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Emergency Medicine News:
doi: 10.1097/01.EEM.0000428251.32717.8d
Emergentology

Emergentology: Burnout: It's All about Weird Hours, Challenging Patients, and High Stress

Walker, Graham MD

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Author Information

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications (www.mdcalc.com), and The NNT, a number-needed-to-treat tool to communicate benefit and harm (www.thennt.com). Follow him on Twitter (@grahamwalker) for daily thoughts on emergency medicine.

“...an erosion of the soul caused by a deterioration of one's values, dignity, spirit, and will.” — Social Psychologist Christina Maslach

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No, we're not talking about having to take your annual guaiac test. We're talking about burnout.

The survey results are in!

Thank you to all 322 people who responded to my burnout survey in November. It was absolutely fascinating to see some of the trends.

Some quick info about the respondents (for you Journal Geeks, think Table 1):

* Average age: 40-something.

* Respondents from all over the United States, 40 internationally!

* 82 percent attendings, 10 percent residents, three percent fellows, five percent other (RNs, PAs, NPs).

* Mostly community EPs (66%), with 24 percent academic and nine percent county.

About 60 percent work full-time clinical, and 30 percent work clinically 75 percent of the time.

And before you Journal Geeks start pestering, nope, this was obviously not scientific. Yup, it was certainly skewed by voluntary response bias. Yup, I'm doing post-hoc analyses with lots of shady R-values. But hey, put up or shut up. Do a better survey yourself, and I'll happily publish it.

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Burning Out

The three most common reasons for burnout included work schedule (nights, weekends), patients/patient interactions, and high-stress work. The least common reasons cited were interactions/relationships with other ED staff, picked the wrong specialty or profession, and no personal satisfaction overall.

These reasons certainly resonate with me. The parts of our jobs that define it — weird hours, sometimes challenging patients, and high stress — strongly contribute to burnout. But we're drawn to the work, we enjoy working with our colleagues, and we are in the right specialty.

And that segues perfectly to why some of us don't feel burned to a crisp: interactions and relationships with other ED colleagues, interactions and relationships with other ED staff (we love you, nurses, techs, and clerks!), and intrinsic personal satisfaction.

How do we typically deal with burnout to prevent it or put it at bay? Exercise, vacations, and time with friends and family mostly. About 13 percent noted using drugs or alcohol to cope and seven percent reported using medications. Eleven percent shopped; 28 percent “treated themselves.”

Thirty-two percent of respondents overall said they feel depressed, but only 15 percent who said they feel burned out were depressed. I think there's obviously selection bias at work here; I hope a third of our specialty isn't depressed, but perhaps burnout isn't as closely related to depression as I thought.

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Oh, The Subgroups

I asked people specifically about types of exhaustion: physical, intellectual, emotional, and moral/spiritual.

Residents were pretty satisfied overall, but if there is one area in which they were the least happy, not surprisingly it was being “physically exhausted.” Attendings fared no better. Physical exhaustion was also their biggest issue. The culprit is certainly weird hours combined with the frequently subpar physical working conditions. No matter how well I patient position and prep, I still find myself struggling to get in the right position for the in-between the toes laceration, the moving-target LP, assessing the elderly patient's gait, or trying to scoot the morbidly obese patient up in bed (or just pull them forward to listen to their lungs). I (somewhat) fondly recall in residency ducking and jumping over cords and IV tubing to get to the head of the bed to intubate a patient or getting my toes run over by an ultrasound machine. Our job requires a lot of physical work and maneuvering.

After physical exhaustion, moral/spiritual exhaustion was the second worst offender. Surprisingly, rates of satisfaction weren't all that different for younger attendings than older ones. I wonder if this means that satisfaction is intrinsic, innate? More personality and outlook, less experience or years in the profession?

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The Comments

I read each and every comment that was included in the survey, and wanted to include some of my favorites from some recurring themes.

On Fewer Shifts and Breaks:

* Time off is key.

* Our group has one month of paid sabbatical after each 17 months worked. That has been a huge help in physician wellness and satisfaction.

On Press Ganey:

* The hospital administration knows the lack of scientific validity of Press Ganey, but are unwilling to do away with it and demand that we maintain our scores. How can we value the survey of a patient physically restrained for 12-24 hours or a patient placed on a medical hold? God help our health care system.

On What Emergency Medicine Does to Us:

* I retired within the past few months. I was amazed by the relief from the feeling of oppression and “chronic impending doom” that I had been working hard to ignore over the past several years. This job had [affected] my health, both physically and mentally; at this point, recovery has begun: the “Bad ER dreams” are beginning to taper off, I've dropped 20+ pounds, and my blood pressure has normalized without specific medical intervention. I sometimes wonder whether there isn't a type of PTSD that many of us develop from the chronic stress and threats that are part of the nature of emergency medicine.

On Patient Demands, Expectations, and Entitlement:

* If patients had to be even slightly mandatorily accountable, our frustrations would plummet, like being forced to use the clinic for non-emergency care or being forced to pay one dollar for our services.

On Real Emergency Medicine:

* Perhaps one of the biggest drivers keeping me going is those occasions when I get to do what I am trained to do: “emergency medicine.” I was feeling extremely burned out a couple of months ago when I had a shift with one critical patient after the other; on top of that, I had to respond to a neonatal resuscitation that was going poorly. I was able to save that baby, and I left the hospital feeling incredible, making up for what had seemed to be weeks of feeling burned out. It seems when I do what I have been trained to do, when I take care of sick people or people with acute disease, I feel satisfied with my career choice. Unfortunately, so much of what we do now is manage expectations.

Other Themes:

* External forces (like hospital administration, checklists, and the government) encroach on our practice.

* EMRs and spending more time documenting than caring for patients.

* Night shifts.

So where do we go from here? Luckily, there's been some study about burnout. I spoke with Drew Lawson, MD, an emergency doc who contacted me after having dealt with his own burnout issues. He now helps physicians who are struggling with burnout. A few great points he made:

* Everyone feels burned out after a string of really difficult shifts, but most of us bounce back after a few days off. If you find you're not bouncing back like you used to, maybe you're experiencing a little burnout.

* Burnout has categories of symptoms, and Drew gave some suggestions on how to address all of them. If you are experiencing lack of energy and fatigue or feelings of being overwhelmed, work a little less. Go down a shift or two a month, or step down from a hospital committee or two. Also exercise better and eat a better diet. (We all struggle with this one. Who wants to exercise when you're already exhausted? And those nachos sound really, really good on night shifts.)

If you are feeling compassion fatigue or a lack of empathy, or if you are irritable, angry, or blaming, set yourself up in a positive environment. Drew recommends seeking out the positive people and developing relationships with them. Learn their secrets of happiness, and avoid the complainers as much as you can. Surround yourself in positivity, and don't participate in a rant-off, like we all love doing. (I'll fully admit, a bitchfest feels cathartic in the short term, but it's probably not very healthy in the long run.)

If you are losing interest, feeling apathetic, or asking yourself, what's the point, keep a list in your scrub pocket during your shifts. List the things in one column that bug you during a shift. Maybe it's the EMR. Maybe it's no ear speculums in the rooms. Delegate these activities, or find someone who can help you get better at them. List your cravings in the other column. What do you love about your job? Teaching opportunities? Certain patient interactions? Nurture these. Turn up their volume and their frequency in your shifts.

Thanks again to everyone who participated in the survey. Hopefully you've found this information helpful and useful. Visit the EMN website to see the survey results in graph form. (See FastLinks.)

Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available on www.EM-News.com.

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FastLinks

* See graphs of the burnout survey results at http://bit.ly/EMNBurnoutSurveyResults.

* Use Dr. Walker's medical calculator at www.mdcalc.com and his number-needed-to-treat tool at www.thennt.com.

* Read all of Dr. Walker's past columns at http://bit.ly/WalkerEmergentology.

* Comments about this article? Write to EMN at emn@lww.com.

© 2013 Lippincott Williams & Wilkins, Inc.

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