Wellness Week January 25 – 29, 2021

Hello Everyone,

This concludes our 4th Annual Emergency Medicine Wellness week, hosted by the Canadian Association of Emergency Physicians.  We thank everyone for participating, and hope this week brought you value.  We have two treats for you, some wise words from our President Dr. Kirsten Johnson, and a link to a video featuring some of our amazing colleagues across the country (to be released 15:30 ET).  This is to backed up by a song performed by our very own Docs that Rock.  We hope you enjoy!

Rodrick Lim, CAEP Wellness Committee Chair

Concluding Comments

I wish to applaud the thoughtful and inspiring work by the Wellness Committee and our colleagues in EM for the Canadian Emergency Medicine Wellness week – a week that has come at a time when we are all fatigued from the pandemic and many of us are facing burnout. I appreciated how each day of EM Wellness week brought a fresh approach to wellness: from self-care to humour; individual perspectives on wellness to journaling as a tool. I especially liked Dr. Purdy’s list of seven values that are core to our practice and how our approach to wellness needs to maximize their congruence. It certainly makes one reflect that wellness is an essential part of our profession and that it can be approached in many different ways.

It is so important that we all reflect on our personal wellness and that of our colleagues now and going forward. The tragic passing of one of our colleagues, Dr. Karine Dion, an emergency physician from Granby, Quebec, due to the stress of the COVID-19 pandemic, is a devastating loss to our community. Her heart-breaking death is a reminder that members of our EM community may be suffering from stress and burn-out and that we all need to pause to consider what we are doing to promote our own wellness and that of the people around us.

Medscape’s National Physician Burnout and Suicide Report 2021 shows that Emergency Physicians have amongst the highest rates of burnout compared to all other specialties. Furthermore, 80% of doctors stated they felt burnout before the pandemic. This means that the any solution to address this problem must also outlast COVID-19.

According to the World Health Organization, burnout is a syndrome resulting from chronic workplace stress that has not been successfully managed. The emphasis is equal between the workplace and the worker, meaning that action is required from both sides. Until now, there has been too much focus on individuals addressing the problem. Going forward we must also consider this from a health-system point of view. This includes staffing shortages, working conditions, shift scheduling, bureaucracy, government regulations and the effects of culture and societal expectations. We need to involve hospital administrators, policymakers, governments and even our patients.

The Canadian Emergency Medicine Wellness week may be at a close, but wellness must remain central to our practice and specialty going forward. I encourage you to practice kindness to yourselves and to your colleagues. We may be 6 feet apart but we are in this together.

Dr. Kirsten Johnson

CAEP President

Hello colleagues!  As we kick off the 4th Canadian EM Wellness week, it is now more than ever that we need to discuss the state of our profession, and the importance of wellness.   Even prior to this pandemic, emergency medicine in Canada was in trouble.  A recent study showed we were in the range of 85% burned-out based on the Maslach Burnout Inventory, approximately 2-3x our peer physicians in Canada.  With the intense pressures over the past 10 months due to COVID-19, we are in real danger acutely, and after it is finally over. 

 This has been highlighted with the tragic passing of our colleague Dr. Karine Dion, an emergency physician who worked in Granby, Quebec.   Having helped patients for 10 years, her loss is devastating to her family, her community and to all of us.   The conditions we work under, the support we require, and how we can do better for ourselves and each other is the most important conversation we need to have.

 Throughout this pandemic, the importance of connection and building support for yourself and each other could not be clearer.  We are truly “6 feet apart and in this together”.  There will be impactful talks this week on the importance of self-care, how to deal with occupational stress, the power of positivity and humour, strategies on how leaders can create and promote positive work culture, and the power of narrative medicine on reflecting the world we live in.  I hope this week’s content brings you value. I hope that all of you know how important your work is and how much you help your communities.  We have tried to carry forth as best as we can, under immense “pressure”. 

Dr. Lim is an Associate professor and Medical Director & Section Chief of the Paediatric Emergency Department at the Children’s Hospital at London Health Sciences Centre and Chair of the Wellness Committee, and Leadership Committee at CAEP.

In today’s post, Dr Lisa Fischer takes a different twist on self care. While the age old saying of “putting your own oxygen mask on first” or “you can’t give what you don’t have” holds true, what if self care was extended to taking care of others as well?

 

Dr Lisa Fischer is an associate professor at the University of Ottawa and works as an emergency physician and palliative care physician at the Ottawa Hospital. Her professional interests are in physician health and wellness. She’s most herself outdoors, rain or shine, with her family of 5, with some form of sporting equipment strapped to her feet. She struggles with finding enough time to do the above and wastes a decent amount of time on social media (it’s CME sometimes though right?)

Self Care. Before you roll your eyes and doom scroll to the next social media topic, please note that this post is NOT about: yoga, kale, exercise, and sleep (disclaimer: I may mention peloton and pandemic puppies). The TL/DR of this post can be summed up by the following: 

If only it were that simple. 

It being 2021, you’ve likely been asked to attend a mandatory wellness session at some point over the last few years (note- I believe that the words mandatory and wellness should never exist in proximity to each other). Many of us know some relatively quick “go to” ways to work through acutely stressful events. Box breathing comes to mind, physical activity, even a big old ugly cry will help you process feelings. However, the limitations of being physically apart from each other has removed some important and high yield tools from the self-care toolbox: positive social interactions, deep laughter, and affection. This post is going to focus on putting yourself first, healing yourself first, on how we can kill Covid-19 with kindness, and on how we can beat Covid-19 at its own game (by moving the goal posts). 

STEP 1: STOP THE BLEED

You can give all the tranexamic acid you want to a bleeder but if you don’t achieve source control, you’re in trouble. Many of us are metaphorically bleeding; socially, financially, ethically, the list goes on. Our energy, empathy, and compassion reserves are dwindled with no replenishment in sight. How can we stop the bleed? The challenge is that everyone is bleeding from a different place, and for a different reason. There is no one size fits all answer. In this pandemic, some of us have purchased puppies (which is actually a good and evidence based gesture) and we have renovated home gyms, but why do we keep feeling so fatigued? I propose that we are doing this too late. By the time you are experiencing burnout, it’s much harder to muster up energy to take care of yourself. Adding a stacked workout to your stacked clinical day ends up feeling like another way to fail when you are too exhausted to do it. 

Imagine if, as a society, we spent as much time and effort exercising our mental health as we do our physical health. As a parent, I must say that I am guilty of this. My kids live in a carefully crafted extra curricular plan centered on physical activity year round, yet, how often do I delve into CBT to help them problem solve or regulate their emotions? Many of us wouldn’t bat an eye at hiring a (virtual) personal trainer. How many of us hire mental trainers (ie go to counselling? Get a life coach?). Imagine if you treated yourself with as much kindness and grace as you do your new dog. Or young toddler. If you don’t do this when you are “well”, how will you expect yourself to do it when you are unwell?    

We train exceptionally well for our profession. Unfortunately, this is often at a high cost to our personal selves. We need to practice wellness when we are well in order to be able to practice it when we are stressed. It’s kind of a wax on, wax off analogy. Find your tourniquet that stops your bleed so when/if you do need to reach for it, it feels natural, familiar, comforting, effortless.

 

 

 

STEP 2: KILLING WITH KINDNESS

Once you’ve prioritized treating yourself with kindness, share the love. By now, we’ve all had crash courses in public health, immunology, virology and epidemiology. R-naught is likely trending right now. What if, instead of the R-naught of infectivity, we replaced it with kindness? This is taking “random acts of kindness” up a notch. While it’s great to start a kindness train where one person does one nice thing for another and so on, let’s leverage the laws of exponents and have one person do a nice thing for TWO others. If corona can burn its way through a whole hockey team, surely kindness can do the same.

Kindness can look like so many different things. I am not going to placate you with my ideas of kindness (hint, they involve coffee), but know this: being kind to others is, in a way, selfish? It will bring you MORE joy than it does to those on the receiving end of an act of kindness. WIN-WIN!

STEP 3: CHANGE THE RULES 

When all else fails, when you are dealing with so many things outside of your control, it helps to redefine winning, and, redefine losing. Remember the intubation box? Many of you might have spent significant time and effort researching, designing, purchasing these devices only to learn later on that they were not the hail Mary they were led to be. Is this a loss? Maybe. Or, in this “failure” did we learn a lot about aersolization, physician and patient optimal positioning, best practice pharmacology and PPE that has since led to the development of safe and efficient protected Code Blues?

In this pandemic, I can’t say I have found a gregarious “win” yet, but there are some small ones. The various online physician forums have forged many new virtual connections amongst us (did you know that there’s even a spin off group for MDs looking to date MDs?), a simpler life has led to fatter pocketbooks and time for hobbies old and new, and I am hoping there’s been a mildly positive environmental aspect from decreased air and car travelling, to name a few. 

I’ll close on Meaning. Humans can tolerate suffering, if we know why. Dr. James Maskalyk eloquently wrote “Pediatricians and parents will tell you that after a viral infection, a child will have a growth spurt. Taller, smarter, more resilient. I believe the same will be true of our global body, from this collective time of sickness, that we will become a healthier version of ourself”.  I can’t say that I pretend to know what this healthier version of ourselves looks like, sounds like, feels like, but the concept of post traumatic growth is something I will be holding on to. Thus, (I can’t believe I’m quoting Jerry Springer) “Until next time, take care of yourself and each other”.

(random posters spotted in hospital)

Dr Brittany Cameron has conducted rapid fire interviews with leaders across the country examining work related stress and how we can work together to overcome occupational challenges. Listen in to hear some vulnerable and challenging moments we’ve lived and for some practical tips to try out yourself!

Originally from Halifax, N.S., Dr. Brittany Cameron works as an emergency physician at Michael Garron Hospital in Toronto, ON. She enjoys teaching yoga, distance running and travelling. Her new pandemic pastimes include attempting kundalini meditation, homemade pizzas on her new ‘Pizza Steel’ and a lot of walks and coffee. Professional interests include physician wellness and medical education.

Click on the images to hear the interviews

Dr. Samantha Calder-Sprackman

  • “The pandemic has affirmed what I have always known to be true: that wellness is important in emergency medicine both personal and wellness supported by the organization that you work in. I have, for a long time, believed that creating a healthy, well work environment creates healthy, well physicians and therefore optimizes patient care.”
  • “Despite having many wellness initiatives in place or being a person that prioritizes wellness , there are sometimes unexpected challenges, like a pandemic that turn things upside down and sometimes it’s hard to be well even if you’re someone that has prioritized wellness for a long time… sometimes it’s okay to not be optimally well. Being okay with that and learning to accept that actually has helped me to be more well during these times of uncertainty.”
  • “I am a new mom. I have a thirteen month old and I came back to work three months post-partum at the start of March when the pandemic was declared. The biggest thing I did to outsource stress was hire a nanny… this allows me to use my free time to focus on my work and to be present with my family. This has allowed me to do things that are very meaningful to me and that is invaluable.”

Dr. Joe Nemeth, Emergency Physician, Trauma Fellowship Director  McGill University

  • On shift:  “Every 2-3 hours I tell my trainees and myself that we have to do something in-shift for physician wellness … anything for 3-5 minutes. There is no way that we can’t take 3-5 minutes to either go get a cup of coffee, talk to a fellow colleague or a nurse about something clinically unrelated,  play Donkey Kong  on your phone, call a significant other..”
  • “Wellness is an incredibly important aspect of what we do and how we manage our days and our personal life and our professional life.”
  • “To have an incredibly peaceful background, inner contentment helps you to manage uncertainty and anxiety and the challenges we face in the emergency department.”

Dr. Laurel Murphy, Emergency Physician, Intensivist, Program Director Emergency Medicine Dalhousie University

  • “When my life outside of medicine feels like it is in order I function better as a doctor. The ABC’s of life are eating and sleeping and exercising. If I can accomplish those in my life, I do feel that I am better at work and I do feel like I am a better person and parent and wife… even 2 out of 3 ABC’s is actually pretty good!”
  • On-shift: “When I was brand new I felt bad asking my colleagues for an opinion on something….. If I have a challenging case now I have a much lower threshold to ask people’s opinion who is also on shift. I find it takes some of the stress off me if it’s a decision that I truly don’t know what to do with.  It was kind of foolish of me to think people would have thought less of me.”
  • On wellness: “It’s nice to see it talked about, to see national interviews being done. There have been lots of positive improvements in the specialty overall.”

Dr. Gordon Jones, Emergency Physician, Queen’s University

  • “Remind yourself that you are privileged to work, that you are privileged to be helping people and doing a good job, and to be grateful for the incredibly nice patients you work with. And the patients seem a little bit better than they used to be, they are more understanding, more grateful for their care, they say thank you more.”
  • On the pandemic: “These are tough times in terms of worrying about what’s going to happen in the future- am I going to catch this, am I going to get sick… it makes us a little more aware that in life you can’t waste any time, you have to remain fit and look after your wellness.”
  • On a pre-shift routine: “Try to come in (to work) as fresh as you can basically- mentally and physically. Emerge shifts are a little bit like a sporting event, you have to be prepared, show up fit and you go. It’s an athletic event so you have to be ready for it.”

Dr. Jessie Breton Emergency Physician University of Alberta

  • Pre-game routine:” I sometimes listen to a Spotify playlist that I made for myself. I had some friends submit some songs and it’s just been a good positive mindset to walk into work with and play during my drive into work… definitely a pump-up list.”
  • “Prior to the pandemic, wellness was something that we took for granted…it became very clear for me that I was going to have to be more proactive and mindful about how I established wellness more meaningfully and in my patterns.”
  • “I try to limit my time on social media after shifts. I find that anxious energy I feel after work can spill over into doom scrolling on Twitter. I put a maximum limit on my time on social media on my phone, which I highly recommend to everyone. Instead, I listen to an audio book or a podcast and get some sleep.”

Dr. Erin Brennan Emergency Physician, CAEP Sim  Olympics Co-Chair Queen’s University

  • “My colleagues and residents working with me would certainly make fun of me for bringing a ‘Brennan Box’ which is a little Tupperware full of vegetables to work… I really got used to having that next to me when I was charting….it made me feel I was doing something good for my health. Now that I can’t have food during my shift, I really find I miss that a lot.”
  • “With challenging cases I think it almost always comes down to communication… this is the way I’ve found most effective to deal with times I’ve felt uncertain.”
  • “If I’m driving into a night shift I pump the party jams. Ten minutes of solitude on my drive to work is how I prepare”

The world is clearly not a funny place these days. But did you know that humour is actually as good as, or even better, than exercise to help decrease anxiety and depression in medical providers? Even forced laughter has been shown to decrease cortisol levels, increase activity of Natural Killer cells, increase your pain threshold and even cognition. Surprisingly, the absence of in person meetings and social gatherings has provided new ways for humour to bring us together, and it seems like this is more important than ever.  

Dr Francis Bakewell takes a slightly humorous yet evidence based approach on how we use (and at times abuse) humour in medicine, the acceptable types of humour to use with patients and each other, and more. The link below will take you to the University of Ottawa Emergency Medicine Grand Rounds on Best Medicine: Humour in Medical Culture and Practice

Unfortunately, during the recording of this lecture, the video aids did not transfer well. Please see below for the video links that can be watched concordantly. Note the links below are copyrighted material and are included for educational purposes only. They may include language unsuitable for all viewers.

MINUTE 2:08

Ricky Gervais, The Office – Laughter is the Best Medicine

https://www.youtube.com/watch?v=h0_ckdS-2KU

MINUTE 11:07

That Mitchell and Webb Look – Medical Drama

https://www.youtube.com/watch?v=C_AmdvxbPT8

MINUTE 21:40

That Mitchell and Webb Look – Ice Cream Taster

https://www.youtube.com/watch?v=OzRlDyI0OGA

MINUTE 36:26

That Mitchell and Webb Situation – Surgeon Pranks

https://www.youtube.com/watch?v=HdL2Y-l00cA

Trust us when we say it’s an hour definitely worth listening to! 

Dr Bakewell is an emergency physician at the Ottawa Hospital. He is an Assistant Professor and the director of the Medicine, Ethics, and Humanities Program at the University of Ottawa in the Faculty of Medicine. His interests are in Enhanced communications skills, Medical Humanities and Ethics.

In the post below, Dr. Luckett-Gatapoulos shares her experiences and expertise in Narrative Medicine and how writing can help us make sense, or find sense, in a sometimes nonsensical world. Be sure to navigate to the bottom of the page for your chance to participate in the first CAEP Narrative Medicine showcase. It’s your turn to test the waters of Narrative Medicine for a chance to win a CAEP voucher! Select entries will be published in an upcoming issue of CJEM.

Dr. Luckett-Gatopoulos is an emergency physician in London, Ontario, and a paediatric emergency physician in Hamilton, Ontario. She studied Narrative Medicine at Columbia University, and has spent her free time during the pandemic tending to her ever-growing collection of succulents and animals.

When I was a kid, I was given a copy of the book Dear Mr. Henshaw by Beverly Cleary.

Cleary was a god to me. Her Ramona books anchor some of my earliest memories, and still hold a special place in my heart. I loved and identified with the spunky Ramona Geraldine Quimby, the rambunctious and often-annoying younger sister of Beatrice. Curious, outgoing, and well-intentioned, she still landed herself in hot water more often than not. I could relate.

Imagine my disappointment when I discovered that Dear Mr. Henshaw was written from the perspective of a quiet and introspective boy named Leigh. Leigh writes a poorly-written letter to his favourite author, Boyd Henshaw. It’s boring, shoddily-researched, and littered with spelling mistakes. Still, Mr. Henshaw writes back, gently chiding Leigh for his lack of effort.

Leigh resents Mr. Henshaw’s critiques, but through the twists of fate and circumstance that describe any children’s literature of the era, the two strike up a correspondence. When the volume of Leigh’s writing becomes overwhelming, Mr. Henshaw encourages Leigh to keep a diary, a sly way to keep Leigh writing without requiring a response, I suspect.

As Leigh writes in his diary, addressing his entries to Mr. Henshaw, we hear about his difficulties in being the new kid at school. We watch him process the realities of an absentee father. We lament his stolen lunches, and we see his spelling improve. More importantly, we observe Leigh as he matures into a reflective young man who learns to understand the important people in his life and his own emotional experience in turn.

Thinking of Dear Mr. Henshaw, I’m reminded of the following quote attributed to Anglican cleric William Griffith Thomas:

The only bit that’s ever really stuck with me is the part about writing yourself clear. To me, it reads like a directive, an exhortation to spill out in the words in our muddled minds onto paper until what was inchoate finally makes sense.

When we write, we can bring ourselves to a reckoning with the parts of ourselves and our experience that we don’t really understand. We explain ourselves to ourselves.

It’s perhaps not surprising that Dr. Rita Charon, an internal medicine physician with a PhD in English literature grounded the field of Narrative Medicine in the literary critical technique of close reading.

When we closely read a text, we focus sustained attention on it. We think about the formal elements of the text, like the voice, structure, and tone, even as we think about our reactions to it, like what we see, hear, smell, and taste.

In a typical Narrative Medicine session, we closely read a text. Sometimes, it might be a poem or piece of ‘literature’, but it might also be a music video, an advertisement, or an account of an interaction between a patient and physician. After we’ve done this, we move on to the process of reflexive writing.

When we write reflexively, we set a timer, read a short prompt, and then write whatever comes to mind. The only real rules are that we don’t self-edit, but instead write freely. Then we share our writing without prefacing it, ignoring the urge to say ‘well, this isn’t really very good,’ or ‘I’m not much of a writer,’ or ‘I could have done better if I had 8 minutes to write instead of 7.’

In sharing our written work, we again apply the principles of close reading, observing for ourselves and for one another what our choice of words, our syntax, and our tone can tell us about our inner experiences. Often, this process can lead us to an understanding of ourselves and our relationships to our colleagues and patients that we would not otherwise have access to.

I graduated and began working as an emergency physician shortly before the pandemic began. Not knowing much about what life was like in pre-pandemic times for attending physicians, I don’t have much to compare my current experience to. 

Still, I sense that times are particularly tough. 

We are navigating a new and challenging landscape, and the map keeps shifting before our eyes even as the ground moves under our feet. We are being challenged to practice medicine in new and different ways, even as we stay 6 feet away from our closest supports. We endeavor to shield and protect our learners while striving to provide them with the educational experiences they need to become competent and confident physicians.

These are difficult times to make sense of, but that’s where the principles of Narrative Medicine are best applied. We aren’t sure where we are going, and sometimes it’s difficult to even know where we are. But, whether we are writing a diary addressed to Mr. Henshaw, sharing our written words with our colleagues, or privately writing to explain ourselves to ourselves, sometimes we can write our way to clarity.

Now it’s Your Turn! CAEP is pleased to launch it’s first ever Narrative Medicine showcase! Submit your personal 55 word “Write Yourself Clear” entry for a chance to win a 50$ CAEP voucher and be published in CJEM.

  1. Consider the challenges of the past year within the context of the theme “6 feet apart and in this together”.
  2. Set a timer for 10 minutes.
  3. Write reflexively whatever comes to mind until the time is up.
  4. Take a break, and then return to edit your work. Pare down your entry to a total of 55 words. Grammar is not important. The goal is to eliminate the extras and retain the essence of those thoughts.

Deadline: midnight, February 28th, 2021

Example/Process 1                                          Example/Process 2                                         Example/Process 3

    Now it’s Your Turn! CAEP is pleased to launch it’s first ever Narrative Medicine showcase! Submit your personal 55 word “Write Yourself Clear” entry for a chance to win a 50$ CAEP voucher and be published in CJEM.

    1. Consider the challenges of the past year within the context of the theme “6 feet apart and in this together”.
    2. Set a timer for 10 minutes.
    3. Write reflexively whatever comes to mind until the time is up.
    4. Take a break, and then return to edit your work. Pare down your entry to a total of 55 words. Grammar is not important. The goal is to eliminate the extras and retain the essence of those thoughts.

    Deadline: midnight, February 28th, 2021

    Example/Process 1                                          Example/Process 2                                         Example/Process 3

      In closing out this year’s wellness week, we thank Dr. Purdy for her thoughtful and intellectual take on leadership, culture, and the importance of maintaining an alignment with who you are and who you want to be. Staying connected to oneself and demonstrating authentic leadership translates to an ability to better connect with others. Simply put: together we are stronger. Together we can work on tackling systematic issues that threaten the culture of Emergency Medicine.

      Eve Purdy (MD, MSc, FRCPC)  is an emergency physician and applied anthropologist. While training in Emergency Medicine at Queen’s she completed a Master’s in Applied Anthropology through the University of North Texas and a fellowship in translational simulation and team performance at Gold Coast University Hospital. She draws on tools in anthropology and simulation to explore the messy intersections of people and their work. In different contexts including trauma, emergency department response to COVID-19, and obstetrics –  she is working to understand and shape organizational culture and high performing teams. You can find her on twitter @purdy_eve.

      A national conversation around wellness within our Canadian “emerg” community is not complete without a reflection on culture – the values, beliefs, and practices that make us who we are.  As an applied anthropologist and emergency physician, I have spent a fair bit time thinking about the culture of emergency medicine…diving into what really makes us tick. The more I learn, the more proud I am to belong to such a unique and motivated group. The more I dig, the more complexity I uncover in our core values and beliefs and the surer I become that there is much left to learn. The more I observe, the more I appreciate the tensions at the interfaces of our values. Together, we feel and manage the acute conflicts of our organizational culture every day, often without knowing it.

      So, why does a discussion of values and their interfaces belong in a week focused on wellness?

      Simply put:

      When the work that we do does not align with our core values, we feel bad. We all know that feeling. A moment when we notice that a patient we saw 24hrs ago is still in the department waiting to be admitted. Or when we are struggling to arrange a test a patient requires on the timeline that we think it needs to be done. That feeling when we leave a shift heavier, wishing we could have done better.

      And, the obvious corollary:

      When the work that we do aligns with our core values, we feel good. We have all been part of a well-oiled team that saves a life, or that moment when we coordinate seamless outpatient follow up for a patient with a specialist. That feeling when we leave a shift lighter, knowing that we did good work.

      These statements refer to the concept of value congruence: how well the work aligns with our core values. One way to think of how our organisations should approach wellness is to consider how to maximize value congruence1,2,3,4 and minimize value incongruence.

      Emergency Medicine: Who Are We?

      This might seem like a simple question to answer. Heck, we look after any patient with any problem at any time. We are the calmest people in a crisis. We make order out of chaos. And, we all have a few good stories to tell.

      But it turns out that it isn’t quite so straightforward. The values, beliefs, and practices of a group are learned, and taught, and always changing. No single emergency department culture in Canada will be the same but based on my experience there is likely significant overlap in how we see ourselves and our work.

      “ We are emergency doctors and nurses and team and so, sort of accepting and dealing with uncertainty is our specialty and we’ve been training for some years to do that.” – Resident

      As an anthropologist, I have made a habit of studying groups during times of cultural compression – moments when the values and beliefs of a group bear down with particular intensity. These are moments when culture is both magnified and prospectively shaped. I have studied moments of educational cultural compression like simulation and departmental moments of cultural compression like the COVID-19 pandemic. So far, across these contexts, I have found seven core values particularly relevant to emergency medicine (Figure 1)5. This is by no means a definitive list but rather serves as a starting point for conversations around our collective identity.

      Tensions Between Values

      When we look at each of these values individually, they all make sense…but where things really start to get interesting is when we think about how and when these values intersect and conflict. Sometimes tension happens because of the inherent contradictions between our core values and sometimes external factors are the cause of the conflict.

      When values conflict directly with each other we start to appreciate the inherent contradictions in our values framework. The ability for us to “keep patients and families at the centre of care” sometimes conflicts with our interest and responsibility to “treat and identify life threatening illnesses” and our ability to “balance needs and resources at a system level”. For example, the patient who has a simple runny nose could have a poor individual experience because they had to wait while we resuscitated a critically ill patient. Sometimes we can adapt our systems to fix the inherent conflicts – in this situation, a department may actually have a dedicated “fast-track” doctor to prevent the backlog of minor cases. These inherent conflicts are hard to avoid but worth naming and ameliorating where we can.

      Even more pressing are external stressors that directly threaten our core values. For example, for years ED overcrowding has threatened our identity and ability to provide care that aligns with our cultural values. More recently, the pressures associated with COVID-19 are an extreme example of this threat. Our how do we provide care that aligns with our values when resources are overwhelmed?

      “You should have a room for everybody, the hallway thing is, you know, I’ve seen it develop over the years and it’s like a bit distressing because it’s not a good thing and I know we’re not the only place that does it, that’s for sure, but how did we get to that?” – ED Nurse

      When we start to reframe resource allocation in times of scarcity, or emergency department boarding, or lack of access to outpatient services, or poor infrastructure through the lens of a direct threat to our fundamental identity, we understand more about why these challenges are so problematic, not only for patients, but for the wellbeing and longevity of our emergency medicine community.

      Value Congruence and Wellness at the Organization Level

      Evidence around individual and organizational wellness is starting to highlight the fundamental importance of value congruence – seeing your work and your values as aligned.1,2,3,4 Organizations espousing shared values and more importantly facilitating employees’ ability to live out those shared values is necessary for individuals and groups to thrive. What does that mean? It means we need to amplify aspects of our work that align with our culture and support identifying and fixing the tensions at value interfaces we find. And they are everywhere…

      Some external stressors, like hallway medicine and COVID-19 are “hot topics” – obvious areas of significant tension – at national, provincial, and local levels. Emergency care providers across this country are working tirelessly at leadership tables and especially on shifts each and every day to mitigate the effects of the many big external stressors on our patients and on ourselves. This work feels endless but it is so necessary to both preserving and shaping the culture of emergency medicine.

      Skilled leaders understand the significance of value congruence and more importantly how to operationalize this understanding into policies, procedures, and a thriving organic organizational culture that allows people to work in a way that aligns with who they are and how they see their job. The best leaders enable their colleagues to embody the core values of emergency medicine all shift, every shift. In doing so, they empower their workforce to further engage with tensions in a productive way, amplifying the potential.

      There are an endless number of smaller areas of tension that can be addressed in our departments by emergency providers at all levels of leadership and practice, the “lower hanging fruit” so to speak. Can the equipment in your resuscitation room be organized better to allow your team to provide more seamless acute care – aligning with the value of “treating and identifying life threatening illnesses”? Maybe you can compile a central list of services affected by the pandemic so each physician isn’t left trying to sort this out on their own for every patient- allowing them to better “balance needs and resources at a systems level.” Perhaps your simulation program should bring together different professions aligning the values of “education is integral” and “a team approach is necessary.” Understanding what values are most important to, or at threat within, your department may help leaders and individuals decide where to focus such efforts.

      When we all start to see wellness through the lens of organizational value congruence, it becomes clear that every single decision has a consequential impact. Consideration of that reality should make wellness a part of the very fabric of our departments and communities, rather than simply a “nice to have” optional add on. I like to think that by acknowledging the importance of value congruence in planning initiatives and making decisions, both big ones and small ones, we might preserve a little more of who we are. And, we might even move closer towards the version of ourselves that we most hope to become— that is a charge worth leading.

      1. Molina, A. Value Congruence. Global Encyclopedia of Public Administration, Public Policy, and Governance.
      2. Asensio-Martínez Á, Leiter MP, Gascón S, et al. Value congruence, control, sense of community and demands as determinants of burnout syndrome among hospitality workers. Int J Occup Saf Ergo. 2017;25(2):1-32. doi:10.1080/10803548.2017.1367558
      3. Saito Y, Igarashi A, Noguchi‐Watanabe M, Takai Y, Yamamoto‐Mitani N. Work values and their association with burnout/work engagement among nurses in long‐term care hospitals. J Nurs Manage. 2018;26(4):393-402. doi:10.1111/jonm.12550
      4. Baugh JJ, Takayesu JK, White BA, Raja AS. Beyond the Maslach burnout inventory: addressing emergency medicine burnout with Maslach’s full theory. J Am Coll Emerg Physicians Open. 2020;1(5):1044-1049. doi:10.1002/emp2.12101
      5. Purdy E, Alexander C, Caughley M, Bassett S, Brazil V. Identifying and Transmitting the Culture of Emergency Medicine Through SimulationAem Educ Train. 2019;3(2):118-128. doi:10.1002/aet2.10325

      Interested in joining the CAEP Wellness Committee? Email wellness@caep.ca to get involved.

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