The Patient, Peaceful, Professional

Handling Stress and Compassion Fatigue in the Emergency Department

(Change your work without changing your job or profession)

(Make Emergency Medicine Your Career Instead of Your Job) 

Why patient satisfaction?

“They measure it and we are supposed to do it.”

Studies show that you are less likely to be sued by a satisfied patient.

Keeping the patient (and all the people you work with) copesthetic makes the job flow much more smoothly.

But the true reward of excellent patient satisfaction is generating emotionally nurturing moments of genuine connections with people, as well as earning thanks and appreciation for your work as a physician (and a healer). The Harvard 75 year longitudinal study on a class found that  positive alacrity: (” the art of creating micro-experiences that have an emotionally uplifting impact on others”) is the single most important experience for creating a happier and more fulfilling life. I feel good after a shift when I think of a case where I’ve gotten through to someone and something clicked. Our job presents us with multiple opportunities to do this.

It is very difficult to generate excellent patient satisfaction unless you are satisfied with your job. I’m going to teach you some specific behaviors that are going to make your shifts flow more smoothly and keep everyone happier. But first we will talk briefly about strategies that you can use to avoid or recover from burnout.

Stress has been the most difficult thing for me to deal with in my practice. I was not a “natural” for emergency medicine in my neurophysiology, personality, or worldview. Some of my CEP Partners seem to be just suited to this kind of work-working amazing hours without any sign of burnout or stress while others seem to struggle year in and year out to survive. Of those who seem to be doing well I would guess that some are just born to the job while others may be quicker learners than me. Compassion fatigue and stress exacerbate each other in encouraging burnout. The problem with Emergency Medicine is not only that it is inherently stressful (for an entire litany of reasons); but also that most human beings (unless you one of the exceptions) are susceptible to compassion fatigue.

I have burned out and come back at least 2 or 3 times in my career of over 30 years in Emergency Medicine. My work history includes 2 sabbaticals and a leave of absence prompted by the untimely deaths of 3 CEP Partners within 18 months, including my former Medical Director Owen Duggan. Right  now I feel I’m in a better place with work than I have ever been. For me this process is the proverbial journey because I would never say that I have it totally handled, even without those land mines that can blow up at anytime-a malpractice suit, an EMTALA action, or an especially tragic patient death or outcome.

I like to handle problems by looking at them, and then breaking them down into smaller pieces.

The 900 pound gorilla is the inherent nature of the job itself. It looks like one big insolvable problem.

The first and most important step for me that changed the nature of my work was being honest with myself. And what did that mean? It meant opening my eyes, looking around and realizing I wasn’t going to retrain, I didn’t have any obvious other job options, and I was not astute enough or frugal enough or whatever to retire early. So I was in it for the long haul! And I did know one thing-I was an idiot if I continued at a  consuming job I hated.  So I knew at that point that the only logical, respectable thing that I could do was change my attitude. Victor Frankl’s quote is probably best known, “If you can’t change the situation, change yourself .” This realization and decision might seem trivial but it’s not. I wanted to change. It’s the same thing with the cigarette smokers in the ER-there are lots of different ways to quit but you’ve got to want to quit.

But it’s very hard to change, improve and maintain your entire attitude just because you have made the decision. I chose to do it by looking at every minute detail, and then attending to the details until the entire thing came together.

I think there are two pieces to maintaining your new attitude. The first is cognitive reframing. You need a new lens, a new philosophy, a new paradigm, a new theory, a new spiritual view (or just bring your spiritual values along) to see your work and what you do. Perception is a conscious or subconscious act and you can change your perception by changing the lens of your consciousness. The catchphrase of one of the docs I worked with was “They are all God’s children.” Many of the spiritual teachings say the same thing about how you see the world. You can be a scholar of psychology, spirituality and religion but you may not know how you can bring these principles into your everyday life-helping to heal or comfort the sick The problem is you have to pause for a moment and have the chance or framework or perception or compassion to see things differently . Most of us have been through enough that we have some ideas about how we can see things more compassionately, or with more tolerance and understanding. For me these practices made it easier to deal with situations and allowed me to be more peaceful in my work.

Some physicians have brains that are hardwired to be able to create that moment of reflection before making a judgment. If you’re not blessed in that fashion ( I was not) you need to be awake enough and in the moment enough to be able to think before reacting. For me the best approach to to solving this problem is some version of mindfulness training (but you could  also sit  in the garden, say a rosary, listen to music or hold the baby). Mindfulness training is becoming increasingly popular and many businesses are pursuing it with their employees and giving them some space to meditate. I took John Cabot-Zin’s course in Mindfulness-Based StressReduction. It gave me the basis for my personal meditation practice but there are many other teachers and many other approaches to teaching meditation or mindfulness. You also don’t need to take a class or any kind of formal instruction you can just start practicing meditation on your own. Actually sitting down and doing it is the hardest part. What you do is extremely simple-you just sit in a quiet place or put your mind in a quiet place and concentrate on following your breath in and out. That’s all you have to do! When you meditate consistently over a period of time you develop structural changes in the brain showing that you are learning something new. Of the thousands of books that have been written by thousands of experts, long-term Buddhists, and long-term meditators, my favorite that I have read is  10% HAPPIER- HOW I TAMED THE VOICE IN MY HEAD, REDUCED STRESS WITHOUT LOSING MY EDGE, AND FOUND SELF HELP THAT ACTUALLY WORKS by Dan Harris. It is an easy read and inspirational because it tells a story of a high stress professional news commentator and his process of learning and understanding meditation. I think the 10% happier part of it is the inspirational theme of the book. It’s not magic, you’ll probably never be enlightened, you will not be in endless bliss and serenity for the rest of your life, but it can make you a little happier or your life a little easier.

Cognitive therapists, cognitive groups, and cognitive psychology books are easy to find. There are different approaches, different styles of instruction, and different underlying philosophies. Find the one that appeals to you whether it is secular or spiritual.*

The second difficult thing is arriving centered and calm, and then staying that way. For this you can’t be just a scholar-you need to live your theory, practice your practice,   and then it becomes easier to do. But the learning curve sometimes is the journey that is the true destination.

My first goal is to show up relaxed and serene. But how do you do this when you are thrown into a chaotic, crowded, noisy “pit”? First come in on time, not rushing and running late. Be relaxed and rested when you arrive. Much of the brouhaha will just roll off you. I take a 15 minute easy run before my 6AM shifts and usually do at least a few minutes of meditation.

We all know the ideal staffing model-a full time night doctor, otherwise isolated nights, long blocks of nights, forward rotation of schedules to honor circadian rhythm trends, or 3-4 AM turnover times to give each physician anchor sleep. Given a disruptive and rotating schedule it can be difficult to come in rested.

How do I attempt to come in relaxed and rested? Be a professional! I go to bed early enough that I wake up without an alarm for day shifts, I nap before afternoon shifts, and I sleep 3-4 hours before a night shift. A good sleep situation is important for me. I need to be as rested as I can before work; I have a separate, dedicated sleeping room over my garage where I am out of the house and won’t be disturbed. Another ER MD I know put a large walk in closet in his house with an air conditioning vent for a sleep room. Is this an indulgence? No, rather we are paying attention to the details of being rested enough to do our best at work.   Don’t be tired when you come to work. Have enough   energy to do your job. It’s an important job. When you are in the right space everything can flow smoothly–even when it is crazy all around you. And if you are on a wildly rotating schedule and can’t sleep well ask your PMD for a prescription for a short acting sleeper to use when your circadian rhythms are totally disrupted. If you had a patient that had to stay up all night at work a couple of times a month for a night shift and then the day after might have to get up at 4AM for a day shift you would think using an occasional sleeping pill would be appropriate.

Consider shorter shifts!

Consider fewer shifts! If you are working 15 shifts per month cutting back by a shift and a half is a 10% reduction in your hours worked. That may be the critical reduction that puts you at rather than over your threshold. You’re in it for the long haul, the marathon of life-don’t go out too fast.

Consider scribes! With my practice style and an Electronic Healthcare Record  I absolutely need a scribe. Without a scribe I am doing the entire laborious set of templates by myself in an office or work station after the patient encounter and this is much slower for me than doing a rapid fire dictation to a transcriptionist who is remarkably good at understanding me. If I do the record myself in the room I feel at risk of losing the patient connection I have worked so hard to establish. With scribes you don’t have a pile of dictations to do or templates to complete at the end of your shift. I prefer the advanatages of an EHR with a scribe (and a Dragon interface) to a dictated note. With a good scribe much of the documentation is contemporaneous.

Do some teaching. The formal studies show that teaching and shorter shifts decrease burnout. You don’t have to be in an academic center. Explain things to the nurse or volunteer or medic. Scribes are also fun to teach. They are at your side during the patient encounter and most that I work with are pre-med, pre-nursing, pre physical therapy or going to grad school in a health profession-enthusiastic young people going places. I’ve worked closely enough with some to be asked to write a letter of recommendation.

Be interested in the fascinating medicine you see. After 30 plus years I have never felt I’ve seen it all. If you think you have seen it all then you are asleep and not paying attention to the patients and medicine all around you. I work with one of the best ER physicians I have the pleasure to know (and he’s a night doc and he’s a toxicologist). When I arrive in the morning he almost always greets me with “I saw an interesting case last night.”

Stop complaining about your job to yourself and your friends or family. It doesn’t mean that you shouldn’t download when you need it with co-workers, and other docs or providers, or even your therapist or a group, but don’t bring it home all the time. It isn’t good for you and it isn’t good for your family.

Positive psychology is a growing field these days. Essentially instead of psychopathology it focuses on the positive tools and lessons of psychology. In some ways it is similar to cognitive psychology. One of the better known psychologists in this field is Mihaly Csikszentmihalyi with his books such as Flow: The Psychology of Optimal Experience. Another movement in positive psychology is gratitude. Look for, identify and even write down the things that you are grateful for. If you are an emergency physician I guarantee there are many things you can be thankful for starting with the IQ points that allowed you to begin your journey. Know that if you stay out of serious trouble you will always have a job.

Being centered is the key before you enter the pit. Once you get there and run into your first challenging patient your serenity becomes much more difficult to maintain. Be conscious and awake and perhaps you will learn some insights into human nature, and develop more tolerance for difference and variety

Do a little ritual before work, say a prayer, meditate, do a visualization, take a couple of deep breaths, take a pre-work shower, kiss your wife or husband, hug your kids, pet your dog, play with your cat, exercise, do something to find your center and your awareness before you dive into the fray.

You want to be calm and peaceful when you arrive at work. I asked one of my mentors how I should strive to be at work-Professional, Authoritative, Friendly, Reassuring. He told me that the single thing the patient wants most is a peaceful doc-let’s exude calmness and serenity.

Once you start working how do you avoid getting burned out or angry or disgusted by what you see? There are 2 ways really. One is to see what you are doing through your own spiritual or psychological paradigm and let it reframe what is going on around you. What you perceive is not what you see and what you see is not what you perceive. We filter and view what is going on through our own judgments-we can choose to see things differently. Much of my personal growth effort has been in this area..

Complementary to the cognitive psychology are the varied moral and spiritual teachings that many of us have grown up with as well as the values we live outside the ER.

I come from a Judeo-Christian background, though I am more a Gnostic Christian and Buddhist meditator these days. The parables and sayings from the Bible are very helpful to me in seeing people with greater compassion.

There but for the grace of god go you or I.

Judge not lest ye shall be judged.

Remove the beam from your own eye instead of the mote in mine.

Do unto others as you would have someone else do unto you.

The Buddhists say life is often suffering so please have compassion for others and all those who suffer. Try and practice “loving kindness.”

One of my mentors, Bob Draper, called the kind of angry, rude, or demanding behavior we often see in the ER “An inarticulate cry for help”. Sometimes you can see that they just want the best for their loved ones or are just afraid for themselves. I try to be transparent and just let it all go through and past me. I’ve never met them before-their feelings aren’t directed at me personally but rather at doctors in general, or the healthcare system, or the government or the economy and we are one of the few authority figures many of these patients can interface with and complain to about their sometimes very sad and unrewarding lives.

For us coming to the ER and seeing a patient tends to become somewhat routine. For the patient or their family this may be one of the major events in their life.

You can be compassionate and empathetic some of the time but you need to be calm (at least on the outside) and professional all of the time. I consider this an important part of what I am paid to do. And being professional is what helps when the first strategy fails. Use good manners and remember when you are interacting with the patients, the nurses, the housekeepers, the engineers, the administrators and the other docs you are always on stage. I see on and off stage signs for staff who are leaving or entering a break room but for me to some degree the ER doc is always on stage. So be proper in your actions even if you don’t feel that way. My favorite Greg Henry quote is “medicine is show business for ugly people.” On any given day even if you feel you “don’t have it” walk the walk and talk the talk and don’t be surprised if it comes to you.

A superb book that discusses how to handle interactions with the general public from the standpoint of a public service professional was written by a police officer and psychologist-George Thompson, Ph.D. It’s titled Verbal Judo and it’s great because it tells you how to control an encounter with a patient or someone who broke the law without being forceful or authoritarian or confrontative. One of the things that he emphasizes is that everyone wants Respect! He will wear his police hat so that he can take it off as a sign of respect and he gives them his business card.

For me the ritual begins even before I pick up the chart. I want to be neutral or non-judgmental when I see that patient. I don’t want to walk in with a predetermined opinion, attitude, or paradigm lock. Not only will preconceptions make your life more difficult and impair your patient satisfaction scores, they can cause you to miss significant diagnoses. Most recently I remember the staff rolling their eyes over, “a frequent flyer narcotics seeker back again!” I did a careful exam, noticed a couple of bruises, made the diagnosis of domestic violence and was able to intervene with positive results.

When I approach the gurney, I want to be peaceful and calm. One of the tricky things for me to do is move fast and then slow down when I get to the patient.  And I slow down by going through my ritual. I show respect when I walk into the room by formally introducing myself, individually, by my first and last name to everyone in the room unless it sis an extremely large group.  If I am fortunate enough to have a business card for my site I hand it to them at the beginning or end of the visit as an additional sign of respect and so they remember who they saw and that they saw a doctor. It seems to me there is some degree of apprehension among healthcare providers that somehow if you give the patient your name, or full name, or they can see your picture somehow they are planning to track you down. In our information technology society I’m so visible that I don’t worry about that anymore! I wear my Hospital Photo ID Badge on one of those spring loaded string holders so that I can show it to them closely so they can both see and hear my name. When I leave the room I do the same thing again- reintroduce myself and show them the badge. I alcohol my hands before I enter and let them see me finish the process before I shake hands with them.  I look everyone in the eye when I introduce myself and shake hands with everyone (including the children) if culturally appropriate. This practice has changed in these times so instead I look them in the eye to introduce myself. I may make a respectful “steeple” with my hands.  I always sit down unless the patient is obtunded and there are no friends or relatives present. I respect the visitors by having them stay in their bedside chair and fetching a new one for myself or even an extra one for an additional visitor. I don’t let a friend or family member ever give me their chair unless I perceive there is a cultural customs issue. Personally I don’t mind if there are multiple family members present unless they are ill-behaved or disruptive. I find it is better to directly communicate with everyone present and leave less room for “errors in translation.” I address the patient initially by his or her full name and then by Mr., Mrs, or Ms. I will only call them by their first name if asked or if they are a child. . The patient visit to see an emergency physician is a formal encounter laden with cultural, emotional and financial issues for the patient and I believe that one should use professional manners. I prefer to be addressed as doctor by my patients but if it is important to them to call me by my first name it is fine with me. My experience is that initial formal manners are never a mistake in the ER. I would also be cautious in the use of humor. What might be funny to you from your perspective may not be funny to the patient. I will sometimes strike up a brief tangential conversation by asking about a book that the patient or companion is reading or I may ask where they come from.

After I come back with the chairs, I sit close enough to the head of the bed that they know I am there-actually as close as I can sit without being inappropriate. I review the nurse’s triage note with the patient and take notes as they talk to me-both for my memory and as part of the theater. I try to interrupt as little as possible and listen. . We are trained to be high-speed, decisive docs so this can be difficult for me, but I try to listen for more than the usual 20 seconds before jumping in and interrupting the patient. This is important because one of the things that patients want, and maybe even what they pay for is just to be listened to. Fewer interruptions will increase patient satisfaction-and is also good manners! If pain is a potential issue address it early and make sure that the patient understands how you plan to manage their pain.

If I am fortunate enough to have a business card for my site I hand it to them as an additional sign of respect and so they remember who they saw and that they saw a doctor. It seems to me there is some degree of apprehension among healthcare providers that somehow if you give the patient your name, or full name, or they can see your picture somehow they are planning to track you down. In our information technology society I’m so visible that I don’t worry about that anymore!

For follow-up and discharge, I support the standard patient satisfaction initiatives – pollinate the room, return to the bedside, take 10 seconds and let the patients know you haven’t forgotten them. When discharging a patient with an extensive workup, I sit down at the bedside again and go through the test results with them. I realize that most of it is going over their heads, but I still believe the process is helpful for both aftercare and patient satisfaction. Sometimes I will have them explain the discharge instructions back to me .Our recommended scripting includes using the words concern or concerned. I personally like to close with an open-ended question such as, “Is their anything else that I can do for you?”, or “Do you have any questions?” Our ER uses a basic, free-standing aftercare system which enables docs to type in specific recommendations we want to emphasize. This helps wrap up the visit with any personalized specific follow up instructions.

One of the benefits of ageing is that you look more like a wise doctor when you enter the room. I was impressed by Malcolm Gladwell’s insights in Blink. You want to hit that first impression spot on-please either wear a recognizable medical uniform like scrubs and/or a white coat. If you don’t wear a medical uniform dress nicely and make sure that you wear a very visible name tag. When you come through that door or curtain you want them to recognize you as a professional. I wear scrubs and I’ve had them all embroidered so I have my name on my coat and scrubs as well as wearing a nametag. One of my hospitals has a two sided nametag. I don’t like the habit of hiding your name. It is disrespectful in some ways.

I recommend that midlevel providers comport themselves formally also, and introduce themselves by their formal title: “I’m (Miss.) Lynn Richards, Registered (or Licensed) Physician Assistant” or “I’m (Mr.) Randy Booth, Licensed Nurse Practitioner.” It will also help the patient keep the different caregiver roles sorted out. Nurses culturally seem to primarily use their first names with the patients and that is fine but they should also formally introduce themselves and wear a visible name tag.

And you know what happens when you attend to all these minute details?

Yes, you make your life easier but you also open up the opportunity to make those episodic real connections with patients that provide some of the nurturing for us caregivers who are doing emotionally draining jobs. I use formal manners but I’m not afraid to hug someone in one of those moments of loss. And you might find that some of your patients are actually interested in stopping smoking or controlling their drinking. The ER is a perfect setting for generating those emotionally powerful teachable moments that can help someone make a long term behavior change. And the funny thing is that sometimes you make a difference when you little expect it. I have had the rewarding experience of seeing patients who told me that their teachable moment with me (often around cigarettes or alcohol) did cause them to change their behaviors

For me, the simple part of the patient encounter is following these scripted routines, especially now that I understand their importance. What is the difficult part? Being peaceful, calm and neutral when you pick up that chart and go to see the patient. To quote Shakespeare, “There’s the rub.” That part – the attitude adjustment – is the long journey.

*The best practical discussion of this cognitive psychological approach that I have read is   by a psychologist named Ken Keyes (Handbook to Higher Consciousness: The Science of HappinessHow to Enjoy Your Life in Spite of It All,  one website surviving )   though one can cite multiple teachers from Victor Frankel to Albert Ellis.