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ER Goddess

ER Goddess

A Career in Medicine is a Cruel Mistress

Simons, Sandra Scott MD

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doi: 10.1097/01.EEM.0000480792.15749.46
    This grainy photo of an emergency physician crying after his 19-year-old patient died went viral last March with a caption that also said, “Within a few minutes, the doctor stepped back inside, holding his head high again.”

    ‘A hospital is people,” said the nun at candy-striping orientation. I was 15. The vibrancy of my crisp, new red-and-white-striped uniform was matched only by the sickening perkiness of a vibrant, young, Pollyanna-ish future physician.

    Fast forward 25 years. “Hospital admin wants you to improve your wait times and satisfaction scores,” said my boss as I walked in for my nightshift. I'm 40. The mandated “Doc Vader” black of my scrubs is appropriately dark for the gloominess of an exhausted middle-aged snarky emergency physician. Where is the satisfying career I envisioned two and a half decades ago? What happened to the most noble profession?

    After years of work to become a physician, I'm crestfallen to see the chasm between everything that young, Pollyanna-Sandy had hoped and the harsh reality of a career in medicine. These days, bureaucracy drowns our beloved profession in countless ways, and satisfying moments are quickly suffocated by frustration. For starters, wait time, length of stay, and patient satisfaction requirements are rammed down our throats. It is no longer OK to rule out medical emergencies competently; now we have to do it faster while making everyone happy. Somewhere along the way, it stopped being all right for us to be human.

    It is not natural to smile and take it when someone is getting crazy with us, but we endure the verbal abuse in the name of the almost-superhuman professionalism expected of us. It is not natural to ignore our compassionate human instinct to sit and hold the hand of a young terminal cancer patient, but we hurry out of her room because time spent consoling her directly conflicts with our responsibility to hustle through the tooth-pain patients and keep the wait time billboards under 10 minutes.

    We spend more time in front of computers than with patients and have essentially turned into highly paid secretaries, sitting and entering Foley, ECG, and saline lock orders. We stay late, unpaid, to complete a ridiculous amount of data entry into inefficient EMRs so we can keep up during our shifts, yet it seems patients and administrators are never happy.

    Nonclinical Benchmarks

    The biggest slap in the face was being told that administration would start firing doctors for suboptimal patient satisfaction scores. It is ludicrous that we now have to worry about losing our jobs over nonclinical benchmarks, and it is bastardizing the art of patient care into the business of customer service. We are doing more with less, and the bar is perpetually being raised higher. Something has to give. Liz Crowe, a pediatric critical care social worker in Queensland, Australia, beautifully encapsulated the stress of it all in her talk at the 2015 Social Media and Critical Care Conference: “What people ask of doctors, nurses, teachers, social workers, and the police is that they want us to absorb all the really foul, beat-up part of the world, and they ask us to keep it to ourselves. ... The only time we're ever really scrutinized is when we beat up. ... Suddenly we're on the front of the paper because someone was in a hallway on a trolley for six hours, 16 hours, 60 hours for an ear infection.” She is right. (Listen to a podcast of Ms. Crowe's talk at

    What is all this stress doing to us? Two words: Physician burnout. Too many physicians are feeling demoralized and wondering if it is worth it. Fed up with feeling devalued, I recently emoted to my boss, “If they are going to start firing docs over wait times and Press Ganey scores, I don't even want to be in emergency medicine anymore.” It is not an uncommon sentiment.

    One of my favorite colleagues, another young mom, is leaving the ED to do urgent care because she is getting burned out. Constantly feeling like we are falling short of unrealistic expectations will do that. Where is the positive feedback? What about nurse and physician satisfaction? Sadly, it seems that nobody cares about the caretaker.

    What can we do to address the physician burnout epidemic so we can keep seasoned emergency physicians where the emergencies are and prevent them from being pushed into urgent care or out of medicine entirely?

    • We need to manage the expectations of ED patients more realistically so they are not expecting the equivalent of a Morton's steakhouse meal at Burger King speed and price.
    • We need to be unencumbered with patient-encounter scripts. No patient is the same, and no physician is the same. Heartfelt empathy is rarely scripted.
    • We need to be able to tell patients no when appropriate without being afraid for our safety when they become enraged or for our job because of Press Ganey ramifications.
    • We need to take actions for self-care, like saying no to excessive shifts and ungodly hours, and we need more resources for physician mental health.
    • Hospital management needs to embrace the concept that happy nurses and happy physicians lead to happy patients. “A hospital is people.” Employees should be treated like people, not revenue generators.
    • We need positive feedback. A patient recently said, “Thanks for being on it. You knew what you were doing,” and it meant the world to me. We can't expect patients to thank us, only cherish it when they do, but we can promote more praise among health care teams.

    Now more than ever, in the maelstrom of modern medicine, we need beautiful moments to keep us treading enough to hold our heads above water. Uplifting connections have been the life preservers to my inner Pollyanna. A priceless example is the patient I saw one December who returned to my ED for no reason other than to thank me. “You don't recognize me?” she gushed with a huge grin as she wrapped me in a ginormous hug. “I'm your Christmas miracle! If it weren't for you, I wouldn't be here.” That five-minute reunion lifted my morale enough to undo years of the soul-sucking stuff with which we deal. That is why I do what I do, and that is what we need more of. So, please, thank a physician today. Thank your team. Give positive feedback. We live for that stuff, and you may just be pulling someone out of a dark place.

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