Procedural Skills and Resident Wellness

Topic 1 - Summary
1. Citation:

3 Papers were discussed: 

  • Resident Physician Wellness: A New Hope, Dennis C. Lefebvre, M.D., Ph.D.

  • Who Is Sicker: Patients—or Residents? Residents' Distress and the Care of Patients, Linda Hawes Clever, M.D.

  • How's Work? Daniel S. Schwartz, M.D.

2. Summary/Bottom Lines:
  • Resident burnout papers -  Authors address how residents’ distress affects patient care & home life. Burnout has been associated with workplace stress, workload, environment, time constraints, inadequate sleep, & inadequate leisure time. Studies revealed that compared with faculty & medical students, residents demonstrated higher burnout scores & were found to score significantly lower in measures of exercise, sleep, seatbelt use, & overall wellness.
    The demands & stress of residency training have been linked to depression & suicide. Residents demonstrated a higher prevalence of depression compared to the general population. Additionally, Burn-out residents were found to be more likely to commit medical errors & provide suboptimal care.
  • "How's Work?" Editorial -  Author addresses the difficulty that physicians sometimes encounter when posed with a common every day question from people not in the medical field. The most common response given is a vague one, which serves to spare any details & shield others from the realities & demands of a physician’s work life.
3. Methods:
  • No methods were discussed
4. Limits:
  • No limitations were discussed
5. Additional Info:
  •  Efforts undertaken to address this issue have focused mostly of duty hour limitations. These measures have failed to demonstrate measurable benefit to patients or residents. Furthermore, duty hour reform has been found to a have a negative impact on education, residents’ training, as well as patient care.
    Resident wellness programs on the other hand may offer a better solution. RWPs implemented in various residency programs have employed active & passive strategies such as a confidential environment for meetings, gym access, resident retreats, social outings, mentoring, & charitable donations. Initial data demonstrated positive results & hold much promise in counteracting burnout; however, more research is required to amplify & confirm these results.

 

6. Author: Dr. Nadia Bakor

 

Topic 2 - Summary
1. Citation:
  • Does End Tidal CO2 Monitoring During Emergency Department Procedural Sedation and Analgesia With Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled Trial. 
2. Summary/Bottom Lines:
  • Summary – Capnography identifies respiratory depression earlier than clinical observation and earlier than oxygen saturation changes. The purpose of this study was to evaluate if capnography monitoring could decrease the incidence of hypoxia in procedural sedation with propofol. This study reduced hypoxia by 17%, increased early intervention to prevent progression to hypoxia and identified in advance all cases of hypoxia prior to onset.
3. Methods:
  • Methods – Patients were enrolled in consecutive fashion, were excluded if they had significant comorbidities which would affect oxygenation at baseline. The patients were randomized to a group where capnography was available to treating physicians and a group where capnography was recorded but the treating physicians were blinded. All patients received standard doses of pain meds and of propofol. All patients were monitored with standard equipment. Data was collected by research associates and physicians who were not involved in patient care. Prior to study blinding being broken the data was analyzed by 3 investigators and criteria for hypoxia was defined a priori. Patients were excluded if there was significant data loss.
4. Limits:
  • Limitations –  The main limitation was that the observed rate of hypoxia was high (32.5%).  This is likely due to SpO2 threshold for hypoxia being set at 93%.  The value for respiratory depression was also set at a level such to make the definition highly sensitive.  Obviously the study makers did so they could claim to identify “in advance all cases of hypoxia”.   The study refers other limitations but then spends more time refuting those limitations than actually candidly discussing their significance. 
5. Additional Info:
  • Additional information – While all agreed that this is a useful tool and we should learn how to use it, the point was made that authors of this study chose a low threshold or high number to identify hypoxia (<93%). Therefore they were categorizing more patients as becoming hypoxic and this made it easier to show difference because it made the patients at higher risk of having an outcome which they were interested in reducing. These “hypoxic events” of less than <93% may not have any clinical significance. However since identifying respiratory depression earlier rather than later is of benefit especially in those patients who have significant comorbidities, it was generally concluded that this is something we should be aware of and try to use. However it is important to note that they excluded some of these most high risk patients from the study.
6. Author: Dr. Stephen Howard