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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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products. Common side effects, such as local irritation of the mouth and throat,
coughing, and rhinitis, usually decline with continued use.
Nicotine Nasal Spray. Another therapeutic option is the nicotine nasal spray.
The spray provides 0.5 mg of nicotine per inhalation and can be used at a starting
rate of 1 to 2 doses per hour, for a maximum of 40 doses per day (5 doses per hour).
The inhaler can also be used over months, with gradual tapering of the dose. Nasal
irritation is the most common side effect. Of all the nicotine replacement products,
the inhaler has the highest peak nicotine level and therefore also has the highest
dependency potential.
Nicotine Lozenge. The nicotine lozenge is available over the counter in 2-mg and
4-mg nicotine doses. The 4-mg nicotine lozenge is recommended for those who
smoke their first cigarette within 30 minutes of waking, and the 2-mg nicotine
lozenge is for those who smoke their first cigarette more than 30 minutes after
waking. The patient should allow the lozenge to dissolve in the mouth without
swallowing or chewing. The recommended dose is 1 lozenge every 1 to 2 hours, not
to exceed 20 lozenges a day, for the first 6 weeks and then a gradual 6-week taper
for a total of 12 weeks of treatment. Common side effects include nausea, hiccups,
and heartburn.
Nicotine Patch. Compared to the other methods outlined, the nicotine patch is
a passive nicotine replacement system. The patches are available over the counter
and in varying strengths. The patch is replaced daily, and consideration should be
given to starting with higher dose patches in heavy smokers. Treatment with the
patch for fewer than 8 weeks is as effective as longer treatment periods. The most
common side effect is irritation of the skin at the site of the patch. When used overnight, the patch has been shown to decrease morning cravings of nicotine.
Electronic Nicotine Delivery System. Electronic nicotine delivery systems (ENDS)
have become popular over the past decade or so. Specifically, the use of electronic
cigarettes (also called e-cigarettes) for smoking cessation has gained popularity
since introduced to the United States in 2007. These battery-operated devices
convert liquid nicotine into a vapor that is inhaled. Depending on the version of
e-cigarettes used, flavors, additives, herbal extracts, or vitamins may be added, and
nicotine may or may not be present. There is insufficient evidence for electronic
cigarettes being safer than cigarettes. Previously, they were considered a safe option,
as they were free from tar or known carcinogens. Recent studies, however, have
shown that the exhaled smoke is not just water vapor. It contains products that are
carcinogenic to not only the smoker but also those in the smoker’s immediate vicinity. It is still unclear if e-cigarettes are more effective for treating smoking cessation
than traditional nicotine replacement modalities. In an effort to halt the increased
use of e-cigarettes among children and adolescents, in 2014 the FDA prohibited
the sale of smokeless tobacco to individuals younger than 18 years old. Caution
should be used when suggesting smokeless tobacco as a means for quitting. Until
further research is conducted, more familiar methods should be recommended.
Other Considerations
Pharmacologic Interventions in Pregnancy. The nicotine inhaler, nasal spray,
patch, and gum are pregnancy category D drugs. Pregnant smokers should be
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encouraged to quit without the use of any pharmacologic agents. However, these
products can be considered for use in the pregnant smoker if counseling is insufficient to promote cessation and if, in discussion with the patient, it is determined that the risks of continued smoking outweigh the risks of the medication.
Bupropion and varenicline are pregnancy category C. They have not been studied in pregnancy and should only be used if the benefit justifies the potential
risk to the fetus.
Screening. The United States Preventive Services Task Force strongly recommends screening all adults and pregnant patients for tobacco use and offering cessation intervention for those who use tobacco products (Grade A recommendation).
For adolescent smokers, counseling has been shown to be effective, and counseling
interventions should be provided to aid in quitting (Grade B recommendation).
The strongest risk factor for smoking initiation among children and adolescents is
parental smoking.
CASE CORRELATION
See also Case 1 (Adult Male Health Maintenance) and Case 56 (Wheezing
and Asthma).
COMPREHENSION QUESTIONS
7.1 A pregnant woman who smokes one pack of cigarettes a day asks for your
advice regarding smoking cessation while she is pregnant. Which of the following statements is most appropriate?
A. Bupropion is pregnancy category C and relatively safe in pregnancy.
B. Varenicline is pregnancy category B and relatively safe in pregnancy.
C. Nicotine gum delivers a lower and safer dose of nicotine than the nasal
spra y.
D. The use of smoking cessation products during pregnancy frequently leads
to adverse outcomes.
7.2 Which of the following statements regarding available treatments for smoking
cessation is accurate?
A. Bupropion can be used in combination with nicotine supplements.
B. Nicotine gum is most effective if chewed continuously, to promote a con-
stant release of the nicotine.
C. Nicotine supplements are most effective when used as needed for with-
drawal symptoms.
D. All of the available agents are more effective when used in combinations
with each other.
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7.3 Which of the following counseling strategies is most likely to enhance your
patients’ smoking cessation rates?
A. Discuss smoking cessation techniques only with patients who ask for your
advice, as others will resent your suggestions.
B. Emphasize primarily the health risks of smoking.
C. Note in each patient’s chart that you have discussed cessation, so that you
do not repeat the message to the same patient at subsequent visits.
D. Ask about smoking cessation at each encounter.
ANSWERS
7.1 A. Bupropion and varenicline are both pregnancy category C (not category B,
as in answer B). Pregnant smokers should be encouraged to quit without the
use of any pharmacologic agents. However, pharmacologic aids to increase
the rate of smoking cessation during pregnancy can be used (answerD) after
discussion with the patient of the risks and benefits of the medications and
of continued smoking. Cessation of smoking at any time during the pregnancy is likely to provide health benefits for the mother and fetus. Nicotine gum (answer C) delivers higher doses of nicotine than its nasal spray
counterpart.
7.2 A. Bupropion can be used in combination with any of the nicotine supplementation products. The nicotine products can also be used in combination
with each other. While some studies have looked at the use of varenicline with
nicotine replacement, the prescribing information for varenicline still states
that it has not been studied for use with other smoking cessation agents and
cautions against the combination (answer D). Two common pitfalls in using
nicotine supplementation are using supplementation only when having withdrawal symptoms (answer C) and failing to use nicotine gum correctly. The
gum should be chewed briefly and then parked in the cheek. It is less effective
if chewed continuously (answer B).
7.3 D. Asking patients about tobacco use is a key to promoting cessation. It is important to ask all patients (not only patients who ask for advice, as in answerA) at
each visit (not solely at one visit, as in answer C) and to be prepared to provide
advice and assistance at any time. Motivational counseling is most effective,
which means describing both the positive effects of smoking cessation and the
risks (answer B).
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CLINICAL PEARLS
» Most smokers require multiple attempts before successfully quitting for
good. Remind your patients of this if they become discouraged in their
efforts.
» Use the five A’s—ask, advise, assess, assist, and arrange follow-up—to
help your patients quit smoking.
» Common nicotine withdrawal symptoms include mood changes
(irritability, anxiety, frustration), difficulty concentrating, increased
hunger, and restlessness.
» The approved nonnicotine medications are bupropion sustained release
(brand name Zyban) and varenicline (brand name Chantix).
» The combination of a daily nicotine patch and an as-needed nicotine
replacement therapy (nicotine gum, inhaler, nasal spray, or lozenge) has
been shown to be more effective than the patch alone.
REFERENCES
Centers for Disease Control and Prevention. Fast facts and fact sheets. https://www.cdc.gov/tobacco/
data_statistics/fact_sheets/index.htm?s_cid=osh-stu-home-spotlight-001. Accessed May 7, 2019.
Crawford P, Cieslak D. Varenicline for smoking cessation. Am Fam Physician. 2017;96(5). https://www
.aafp.org/afp/2017/0901/od1.html. Accessed May 7, 2019.
Drew AM, Peters GL. Electronic cigarettes: cautions and concerns. Am Fam Physician.
2014;90(5):282-284.
Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guide-
line. Rockville, MD: US Department of Health and Human Services, Public Health Service;
May 2008.
Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation.
Cochrane Database Syst Rev. 2014;(1):CD000031. doi: 10.1002/14651858.CD000031.pub4
Larzelere MM, Williams DE. Promoting smoking cessation. Am Fam Physician. 2012;85(6):
591-598.
Okuyemi KS, Nolen NL, Ahluwalia JS. Interventions to facilitate smoking cessation. Am Fam Physician.
2006;74(2):262-271.
United States Food and Drug Administration. Compliance with regulations restricting the sale and
distribution of cigarettes and smokeless tobacco to protect children and adolescents. Available
at: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/complianceregulations-restricting-sale-and-distribution-cigarettes-and-smokeless-tobacco-protect. Accessed
April 23, 2020.
United States Food and Drug Administration. Vaporizers, e-cigarettes, and other electronic nicotine
delivery systems (ENDS). Available at: https://www.fda.gov/tobacco-products/products-ingredientscomponents/vaporizers-e-cigarettes-and-other-electronic-nicotine-delivery-systems-ends. Accessed
January 27, 2019.
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United States Department of Health and Human Services. The Health Consequences of Smoking—
50 Years of Progress: A Report of the Surgeon General. Atlanta, CA: US Department of Health and
Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health; 2014. Available at: https://
www.hhs.gov/sites/default/files/consequences-smoking-exec-summary.pdf. Accessed January 27,
2019.
United States Preventive Services Task Force (USPSTF). Tobacco smoking cessation in adults,
including pregnant women: Behavioral and pharmacotherapy interventions. https://www
.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnantwomen-counseling-and-interventions. Accessed April 23, 2020.
CASE 8
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A 24-year-old medical student is about to begin her first clinical rotation and
has been eagerly awaiting the chance to apply her medical knowledge to real
patients. She also hopes to identify physician role models.
On her first rotation, she is disappointed to find that her attending is
miserable. Scurrying between patient rooms, the attending barely has time to
speak to her patients and perform a minimal examination. Instead, she mostly
types and clicks on the electronic health record (EHR), rarely even looking at
her patients while she talks. The attending often has to pause the visit to locate
missing laboratory or imaging reports. Meanwhile, the clinic staff seems to be
in perpetual crisis mode, interrupting the attending with requests for help with
patient calls, emergency visit slots, refills, and patient complaints. Additionally,
after the attending goes home at night, she still spends several hours charting
in the EHR.
At the end of a particularly difficult day, the attending, slumped in her chair
in a daze, tells the student that she regrets becoming a physician. “I used to see
patients; now I stare at the computer screen. I used to be in charge of my day, but
now an administrator tells us how many patients to see and how much time to
spend with each one. I used to care about each and every one of my patients; now,
I just want to get through the day and go home. I work so hard, but I wonder if I’m
really making a difference,” she says.
▶ What syndrome is the attending physician suffering from?
▶ What are some of the underlying causes of this syndrome?
▶ What are some characteristics of this syndrome?
▶ What should the medical student do to preserve her own well-being?
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ANSWERS TO CASE 8:
Clinician Well-Being
Summary: A new medical student
Is working with a physician in a dysfunctional clinic setting
Observes the dysfunction affects not only the physician’s work satisfaction but also
the quality of her patient care and teaching
Hears the attending say she regrets becoming a physician and does not know if she is
making a difference
What syndrome: Job burnout.
Causes of burnout: Work overload, clinical inefficiencies, excessive time document-
ing on the EHR, loss of job autonomy, and not being able to focus on patient care.
Symptoms of burnout: Feeling exhausted at the end of the workday, frustration
with clinical inefficiencies, loss of empathy for patients and coworkers, loss of a
sense of personal accomplishment, and loss of a sense of meaning in work.
Medical student response: The student should recognize that her attending physician is stressed and demoralized because she is working in a toxic job environment.
The student has an opportunity to use this unfortunate situation to learn about
physician burnout, including ways that high-functioning medical organizations
are creating healthier job environments. In the future, when choosing electives,
her specialty, her residency, and eventually her job, she should consider the job
environment.
ANALYSIS
Objectives
1. Describe health care provider burnout, including symptoms, causes, and
impact. (EPA 1, 12)
2. Discuss the solutions currently proposed for burnout. (EPA 12, 13)
3. Discuss coping strategies for clinicians at risk of burnout. (EPA 12)
Considerations
The physician in the case is suffering from job burnout, a syndrome that affects
her energy, mood, attitude about her patients and coworkers, and effectiveness as
a physician. The source is the dysfunctional clinic organization, beginning with
a mismatch between the period of time the physician needs to care well for her
patients and the actual time allotted. Additional aspects of this clinic’s dysfunction
include the time the physician spends doing clerical work rather than patient care
and the time spent after hours with the EHR. Rather than improving workflow
and respecting the doctor-patient relationship, the staff hinders by interrupting the
physician during visits.
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In addition to having a negative impact on the physician’s morale, the clinic dysfunction is likely to have a negative impact on the quality of patient care. Instead
of a rich physician-patient relationship marked by trust, open communication, and
attention to detail, patients will likely feel that their physician is inattentive and
uncaring, and the distracted provider is likely to miss subtle communication hints
and important clinical details. As for the staff, instead of being part of an efficient,
productive, happy team, they may feel ignored, underutilized, and bored. Trainees
observe the chaos and wonder if they chose the right profession.
Because the problem is rooted in a toxic work environment, the solutions will
require a systemic approach and culture change within the health care organization. The attending physician will need to enlist help from clinical colleagues and
support of organizational leadership to identify the drivers of burnout and to
implement strategies for correcting them.
Although health care providers are not to blame for their high rates of job
burnout, they are still the symptom bearers and thus are at risk of serious health
and relationship problems. The attending physician in this case needs to pay close
attention to her own self-care: sleep, exercise, diet, and relationships. Ultimately,
she may need to change jobs or transition to part-time.
APPROACH TO:
Clinician Well-Being
DEFINITIONS
DEPERSONALIZATION: Treatment of patients, patients’ families, and/or coworkers as objects rather than persons. It often involves a reduced capacity for empathy,
clinical insight, and creative problem-solving.
PROVIDER BURNOUT: A syndrome of disengagement from work by a variety of
factors such as consequence of a poorly structured clinic environment. These providers feel exhausted physically and emotionally. Instead of their work being satisfying and rejuvenating, it drains their energy and enthusiasm. Many also experience
symptoms of depersonalization and a low sense of accomplishment.
CLINICAL APPROACH
Sources of Burnout
Being a health care provider has always been a demanding profession. Clinicians
care for those who are most sick and vulnerable in our society. They bear a heavy
burden of responsibility for the lives of others, they see disability and death on a
near-daily basis, and they suffer the collateral damages of physical exhaustion and
family stress due to working long hours. Job stress and workaholism have always
been features of the profession.
From the physicians’ perspective, there was one saving grace: Physicians were in
control of their jobs, their clinics, and their hospitals. The work was hard, but it
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was “their” work: They controlled the appointment templates, the operating room
schedule, hiring of staff, and which medical record to use. They also enjoyed consultations and camaraderie with their colleagues via phone calls, hallway conversations, lunch meetings, and breaks in the lounge. They experienced the joy and
privilege of doing meaningful work: solving problems, helping people, and being
part of a team of dedicated professionals. There was more physician autonomy in
the past.
In the past two decades, however, the structure of health care has changed. As
a consequence, physicians as a whole have less control of their jobs, clinics, and
hospitals. In many settings, it appears that administrators focus on efficiency, and
financial goals have shortened clinic visit times, increased numbers of patients seen
per clinic session, and reduced the number of ancillary staff. Insurance companies
have required clinicians to justify needed procedures or medications, a frustrating
task. In an effort to increase patient safety and legibility and portability of medical
records, government policies require the use of the EHR. Sadly, from the clinician’s
viewpoint, the typing, clicking, and peering at the computer screen in the examination room can interfere with the provider-patient relationship. In summary, today’s
providers not only face the burden of numerous nonclinical tasks, but they also feel
that they have a reduced ability to fix problems.
Effects of Health Care Provider Burnout
Provider burnout has a negative impact on health care delivery and the health and
happiness of the individual provider. Burned-out clinicians tend to deliver inferior
care, make more mistakes, and are at increased risk of malpractice suits. Sensing
their provider’s disinterest and demoralization, patients are dissatisfied with their
care and are less likely to follow their provider’s advice. Burned-out providers are
not as productive as healthy ones. They often work fewer hours, see fewer patients,
and are more likely to leave jobs in search of something better. Burned-out providers also pay a high price in terms of their own health and well-being. They experience higher rates of depression, alcohol and substance abuse, suicide, work-home
conflicts, job dissatisfaction, and career abandonment.
Solutions to Burnout
Research has shown that physician burnout can be prevented and reduced by the
organizational interventions and approaches discussed next.
Addressing Local Issues at the Local Level. With the endorsement of institutional
leaders, clinic- or department-based focus groups identify key drivers of burnout
and are empowered to fix them for their particular unit. Typical issues and solutions include previsit planning, individualizing appointment templates, delegating
clerical tasks, utilizing EHR scribes, sharing clinical care among the entire team,
and improving communication and care of complex patients via team meetings.
Appointing, Training, and Empowering Physician Leaders. Physician leaders are
an important component of health care organizations because they understand
and embrace the values of health care rather than the values of corporate America.
Empowering physicians who possess leadership skills to address problems within
their domain helps reduce physician burnout.
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Letting Providers Follow Their Passion. Providers who are able to identify a professional activity that gives them high levels of meaning and satisfaction and are
allowed to spend at least 1 day per week focusing on that activity are less likely to
experience job burnout. Such activities might include caring for a particular type of
patient, teaching health care students, chairing a task force, or writing a textbook.
Building Teamwork, Community, and Camaraderie. Providers who meet together
with colleagues to discuss difficult cases, to process the emotional impact of their
work, and to reflect on the meaning of their work are less likely to experience job
burnout.
Avoiding Productivity-Based Compensation. Studies showed that providers are
motivated to provide a high quality of care, not a high quantity of care. Providers
whose pay is based on productivity experience higher rates of burnout.
Promoting Work Flexibility and Work-Life Integration. Many young clinicians,
particularly women, experience high rates of burnout due to the difficulty of juggling work, home, and personal needs. Those who work in organizations sensitive
to these needs are less likely to experience job burnout.
Promoting Individual Wellness. While stress management training, meditation,
exercise, and nutrition are not the cornerstones of burnout prevention, they do
help individuals cope with the stressors of their jobs, families, and lives. Other
practices that might enhance individual wellness include self-compassion in the
face of bad patient outcomes, journaling about meaningful patient interactions,
taking time for breaks and vacations, and reducing personal financial pressure by
living a less affluent lifestyle.
Other Solutions. Other burnout solutions might include measures to reduce conflict and improve workplace civility, train and reward good mentors, and improve
communication and trust within the organization.
Learning From the Problem of Burnout
While the drivers of burnout are largely beyond the control of health care students
or residents, what trainees can do is understand the symptoms, causes, and solutions so that they can identify the problem in themselves and others and make
wiser choices in terms of future training and practice. Since students have little control over their hours, assignments, patients, and rotations, it becomes more important to emphasize areas in which they do have some control, such as supportive
relationships, regular exercise, a healthful diet, and adequate sleep. Choosing good
mentors and staying active in nonmedical social groups are also helpful.
It is also important to be aware of other mental health problems with similar
symptoms as job burnout. These include clinical depression, imposter syndrome,
and life imbalance. Clinical depression can be distinguished from job burnout in
that it is often driven by factors other than work or it continues after the work
stressors are removed. However, burnout can be a contributing factor to clinical
depression. Clinical depression is particularly troubling because of its high association with suicide. It is often associated with substance abuse as well. Imposter syn-
drome is common among students, trainees, and young professionals. Its hallmark
is anxiety regarding one’s ability to perform job tasks or one’s overall fitness for a
particular career. Imposter syndrome can be distinguished from job burnout in that
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