Why are emergency physicians burning out?

Why are emergency physicians burning out?

Emergency physicians experience burnout at a rate of more than three times that of the average doctor and more than anyone else inside or outside of the medical field, according to a study published in the Archives of Internal Medicine. The study surveyed over 7000 physicians in more than two dozen specialties and compared them with almost 3500 working adults in fields outside of medicine. More than 65% of emergency physicians reported burnout, compared to 55% of internists (the next crispiest specialty), and 27.8% of the general population.

What is most striking to me, as a practicing emergency physician and former assistant residency director in emergency medicine, is that while emergency physicians are tired of their work, medical students are competitively vying for it. In the 2012 NRMP® Match, all 1668 of the available Match positions in emergency medicine were filled. This year, too, after the Match and SOAP (Supplemental Offer and Acceptance Program, which replaced the “Scramble”), there were, again, no unfilled emergency medicine residency slots. What explains this strange disconnect?

To solve this puzzle, we must start by exploring why emergency physicians are burning out in the first place. When I started my residency in the mid-1990s, mentors told me that the professional chronic fatigue syndrome (a recognized problem even then) stemmed from the fact that so many emergency physicians had not been trained in the field. Because emergency medicine did not even become a recognized specialty until 1979, many doctors working in the emergency department had not been residency-trained in emergency medicine. The conventional wisdom then was that the people who couldn’t last in this specialty had never anticipated entering it. Thirty years after emergency medicine’s recognition as a formal specialty, this explanation for burnout seems deficient. Today’s burned-out physicians should have known what they were in for.

Alternate reasons I was given for burnout included what a mentor told me were the two worst aspects of emergency medicine: consultants and nights. Here we may be getting closer to the real root of the problem and the disconnect with the field’s medical student popularity.

My mentor may have said “consultants” half-jokingly, but actually, I think identifying consultants as a root cause of emergency medicine burnout really speaks to the lack of autonomy and control in the field. Usually, an emergency physician doesn’t pick whom she works with, whom she treats, how heavy her workload is, or how heavy the emotional toll of her workday might be.

For many medical students, a lack of autonomy is not the first worry on their minds. After all, they have little autonomy already as medical students. Furthermore, it’s hard in one’s twenties to envision what one’s future medical practice should look like to maximize individual happiness and self-determination.

With regard to nights, there is no question that the erratic schedule that full-time emergency physicians manage is exhausting. Shift work has been associated with health problems, including an increased risk of diabetes, depression, heart disease, and breast cancer. It also adversely affects one’s personal life, a problem that may be heightened if someone has a partner and children. Again, though, early in a medical career – when someone is in her twenties – these issues may not be pressing, depending on one’s physical and family state. It’s hard to envision preschool carpools and community barbecues when you are still pulling all-night drives to Vegas on your weekend off.

The best advice I’d offer to prospective medical students is to find someone in the field who embodies the life you envision for yourself. Do you ideally hope to have children and practice part-time? Or do you have an interest in international emergency medicine with plans to practice abroad half the year? Ask your mentors to direct you to practicing emergency physicians in the community who are in these situations and can speak frankly about the pros and cons of their careers. Unable to find a role model who fits the life you hope to lead? While enthusiastic supporters may cheer you on to become the pioneer who beats a new path, the realist in you should take note that if nobody is doing what you’d like to do yet, it may be because it’s impossibly hard to do.

A primary goal of medical education should be to ensure that medical students are choosing the right fields and developing into physicians who lead lives with sufficient balance and satisfaction such that they can be productive and provide excellent patient care. With today’s emphasis on preventive care, the best way for the proverbial physician to “heal thyself” may be to know intimately in advance which individual pitfalls to avoid in the first place.

Michelle Finkel is founder, Insider Medical Admissions.  She can be reached on YouTubeFacebook and on Twitter @Insidermedical.

Image credit: Shutterstock.com

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

  • Guest

    There seems to be a tremendous disconnect between what medical students think are great lifestyle specialties and what specialties (or non-specialties) will provide for them best in the future. I still see so many med students matching in certain “lifestyle” specialties – derm, optho, anesthesia, radiology, and ER.

    However, anesthesiology may not be a great bet for the future considering CRNAs and even AAs may be able to do the same job for less cost.

    ER regularly deals with the dregs of society, is unappreciated by nearly all other fields, and the shift and night work can certainly take its toll.

    I envision radiology having the potential for outsourcing to other, cheaper countries as technology improves. Someone in India could be sitting at home and reading x-rays at any time of the day or night for far less money than an American radiologist receives.

    Will optometrists vie for the opportunity to do cataract and retinal surgery in the future at lower costs than the MDs? I wouldn’t doubt it.

    Dermatology – probably could be done as effectively by midlevels too.

    Long story short, I doubt they are educating medical students about the “realities” of practicing medicine in the future.

    • JayCeeMD

      This comment is loaded with uninformed, broad-sweeping generalizations of the aforementioned sub-specialities.

      One of the most difficult tasks in medical school is having to choose a vocation based on variables that are both transitory and incredibly difficult to anticipate – (1) a future self (single and spending the weekend in Vegas during med school vs being a parent using time off for soccer games and errands as an attending) and (2) the future of any particular field in medicine. There are trends, of course. But trends are only helpful in short-term decision-making because who can really anticipate how both politics and technology will influence medicine in the long-term?

      As such, there doesn’t seem to be a fully satisfying answer to the issue of choosing the “speciality of best fit” other than remaining flexible and finding mentors who are living the kind of personal and professional life with which your medical-school-self identifies.

      Speaking as an MSIII currently in throes such vocational decision-making, this is easier said than accomplished.

      • Guest

        I assure you I am NOT uninformed – I am actually a private practice physician who is one of the aforementioned “lifestyle” specialties. Things are OK right now. But we in private practice are on the front line for seeing how things in our specialties will (and have) changed.

        The speculations I made did not come out of thin air.

    • Dave

      I would add technology to the list of things threatening some of the cushier specialties and the status quo in general. For anyone who has seen the youtube video of IBM’s Watson at MSK, it’s not hard to imagine a world where every physician and every non-physician provider has access to such a supercomputer right on their ipad. That would definitely close the gap in knowledge between physicians and others.
      For Rads, this kind of AI could be more potent than outsourcing. If a computer can effectively read an entire medical record in normal written english, read the imaging by comparing it with millions of images in its database, and synthesize the two in light of the totality of medical literature and present a list of findings with precise confidence levels, that could be a game changer.
      They definitely don’t talk about this in school, but students are smart and many are considering such eventualities.

  • northeastchris

    we can all agree that shift work is tough, especially with a family. But, I also think that a major cause of burnout in the ED is the “baby sitting” of all the frequent fliers of any ED.

  • chintzen

    I wonder if emergency departments are being asked to do too much. Not only do they have to deal with true medical emergencies, but also the streams of individuals and families who have no regular physician to address their health needs. Maybe hospitals (and maybe some already do this) should open separate clinics for the latter so that the ED staff can focus on truly emergent care. The intake process could detect and refer less serious cases to the hospital clinic. Eventually, people would go there first.

    In our area, the local medical clinic runs urgent care centers and there are several independent urgent care clinics too and still, the ED waiting room is packed with patients who could have, and probably should have, gone elsewhere. Is this because hospitals can’t refuse to treat anyone who walks through the door? It’s a serious detriment to quality healthcare to expect folks in the ED to handle it all.

    • Guest

      But someone recently shared a picture advertisement from England trying to educate patients when to go or not go to the ER. Seems that even with NHS their ERs are inundated with non-emergencies (just like ours).

      I agree – EDs are overburdened and being asked to do too much. I think the ultimate answer comes in shifting cost to the consumer. Get rid of EMTALA. Don’t bill people after the fact – charge a fee to get into the door (unless of course you’ve got a life threatening emergency). People may learn how to game that too, but it might help cut down on the 3 AM sinusitis or acne complaints.

      • Elvish

        At least the British are trying to solve this problem by giving their people other options and let them know about such solutions via advertisements.
        I hope you are not a physician nor a medical student.
        Here is a rule British physicians love :”Don`t blame the sick for being sick”.
        Patients don`t have health insurance and can`t afford to pay out of pocket , so they seek refuge at ED`s, but no, we have to make it even worse by asking them to pay money that they don`t have before being seen.
        In case you don`t know, most ED`s have something called fast-track, so it`s not doctors leaving MI`s and Aortic dissections for the sniffles !
        If it wasn`t for the liability, Emergency Medicine would`ve been as competitive as Dermatology and Ophthalmology; shifts, no calls, relatively better pay and a strong safety net of specialists.

        • Guest

          Americans too are trying to unburden the ER with more insurance options for people and urgent care centers. There are plenty of low income clinics in my area (granted, I live in a major metropolitan area). People DO have other options; it’s easier to go to the local ER than research other locations they could go. Plus, urgent care will charge them a copay while the ER will NOT.

          No one is blaming the sick for getting sick. I do think it is irresponsible to go to the ER for ailments that can easily be managed with OTC meds. When people are not burdened with the cost of an ER visit where’s the disincentive to go for even the most minor of issues?

          • Elvish

            :) We need to try harder then.
            Until you give a dignified, practical solution, people will continue going to the ER; urgent care clinics, that are affordable and accessible can be such a solution.
            It`s not fair to consider the patients irresponsible for not knowing that their sickness at the time could`ve been treated with an OTC, especially without having an active, well funded preventive medicine body that educate people.

            People are weaker and need more help than we think and afford to give.

    • Mengles

      You can thank EMTALA for that.

  • czil

    as health care providers who swore the hippocratic oath, doesnt that imply that theres no discrimination in who to provide medical attention, giving their best and treating each patient equally?

  • Molly_Rn

    Mitt Romney said if you don’t have any money and are sick you just go to the Emergency Department and they will take care of you, an example of Republican healthcare.

  • John Henry

    It is attractive because the residency is not that long and has reasonable hours, the work is negotiable for hours, full or part-time, the specialty is highly portable in that you can pick up and go to some other part of the country without having to worry about selling a practice or buying or building a practice elsewhere, and there is the option of non-hospital urgent care practice which is paid better and less subject to the indignities of EMTALA abuse common to hospital ED work.

  • buzzkillerjsmith

    Every single ER doc in my town is burned out, every single one. It’s worse than family medicine, which is no great shakes itself. The med students are swinging and missing on this one.

    What could be done to make the ER a better place? Get rid of the night shifts? Nope. Send the consultants to charm school? They won’t go. Improve the pt population? I am dubious.

    Tough gig.

    • Guest

      That’s very interesting. We seem to have an incredibly high turnover of physicians in our ER as well. Each subsequent turnover produces less invested, less meticulous physicians than the last bunch. It’s disheartening. Every time I go down to do a consult the ER is jam packed with patients in the hall. It seems like such an awful workplace.

Most Popular