Emergency physicians: "burned out" or "fired up"?
Editorials / Commentaries
*Chair, CAEP Continuing Medical Education, from the Department of Emergency Medicine, Dalhousie University, Halifax, NS, and the †Emergency Department, Southampton General Hospital, Southampton, UK
CJEM 2007;9(2):121-123
Background
It is a commonly upheld belief that emergency physicians (EPs) become burned out at an increased rate, compared with other physicians or to the population. The primary objective of this study was to survey physicians and other healthcare workers attending an emergency medicine (EM) conference to collect information on the signs of burnout. We sent a survey to delegates attending the International Conference on Emergency Medicine. Most respondents addressed important signs of well-being, such as a sense of enthusiasm and "fun." Interests other than medicine and time for outside endeavours were also highly scored. On the other hand, cynicism was also identified as significant. Although more information is needed, this survey suggests that we are not as burned out as many think.
When asked to sit on a 2006 International Conference on Emergency Medicine (ICEM) panel to debate the purported rampant rate of burnout among EPs, we did not hesitate to support the "nay!" side. To our horror, a literature review uncovered only one article1 to suggest that we were not fighting a losing battle.
The term "burnout" was coined by Freudenberger in 1974.2 It is defined as a syndrome of depersonalization, emotional exhaustion and a sense of low personal accomplishment.3 At any time, 40%-60% of the general physician population suffers from burnout4,5; and 2 prior studies suggest a higher rate of 46%-93% in EPs.1,6 The literature reports a range of burnout rates, but the overall numbers appear to be higher for EM than for most other professions. Despite this dismal assessment, many students seem keen to follow in our footsteps, lining up for emergency electives, selectives, rotations, traineeships and residencies. If EM is so destructive, why are so many people clamoring to get in?
The data are not all depressing. In fact, one study concluded that, while EPs scored in the moderate-to-high range for depersonalization and emotional exhaustion, they also reported high levels of personal accomplishment.7 In addition, a survey of American Board of Emergency Medicine members reported a burnout rate of 25%—lower than the average physician rate.8 More recently, the Longitudinal Study of Emergency Physicians, a large randomized survey on "work and career satisfaction," discovered that EPs found the current state of EM "exciting," an adjective not usually found in the burnout literature.9 Recently published data10 provide professional satisfaction rates among 36 specialty groups in Canada. In this survey, EM physicians ranked fifteenth most satisfied among the groups surveyed.
Survey design
In order to assess the current status of emergency physician burnout, we developed an informal survey and just before the conference we emailed it to all 785 delegates who registered to attend the 2006 ICEM in Halifax, NS. The 18 survey questions, based on established markers of burnout explored each of the burnout "domains' defined by Maslach (questions about sexual habits were excluded).3 For example, we assessed "emotional exhaustion" by asking questions about enthusiasm, about whether ED work was still fun, and questions relating to career choice and change. Similarly, we assessed "depersonalization" using questions pertaining to outside interests, family time and cynicism. Finally, we assessed "sense of accomplishment" by asking respondents whether they would encourage students to choose a career in EM and whether they felt they positively affected patients' lives.
Survey results
Table 1 describes the survey population, showing that 223 (28%) of the 785 contacted subjects returned the survey within the 2-week time frame. Physicians constituted 87% of respondents. Table 2 summarizes physicians' attitudes toward their work. When offered a chance to provide 3 descriptors that characterize their work, the majority (85% of first responses, 79% of second responses and 66% of third responses) were positive, as shown in Table 3. Our respondents also reported participating in a wide range of leisure, outdoor and sports activities. There were volunteers, professional river guides, Cub Scout leaders, car racers, and even a goat farmer, which suggested at least some life balance. Our respondents appear to be coping well and to be using innovative strategies to adapt to the high intensity, shift-work and time pressures of EM, which are all significant stressors. The notion of a career in EM as an evolving portfolio of activities (only one of which is clinical medicine11) will favour the adaptive behaviours we believe are key to survival.
| Variable (number of responses to questions) | n (%) | Variable (number of responses to questions) | n (%) |
|---|---|---|---|
| Home continent (n = 222) | Age, years (n = 223) | ||
| Australia | 37 (17) | <30 | 21 (9) |
| Europe | 20 (9) | 30-39 | 94 (42) |
| North America | 159 (72) | 40-49 | 63 (28) |
| Africa | 0 (0) | 50-59 | 39 (18) |
| Other | 6 (3)* | >60 | 6 (3) |
| Years of EM practice (n = 222) | Sex (n = 222) | ||
| <5 | 52 (23) | Male | 146 (66) |
| 5-9 | 59 (27) | Female | 76 (34) |
| 10-14 | 35 (16) | Percentage of practice in ED (n = 222) | |
| 15-19 | 32 (14) | <25% | 23 (10) |
| 20-24 | 20 (9) | 25%-49% | 39 (18) |
| >25 | 24 (11) | 50%-74% | 43 (19) |
| Main other area of practice (n = 211) | ≥75% | 117 (53) | |
| Administration | 58 (27) | Practice setting (n = 222) | |
| Education | 82 (39) | Academic institution | 128 (58) |
| EMS | 16 (8) | Regional hospital | 39 (18) |
| Research | 23 (11) | Community hospital | 42 (19) |
| Family Medicine† | 12 (6) | Rural or remote | 9 (4) |
| Other | 20 (9) | Other | 4 (2)* |
| *Due to rounding, totals do not all equal 100%. †Separated due to prevalence in "other" category. EM = emergency medicine; EMS = emergency medical services |
|||
| Question and response (number of responses out of 223) | n (%) | Question and response (number of responses out of 223) | n (%) |
|---|---|---|---|
| Have you ever considered changing careers? (n = 217-219)*† | Do you encourage students to choose EM? (n = 219) | ||
| Yes | 78 (36) | Yes | 167 (76) |
| No | 139 (64) | No | 6 (3) |
| Sometimes | 44 (20) | ||
| Other | 2 (1) | ||
| Has EM allowed time for outside interests? (n = 214) | |||
| Yes | 169 (79) | Has cynicism become a way of life for you? ( n = 219) | |
| No | 45 (21) | Yes | 24 (11) |
| No | 34 (15) | ||
| Are you still enthusiastic about ED work? (n = 222) | Sometimes | 135 (62) | |
| Yes | 194 (87) | Always | 26 (12) |
| No | 9 (4) | ||
| Sometimes | 19 (9)† | Your time with family and friends has? (n = 220) | |
| Increased | 34 (15) | ||
| Is ED work still “fun” for you? (n = 220)‡ | Decreased | 110 (50) | |
| Yes | 195 (89) | Remained the same | 74 (34) |
| No | 19 (9) | Not interested | 2 (1) |
| Sometimes | 6 (3) | ||
| *The number of responses to this question varied because there were some applicable text responses that were not responses to this specific question. †These questions had 2 parts. Some respondents provided no details, others provided only their alternative career choices, which resulted in a greater number of responses than there were to “yes” or “no.” ‡Due to rounding, the totals are greater than 100% ED = emergency department; EM = emergency medicine |
|||
| First response | Second response | Third response |
|---|---|---|
| Challenging | Hectic | Fun |
| Multitasking | Rewarding | Teamwork |
| Variety | Exasperating | Have to be nuts |
| Fast; exciting | Dynamic | Demanding; stressful |
| Instant gratification | Intense | Frustrating; litigious |
| Diverse | Stimulating | Always learning |
| Whoever | Whatever | Whenever |
| *A sample of 177 responses to this question. EM = emergency medicine |
||
EM has evolved over the years, as have EPs. We are not the "high paid traffic cops" we once were, triaging patients to other specialists and waiting to be seized by our own true calling within medicine. EM has become a sustainable career with its own skill-set, research agenda and administrative challenges. From an educational perspective, EM offers medicine "where the rubber hits the road" like no other specialty can. We have developed specialized expertise and gained reputations as excellent teachers of knowledge, attitude and procedures. Who better to deal with SARS, pandemic flu, international issues, disasters and life itself? With changes in EM practice and EM practitioners, it is not surprising that satisfaction would also change. Attrition was high in the early days of EM, but this may be because many of those who left had no intention of being career emergency department physicians. As a young specialty and area of focus, we should be proud of our progress and attempt to determine the scope of this problem amid our peers.
Summary
While our survey was flawed and informal, it gives us reason for hope, and it suggests emergency physicians are not as burned out as many believe. Where we work, we see people who smile at small things, live for the day and have fun. There are good shifts, bad shifts, sad ones and challenging ones—but never boring shifts.
References
- Goldberg R, Boss RW, Chan L, et al. Burnout and its correlates in emergency physicians: four years' experience with a wellness booth. Acad Emerg Med 1996;3:1156-64.
- Freudenberger HJ. "Staff burn-out'. J Soc Issues 1974;30:159-65.
- Maslach C, Jackson SE. The measurement of experienced burnout. J Occupational Behav. 1981;2:99-113.
- Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995;71: 1263-9.
- Shanafelt TD, Bradley KA, Wipj JE, et al. Burnout and Self-Reported Patient Case in an Internal Medicine Residency Program. Ann Intern Med 2002;136:358-67.
- Lloyd S, Streiner D, Shannon S. Burnout, depression, life and job satisfaction among Canadian emergency physicians. J Emerg Med 1994;12:559-65.
- Keller KL, Koenig WJ. Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med 1989;18:42-7.
- Doan-Wiggins L, Zun L, Cooper MA, et al. Practice satisfaction, occupational stress, and attrition of emergency physicians. Wellness Task Force, Illinois College of Emergency Physicians. Acad Emerg Med 1995;2:556-63.
- Reinhart MA, Munger BS, Rund DA. American Board of Emergency Medicine longitudinal study of emergency physicians. Ann Emerg Med 1999;33:22-32.
- Baerlocher M. Happy doctors? Balancing professional and personal commitments. CMAJ 2006;174:1831.
- Heyworth J. Stress: a badge of honour in the emergency department? Emerg Med Australas 2004;16:5-6.
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