The exhaustion of emergency physicians, and its toll on patients and family

When I advise students about how to choose a specialty, I suggest that they seek out advice from physicians who are at least 10 years out of residency and leading the type of life they hope to have in the future.

It is difficult, and perhaps impossible, to anticipate  in your late 20s or early 30s what practicing a certain specialty will be like when you are 40, 50, or 60.

Find someone who is the same gender and has the same ideals about the type of life you hope to lead. If you are a woman who hopes to marry and have children, for example, asking  an unmarried man about whether or not his specialty is the right choice for you could be misleading.

As a fourth year medical student, I decided to pursue a residency in emergency medicine (EM) by evaluating which rotations I enjoyed most and seeking out advice from wonderful medical school mentors, most of whom happened to be men. I watched the first episode of “ER” with anxious anticipation. I wanted nothing more than to train in EM at the famed Cook County Hospital where the show “ER” was fictitiously based. My reasons to pursue a career in EM were similar to those of many medical students; I loved the excitement, the diversity of cases and the opportunity to be a part of patients’ lives during some of their most vulnerable times; I wanted to become the physician who could care for anyone, regardless of how minor or serious the problem.

When I started working as an attending physician, I was naively disturbed by a trend I observed. It seemed that the goal of many colleagues and peers was to “decrease their clinical time” and the number of evening and night shifts they worked.  As someone in her early 30s, I couldn’t understand why physicians would want to spend less time taking care of patients; after all, this was what we loved and were trained to do.

As I read an article in the New York Times that focused on three generations of doctors in one family and how their priorities have changed, I was reminded of another reason EM appealed to me. Like Dr. Dewar, who is featured in the article, I wanted a career that would allow me to spend time with my future family. I thought the shift work in EM would allow me to have the best of both worlds.

Then I had kids.

By this time, I had worked hard to earn leadership roles within my department and the night and late evening shifts had become more difficult. The responsibilities I had at work during my “non-clinical” days, which I fundamentally enjoyed, were made painful by exhaustion and fatigue. On top of this, I was pressured by my superiors to more clearly define my family and work priorities. I was often tired at home and had less emotional and physical energy for my family.

Working until 1 or 3 in the morning did not fit well with family life. Before children entered my life, I could sleep in after a “late shift” without missing anything, but this was no longer an option. Even if I had worked until 3 AM, my children still woke up at 6:30 AM. Although my husband, who, like most men in dual career families took an active role in home duties, could care for them while I slept, if I wanted to spend time with my kids, it meant waking up early since they were often in school or daycare when I was off during the day. If I  worked in the evenings when they were home and slept in after every night and evening shift, I might go for days without seeing my children. So, like those colleagues I once criticized, I found myself negotiating for less clinical time and fewer late evening and night shifts.

When I applied for residency, the literature suggested that the burnout associated with practicing EM applies primarily to physicians who weren’t trained in this specialty. But a recent longitudinal study of EM physicians by the American Board of Emergency Physicians shows something different: It reports that one third of EM physicians report burnout. Other studies suggest an increased incidence of breast cancer, obesity and other comorbidities in night shift workers. One survey of EPs over 55 reported several “age related concerns”;  74% found it more difficult  to recover from night shifts, 44% reported a higher level of emotional exhaustion after shifts, 40% were less able to manage high patient volumes, and 36% reported less ability to manage the stress associated with EM practice.

Anecdotal evidence supports these findings. Many of my friends and colleagues who are more than eight years out of residency, claim to be exhausted. One friend has fallen asleep at the wheel, and many complain of bickering at home with spouses and kids because they have no patience after working late evening and night shifts. Some have gained a significant amount of weight and developed hypertension. Others say that days can pass without seeing their children because of the wacky hours. Several have decreased their clinical time significantly or have left clinical medicine completely.

This year, EM was one of the most competitive specialties for residency with the National Residency Matching Program reporting a 7% increase in US seniors matching in emergency medicine and only a few open positions during the scramble. I wonder, if like Dr. Dewar and myself, many chose the specialty for increased flexibility and family time. Is the toll that working odd hours worth it? Is the exhaustion EM physicians experience jeopardizing patient safety? What are possible solutions to this problem since the highest need for EM clinical coverage is in the evenings and nights when office-based doctors have already gone home?

The night before my match day, I rented The Fugitive, which was filmed at Cook County Hospital. Even though I am not superstitious, I thought this might bring me good luck. I was fortunate to match at “The County” and the years I have spent in residency and clinical practice have been some of the most interesting and enjoyable of my life. I consider the time I have spent caring for patients,  literally saving lives, and offering sick and terrified patients and families reassurance and solutions my greatest achievements. The emotional and physical toll this work takes on my well being and my family’s comes at a cost, however.

Jessica Freedman previously served in the residency leadership and on the medical school admissions committee at Mount Sinai School of Medicine in New York.  She is founder of MedEdits, also on Facebook and Twitter.

Submit a guest post and be heard on social media’s leading physician voice.

Comments are moderated before they are published. Please read the comment policy.

  • http://www.dialdoctors.com Dial Doctors

    I can definitely agree with you that before choosing a specialty we need to ask around. Different areas of medicine lead to different lifestyles. My sister is a plastic surgeon and she can make plans and keep them (I can’t remember the last time I didn’t consider sleep more important than a social event) unless there is an emergency. But I’m jealous at times because she has much more control over her day. I work at Dial Doctors as well as in a hospital setting which prevents me from spending too much time with my family. I read http://anondoc.blogspot.com and remember my residency. I love my job and helping people but I can definitely see the toll it has on my personal life.

  • Eye Rick

    I had a 4th year EM matched med student in my ophthalmolgy for 2 weeks. Hopefully she will turn to the dark side and swich to eyes.. Article was a week to late to show her

  • Drrjv

    Glad I picked neurology over EM – seems like today’s ER’s are CT triage areas and really the last place most patients should go

  • http://www.picumd.com PICU MD

    I definitely agree that students (and residents thinking about fellowship) show spend time with an attending doing that field as opposed to getting opinions from trainees in the field. Often a trainee’s perception of the field is different from that of the attending. I don’t think I’ve ever worked as hard as I did while I was a critical care fellow. However, as an attending, with out the protection of the 80 hour work week I’ve had a few weekends spent between the ICU and the couch in my office.

    I do think that once you are an attending your lifestyle is what you make of it. I know a few peds intensivists who have kids and families that work part time and have pretty good quality of life. As a med student and resident the whole concept of work life balance does not really exist. Once you are an attending you realize there’s more to life than medicine (and you have a little more means to experience it) so you start to think about your work life balance more.

  • alex

    EM doctors work fewer hours than other medical specialties. The tradeoff is that you have to work weird hours. This is extremely basic choosing a career stuff.

    Nobody who’s survived a surgery residency wants to hear about how horrible the ED lifestyle is. Seriously.

  • http://www.edwinleap.com/blog Edwin Leap

    Dr. Freedman hits the nail on the head with this discussion. This summer will be my 18th year in emergency medicine practice. The circadian disruption, the unchecked chaos, the ever increasing addition to our duties (as on call specialists stop taking call), the endless stream of patients saying, ‘I can’t pay a doctor so I’m here to see you…I’m out of Xanax,’ all take a toll and result in a complex form of physical and emotional exhaustion. I know that many in other specialties tell us to ‘quit whining…you’ve got it easy,’ but the fact is, in modern medicine, few people have it easy in any specialty, EM, surgery or any other. Students are poorly prepared (from college on) for what their futures hold, and we owe it to them to explain that their specialties can be equal parts adventure and misery. Thanks Dr. Freedman!

  • ninguem

    I’m interested in her suggestion that burnout in EM-trained docs is about the same as non-EM-trained docs who migrated to emergency medicine. Assuming I understand correctly.

    Is this accurate? As she wrote, I too was under the impression that burnout was seen in non-EM docs who drifted to EM, perhaps reflecting something with those docs, themselves.

    If burnout is showing to be the same in EM-trained docs, it may reflect something in the field itself.

    • http://www.mededits.com Jessica Freedman

      Ninguem,

      I do not know if the non-EM trained burnout rate is the same for those trained in EM; I did not mean to suggest this in the article.

      However, here are references for the data presented about EM physician burnout:

      Goldberg R, Thomas H, Penner L. Issues of concern to emergency physicians in pre-retirement years: a survey. J Emerg Med. 2009; Epub ahead of print.

      Cydulka RK, Korte R. Career Satisfaction in Emergency Medicine: The ABEM Longitudinal Study of Emergency Physicians. Annals of Emergency Medicine. 2008;51(6):714-722e1.

      Jessica

  • anon

    is there any specialty in medicine where the docs are not burning out at alarming rates?

    • Molly Ciliberti, RN

      Maybe dermatology.

  • http://www.drjoe.net.au Dr Joe

    Why as doctors are we so bad at looking after ourselves and our colleagues? Burn out helps no one. It is time we stopped seeing exhaustion as a de-facto badge of honor.

  • http://anapolschwartz.com Karen Swim

    “I suggest that they seek out advice from physicians who are at least 10 years out of residency and leading the type of life they hope to have in the future.” This is profound advice for those in all professions. It was the lifestyles of older peers that helped me to redirect my own career path early on. Your post also gave me a greater appreciation for those in EM and the stresses they face. Thank you for your insight and advice.