A is for Affect

A = Affect
Mental & Emotional Wellness

A is for affect test

A of BASICS is the domain dedicated to wellness of the mind. This consists of mental, emotional and psychological wellness. A also stand for Assets which is financial wellness. 

The Forces that Oppose Wellness of Affect

The four horseman of the burnout apocalypse are very destructive to mental, psychological and emotional wellness. 

  • The Horseman of the Perfectionist

    At least one study has measured perfectionism in a population of health professional students (medical, dental, pharmacy and nursing) and notes it to be prevalent, and, not surprisingly, highly correlated with symptoms of psychological distress.

    There is a strong association generally between perfectionism and increased risk for depression, anxiety, obsessive compulsive symptoms, and even suicide.4

    The perfectionist horseman of the burnout apocalypse does most of his work by setting expectations that result in perfection. These expectations are often unrealistic. This horseman works in many ways:

    • Filtering: Perfectionists tend to select certain details they will focus upon — usually negative ones. Expecting perfection, they tend to discount the impact of positive feedback. The result can be an obsessive and upsetting preoccupation with criticism that is not balanced by the appreciation of compliments or a job well done.
    • Mind reading: The perfectionist, especially one who is socially prescribed, will think he or she knows what others are thinking of them. And all too often they will believe that others are judging them harshly.

    The perfectionist horseman often drives physicians to place unrealistic demands upon themselves. This is behind the feeling that no mistake is acceptable. This horseman also leads to physicians imposing these same impossible expectations onto others. This horseman also drive the common physician perception that others expect them to be perfect. The expectation that others expect perfection is highly associated with distress.  

  • The Horseman of the Superhero

    The superhero horseman of the burnout apocalypse makes physcians feel that they can meet all  the unrealistic expectations set by the perfectionist horseman. 

    Some common manifestations of the superhero include…

    • Over confidence: This is one manifestation of the Superhero trait. The superhero trait often causes doctors to have the sense that they are in greater control of situations than they realistically are. So, when outcomes don’t match expectations, the tendency is to blame oneself. Anger, frustration and guilt are common feelings that result. 
    • Over responsibility: The superhero trait also causes doctors to falsely assume that their role is to stamp out disease, suffering and death. 
    • Over inflated ego: The superhero trait also causes doctors to often assume that they are is indispensable to patients and profession. It also leads to the assumption that no patient could ever be angry with you, or leave your practice. 

  • The Horseman of the Lone Ranger

    The  Lone Ranger horseman of the burnout apocalypse drives many physicians to work alone, disconnect from others, and have a self-centered viewpoint.

    It manifests in many ways, including:

    • All or nothing approach: The Lone Ranger horseman drives a form of self-centered thinking that often leads to a false dichotomy mindset. This mindset causes people to see only two ways about anything…  Their way or the wrong way. All or nothing thinkers will, of necessity, face frustration trying to navigate a world of uncertainty and shades of gray. 
    • Isolation during stress and/or uncertainty: The Lone Ranger horseman often drives us to disconnect from others during times of stress and uncertainty. This can be very destructive since the best solution to uncertainty and stress is to connect with others for partnership and support.

  • The Horseman of the Workaholic

    The Workaholic horseman of the burnout apocalypse drives the feeling that the impossible expectations set by the perfectionist can be achieved with hard work.  This horseman says that not meeting an expectation only happened because of lack of hard work. Physician’s often project this mindset on themselves and others. They also feel that other’s feel the same way about them.

    A really dangerous expression of this trait is catastrophizing.

    Catastrophizing: This involves the magnification of negative outcomes coupled with the sense that they can be prevented or managed with hard work.

The following are some tools to combat the four horseman of the burnout apocalypse.

BASICS Ideas for Wellness of Affect

  • Tool: The principle of option 3

    Ask if you are thinking in terms of a false dichotomy.

    • Do you falsely think their are only two options? Look for options that combine both option 1 and option 2 (i.e. 1 and 2 not 1 or 2). 

    Even worse, is your false dichotomy using extremes (an extreme false dichotomy)?

    • Are you thinking in “all or nothing” terms?
    • Look for words that suggest absolutes, like “always” or “never.”

  • Tool: The Reality Check

     Am I confusing a rare occurrence with a probability? This is a reality check.

  • Tool: World is not Ending

     Am I assuming the worst possible outcome? This is not the same as a rational consideration of a worst case scenario when charting a course of action.

  • Tool: Excuse Expectations

    • Am I blaming myself for something that was beyond my control? The benefit of accurate hindsight is helpful here.
    • Look to see if the expectation was realistic, supported and clear. Then put your energy into improving things that you can actually control to try and make the expectation clear, realistic and supported for the future. Learn from the past, focus on the future. Use your energy to improve the future based on what you learned from a negative event. 

  • Tool: Imperfect hindsight

    What would have happened if I  had handled the situation differently?

    Especially consider alternatives less shaped by perfectionism.

  • Tool: Consult your future self

    Ask yourself the following questions

    What difference will this make in a week, a year, or 10 years?

    Will anyone really judge me harshly in the future?

    I like to think of it as consulting your future self

  • Tool: Stepdown not ICU

    •  Consider alternatives to the perfection based approach. Can standards of perfection for oneself or others be “downgraded” to just plain excellent? Or good?

    • How would someone else think about the same situation? 
    • Challenge your value system. Open your mind and list alternatives. Then choose a new, more helpful way of thinking about the situation.

More Ideas & Interventions for achieving Wellness of Affect

  • Tool: The Wishka Jar

    The Wishka Jar is a tool that Christian Wishka provided to us. 

Suicide Awarness

Cardiovascular ICU Selective/Elective

Teaching Chief: Kartheek Nagappala MD

Description: Advanced Cardiovascular Critical Care rotation will allow residents to further develop their skills, knowledge and attitudes obtained during their previous rotations, specifically expanding on their critical knowledge to patients that are post cardiac surgery, major vascular surgery, and critically ill due to compromise of their cardiovascular system. The rotation will involve 21-22 12-hour shifts, similar to the EM core ICU experience. 

Availability: Generally available year-round and will occasionally share the experience with an Anesthesia co-rotator.

Scheduling: Schedule to be made by the rotator with final schedule approval by the teaching chief

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Community Emergency Medicine Elective

(PGY-3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Palliative Care Selective/Elective

Teaching Chief: Ryan Howard MD

Description: The Palliative Care Selective or Elective is a 2- or 4-week inpatient rotation designed to expose the rotator to all aspects of inpatient palliative care. Residents will work alongside the palliative director and/or the palliative fellow along with the interdisciplinary palliative team throughout the rotation. The goal is to provide either PGY2 or PGY3 residents with an immersive clinical experience to learn more about inpatient palliative services.

Availability: Generally year-round, those interested in applying to Palliative Fellowship get precedence on the rotation as space is limited

Scheduling: M-F, 8am-5pm, with call shifts if required/desired per Dr. Howard

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Intro and Advanced Pharmacology Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD and Savannah Lail PharmD

Description: A 2 or 4-week rotation where the resident works and learns alongside the ED pharmacists on assigned shifts. The Pharmacology rotation is designed to provide training concerning the application of pharmacology knowledge, pharmaceutics, drug information, medication safety, communication skills, critical thinking, pathophysiology, and therapeutics to the care of patients in an emergency department setting. The advanced rotation is for those who have already had the introductory Pharmacology rotation experience.

Availability: Generally year-round, but must contact PharmD teaching chief prior to choosing the rotation to ensure availability. 

Scheduling: Variable shifts, 10-shifts per rotation, to be assigned by PharmD teaching chief

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Pulmonary and Ventilator Management Selective/Elective

Teaching Chief: Leland Beggs MD

Description: This is a 4-week rotation based in the ICU, CVICU and ED. Residents will work side-by-side with designated respiratory therapists as well as core faculty physicians. The goal of this rotation is to focus solely on vent management and non-invasive ventilation techniques in patients with a wide variety of disease processes. Residents will be expected to manage vent settings for intubated patients in the ED, ICU and CVICU. Residents on service should gain an in-depth understanding of the events surrounding intubation, including strategies in pre oxygenation as well as the various drugs used for RSI and post intubation sedation. In addition, they will learn when to initiate, and how to manage non-invasive ventilation.

Availability: Generally year-round

Scheduling: M-F, 6am-4pm

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Radiology Selective/Elective

(Two-week experience) 

Teaching Chief: Ashkan Shahkarami MD

Description: The two-week Radiology rotation will provide the resident with an opportunity to learn normal and abnormal radiographic anatomy, recognize radiographic findings of common diseases, understand the indications for commonly ordered imaging studies, and learn the appropriate use of IR procedures. The goal of the rotation is to help the resident become competent in the use of imaging in the evaluation and treatment of disease.

Availability: Generally year-round, but must contact teaching chief before choosing the rotation to ensure availability

Scheduling: M-F, 8am-4pm, or as adjusted by the Radiology attending

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Wilderness Medicine Selective/Elective

Teaching Chief: Various

Description: The one-week wilderness medicine selective is offered twice a year at Kaweah Health, usually once in the Spring and once in the Fall/Winter. If not available during the allocated selective/elective block, previous residents have participated in 4-week experiences in Utah and Redding, CA. Experiences are variable and depend on the chosen course, so for this one touch base with Dr. Sukhija to see what is feasible both locally and away.

Availability: Highly variable, see description above

Scheduling: Highly variable

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Emergency Medicine Admin Selective/Elective

Teaching Chief: Kona Seng DO and Khoa Tu MD

Description: This is 2-4-week rotation in conjunction with the Department of Emergency Medicine Medical Director. The purpose of the ED Administration rotation is to provide an understanding of the administrative components of EM clinical services and operations. This will allow early exposure to ED administration to determine if the resident is interested in the administration and business of emergency medicine. The EM residents will attend all assigned meetings and participate in administrative projects. 

Availability: Generally year-round, will share the rotation with the PGY3 on their core admin rotation

Scheduling: M-F, 9-5pm, or as adjusted by the teaching chiefs

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Patient and Physician Advocacy and Street Medicine Selective/Elective

Teaching Chief: Kunal Sukhija MD, Omar Guzman MD, Lori Winston MD

Description: The Advocacy 2- or 4-week rotation is designed to be a self-directed customizable experience that will provide immersion into various aspects of physician and patient advocacy. The resident will be able to participate in local, state-wide, and national (schedule permitting) advocacy efforts while simultaneously learning about effective strategies to engage community leaders, legislators, and the local constituency. The rotation will offer experiences in both the legislative and community advocacy (the latter will be based in the Street Medicine program). 

Availability: Generally year-round, however certain months tend to be better given the yearly CMA, AMA, CalACEP, ACEP schedules. Touch base with Dr. Sukhija prior to choosing this elective in order to ensure you can get the individualized experience you desire.

Scheduling: Highly variable depending on advocacy events and meetings, Street Medicine tends to hold its events on Friday

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Performance and Quality Improvement (PI/QI) Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD

Description: The Performance Improvement (PI)/Quality Improvement (QI) selective rotation will provide exposure to ongoing PI and QI efforts at KDHCD and provide opportunities for the PGY2 or PGY3 EM resident to become involved in PI/QI projects on an individual, departmental, or institutional level. The resident will join the Emergency Medicine PI director in the regular duties of chart review, M&M conference coordination and presentations, and committee meeting attendance as appropriate. It also offers time for the resident to work on their PI/QI project as part of residency graduation requirements. 

Availability: Generally year-round

Scheduling: Variable depending on meetings and current on-going projects

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Public Health Elective (PGY3 only)

(PGY3 only)

Teaching Chief: Karen Haught MD MPH, Tulare County Public Health Director

Description: This is a 4-week rotation with the Tulare Public Health Department designed to expose the rotator to all aspects of public health. Residents will work alongside the Tulare Public Health Director and/or the epidemiologist throughout the rotation. The goal is to provide PGY3 residents exposure to the role of the local public health department in the community. Residents will be expected to work at the Tulare Public Health Department and contribute to a community health project of the resident’s choice.

Availability: Generally year-round, though an interested resident should first contact Dr. Haught prior to selecting this experience (Dr. Sukhija will help you with contact information)

Scheduling: M-F, 9-5, though historically it’s been less than this as independence is given to work on the resident’s chosen project

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Research Selective/Elective

Teaching Chief: Chris Patty DNP, Director of Research

Description: The goal of the resident research rotation (2 or 4 weeks) is to improve the resident’s understanding of how new knowledge is created and translated into practice.  At the end of the rotation, the resident will present a deliverable which demonstrates ACGME competencies in knowledge development and translation. Many residents choose this rotation in order to work on their chosen Scholarly Activity as part of residency graduation requirements. 

Availability: Generally year-round, the resident must contact the director of research 4-weeks prior to the rotation in order to state deliverables and set up the rotational requirements.

Scheduling: Variable, generally self-directed independent work

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Simulation and Education Selective/Elective

Teaching Chief: Kim Sokol MD

Description: This is a 4-week rotation includes developing simulation scenarios, teaching simulation-based educational sessions, and assisting in daily operations in the simulation center. The rotation’s purpose is to develop skills associated with teaching. The rotation will provide an introduction to simulation with multiple adjuncts such as high and low-fidelity mannequins, task trainers, and the use of standardized patients.  A basic understanding of simulation-based education and debriefing will be taught along with basic principles associated with adult education. The resident must choose teaching shifts as their clinical experience.

Availability: Generally year-round

Scheduling: Variable, to be determined with the teaching chief prior to the rotation start date

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Teaching Elective with Dr. Stanley

(PGY3 only)

Teaching Chief: Michael Stanley DO

Description: This 4-week rotation is a highly-desired advanced elective rotation for PGY3 EM residents. It is intended only for those residents who are serious about improving their ability to teach AND lead. This rotation is as much about leadership as it is about teaching because both utilize the same skill sets. Residents will gain knowledge in effective communication techniques while learning about the underlying psychology of teaching, learning, and leadership.

Availability: Generally year-round

Scheduling: 12 10-hour shifts to be scheduled in accordance with Dr. Stanley’s clinical schedule, along with didactics (also to be scheduled with Dr. Stanley prior to the start date). If Dr. Stanley has less than 12 shifts, then the remainder can be completed with either Dr. Oldroyd, Dr. Sokol, or Dr. Alexeeva.

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Advanced Ultrasound Selective/Elective

Teaching Chief: John Hipskind MD

Description: This 4-week rotation is designed to augment the resident’s diagnostic (and therapeutic) skills in relation to the ultrasound, and to explore more advanced US modalities such as TEE. The resident will gain experience with nerve blocks, enhanced approaches to the core EM ultrasound studies, and explore novel ways to use the ultrasound in the ED setting. They will work alongside the teaching chief as well as the ultrasound fellows.

Scheduling: The expectation is to be scanning daily M-F, with weekends off. Due to PGY1 EM rotators and the popularity of this selective/elective, there may be many residents on rotation, and thus scheduling must be in conjunction with Mia Zavinovich and Dr. Hipskind prior to the start of the rotation. 

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International & Global Medicine Elective

(PGY3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Patient Callbacks and PBLI form

Patient callback instuctions - complete 12/block when you are on the emergency medicine service

PBLI form - complete 4/year to reflect & self-evaluate your patient care

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