Jack is an emergency physician at a busy community hospital. You have been friends for years, and you occasionally catch a drink together. Things have been stressful at work with a new electronic health record (EHR) in the past year, which has productivity down and wait times up. Jack is a known clinical machine, so the productivity drain has been particularly frustrating for him. He considered the assistant director position that opened up six months ago, but he decided he was too busy already.
Over drinks recently, you caught up on home life as well, and he says things are going well with his wife and two kids, although the kids’ schedule conflicts with his work hours, which has been tough on everyone. He laments that the new opioid regulations have made caring for drug seekers even more painful. After a drink, you headed out, but Jack said he was going to have another.
Are you and Jack on the road to burnout? Technically, yes. The data show burnout rates of up to 65% percent in emergency medicine, more than any other specialty, and they’re increasing.1,2 We are all, by being emergency physicians, on the road to burnout; the question is: How far down that road are you? We are also all on the road to satisfaction, cynicism, happiness, prosperity, and compassion. In emergency medicine, we experience all of life amplified. Whatever resources we started with will dwindle if not replenished. Operationally, Christina Maslach and her colleagues have quantified this depleted burned-out state as a triad of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment.3 Their social science research let to the Maslach Burnout Inventory, a scale that is currently regarded as the gold standard to assess workplace burnout.
Jack’s Case
Let’s look at the specifics. Jack is a clinical machine. Burnout is associated with high clinical load.4 The more emotionally taxing cases we see, the less time we have to process them, and the more at risk for emotional exhaustion we become.5 Although Jack is mid-career, burnout seems well-distributed among different-aged physicians, and it occurs at higher rates than in the general population.6 Jack is bothered by the EHR. He considered becoming more involved in decision making. Inefficacy, or lack of control, is a risk factor for burnout in physicians and may be why emergency physicians score so high on burnout surveys. Lack of career or workplace involvement is also a risk factor for burnout. Niche development or career diversification may be somewhat protective, combating a sense of depersonalization.
Labeling patients can be an efficient way of describing an emotional frustration, but it can also be a sign that Jack has stopped seeing drug seekers compassionately and is becoming more depersonalized.
Jack is married and talks about how his job is affecting his home life. Marriage is generally associated with lower rates of burnout. However, in medicine, marriage seems to lose its protective factor compared with the general population, possibly given the demands of medicine and schedule conflicts.5 This is one reason it is so important that you and Jack are getting together on a social level. It is important to connect in a healthy way with other people who understand the challenges of our job. Be careful to go lightly with alcohol and other substances. Substance abuse is both a risk factor for and can be cause of burnout. The rates of alcoholism in medicine are slightly higher than in the general population.7 The exact reason is unclear, but it may be that what starts as an unhealthy coping mechanism to deal with stress and trauma exposure can develop into a chronic problem. Burnout combined with substance abuse is a major risk factor for physician suicide. Increased reliance on alcohol to cope with stress may be a red flag that Jack isn’t coping well.
Spot and Stop Burnout Before It Becomes a Problem
There are two crucial aspects of medicine: the facts of medicine and the art of medicine. Of the two, the art of medicine is the first to go when physicians experience burnout. In emergency medicine, more so than in many other specialties, that loss is devastating, both to the patient and physician. While severe burnout is a big and dangerous problem for our field in general, there are far more of us who are experiencing minor burnout and haven’t yet recognized the signs. When we start to lose sight of the art of medicine, we find ourselves drifting away from that basic ability to be present, listen, and really care. We may lose the ability to separate our work from our home or our day off from our day on, such that we feel constantly under fire. The important thing is to recognize that your resources are running low and it’s time to restock.
When the facts of medicine start leaving you or are getting discombobulated, you are already well down the road to burnout. Call a friend or do whatever you can think of, but do something, and do it NOW!
Recognize the signs. Don’t let your pride override your sanity. You, your patients, and your coworkers are at risk. Let some trusted people from different realms of your life know so that you have help from multiple sources. If you have a lot of clinical shifts, cut back when you can, trade for less-intense shifts, and move ahead cautiously. If you don’t already have psychological or pharmacological support, seek out whichever options are available and applicable to your situation. Accept the fact that both may be the best option in the short-term. Remember that you probably have sick leave and disability available to you for an emergency, and this may be it. Remove any optional obligations from your schedule, and put yourself in harm-reduction mode. This is not the time to worry about if you are the fastest, most cost-efficient, or most creative doctor in the world. Honestly answer the hard questions: Are you safe? Are others safe?
The remedy for burnout will always be very personal and individualized. You could easily argue that anyone in emergency medicine could benefit from a counselor, maybe even medication, but that isn’t going to resonate with most. Maybe an after-shift sit-down with a colleague will work best for you. We all need some physical activity, but how much will vary for each person. Spend time with people who see the best in you (eg, family, a friend, or a group who is always glad to have you in their life). Finally, find some structure that you can weave into your day that supports growth and learning. When you are ready or when you have your next shift scheduled, take it easy on yourself, start slowly, keep your eye on the horizon that marks your way, and find refuge if you feel like you are low on resources.
Resources
Self-Assessment Tools
- Maslach Burnout Inventory: Online access to the current gold standard burnout scale. You can buy individual reports or a license to assess your group.
- American Medical Association (AMA) Mini Z Burnout Survey: A three-minute tool put out by the AMA for physician burnout self-assessment.
- Professional Quality of Life (ProQOL) Assessment: A free 30-question test assessing compassion satisfaction, burnout, and compassion fatigue, as well as secondary traumatic stress.
Burnout
- ACEP Wellness: Links to wellness resources, the ACEP wellness guidebook, wellness at different career stages, tips for dealing with litigation stress, and ACEP member access to recent ZDoggMD presentation at the ACEP Leadership and Advocacy Conference (not to be missed!), as well as a link to joining the ACEP Wellness Section, where your struggles with burnout or your tips for maintaining wellness will be put to good use. Resources include both individual and organizational recommendations for improving wellness.
References
- Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.Arch Intern Med. 2012;172(18):1377-1385.
- Peckham Medscape Physician Lifestyle Report, 2017, Race and Ethnicity, Bias and Burnout. Medscape website. Available at: https://www.medscape.com/features/slideshow/lifestyle/2017/overview. Accessed Dec. 14, 2017.
- Maslach C, Jackson SE, Leiter MP. The Maslach Burnout Inventory. 3rd ed. Palo Alto, Calif: Consulting Psychologists Press; 1996.
- Arora M, Asha S, Chinnappa J, et al. Review article: burnout in emergency medicine physicians. Emerg Med Australas. 2013;25(6):491-495.
- Kimo Takayesu J, Ramoska EA, Clark TR, et al. Factors associated with burnout during emergency medicine residency. Acad Emerg Med. 2014;21(9):1031-1035
- Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443-451.
- Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168-174.
Dr. McPeake is associate professor of emergency medicine and director of the program in physician wellness at the University Emergency Medicine Foundation of the Warren Alpert Medical School of Brown University in Providence, Rhode Island.
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2 Responses to “Recognizing You Are on the Road to Burnout—and What to Do”
December 25, 2017
Mark BuettnerThese solutions lack the courage to confront the power that forces an unhealthy work environment upon us. Instead, it recommends that we as individuals make change in ourselves to avoid burnout. What changes should we make? 1) Alter our brain chemistry with “Pharmacologic Support” and/or 2) Work Less. This advice serves to enable the power that binds us. By definition this advice is cowardly because it charges the powerless individual physician with the responsibility to prevent burnout while excusing the powerful federal government for the unhealthy work environment that it mandates.
It is a detachment from reality to recommend working less to avoid burnout. We have families to support. We have student loans to pay while at the same time saving for our children’s future education. Most of us have our own retirements we are responsible for funding. Seeking a less intense work environment translates to less income. Are these recommendations to the benefit our patient population? I think not. Who will care for our patients in our absence? Notwithstanding, I believe the overwhelming majority of us enjoy the true core of our work as Clinical Emergency Physicians. We did not seek this career field to hide from it. When the time comes whereby an overwhelming majority of us are unable to recognize a career of full time clinical Emergency Medicine without burning out, then a call for immediate change should be in order. Where is the call for change?
Finally, there seems to be a cottage industry opening up in the physician wellness arena. Is there really any serious call for change? There comes a time when merely writing about physician burnout is just self-serving. We all should be demanding of our physician organizations and academia to use their platforms in an effort to make change. The time is Now!
February 11, 2018
Laura McPeakeDear Dr. Buettner,
Thank you for your response. I completely agree with you that we need to do much more as a specialty, and in the house of medicine in general, in addressing systemic burnout, and having institutional level interventions to combat burnout.
The scope of this article was purposely narrow, to make suggestions to help physicians evaluate their safety to practice and perhaps recognize symptoms and benefit their colleagues who might also be suffering from severe incapacitating burnout. This is important because, as experts in keeping a straight face in the most disturbing adversity, it isn’t always obvious who is burnt out and who isn’t. This is similar to how we need all emergency physicians to understand the warning signs of impending respiratory collapse in a failing asthmatic. Once the patient is hypoxic, you have lost the battle. Similarly, once a physician is too far down the road to burnout, he or she is at personal and professional risk.
Your response also highlights a very important topic in the realm of burnout and wellness, the belief that solutions are either individual or organizational, and that emphasizing one undermines the other. This false dilemma negates much of the work that is being done and needs to be done to combat burnout on any level. Essentially, this polarization lets the good be the enemy of the perfect. Systemic change is crucially needed, as called for in much of the most current literature on burnout. And while needed, that level of intervention will not be immediate. In the meantime we also need to support the individuals working in a difficulty system. In fact, those same burnt out physicians, when supported can be some of the most powerful catalysts for change. When we support the individual, as well as the organization, we empower people to speak up, advocate and innovate to move toward a healthier healthcare system. Increasing polarity just pits one side against the other, and we waste limited energy bickering amongst ourselves on whose approach is better and little is accomplished. Whereas in reality, both well meaning sides of this false dilemma need to work together. We need all hands on deck, including yours and I truly appreciate your willingness to speak your objections, to forward an important cause both for the physicians we work with and the patients we serve.