Director’s Corner: Battling Burnout | Emergency Physicians Monthly

Try these strategies to reduce opportunities both inside and outside of the ER that affect your wellbeing.

Dear Director,

I’m so burned out right now, I’m thinking about leaving emergency medicine. Is there anything I can do to save my career?

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Besides being on the front lines of a pandemic for nearly three years, we’ve also dealt with births, deaths, marriage, divorce, cancer diagnoses, graduations and financial concerns just to name a few things outside of work that impact our day-to-day stress. Even when I was considering emergency medicine in the early 1990s, people asked me about the burnout that came with the intensity of the field.

The standard answer back then was that we’d be better equipped to deal with the intensity and complexity of the job because of our residency training. Perhaps that was true 20 years ago, but maybe training alone can’t prevent burnout when it comes to documentation requirements, non-stop metrics and increasing workplace violence.

And oh yeah, let’s add in a pandemic and practicing waiting room medicine. Personally, I think I’ve lived with intermittent burnout for a long time. About 15 years ago, I stopped doing burnout surveys at wellness booths because my results indicated I was burned out even when I didn’t feel it. With that said, I’ve found a variety of strategies that allow me to generally enjoy being an emergency physician and not let work interfere with my personal life.

Burn-out is defined in ICD-11 as follows: a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It occurs in the occupational context and doesn’t impact other areas of life. It is characterized by three dimensions:

feelings of energy depletion or exhaustion;
increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
reduced professional efficacy.

The 2022 Medscape Physician Burnout and Depression survey found that 47% of all physicians reported burnout. However, emergency physicians experienced the most burnout among specialties, with 60% of our physician’s reporting burnout. This has increased from 43% in 2021. In this survey, females experienced more burnout than males as they assumed more childcare responsibility at home during the pandemic.

At work, the leading contributing factor to physician burnout was bureaucratic tasks like paperwork, followed by lack of respect from colleagues, staff and administrators. Lack of control over our lives, too little pay and too many work hours were farther down the list.

I think it’s important to remember why we work. It could be about money, professional satisfaction, respect, or helping people.

As it turns out, docs get paid pretty well. The Medscape 2022 Physician Compensation report shows that emergency physicians earn more than the median annual income for all specialties. About 53% of emergency physicians felt their compensation was fair, which was just below the median compared to other specialties. Don’t get me wrong, I’d love to make more money, but the majority (barely) of emergency physicians feel we get paid fairly. And conventional HR wisdom says that pay raises cause temporary improvement in job satisfaction but don’t fix burnout.

Physicians are also among the most trusted and respected professions out there. For the most part, I’m sure all of your non-medical friends think you’re a hero the last few years. And that’s well deserved. In a variety of polls, doctors and nurses lead the way for most trusted profession and profession with the most honesty/ethical values.

Since the pandemic started, I’ve had a couple of EM friends of retirement age get diagnosed with cancer. When retiring was a real option, both were eager to return to working in the ER. Therefore, I can’t help but think there’s something positive about being an emergency physician.

I believe we have a great job. We get to help anyone who comes to the ER — without worrying about payment. That’s a noble calling. Throughout my career, I’ve thought about what other specialty I might have liked more than EM, and I’ve not been able to come up with any. I tried to like derm and radiology as a med student, but those specialties didn’t fit my brain and how I like to work. There are parts of ortho, cards and critical care that I really like, but there’s plenty about those specialties that don’t fit my personality or innate skill set. So, if I’m going to be a doctor, emergency medicine is the right choice for me.

Below are several suggestions to reduce burnout. There are opportunities both inside and outside of the ER that can impact your burnout.

Strategies to reduce burnout by positively impacting our work environment

Work Fewer Hours

For starters, work less. Some of the jobs I hear about have crazy annual hour requirements for benefits. Others are much more reasonable. Find the minimal number of hours you can work that will give you the benefits and pay that you need. I’ve known too many docs that have worked a crazy number of shifts because of bills. Consider constructing a lifestyle that will allow you to cut back on hours. Even cutting back a couple of shifts every few months can make a difference in your mood and outlook. It’s amazing what a little more sleep and family time can do for your mental health.

2. Streamline Documentation

My charts were always complete when I was on a paper T-sheet. I really like EMRs for a lot of reasons, but the charting is crazy. And if you leave charting for later, you’re work hours have just been extended. First off, there’s probably someone who is very efficient in your group who always has their charts done by the end of their shift. Talk to them. What can you learn? I have a pretty good routine of completing charts. I dictate my HPI after I see the patient and usually do the physical exam as well. When I’m getting ready to dispo the patient, I’ll dictate my reevaluation note and add in my MDM. This process helps me confirm I’ve reached the right diagnosis and plan. I end up signing a bunch of charts towards the end of my shift, but the critical work is done. I’m sure there are others in your group who are more efficient than me.

Consider hiring a scribe. A friend of mine employs his own scribe. He works in a very busy place that is productivity based. It’s busier than I would want to work in, but his hourly rate ends up being much higher than mine. He pays the scribe out of his pocket and is responsible for training the scribe as well. At the end of the day, he says it’s completely worth it to him take much of the charting and scut work off his plate and pass it to the scribe. Charting is complete by the end of the shift. The money is well spent and the return on investment isn’t as bad as he initially thought it would be since he can usually see an extra patient or two since he’s not charting.

3. Get to Know Your Patients

I have always liked interacting with people and part of choosing EM was that I would get to meet a lot of people. It’s easy to think of each patient as a chief complaint in a room and not get to know them. Patient connection is a common trait among the happiest doctors. And each day, I try to connect with one or two of the patients and end up having a bit of a non-medical conversation with them. I’ve had some truly fascinating patients. I’ve also talked a lot about sports or what game the patient is watching on television. Not everyone is critically ill and taking a few minutes to be human and interact with people can be rewarding.

Connecting with patients extends to knowing that we’ve helped people. We have to accept that we’re almost never going to get thanked for this job. But if you want to connect with patients and get positive feedback, consider doing patient callbacks. Patients are often surprised and appreciative that an ER doc called to check up on them. There’s also some risk reduction benefit and patient satisfaction benefit but mostly I do it because it like it.

Sometimes I must redirect them to the ER or a specialist, or help them trouble shoot follow up or an issue, but typically the calls are short, the patient is better, and they just say thanks for calling. To develop your own callback program or better understand the benefits, I wrote this article click: A few minutes before a shift or even making a few calls throughout a shift can reduce your stress of worrying about the patient and their appreciation can help motivate you to go see that next patient. My callbacks average about one to two minutes per call.

4. Remember that “the patient is the one with the disease”

You can’t fix the system during your shift. I’ve seen many colleagues get frustrated over patients they didn’t think needed to come to the ER or patients who were drug seeking. At the end of the day, realizing that you can’t control what comes in the door is important. I’m going to see roughly two patients an hour. Whether it’s a patient with low-risk chest pain, a med refill, or a drug seeker, I know after dispositioning that patient I’m just that much closer to the end of my shift. Yes, some patients are more frustrating or stressful than others, but I can’t fix that in the moment. I’m going to treat the patient and move on to the next one. For those who remember the book, The House of God (Shem), House Law IV, “the patient is the one with the disease.” This applies in the ER as well.

Every ER has its issues. And some of these contribute to burnout. Don’t’ be afraid to talk to your chair or medical director with the goal of improving your work environment. What’s contributing to the burnout—shifts, patient acuity, nursing interactions, metrics? Figure it out. We can make a difference in our work environment and ultimately improve job satisfaction for everyone.

Strategies to reduce burnout outside of the ER

Schedule times to disconnect

We live in a 24/7 world. The ER never closes, and we’re rarely disconnected from technology. Therefore, work emails, catching up on charting, attending a zoom meeting, never seem to end. These things are part of our job but much of it can be done on your timeline. Expect to spend some time completing work tasks outside of your clinical time. Don’t let work dominate your personal time. Check your email. Get your work done. And then forget about work until your next shift.

Consciously create your work life balance

Block time to exercise on your calendar. Studies show that regular exercise may protect against burnout to some extent. Find a hobby and build it into your schedule. Spend time with family. Some studies show that having a pet improves mental health. Dogs can reduce stress, anxiety, and depression. Walking your dog also gets you moving. The bottom line is that we need to be sure to do things in our life that we truly enjoy.

Living a healthy lifestyle isn’t just for our patient

And while we’re on healthy choices, like exercising, let’s mention diet and alcohol intake. Having a healthy diet and keeping alcohol consumption reasonable will give you more energy and help you sleep better. There are studies showing that increased fast food consumption correlates to burnout and that maintaining a healthy diet may be protective of burnout. Wellness programs that teach nutritional education, particularly ones that focus on mindful eating, can help reduce burnout.

If you’re working in the ER, you’re probably sleep deprived. Unfortunately, sleep deprivation tends to go hand in hand with shift work. There’s plenty of research showing the relationship between burnout and poor sleep quality.

Watch your time on social media

I’m probably on many of the same social media sites as you. We all know that we usually put our best foot forward when it comes to social media posts. Unless of course, it’s about work. Then it’s easy to go down the toxicity or burnout rabbit hole and have plenty of people jump in to pile on. If you want to reduce your stress and burnout, consider avoiding social media.

Talk it out

Replace social media by talking to people about work issues outside of work. Talking to someone can help. This is a broad category and could include a professional coach, therapist, or mentor. It could also be a peer. A friend of mine told me about having a “peer mentor,” and I love this concept. This is a true peer but someone outside of your facility, where you can talk through the issues or struggles at work and see how your peer might attack the same problem.

A colleague of mine gets to together with a friend and residency mate who works at another ER for regular “therapy sessions.” My former mentor and I will text each other about it being time to get oysters. No matter how you get your peer out to talk, when you’re using the key word, it’s means it’s time to compare stories, get some perspective, and talk work. Of course, if burnout is severe where you’re considering leaving the field, or it’s causing clinical depression, then getting professional help is likely the right move.

Give it time

My daughter is graduating college this year and is set to start her first real world job. Over her winter break, she learned that not only will she not get a month off next winter, she won’t even get the week off between Christmas and New Year’s unless she uses her limited vacation days. Becoming a new attending comes with some of the same harsh realities. For most people, taking an attending job, particularly in the community, is different than being a resident. One of my new docs confided to me that while she liked her job, it was very different than she expected.

Attending life is not necessarily better or worse than being a resident, (okay, the pay and hours are definitely better but the responsibility could be considered worse), it’s just different and it takes time to get used to the focus on flow, metric responsibility, and the pressure that comes with running an ER and independently managing multiple sick patients versus presenting cases to an attending in residency and having more a team of residents to lean on. This stress can feel like burnout when it’s more likely anxiety and it generally improves with time and experience.

Don’t be afraid to change it up

Not all jobs are created equal. Changing jobs is a big deal but don’t be afraid to find a new position if you are unhappy in your current position. I have a friend who was pretty burned out and unhappy in his job – so much so that he thought he needed to leave medicine. To no one’s surprise, he couldn’t find a non-clinical job that paid as well as being an ER doc, and in an act of some desperation, he found a job on the other side of town. He didn’t know it at the time, but he just needed a new environment.

As it turned out, he loved the new ER, got a lot of respect from his fellow clinicians, and said it felt like a new opportunity. I’ve changed jobs a couple of times. It’s not easy to learn new EMRs, flow patterns, and consultants, but I’ve always found it to be energizing. There are some great jobs out there, so if you think burnout may be related to your environment, consider looking around.

Take a Sabbatical

A recent article in NEJM outlined how a private group provided doctors one month of (paid) time off every year resulting in less attrition and burnout and “sustained career satisfaction.” While sabbaticals may be common in other professions, and I’ve seen them discussed in medicine for the last decade, I’ve never actually worked for a group that offered one. They appear to be offered inconsistently in our industry. Having the chance to take a longer break from the demands of the emergency department may prevent docs from walking away forever.

As I’ve discussed this concept with others and looked at models, I think there is room to develop the concept to make it financially feasible for your group. Consider how your group handles FMLA—it may be paid or not. A sabbatical could work the same, while maintaining benefits. Some groups offer it annually, while others only after an employee has worked for many years. If your group doesn’t offer the opportunity for a sabbatical, it’s worth a discussion.

Conclusion

At the end of the day, we each have to understand our motivation to work. Couple that with appropriate work-life balance. Depending on what’s contributing to your burnout, there are many possible solutions. Find the positivity in your life, both in your professional life and in your personal life. And don’t be afraid to make a change for the better.