicine (and what is happening now)”

What is hard in emergency medicine right now?

“Emergency physicians stepped up in March 2020. We trained on how to manage COVID-19. We turned up to our shifts when everyone else was at home. We home-schooled our children, distanced ourselves from family and friends, dealt with our fears and anxieties, stopped travelling. But perhaps the hardest thing has been to maintain our enthusiasm and energy for our jobs when Canada re-opened. Emergency department patient visits are at records highs. Viruses are unabating. Patients are without family physicians. Many of our colleagues have retired, side stepped into other roles or left emergency medicine. Emergency departments have closed. We are too few physicians covering too many shifts. We worry how we will be able to sustain the system and what is going to happen to emergency medicine.

What is hard for us right now? Burnout, real, raw burnout. We have followed almost 600 Canadian emergency physicians since the pandemic start. During the first two months less than 20% of physicians reported experiencing high burnout. You could invert these numbers for our most recent emergency physician survey with high burnout levels found in the vast majority of the same participants.

Words like ‘tired’, ‘exhausted’, ‘lack of empathy’, ‘hopelessness’, ‘getting out’, ‘leaving’ and ‘retiring’ are recurrent in the October 2022 survey. Recurrent themes are the utter lack of energy, that things are worse now than they were at the height of the pandemic, that work is overwhelming and there is political inaction.

 If you are feeling like this, know that you are not alone.”

This week is an invitation to keep taking it one shift | patient | coffee at a time, and to recognise 2 things: one day at a time is OK, and doing it with others that you care about, is a win. Join the twitter conversation with #CAEPWW23

1. https://self-compassion.org/the-three-elements-of-self-compassion-2/

See you everyday for new content!

Rod & Louise

What is it like to be a Swiss EM Doctor?

In Switzerland, the title of EM doctor may describe different roles: It may be an internal medicine or surgery specialists with additional qualification in emergency medicine who works in an ED. Or, it may be an anesthesiologist who accompanies paramedics to provide preclinical emergency care. Some do both. For me, working at a medium-sized urban hospital, it means spending each day closely working with a team of nurses and residents trying to solve medical puzzles and providing primary care.

3 things that are going well in EM in Switzerland:

Swiss EDs are well equipped with readily available diagnostic tools, including MRIs and specialist consultations. Follow-up specialist consultations usually take place within a short time span, as required by guidelines.

EM is seen as an attractive occupation among young residents. It is an incredibly interesting field with varying working hours, which is why – luckily – positions available at EDs can usually be filled. However, this is threatened by less attractive working conditions that have emerged post COVID-19.

Collaboration between hospitals usually works well: If a there is no availability in-house, or patient needs care that is only available in a different hospital, we work together to transfer patients to wherever care can optimally be provided.

3 things that are hard:

Currently there is a concerning shortage of (mostly nursing) staff, which results in a severe lack of in-hospital care availabilities. This has worsened after the COVID-19 pandemic. We now engage daily in long searches for an available hospital bed elsewhere for a patient in need, which binds resources and results in stress for everyone involved.

While there is a diploma for EM, it is not its own specialty. This results in greatly varying skills and backgrounds of EM physicians, and weakens the position of EM in cooperation with other disciplines. This has even resulted in interdisciplinary EDs being shut down and medical emergencies being directly referred to specialists.

The increasing shortage of family doctors, the growing population, and the shifting understanding of a medical emergency in the public leads to staggering increases of emergency consultations each year. We continually expand resources to accommodate this increase, but it still leads to longer wait-times and over-filled EDs.

Description of 2-4 solutions underway

There are continuous political efforts on multiple levels to establish EM as its own specialty. Recruiting initiatives of family doctors and nursing staff look promising: We just passed a political initiative to improve working conditions for nurses. Family doctors have been working closely with universities to create interest in the profession among medical students.

Day 3 – CAEP National Grand Rounds (Wednesday, January 25th)

Day 4:  We are all in this together! A Danish perspective (Thursday, January 26th)

What is it like to be a Danish EM Doctor?

As a specialty, emergency medicine is popular and meaningful. Emergency departments are very different in DK both in terms of organization, the number of specialists and the conditions they are run on. Most emergency departments are organized as hybrid organizations where staff coverage is shared by emergency physicians and other specialties. In general, resources do not balance patient volume and the emergency departments suffer from existing capacity problems in the healthcare system.

There are more and more role models in emergency medicine. The work of DASEM and YDAM (Younger Danish Emergency Physicians) and their priorities for change are recognized on the national agenda.

What three things are going well in EM in Denmark?

There are increasing numbers of interns and residents and specialists nationally.

Important subjects on the national agenda have been identified and prioritized including finances, specialist capacity and organization as well as national agreement on how to run the emergency departments.

Emergency medical doctors have gained greater representation in central bodies nationally.

What are three things that are difficult right now?

1. Resources do not match patient volume. We have too many patients entering the emergency departments who are not acutely ill. Possible solutions to this problem:

• Sub-acute slots in the outpatient clinics
• Have elderly patients treated in their own homes
• 72-hour follow-up on discharges and the possibility of re-admission in those discharged wards if necessary
• Pre-visiting emergency vehicles with paramedics/ambulance doctors with the possibility of transferring care to the emergency departments or treatment at home under the supervision of emergency physicians

2. The bed capacity does not match the demand. This may be solved if one succeeds with

• The solutions mentioned under 1 (see above).
• Specialists on duty 24/7 – especially in the internal medicine specialties with focus on the ward corridors, so that patients are discharged as soon as they are ready – this reduces limitations on beds, which in turn reduces boarding (one of the main causes of crowding in the Danish emergency departments).
• More emergency spots or “transition places” for the elderly, so that the only options are not only limited to either 1) home, 2) ambulatory follow-up or 3) hospitalization.

3. The shift structure and 100% clinical/shiftwork does not match the work life balance for doctors and risks burnout. DASEM and YDAM have in recent months arranged both events and surveys with the goal of identifying an estimate of amount of emergency medicine doctors who are burned out and why – with the focus being how we can change that.

Possible solutions:

• Take individual consideration of the individual doctor to the extent that it can be done instead of everyone being treated the same. Doctors have different needs depending on where they are in life – correct reality in relation to the art of the possible.
• Change the collective agreement and the shift structure.
• Increase finances to ensure adequate staffing.
• Include the possibility of having a few days a month where you have non-clinical functions that focus on developing and strengthening the department and the community.

Can you describe the collaboration and work your committee is doing for EM Staff Wellbeing?

YDAM (Younger Danish Emergency Physicians) was established under DASEM as an independent organization. They work closely with DASEM to prioritize especially the below mentioned areas. The involvement of YDAM in DASEM’s work ensures the representation of young emergency physicians and their opinions in the decisions that are made in regard to their future work life.

1. Improvement of the working environment
2. Revision of the competence card and the goal description
3. Ensure representation in national central bodies
4. Advocate for a collective agreement that adequately reflects and renumerates the demanding nature of emergency medicine work and shift structure
5. Bringing “how to reduce the load on the emergency departments” on the national agenda
6. Increasing post-graduate education in emergency medicine, so that we can succeed in becoming enough to handle the emergency task
7. Work for larger training community in emergency medicine, for example through regional educational days

Final Thoughts:

Despite our differences, we are very much the same.  We share a common vision to provide high  quality care for the people in a timely and efficient manner.  Despite system differences, we experience similar physician burnout.  We really appreciate the two groups learning from each other to help solve problems that are common beyond our borders.