Baggage

Shilpi Ganguly, MS-IV, University of Miami Miller School of Medicine
EMRA MSC Southeast Regional Coordinator, 2022-23

Matthew Lyons, OMS-IV, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
EMRA MSC Southeast Regional Representative I, 2022-23

Daniel Aloise, MS-IV, Florida International University Herbert Wertheim College of Medicine
EMRA MSC Southeast Regional Representative II 2022-23

Kyle Cohen, NRP, OMS-III, Alabama College of Osteopathic Medicine
EMRA MSC Southcentral Regional Representative 2022-23

Is it okay to have baggage?

Having worked as a full-time paramedic firefighter for nearly 10 years, I have certainly seen my fair share of harrowing and traumatic situations that I will likely never be able to forget. These days, as I look towards my future career in emergency medicine, I find myself asking — is it okay to bring this baggage with me?

Thinking back, when probed if I was ok by colleagues and friends after these tough days, I always found myself answering “yes” or “I’ll be alright.” But was it okay to say “no?” The truth is, many of us who work in healthcare even today, encounter the stigma of being “weak” or “unfit for the role,” if we say “no.” However, as we shepherd in a new generation of providers, it is our duty to rewrite this narrative and make it clear that it is perfectly acceptable to say “no” and to not be okay. Every person who endures traumatic experiences should have the right to cope and process in their own way, and with the support and time necessary to come out stronger.

In emergency medicine, we routinely see situations that no human should have to see. For us, the average person’s worst day is just another day at the job. Understanding this as our reality, what we should be addressing is how do we handle these traumatic experiences? What are things we should avoid when trying to cope? What are positive coping tools we can employ? And how do we grow from these experiences?

Harmful Coping Strategies

Alcohol

 Alcohol is often used as a coping mechanism because it is easily attainable and relatively socially acceptable. In fact, it has been reported that alcohol use among emergency physicians is becoming a problem. In a 2021 study by Medscape, 34% of responding emergency physicians reported drinking alcohol as a means to cope with burnout and 27% reported consuming 5 or more drinks a week¹. Additionally, in a 2021 multicenter survey pertaining to coping mechanisms related to COVID-19 stressors revealed that daily drinking increased from 8% to 15% among respondents². While alcohol is known to have the perceived effect of reducing stress, prolonged consumption can lead to the further release of stress type hormones³. Alcohol consumption has also shown to decrease REM sleep, increase anxiety, depression, and the likelihood of aggressive behavior, while also making you less self-reflective, leading to prolonged intrapersonal conflict⁴.

Drugs

Drug use in response to stress is similar to that of alcohol in that it provides a temporary feeling of reduced stress or anxiety but has detrimental long term effects. In a 2014 survey of emergency physicians in a physician health program, 38% reported abuse of opioids and nearly 10% reported abuse of stimulants⁵. Additionally, 13% reported using IV drugs and 55% were abusing multiple drugs or alcohol at the time of enrollment in the physician health program.

Isolation

In the 2021 Medscape survey, 45% of respondents reported isolation from others while 42% reported sleep as means of coping with stress¹. The idea of community has long been understood as a positive influence on health and aging, as well as beneficial after acute or chronic stressors. Social isolation after stress has shown to induce depression and anxiety and increase rates of suicide⁶. Furthermore, prolonged isolation has shown to increase rates of cardiovascular disease, dementia, and premature mortality.

Suppression/Repression

Suppression/Repression are common coping strategies employed by physicians and medical students. The emergency department is busy with the list of urgent tasks constantly growing. It is easy to have the “roll with the punches” mentality, pushing your emotions aside to deal with the next patient. However, it is important that we revisit these emotions at another time, so they don’t pile up.

Risky Behaviors

In response to undue stressors or periods of heightened negative emotions, it has been demonstrated that people often partake in high-risk behaviors as a way to cope and mask difficult emotions, trading sadness and frustration for adrenaline and thrill. High-risk behaviors are defined as actions which are associated with an increased risk of injury or disease, and can have consequences ranging from disability, social difficulty, and even death.⁷ The most common high-risk behaviors include many of those discussed above including alcoholism, tobacco, and drug use, as well as risky sexual behavior and disordered eating⁷. Although there is a lack of empiric data regarding risky behaviors in the physician populus, there are numerous anecdotal stories and reports of physicians who have been caught in risky sexual encounters, using copious illicit drugs, or partaking in violent acts.

Helpful Coping Strategies

Talking with a Confidant

As members of the healthcare team, we face unique challenges that non-medical friends and family often cannot understand. For many, having someone to talk to who understands these unique challenges can be a tremendous asset. The 2021 Medscape survey showed that 44% of emergency physicians talked with family or a close friend regarding their stressors as a way to cope.¹ As future physicians, we will come across many difficult situations that will most certainly challenge our mental health. With this in mind, you shouldn’t be afraid to lean on someone you trust.

Therapy

As physicians and members of healthcare teams, we endure a level of trauma and anxiety unique to our profession. Although historically the utilization of mental health services by providers has been low, there has been a growing movement for increased access to psychotherapy services given the inherent stressors associated with our work. It has been shown that while psychotherapy and pharmacotherapy in terms of symptom reduction are comparable effectiveness wise, the benefits of psychotherapy far outlast those of sole medication use. Structured therapy is a service that we as healthcare providers should not be afraid to utilize and can even consider as a tool for mental health prophylaxis.⁸

Journaling

Writing can serve as a cathartic way for physicians and student doctors to look introspectively and reflect on the experiences they have had. Oftentimes it is difficult to talk about our most personal and traumatizing experiences, and writing can serve as another effective outlet for our innermost feelings. It serves as a tool to express previously unexpressed emotions and ultimately process experiences that may have been locked deep within. Writing can come in many forms: journaling, blogging on social media, writing poetry, etc. While the method of writing may vary, a study published in 2018 by Smyth et al focusing on “positive affect journaling”, found that patients displayed decreased mental distress and increased well-being relative to baseline, as well as less depressive symptoms and anxiety after one month⁹. Another study published in 2013 by Krpan et al found that patients diagnosed with major depressive disorder displayed lower scores of depression after just 3 days of 20 minutes of expressive writing¹⁰.

Pleasurable Activities

Physicians taking the time to treat themselves outside of the ED may allow them to better treat others inside of it. According to a review by Karr in 2019, the practices of physical, mental, and emotional self-care are important in avoiding burnout¹¹. By decreasing physician burnout, doctors have shown improved rates of job retention, monetary savings, improved patient safety, and better overall patient care. Though we recommend taking 30 minutes a day 5 days a week to exercise for our patients, how many of us take the time to do the same? Exercise is a unique tool that improves both our physical and mental well-being. Sublimation has long been hailed as a healthy means with which to cope with stress and channeling all our angst and frustration at the gym appears to be a great way of accomplishing this. In addition to exercise, setting aside time for hobbies that we enjoy can also be an effective means to relieve stress and take our minds away from our busy and taxing schedules.

Meditation/Mindfulness

Mindfulness is a topic that has been explored and researched tremendously over the past decade. Although the definition of mindfulness differs between sources, it is essentially the act of focusing your attention on the present moment while acknowledging your feelings without judgment. The effects of mindfulness on physical and mental health have been well supported in the literature. It has also been shown to decrease physician burnout¹². Dedicating just a couple minutes per day, especially after a stressful shift, can help you process what you are feeling and prepare you for the next shift.

Acceptance

Although this might be the hardest tool on the list, acceptance of the realities and hazards associated with our roles as healthcare providers is crucial in being able to begin processing the difficult situations we are going to endure. Lessons learned through experience have helped us create a framework to help with this.

Rule Number 1: In medicine, especially emergency medicine, people are going to die. This rule has no exclusions and applies to all people from every age group, gender, race, and ethnicity.

Rule Number 2: No matter what you do, no matter how hard you try, you cannot change rule number one.

With the acceptance of these two rules, the implementation of positive coping mechanisms, and recognizing when you need to ask for help, we can move towards improving the mental health climate for healthcare providers and specifically, recognize our needs as human beings first and emergency medicine physicians second.

Additional Resources

If you are experiencing thoughts of suicide, please contact the National Suicide Prevention hotline by dialing 988.

If you are struggling with substance abuse, please reach out to your state’s Physician Health Program. The list of organizations can be found at https://www.fsphp.org/state-programs

As of October 2022, EMRA has partnered with Headspace to provide a 90-day free trial to all EMRA members. You can sign up for the free trial at https://www.emra.org/about-emra/benefits/headspace/

References

1. Martin KL, Koval ML. Medscape Emergency Medicine Physician Lifestyle, Happiness & Burnout Report 2021. Medscape. https://www.medscape.com/slideshow/2021-lifestyle-emergency-medicine-6013508#1 Published February 19, 2021. Accessed October 8, 2022.
2. Dehon E, Zachrison KS, Peltzer-Jones J, et al. Sources of Distress and Coping Strategies Among Emergency Physicians During COVID-19 [published correction appears in West J Emerg Med. 2022 Mar 03;23(2):291]. West J Emerg Med. 2021;22(6):1240-1252. doi:10.5811/westjem.2021.9.53406
3. Anthenelli RM. Overview: stress and alcohol use disorders revisited. Alcohol Res. 2012;34(4):386-390.
4. Government of Western Australia. Alcohol and mental health. Alcohol Think Again. Update October 4, 2022. Accessed October 8, 2022. https://alcoholthinkagain.com.au/alcohol-your-health/alcohol-and-mental-health/
5. Rose JS, Campbell M, Skipper G. Prognosis for Emergency Physician with substance abuse recovery: 5-year outcome study. West J Emerg Med. 2014;15(1):20-25. doi:10.5811/westjem.2013.7.17871
6. School of Public Health and Tropical Medicine. Understanding the effects of social isolation on mental health. Tulane University. Published December 8, 2020. Accessed October 8, 2022. https://publichealth.tulane.edu/blog/effects-of-social-isolation-on-mental-health/
7. Tariq N, Gupta V. High Risk Behaviors. [Updated 2022 Jul 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560756/
8. Fansi A, Jehanno C, Lapalme M, Drapeau M, Bouchard S. Efficacité de la psychothérapie comparativement à la pharmacothérapie dans le traitement des troubles anxieux et dépressifs chez l'adulte : une revue de la littérature [Effectiveness of psychotherapy compared to pharmacotherapy for the treatment of anxiety and depressive disorders in adults: A literature review]. Sante Ment Que. 2015;40(4):141-173.
9. Smyth JM, Johnson JA, Auer BJ, Lehman E, Talamo G, Sciamanna CN. Online Positive Affect Journaling in the Improvement of Mental Distress and Well-Being in General Medical Patients With Elevated Anxiety Symptoms: A Preliminary Randomized Controlled Trial. JMIR Ment Health. 2018;5(4):e11290. Published 2018 Dec 10. doi:10.2196/11290
10. Krpan KM, Kross E, Berman MG, Deldin PJ, Askren MK, Jonides J. An everyday activity as a treatment for depression: the benefits of expressive writing for people diagnosed with major depressive disorder. J Affect Disord. 2013;150(3):1148-1151. doi:10.1016/j.jad.2013.05.065
11. Karr S. Avoiding physician burnout through physical, emotional, and spiritual energy. Curr Opin Cardiol. 2019;34(1):94-97. doi:10.1097/HCO.0000000000000574
12. Zhang XJ, Song Y, Jiang T, Ding N, Shi TY. Interventions to reduce burnout of physicians and nurses: An overview of systematic reviews and meta-analyses. Medicine (Baltimore). 2020 Jun 26;99(26):e20992. doi: 10.1097/MD.0000000000020992.