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Date: April 9th, 2020

Reference: Kline et al. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers. AEM April 2020

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com

Case: It has been a hard shift. You wish you could say “uncharacteristically”, but recently all your shifts in the emergency department have felt a little hard. The increased workload due to COVID-19 hasn’t been helping. You sit down to chart after a difficult resuscitation, and the charge nurse, seeing that you look a little stressed, asks if you would like to take a break to play with a dog.

Background: Medicine is an incredibly rewarding profession. However, it is undeniably marked by significant levels of stress. Reports of burnout are high across medicine, and even higher in emergency medicine (1,2). A study of USA physicians showed that they had more than  50% with at least one symptom of burnout. Emergency physicians reported the highest prevalence of burnout at around 70% (3).

Burnout is associated with a loss of empathy and compassion towards patients, decreased job satisfaction, and shorter careers in medicine (4,5). It has also been associated with negative impacts on patient care including self-perceived medical error (6), risk of medical errors (7), and quality of care (8,9).

We have covered burnout a few times on the SGEM including my own personal experience of being on the edge of burnout:

  • Five Tips: To Avoid Emergency Medicine Burnout
  • SGEM#178:Mindfulness – It’s not Better to Burnout than it is to Rust
  • SGEM Xtra: On the Edge of Burnout ACEM18
  • SGEM Xtra: CAEP Wellness Week 2019
  • YouTube: Being on the Edge of Burnout One Year Later

There is some prior literature that exposure to animals decreases stress (10,11). Theoretically, time spent deliberately coloring as a mindfulness practice could also decrease stress (12). Therefore, these authors designed a prospective, randomized trial comparing the effects of dog therapy, deliberate coloring, and control on stress levels for emergency department providers (13).

Clinical Question: Does dog therapy result in lower perceived stress than deliberate coloring or control when applied as a break during an emergency medicine shift?

Reference: Kline et al. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers. AEM April 2020

  • Population: Emergency care providers, including nurses, residents, and physicians, from a single center emergency department.
    • Exclusions: Dislike, allergy, fear, or other reason not to interact with a therapy dog.
  • Intervention: There were two interventions, which occurred approximately midway through the provider’s shift. Dog therapy consisted of an interaction with a therapy dog, which providers could pet or touch if they wished. The coloring group was provided with three mandalas to choose to color and a complete set of coloring pencils. Both of these activities occurred in a quiet room, physically separated from the clinical care area, with no electronic devices, telephone, window, or overhead speaker.
  • Comparison: A convenience sample of providers that were not offered any break.
  • Outcomes:
    • Primary Outcomes: There were two primary outcomes. The first was a self-assessment of stress using a visual analogue scale. The second was a 10-item validated perceived stress scores, altered to focus providers on the past several hours rather than months, as it was originally designed. These were both measured at the beginning of the shift, about 30 minutes after the intervention, and near the end of the shift.
    • Secondary Outcomes: They looked also looked at a FACES scales as a measure of stress, and provider cortisol levels.

Dr. Jeff Kline

This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Jeff Kline (@klinelab) is the Vice Chair of Research in Emergency Medicine and a professor of physiology, Indiana University School of Medicine. He is the editor in chief of AEM, creator of Pulmonary Embolism Rule-out Criteria (PERC) Rule and has published extensively in the area of pulmonary emboli.

Authors’ Conclusions: “This randomized, controlled clinical trial demonstrates preliminary evidence that a five minute therapy dog interaction while on shift can reduce provider stress in Emergency Department physicians and nurses.”

 Quality Checklist for Randomized Clinical Trials:

  1. The study population included or focused on those in the emergency department. Yes
  2. The patients were adequately randomized. No
  3. The randomization process was concealed. Unsure
  4. The patients were analyzed in the groups to which they were randomized. Yes
  5. The study patients were recruited consecutively (i.e. no selection bias). No
  6. The patients in both groups were similar with respect to prognostic factors. Unsure
  7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
  8. All groups were treated equally except for the intervention. Yes
  9. Follow-up was complete (i.e. at least 80% for both groups). Yes
  10. All patient-important outcomes were considered. Yes
  11. The treatment effect was large enough and precise enough to be clinically significant. Unsure

Key Results: They enrolled 127 providers, but five withdrew because they thought their shift was too busy to participate. 47% were resident physicians, 23% were attending physicians, and 30% were nurses. They were most frequently (60%) enrolled during an evening shift.

The coloring intervention took a median of five minutes and 26 seconds. In the dog group, providers spent a median of five minutes and 49 seconds with the dogs and had significant interaction with both the dog and the dog’s handler.

  • Primary Outcome:
    • Stress based on the VAS was the same in all three groups at the beginning of the shift (18mm) but rose in the coloring group and fell in the dog group.
    • Stress based on the validated stress score rose in the control group, but otherwise was not statistically significant.
  • Secondary Outcomes: In all three groups, cortisol levels were highest at the beginning of the shift and decrease over time. The cortisol level fell more in both intervention groups.

We asked Jeff ten questions to get a greater understand of his publication. Listen to the SGEMHOP podcast to hear all of his answers.

1) Allocation Concealment: Allocation concealment is one of those EBM terms that gets thrown around a lot but isn’t often discussed. It’s really important, because if you can guess what group you are going to be in, it might affect your decision to join the study. For example, in this study, if I thought I was going to be in the dog group, I would definitely say yes, but I have no interest in coloring, so probably would have said no. Can you comment on your allocation concealment procedures and whether you think they are adequate?

2) Nocebo / Convenience Sample: First, the idea of nocebo is fascinating, and it would be great if you could explain your logic for not randomizing the control group to the listeners. Second, I worry about the convenience sample as a source of bias. The study’s objective was not blinded, so it is possible that the convenience sample could have been selected on particularly stressful days or particularly not stressful days, which would impact the results. 

3) Two Primary Outcomes: This paper had two co-primary outcomes, but as we frequently say on the SGEM, “there can only be one.”

Perhaps as the editor in chief of Academic Emergency Medicine, you can settle this one for us.  Are you really allowed to have more than one primary outcome?

4) Statistical vs Clinical Significance: Overall, the results suggest a statistical decrease in stress in the group exposed to dogs. However, it is unclear whether the magnitude of change was large enough to be noticeable. Do you think the results are clinically significant?

5) Blinding: Obviously, it is essentially impossible to blind a study like this, but the lack of blinding does make it harder to interpret the subjective feelings of stress. It is possible that people just like dogs (who doesn’t), and the lower scores don’t really reflect stress.

6) Short vs Long Term Outcomes: You focused on same-day stress, but presumably for burnout, long term outcomes might be more important. Do you think these results will extrapolate to longer term benefits?

7) Language: I noticed that one of the coloring options had crude language. I found the message funny, and it would have lifted my spirits on shift, but I can imagine problems if the completed picture accidentally found its way into a patient’s hands. They might not understand the emergency provider’s darker humour.

8) Harms from Dogs: Did you consider potential harms from the interventions? For example, you let participants opt out if they had dislike, fear, or had allergies to dogs. Personally, I love dogs, but I am also incredibly allergic. I can imagine ignoring my allergies to play with the dog mid shift, but then regretting that choice and having increased stress as I trying to manage my remaining patients with incredibly itchy eyes and an endlessly runny nose.

Puppies PRN and Dogs on Demand

9) Scheduling the Intervention vs Stress Relief on Demand: In this study, the intervention was scheduled for a specific time during the shift. Emergency shifts aren’t very amenable to strict schedules. In fact, when someone tries to schedule something at a specific time during one of my shifts, it tends to increase stress. I wonder whether interventions like this would be more effective if they were available when the provider felt they needed them – such as after a stressful resuscitation. You mention this in the discussion section – can you describe what you think is the ideal set up for a program like this?

10) Treatment Effect: As mentioned you had two primary outcomes. They showed different results. Which one should the SGEMers believe?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree that this study represents preliminary evidence that a brief interaction with a dog can reduce stress on shift, but more research is required to confirm the effect, look at the long term benefits of such a program, and determine whether the magnitude of the effect is worth the cost and potential harms.

SGEM Bottom Line: Novel approaches to managing stress and burnout are welcomed in emergency medicine. If you like dogs, we encourage you to maximize the joy in your life and play with a dog whenever possible. Dog therapy during emergency shifts is promising, but at this point probably needs to be considered unproven.

Case Resolution: You are thrilled at the opportunity to take a few minutes away from the department. You have been trying to teach your residents for years that short breaks are important – both for your own health, but also to let you concentrate on your next patients. The availability of a dog to play with is just and added bonus and keeps you off twitter for those five minutes.

Dr. Justin Morgenstern

Clinical Application: I don’t think hospitals should be rushing to start dog therapy programs yet. However, if they are already in place for patients, making them available to staff as well makes sense.

What Do I Tell the Staff?  Stress is a huge problem in emergency medicine. You don’t need to play with a dog, but you absolutely need to take breaks and look after yourself. This is so you are able to provide the best care to patients, based on the best evidence.

Keener Kontest: There was no winner last week. The question was where was the first emergency ultrasound training site? The answer was “The Medical College of Wisconsin (eusfellowships.com) in Milwaukee was the first Emergency Ultrasound Fellowship training site. In the early 1990s. Dr. James Mateer trained the first three fellows in what is now termed Clinical Ultrasound. The number of clinical ultrasound fellowship programs exponentially grew to over 100 sites across North America.

Listen to the SGEM podcast to hear this weeks’ question. Send your answer to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode that has clearly gone to the dogs…Tweet your comments using #SGEMHOP. What questions do you have for Jeff and his team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article.

  • Go to the Wiley Health Learning website
  • Register and create a log in
  • Search for Academic Emergency Medicine – “April”
  • Complete the five questions and submit your answers
  • Please email Corey (coreyheitzmd@gmail.com) with any questions or difficulties.

REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

References:

  1. Bragard I, Dupuis G, Fleet R. Quality of work life, burnout, and stress in emergency department physicians: a qualitative review. Eur J Emerg Med 2015;22(4):227–34.
  2. Li H, Cheng B, Zhu XP. Quantification of burnout in emergency nurses: A systematic
  3. review and meta-analysis. Int Emerg Nurs 2018;39:46–54.
  4. Maslach C, Jackson SE, Leiter MP. 1986. Maslach burnout inventory. Palo Alto (CA): Consulting Psychologists Press.
  5. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006; 296(9):1071-1078.
  6. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6): 995-1000.
  7. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997; 44(7):1017-1022.
  8. Grol R, Mokkink H, Smits A, et al. Work satisfaction of general practitioners and the quality of patient care. Fam Pract. 1985; 2(3):128-135.
  9. Lu DW, Dresden S, McCloskey C, Branzetti J, Gisondi MA. Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians. West J Emerg Med 2015;16(7):996–1001.
  10. Bellolio MF, Cabrera D, Sadosty AT, et al. Compassion fatigue is similar in emergency medicine residents compared to other medical and surgical specialties. West J Emerg Med 2014;15(6):629–35.
  11. Barker SB, Dawson KS. The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatr Serv 1998;49(6):797–801.
  12. Lundqvist M, Carlsson P, Sjödahl R, Theodorsson E, Levin L-Å. Patient benefit of dog-assisted interventions in health care: a systematic review. BMC Complement Altern Med 2017;17(1):358.
  13. Mantzios M, Giannou K. When Did Coloring Books Become Mindful? Exploring the Effectiveness of a Novel Method of Mindfulness-Guided Instructions for Coloring Books to Increase Mindfulness and Decrease Anxiety. Front Psychol 2018;9:56.
  14. UPDATE WHEN PUBLISHED. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers.