HealthMay 21, 2020

Burnout in emergency medicine: Sometimes it doesn’t “hurt so good”

By: Michelle A. Finkel, MD

I found the field of emergency medicine just as the television show “ER” was becoming popular. In the year I matched, there were only a handful of other applicants in my medical school class who were also pursuing the specialty. Eventually, however, the television show won 23 Emmy Awards, and whether causative or just correlative, the field of emergency medicine became red-hot.

Fast forward to the past few years when burnout in emergency medicine has become a concerning conundrum, and the field—while still relatively popular—elicits mixed responses among some medical students. In 2015, the Medscape Physician Lifestyle Report documented a 52% emergency physician burnout rate, edged out only by critical care at 53%. By 2020, the survey no longer showed emergency physicians in the top five, but a sizable 43% of emergency physicians surveyed still reported burnout.

All of this was before COVID-19 plagued the world. Now, with emergency physicians on the front lines literally risking their health and their families’ well-being, burnout in emergency medicine is likely to persist or worsen.

6 reasons for burnout in emergency medicine

The causes of burnout in emergency medicine are several.

1. Erratic schedules

What some consider emergency medicine’s greatest asset—the clock-in-clock-out aspect of the work—can also be its biggest liability. Night shift work in particular has been correlated with an elevated risk of depression, diabetes, heart disease, and cancers of the breast and colon.

Erratic schedules also adversely affect family and friends, such that social plans can be difficult to make, especially spontaneous ones.

2. Lack of autonomy

Most medical students searching for a specialty are millennials, a generation well-known for prioritizing autonomy when it comes to career choice. Because emergency physicians cannot run their own offices and rarely hire the nursing staff they work with, there is limited control of the professional environment.

Additionally, as a mostly hospital-based practice (limited states legally permit freestanding emergency departments), emergency physicians serve at the pleasure of hospital administration—a source of potential job insecurity.

Perhaps more difficult still, emergency physicians cannot select their doctor colleagues, meaning they sometimes rely on consultants they don’t choose. We have to play well with others, even when they do not play nicely with us.

3. Speed and volume

The fast-paced nature of emergency medicine is what propels some medical students to choose the field. However, that roaring pace can be exhausting after years.

Emergency departments in the United States are overutilized, making a full day sometimes physically and mentally exhausting for emergency physicians. The action-packed, trauma-filled cases that make the specialty appealing to a younger physician hungry for experience can feel quite different to an older physician yearning for a more routine, less stressful clinical environment.

4. The unknown

While pathophysiology is inherently interesting to most medical students and physicians, having no idea what disease process might walk through the door can be a bit discombobulating.

Emergency physicians are responsible for a large breadth of knowledge, which can be thrilling but also a source of stress. It’s a plus to be the doctor who can always raise her hand when the captain appeals for help during an in-flight emergency. But it can leave certain personalities unsatisfied to routinely discharge patients for whom the diagnosis remains uncertain.

5. Social ills

One of the reasons I chose emergency medicine was my desire to work toward social justice. However, societal problems and patients’ psychosocial diseases are brought into sharp relief in the emergency department, and answers are often hard to find despite everyone’s best efforts.

This impotence can lead to burnout in emergency medicine, not only for physicians but also their colleagues in nursing, social work and case management. Our regulars include alcoholics, victims of abuse, addicts and persons with severe mental illness for whom there are limited resources and few straightforward solutions. This can breed a sense of Sisyphean futility over time.

6. Physical well-being

According to the American College of Emergency Physicians and the Emergency Nurses Association, almost half of emergency physicians report having been physically assaulted on the job; more than two-thirds of emergency nurses report having been hit and kicked. Fear of violence and physical threats can be a source of emergency physician burnout.

Furthermore, even before COVID-19, emergency physicians, who oftentimes complete several high-risk procedures per day, grappled with concerns about contracting infectious diseases from patients either parenterally or through airborne or contact transmission. Now, with COVID-19, emergency physicians are concerned for their health or even for their lives. While many emergency physicians are eager to help during the crisis, many are, understandably, simultaneously anxious about the risks they are subject to at work. One recent JAMA study showed that a considerable proportion of healthcare workers in China who worked with COVID-19 patients experienced depression, anxiety and insomnia.

Emergency medicine beyond burnout

Despite the many reasons for burnout in emergency medicine, the field still draws a large group of enthusiastic medical students. As of October 2019, the average emergency medicine residency program had received 889 applications for the 2019-20 residency admissions cycle, according to the Emergency Medicine Residents’ Association. The ability to make a positive impact on patients during their most vulnerable moments, the diversity of pathology and the camaraderie of a well-oiled emergency department are appealing and meaningful to many physicians even if the day-to-day is not quite as seductive as the heyday of the television show “ER” portrayed it to be.

Michelle A. Finkel, MD