Wellness Book for Emergency Physicians

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Wellness Book

for

Emergency Physicians

Editors

S. Shay Bintliff, MD, FACEPJulius A. Jay Kaplan, MD, FACEPJ. Mark Meredith III, MD, FACEP


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The American College of Emergency Physicians makes every effort to ensure that contributors to College-sponsoredpublications are knowledgeable authorities in their fields. Readers are nevertheless advised that the statements and opinionsexpressed in this book are provided as guidelines and should not be construed as College policy unless specifically referred to assuch. The College disclaims any liability or responsibility for the consequences of any actions taken in reliance on thosestatements or opinions. The materials contained herein are not intended to establish policy, procedure, or a standard of care.

Copyright 2004, American College of Emergency Physicians, Dallas, Texas. All rights reserved. Except as permittedunder the US Copyright Act of 1976, no part of this publication may be reproduced, stored, or transmitted in any form or by anymeans, electronic or mechanical, including storage and retrieval systems, without permission in writing from the publisher.Printed in the US.


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Authors

Louise B. Andrew, MD, JD, FACEP

S. Shay Bintliff, MD, FACEP

Dawn M. Ellison Jordan, MD, FACEP

Richard M. Goldberg, MD, FACEP

Rachelle A. Greenman, MD, FACEP

Charles W. Henrichs, MD, FACEP

Julius A. Jay Kaplan, MD, FACEP

Frani S. Pollack, MS, MSW, RD

Marc L. Pollack, MD, PhD, FACEP

Walter A. Schrading, MD, FACEP

Lawrence A. Vickman, MD, MHA, FACEP

ACEP Development Staff

Marilyn Bromley, Director, Emergency

Medicine Practice Department

Julie Dill, Administrative Assistant

Rhonda Whitson, RHIA


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Table of Contents

This book is a work in progress. Additional chapters will be added as they are available.

Wellness Book for Emergency Physicians

ForewordIntroduction

Planning for Wellness in Emergency Medicine

Career Planning and Longevity

Using Circadian Principles in Emergency Medicine Scheduling

Health, Diet and Exercise

Stressors in Emergency Medicine

Burnout

The Scheduling Process

Work Relationships

Litigation StressInfectious Disease Exposure

Physician Impairment

Gender and Related Forms of Discrimination and Harassment

Coping Mechanisms for Emergency Physicians

Critical Incident Stress Debriefing

Communication, Conflict Resolution, and Negotiation

Wellness for the Emergency Medicine Resident

The Adult APGAR An Instrument to Monitor Wellness


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Wellness Book

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Emergency Physicians

Foreword

The first foray into the subject of wellnessfor emergency medicine physicians waspublished in 1995. Emergency medicine was justbeginning to experience the pain of adolescence.In response to a burgeoning need, ACEPsPersonal and Professional Well-Being TaskForce and Committee had the foresight to writethe first edition ofWellness for EmergencyPhysicians. Described as a labor of love,Wellness for Emergency Physicians, was writtento serve as a resource for emergency physiciansof all ages, in all stages of their career. We knowmany members have used the book as they metthe challenge of balancing both personal andprofessional well being.

The Wellness Section is deeply committedto providing emergency physicians with theinformation and resources necessary to keeptheir personal and professional lives balancedand on target. In keeping with this mission we

have taken a look at the original wellness bookand revised it. We have looked at the changingdemands of our specialty and have listened tothe needs of the men and women on the frontlines. New information is provided and the oldhas been updated.

Many predicted that the specialty ofemergency medicine would never survive. Notonly has it survived, it has thrived. We continueto grow and mature. The key to our success hasbeen finding effective strategies to manage our

unique personal and professional stressors.Wellness for Emergency Physicians, 2

ndEdition

is an excellent resource for all emergencymedicine physicians. It is our sincere wish thatyou use it in good health.

Best wishes,

S. Shay Bintliff, MD, FACEPJulius A. Jay Kaplan, MD FACEPJ. Mark Meredith, MD, FACEP

Introduction

Some years ago, when the AmericanCollege of Emergency Physicians (ACEP)

looked at what the practice of emergencymedicine was doing to emergency physicians, itdeveloped a Personal and Professional Well-Being Task Force and followed with aCommittee. Under the leadership of Louise B.Andrew, MD, JD, FACEP, and others, ACEPpublished a booklet Wellness for EmergencyPhysicians in 1995. This wellness bookletexplored the stressors in emergency medicineand provided guidance for coping mechanismsand wellness planning. The editors intended thatwe keep this reference readily available when

issues come up in our lives, as they knewalmost certainly will.

Now the Wellness Section, thanks to S.Shay Bintliff, MD, FACEP and J. MarkMeredith III, MD, FACEP, and their dedicatedsubcommittee members, has revised the book.The issues are no less compelling now as whenemergency medicine was young. They areimportant to each of us in all stages of ourcareers, whether we realize it or not.

Julius A. Jay Kaplan, MD, FACEPCharles Chuck Henrichs, MD, FACEPCo-chairs, Wellness Section


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Career Planning and Longevity

Julius A. Jay Kaplan, MD, FACEP

To discuss career planning and longevity inemergency medicine, we should first start out bydefining some key words:

Career: a field for or pursuit of consecutiveprogressive achievement especially inpublic, professional, or business life; aprofession for which one trains and which isundertaken as a permanent calling.

Planning: the act or process of making or

carrying out plans, specifically theestablishment of goals, policies, andprocedures for a social or economic unit.(Plan: a method for achieving an end, anoften-detailed formulation of a program ofaction.)

Longevity: a long duration of individual life;long continuance; durability.

(Source: Merriam Websters CollegiateDictionary)

Thus, if we are looking at our desire to have a

long and rewarding experience of workthroughout our lives, we need to focus onspecific approaches which will engender thatfulfillment. In other words, we needs to plan ourlives rather than just letting life happen to us.

When we began (or, if we are just starting out,begin) a career in emergency medicine we did sobecause we were attracted to the field for avariety of reasons: personal autonomy; thechallenge of meeting and handling crises; theopportunity to establish relationships with

people and influence their lives; the opportunityto make the world a better place to live in;lifestyle the ability to create a work schedulethat allows ample time for hobbies, play andleisure pursuits; finances ability to make areasonable income; security as a physician ourservices would always be needed. You haveyour own reasons take a moment and write

down what you think were your reasons. As weall know, emergency medicine is fundamentallydifferent from other medical specialties: People do not come to us for their regular

check-ups nor are their appointmentsscheduled.

There is not an established relationshipbetween patient and physician and so thatbond must be created instantaneously in anoften difficult, impersonal environment.

When people come to us they are commonlyin crisis, whether that is physical oremotional in nature.

Their expectations and needs varytremendously and so we must constantlychange the way we approach them, ie, noone size fits all, and that adds challenge toour task.

Our workday is also not scheduled interms of the workload, which is neverpredictable and can change in a moment. Wecan go from caring for patients at a

comfortable pace to crisis and chaos in aflash.

Generally speaking we have no control overthe day and many variables which affect usand our patients also over which we havelittle influence.

We must work different shifts at differenttimes of the day and night which affects ourcircadian rhythms and our ability to copewith the usual demands of daily livingincluding our personal and family needs.

Now, add to those inherent stresses, thefollowing which have also become part of ourdaily lives: Constant pressure for perfection

Re: the patients diagnosis the threatof malpractice litigation

Re: the patients satisfaction the threatof a patient complaint


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Loss of any assurance of professionalsecurity there is no such thing assecurity as physician contracts may be lostwith little warning and one bad outcomewhether quality or service related may cost aphysician his/her job.

Risk of violence and/or infectious diseaseexposure

Declining compensation as managed careratchets down physician reimbursement.

Given these facts, it is clear that we cannot bepassive with regard to our practice of emergencymedicine and any hope for career satisfactionand longevity. We must take this on, just as wewould accept the challenge of treating a patientwho presents to us in pulmonary edema andneeds our organized approach to doing the right

things at the right time to help our patient returnto health and live a long life.

The first step in our career planning should be totry to start in the right place. The poet WilliamBlake wrote, Follow your bliss, and the authorJoseph Campbell in a similar way stated,Follow your excitement. It is important toconnect to what turns us on even amidst thenecessities of fulfilling previous commitmentswith regard to home mortgages, schoolpayments, car leases, etc. If just starting out,

there are a number of key questions which youshould answer for yourself as you choose whereand how you want to work. These include thearea of the country in which you want to live,the practice location (emergency department orurgent care or other, the patient mix in terms ofacuity and/or illness, urban/suburban/rural), thekind of group which you join (democratic group,single hospital or multi-hospital,local/regional/national, employee or independentcontractor, opportunity for ownership or not),and whether there are opportunities for you to

develop special interests (administrativeresponsibilities, subspecialty expertise such aspediatric emergency medicine, toxicology,occupational health, etc). Even if you have beenin practice for a while, doing a periodic re-assessment with regard to these issues is veryworthwhile. In the same way that we think ofhaving a yearly or regular physical check-upwith our personal physician, we perhaps should

adopt the concept of a yearly metaphysicalexamination where we take time to reviewwhere we are in our lives and where we wish togo from here (Silverman J. On the Meta-Physical Aspect of Health Care: Attitudes,Values and Other Thoughts We Use to Think.

Family and Community Health. 1980;3(2):93-103). Such a periodic self-examination can oftenhelp re-direct course and focus on what fulfillsus before burnout happens.

An important initial step in career planning atany stage of a career is to ask yourself what isimportant to you (your values) and how youwant to operationalize those values in your life(your goals). Setting goals is vital to any careerplanning process and writing down your goals isessential. One exercise is to set aside one hour

(at least) and sit down in a quiet place and writedown everything that you want in your life: what you want to accomplish what you want to do what you want in terms of relationships what you want to have how much money do you want to make where you want to go what you want to give what you want to learn what are your dreams

You should write down at least 50 entries. Onceyou have completed that, the next step is to writedown next to each goal your target date foraccomplishing that goal, whether that is 1 year,3 years, 5 years or 10 years. Thereafter,prioritize the goals within each category andcreate separate pages for each time period. Youwill want to keep these lists visible and availableto you rather than just filing them away in adrawer where they will most certainly do you nogood.

You may also separate your goals out in terms ofprofessional and personal goals. Balancing yourpersonal and professional life is crucial to beinghappy and fulfilled and to longevity in a careerin emergency medicine. You simultaneously fillmany roles in your life. In your work you arecommonly physician, psychologist, colleague,manager, teacher, businessperson, and/or leader,


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all at the same time. In your personal life you arean individual woman or man, partner wife/husband/significant other, mother/father,daughter/son, and/or friend. You are not yourjob and emergency physicians sometimes musttake special effort to avoid taking too narrow a

view of their careers and overly identifying withtheir profession. When that occurs, a medicalmalpractice summons or poor patient outcomecan be devastating.

It is important to remember that no one achievessuccess alone. Once you have begun planningyour career, whether you are at the beginning orin the middle of it, it is important to share it withthose closest to you. It may also be worthwhileto sit down with your professional colleaguesand have a group discussion of individual and

group goals. You may find that your aspirationsare very consistent with those with whom youwork. But you may also find that there are majordifferences, and if so, these will need to beaddressed or will cause conflict in the future.Some physicians groups, on the basis of thesediscussions, have altered shift length andschedule, hired additional physicians to allowfor more vacation time, decreased hours,provided for periodic sabbaticals, andencouraged and supported physicians to becomeentrepreneurs in related fields. Sharing of goals

and hopes and dreams is crucial to the careerplanning process.

The concept of continuous quality improvement(CQI), or as it is now commonly referred toperformance improvement (PI), may be adaptedto the career planning process. It perhaps couldbe called continuous personal improvement(CPI). In CQI we learned that there are severalphases of the change cycle plan, develop,change, assess. Consequently, once we have setgoals, we need to look at specific methods of

implementing change so that we can attain ourobjectives. Then we need to periodically assesshow we are doing to see if we need to alter ourcourse or the path we are walking upon. Thisfurther builds upon the notion of the yearlymetaphysical examination mentionedpreviously. One method of doing that is to takeyour own Adult Apgar score. (Please see TheAdult Apgar: an Instrument to Monitor

Wellness, last chapter of this book.) Ratherthan allowing the state of burnout to happento you, monitoring your own personal andprofessional satisfaction and work life canproactively prevent that condition fromdeveloping. Jim Rohn, the noted author and

business philosopher, has written, You cannotchange your destination overnight, but you canchange your direction overnight. (Jim Rohn.The Treasury of Quotes. Jim Rohn International,Southlake, TX, 2001)

Emergency medicine as a profession is not easy.People do not come to us when they are happy,as when they have a wanted pregnancy come tofruition with the birth of a healthy child. Theypresent to us with their pain, anxiety and/orgrief. In the emergency department, we have a

choice we can ourselves keep them at anemotional distance in which case we will not beaffected by their negative or difficultenergy; the other option, which I suspect is theone most chosen, is to empathize and connectto the human being sitting or lying across fromus. When we do that, invariably we will beaffected by their stress and pick up or takein some of their pain or anxiety. Unless wedevelop methods to channel that stress and dealwith it constructively, we may keep it in ourbodies and become ill or anxious or depressed.

As many of you are aware, the rate of substanceabuse, suicide and divorce in physicians is 3times that of the general population, and somesay it is even higher in our specialty.

R.I.P. is thought to stand for Rest in Peace.While at times we use that phrase prefaced byMay he . . . or May she . . . referring tothose who have passed on, Tom Peters, thegifted management consultant and inspiringspeaker, suggests the abbreviation be used torepresent Renewal Investment Plan. (TomPeters. Reinventing Work: The Brand You 50.Alfred A. Knopf, New York, 1999). To be activewith regard to our health and wellness isfundamental to career longevity in emergencymedicine. So what can we do? Create aformalized renewal investment plan forourselves, to help us remain healthy and enhanceour well-being. We may choose to keep it


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private or share it with our significant others inorder to obtain their support. Some areas toinclude in your RIP are the following:

1. Rest how much sleep do you need on anightly basis? Plan to get it even if that

means setting an alarm clock or watch to tellyou not when it is time to wake up but ratherwhen it is time to go to sleep. Make certainthat when you are working other than dayshifts you get enough rest and have thesupport of your family and environment tosupport your sleep time.

2. Exercise what and how often you shouldput this into your calendar. Most studiessuggest that people who exercise early in themorning are more successful in maintainingan ongoing and regular exercise program.Give yourself enough time to warm up, cooldown and stretch in general in order toremain flexible in both mind and body.

3. Family/Significant Other time amidst ourharrowing and busy work lives we mustensure that we take the time to connect withthose we love and who love us. As Gandhionce said, There is more to life than merelyincreasing its speed (and he said that morethan 50 years ago).

4. Build down-time into your schedule timeto just be rather than do. I am not anexpert in this field. I was recently at a poetryworkshop and we were given the exercise towrite the first line of a poem that wewouldnt have the courage to finish. I wrote:pure terror at the mere thought of nothingto do and nowhere to go.

5. Spirit time and energy to relate to ourhumanity and to a power greater thanourselves. How do you connect to spirit andfrom what do you derive your sense ofmeaning in your life? Write out a missionstatement for yourself, in a similar mannerto the way that the organizations for whichwe work do.

6. Nutrition how do you physically nourishyour body? What kind of diet makes youfeel great? As a friend of mine once said,My body is my temple, not just a vehicle tocarry me from place to place.

7. Joy how do you emotionally nourishyourself? Create a joy list a list of things

which you can do or how you can be thatreally brings you happiness and joyfulness.After you create the list, write down next toeach entry the last time you did orexperienced that particular event. It can besobering to realize that it has been a very

long time since you gave yourself aparticular experience of joy or pleasure.

Finally, it may be helpful to start each day withthe following exercise. Ask yourself to answerthe following questions:

What am I most grateful for in my life?

What am I happiest about in my life?

Who/what am I proudest of in my life?

What am I most enthusiastic about in mylife?

Who/what am I most committed to in mylife?

Who do I love? Who loves me?

By asking yourself these questions when youfirst get up in the morning, in the shower or onthe way to work, your whole day (and life) getsput into proper perspective.

To summarize, consideration of sustaining along and successful career in emergencymedicine begins with planning. Taking time to

consider what is important to you and stettinggoals to help you live your values are initialsteps. Writing down those goals and prioritizingthem are next, and then developing specificplans (objectives, guideposts along the way,implementation strategies). Periodic re-assessment is critical as is occasional re-direction based on changes which will invariablyoccur in our age, health and desires. FerdinandFoche, the French Allied Supreme Commanderwho led the French in World War I wrote thatThe greatest force on earth is the human soul

on fire. If we can stay connected to thatcreative fire within us and keep it burningbrightly, longevity in whatever we choose to dowill be a natural outcome.

Resources

Albom M. Tuesdays with Morrie. New York,NY: Doubleday; 1997.


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Bach R.Illusions: Adventures of a reluctantmessiah. New York, NY: Delacorte; 1977.

Bintliff S. The adult APGAR: An instrument tomonitor wellness.Emerg Med News. 1998:42-43.

Carius M. Avoiding training toxicity stayinghuman during residency.Ann Emerg Med.2001;38(5):596-597.

Chipman C. If the walls could speak.Ann EmergMed. 2002;40(1):120-121.

Covey S. The seven habits of highly effectivepeople. New York, NY: Simon & Schuster;1989.

Goldberg R, Boss RW, Chan L, et al. Burnoutand its correlates in emergency physicians: fouryears experience with a wellness booth.AcadEmerg Med. 1996;3:1156-1164.

Goldberg R, Kuhn G, Andrew L, et al. Copingwith medical mistakes and errors in judgment.Ann Emerg Med. 2002; 39(3):287-292.

Heider J. The tao of leadership: Leadershipstrategies for a new age. New York, NY:Bantam Books; 1985.

Houry D, Shockley LW, Marcovchick V.Wellness issues and the emergency medicineresident.Ann Emerg Med. 2000;35:394-397.

Hunter ML. The five stages of dying in amalpractice suit. Tex Med. 1990;86:50-53.

Johnson S. Who moved my cheese? New York,NY: Putnam Publishing Group; 1998.

Klein A. The courage to laugh: Humor, hope

and healing in the face of death and dying. NewYork, NY. Jeremy P. Tarcher, Putnam; 1998.

Kuhn G. Circadian rhythm, shift work, andemergency medicine.Ann Emerg Med.2001;37(1):88-98.

Lum G, Goldberg RM, Mallon WK, et al. Asurvey of wellness issues in emergency

medicine (part 1). Ann Emerg Med. 1995;25:81-85.

Lum G, Goldberg RM, Mallon WK, et al. Asurvey of wellness issues in emergencymedicine (part 2). Ann Emerg Med.1995;25:242-

248.

Lum G, Goldberg RM, Mallon WK,et al. Asurvey of wellness issues in emergencymedicine (part 3). Ann Emerg Med.1995;25:407-411.

Muller W. Sabbath: Restoring the sacred rhythmof rest. New York, NY: Bantam Books; 1999.

Needleman J. Money and the meaning of life.New York, NY: Doubleday and Company, Inc.;

1994.

ODonohue J.Eternal echoes: Exploring ourhunger to belong. London: Barton Press; 1998.

Oliver M.New and selected poems. Boston,MA: Beacon Press; 1992.

Peters T. The circle of innovation. New York,NY: Knopf; 1997.

Peters T. The brand you 50: Reinventing work.

New York, NY: Knopf; 1999.

Pirsig RM.Zen and the art of motorcyclemaintenance. Toronto, Canada: Bantam Books;1974.

Reinhardt MA, Munger BS, Rund DA.American Board of Emergency Medicinelongitudinal study of emergency physicians.AnnEmerg Med. 1999;33:22-32.

Rohn J.Leading an inspired life. Niles, Ill:

Nightingale Conant; 1997.

Seligman M.Learned optimism: How to changeyour mind and your life. New York, NY: PocketBooks; 1990.

Smith-Coggins R, Rosekind M, Hurd S, et al.Relationship of day versus night sleep to


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physician performance and mood.Ann EmergMed. 2001;24(5):928-934

The Arbinger Institute.Leadership and self-deception. San Francisco, CA: Berrett-KoehlerPublishers, Inc; 2000.

Wenokur B, Campbell L. Malpractice suitemotional trauma.JAMA. 1991;266:2834

Whyte D. Crossing the unknown sea: Work as apilgrimage of identity. New York, NY:Riverhead Books; 2001.

Whyte D. The heart aroused: Poetry andpreservation of the soul in corporate America.New York, NY: Currency Doubleday; 1994.

Whyte D. The house of belonging/Songs forcoming home/Fire in the earth/Where many

rivers meet (books of poetry). Langley, WA:Many Rivers Press; various years.

Wilbert JR, Charles SC, Warnecke RB, et al.Coping with the stress of malpractice litigation.Ill Med J. 1987;171:23-26.

Zun L, Kobernick M, Howes D. Emergencyphysician stress and morbidity. Amer J EmergMed. 1988;6:370-374.

Audio Tape/CD Sets(Available through the Nightingale ConantCorporation www.nightingale.com phone800.560.6081; fax 800.647.9198)

Blanchard K. Personal Excellence.

Covey S, Merrill AR, Merrill RR. First thingsfirst.

Gerber M. Taking charge of your business andyour life.

Gerber M. The E Myth manager seminar.

Metcalf CW.Lighten up the amazing power ofgrace under pressure.

Peters T. The innovation revolution.

Rohn J. The art of exceptional living.

Rohn J. Take charge of your life The winnersseminar.

Rohn J. The power of ambition Unleashing theconquering drive within you.

Whyte D. Footsteps:A writers life (available

through The Mary Rivers Company,360.221.1324)


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Financial Planning

Jack Healy

Introduction

Ideally, physicians entered the field ofemergency medicine with the intention ofhelping those who have been physically, orperhaps emotionally, traumatized. Patients whopresent to the ED bring not only their physicalills but also the difficulties of their socialsituations with them. The same is true for theemergency physicians who care for them.Emergency physicians are faced with the samesocial issues as the rest of the population,including the issue of financial security. In fact,it is in the best interests of both the emergencyphysician and his/her patients that financialaffairs be as sound as possible so that theemergency physician can be mentally andemotionally focused on the emergent patientcare issues and challenges that are faced on adaily basis.

The IssueJust as the issues in medicine are complex andrequire constant study to maintain competency,so are the issues related to maintaining a soundfinancial position. Although incomes will varyfor emergency physicians depending uponseveral factors such as location and population,there is no doubt that the monetary rewards ofthe profession are adequate to support acomfortable lifestyle. A physician can start acareer as a board certified emergency physician

in his late twenties and can command a startingsalary between $125,000 and $175,000. If weassume that a physician begins his career at age30 starting at $150,000 and works to theaxiomatic age 65, or 35 years, he will have beencompensated over $5,000,000 in his workingcareer. This, of course, does not include anyincreases in salary or stipends to which thephysician may be entitled.

Since there are no courses offered in medicalschool to provide the physician with in depthknowledge as to how to handle finances, it is notsurprising that the physician generally does nothave the financial savvy necessary to adequatelymanage this revenue stream and achieve themaximum benefit from it.

The Art & The Science

Building personal wealth and creating financialindependence is both an art and a science. To befinancially successful, one must use a variety ofskills in planning the outcome, implementing theplan and, as in any scientific procedure,controlling the desired results. It is thecoordination of these three steps that providesthe art in an ongoing and ever-changing process.These changes are due to variations in the

economic circumstances surrounding thephysicians life, both personal and professional,as well as changes in tax law and otherinvestment considerations (ie, fluctuating marketrates, changing inflation rates etc.)

There are also daily decisions that are madewhich affect the physicians financialfoundation. How much should I spend on ahouse? How large of a down payment should Iput down? Should I send my children to privateor public school? Should I buy a luxury

automobile or a basic transport? The answers tothese types of questions are not simple and willvary depending upon ones age andcircumstances. For example, a physician earning$225,000 who is already a homeowner and hasbeen successfully funding his basic financialplan for several years will look at the purchaseof an automobile very differently than the young


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physician just starting out with $150,000 ofschool loan debt.It is this homogenization of art and science thatmakes it is very possible for a physician toengineer his finances in such a way as to enjoythe same, or higher, level of spendable income

in his retirement years as in his peak earningyears.

The Phases

There are basically three distinct phases to thephysicians financial life: Wealth Creation,Wealth Distribution and Wealth Conservation.

The Wealth Creation phase focuses on savingand investing money for both current and futureneeds, wants and desires such as cars, homes,appliances, childrens education or for thephysicians own retirement. Most physicianswill save and invest in the traditional ways, thatis, compounding interest, dollar cost averaginginto investments, reinvesting dividends andcapital gains and using tax deferred retirementplans such as IRAs, and 401(k) plans. In thisphase, the prudent physician will also sequesteraway funds for use in the event of unforeseenemergencies such as temporary loss ofemployment and other such emergencies.Traditional financial planning does not fully

disclose the effects of these various investmenttools and it is probable that no exit strategieshave been discussed for these traditional tools.Such exit strategies could potentially save thephysician and his family millions of dollars inunnecessary costs over his lifetime.

The Wealth Distribution process is the phasewhen people need or want their funds. Thisphase, if not properly strategized, can be verycostly. Excessive or unnecessary income taxes,early withdrawal penalties (both governmental

and institutional), sales charges, distributionrestrictions (timing issues) and inflationarypressures can substantially reduce the spendableincome one had planned to have in this phase.

The last phase of a financial life is called WealthConservation. Leaving wealth to family or toothers of our choosing without considerable

wealth erosion is no mean feat. It is possible forportions of an estate to lose up to 80% of theirvalue because of the lack of wealth conservationplanning. The estate laws are not friendly whenthe wealthy physician dies without planning.Estate taxes, income taxes, attorney fees,

accounting fees, appraisals, penalties, salescharges and liquidation sales of assets can beconfiscatory to your wealth and providefrustration and distress to your heirs.

The Macroeconomic Approach

During all three of these phases, one must beconstantly aware of the total, or macroeconomic,picture surrounding ones investments. As in anybusiness venture, the physician must payattention to all of the obvious, as well as thesubtle, costs associated with financial decisions.One example of the obvious costs in a plan is theannual taxes paid on interest, dividends andcapital gains. The subtle costs would be the lostopportunity costs (LOCs) associated with thesesame taxes. To understand LOCs, simply thinkof what happens if you lose a dollar: not only doyou lose the dollar, but you also lose the value towhich the dollar may have grown at someinterest rate. Even though LOCs are taught inEconomics 101, most traditional planners rarelydiscuss them. A classic example of the impact of

LOCs can easily be demonstrated using acommon investment vehicle like a Certificate ofDeposit (CD). If we project a 6% interest ratefor 30 years on a $50,000 CD, the physicianwould have an account value of $287,175.Conventional planners would then subtract theoriginal $50,000 and report a profit of $237,175.While this analysis is simple, it is not at allrepresentative of what is going onmacroeconomically. By contrast, a costaccountant would look a little deeper. If weassume a 36% Federal Income Tax bracket for

this physician, there would have been a total of$85,383 of taxes paid over the 30-year period. Ifwe then assign a highest and best use of money,or LOC, of 9% to these taxes paid each year, theLOC on the taxes totals $209,866. This bringsthe true cost of the taxes plus LOC to $295,249.Adding in the original $50,000 reveals a truecost of a staggering $345,249to acquire


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$287,175! Simply put, if you were running awidget company and you sold the widgets for$1, but they cost you $1.25 to manufacture, youwould not remain in business for very long.

It would take an extraordinary amount of time

and effort for the physician to remain currentwith the issues at hand. Most physicians spendlarge amounts of time keeping current in theirown specialty and just do not have the time todevote to financial analysis.

Traditional planners will discuss different types(risk level) of investing to do at different ages.Generally speaking, this is because mostplanners, as well as investors, are accustomed tothe risk-reward premise of stock marketinvesting. Simply put, the higher the risk, the

greater the reward. Often times, the rate ofreturn must be chased to make up for theinefficiencies introduced by market risk itself,taxes and their associated LOCs, inflation andbuilt in obsolescence etc. In addition, mostphysicians will look at spending only the growthor interest in their investments so as to protecttheir assets from being depleted at retirementtime. This is done in contrast to a paydownmentality that will allow more spending by thephysician as well as having positive taxconsequences. By using a paydown

methodology, the physician does not have toworry about the rate of return, and its associatedrisk, being so high and can achieve the same, orperhaps a higher, standard of living throughoutretirement while greatly reducing his concernsand anxiety levels concerning volatility in themarket.

Since most physicians will enjoy a higherincome level than the general populace,traditional investing needs to be analyzed beforeany money is put away and a cost/benefit

analysis performed at the same time. Forexample, most traditional mutual fund and stockmarket investing will produce annual dividendsand short-term capital gains that will thengenerate current income and capital gain taxes.If current income were not necessary from theportfolio, most physicians would be betterserved by being invested in funds or stockswhich will show only capital appreciation and

therefore no current taxes to affect the efficiencyof the plan.

Asset Protection

It is important to keep in mind that once anaccident or lawsuit liability claim is in excess ofthe physicians policy limits, personal assets areattacked. Very seldom will the physiciansfinancial advisor discuss ways to protect assetsonce they are accumulated. One area that doesnot receive adequate discussion with mostphysicians is in this area of asset protection,otherwise called liability protection. Mostphysicians are familiar with medicalprofessional liability or malpractice insurance.This product is extremely important in todayslitigious society. Many times whether or not thephysician is at fault is irrelevant to thesettlement of a claim. For example, manyinsurance companies will evaluate a claim,determine what the cost is to defend the claimand based upon that determination, settle theclaim with no regard for how the physicianwould like to proceed. Also, many companieswill allow the physician to choose the legalrepresentation that he would like to use andmany will not. For many physicians, this choiceof legal representation is as personal as a patienthaving the opportunity to choose their own

medical practitioner. The physician shouldinvestigate the types of policies and optionsbeing offered by various companies with aninsurance advisor in whom he has confidence.

Another aspect of liability protection has to dowith the physicians automobile andhomeowners liability insurance. Since eachstate has its own regulations regarding thesetypes of policies, an in depth dissertation cannotbe given here. However, there are somegeneralities that can be made. As far as

automobile and homeowners liability coverageis concerned, liability coverage through the autoor homeowners policy is generally moreexpensive than if the physician purchased aseparate excess, or umbrella, liability policy.This umbrella policy would be used if theliability of the physician were deemed to exceedthe limits provided by the auto or homeowners


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policy. If the physician has to make choicesbetween low deductibles on his collisioncoverage or funding an umbrella liability policy,most often the better choice is to fund theumbrella policy. This analysis is really quitesimple. In the event of a collision, could the

physician better afford to pay a high deductibleto fix his auto or to pay a liability claim inexcess of $1,000,000? It is important to keep inmind that once an accident or lawsuit liabilityclaim is in excess of the physicians policylimits, personal assets are attacked.

Income Replacement Life

Insurance and Disability

Insurance

The topic of income replacement will take twoforms: human life value replacement anddisability income protection insurance. The firstissue, human life value replacement, concernsthe loss of income to the physicians family inthe event of his death. This replacement wouldbe provided by life insurance. By definition, lifeinsurance is concerned with providingindemnification of the loss of values. This valuemay simply be defined as the capitalizedmonetary worth of the earning capacity of thephysician in his chosen specialty. Simply stated,

how much money would a family need to havein an account to generate the same level ofincome for the family as while the physicianwere still alive? In the past, well meaningadvisors calculated the amount of life insurancerequired by subtracting the physicians currentassets from the total amount of capital needed toprovide the same level of income as if thephysician were still alive. There are somefundamental flaws in this traditional approach.By subtracting current assets, you are severelylimiting the normal capitalistic nature of the

family. The ideal scenario would be to allow thefamily to have the same standard of living as ifthe physician were still alive. Ideally, the familyshould still be in a financial position to save andinvest money at the same rate as if the physicianwere still alive. Ideally, you would want thefamily to spend money and consume assets as ifthe physician were still alive. Ideally, you wouldwant the children to still have the opportunities

for higher education as if the physician were stillalive. By not providing the full replacementvalue for the physicians family, thefundamental definition of life insurance is beingviolated. An example of full replacement valueis simple to compute. If we use a physician

making $150,000 as our example and assumethat the family can safely expect a 6% return onits investment, then the physician would need$2,500,000 of life insurance to fully indemnifyhis family against his economic loss.

With the discussion on how much insurance toprovide completed, let us now discuss the twobasic types of life insurance. These are term andwhole life. First lets discuss term life insurance:Term insurance gives death benefit protectionand no cash accumulation. Depending upon the

product, premiums either increase annually orthey can remain fixed for certain periods of timesuch as 5 years, 10 years or 20 years. Mostpeople would say that term is the cheaperproduct to purchase, and if premium paymentswere the only consideration, this would becorrect. As discussed earlier, making paymentsfor something, such as taxes, and receiving noreturn, results in an LOC. The same is true ofterm insurance premiums. If premium paymentsare made and the physician does not die, notonly are the premium payments lost but also the

opportunity costs associated with them. Also, ifthe physician makes the wrong purchaseregarding how long the plan will be in force andhe lives past the expiration of the plan, he mustnow hope to still be physically insurable. Notonly will he have lost the term premiums andLOCs but the death benefit will also be lost. Ofcourse, the physician could still be alive andinsurable, but now the premiums may beprohibitively expensive. If the physician hadtaken out the policy many years before and notpurchased additional coverage through the years,

he will probably be underinsured for hisreplacement value.

The second type of insurance, whole lifeinsurance also comes in several forms. There istraditional whole life, variable whole life,universal life, and variable universal life. Thereare other forms of whole life and, as theconsumer demands it, there will probably more


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variations in the future. Traditional whole life isthe most basic of the whole life policies and isthe one we will discuss. A whole life policy haspremiums that are initially higher than a likeamount of term insurance. However, thesepremiums are guaranteed level for life. Whole

life offers cash accumulation. This accumulationis on a tax-deferred basis. The cashaccumulation can then be accessed tax-free.Whole life offers loan provisions at favorablerates and there is no fixed repayment period forthe loans. Whole life generally pays dividendsthat can either be left to accumulate or taken ascash to supplement income or to reducepremium payments. The dividends are notreported to the IRS and so they generate no taxissues. Whole life has no LOCs. Whole life doesnot require the physician to reapply for coverage

later in life so changes in health are not an issue.

The decision as to whether to purchase term orwhole life should only be made after carefulconsideration of all the issues surrounding bothproducts and in the context of the physiciansfinancial situation.

The second issue mentioned above, disabilityincome protection insurance, is invaluableprotection to the physician and his family. Yet,many physicians treat this potential lifestyle

saving product very lightly. Some of the reasons,while questionable, are understandable.Typically, most physicians will be approachedabout disability insurance while in residency. Atthis point in time, income is low, free time foranalyzing the product is short and concentrationis on the task at hand, namely, getting throughresidency. Also, due to the youthful age of mostresidents, many physicians consider themselvesinvincible and that disability happens to otherpeople. Quite the opposite is true. Statistically,we know that between the ages of 20 and 45, the

odds of either the physician or his spousebecoming disabled for more than 90 days areone out of three. Also, the average duration of adisability that lasts more than 90 days is morethan two years. Lastly, it is an actuarial fact thatbetween the ages of 20 and 65, the physician ismore likely to become disabled for at least 90days than to die.

The physician cannot count on social programssuch as Social Security to meet his disabilityneeds. First of all, the maximum benefit paid isnowhere near even the starting salary of anemergency physician. Secondly, nearly twothirds of Social Security claims are denied.

Some states offer their own social program, buttheir income limits are also very low andgenerally short lived, perhaps six months ofbenefits are available. Many physicians will tryto save their own money to provide for adisability. Lets look at this approach. If thephysician were to save 5% of his income toprovide for a disability fund, just 90 days of totaldisability could wipe out nearly 5 years of theprinciple saved. One year of disability coulddestroy over 15 years of disciplined savings.Clearly, risk shifting to the insurance company

is the best option for the physician.

The products available are varied and arechanging constantly. As with most purchases,this is a product with which you will get whatyou pay for. The product that offers the highestlevel of benefits and the most flexibility isindividual disability insurance. A huge benefitfor this product, since the physician pays thepremium with after tax dollars, is that the benefitis received income tax free.

When looking at an individual policy, thephysician should make sure that he is covered byan own occupation definition of disability.That is, if the physician becomes disabled, andcannot work in his recognized specialty, hecannot be required to go back to work in anotheroccupation. With this provision, the physicianmay be at work in some other occupation, butwill still be eligible to collect his disabilitybenefit. If available, a lifetime benefit period ispreferred. As a minimum, the benefit periodshould extend to age 65. Also important is a cost

of living increase benefit that will allow abenefit being paid to increase with the ConsumerPrice Index rate of inflation. Another importantfeature is the elimination period, or the amountof time that will pass before the physician is ableto start collecting a disability benefit. Areasonable amount of time for an eliminationperiod is ninety days. With less than a 90-dayelimination period, the premium increases


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dramatically, more than 90-day elimination has avery small relative decrease in the premium. Thephysician should also look for a policy that isnon-cancelable and guaranteed renewable. Thiswill insure that the insurance company can nevercancel coverage for the occupation class that the

physician is in and that the premium will neverincrease. Individual disability insurance is alsocompletely transportable throughout thephysicians career. Once the individual disabilitypolicy is in place, the physician can obtain groupcoverage, if offered by his employer, and trulymaximize his disability protection.

Concerning individual disability insurance, thisproduct should be the core of the physiciansdisability income protection portfolio.

The other type of disability insurance is groupcoverage. The best feature of this type ofcoverage is that it is relatively low cost. Butremember, very often you get what you pay for.Most group policies will pay a benefit of up to60% of earned income, but will generally have acap on the benefit amount paid. A typical cap ona group plan would $5,000 per month of benefitpaid. So, if the physician were earning $150,000annually, the maximum benefit paid under thecap would be $5,000 per month or 40% of pre-disability earnings. Depending upon who pays

the premium, the benefit could then be taxable.Many group policies will only cover basesalary. This could have a significant impact ifthe physician receives bonuses, elective deferredcompensation or other forms of income notclassified as earned income. By contrast,many individual disability policies will coverthese other forms of income, including pensioncontributions. Many physicians are also notaware that coverage provided by a group policywill offset the amount of coverage availablethrough an individual policy. Unlike individual

policies, the premiums for group can be changedat will by the insurer and the insurer can cancelcoverage at any time. In most cases, groupcoverage is not transportable.

The ideal disability plan would be that theresident obtain the maximum individualdisability coverage available and then apply forany group benefits that his employer may offer.

By implementing the disability plan in thismanner, it is possible for the physician to have100% of his pre-disability earnings provided bythe insurance program.

Retirement Planning

Many physicians consider retirement planning tobe the use of tax-deferred vehicles to accumulatefunds for later in life. The basic reason mostphysicians prefer tax deferral is that they assumethat they will be in a lower marginal tax bracketat retirement so the tax burden will be lessonerous. Also factoring into the analysis is thatthe taxes built into the retirement plan will makethe account grow faster. While it is true thatleaving the taxes in the plan will allow it to growfaster, there are other considerations to be givento conventional retirement planning. Thephysician must be sure to fully understand all ofthe implications of using tax deferral forretirement. No blanket statements can be madefor all physicians as to the benefit of traditionalretirement plans with perhaps one exception.That is, that retirement plans, be they 401(k),403(b), IRA, SEP or Keogh plans are greatwealth accumulation vehicles.

One issue surrounding tax deferral is that thetaxpayer never knows what the tax brackets will

be at retirement age. They could be higher thanthey are now or they could be lower. The IRSalways maintains the right to change the taxlaws. Lets consider the possibility of being in alower marginal tax bracket at retirement.Assume that our new 30-year-old emergencyphysician is married, has children, owns a homeand has a taxable income of $100,000. Hiscurrent marginal tax bracket is 28%. Assumethat he is able to put $10,500 per year into hisretirement plan at 10% interest. By his age 65 hewould have accumulated $3,130,331. If we

assume that he just draws $310,000 per year atretirement, his marginal tax bracket would be36% under current tax law. There is no doubtthat the account grew faster than if the had beennetted of taxes. If netted, the $10,500 wouldhave been reduced by 28% or $2,940; leaving$7,560 to invest. This amount would havegrown to $2,253,839.


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Other tradeoffs are made when using tax-deferred vehicles. At retirement time, thephysician would not have capital gains treatmentfor stock market investments in his qualifiedplan. Capital gains tax rates are generally morefavorable than income tax rates for high net

worth individuals. The physician would not beable to offset capital gains with capital losses fortax planning purposes. Access to the plan isgenerally limited to loans of not more than 50%of the account value up to $50,000 and must bepaid back within a 5-year period. The physicianis prohibited from taking distributions beforeage 59 or he faces a 10% early withdrawalpenalty in addition to paying current incometaxes. On the other hand, distributions must startby age 70 or he faces a severe penalty(currently 50%) on the distribution not taken.

The bottom line to retirement planning and taxdeferral is that it must be done in concert withthe rest of the physicians financial plan. Thephysician must seek the help of a competentpersonal financial engineer to determine a planfor retirement. Options and strategies must beavailable to the physician in to order tomaximize the efficacy of a traditional, taxdeferred retirement plan. There are exitstrategies which could allow a much morefavorable treatment of withdrawals from

qualified plans.

Estate Planning

The topic of estate planning is very complex andshould be done with an estate-planning attorneyand a personal financial engineer. There aresome basic steps that all physicians should takeregarding estate planning regardless of the stageof their career. Writing a will is a must for all.Without a will, the state will determine whoyour beneficiaries are according to strict rules of

intestacy. Most emergency physicians will haveheard of a living will and again, all should haveone. If you dont, it is your loved ones who areleft the task of determining your ultimate fate atan already stressful time and your wishes maynot be the same as theirs. Also in this must havecategory is a Durable Power of Attorney. Thisdocument will allow someone else to make

decisions for you when you have becomeincompetent to do so for yourself. Having thisdocument will avoid the need of a friend orrelative going to court to be granted a power ofattorney. Since named beneficiaries receiveassets outside your will, one simple way to avoid

probate costs, attorney fees and other legalissues is to have named beneficiaries for asmany of your assets as you can. Simply properlyarranging ownership of assets can also avoidmany of the legal issues with the physiciansestate.

The subject of estate taxes has come and gone 5separate times in our history. Currently, the IRSis phasing out estate taxes over time. However,they will be completely gone for only one yearand then, by law, must come back in again.

Estate taxes can take 55% of the physiciansestate, depending upon its value. This is inaddition to any income taxes due from the estate.An example of confiscatory taxation would beour physician who died leaving $5,000,000 inhis pension plan. His heirs would first have topay 55% federal estate tax ($2,750,000) and then36% federal income tax ($810,000) leaving$1,440,000.

Many planners will recommend the use of truststo protect various assets. The pros and cons of

these tools must be carefully evaluated beforeimplementing them. Many of these decisions areirrevocable and will be out of the control of thephysician once these decisions are made. Someof these decisions could completely disinheritthe physicians loved ones if not carefullyplanned.

The Summary

Personal financial engineering is something thatall physicians should make use of. Just as the

prudent physician would not try to practicemedicine that was current 50 years ago, soshould he not try to plan his financial futurebased on tax laws and economic issues that areequally outdated. Also, just as the competentemergency physician refers his patients tospecialists once the emergent situation is undercontrol, he should also seek the help and


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expertise of those specialized in the financialworld. Just as the physician would advise hispatient of any side effects of medications ortherapies, be sure that your advisor gives you thesame disclosure regarding taxes, LOCs and thelong and short term effects of your financial

plan.

Hopefully, some topics have been mentioned inthis primer that will serve as a guide to a path offinancial well being and prosperity for allphysicians, young or old.


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Health, Diet and Exercise

Marc L. Pollack, MD, PhD, FACEP

Frani S. Pollack, MS, MSW, RD

Maintenance of physical and mental health arekey elements for emergency physicianlongevity. Health and well-being can bemaintained throughout a career in emergencymedicine by careful attention to signs andsymptoms of fatigue, stress and burnout. Ofcourse, certain predictable changes will occurwith aging. The decision to make certain healthenhancing choices, such as to quit smoking or tostart an exercise program, is the first step toenacting these life saving changes. There mustthen follow an emotional decision so that thesechanges will actually occur. Changing onesdaily patterns at first seems impossible, but oncesuccess has occurred, the rewards of new goodhabits bring a sense of energy and physicalfreedom that few willingly relinquish.

You Are What You Eat

It has become clear, through laboratory andepidemiological research, that a low-fat, high-carbohydrate diet is the best way to improvedhealth and increased longevity. Standardguidelines recommend a total fat intake of 30%or less of total calories consumed, saturated fatof less than 10% of calories, and totalcholesterol less than 300mg per day. Theguidelines also recommend an increased intakeof complex carbohydrates, moderate proteinintake, about 1 ounce of ethanol per day, lessthan 6 grams of salt per day, adequate calcium,

magnesium and fluoride, and generally not morethan the RDA of supplemental vitamins andminerals.

The four food groups we learned in school havebeen replaced by a classification system calledthe food pyramid, designed to help put theseguidelines into daily food choices. The emphasisis shifted toward carbohydrates, fruits, and

vegetables. For an adult, the pyramidrecommends daily intake of 6-11 servings ofbread, cereal, rice, pasta, or other complexcarbohydrates; 3-5 servings of vegetables orbeans; 2-4 servings of fruit; 2-3 dairy servings;and 2-3 servings of fish, poultry or meat. Thispyramid represents a large reduction in theconsumption of animal products and offersalternative protein sources. Adequate protein canbe derived from non-animal sources such asbeans or soy.

Other important considerations in planning ahealthy diet are moderation and variety. Eating avariety of foods in each category provides abetter balance of nutrients. A moderate dietprovides limited salt and simple sugars withoutexcess calories.

Despite the popularity and early success ofquick weight loss programs, they almost neverwork for the long term. The vast majority ofparticipants eventually gain the weight back. Aprogram that works long term must includedietary changes you can live with for the rest ofyour life and that you actually enjoy. The highprotein, low carbohydrate diet (such as theAtkins Diet) for weight loss is currently popular.The initial rapid weight loss that is observed islikely due to water loss, decreased caloric intakeand possibly decreased insulin resistance. Thisdiet is often high in cholesterol and fat andworsens the risk for progression ofatherosclerosis. The long-term effect of this dieton overall health has not been established.

Over consumption of food is a major problem inWestern society. Much pleasure and socialactivities are centered around food consumption.Many people do not recognize the sensation ofsatiety and therefore do not know when to stop


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eating. They may have been told in childhood tofinish your plate and never learned torecognize satiety signals. A useful method tolearn to recognize satiety and to reduce overconsumption is listening to your internal signalsof hunger and fullness. Frequently, weight gainresults from not listening to appropriate satietysignals during a meal. Rate your satiety on ascale from 1 to 5 where 1 = hungry, 2 =moderately hungry, 3 = satisfied, 4 = full, and 5= stuffed (Figure 1). Ideally, you should only eatwhen you are moderately hungry to hungry, andyou should always stop eating when you aresatisfied to full. It takes at least 20 minutes forthe body to send and have recognized itshormonal signals of satiety, so eating slowly isimportant so you can readily evaluate the satietysignals. Try rating your satiety on this scale and

get in touch with these submerged signals.

For an emergency physician, work is often busyand stressful, lending itself to quick meals, fastfoods and doughnuts at the nurses station. Youmust learn to eat slowly and listen to the satietysignals, even in the midst of a chaotic ED shift.Do not use food as a stress reducer ormisinterpret stress/anxiety feelings as hunger.Try to get in a good, low fat, complex-carbohydrate meal before your shift. Make timefor an adequate meal break during the shift.Bring in some low-fat muffins, fruit, and high-fiber snacks for the staff (Table 1). Althoughcaffeine initially provides increased alertnessand stamina, the long-term effects includefatigue and less restful sleep, especially at higherdoses.

Figure 1

Satiety Scale

1_________2_________3_________4________5hungry mod hungry satisfied full stuffed

Table 1

Good ED Snacks

Grapes, cherries, fruits, dried fruitLow-salt, whole grain pretzelsAlmonds, peanutsNon-fat popcorn


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Excessive caffeine intake (>5 cups coffee/day)can produce nervousness, palpitations, andanxiety. There is a caffeine withdrawalsyndrome that generally occurs 12-24 hoursafter cessation and is usually manifested byheadache. It is best to restrict caffeine to 1-2

cups of coffee/day and use substitutes such asdecaffeinated beverages.

Aerobic exercise and strength training areessential components of any weight loss andfitness program. Reduced caloric intake by itselfwill reduce both muscle mass and adipose tissue.The combination of caloric restriction andregular exercise of the major muscle groups willmaintain muscle mass and tone and reduceadipose tissue.

Emergency Medicine RequiresTotal Fitness

The successful practice of emergency medicinerequires a high degree of mental and physicalfitness. The demands of a busy shift are bothphysically and emotionally exhausting. Thesedemands are more noticeable as we get olderand during times of personal stress or illness.Careful preparation will allow the emergencyphysician to weather the storm of thedemanding shifts. If you find all or most of yourshifts physically or emotionally draining, acritical reassessment of your job and lifesituation is warranted.

The first step is physical fitness, which usuallyrequires planned and regular exercise. You willnot only be better prepared for the busy shift, butwill look and feel better and maintainappropriate weight. Regular aerobic exercisewill enhance your cardiovascular and respiratoryfitness. In addition, an aerobically fit EP will notsuffer the physical fatigue often associated witha busy ED shift. Aerobic exercise involves therepetitive use of large muscle groups over aperiod of time. In general, during aerobicexercise, you want to maintain your heart rate at60% - 85% of your age-adjusted maximum heartrate. A rough estimate of maximum heart rate is220 minus your age. The duration of eachsession should be greater than 20 minutes, and

ideally 45 minutes, and should occur 3-5 timesper week. If you cannot exercise 30 to 45minutes in one session, you still get the samebenefit if you exercise that time broken up intotwo or three session in a day. Most newexercisers do too much too soon. Start slowly

and gradually increase your exercise time whilemaintaining your target heart rate.

What is the best aerobic exercise? A programthat you can stay with on a long-term basis. It isusually something you enjoy, is easily accessibleand is compatible with any physical limitations.Prior to starting a regular aerobic program anevaluation for occult coronary artery disease isappropriate. Evaluate your cardiac risk factorsand seek an objective medical evaluation (not ahallway conversation with your buddy). Do you

want to end up as an ED patient with exercise-induced chest pain? You know where thatpathway goes.

Resistance training is another aspect of apersonal fitness plan. Weightlifting keepsmuscle mass and tone high and has a positiveeffect on bone density and joint function, whichis especially important for women. Increasingyour muscle mass will increase your overallmetabolic rate and will reduce body weight.Isotonic resistance exercise is an alternative if

there are physical limitations that prevent weighttraining. Starting a weight lifting programshould involve a fitness instructor or getting abook on weight lifting. Remember, doing toomuch too soon can result in injury and will resultin early termination of your program.

Flexibility is the third aspect of a personalfitness program. The key to flexibility isstretching. Proper stretching keeps the musclessupple, prepares you for movement, and helpsyou make the daily transition from inactivity to

vigorous activity without undue strain.Stretching should be slow and gentle and notpainful. No extreme painful stretching orbouncing. An excellent book on stretching byBob Anderson is listed at the end of this chapter.

How do you get started on a fitness program?How do you exercise regularly with rotatingshifts and all the other life commitments? It is


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difficult to transform a commitment to exerciseand get fit from an intellectual level to reality.Getting and staying motivated is difficult, evenfor regular exercisers. One strategy is to insertexercise time into your schedule as a requiredevent, like an ED shift, not an optional activity.

Make Time to Preserve the

Only Body You Have

Exercise does not have to be boring,inconvenient, and time-consuming. All physicalactivity counts. Make a list of all physicalactivities you enjoy, such as walking the dog orthrowing a Frisbee. Commit yourself to theseenjoyable activities for at least 30 minutes perday. Take a look at your weekly schedule and

block out times you plan to exercise. Exercisingwhen you first wake up is often convenient andprevents daily events from interfering. Also,studies have shown that those who exercise atthe beginning of their day exercise moreconsistently and more persistently than thosewho wait until later in their day. In addition,exercise raises body temperature, so it can helpyou wake-up and feel more alert. Be sure towarm-up properly as your muscles will havebeen at rest while sleeping. Do not exercisewithin 1-2 hours of bedtime. Aerobic exerciseraises your metabolic rate for several hours afterexercise. This condition can make falling asleepdifficult.

Many emergency physicians find exercise after ashift an excellent way to wind down andrejuvenate themselves. You can also squeeze inbits of exercise throughout your day, such asusing stairs instead of elevators or parkingfarther away from your destination.

Once you are involved in regular fitnessactivities, you may need incentives to maintainyour program. These incentives may includegoal setting, working out with a friend, keepinga daily log of accomplishments, or rewardingyourself with a treat such as a massage, newbicycle, or a new outfit.

Aging is Not a Disease

As EM matures into an established specialty, therange of ages of EM practitioners reaches paritywith other specialties. There are many moreolder EPs in full time practice than 20 yearsago. Even though we do not necessarily lookforward to getting older, it is inevitable. Afterall, what is the alternative? You can postponeand even avoid many of the negative aspects ofaging by taking care of your mind and body. Theaging physician can expect alterations in visionand hearing that can affect the ability to practicemedicine. Even seemingly minor abnormalities,such as the ability to ambulate, sit or stand canhave a significant impact of the ability topractice emergency medicine. Cognitive changeswill have a profound effect on the ability topractice medicine and are the most difficult tocope with for the practicing physician. The EP isrequired to suture, auscultate, reducedislocations and perform other procedures thatmay become more difficult as we age. Rotatingshifts become much more difficult after the ageof 40 and is a leading cause of leaving EMpractice for the older EP. An alteration inpractice may become necessary as these changesoccur. A loss of muscle mass commonly occurswith aging and is primarily due to anincreasingly inactive lifestyle. An active lifestyle

and regular fitness program will maintainmuscle mass and tone and physical strength andavoid an increase in adipose tissue. Regularvisual and audiometric screening will permitcontinued high-level sensory function. Physicaland cognitive limitations are inevitable andplanning for practice limitation and retirementare advisable.We all want to practice successfully for as longas we can. Paying attention to our nutrition, ourfitness, and our capabilities as we age will helpus thrive at work and at home.

Additional Reading

Anderson RA, Anderson JE. Stretching. ShelterPublications Inc. Bolinas, CA; 1980.


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John Robbins.Diet for a New America: HowYour Choices Affect Your Health, Happiness &

the Future of Life on Earth. HJ Kramer; 1998.

Julie Waltz Kemble.The Weight and WellnessGame. Northwest Learning Associates Inc.,

Tuscon, Arizona; 1993.

Hope S. Warshaw.Restaurant Companion: AGuide to Healthier Eating Out. Surrey BooksIncorporated, Chicago, Illinois; 1990.


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Stressors in Emergency Medicine

Burnout

Larry Vickman, MD, MHA, FACEP

Introduction

Burnout is a risk faced by physicians as well asother professionals. Emergency physicians maybe at increased risk of burnout for two groups ofreasons: Unique characteristics of both our work and

of our workplace; Personal characteristics that make us quite

effective as physicians predispose us toburnout.

Unfortunately there is a great deal of denialamongphysicians. We tend to deny that we havea problem even when others can see it clearly.When faced with hard evidence or by a truefriend, our denial frequently becomes even moreresolute.

Definition of Burnout

There are many similar definitions of burnout,and the most useful of these is offered byMaslach & Leiter. These researchers see burnoutas erosion within three critical areas: Erosion of engagement. The initial energy,

involvement, and engagement we felt whenbeginning our work are replaced byexhaustion, cynicism and ineffectiveness.

Emotional erosion. The initial enthusiasm,patience, and compassion we had at theoutset lead to anger, cynicism, bitterness andfrustration.

Erosion of fit. The initial feeling of fit, theexcitement in being a part of a greatergroup, and engagement in our work fall tolack of fit, discomfort, a lack of belonging,and isolation.

The term erosion implies that burnout is agradual process. It does not happen overnight,but occurs with repeated insults to our personal

being as a result of difficulties in the interface ofour personal selves with our work world. It is anongoing and evolving process. Burnout can beavoided completely if each of us understands theforces that tend to create it and learns to takeaction in terms of life behaviors that createproper balance.

Burnout can vary in severity it can beexperienced at a low level and can be fullyhealed with proper treatment, or it can be full-blown and irreversible. At this more seriouslevel, significant changes are needed in the worksetting and perhaps the work itself combinedwith professional assistance to both assess andtreat the manifestations.

Signs & Symptoms

Burnout is a syndrome that can arise in any ofus. Although the way it manifests can vary, thereare some commonalties.

We experience a loss of interest in our work.The attraction we once felt for our work isreplaced by fear, avoidance, isolation, andultimately loathing. We may find ourselvesangry much of the time, and triggers that mightordinarily be deflected by properly functioninginternal psychological mechanisms are put awry.

We may find that we are less able or unable tofind joy in life; activities that once were fun areno longer enjoyable and do not provide usrefreshment. Vacations become a chore and wereturn from them no more refreshed than whenwe left. The financial abilities of manyphysicians allow them to indulge in more toysand many who spend to find peace only findthat they do not enjoy what they have purchased


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and are now in a hopeless spiral of debt, onlyadding to the problem at hand.We may develop any number of physical oremotional symptoms when we think of going towork. These include anxiety, fear, or anger andloathing about having to attend the workplace.

We may develop headache, back or neck pain,abdominal distress, nausea, or a general sense ofmalaise. Our appetite may suffer. Sexual interestmay wane.

We may become isolated. Our interactions withpeers, patients, and the most beloved of ourfamilies then invariably suffer. Most seriously,we can become depressed or dependent upon anumber of substances to help us get through thedays. Abuse of alcohol by itself or inconjunction with any of a large number of

prescription drugs is common.

Since having a good relationship with the patientis vital to making the correct diagnosis, decidingupon correct treatment, patient compliance, andperhaps malpractice risk reduction, burnout thatis manifest by poorer physician-patientcommunication poses a great risk to thephysicians practice activities as well.

It is important to remember that often others cansee the effects of burnout in us even when we

are blind to them. We cannot usually hide iteven though many of us develop elaboratemechanisms to conceal our pain. Additionallywe are so good at denial that even when signsand symptoms are florid, we tend to hide behindthe myth that we are still okay. This is thegreatest tragedy and is no different from thedenial we observe in a patient who is havingchest pain and rejects the possibility that it is hisheart, only to delay the benefits of earlytreatment and then to suffer untowardconsequences. The metaphor is clear: we deny,

we delay, and we suffer the consequences. Thesame is true when we see symptoms in ourcolleagues. We tend to think that He/she will beokay and will be able to take care ofhim/herself. So we keep our mouths shut as ourassociates slip into the mire of worseningdepression or substance abuse. Part of the reasonfor this is that in recognizing the symptoms inanother, it puts us more in touch with our own

state of being. So it is our own denialmechanism that comes into play as we begin todefend our partners who also seem stricken.

Why are we at risk?

Physicians undergo serious socialization in theirprivate lives and most importantly in theirtraining. We are taught to think in certain waysthat may interfere with the establishment andmaintenance of balance in our lives and this putsus at risk for burnout. These thought processesare exemplified by the following: Medicine monopolizes my being

(enantiadromia) and leads to a lack ofbalance.

My success as a physician counts as mypersonal success and I do not have to doanything else in my life to be successful.

The final responsibility for patient care ismine and I will be held to task (leading to anover-developed sense of responsibility).

Can I really trust anyone else to do it right?(I am irreplaceable, so I cannot leave work.)

I delayed my gratification through years oftraining, so now what am I entitled to? (Do Ideserve to have the time to let down andrelax?)

I deserve respect for my role and I do nothave to earn it.

Patients always expect me to know theanswers and to do the correct thing . . .always (I have to know it all, and I must beperfect.)

The system needs to revolve around mydecision-making. The world of work pivotsaround me. (I am the quarterback of theteam and hence the most important playeron the team.)

I am expected not to display vulnerability oremotions, especially sadness with death. (Ihave to keep it all together all the time.)

This latter feeling is one of the most tragicthings many of us learn. Unexpressed grief is ahuge contributor to burnout.

There are many more thoughts that we havelearned which put us at risk, but I think you getthe point. We are taught to think in ways that


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lead us to a state of being emotionally andpsychologically at risk for the erosions notedabove.

What is it about emergency

medicine that might add evenmore to our risk?

We exist in a fishbowl type of practice that isunlike that of any other practitioner in thecommunity. Most of our work is eventuallyexamined by another physician - either one ofour colleagues or another practitioner in thecommunity - and the judgment exacted upon us,especially by those who do not set foot in ourbusy departments, can be brutal.

We practice to a greater or lesser degree inisolation - physically within our departments andoften professionally within the often-narrowscope of our involvement within the larger socialand political framework of the hospital. Theoutcome of this is that we may experience a poorsense of community, and the support we all needto flourish is sadly lacking. Furthermore, someresidency programs in EM teach that only thephysician who has completed a residency in EMis qualified to treat patients in the emergencydepartment (ED). This sets up non-EM-trained

physicians for additional isolation in ourprofession.

Emergency physicians differ from many othermembers of the medical staff in that we arehospital-based physicians and depend upon acontract with the hospital in order to have aplace to practice. In addition, we are not solopractitioners, but must be part of a group,whether we are employed by the hospital, part ofa single hospital group, or part of a larger groupstaffing multiple hospitals. Our ability to control

many of the aspects of our own practices is oftenlacking due to the contractual relationshipsmany of us have with our hospitals or with thephysician groups of which we are a part.Inequities and perceived injustices can occur inany EM practice setting, increasing our sense oflack of control. With regard to the EDenvironment, we often have little influence as to

the quality or quantity of the support staffing weneed to perform our work with excellence.Additional factors that are common in EM thatpredispose us to stress and burnout include (afterPfifferling): The intensity of the work by case types, by

volume, and the unpredictability of bothabove factors.

Rapid critical decision making is neededwith often a paucity of data.

Our successes in the ED may lead us intothe delusion that since we can do all we doin the ED, we can have the same successesin the rest of our lives

Shift work and circadian rhythm issues.Performance declines with night shift workand mistakes are more common then. Withsleep deprivation, days to nights, and the

time it takes to catch up, we may never catchup.

There is rare appreciation shown for ourwork, both by patients and by ourprofessional colleagues.

Unrealistic expectations are set for us byothers (patients, families, staff, hospitaladministration, regulatory agencies) or weset them unrealistically for ourselves.

We leave little margin for ourselvespersonally with all we do. Any additionalstress or illness or other personal unplanned

event can throw us over the edge. Difficulty in establishing healthy

boundaries. We are often asked to serve oncommittees or to take extra shifts. Many ofus have extreme difficulty saying no whenwe need to do that. We end up spendingmore and more time professionally to theexclusion of supporting our personal lives.

What about the workplace

itself?

Maslach & Leiter have identified six criticalareas that must be examined when assessing theorganizational contribution to burnout. These sixareas include: Workload, especially in excess. Control, or more specifically, lack of

adequate control over ones work setting.


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Community, or more specifically,breakdown of the workplace as a supportivecommunity.

Reward systems, or more specifically,inappropriate reward systems.

Fairness, or more specifically, lack of

fairness in organizational decision-making.Values, or more specifically, conflictingvalues expressed by the workplace ascompared with our own values.

Excess workload. Demanding too much of anindividual in terms of workload, from theoverlapping perspectives of volume, intensity,complexity, and time constraints of work. We ashuman beings can only do so much at once. Wehave the audacity to expect that we can performlarge volumes of complex work for long periods

of time without adequate respite. Eventually atoll is exacted on the person. The toll for us isburnout. Some of us have a bit of a cavalierattitude about what we feel we can do and thiscan be disastrous for us.

The perception of a lack of control. We all needa certain amount of influence over ourenvironments. We may not be able to have muchcontrol, but we certainly must be able to haveenough to create a feeling of self-protection forourselves. Emergency medicine (EM) exists in a

milieu of variable and often minimal control forthe EP. The perception of inability to control orinfluence is the key issue. The reality of ourpractice is that we have minimal control orinfluence over ancillary staffing in our EDs,minimal control over the critical support offeredby our on-call consultants, and absolutely nocontrol over patient volumes or illness acuity.The moderate amount of control we all wouldlike for personal comfort exists variably if not atall for us in EM.

The breakdown of community. Community isthe concept that we have a group identity ofwhich we are proud, a group that supports oneanother and that cares for one another. We needgroup support to thrive in our work. Supportingcommunity takes awareness and thecommitment of resources. Without adequatecommunity, we lack the support we need toavoid burnout.

Inappropriate reward systems. If our rewardsystems, both monetary and non-monetary, arenot in balance and effective, we will suffer. Weneed to be paid adequately for our work, and weall need adequate time off as well as appropriatenon-monetary benefits. As important as the

money are the words of encouragement that weall need to give and receive. As physicians, weare taught that the rewards are in seeing a goodresult and that this should be enough.Additionally, since we are taught not to expect apat-on-the-back ourselves, we do not oftengive out those types of rewards to others. This isanother reason medical organizations aredifficult places to work. Our compensation andreward systems need to be structured to rewardthe behaviors that are important in EM.

Fairness, or more accurately, the appearance ofthe lack of fairness. Decisions and policiesshould represent the right thing at the right timefor the right reason. Granted, this is all subject tointerpretation, but most of us know whensomething is fair or not. Scheduling of shifts andhaving financial remuneration based on hoursworked and the desirability of the shift ratherthan just on seniority are important factors ininsuring fairness.

Conflicting values. Values are the underlying

reasons why we do what we do and how weinterface with our world. Examples of values arebalance, fairness, truth, honesty, and value to thecustomer. These values are firmly anchored inthe culture of the organization and influencehow it operates. Emergency physician valuesmight include providing the best service to thepatient, excellence in care and communication,choosing only the indicated diagnostics andtherapeutics, and keeping unnecessaryadmissions out of the hospital. Hospital valuesmight include some of the same - providing

services, etc. However, they will want to fillbeds, increase the utilization of services,minimize the cost of doing business, and exertcontrol over the physician practice to the degreethey can. These differences can serve to createconflict for the physician and add to the burdenof stress, therefore adding to the risk of burnout.


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Approaches to dealing with

burnout in the practice of EM

There are as many approaches to dealing withthe risk of burnout as there are causes. Here are

some that make sense in the context of thegreater picture as we know it:

1. Understand and admit that you are at risk.Our denial in this arena is astounding. I haveheard the physician title, MD, asrepresenting malignant denial. We are allat risk.

2. Understand that you cannot see the forest forthe trees. You cannot see the early signs orsymptoms of burnout in yourself. You mightnot even be able to comprehend how your

approach to balance (or lack of it) and otherbehaviors currently add to your risk. Realizethat others can see the symptoms in you;however, they might not be willing to takethe risk of saying anything because of theirown fear and because of the long-lastingwall of silence that exists in this area. Howthen, do you know? Ask others. Ask yoursignificant other or best friend. Then bewilling to listen. You could take the MaslachBurnout Inventory, a 22 question assessmenttest with proved statistical reliability(usually available at the Wellness Booth atthe ACEP Scientific Assembly). You couldask for professional help from a counselor orsome other professional who is qualified toassess you and your situation.

3. Read articles and books on the subject.Some very good references follow thisarticle.

4. Learn to develop emotional honesty. Thiscan be very challenging for physicians whoare often taught not to show emotion,particularly grief and sadness, at some of theuntoward or grievous outcomes we witnessevery day. We often consider itinappropriate to share sadness with tearsover the tragic loss of a patient. And yet,unexpressed grief can be a major cause ofburnout. We are expected to perform atstandards nearing perfection and to handlevery difficult or sad situations. Theexpectation that we can be immersed in

suffering and loss daily and not be touchedby it is as unrealistic as expecting to be ableto walk through water without getting wet.This sort of denial is no small matter. Theway we deal with loss shapes our capacity tobe present to life more than anything else.

The way we protect ourselves from loss maybe the way in which we distance ourselvesfrom life. (from Kitchen Table Wisdom byRemen) Critical Incident Stress Debriefing(CISD) counseling and group sessions tomanage the emotional scourge of a tragicloss can be very helpful for us.

5. Develop a sense of balance. It is in being inbalance with several important areas of yourlife that you will be able to develop thegreatest immunity to burnout. Significantareas in which we should search to attain

balance include (after Moskowitz):physical balance (staying in shape) emotional balance (our underlying state of

calmness and resilience) spiritual balance (our internal

connectedness to a higher essence) relationship balance (in all of our levels of

relationships) community balance (developing

community relationships to keep ushealthy)

work and career balance (with flexible

boundaries that preserve health andhappiness)

6. Remember why you went into emergencymedicine, provided you did it for the serviceyou can provide to humanity. It is in thereconnection to the humanity that many findrenewed energy and vigor in medicalpractice (see the article noted inHippocrates, 1993, below).

7. Face the issues c

Documents

Wellness Book for Emergency Physicians