29 minute read
Emergency Medicine: A Venezuelan Perspective
An interview with Dr. Carmen Sofia Rosales by Atillio Atencio, MD and William Weber, MD, on behalf of the SAEM Global Emergency Medicine Academy
For the last decade Venezuela has been battling political unrest and a failing economy. In a mere eight years the country's gross Carmen Sofia Rosales domestic product (GDP)) has dropped by over two-thirds. More than 75% of Venezuela’s 28 million residents live in extreme poverty, with annual inflation rates ranging from 2,000% in 2021 to 60,000% in 2017. Dr. Carmen Sofia Rosales is a pediatric emergency physician and professor at Instituto Autónomo Hospital Universitario de Los Andes (IAHULA) in Merida, Venezuela. She sat down for an interview to discuss her experiences and the challenges faced while practicing medicine in a country battling economic crisis amidst a global pandemic. While there are universal similarities seen in all emergency departments, Dr. Rosales provides a unique insight into the training and resources available in Venezuela.
What does emergency medicine training look like in Venezuela?
There is no formal emergency residency in Venezuela, so training varies depending on the institution where you practice. Here at IAHULA, our emergency department (ED) is run by residents who spend an average of two months out of the year with us.
On the pediatric side, first-year residents see less acute patients and staff them with attendings. Secondyear residents rotate through our Unidad de Cuidados Especiales Pediátricos — essentially an ICU set up in the ED. Third-year residents oversee triaging and managing all patients. Our internal medicine colleagues cover the adult ED with a similar set-up.
Are there resources available for physicians seeking emergency medicine specific training?
The short answer is no, not outside what is taught during medical school and residency. We have few resources with regards to supplies and technology. With that said, we have an excellent university that has trained some remarkable physicians.
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The best training asset our hospital offers is our patient population. Our residents are exposed to the sickest of the sick who, in general, are extremely under resourced with minimal health literacy.
Can you describe the emergency medicine culture in your hospital?
I do not think we have a culture of our own as emergency physicians, but we are all bonded by the limiting circumstances in which we practice medicine. Our patients are the priority of all physicians remaining here at IAHULA. I am also proud to say that we have seen a rise in women physicians in the ED, which was not always the case.
What do you mean by “physicians remaining here at IAHULA?”
In the last 6-8 years we’ve seen an exodus of Venezuelans from our country due to economic and political instability. This is especially true of our new physicians who understandably would prefer practicing in more stable conditions. We are short on nursing staff for similar reasons.
How has the current political and economic situation affected your ability to practice medicine in Venezuela?
This is a question too complicated to answer in just one interview. The easy answer is that the current political environment limits access to diagnostic and therapeutic tools. We have been forced to make do with what there is and not with what there should be; with what patients or relatives can buy, as the hospital does not supply them. This leads to many ethical conflicts. Medicine isn’t the same as it used to be 15-20 years prior.
Are you aware of any United States policies affecting Venezuelan health care?
I am not aware of a policy affecting our health care but I do see the influence of American business. Within the last year our country’s economy has transitioned to the U.S. dollar. Purchases ranging from groceries to antibiotics are made through Zelle transactions on our phones. I doubt this is sustainable, but it has allowed for a new market of goods, including medicines, that we have not seen available for years.
What are the biggest challenges you face as EM physicians in Venezuela?
Not having enough resources to effectively diagnose or treat. It has been many years since our hospital has been able to reliably count on things like routine antibiotics or imaging. For example, we have not had a working CT machine for the last 10 years. Even our ultrasound and X-rays are hit-or-miss. We’ve started to rely on local private clinics where we send our patients for imaging. Patients must buy an ambulance ride to the clinic, purchase a CT scan, then pay for the ride back to the hospital. All together, they can end
up spending $300 (USD) — an amount that takes an average family weeks to get together. Patients must often provide the medications for us to administer because our hospital pharmacy is rarely stocked with what we need. Even basic supplies such as sheets or pillowcases often must be brought by a patient’s family; this leads to some colorful rounds. Patients have turned to private pharmacies, the black market, or friends and family in other countries to send supplies. Resources available depend on the day and we’ve learned to ration what we have. It's a dysfunctional system that has led to more problems than I care to admit.
Any specific examples that come to mind?
Just last week we had a five-yearold present after falling off his father’s motorcycle. We sent him out for imaging, and he decompensated on the way to the CT clinic. The child was rushed back to the ED and immediately treated for a presumptive intracranial bleed. I can’t help but imagine how much safer he would have been if we had CT imaging capabilities here in our ED.
How has COVID affected IAHULA policies and the way physicians in the ED practice medicine?
COVID has exacerbated nearly every problem in our ED and hospital. For example, there weren’t enough critical care beds even before the pandemic, but now we have taken half of the pediatric and adult EDs and converted them into COVID units. Another struggle has been managing our ventilators. We have five ventilators to share with the entire hospital. One is solely for the use of pediatric patients and three are set aside for adults; the other one is shared based on need. Fortunately, we’ve only had two COVID related intubations on the pediatric side since the onset of the pandemic; however, I’ve heard from my adult critical care colleagues that they have not been as lucky. It’s rare that we have a free ventilator, so we’ve become good at triaging its use for only our very sick patients.
Where do you see emergency medicine in Venezuela progressing in the next 10 years?
Without changes in national health policies there will be more patients who will not have adequate management of their diseases. We have a deteriorating health care infrastructure, and our newly trained physicians are leaving the country. The lack of resources poses a threat for the longevity of emergency medicine in Venezuela, and our patients will be left with either seeking health care in other countries or not receiving medical care at all.
What do you think that other clinicians could learn from Venezuelan emergency physicians?
Our scarcity has forged us to be experts at diagnosing patients by means of clinical presentation, history, and physical exam rather than relying on imaging or more involved studies. I believe we
could teach a course on using this clinical expertise to manage patients. We also see a myriad of tropical diseases including dengue, yellow fever, and parasitic illnesses.
What are ways that emergency physicians from other countries could get involved with the work you are doing and support the emergency medicine infrastructure at IAHULA?
We are currently lacking therapeutic and diagnostic resources and we’d welcome any assistance procuring these. We also would love to establish relationships with EM residency programs internationally. We base our management on American Medical Association guidelines, more so than other European guidelines, and would like to continue practicing up-todate, evidence-based medicine.
ABOUT THE AUTHORS
Dr. Atencio is an emergency medicine resident at the University of Chicago. He is interested in global emergency medicine, medical education, and LHS+ equitable healthcare. Atilioeatencio@gmail.com Dr. Weber practices at Beth Israel Deaconess Medical Center. He helped found the Medical Justice Alliance to advocate for the health of individuals in carceral settings. On the side, he helps lead ACEP's Public Health and Injury Prevention Committee and developed Chart Decoder, an app to help patients understand their medical records.
About GEMA
The Global Emergency Medicine Academy (GEMA) focuses on improvement of the worldwide delivery of emergency medical care. Joining GEMA is free! Just log in to your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
The Blurred Lines Between Employee, Government Contractor, and Private Citizen Revealed in Recent SCOTUS Decision
By Kyle Stucker, MD
In our endeavor to treat and care for our friends and neighbors, do we give up more than just our time? Do we risk our rights in addition to our health? How much control should we have when our decisions can impact the lives and wellbeing of others?
On November 4, 2021, the Centers for Medicare and Medicaid Services (CMS), released an emergency requirement for COVID vaccination of staff at health care facilities which receive funding or reimbursement from the Medicare/Medicaid programs. This distinction includes a litany of programs for entities from emergency departments to hospices. The deadline for a second vaccine dose was initially January 4, 2022, putting an estimated 10 million CMS-associated employees on the clock. Missouri, Louisiana, and others quickly filed suit, setting up an impending legal discussion over the possibly unique roles, responsibilities, and rights of healthcare providers in our society.
The peer reviewed data relevant to this debate is interesting, but limited, likely due to the novelty of the COVID-19 pandemic and its associated issues:
A 2021 systematic review and metaanalysis from Ponsford et al published in Frontier Immunology examined the differences between outcomes of community-acquired and nosocomial COVID. The study examined 8,251 admissions across 8 countries during the first wave, comprising
1513 probable or definite nosocomial COVID-19. Across all studies, the risk of mortality was 1.3 times greater in patients with nosocomial infection compared to community-acquired.
Gómez-Ochoa et al examined the prevalence, risk factors, clinical characteristics, and outcomes of COVID-19 affected health-care workers in their 2021 American Journal of Epidemiology meta-analysis. At that time, COVID prevalence was around 11%. Severe clinical complications developed in about 5% of the COVID-19-positive HCWs, and almost 0.5% died.
Biswas et al conducted a Journal of Community Health systematic review exploring hesitancy in 76,471 participants. About 22.5% of healthcare workers were hesitant, and mostly expressed concerns about vaccine safety and efficacy as their reasoning.
On January 13, 2022, this question was considered by the U.S. Supreme Court, which rendered a 5-4 decision in favor of issuing a stay of the injunctions blocking the CMS mandate.
Justices Roberts, Breyer, Kagan, Sotomayor, and Kavanaugh composed the coalition ruling in favor. They begin their argument by stating that “Medicare and Medicaid are administered by the Secretary of HHS, who has general authority to promulgate regulations ‘as may be necessary to the efficient administration of the functions with which [he] is charged.’” One of the functions granted to the Secretary by the Congress is “to ensure that the healthcare providers who care for Medicare and Medicaid patients protect their patients’ health and safety.” The Secretary is authorized to “promulgate, as a condition of a facility’s participation in the programs, such ‘requirements as [he] finds necessary in the interest of the health and safety of individuals who are furnished services in the institution.’” The Justices further argue that the Secretary has given many long “lists of detailed conditions,” including requirements for “immunization” and “that certain providers maintain and enforce an ‘infection prevention and control program.’” Since the unvaccinated staff “pose a serious threat to the health and safety of patients,” requiring providers receive the vaccine “is consistent with the fundamental principle of the medical profession: first, do no harm.”
Justice Thomas was joined in dissent by Justices Alito, Gorsuch, and ConeyBarrett. Justice Thomas focuses his argument on the lack of Congressional authority granted to CMS by Congress to enact such a sweeping “omnibus rule [that] compels millions of healthcare workers to undergo an unwanted medical procedure that ‘cannot be removed at the end of the shift.’” He mentions the same authorizations quoted by the affirming justices, but notes that they are intended to allow CMS to “carry out the administration of the insurance programs” under the Medicare Act, and that the clause directing providers to “maintain and enforce an ‘infection prevention and control program’” is directed only at long-term nursing facilities. One of the consistent presumptions made by the Court in past rulings is that “Congress does not hide ‘fundamental details of a regulatory scheme in vague or ancillary provisions.’” He continues, saying that it is precedent to “expect Congress to speak clearly when authorizing an agency to exercise powers of vast economic and political significance.” Yet in this case, Thomas claims, the entire argument by the government is a proposition “to find virtually unlimited vaccination power, over millions of healthcare workers” buried in these very same vague and ancillary provisions. “Had Congress wanted to grant CMS power to impose a vaccine mandate… it would have...”
The Court’s ultimate decision ended the block on the federal government’s order. Now, most health care workers throughout the nation have until the end of February to comply with the mandate. If you would like to read the text of the Court’s decision, you can find it here:
If you would like to share your opinion with your representative, visit www. house.gov/representatives/find-yourrepresentative.
ABOUT THE AUTHOR
Dr. Stucker is a PGY-1 at the University of Louisville School of Medicine
Psychiatric Observation: Driving Improvement and Capturing Opportunity
By Megan R. Hunt, MD and Aaryn Kelli Hammond, MD
Given the mental health crisis in America, patients frequently present to emergency departments in need of evaluation and care and there is a subsequent responsibility on emergency departments to find the appropriate disposition for these patients. These dispositions are often complex and for many patients many hours of care are necessary to identify appropriate inpatient or intensive outpatient psychiatric care. Psychiatric observation protocols provide the opportunity to capture reimbursement for our work and define areas of improvement in the care of these patients. How can closer examination of this care capture the impact of upstream factors such as community resource availability as well as downstream factors like a lack of a transportation for transfer to inpatient facilities? Closer examination of psychiatric observation care will identify the opportunities to request the right resources to improve provider and patient experience. This article would focus on the utility of utilizing and examining observation protocols for extended care of psychiatric patients pending complete psychiatric evaluation and safe disposition. No one working in an emergency department (ED) can deny the impact of our nation’s mental health crisis on workplace violence, physician and staff experience, and patient care quality. Patients present to our EDs desperate for mental health evaluation and care due to the continued lack of community, outpatient, and inpatient resources that has been a problem for years. The COVID-19 pandemic has only accelerated this trend. Regulatory bodies, including The Joint Commission, continue to note the increasing impact of psychiatric boarding on our ability to provide emergency care while simultaneously requiring our teams to expand services to this population with no additional resources. Thus, we find ourselves drifting farther downstream, right alongside our patients, on the waves of an upstream crisis with little hope of anyone building a dam. While we await the necessary aid, we have found that the use of observation in our patients suffering from acute exacerbation of mental illness has allowed us to recoup necessary reimbursement, improve patient care, and decrease length of stay.
At Wake Forest, we deployed a protocol for the use of observation status for patients presenting with psychiatric complaints in March of 2019. We employed a conservative threshold, which allowed for the use of observation for patients with undetermined disposition. This protocol resulted in partial compensation for resources, including provider, nursing, and care coordination services, required to manage patients who were not immediately appropriate for discharge or admission to an inpatient unit. While this did not address patients definitively in need of inpatient psychiatric care and still awaiting inpatient bed availability, it was a useful first step in gaining appropriate compensation for the care of this rapidly growing population. Later that same year, the AMA CPT committee provided guidance that observation codes were appropriate for use in boarding patients with acute psychiatric illness. After a process of establishing institutional buy-in, we transitioned to an expanded criteria for psychiatric observation in October of 2019 that included those patients meeting inpatient criteria as well, but who remained in the ED, receiving
active management, for a prolonged period of boarding. At that time, we also disseminated this observation protocol to our network of community hospitals and EDs that were providing psychiatric care via telemedicine from the academic psychiatry group. While some feared that formally placing patients in observation would increase the hours and cost of ED care by providing a different, if temporary, disposition, our experience in both community and academic settings demonstrated no significant impact on length of stay and did result in reimbursement for previously uncompensated days of care. We invite those not already providing and billing observation care for this population to leverage our experience and begin the work to seek appropriate reimbursement for the care that you are already delivering.
In addition to financial resource generation, we have also observed improvements in the care of our patients suffering from acute exacerbations of mental illness. With the institution of regular rounding and review of placement efforts, we have been able to decrease problems often associated with long stays in the ED. With comprehensive observation care, we can avoid the development of emergent conditions from unmanaged chronic diseases including diabetes and hypertension, the progression of coexistent acute infection, and development of dangerous withdrawal syndromes. Additionally, with the routine psychiatry reevaluation (either in person or via virtual consultation) and improved care coordination included in these protocols, observation care can reduce overall need for admission in patients presenting primarily with medication non-compliance or need for minor medication adjustment.
With nursing and ancillary staff shortages projected to extend into the future, any measure that could reduce the need for admission and reduce length of stay will likely reap dividends. As our psychiatry and other inpatient colleagues suffer from the same decrease in staffed spaces to provide care, we should capitalize on the opportunity to collaborate with them in the ED space to advance and improve patient care. As ED teams, we excel in offering the right care, to the right patients, in the spaces available to us. We have shown with chest pain and TIA protocols, that ED observation protocols can decrease hospital length of stay and admission rates. We believe that we can demonstrate similar gains in the care of patients with mental health complaints. While our goal was not to take on additional days of care for these patients, due to decreased inpatient capacity throughout our region, we have been required to do so to make the most of a difficult situation. Instead, we advocate for stronger partnership with psychiatric resources within our departments via in person or telemedicine services to enhance patient care with greater efficiency and efficacy within our walls. We are confident that this work will reduce the footprint currently consumed by our psychiatric observation population and reduce their inpatient length of stay following an ED observation when required.
Moreover, it has become apparent that managing the current mental health crisis takes a toll on clinical staff. Workplace violence has increased across the health care spectrum and the management of patients with acute psychiatric illness can present safety concerns. While some sites are fortunate enough to have a space separate from the ED to room this subset of ED patients, many facilities do not have that luxury. Observation care allows us to play an active role in the care of patients boarding in the emergency department or with prolonged dispositions. As a result, we maintain better situational awareness of patient care needs to prevent under treatment, overstimulation, and rising patient frustration as stays extend. Our hope is that these efforts can both improve patient care and, perhaps even more importantly, reduce workplace violence.
Emergency department care of patients with acute exacerbations of mental illness is fraught with many barriers. Psychiatric observation is one route by which we can improve care. In its current iteration, we can gain modest financial benefit while ensuring quality patient care and, when appropriate, decrease the need for inpatient admission. We are the experts in offering care to every patient and every disease process under the sun and the use of observation for patients with psychiatric complaints allows us to do just that, while also working to reduce workplace violence. Furthermore, this work will allow our teams to engage in their why, providing patient care for those acutely in need.
ABOUT THE AUTHORS
Dr. Hammond is an assistant professor of emergency medicine at Atrium Health Wake Forest Baptist Medical Center where she also serves as the assistant medical director for the Adult Emergency Department. She is passionate about reducing health care disparities and improving health equity through the optimization of clinical operations. Dr. Hunt, an assistant professor of emergency medicine at the at the Wake Forest University School of Medicine, serves as medical director for the Adult Emergency Department at Atrium Health Wake Forest Baptist Medical Center. She is committed to improving care for patients suffering with acute psychiatric illness.
Photo headshots are courtesy Atrium Health–Wake Forest Baptist Creative Photography Services.
The Female Athlete Triad Examined Under the New Lens of Sex and Gender Evidence
By Yael Sarig and Mehrnoosh Samaei, MD, MPH on behalf of the SAEM Sex & Gender Interest Group
The female athlete triad is a condition afflicting female athletes with low energy availability, which may be the result of over training, under eating, or both. The “triad” is so defined because it involves three key components: menstrual cycle irregularity or absence, low bone mineral density, and energy deficiency. Athletes need not display all three components of the triad to be diagnosed with it and suffer the health consequences. The female athlete triad may impact anyone who is biologically female, and able to menstruate, regardless of gender identity. However, the female athlete triad’s prevalence is certainly influenced by sociocultural stigma and pressures acting against women.
The Triad Components Menstrual Cycle Irregularities
Amenorrhea exists on a spectrum, ranging from oligomenorrhea, to anovulation, to luteal-phase defect, to complete amenorrhea. Discourse about the fertility-related consequences of menstrual irregularity has long dominated conversations about the female athlete triad; however, the impacts of amenorrhea, and of the female athlete triad more broadly, go far beyond infertility. A commonly occurring form of amenorrhea in individuals in an energy deficit is functional hypothalamic amenorrhea (FHA). FHA, which is characterized by low levels of estrogen, leads to higher rates of premature cardiovascular disease, decreased immune function, and decreased skeletal health, osteopenia and osteoporosis. Moreover, women with FHA have higher depression scores, more anxiety, and more difficulty coping with daily stress; they tend to describe feeling more insecure, and feeling lack of control; they have far higher incidences of binge-eating disorder. Additionally, FHA strongly correlates with perfectionist attitudes, which correspond to the unique social pressures that act on women athletes. These athletes often feel a greater need to prove they deserve to share the stage with their male counterparts due to gender stigma. Finally, the social stigma against menstruation that is prevalent in numerous cultures, which is internalized in women athletes, discourages the reporting of missing menstrual cycles. For instance, it was seen as a massive break in standards of conduct when Chinese swimmer Fu Yuanhui spoke about the impact her period had on her performance in her 4x100 meter relay. Even in her admission that she felt she had not swum well because of physical pain from her period, she was quick to
note that her period should not be used as an excuse: “I feel I didn’t swim well today…My period came last night and I’m really tired now. But this isn’t an excuse, I still didn’t swim as well as I should have.” Moreover, women athletes may be socialized to view their menstrual cycle as a distraction from or a hinderance to sports performance, and thus may not be concerned with losing it.
Energy Deficiency
Low energy availability is particularly worrisome in the context of women athletes since women face intense social pressure to remain thin. Energy deficiency may be caused by eating disorders, which occur far more frequently among women than among men. Women athletes specifically are 5 to 10 times more likely to have eating disorders than male athletes. Women who participate in lean-body sports are at a particularly high risk for the Triad, demonstrating that ideas of body image and worth correlating with body size—ideas that act pervasively against women—influence the incidence of the Triad.
Low Bone Mineral Density
Bone mineral density may be the most clinically concerning element of the Triad. Bone mineral density is lower in amenorrheic athletes than in eumenorrheic athletes, and a review article by Khan et al found that in female athletes, the prevalence of osteopenia ranged from 22% to 50%, and the prevalence of osteoporosis ranged from 0% to 13%, compared to 12.2% and 2.3% respectively expected in a normal population distribution. Yet even in light of this evidence, oral contraceptive pills remain among the most commonlyprescribed treatments for the Triad. OCPs restore menstruation, but fail to treat low bone mineral density, and do not actually fix the energy imbalance that the athlete is experiencing. The prescription of OCP to treat the Triad also goes against the guidelines for the treatment of the condition as established by the American Academy of Family Physicians (AAFP).
In addition to gender stigma that acts against women and women athletes, limited education contributes to the lack of effective and evidence-based treatment and intervention for the triad. Female athletes, coaching staff, and health staff alike have been shown to underestimate the severity of the Triad.
To properly treat the Triad, the knowledge gap regarding the Triad’s prevalence, presentations, and severity must be rectified. Proven, effective measures like weight gain and reduced exercise should become the standard treatment for the Triad. However, treatment of the Triad must extend beyond the mitigation of physiological symptoms. It is necessary to also address the culturally-held beliefs about women which discourage women athletes from seeking treatment for the Triad or from recognizing the consequences beyond infertility that the Triad may have, and which prevent coaches from holding open and honest conversations about menstrual health with their athletes.
ABOUT THE AUTHORS
Yael Sarig, is an AB medical anthropology candidate at Brown University.
Dr. Samaei, is a research fellow in the division of sex and gender in emergency medicine at the Warren Alpert Medical School of Brown University
About SGEM
The Sex and Gender in Emergency Medicine (SGEM) Interest Group works to raise consciousness within the field of emergency medicine on the importance patient sex and gender have on the delivery of emergency care and to assist in the integration of sex and gender concepts into emergency medicine education and research. Joining SGEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
Work-Life Balance: Why It Doesn’t Work and How to Design a Life With Harmony
By Jennifer Kanapicki Comer, MD and Al’ai Alvarez, MD, on behalf of the SAEM Wellness Committee
At times our lives can feel like a gnarled tree with twisted branches — some that flourish and others that break. When life feels like this, people who are close to us say we need a better work-life balance. But work-life balance doesn’t work. Instead, we offer you another perspective: focus on designing the life you want based on your values and priorities.
Debunking the Work-Life Balance Myth
We are all on this elusive quest to balance our work commitments and personal life. Despite our best efforts, we often fail, which can be a source of burnout. Think of work-life balance as a scale. When your focus is weighted on one side of the scale, the other side suffers. This imbalance is uncomfortable, unsettling, and frustrating. Work-life balance implies a tradeoff. Who wants to have to choose between work and life all the time? What if, instead, we strive for work-life harmony. The definition of harmony is a pleasing arrangement or combination of parts. It leads to tranquility and congruence. Living with work-life harmony puts you at the center. You are the trunk and roots of the tree. It’s about where you want to invest your time based on your priorities. It’s also about understanding how you fit in your institution’s mission, vision, and values. Alignment of your values with your institution’s values are critical for professional fulfillment. Harmony comes from living a life that aligns your set of values with your environment. This helps us with our priorities and goals. Work-life balance is about the what, when, and how. Work-life harmony is about the why.
Designing the Life You Want
Designing your Life, by Bill Burnett and Dave Evans, suggests expanding our view of life to three specific gauges: love, play, and health. We can understand which areas require more attention by thinking of work, love, play, and health as gauges.
In his book, The Productivity Project, Chris Baily writes about “hotspots,” which is what makes up your life portfolio. Baily points out that every task, commitment, or project can fit into a hotspot and that 90% of people have the same seven hotspots: mind, body, emotions, finances, career, fun, and relationships. Write down the seven hot spots and what they mean to you. Maybe under mind, remind yourself of that longing to take up a new hobby. Under body, you may mention exercise as something important to your well-being. Think about what you value in your career and your own career vision. By doing this exercise, you write your personal mission, vision, and values and design the life you want.
What is clear in both books is that there is a benefit to introspection around how we fill our tanks. The more specific we are and more intentional we are about doing this, the better we can be at finding worklife harmony. What follows are some tools to set you up for success.
Calendaring
Most people have a to-do list. The Kruse research team showed that 41% of items on a to-do list never get done. Unfinished goals are stressful; they swim around in your head and divert your attention from the task at hand. Highly successful time managers don’t have to-do lists but very well-prioritized calendar tasks. For example, if you need to do a literature search for your next research project, put on your calendar “Literature search,” Tuesday, 9-11 am. By providing a definite date and time entry on your calendar for accomplishing this task, it becomes less nebulous.
To-do Lists Are Where Ideas Go to Die
Pick a night of the week to calendar the week ahead of you. Review your hotspots and remind yourself of your personal mission, vision, and values, and use your calendar to reflect these values. That Wednesday, 8 p.m. “Date with my partner,” is just as important as that Wednesday 9 a.m. “Methods Writing Session.”
Creating a “Not to Do” List
The Pareto principle tells us that 20% of our actions account for 80% of the results. Consider that 80% of your actions aren’t producing results. What can you automate, outsource, or eliminate? Check to make sure all your bills are on autopay and use apps like Instacart to save hours spent at the store grocery shopping. Lastly, what committees are you on or roles do you hold that aren’t in line with your personal mission, vision, and values? Pivot your focus on those that have better alignment.
Say No
It’s often challenging for us to say no, but remember that every yes is a no to something else. In this virtual world, it’s so easy to get asked to jump on that last-minute Zoom call or be tempted to check Slack many times during the day. Remember: you calendared your week based on your personal mission statement when you had the 30,000-foot view of your week. Don’t get deterred by “got-a-minute?” meetings. Practice selfcompassion and stick with your original plan based on your life’s priorities.
Finding balance in our life sometimes feels impossible, so let’s design a life that aligns work with our own personal mission, vision, and values. Only then can we truly embrace work-life harmony.
ABOUT THE AUTHORS
Dr. Comer is associate program director at Stanford Emergency Medicine Residency. @kanapicki
Dr. Alvarez, is the director of well-being at Stanford Emergency Medicine. @alvarezzzy
