I took up smoking for about 6 months in college, but not for the reasons you’d guess. This was during my freshman year shortly after I got a job waiting tables. It was a hard job. There was always work to be done—refill a drink, check how the food was cooked, and, most importantly, bring the check post-haste when the customers wanted to leave. The shifts always seemed like a blur. I’d run around non-stop without a break until there was no more work left to be done—not unlike many of your shifts in urgent care, I’d imagine.

So, how does smoking fit into all this? I’m glad you asked. Because of the nuances of labor law and being paid in tips, servers were not given dedicated breaks. Sure, I’d run to the bathroom or slam a glass of water occasionally, but other than that I was always going. However, after a few weeks, I noticed that there was a group of servers who got special treatment from the manager when it came to breaks: the smokers.

About every 2 hours, my co-servers who smoked would make a gesture to the floor manager putting two fingers to their lips—the universally accepted, yet unofficial pantomime, for a cigarette. The managers, all smokers themselves, would give an approving nod and then watch the server’s section for 5-10 minutes so they could smoke. Breaks were accommodated, even facilitated, in cases of nicotine craving alone. So, despite my distaste for tobacco, I decided to take up smoking—not because I enjoyed it, but because the work was just much less overbearing with an occasional breather.

As clinicians, regardless of our practice environment, we face this same paucity of break opportunities. There is always another patient to be seen, a note to finish, and an inbox of results to sift through. There’s always work to be done and we belong to a culture, as practitioners, defined by stubbornness and reluctance to pause until it’s all completed. All of the support staff, whether it be nurses, techs, or medical assistants, typically have dedicated (even mandated) breaks scheduled several times per day. However, despite having the most cognitively demanding role, providers are rarely compelled to pause their work and rest. And even if breaktime were offered, many clinicians would bristle at the notion because of the very ethos mentioned above. The work’s gotta get done. Breaks will just slow me down, keep the patients waiting, and keep me here longer, the thinking goes.

While this line of thinking is common among clinicians, organizational psychologists who study workplace effectiveness have found that it is also fundamentally flawed for several reasons. Most notably, we do not perform with the same efficiency throughout the workday.We all have times of the day where our mental acuity is best. Some of us are early birds and some of us are night owls; psychologists call this a chronotype. Additionally, our mental vigilance is depleted through the day with each decision we make. And we all make hundreds, if not of thousands, of decisions per day, with each decision taking an incremental cognitive toll.

What’s the impact of this? Two-fold. The work becomes increasingly less pleasant for us and the care becomes increasingly less safe for our patients. The latter being a natural consequence of the former. As our mental reserves become depleted, our cognitive and emotional states worsen.

Think about how you feel during busy days seeing patients and how your mood changes from the start to the end of the shift. Many researchers, most notably Daniel Kahneman, have explained that our ability to avoid bias and make well-reasoned decisions rather than quick, ”shoot from the hip” guesses becomes compromised when we are tired or in a bad mood. Kahneman details this phenomenon at length in his oeuvre, Thinking Fast and Slow.

The result of this bias is worse outcomes for patients. This has been substantiated across specialties and care settings. For example, later in the day, patients in primary care settings are prescribed more unnecessary antibiotics, patients undergoing surgical procedures have more adverse anesthesia events, and patients having colonoscopies have fewer polyps identified. There’s no reason to believe that patients seen in the afternoons are systematically different from those seen in the mornings. It must be the care that has changed as the day wears on.

Now, if we trust the researchers studying our ability to deliver care safely, we as clinicians must also develop a sense of obligation to combat this issue of diminishing quality later in the workday.

Fortunately, the solution is simple: take a short break a few times per day. Nearly all studies on cognitive performance unequivocally demonstrate significant improvements after breaks lasting even just a few minutes.

However, just because the solution is simple doesn’t make It easy. In fact, there are a number of reasons why implementing breaks will present a challenge for most of us. We are not in the habit of taking breaks and, therefore, most hospitals and clinics have limited dedicated space for providers to take an uninterrupted breather. It’s incumbent upon us to create new habits. We need to be intentional about arranging, and at times fighting for, the necessary breaks.

In the April 2019 issue of JUCM, I offered a few tips to help you get the most out of your break time once you do find the time and space to pause. They bear expanding upon here:

  1. Unplug. In the smartphone era of constant connectivity, we generally reach for our phones to fill any short moment of interstitial time. Logging into social media or checking email, while certainly a distraction from work, is far from a relaxing mental resetting exercise. We rely heavily on our ability to focus during clinical work. Avoiding the trap of simply shifting our focus to our phones and spending the break time with an unfocused mind allows for this function of our brains to be recharged.
  2. Get some nature. In the movie Office Space, Peter Gibbons memorably says, “Human beings were not meant to sit in little cubicles staring at computer screens all day,” and he’s right. There is something restorative about nature. Getting some fresh air, even for a few minutes, has been shown to improve mood and reduce stress among many types of workers. And if it’s too cold/wet/dark, not to worry. Even looking out a window seems to confer similar benefits.
  3. Talk to people (and not about work). After talking with patients all day, it may feel that talking with your co-workers is the last thing you’d want to spend your break doing. However, research suggests that social interaction, which differs from goal-directed clinical interactions, is physically and mentally restorative. Plus, it boosts team performance when you get to know the people you work with better. Not in the mood to talk to your colleagues? Calling to chat with a friend for a few minutes can offer similar benefits.
  4. Meditate. Mindfulness practice improves what psychologists call “cognitive inhibition,” which refers to our ability to tune out irrelevant stimuli and focus on what matters. In other words, we get better at discerning the signal from the noise. While the idea of meditation may sound daunting to those who don’t practice regularly, it need not be an intimidating. There is a multitude of guided mediation apps now available for smartphones that make meditation as easy as pressing play, sitting down, and closing your eyes for a minute or two.
  5. Get a tea or coffee (and water). Take a walk. Change the scenery. Stay hydrated. Re-caffeinate. What’s not to love?
  6. Get physical. It turns out that the ortho residents at your hospital were right about one thing: working out is a good way to recharge your mental energy during the workday. While we’ve known for decades that physical activity reduces stress and improves mood, more recent evidence suggests that there is also an immediate boost in cognitive performance, as well, conferred by short bursts of intense exercise (commonly called, high-intensity interval training, or HIIT). Intense muscle contraction causes the release of myokine hormones, many of which are brain-derived neurotrophic factors that encourage healthy brain function. HIIT exercises are perfect for breaks on shift because they require only a few minutes to reap the benefits and can consist of simple calisthenics like push-ups, jumping jacks, and lunges, which require no equipment.

Break Length and When to Schedule Them

As we’ve discussed, the utility of breaks is to improve mood and cognitive function so that work is more enjoyable for us as clinicians and care is safer for our patients. This means that breaks should make work less stressful and not more. However, because taking breaks will require adjusting your workflow and perhaps receiving awkward gawks from colleagues, there may be some discomfort that arises with integrating intentional pauses into your workday. Don’t be discouraged! Even a break of 1-2 minutes can offer a powerful mental recharge.

Microbreaks

Rather than trying to schedule a 30-minute break, set yourself up for success by trying “microbreaks.” While there is no universally accepted definition, a microbreak usually consists of a period of about 1-3 minutes where work is completely paused. I recommend a 2-minute break fully away from patient care every 2 hours on shift. Setting an alarm or using a reminder app on your phone can be helpful, especially as you are beginning to develop the habit.

Vigilance Breaks

If you are feeling totally cognitively drained but can’t steal away, even for a few minutes, try taking a “vigilance break.” The concept of a vigilance break is the same as that as a pre-procedural timeout. Recognizing that you’re fried, pause and review the case you’re thinking about. It’s best to actually do this out loud, even if just to yourself. This will help to focus your fading attention on where you are and where you are going, thus reducing the chance of cognitive error.

Psychologists refer to “habituation” to describe the phenomenon when we lose the forest for the trees. On shift, habituation is our enemy. Cognitive psychologists also have identified the “fresh start effect,” which refers to the vigor we feel with new beginnings. This is why many of us experience peak motivation on the first day of a new year, for instance. With intermittent breaks, our workday becomes transformed from a long, slow grind riddled with habituation to a series of short, manageable episodes each beginning with a fresh (or at least fresher) start.

Over recent years, as I’ve learned more about the neuroscience and psychology of taking breaks, I think back to my days waiting tables. I realize now it wasn’t choking down the nicotine that refreshed me, but rather it was taking 5 minutes outside and breathing deeply. It was getting better acquainted and laughing with my co-workers. That’s what rejuvenated me so I could better handle whatever was awaiting me for the rest of the shift.

Resources

Alves CRR, Tessaro VH, Teixeira LAC, et al. Influence of acute high-intensity aerobic interval exercise bout on selective attention and short-term memory tasks. Percept Mot Skills. 2014;118(1):63–72.

Kahneman D. Thinking, Fast and Slow. New York, NY: Farrar, Straus and Giroux; 2011.

Largo-Wight, E, Chen WW, Dodd V, Weiler R. Healthy workplaces: the effects of nature contact at work on employee stress and health. Public Health Rep. 2011;126(Suppl 1):124-130.

Sievertsen HH, Gino F, Piovesan M. Cognitive fatigue influences students’ performance on standardized tests. Proc Natl Acad Sci USA. 2016;113(10):2621-2624.

Wimmer L, Bellingrath S, von Stockhausen L. Cognitive effects of mindfulness training: results of a pilot study based on a theory driven approach. Front Psychol. 2017;7:1037.

Why Don’t You Take A Break?

Joshua Russell, MD, MSc, FAAEM, FACEP

Quality and Provider Education, Legacy - GoHealth Urgent Care, is affiliated with the University of Chicago Medical Center in Vancouver, WA, and is Editor-in-Chief of JUCM.
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