There are logical reasons for emergency physicians to feel frustrated and on the edge of burnout, but there are also proven strategies for pushing back this tide and finding satisfaction in your next shift.
Part of a series. Click here to read Mastery vs. Misalignment: Identifying Types of Burnout by Laura Dabney, MD
Dear Director,
It’s getting harder for me to wake up every day excited to go to work in the ED. I just don’t like what’s happening in the department. I’m not sure I can continue for another 15 years. What do I do?
Burnout is defined as a loss of enthusiasm or interest in your job or frustration that interferes with job performance. Sounds like you’d fall into that category. Physicians suffer more burnout than the typical worker in America and in the Medscape Emergency Physician Lifestyle Report issued in January 2015, 52% of emergency physicians were burned out, giving us the second highest rate of burnout among medical specialties. Upwards of 60% of EPs may be burned out between the ages of 36-55. That’s a huge number for docs in the prime of their careers and presents potential workforce implications if we can’t reduce this.
Burn out is a real issue in emergency medicine. Most of us were warned about it while in medical school before applying for residency but we rationalized that burnout from previous generations of ED docs was due to a lack of formal training or that somehow we’d be immune to it because we had a better understanding of the job. How many jobs have annual meetings where you can take a test to see how burned out you are? ACEP offers it as part of their wellness booth and I actually stopped taking the test years ago years ago after not liking my results, although I should take it this year now that I’m in a different hospital.
Causes
There are both personal and universal factors impacting our job satisfaction. Research shows that major factors contributing to burnout are bureaucratic tasks, working with difficult patients and a loss of autonomy. These shouldn’t surprise anyone. Doctors don’t want to be managed and we went into this profession to take care of patients and do what we thought is best for the patient. However, more and more, we’re being told what to do. In reality, we probably mismanaged ourselves so others have now stepped in to take control and set standards over things like metrics and patient satisfaction. The root of this may be based in the for-profit hospitals that advertised metrics like short wait time or high patient satisfaction to their advantage. We are being asked to do more than ever from a productivity point of view in the setting of older and sicker patients. We’re also dealing with potential reimbursement decreases, CMS audits, and the added pressure of the hospital’s Pay for Performance achievement. Many docs I’ve spoken to are also frustrated over the retailization of healthcare, which includes the push for patient satisfaction but also includes discussions about quality, cost, and value. Like it or not, I think these issues are part of medicine for now. I’ve been fortunate to hear the AMA and ACEP leaders speak several times over the last few months and none of them are have discussed working to repeal outcome and quality measures and value based purchasing but rather their agendas cover how we can become more successful by working with CMS going forward by providing meaningful data in registries such as ACEP’s new Clinical Emergency Data Registry (CEDR).
Based on the Medscape survey, there is a relationship between debt and burnout. Free time is one of the great aspects of emergency medicine. However, many emergency physicians then have the capacity to pick up extra shifts for more dollars and this in turn can allow us to quickly live beyond our means or be forced to work more than full time to keep up with our lifestyle. Additionally, there is a relationship between burnout and those who take less than 2 weeks of vacation a year. Vacation, or time away from work is critical to recharging your battery and enjoying life.
I frequently tell people that the scheduler is the most important person in the group.
Not a surprise that not being in control of your work hours increases stress. We’ve picked a shift-work career that involves weekends and holidays so it doesn’t surprise me that docs in the prime of their career are now frustrated with the lifestyle that the career they picked entails. Many of these docs are tired of the nights, weekends, and holidays and want control over their schedule. Sometimes people realize that having a fixed schedule (even if it’s nights or weekends), gives them the control and stability to live a fuller life with regular hours.
Solutions
First, we should take great pride in what we do. 130 million patients come to EDs each year and put their trust and faith in you to care for them regardless of their complaint. Our skill set is amazing—we’re great diagnosticians and find solutions to problems that others can’t.
But I’m also a realist and I have two basic management philosophies. The first is to play the cards I’ve been dealt the best way I can. And the second comes from the Serenity Prayer, i.e. to accept the things I can’t change, etc… While there is a time and a place to fight for change, many of the frustrated docs I encounter (friends or at work) don’t do this productively. While I play the game the best I can, if you want to work for change, I think you need to take your frustrations and turn them into organized action and the best way to do this may be to get involved with organized medicine, like ACEP and the AMA.
Any investment that you make in addressing symptoms of burnout will pay dividends in many ways. You’ll extend your career, enjoy work more, and probably be a better spouse, friend, etc…As an individual, we all need to self-reflect to see what motivates us. Author Simon Sinek discusses why inspirational leadership starts with explaining “the why,” which is the groups purpose. Consider this self-reflection on understanding your motivation as knowing your own why. Hopefully, it’s taking care of patients. In a different Medscape survey, the EM Physician Compensation Report (April 2015), 40% of us listed the most rewarding part of our job being “very good at what I do/finding answers, diagnoses.” Unfortunately, in the same survey, 4% of men and 7% of women found no aspect of their job rewarding. We need to understand what we value and find rewards within our job. We all went into medicine with tremendous passion and excitement and while I don’t expect a 10 year vet to have the same eyes-wide open view as a med student, I hope that each of us when we’re feeling really frustrated with the job can remember why we originally went into medicine. I’ve spoken to several people recently who had just returned from medical mission trips. These may be as short as a week, but universally, the docs told me they found these to be recharging experiences—caring for hundreds of patients with limited equipment but doing “real medicine” with no paperwork. Some docs describe these trips as the antidote to compassion fatigue. This may be the rewarding experience you need to remember why you went into medicine.
If you can’t go on a medical mission, you could go back to the basics and define for yourself what constitutes a good shift and understand why you go to work each day. Perhaps you could take a course and develop a new area of expertise or consider having med students rotate in your ED and do some teaching (even if you can’t or don’t want students for a 4th year rotation, most med schools are looking for docs to teach 1st and 2nd year students H and P skills). Like you, I have good and bad shifts. I find each shift has a theme. Sometimes it’s drug seekers, sometimes it’s elderly patients who are weak and dizzy and I have no idea what’s going on, and sometimes I do a ton of critical care. But in every shift, we should be able to find meaningful and enjoyable moments that allow us to take pride and satisfaction in the work that we do. We also have to understand what our limitations are. If we’re working too much, haven’t taken a vacation, or don’t like our work environment, we will need to take action. I’ve worked in places that were very challenging and burned people out—note the past tense of “worked in places.” Change is difficult but there may come a time where we need to find a new environment. I’ve switched hospitals a few times and have found change to be invigorating. I recently had dinner with a prominent emergency physician who told me she was recognizing herself being burned out and decided to mix it up by doing locums and is much happier—new environments, nurses happy to have docs covering the ED, and control over her schedule.
Teamwork is an almost universal theme of why we went into emergency medicine. Your job satisfaction will go up the more you get to know your staff and the more positive interactions you have with your staff. Everyone loves food at the start of the shift, and most EDs have some sort of group activity you can get involved in. Lately I’m seeing a lot of biggest loser contests, perhaps because of all of the donuts and pizza people have brought. These are important bonding opportunities that will make you closer to your staff and make work more enjoyable. If nothing else, ask some questions about their kids or summer vacation plans and get to know them better.
In the book The Energy Bus, author Jon Gordon uses a fable-styled book to go through his 10 rules of positive thinking to overcome life’s obstacles while achieving the best outcomes in life and at work. While I’m not always a glass is half filled guy, I did find this book to be very useful in establishing the link between attitude and outcome and also for making a team better. We need to have ownership over our attitudes and emotions. I also think the chairman has the additional responsibility to present a positive attitude and fix the issues that frustrate the physicians and help to create the best working environment possible.
Conclusions
Burnout is real but our careers are long and we spend too much time at work not to be enjoying it. More research is needed to better understand the causes of burnout and ways to reduce it so that emergency physicians don’t leave the workforce. For starters, I recommend that you understand what motivates you, have balance in your life, bring a positive energy, and work to make constructive change and improvements in your ED, your career, and perhaps medicine.
