PHYSICIAN WELLNESS/RESIDENTS’ PERSPECTIVE
Posttraumatic Stress Disorder in Emergency Medicine Residents Lara Vanyo, MD*; Randy Sorge, MD; Angela Chen, MD; Dan Lakoff, MD *Corresponding Author. E-mail: [email protected], Twitter: @vanyo_l.
0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.07.010
[Ann Emerg Med. 2017;-:1-6.] INTRODUCTION The emergency department (ED) is an environment of high intensity and stress for all its staff members. In addition to the daily challenges experienced in the ED, emergency medicine resident physicians are also regularly exposed to trauma, illness, death, and violence, which compose the primary triggers for the development of posttraumatic stress disorder (PTSD). They are confronted with these difficult scenarios and tragedies from the onset of their training, leaving them prone to the emotional effects. The terms burnout and depression are often discussed and dissected in relation to physician well-being; however, PTSD may be a more applicable concept than we realize. In fact, physician PTSD has become a new topic of investigation, and with good reason. The prevalence of PTSD is approximately 2 times greater in physicians, at 14.8%, than in the general population, with emergency medicine resident physicians’ incidence falling in the range of 11.9% to 21.5%. Although all practitioners of medicine are at risk for PTSD, ED workers are particularly vulnerable, and oftentimes, emergency medicine resident physicians are left to learn coping skills on their own. Fortunately, some programs have sought to combat the effects of their stressful work environment, but the future health of our specialty demands that we broaden our search for answers. The extrapolation of data from military, emergency medical services (EMS), and trauma victim studies may serve as a significant means to address the issue of emergency physician PTSD and provide management strategies. BACKGROUND Emergency physicians experience high rates of burnout, at 65% during a career,1 and ranging from 49% to 65% among emergency medicine resident physicians.2,3 Such statistics have attracted the attention of the Accreditation Council for Graduate Medical Education and resulted in a movement to Volume
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improve mental health among physicians.4 However, a critically important and largely overlooked aspect has been the recognition and treatment of PTSD in emergency physicians. The purpose of this article is to explore the rarely discussed concept of PTSD in emergency physicians, its influence, and how this problem may be managed through early interventions on the residency level. Emergency physicians are regularly exposed to trauma. Despite these exposures, the majority of emergency physicians will not develop PTSD, likely because of personal and professional protective factors.5,6 PTSD results from trauma and is characterized by the 4 symptom categories of intrusive thoughts, avoidance, negative alterations in cognition and mood (including numbing), and alterations in arousal and reactivity, causing distress or impairment for more than 1 month and not caused by medication, substance use, or other illness.7 A temporal or contextual relationship must exist, with the symptoms worsening or beginning after the trauma. With the advent of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5), several major changes were made to the definition of PTSD, including additional symptomatology (Figure). Most important, a new exposure type was added, type 4A, which likely captures the essence of the emergency physician experience with PTSD: “repeated or extreme exposure to aversive details of a traumatic event(s), which applies to workers who encounter the consequences of traumatic events as part of their professional responsibilities.”8 Should an emergency medicine provider experience any of the 4 major symptom categories, further exploration with a trained professional may be warranted because this may represent a pathologic response. PREVALENCE OF PTSD AMONG EMERGENCY PHYSICIANS The evolving definition of PTSD over time and surrounding controversy have hindered attempts at estimating its prevalence among physicians.8 The lifetime Annals of Emergency Medicine 1
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Figure. PTSD diagnosis by the DSM-5.
prevalence of PTSD among adults is estimated to be 6.8%, and certain subgroups such as veterans and torture victims have higher rates, ranging from 14% to 30%. A meta-analysis of 1,616 physicians found a prevalence of PTSD, diagnosed by DSM-5 criteria, of 14.8%, and an abstract recently presented at the Society of Academic Emergency Medicine conference demonstrated emergency medicine–specific rates of 15.1% among 526 emergency physicians9; emergency medicine resident physicians’ data fall in the range of 11.9% to 21.5% for diagnosed PTSD, with symptoms of PTSD affecting 30% and significantly increasing as resident level of training increases.10,11 2 Annals of Emergency Medicine
PTSD in physicians is further linked to the specific stressors of residency training, treating trauma patients, multiple trauma with massive bleeding or dismemberment, death of a child, providing care to a traumatized patient who resembles the resident or family members, treating the severely burned, death after prolonged resuscitation, and workplace violence or threats.10,12 Unfortunately, PTSD is often underdiagnosed because of failure to recognize a specific inciting traumatic event, as well as failure of the patient to seek help because of stigma, and therefore experts agree that statistics are likely underreported.13,14 Volume
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IMPORTANCE OF RECOGNIZING PTSD IN EMERGENCY PHYSICIANS Recognizing PTSD among emergency physicians is critical. Physicians with PTSD symptoms experience significantly more anxiety, depression, negative coping strategies, and burnout.15,16 PTSD is also associated with higher rates of suicide, a risk that is already reaching concerning levels among the physician population, with male and female physicians at a 40% and 130% higher risk, respectively, than the general population.17-19 Given the overlaps between PTSD, depression, suicidality, anxiety, and burnout, it is also possible that PTSD is a missing link in the adequate treatment of any one of the other 4 illnesses for certain individuals. Without a diagnosis, individuals’ PTSD goes unrecognized and undertreated.20 Having PTSD reduces physician performance as well, interfering with the ability to manage patients efficiently and increasing the risk of errors and complications.10 PTSD poses a risk to both the physician’s mental health and the appropriate management of his or her patients. Given that traumatic exposures begin in residency, addressing signs and symptoms of PTSD early is important for the health of emergency medicine providers and their future careers. Currently, limited research exists focusing on PTSD among emergency medicine resident physicians, but using efforts that have been made toward physician wellness, combined with studies detailing trauma victims, first responders and veterans may provide a framework for recognizing and managing PTSD within emergency medicine.
cognitive, behavioral, and mindfulness interventions are associated with decreased anxiety and burnout.21 Examples of interventions include behavioral stress management workshops, goal prioritization, relationship building, and mindfulness and relaxation techniques.22,23 Several randomized controlled trials have examined outcomes including stress biomarker reductions and improvements in scales of positive state of mind, distress, rumination, and burnout after implementation of mindfulness techniques, all with positive results.24-27 Although these studies demonstrate exciting results in the realm of physician mental health, outcomes in regard to PTSD specifically were not explored, leaving a vacancy for future studies and potential interventions. On the residency level, the efforts to identify and treat physician mental health issues have been primarily through residency wellness programs, focusing on coping mechanisms and group support systems. For example, Stanford University has created the Peer Support Program, which encourages peer-to-peer communication and shared understanding of a common experience.28 The University of Alberta conducts one-on-one, confidential, biannual meetings between a resident and designated wellness mentor as an opportunity to “check in” on the mental health of the resident.29 Although PTSD may or may not be specifically addressed by these residency wellness programs, the framework for identification of physicians in need and significant support systems have been established for possible future interventions. On the national level, several efforts have been made to change the culture of medicine. For example, the American Medical Association has drafted a consensus statement on the need to encourage physicians to seek help when dealing with issues of depression, burnout, and suicide. Within the realm of emergency medicine, the Emergency Medicine Residents’ Association and Council of Emergency Medicine Residency Directors have recently built wellness committees that have performed physician wellness research, provided mental health resources in multiple formats, and established safe environments in which physicians can discuss the stressors they face. On the national scale, wellness interventions are being discussed and explored, and the potential exists to extend these actions to PTSD research. All of these efforts demonstrate an increasing awareness of the prevalence of mental distress in emergency medicine resident physicians. However, the issues of stress, burnout, depression, and suicidality tend to take the forefront, with PTSD less frequently cited as contributing to reduced
CURRENT MANAGEMENT OF MENTAL HEALTH IN EMERGENCY MEDICINE RESIDENTS Because of several recent resident suicides, residency programs and governing bodies have been pushed to address resident mental health. Using information gathered from research on physician stress and resiliency, many wellness programs and committees have been enhanced. Stress and burnout have received significant attention, and the general approaches to these problems within the emergency medicine world may be useful for application toward future PTSD management. The prevention of PTSD, however, remains an area of exploration, and to date little concrete evidence supports any particular treatment. Although wellness and the reduction of mental stress and burnout are laudable goals, it is important not to confuse stress and burnout with PTSD, or to believe the former causes the latter. Several studies have investigated stress reduction efforts in physicians, with the overall findings that Volume
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well-being. As mentioned in an address to the Accreditation Council for Graduate Medical Education in regard to resident wellness, Jennings wrote that “a less discussed aspect of residency.is the emotional burden that results from witnessing suffering and death, losing a patient, or feeling incompetent.”30 While steps are being taken toward improving resident well-being on the national and residency levels, and the framework for future interventions is being established, no specific effort has yet been made to identify, prevent, and treat the emotional distress that results directly from repeatedly witnessing trauma among emergency medicine resident physicians.
aspects of PTSD prevention and treatment attempted for these victims could be considered. A 2009 review of randomized control trials by Ponniah et al31 found that trauma-focused cognitive behavioral therapy had the most supported evidence for improvement in PTSD symptoms overall across multiple types of trauma victims. Results of the study demonstrated significantly reduced rates in the development of PTSD: 9% versus 46% in individuals who received simple supportive counseling. Studies of group cognitive behavioral therapy also demonstrated efficacy in several studies. Kearns et al32 showed that the use of cognitive behavioral therapy immediately after a trauma may prevent PTSD, as well as improve symptoms of chronic PTSD. Despite these significant findings, PTSD is a complex disorder, and as such, cognitive behavioral therapy does not work for all patients and its use in prevention remains novel. EMS has created several initiatives to combat PTSD in its personnel. EMS uses critical incidence stress debriefing wherein EMS personnel are permitted downtime to discuss their reactions after a traumatic event, with a supervisor and peers involved in the case.33 The Cochrane recommendations in regard to downtime proposed that rather than enforcing compulsory debriefing for anyone involved in a traumatic incident, a “screen and treat” model may be a more appropriate method.34 Individually, commonly cited EMS coping strategies are use of family and social supports, as well as awareness and release of
FUTURE MANAGEMENT OF PTSD IN EMERGENCY MEDICINE RESIDENT PHYSICIANS: EXTRAPOLATION FROM PREVIOUS PTSD STUDIES Although attempts have been made to mitigate the effects of emergency medicine–related stressors, few have specifically addressed PTSD. As such, important treatments for emergency medicine resident physicians may be extrapolated from previously studied PTSD populations (Table). Civilian Studies Although emergency medicine resident physicians are not easily compared with victims of direct trauma, some Table. PTSD management strategies. Intervention Trauma-based cognitive behavioral therapy Debriefing (critical incidence stress debriefing) Cognitive behavioral stress management Mindfulness-based stress reduction*
Autogenic training
Relaxation response training*
Description Prolonged, imaginal exposure to the patient’s memory of the trauma plus in vivo exposure to various reminders of the trauma, followed by cognitive restructuring and anxiety management techniques In individual or group setting32 Period after a critical incident wherein one is removed from his/her position May opt to reflect in a group setting with colleagues and superiors, or individually33,35 Typically a 10-wk group-based program that combines relaxation, imagery, and breathing exercises with cognitive behavior therapy Designed to reduce bodily tension, intrusive stressful thoughts, and negative moods and improve interpersonal skills38 Developed by Jon Kabat-Zinn, using meditation as a tool to cultivate conscious awareness in a nonjudgmental manner Schedule generally consists of 8 weekly classes and 1 day-long retreat Includes guided instruction on mindfulness meditation practices, gentle stretching and mindful yoga, group dialogue and discussions aimed at enhancing awareness in everyday life, individually tailored instruction, and daily home assignments38 Developed by the German psychiatrist Johannes Schultz in 1932 Goal is to achieve deep relaxation and reduce stress by teaching the body to respond to verbal commands, “telling” it to relax and control breathing, blood pressure, heartbeat, and body temperature38 Stress-management approach published in 1974 by the cardiologist Herbert Benson, with the idea that meditation was related to general reversal of the sympathetic activation that produces the “stress response” Uses the following 4 elements to elicit the relaxation response: (1) a mental device (eg, a sound, word, or phrase repeated silently or audibly to free one’s self from logical, externally oriented thought); (2) a passive attitude (eg, not worrying about how well one is performing the technique); (3) a decreased muscle tonus (eg, comfortable, relaxed posture); and (4) a quiet environment with minimal environmental stimuli38
*Includes resilience training.
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emotions.35 Overall, providing a controlled, supportive space for discussion and catharsis may be key in managing the psychological effects of trauma.
anxiety, and burnout, and professionally, with increased errors and inefficiency. Overall, there are many ways the management of PTSD symptoms can be approached for emergency medicine residents. The first step is awareness; that is, to consider PTSD a diagnosis in addition to burnout or depression, and to allow a safe environment in which to provide help. The next step is to consider applying strategies based on the aforementioned research, both those specifically studied in physicians and in PTSD populations. A combination of preventive and treatment measures may be necessary. Residents should be aware of the symptoms of PTSD and take steps to address it should they see worrisome signs in themselves or their peers.
Military Military veterans are the most extensively examined PTSD population and may provide insight into management strategies for emergency medicine resident physicians experiencing PTSD symptoms. Although they are exposed to vastly different predisposing conditions, veterans face personal issues in confronting mental health similar to those of physicians. Both parties tend to be reluctant to seek help, to take on the victim or patient role, and to face the “stigma of perceived weakness.”36 Furthermore, both may consider pathologic PTSD symptoms, such as persistent numbness and revisiting, simply as part of the job. Among the management strategies for veteran PTSD, the most ubiquitously supported has been trauma-focused cognitive behavioral therapy, with novel stress management techniques becoming more prevalent in the last several years. A review by Kitchiner et al37 found that veterans responded most to outpatient trauma-focused psychosocial interventions on a one-to-one or group basis with a professional therapist. In 2013, Crawford et al38 performed a review of high-quality randomized controlled trials on multimodal stress interventions for diverse groups of traumatized individuals to evaluate overall applicability to veterans. This research supported cognitive behavioral stress management as one of the most effective interventions; others included mindfulness-based stress reduction, autogenic training, and relaxation response training.38 Across all groups, meditation and mindfulness were found to be highly effective and cost-efficient. PTSD management remains a complicated and elusive undertaking, particularly efforts toward prevention39; however, promising steps have been taken that may be applicable to nonmilitary trauma-exposed populations. CONCLUSION Physicians are at higher risk for PTSD than nonphysicians. Emergency physicians in particular are exposed to trauma, violence, and death, beginning primarily in their residency training. The DSM-5 clearly delineates through the A4 exposure type that regularly witnessing patient illness, trauma, and death may cause PTSD. It is likely that unrecognized and untreated PTSD exists in emergency medicine resident physicians. The dangers of untreated PTSD affect physicians personally, with significantly higher rates of suicide, depression, Volume
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Supervising editors: Tarak Trivedi, MD; Jason D. Heiner, MD. Author affiliations: From Icahn School of Medicine at Mount Sinai, New York, NY. Dr. Vanyo is currently affiliatied with Fairview Hospital, Cleveland Clinic Emergency Services Institute, Cleveland, OH. Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. REFERENCES 1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-1385. 2. Lu DW, Dresden S, McCloskey C, et al. Impact of burnout on selfreported patient care among emergency physicians. West J Emerg Med. 2015;16:996-1001. 3. Kimo TJ, Ramoska EA, Clark TR, et al. Factors associated with burnout during emergency medicine residency. Acad Emerg Med. 2014;21:1031-1035. 4. Daskivich TJ, Jardine DA, Tseng J, et al. Promotion of wellness and mental health awareness among physicians in training: perspective of a national, multispecialty panel of residents and fellows. J Grad Med Educ. 2015;7:143-147. 5. Ben-Ezra M, Yuval P, Nir E. Impact of war stress on posttraumatic stress symptoms in hospital personnel. Gen Hosp Psychiatry. 2007;29:264-266. 6. Weiniger CF, Shalev A, Ofek H, et al. Posttraumatic stress disorder among hospital surgical physicians exposed to victims of terror: a prospective, controlled questionnaire survey. J Clin Psychiatry. 2006;67:890-896.
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7. National Institute of Mental Health. Post-Traumatic Stress Disorder. Bethesda, MD: National Institute of Mental Health; 2016. 8. Pai A, Suris AM, North CS, et al. Posttraumatic stress disorder in the DSM-5: controversy, change, and conceptual considerations. Behav Sci. 2017;7:7. 9. Delucia J. Rate of post-traumatic stress disorder in emergency medicine physicians. Presented at: Society of Academic Emergency Medicine meeting; May 10-13 2016; New Orleans, LA. 10. Sendler J, Rutkowska A, Makara-Studzinska M. How the exposure to trauma has hindered physicians’ capacity to heal: prevalence of PTSD among healthcare workers. Eur J Psychiatry. 2016;30: 321-334. 11. Mills L, Mills T. Symptoms of post-traumatic stress disorder among emergency medicine residents. J Emerg Med. 2005;28:1-4. 12. Laposa J, Alden L. Posttraumatic stress disorder in the emergency room: exploration of a cognitive model. Behav Res Ther. 2003;41:49-65. 13. Howgego IM, Owen C, Meldrum L, et al. Posttraumatic stress disorder: an exploratory study examining rates of trauma and PTSD and its effect on client outcomes in community mental health. BMC Psychiatry. 2005;5:21. 14. Zimmerman M, Mattia J. Is posttraumatic stress disorder underdiagnosed in routine clinical settings? J Nerv Ment Dis. 1999;187:420-428. 15. Einav S, Shalev A, Ofrek H, et al. Differences in psychological effects in hospital doctors with and without post-traumatic stress disorder. Br J Psychiatry. 2008;193:165-166. 16. Klamen D, Grossman L, Kopacz D. Posttraumatic stress disorder symptoms in resident physicians related to their internship. Acad Psychiatry. 1995;19:142-149. 17. Schernhammer E, Colditz G. Suicide rates among physicians: a quantitative and gender assessment (meta analysis). Am J Psychiatry. 2004;161:2295-2302. 18. McKinney J, Hirsch J, Britton P. PTSD symptoms and suicide risk in veterans: serial indirect effects via depression and anger. J Affect Disord. 2017;214:100-107. 19. Boffa J, Stanley I, Hom M, et al. PTSD symptoms and suicidal thoughts and behaviors among firefighters. J Psychiatr Res. 2017;84:277-283. 20. Lazarus A. Traumatized by practice: PTSD in physicians. J Med Pract Manage. 2014;30:131-134. 21. Regehr C, Glancy D, Pitts A, et al. Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. J Nerv Ment Dis. 2014;202:353-359. 22. McCue J, Sachs C. A stress management workshop improves residents’ coping skills. Arch Intern Med. 1991;151:2273-2277. 23. Sood A, Prasad K, Schroeder D, et al. Stress management and resilience training among department of medicine faculty: a pilot randomized clinical trial. J Gen Intern Med. 2011;26:858-861.
24. MacLaughlin B, Wang D, Noone A-M, et al. Stress biomarkers in medical students participating in a mind body medicine skills program. Evid Based Complement Alternat Med. 2011;2011:1-8. 25. Irving J, Dobkin P, Park J. Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness-based stress reduction (MBSR). Complement Ther Clin Pract. 2009;15:61-66. 26. Jain S, Shapiro S, Swanick S, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med. 2007;33:11-21. 27. Rosenzweig S, Reibel D, Greeson J, et al. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15:88-92. 28. Genovese J, Berek J. Can arts and communication programs improve physician wellness and mitigate physician suicide? J Clin Oncol. 2016;34:1820-1822. 29. Lefebvre D. Perspective: resident physician wellness: a new hope. Acad Med. 2012;87:598-602. 30. Jennings M, Slavin S. Resident wellness matters: optimizing resident education and wellness through the learning environment. Acad Med. 2015;90:1246-1250. 31. Ponniah K, Hollon S. Empirically supported psychological treatments for adult acute stress disorder and post-traumatic stress disorder: a review. Depress Anxiety. 2009;26:1086-1109. 32. Kearns M, Ressler K, Zatzick D, et al. Early interventions for PTSD: a review. Depress Anxiety. 2012;29:833-842. 33. Halpern J, Maunder R, Schwartz B, et al. Downtime after critical incidents in emergency medical technicians/paramedics. Biomed Res Int. 2014;2014:483140. 34. Rose S, Bisson J, Churchill R, et al. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002;(2):CD000560. 35. Mishra S, Goebert D, Char E, et al. Trauma exposure and symptoms of post-traumatic stress disorder in emergency medical services personnel in Hawaii. Emerg Med J. 2010;27:708-711. 36. Yehuda R, Vermetten E, McFarlane A, et al. PTSD in the military: special considerations for understanding prevalence, pathophysiology and treatment following deployment. Eur J Psychotraumatol. 2014;5:25322. 37. Kitchiner N, Roberts N, Wilcox D, et al. Systematic review and metaanalyses of psychosocial interventions for veterans of the military. Eur J Psychotraumatol. 2012;3:19267. 38. Crawford C, Wallerstedt D, Khorsan R, et al. A systematic review of biopsychosocial training programs for the self-management of emotional stress: potential applications for the military. Evid Based Complement Alternat Med. 2013;2013:747694. 39. Steenkamp M, Nash W , Litz B. Post-traumatic stress disorder review of the comprehensive soldier fitness program. Am J Prev Med. 2013;44:507-512.
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Posttraumatic Stress Disorder in Emergency Medicine Residents Lara Vanyo, MD*; Randy Sorge, MD; Angela Chen, MD; Dan Lakoff, MD *Corresponding Author. E-mail: [email protected], Twitter: @vanyo_l.
0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.07.010
[Ann Emerg Med. 2017;-:1-6.] INTRODUCTION The emergency department (ED) is an environment of high intensity and stress for all its staff members. In addition to the daily challenges experienced in the ED, emergency medicine resident physicians are also regularly exposed to trauma, illness, death, and violence, which compose the primary triggers for the development of posttraumatic stress disorder (PTSD). They are confronted with these difficult scenarios and tragedies from the onset of their training, leaving them prone to the emotional effects. The terms burnout and depression are often discussed and dissected in relation to physician well-being; however, PTSD may be a more applicable concept than we realize. In fact, physician PTSD has become a new topic of investigation, and with good reason. The prevalence of PTSD is approximately 2 times greater in physicians, at 14.8%, than in the general population, with emergency medicine resident physicians’ incidence falling in the range of 11.9% to 21.5%. Although all practitioners of medicine are at risk for PTSD, ED workers are particularly vulnerable, and oftentimes, emergency medicine resident physicians are left to learn coping skills on their own. Fortunately, some programs have sought to combat the effects of their stressful work environment, but the future health of our specialty demands that we broaden our search for answers. The extrapolation of data from military, emergency medical services (EMS), and trauma victim studies may serve as a significant means to address the issue of emergency physician PTSD and provide management strategies. BACKGROUND Emergency physicians experience high rates of burnout, at 65% during a career,1 and ranging from 49% to 65% among emergency medicine resident physicians.2,3 Such statistics have attracted the attention of the Accreditation Council for Graduate Medical Education and resulted in a movement to Volume
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no.
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:
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2017
improve mental health among physicians.4 However, a critically important and largely overlooked aspect has been the recognition and treatment of PTSD in emergency physicians. The purpose of this article is to explore the rarely discussed concept of PTSD in emergency physicians, its influence, and how this problem may be managed through early interventions on the residency level. Emergency physicians are regularly exposed to trauma. Despite these exposures, the majority of emergency physicians will not develop PTSD, likely because of personal and professional protective factors.5,6 PTSD results from trauma and is characterized by the 4 symptom categories of intrusive thoughts, avoidance, negative alterations in cognition and mood (including numbing), and alterations in arousal and reactivity, causing distress or impairment for more than 1 month and not caused by medication, substance use, or other illness.7 A temporal or contextual relationship must exist, with the symptoms worsening or beginning after the trauma. With the advent of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5), several major changes were made to the definition of PTSD, including additional symptomatology (Figure). Most important, a new exposure type was added, type 4A, which likely captures the essence of the emergency physician experience with PTSD: “repeated or extreme exposure to aversive details of a traumatic event(s), which applies to workers who encounter the consequences of traumatic events as part of their professional responsibilities.”8 Should an emergency medicine provider experience any of the 4 major symptom categories, further exploration with a trained professional may be warranted because this may represent a pathologic response. PREVALENCE OF PTSD AMONG EMERGENCY PHYSICIANS The evolving definition of PTSD over time and surrounding controversy have hindered attempts at estimating its prevalence among physicians.8 The lifetime Annals of Emergency Medicine 1
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Figure. PTSD diagnosis by the DSM-5.
prevalence of PTSD among adults is estimated to be 6.8%, and certain subgroups such as veterans and torture victims have higher rates, ranging from 14% to 30%. A meta-analysis of 1,616 physicians found a prevalence of PTSD, diagnosed by DSM-5 criteria, of 14.8%, and an abstract recently presented at the Society of Academic Emergency Medicine conference demonstrated emergency medicine–specific rates of 15.1% among 526 emergency physicians9; emergency medicine resident physicians’ data fall in the range of 11.9% to 21.5% for diagnosed PTSD, with symptoms of PTSD affecting 30% and significantly increasing as resident level of training increases.10,11 2 Annals of Emergency Medicine
PTSD in physicians is further linked to the specific stressors of residency training, treating trauma patients, multiple trauma with massive bleeding or dismemberment, death of a child, providing care to a traumatized patient who resembles the resident or family members, treating the severely burned, death after prolonged resuscitation, and workplace violence or threats.10,12 Unfortunately, PTSD is often underdiagnosed because of failure to recognize a specific inciting traumatic event, as well as failure of the patient to seek help because of stigma, and therefore experts agree that statistics are likely underreported.13,14 Volume
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IMPORTANCE OF RECOGNIZING PTSD IN EMERGENCY PHYSICIANS Recognizing PTSD among emergency physicians is critical. Physicians with PTSD symptoms experience significantly more anxiety, depression, negative coping strategies, and burnout.15,16 PTSD is also associated with higher rates of suicide, a risk that is already reaching concerning levels among the physician population, with male and female physicians at a 40% and 130% higher risk, respectively, than the general population.17-19 Given the overlaps between PTSD, depression, suicidality, anxiety, and burnout, it is also possible that PTSD is a missing link in the adequate treatment of any one of the other 4 illnesses for certain individuals. Without a diagnosis, individuals’ PTSD goes unrecognized and undertreated.20 Having PTSD reduces physician performance as well, interfering with the ability to manage patients efficiently and increasing the risk of errors and complications.10 PTSD poses a risk to both the physician’s mental health and the appropriate management of his or her patients. Given that traumatic exposures begin in residency, addressing signs and symptoms of PTSD early is important for the health of emergency medicine providers and their future careers. Currently, limited research exists focusing on PTSD among emergency medicine resident physicians, but using efforts that have been made toward physician wellness, combined with studies detailing trauma victims, first responders and veterans may provide a framework for recognizing and managing PTSD within emergency medicine.
cognitive, behavioral, and mindfulness interventions are associated with decreased anxiety and burnout.21 Examples of interventions include behavioral stress management workshops, goal prioritization, relationship building, and mindfulness and relaxation techniques.22,23 Several randomized controlled trials have examined outcomes including stress biomarker reductions and improvements in scales of positive state of mind, distress, rumination, and burnout after implementation of mindfulness techniques, all with positive results.24-27 Although these studies demonstrate exciting results in the realm of physician mental health, outcomes in regard to PTSD specifically were not explored, leaving a vacancy for future studies and potential interventions. On the residency level, the efforts to identify and treat physician mental health issues have been primarily through residency wellness programs, focusing on coping mechanisms and group support systems. For example, Stanford University has created the Peer Support Program, which encourages peer-to-peer communication and shared understanding of a common experience.28 The University of Alberta conducts one-on-one, confidential, biannual meetings between a resident and designated wellness mentor as an opportunity to “check in” on the mental health of the resident.29 Although PTSD may or may not be specifically addressed by these residency wellness programs, the framework for identification of physicians in need and significant support systems have been established for possible future interventions. On the national level, several efforts have been made to change the culture of medicine. For example, the American Medical Association has drafted a consensus statement on the need to encourage physicians to seek help when dealing with issues of depression, burnout, and suicide. Within the realm of emergency medicine, the Emergency Medicine Residents’ Association and Council of Emergency Medicine Residency Directors have recently built wellness committees that have performed physician wellness research, provided mental health resources in multiple formats, and established safe environments in which physicians can discuss the stressors they face. On the national scale, wellness interventions are being discussed and explored, and the potential exists to extend these actions to PTSD research. All of these efforts demonstrate an increasing awareness of the prevalence of mental distress in emergency medicine resident physicians. However, the issues of stress, burnout, depression, and suicidality tend to take the forefront, with PTSD less frequently cited as contributing to reduced
CURRENT MANAGEMENT OF MENTAL HEALTH IN EMERGENCY MEDICINE RESIDENTS Because of several recent resident suicides, residency programs and governing bodies have been pushed to address resident mental health. Using information gathered from research on physician stress and resiliency, many wellness programs and committees have been enhanced. Stress and burnout have received significant attention, and the general approaches to these problems within the emergency medicine world may be useful for application toward future PTSD management. The prevention of PTSD, however, remains an area of exploration, and to date little concrete evidence supports any particular treatment. Although wellness and the reduction of mental stress and burnout are laudable goals, it is important not to confuse stress and burnout with PTSD, or to believe the former causes the latter. Several studies have investigated stress reduction efforts in physicians, with the overall findings that Volume
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well-being. As mentioned in an address to the Accreditation Council for Graduate Medical Education in regard to resident wellness, Jennings wrote that “a less discussed aspect of residency.is the emotional burden that results from witnessing suffering and death, losing a patient, or feeling incompetent.”30 While steps are being taken toward improving resident well-being on the national and residency levels, and the framework for future interventions is being established, no specific effort has yet been made to identify, prevent, and treat the emotional distress that results directly from repeatedly witnessing trauma among emergency medicine resident physicians.
aspects of PTSD prevention and treatment attempted for these victims could be considered. A 2009 review of randomized control trials by Ponniah et al31 found that trauma-focused cognitive behavioral therapy had the most supported evidence for improvement in PTSD symptoms overall across multiple types of trauma victims. Results of the study demonstrated significantly reduced rates in the development of PTSD: 9% versus 46% in individuals who received simple supportive counseling. Studies of group cognitive behavioral therapy also demonstrated efficacy in several studies. Kearns et al32 showed that the use of cognitive behavioral therapy immediately after a trauma may prevent PTSD, as well as improve symptoms of chronic PTSD. Despite these significant findings, PTSD is a complex disorder, and as such, cognitive behavioral therapy does not work for all patients and its use in prevention remains novel. EMS has created several initiatives to combat PTSD in its personnel. EMS uses critical incidence stress debriefing wherein EMS personnel are permitted downtime to discuss their reactions after a traumatic event, with a supervisor and peers involved in the case.33 The Cochrane recommendations in regard to downtime proposed that rather than enforcing compulsory debriefing for anyone involved in a traumatic incident, a “screen and treat” model may be a more appropriate method.34 Individually, commonly cited EMS coping strategies are use of family and social supports, as well as awareness and release of
FUTURE MANAGEMENT OF PTSD IN EMERGENCY MEDICINE RESIDENT PHYSICIANS: EXTRAPOLATION FROM PREVIOUS PTSD STUDIES Although attempts have been made to mitigate the effects of emergency medicine–related stressors, few have specifically addressed PTSD. As such, important treatments for emergency medicine resident physicians may be extrapolated from previously studied PTSD populations (Table). Civilian Studies Although emergency medicine resident physicians are not easily compared with victims of direct trauma, some Table. PTSD management strategies. Intervention Trauma-based cognitive behavioral therapy Debriefing (critical incidence stress debriefing) Cognitive behavioral stress management Mindfulness-based stress reduction*
Autogenic training
Relaxation response training*
Description Prolonged, imaginal exposure to the patient’s memory of the trauma plus in vivo exposure to various reminders of the trauma, followed by cognitive restructuring and anxiety management techniques In individual or group setting32 Period after a critical incident wherein one is removed from his/her position May opt to reflect in a group setting with colleagues and superiors, or individually33,35 Typically a 10-wk group-based program that combines relaxation, imagery, and breathing exercises with cognitive behavior therapy Designed to reduce bodily tension, intrusive stressful thoughts, and negative moods and improve interpersonal skills38 Developed by Jon Kabat-Zinn, using meditation as a tool to cultivate conscious awareness in a nonjudgmental manner Schedule generally consists of 8 weekly classes and 1 day-long retreat Includes guided instruction on mindfulness meditation practices, gentle stretching and mindful yoga, group dialogue and discussions aimed at enhancing awareness in everyday life, individually tailored instruction, and daily home assignments38 Developed by the German psychiatrist Johannes Schultz in 1932 Goal is to achieve deep relaxation and reduce stress by teaching the body to respond to verbal commands, “telling” it to relax and control breathing, blood pressure, heartbeat, and body temperature38 Stress-management approach published in 1974 by the cardiologist Herbert Benson, with the idea that meditation was related to general reversal of the sympathetic activation that produces the “stress response” Uses the following 4 elements to elicit the relaxation response: (1) a mental device (eg, a sound, word, or phrase repeated silently or audibly to free one’s self from logical, externally oriented thought); (2) a passive attitude (eg, not worrying about how well one is performing the technique); (3) a decreased muscle tonus (eg, comfortable, relaxed posture); and (4) a quiet environment with minimal environmental stimuli38
*Includes resilience training.
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emotions.35 Overall, providing a controlled, supportive space for discussion and catharsis may be key in managing the psychological effects of trauma.
anxiety, and burnout, and professionally, with increased errors and inefficiency. Overall, there are many ways the management of PTSD symptoms can be approached for emergency medicine residents. The first step is awareness; that is, to consider PTSD a diagnosis in addition to burnout or depression, and to allow a safe environment in which to provide help. The next step is to consider applying strategies based on the aforementioned research, both those specifically studied in physicians and in PTSD populations. A combination of preventive and treatment measures may be necessary. Residents should be aware of the symptoms of PTSD and take steps to address it should they see worrisome signs in themselves or their peers.
Military Military veterans are the most extensively examined PTSD population and may provide insight into management strategies for emergency medicine resident physicians experiencing PTSD symptoms. Although they are exposed to vastly different predisposing conditions, veterans face personal issues in confronting mental health similar to those of physicians. Both parties tend to be reluctant to seek help, to take on the victim or patient role, and to face the “stigma of perceived weakness.”36 Furthermore, both may consider pathologic PTSD symptoms, such as persistent numbness and revisiting, simply as part of the job. Among the management strategies for veteran PTSD, the most ubiquitously supported has been trauma-focused cognitive behavioral therapy, with novel stress management techniques becoming more prevalent in the last several years. A review by Kitchiner et al37 found that veterans responded most to outpatient trauma-focused psychosocial interventions on a one-to-one or group basis with a professional therapist. In 2013, Crawford et al38 performed a review of high-quality randomized controlled trials on multimodal stress interventions for diverse groups of traumatized individuals to evaluate overall applicability to veterans. This research supported cognitive behavioral stress management as one of the most effective interventions; others included mindfulness-based stress reduction, autogenic training, and relaxation response training.38 Across all groups, meditation and mindfulness were found to be highly effective and cost-efficient. PTSD management remains a complicated and elusive undertaking, particularly efforts toward prevention39; however, promising steps have been taken that may be applicable to nonmilitary trauma-exposed populations. CONCLUSION Physicians are at higher risk for PTSD than nonphysicians. Emergency physicians in particular are exposed to trauma, violence, and death, beginning primarily in their residency training. The DSM-5 clearly delineates through the A4 exposure type that regularly witnessing patient illness, trauma, and death may cause PTSD. It is likely that unrecognized and untreated PTSD exists in emergency medicine resident physicians. The dangers of untreated PTSD affect physicians personally, with significantly higher rates of suicide, depression, Volume
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Supervising editors: Tarak Trivedi, MD; Jason D. Heiner, MD. Author affiliations: From Icahn School of Medicine at Mount Sinai, New York, NY. Dr. Vanyo is currently affiliatied with Fairview Hospital, Cleveland Clinic Emergency Services Institute, Cleveland, OH. Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. REFERENCES 1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-1385. 2. Lu DW, Dresden S, McCloskey C, et al. Impact of burnout on selfreported patient care among emergency physicians. West J Emerg Med. 2015;16:996-1001. 3. Kimo TJ, Ramoska EA, Clark TR, et al. Factors associated with burnout during emergency medicine residency. Acad Emerg Med. 2014;21:1031-1035. 4. Daskivich TJ, Jardine DA, Tseng J, et al. Promotion of wellness and mental health awareness among physicians in training: perspective of a national, multispecialty panel of residents and fellows. J Grad Med Educ. 2015;7:143-147. 5. Ben-Ezra M, Yuval P, Nir E. Impact of war stress on posttraumatic stress symptoms in hospital personnel. Gen Hosp Psychiatry. 2007;29:264-266. 6. Weiniger CF, Shalev A, Ofek H, et al. Posttraumatic stress disorder among hospital surgical physicians exposed to victims of terror: a prospective, controlled questionnaire survey. J Clin Psychiatry. 2006;67:890-896.
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