Wellness issues and the emergency medicine resident

Are You Really the Doctor? Physician Experiences with Gendered Microaggressions from Patients

Background: In contrast to physician implicit bias toward patients, bias and microaggressions from patients toward physicians have received comparatively less attention. Materials and Methods: We captured physician experiences of gendered microaggressions from patients by conducting a mixed-methods survey-based study of physicians at a single academic health care institution in May 2019. A quantitative portion assessed the frequency of gendered microaggressions (microaggression experiences [ME] score) and the association with measures of perceived impacts (job satisfaction, burnout, perceived career impacts, behavioral modifications). A one-tailed Wilcoxon rank sum test compared distributional frequencies of microaggressions by gender, and by gender and race. Chi-square tests measured the associations between gendered microaggressions and perceived impacts. Welch two-sample t-tests assessed differences in ME scores by rank and specialty. Linear regression assessed the association of ME scores and job satisfaction/burnout. A qualitative portion solicited anecdotal experiences, analyzed by inductive thematic analysis. Results: There were 297 completed surveys (response rate 27%). Female physicians experienced a significantly higher frequency of gendered microaggressions (p < 0.001) compared with male physicians. Microaggressions were significantly associated with job satisfaction (chi-square 6.83, p = 0.009), burnout (chi-square 8.76, p = 0.003), perceived career impacts (chi-square 18.67, p < 0.001), and behavioral modifications (chi-square 19.96, p < 0.001). Trainees experienced more microaggressions (p = 0.009) and burnout (p = 0.009) than faculty. Higher ME scores predicted statistically significant increases in burnout (p < 0.0001) and reduced job satisfaction (p = 0.02). Twelve microaggressions themes emerged from the qualitative responses, including role questioning and assumption of inexperience. The frequency of microaggressions did not vary significantly by race; however, qualitative responses described race as a factor. Conclusions: Physicians experience gendered microaggressions from patients, which may influence job satisfaction, burnout, career perceptions, and behavior. Future research may explore the multidirectionality of microaggressions and tools for responding at the individual and institutional level.

Nevertheless, They Persisted: How Women Experience Gender-Based Discrimination During Postgraduate Surgical Training

OBJECTIVE

More women than ever are pursuing surgical specialties despite historical dominance by men. The objective of this study was to examine how surgical residents experience gender-based discrimination during their residency training, including the common sources, settings, and implications of these experiences.

DESIGN

A sequential explanatory mixed methods design was used to combine results from an initial quantitative survey of surgical residents of all genders at the University of Calgary with qualitative data derived from interviews with surgical residents who identified as women.

PARTICIPANTS

Thirty-seven surgical residents of all genders completed a survey. Fourteen women completed a one-to-one, semistructured interview.

RESULTS

Women reported significantly more frequent experiences of gender-based discrimination than men, particularly regarding lack of respect from others, inappropriate jokes or comments, and hostile or humiliating behaviors. Nursing staff and patients were reported as prominent sources of discrimination, and the emergency and operating rooms were the most common settings. The qualitative findings highlighted the additional challenges for women during surgical residency, including navigating the relationships with nursing, having to work "twice as hard" to receive respect from patients and nurses, reports of persistent harassment and bullying, becoming desensitized to mistreatment and discrimination, and the influence of their gender on the quality of their education as well as their well-being.

CONCLUSIONS

Despite the increasing number of women entering surgical specialties, women surgical residents report frequent and severe experiences of gender-based discrimination during their training, even at an academic institution where over half of residents are women.

Gender discrimination against female surgeons: A cross-sectional study in a lower-middle-income country

Introduction

Although gender discrimination and bias (GD/bias) experienced by female surgeons in the developed world has received much attention, GD/bias in lower-middle-income countries like Pakistan remains unexplored. Thus, our study explores how GD/bias is perceived and reported by surgeons in Pakistan.

Method

A single-center cross-sectional anonymous online survey was sent to all surgeons practicing/training at a tertiary care hospital in Pakistan. The survey explored the frequency, source and impact of GD/bias among surgeons.

Results

98/194 surgeons (52.4%) responded to the survey, of which 68.4% were males and 66.3% were trainees. Only 19.4% of women surgeons reported 'significant' frequency of GD/bias during residency. A higher percentage of women reported 'insignificant' frequency of GD/bias during residency, as compared to males (61.3% vs. 32.8%; p = 0.004). However, more women surgeons reported facing GD/bias in various aspects of their career/training, including differences in mentorship (80.6% vs. 26.9%; p < 0.005) and differences in operating room opportunities (77.4% vs. 32.8%; p < 0.005). The source was most frequently reported to be co-residents of the opposite gender. Additionally, a high percentage of female surgeons reported that their experience of GD/bias had had a significant negative impact on their career/training progression, respect/value in the surgical team, job satisfaction and selection of specialty.

Conclusion

Although GD/bias has widespread impacts on the training/career of female surgeons in Pakistan, most females fail to recognize this GD/bias as "significant". Our results highlight a worrying lack of recognition of GD/bias by female surgeons, representing a major barrier to gender equity in surgery in Pakistan and emphasizing the need for future research.

Understanding and Overcoming Implicit Gender Bias in Plastic Surgery

BACKGROUND

Although explicit sex-based discrimination has largely been deemed unacceptable in professional settings, implicit gender bias persists and results in a significant lack of parity in plastic surgery and beyond. Implicit gender bias is the result of a complex interplay of cultural and societal expectations, learned behaviors, and standardized associations. As such, both male and female surgeons are subject to its influence.

METHODS

A review of the literature was conducted, examining theories of gender bias, current manifestations of gender bias in plastic surgery and other fields, and interventions designed to address gender bias.

RESULTS

Multiple studies demonstrate persistent gender bias that impacts female physicians at all levels of training. Several institutions have enacted successful interventions to identify and address gender bias.

CONCLUSIONS

Explicit gender bias has largely disappeared, yet unconscious or implicit gender bias persists. A wide-scale commitment to addressing implicit gender bias in plastic surgery is necessary and overdue. Recommendations include immediate actions that can be undertaken on an individual basis, and changes that should be implemented at a national and international level by leaders in the field.

The psychological health and well-being of emergency medicine consultants in the UK

OBJECTIVE

To explore the experience of psychological distress and well-being in emergency medicine (EM) consultants.

METHODS

A qualitative, interpretative phenomenological analysis (IPA) study based on 1:1 semistructured interviews with EM consultants working full time in EDs across South West England. Eighteen EM consultants were interviewed across five EDs, the mean (SD) age of participants being 43.17 (5.8) years. The personal meanings that participants attached to their experiences were inductively analysed.

RESULTS

The analysis formed three superordinate themes: systemic pressures, physical and mental strain and managing the challenges. Pressures within the ED and healthcare system contributed to participants feeling undervalued and unsatisfied when working in an increasingly uncontrollable environment. Participants described working intensely to meet systemic demands, which inadvertently contributed to a diminishing sense of achievement and self-worth. Consultants perceived their experience of physical and emotional strain as unsustainable, as it negatively impacted; functioning at work, relationships, personal well-being and the EM profession. Participants described how sustainability as an EM consultant could be promoted by social support from consultant colleagues and the ED team, and the opportunity to develop new roles and support ED problem solving at an organisational level. These processes supported a stigma-reducing means of promoting psychological well-being.

CONCLUSIONS

EM consultants experience considerable physical and mental strain. This strain is dynamically related to consultants' experiences of diminishing self-worth and satisfaction, alongside current sociopolitical demands on EM services. Recognising the psychological experiences and needs of EM consultants and promoting a sustainable EM consultant role could benefit individual psychological well-being and the delivery of emergency care.

Relationship Between Socio-Demographic Features, Work-Related Conditions, and Level of Anxiety Among Turkish Primary Health Care Workers

The purpose of this study was to investigate the relationship among Turkish primary health care workers’ socio-demographic characteristics, working conditions, and anxiety. A cross-sectional study was conducted with 88 of 103 (85.4%) eligible health care workers from the city of Mugla participating. The participants’ average age was 31 years, 85.2% were university graduates, 30.7% were nurses, and 64.8% had been working between 11 and 20 years at the time of the study; 93.6% worked 8 hours each day or less. State anxiety scores for males ( p = .016), health care workers age 31 or older ( p = .035), nurse participants ( p = .043), and individuals who had worked 11 or more years ( p = .044) were significantly higher than the rest of the sample; however, trait anxiety scores for participants who did not work overtime and were not scheduled for shift work were significantly higher ( p = .033 and p = .004, respectively) than the rest of the sample. According to the logistic regression analysis, risk factors for anxiety included being male and older than 31 years.

Registered Nurses and Discharge Planning in a Taiwanese ED: A Neglected Issue?

Published research on discharge planning is written from the perspective of hospital wards and community services. Limited research focuses on discharge planning in the emergency department (ED). The objective of this study was to identify ED nurses' perceptions of factors influencing the implementation of discharge planning. This qualitative study collected data from 25 ED nurses through in-depth interviews and a drawing task in which participants were asked to depict on paper the implementation of discharge planning in their practice. Factors influencing discharge planning were grouped into three categories: discharge planning as a neglected issue in the ED, heavy workload, and the negative attitudes of ED patients and their families. The study highlighted a need for effective discharge planning to be counted as an essential clinical competency for ED nurses and factored into their everyday workload. Nurses perceived that organizational culture, and parents' and relatives' attitudes were barriers to implementing discharge teaching in the ED.

Competence and challenges of emergency medicine training as reported by emergency medicine residents

BACKGROUND

The American Board of Emergency Medicine conducts an annual survey of residents in Emergency Medicine, the Longitudinal Study of Residents in Emergency Medicine survey.

OBJECTIVE

This study was undertaken to describe self-reported competence and challenges facing Emergency Medicine (EM) residents.

METHODS

In this descriptive, observational analysis of the Longitudinal Study of Residents in Emergency Medicine survey, survey data from 1996-2008 were compared for 70 survey items. Responses were analyzed with means and 95% confidence intervals by post-graduate year (PGY) and over time.

RESULTS

A total of 496 residents were included in this study. Most participated for 3 years, for a total of 1320 total responses. The most serious day-to-day challenges reported by residents (overall median scores of 3 or more) included knowing enough, keeping up with the medical literature, having enough time for personal life, ancillary support, and having enough time for family. Current level of competence in areas deemed weakest by residents included grant writing, contract negotiation, academic writing, disaster planning, research, and financial management. Residents reported improved competence in most (15 out of 16) areas from PGY-1 to PGY-3 year of training. Resident reports of competence did not change significantly over time from 1998-2008 (15 out of 16 items).

CONCLUSIONS

Emergency Medicine residents identified several important day-to-day problems, including knowing enough, keeping up with the medical literature, and having enough time for a personal life. PGY-3 residents reported improved competence in almost all aspects of EM work and clinical EM as compared to PGY-1 residents. Knowledge of perceived competence and problems among EM residents is crucial to the development of improved educational approaches to address these issues.

Perspective: Resident physician wellness: a new hope

Residency training is a challenging period in a physician's career owing to a multitude of stressors perhaps not previously encountered. In some cases, these stressors may culminate in a state of burnout. In response, much has been written about the issues of personal wellness during residency training. Recently, duty hours reform has been the major focus of addressing resident wellness; however, this intervention has established little benefit and has created unintended negative consequences. Alternatively, an emerging solution may be the implementation of resident wellness programs into residency training. Such programs are defined by a combination of active and passive initiatives targeting the various domains of physical, mental, social, and intellectual wellness. In contrast to duty hours reform, resident wellness programs are generally free from controversy and have been shown to improve resident wellness and enhance empathy.This article highlights the salient causes of burnout as it applies to present-day resident physicians and the patient care they provide. Moreover, in the wake of the controversy surrounding duty hours reform, a novel approach to resident wellness involving structured resident wellness programs is discussed. Specifically included are the fundamental components of a wellness program, the advantages held over duty hours reform, methods to evaluate program efficacy, and the current evidence to support these initiatives. Formal wellness curricula, including an evaluative process, should be an integral component of physician training. These programs represent a new hope in the solution to the long-debated issue of burnout and wellness during residency training.

Emergency medicine residents' use of psychostimulants and sedatives to aid in shift work

OBJECTIVES

We evaluated the frequency that emergency medicine house staff report use of stimulants and sedatives to aid in shift work and circadian transitions.

METHODS

We surveyed residents from 12 regional emergency medicine programs inviting them to complete a voluntary, anonymous electronic questionnaire regarding their use of stimulants and sedatives.

RESULTS

Out of 485 eligible residents invited to participate in the survey, 226 responded (47% response frequency). The reported use of prescription stimulants for shift work is uncommon (3.1% of respondents.) In contrast, 201 residents (89%) report use of caffeine during night shifts, including 118 residents (52%) who use this substance every night shift. Eighty-six residents (38%) reported using sedative agents to sleep following shift work with the most common agents being anti-histamines (31%), nonbenzodiazepine hypnotics such as zolpidem (14%), melatonin (10%), and benzodiazepines (9%).

CONCLUSION

Emergency medicine residents report substantial use of several classes of hypnotics to aid in shift work. Despite anecdotal reports, use of prescription stimulants appears rare, and is notably less common than use of sedatives and non-prescription stimulants.

Measuring wellness among resident physicians

Requirements to include professionalism in residency curricula have generated a substantial body of literature concerning the environments that fail to nurture professionalism. Local and national surveys provide evidence that a high prevalence of depersonalization and emotional exhaustion exists among residents and that clinical practice is impaired as a result of these factors. A group of 34 residents from ten residency programmes participated in the psychometric testing of a resident wellness assessment instrument that can be rapidly administered, scored, and interpreted. The Brief Resident Wellness Profile is composed of a Mood faces graphical rating item and a six-question subscale. The six-item subscale had good reliability (alpha = 0.83; r = 0.84), convergent validity (r = 0.63), discriminant validity (r = -0.37), and concurrent validity ( p = 0.007). The Mood faces item had good convergent validity (r = 0.66), discriminant validity (r = -0.71), and concurrent validity ( p = 0.008). The Brief Resident Wellness Profile appears to be a reliable and valid instrument that measures residents' sense of professional accomplishment and mood and can be rapidly administered, scored, and interpreted.

Tracking workload in the emergency department

OBJECTIVE

The primary objective of this study was to create a methodology for measuring transient levels of physician workload in a live emergency department (ED) environment.

BACKGROUND

Characterizing, defining, and measuring aspects of this interrupt-driven work environment represent the preliminary steps in addressing impending issues concerning ED overcrowding, efficiency, and patient and provider safety.

METHODS

A time-motion task analysis was conducted. Twenty emergency medicine (EM) physicians were observed for 180-min intervals in an ED of an academic medical center. Near continuous workload measures were developed and used to track changing workload levels in time. These measures were taken from subjective, objective, and physiological perspectives. The NASA-Task Load Index was administered to each physician after observational sessions to measure subjective workload. Physiological measurements were taken throughout the duration of the observation to measure stress response. Additional information concerning physicians' patient quantity and patient complexity was extracted from the ED information system.

RESULTS

Graphical workload profiles were created by combining observational and subjective data with system state data. Methodologies behind the creation of workload profiles are discussed, the workload profiles are compared, and quantitative and qualitative analyses are conducted.

CONCLUSION

Using human factors methods to measure workload in a setting such as the ED proves to be challenging but has relevant application in improving the efficiency and safety of EM.

APPLICATION

Techniques implemented in this research are applicable in managing ED staff and real-time monitoring of physician workload.

Noise in the ED

BACKGROUND

The impact of noise pollution on both the patient and the care provider has been extensively studied in the neonatal intensive care unit and in other critical care units. Noise pollution makes errors more probable and is one of the risk factors for provider burnout and negative outcomes for patients. The Environmental Protection Agency (EPA) recommends that the acceptable noise level in a hospital should not exceed 40 dB.

OBJECTIVES

The purpose of this study was to record and analyze noise in a large urban level I emergency department (ED) and compare to the EPA guidelines.

METHODS

A 3-channel dosimeter Quest Q300 (Quest Technologies, Oconomowoc, WI) was placed as a stand-alone unit on the wall of the resuscitation booth in the ED. Sound was sampled 16 times per second for 12 hours and was recorded as peaks and averages for each minute. The dosimeter was then placed in the pocket of a medical student with a small 8-mm shoulder-mount type 2 microphone. The medical student followed an emergency medicine resident throughout an 8-hour shift in the main resuscitation area while monitoring and logging sound fluctuations in the environment. Sound pressure levels were logged in real time and subsequently correlated to the recorded peaks. Sound was sampled 16 times per second and recorded peaks and averages for each minute.

RESULTS

In the initial part of the study, the time-weighted average was 43 dB. The average sound levels peaked approximately 25 times over 12 hours. Individually measured peak levels of 94 to 117 dB occurred every minute. In the second part of the study, the time-weighted average was 52.9 dB.

CONCLUSIONS

When compared to EPA accepted noise levels for hospital (40 dB), the ED under study had excessive noise on a regular basis. There are easily identifiable sources of noise pollution in the ED. By identifying and modifying sources of noise, stress in the ED may be decreased.