Discussion
In medicine, EM is unique in its hours, patient population and stressors. This uniqueness translates into more EP burnout. A four-year survey published in 1996 found that 60% of EP respondents "registered in the moderate to high burnout ranges" on the MBI.[7] In the 2012 landmark burnout study, EM was the most burned-out specialty (~65%), over 10% more "burned out" than the next closest specialty (general internal medicine), and close to 20% more than the mean rate for all physicians responding.[8] While burnout in EM has continued, the most recent Medscape report indicates that EM is the fifth most burned-out specialty behind urology, neurology, physical medicine and rehabilitation, and internal medicine.[11] Like other specialties, burnout in EM starts early, with studies showing between 65–74% of residents (all levels) meet criteria for burnout.[73,74]
Causes of Burnout in Emergency Medicine
The unique stressors in EM may easily lead EP burnout to be attributed to personal characteristics such as poor coping skills or lack of exercise, rest, and hobbies, a view that continues to this day. However, organizational and environmental causes of burnout certainly apply to EPs. One notable exception is the usual connection between burnout and increased work hours. For non-EPs, burnout appears to directly correlate with increasing work hours.[11] On the contrary, while EPs are the least likely specialists to work excessive hours (>40 hours/week), the necessity of working nights and on weekends and holidays may contribute to burnout.[11] Furthermore, the lack of support staff and medical infrastructure during these "off" hours, coupled with high intensity work (heavy workload, multiple sick patients, frequent task-switching, patient and colleague rudeness, and constant uncertainty) may have a similar effect on EP emotional health as the longer hours of other specialists.[75–79]
With fewer weekly hours than other specialties, EPs have the ability to "pick up" extra shifts, increasing their work hours and the associated stress. Many EPs work extra shifts to pay off debt, another stressor and contributor to burnout.[80] In 2016 the median debt of EM residents in one study was $212,000.[81] This debt caused stress and changed plans: getting out of debt reportedly took priority over pursuing further educational opportunities, vacations, and spending time with family, all things that might counter burnout.[80,81] The ability to "pick up" extra shifts to pay down debt and the perception that they are working less than other physicians are examples of particular attributes of EM that increase susceptibility to burnout.[82] Three other causes of burnout in EM deserve mention: clinical pressures/expectations, litigation stress, and fatigue/sleep loss.
Clinical Pressures and Expectations. Society perceives EM as a world of excitement, drama, and miraculous saves.[83] While not wholly inaccurate, television dramas do not show the persistent demand for immediate and error-free care despite limited resources.[84] This mismatch between demands and resources, coupled with constant diagnostic uncertainty, significantly stresses EPs and promotes burnout and emotional exhaustion.[79,84–86]
Both EDs and EPs are limited resources: EDs are closing while visits are increasing, and there is a national shortage of EPs, particularly in less geographically desirable areas.[87,88] Despite a consistent increase in EM first-year residency training positions (1786 in 2014 to 2278 in 2018, 27.5% increase), only 61% of U.S. emergency care providers are EPs, with the rest a combination of advanced practice providers (APPs) (24.5%) and non-EPs (14.3%).[89,90] This shortfall particularly affects rural areas where only 44.8% of rural emergency care providers are EPs.[90] Despite this shortfall, EPs provide care for 85.3% of ED patients, meaning they are working more clinical hours while being responsible for care being provided by APPs.[88,91]
Compensation is often based on productivity, patient satisfaction, and "quality" measures.[92] With more patients and less time to see them, EPs who are judged on patient satisfaction may choose to acquiesce to requested, but not medically indicated, care. This occurs despite patient satisfaction correlating poorly with quality of care.[93–97] Similarly, the guidelines and care metrics nominally designed to improve patient care (eg, door-to-doc/needle/antibiotics time) are rigorously enforced despite lack of evidence of patient benefit.[98–99] Such metrics and guidelines, particularly prominent in EM as the initial provider of care, deprive physicians of autonomy and the ability to practice the art of medicine, leading to job dissatisfaction and burnout.[82,100]
Litigation Stress. Being the first care provider for so many sick patients means inevitably dealing with a malpractice claim, another cause of burnout.[101] Annually, EPs face malpractice claims at a slightly higher rate than the average physician (8.7% vs 7.2%).[102] Each litigation episode can last years, and physicians are counseled not to discuss such cases with anyone, adding to the isolation and lack of peer support.[103,104] Annually, up to 73% of EPs admit to practicing "defensive medicine," ordering extra tests to avoid missing anything, and cite fear of litigation as the reason.[105] This practice leads to physician cynicism and disengagement (precursors to burnout), and increases healthcare spending (by an estimated $750 billion in 2010).[106]
Sleep loss and fatigue. One reason EPs likely face higher litigation rates is that they simply encounter more sick patients than other physicians, as their work environment is available at all times. To fulfill the 24-hour need for high quality emergency care, EM is built around shift work. The resulting disruption of circadian rhythms leads to sleep loss and its associated detrimental effects on health: increased cardiovascular disease, metabolic syndrome, sleep disorders, and possibly even increased mortality.[107,108] The effects of shift work are felt early (84% of five cohorts of EM residents felt a need for intervention for their sleep deprivation and self-perceived exhaustion) and become more pronounced with age.[109,110] Sleep deprivation is associated with worse patient care, decreased job satisfaction, and less personal well-being, all of which contribute to burnout.[111]
Consequences of Burnout in Emergency Medicine
While the consequences of burnout for EPs are similar to those for physicians in general, certain areas deserve specific mention: clinical care, depression, substance abuse, SVS, and suicide.
Clinical Care. Like other physicians, burned-out EPs self-report delivering suboptimal clinical care and more often perceive they have erred medically.[73] Such EPs also have lower patient satisfaction scores and perform worse during high-fidelity simulations compared with their peers who are not burned out.[111,112]
Physician Drop Out. Although attrition from EM has historically been low (1.7% per year, in a 2010 study), attrition rates do not account for those feeling "trapped" in their current jobs due to debt.[81,113] This may be one reasons why EPs are the second least happy at work behind physical medicine and rehabilitation.[11] EPs may forego further training or changing jobs due to debt, creating a feeling of hopelessness that further contributes to stress and burnout.[81] Ironically, further training in a subspecialty of EM could serve to reduce burnout by adding variation to an EP's work schedule and duty.[114]
Depression. Researchers have found rates of depression in EPs (12.1% - 19.3%) consistent with the Medscape survey of depression rates in all respondents (11-15%).[11,115–116]
Self-medication. Both EPs and EM residents experience higher rates of substance abuse than other specialties, with studies estimating that 4.9–12.5% of EM residents drink daily.[116,117] Other research suggests that 7–18% of the physicians treated for substance abuse are EPs, despite only 4.7% of all physicians being EPs.[118–120]
Second Victim Syndrome. While no specialty-specific numbers exist, EPs seem especially susceptible to SVS. EPs rarely have time to debrief or grieve after an adverse patient outcome, because there is always the next patient.[37] Most EPs have a story about a patient dying despite their best efforts and then having to see a lower acuity patient unhappy because of an extended wait. This lack of processing time for patient deaths or medical errors may make EPs more susceptible to SVS and, by extension, burnout. Conversely, burned-out physicians are more likely to commit a medical error and have poorer job-coping skills. SVS is complex and intimately tied to depression and burnout, with all three contributing to and resulting from the others.[37] However, they are related: SVS, burnout, and depression may all result in an EP leaving the specialty in the most final way – suicide.
Suicide. While no specialty-specific data exists and the Medscape data may contain biased responses, extrapolation from that data suggests that, in the last year, as many as 6,000 EPs have contemplated and up to 400 have attempted suicide.[11,121] The following factors may explain why these numbers are so high: (a) EM seems to have a higher rate of gender-based harassment of women (45.3% vs 20.3%) than the medicine average;[122] (b) female physicians have a much higher rate of suicide than their general population counterparts (130% higher);[123] (c) there is an association between workplace harassment, depression and suicide;[122] and (d) physicians tend to "succeed" in their suicide attempts more often than the general population.[72]
Western J Emerg Med. 2019;20(3):485-494. © 2019 Western Journal of Emergency Medicine
