From Burnout to Balance

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According to a JAMA Internal Medicine study, emergency physicians are the most burned out specialty in medicine – over 65% of EP respondents reported burnout. But what exactly is burnout, really? And what can emergency physicians do about it?

Burnout is an ancient concept which can be traced back to our oldest stories. William Shakespeare used the phrase “to burn out” in his 16th century poetry to speak of love that has peaked and faded. A more modern definition is “exhaustion of physical or emotional strength usually as a result of prolonged stress or frustration”. For emergency physicians, burnout is an insidious process that can take a doctor down from having an optimistic and idealistic outlook to dreading going to work each day.

Like Justice Stewart, we may ‘know burnout when we see it,’ but often we do not recognize it in ourselves. Many of us have experienced a stressful shift in the ED that is remedied by a vigorous physical workout or a good night’s sleep. We are able to bounce back. The recognition of burnout begins when we realize we are not bouncing back. This lack of resilience prevents us from “re-charging our batteries” and sets the stage for burnout. Picture a spectrum where the lack of resilience at one end leads to burnout at the other.


An emergency physician may find that he or she is far along the path to burnout before taking any steps to remedy it. Some subtle warning signs and symptoms of burnout include affirmative answers to the following:

  • Are you fatigued even with adequate sleep?
  • Do you find that you are more irritable and less satisfied with work?
  • Have you noticed that you seem to have numerous minor physical ailments?
  • Are you sad, more forgetful, or do you find that you are having trouble concentrating?

Finding a Solution
An emergency medicine career can span decades with many years spent in the pressure cooker of the ED. The secret to avoiding burnout involves a strategy of balance. Jay A. Kaplan, MD, Medical Director of the Studer Group, has written: “Balancing your personal and professional life is the key to avoiding burnout. Think of a scale of one to ten on a seesaw. Place work at one end as a one and your personal life at the other end as a ten. How is your balance? Many emergency physicians will say they’re at three. In other words, they’re more heavily weighted toward work.”

So how do we stay balanced and grounded throughout our careers? What is the secret of maintaining an equilibrium so that burnout doesn’t have a chance to affect us?


Consider a wheel with multiple spokes. Each spoke is critical for the wheel to keep turning, to maintain balance and stability.

Next, put yourself at the center of this wheel and understand that when all the spokes work together you will be balanced. This ability to balance is the secret to avoiding burnout. The real question is how to find this balance.


The Emotional Spoke
Emergency medicine is fast-paced, stressful, and unpredictable. With constant exposure to this pressure, many EPs ignore the feeling that they are overwhelmed or marginalized, setting the stage for burnout. As health care providers we have to acknowledge what we are feeling, rather than deny our emotions. We may be annoyed with cantankerous consultants or difficult patients but we have the power to choose how we will react and manage these feelings. Focusing on the consultant’s positive attributes or the patient’s unspoken plea for help is a way to validate the good that we do in the ED every day. Trying to be optimistic and nurturing meaningful relationships with others are key to wellbeing and balance.

The Occupational Spoke
Are you happy during your commute to the hospital as you anticipate your upcoming shift? Think about what gives you satisfaction when working in your ED. For the moment discard all the negatives and consider all the positive features present in your department. Is it the people, the system, the setting that gives you satisfaction? Do the procedures energize you? Is it the interaction with patients that is satisfying? Are you challenged by figuring out why a patient is so seriously ill? Take a few moments to recall why you chose emergency medicine as your specialty. There was something very captivating about becoming an emergency physician. Do you remember what that was? Think about how the challenges in the upcoming shift ARE actually what drew you to Emergency Medicine.


The “need to fix” departmental and occupational issues will always be present. The key is to balance them with the enjoyable aspects of your job. You will have to find those positives because human nature naturally gravitates to what is wrong first, rather than what is right.

The Financial Spoke
Being financially secure is a key component to your longevity as a balanced emergency physician. Part of financial wellness is to develop a PLAN by establishing goals such as providing for your family, paying your monthly bills, planning for your children’s education, and creating a nest egg that provides for a comfortable retirement and future travel. You can measure your progress and be confident of the result. Develop a financial plan and live within your means. Consider a financial advisor or CPA and protect yourself with insurance: malpractice, homeowner’s, auto, disability, and life.

The Physical Spoke
“A run a day keeps depression away!” Exercising adequately (30 minutes a day 5 days a week), eating well (fruits and vegetables with little or no processed food), getting adequate sleep (set your phone alarm for nightly bedtime), and paying attention to the signs of illness (and getting treatment when needed) play a big role in maintaining physical balance. Avoid alcohol and sleep meds to combat the onset of burnout. Use humor to boost your immune system and make it a point to smile and say “hello” to someone in the ED you would not normally interact with. Emergency physicians who are in good shape physically will reap the psychological benefits of greater self-esteem and self-control and be less at risk for burnout.

The Spiritual Spoke
What gives you meaning and purpose in emergency medicine? Is it the art of helping and healing? Can you draw on your spirituality to get you through the rocky times and remain resilient? This may be a way to reverse the trend toward burnout. Recall that the Vagus Nerve is your friend. During stressful times in the ED, take a deep breath in and expire very slowly. This activates the vagus nerve and the parasympathetics, providing a brief moment of “rest and repose” which is very similar to the effects of meditation, but can be experienced in a micro-moment in the ED. Continue this practice during your of-shift times when you can spare ten minutes in a quiet place sitting down and concentrating only on your breath moving in and out. This is such a simple practice that can help reset your equilibrium and allow you to gain a larger perspective on what is happening in your personal and professional life.

The Intellectual Spoke
As our specialty continually changes and evolves it becomes increasingly difficult to stay current with all the new treatment modalities, medications and diagnostic innovations. This can become overwhelming and contribute to a feeling of helplessness and burnout. There are many free and easy-to-access online resources. Having an open mind in emergency medicine is critical. Sharing what you know with others in the ED (for example inservice presentations to nurses and ED staff) can be stimulating and serve as a way to challenge yourself and renew your self- esteem.

The Social Spoke
Avoiding personal interaction with others is a warning sign of burnout. How are you relating to other providers and staff in the ED and to people in your life outside the department? Developing effective relationships with colleagues, patients, friends, and our families indicates healthy social balance. Kaplan comments that in the ED “we usually approach each other with demands – I need, I want, I must have. What if instead you were to think of everyone on staff with whom you interact as an important customer? So that when you think about someone you work with, the first question you’d ask would be: “If I consider this person one of my most important customers, what would I do differently in order to better serve them?” Providing support and empathy for others often is re-vitalizing to us when the pressure mounts in the ED.

Maintaining balance is a lifelong learning process, every bit as important as the yearly LLSA required by ABEM. One might speculate that devising your own personal LLSA to evaluate balance would be a great strategy to combat burnout. A good place to start is to reflect on how each of the above spokes contributes toward your stability as an emergency physician.


Dr. Manfredi is an Associate Professor of Clinical Emergency Medicine at the George Washington University and the Chair for the ACEP Well Being Committee.

Dr. Jois is an EP who promotes clinical excellence in emergency care and education in cardiovascular emergencies through Jois MD Consulting LLC.

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  1. No such thing as “burnout”. It is abuse by the administrators who are heaping on more and more administrative requirements to enable the collection of $$. Some of which is unethical!! Oppose them, and yoy won’t feel the burnout. They need us more than we need them!!

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