Don't talk to Pamela Wible, MD, about burnout. She doesn't like the term, which she sees as blaming and shaming physicians who are victims of a system that bullies and insults those who are “the crème de la crème” of academic success.
Burnout is epidemic in the medical world, and it particularly affects emergency physicians and residents, who often rank highest in surveys that measure such things. Burnout first got its name in 1974 when psychologist Herbert Freudenberger, PhD, defined it as a prolonged response to chronic emotional and interpersonal stressors on the job characterized by emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment. (J Soc Issues 1974;30:159.)
Dr. Wible focuses her time on burnout (for lack of a better term) and its most extreme consequence—suicide. It was at a memorial service for a physician who committed suicide that she became aware of how many physicians were dying. Five years later, she has counted 723 physician suicides, and is not sure she has captured them all. Writing and speaking on the topic, she calls it a public health crisis that affects the medical community and patients alike. Among those whose deaths she has chronicled are “happy” doctors who took their lives after trips to Disneyland, planning a vacation while having professional and personal crises.
Medical students and residents who commit suicide may have failed exams or failed to match to a residency. Her blog tells the stories of the physicians and their families who seek help in dealing with a system that is exacerbated by “assembly-line medicine” and long hours with little sleep in a system with ever-growing expectations. (www.idealmedicalcare.org/blog/)
Emergency physicians do, however, experience burnout much more frequently than other physicians in general and more than anyone else inside or outside medicine, according to one study. (Arch Intern Med 2012;172:1377.) The percentage of emergency physicians reporting burnout exceeded 65 percent compared with 55 percent in the next most taxed medical specialty, internal medicine. Nearly 28 percent of the general population in comparison considered themselves burned out in their professions or jobs.
Burnout rates vary among surveys. The Medscape National Physician Burnout and Depression Report 2018 placed emergency physicians lower on the list for the most burned out at 45 percent behind critical care and neurology (48% each), family medicine (47%), and OB/Gyn and internal medicine (46% each). (The lowest? Plastic surgery [23%].) No matter where emergency physicians place on such surveys, the problem is real, affects the whole health care system, and can start in medical school.
In the Beginning
Dr. Wible said that's when these gifted, highly intelligent students find a system based on fear and rote. “It's a memorization and regurgitation cycle when they need more foundational knowledge about processes,” she said. “The attendings grill people and humiliate them in front of one another. They pit one student against another.” One physician told her that her time in the military in Afghanistan was less stressful than medical school. “At least she knew who was on her team,” Dr. Wible said.
A study done by Liselotte N. Dyrbye, MD, of the Mayo Clinic in Rochester, MN, and colleagues from a host of U.S. medical schools found that 49.6 percent of the 4,287 medical students at seven medical schools reported burnout and 11.2 percent reported suicidal ideation. (Ann Intern Med 2008;149:334.)
The problem grows worse when students move into residency. Sixty-five percent of 281 emergency medicine residents met the criteria for burnout using the gold standard Maslach Burnout Inventory, according to a study led by the leaders of eight emergency medicine residency programs. (Acad Emerg Med 2014;21:1031.) They found that poor job satisfaction overall, lack of administrative and clinical autonomy, and intolerance of uncertainty correlated with burnout.
“I think we were all surprised when the burnout rates came back this high,” said Edward Ramoska, MD, MPH, a clinical professor of emergency medicine at Drexel University College of Medicine and an author of the study. “Is this real? We all went back and rechecked the numbers. Yet, recent articles suggest that the burnout rate for attending emergency physicians seems even higher. Limitations of our specialty are that we deal with high-acuity patients and large volumes, and we move really fast. I don't think it's a permanent effect. Looking back on my own career, I see there were times, in retrospect, that I was burned out.”
He changed jobs when that happened, staying in emergency medicine but taking on administrative roles while practicing clinically part-time. “Some of it is that it correlated with things like lack of clinical and administrative autonomy,” he said. “You don't have control over your work environment, and you feel beat down by that.”
Dr. Ramoska said he had no data but suspected that the time of year or the length of time in the residency could affect the rate of burnout. “I would be curious to know if at different times of the year or at different levels in training, the burnout rate changes,” he said. “An intern starts in July, and by January or February is six months into training. It is dark and cold in much of the country, and the residents are fully sleep-deprived. Is that worse than a third-year resident in May or June? I'm not sure that you get burned out and stay that way forever.”
“The first couple of months of internship are a big shock. Medical school teaches you fact, but it doesn't teach you to be a doctor,” he said.
But the important factor is that different organizations and governmental entities set rules for physicians and residents, with hospitals controlling much of the practice environment for emergency physicians. That is true in medicine as a whole, not just emergency medicine.
Dr. Ramoska said, for example, that the hospital is responsible for hiring nurses, and physicians can complain if one's performance is subpar, but it is different from a private practice where that nurse can be counseled or let go. “You see patients and they get sent up to the floor to be admitted. You have less control, which can lead people to feel overwhelmed and emotionally exhausted,” he said.
The effects on patient care are difficult to study, but a team led by Dave W. Lu, MD, MBE, an assistant professor of emergency medicine at Tufts University School of Medicine-Maine Medical Center in Portland, asked residents and emergency physicians about the quality of care they delivered. (AEM Education Training 2017;1:55.) Those identified as having the highest level of burnout reported that they delivered suboptimal care more frequently than those who did not score high on burnout measures.
Among those suboptimal practices were admitting or discharging patients early, not discussing options with patients or answering their questions, ordering more tests, not treating the patients' pain, not communicating important information during the handoff to another team, and not discussing treatment plans with the staff. The study found that 31 of the 58 residents with burnout scored lower on performance ratings than those with no evidence of burnout.
Dr. Lu and his colleagues also used the Maslach Burnout Inventory to measure burnout in residents in a single program and asked emergency medicine faculty to identify the burned out trainees. (AEM Education Training 2017;1:75.) The study found that faculty were poor at identifying residents affected by burnout.
Even the Accreditation Council for Graduate Medical Education requires a program to address burnout in trainees, though they don't recommend one. And there lies the problem. “I don't know if anyone has a good way to monitor and address it,” Dr. Lu said.
A group of Turkish emergency physicians took a stab at identifying and monitoring burnout in emergency medicine trainees using Serum S100B as a surrogate biomarker. Serum S100B is a growth and differentiation factor introduced as a marker for mood disorders. Led by Bedia Gulen, MD, of the department of emergency medicine at Bezmialem Vakif University in Istanbul, researchers from three university emergency departments in Turkey measured burnout using the Maslach Burnout Inventory and depression using the Beckman Depression Inventory in 48 emergency medicine residents.
The residents took the inventories prior to their shifts, and blood was drawn to measure the biomarker levels before and after each shift. The researchers found that levels of S100B correlated with depression scores and emotional exhaustion, suggesting it could be used as a marker to screen for residents at high risk for depression and burnout. (Acad Emerg Med 2016;23:786.) The authors noted that more concrete data were needed to state certainly that the biomarker could be used as a screen.
Dr. Gulen did not respond to repeated emails, but Ryan P. Radecki, MD, a clinical assistant professor of emergency medicine at the University of Texas Health Science Center at Houston and the editor of the blog Emergency Medicine Literature of Note (http://www.emlitofnote.com/), evaluated the report and noted that it was not specific to emergency medicine residents. “I think this is a convenience sample,” he said. “Generally speaking, if you are sleep-deprived and bullied, you will get this sort of ‘brain damage’ as evidenced by the activation of these glial proteins.
“There's virtually no value to this approach,” he added. “If the gold standard is a burnout survey, then just use the survey rather than drawing blood. It's also probably not particularly surprising that these residents are susceptible to burnout as the authors stated that were under great workloads.”
Lack of Control
The current environment of emergency medicine and medicine places special stress on emergency physicians and trainees. Keeping current with advances in medicine and their requirements is difficult, and “most people complain about the lack of control over their daily work,” said Dr. Lu. “Electronic medical records, billing requirements, and patient satisfaction scores along with other administrative activities can increase the stress. There are things to document, and if you don't, you lose bonus pay or become subject to disincentives.”
Talking to emergency medicine residents and physicians about mindfulness, meditation, and exercise will be of minimal help when they know the problem is the system and environment in which they practice, Dr. Lu said.
Those whose burnout is accompanied by depression should seek help, but many are scared off by the risk of coming before their state's medical board. That happened to Susan Haney, MD, when she reported her own psychiatric history. She assured the medical board that her problem was not substance abuse, but that treatment was the only kind offered by her state's physician health program. She has a controlled mental illness, but has to undergo urine tests and avoid any kind of incidental exposure to drugs or alcohol. She has undergone eight different evaluations for substance abuse, and the expert agreed each time that drugs and alcohol were not her problem.
Such programs are also extremely expensive, and Dr. Haney estimated that she spent more than $1 million trying to stay in practice.
Three experts in physician burnout—Tait D. Shanafelt, MD; Liselotte N. Dyrbye, MD, MHPE; and Colin P. West, MD—unequivocally laid the cause of burnout at the doorstep of the system, not those who work in it. (JAMA 2017;317(9)901.) “Burnout is a syndrome of exhaustion, cynicism, and decreased effectiveness at work,” they wrote. Pointing out that the first study of the phenomenon in medicine dates only to 2011, they noted that it is difficult to put it into historical context, but they estimated that across the board, the prevalence of burnout among practicing U.S. physicians exceeds 50 percent.
They blamed an excessive workload, clerical burden, and inefficiency in the practice environment, a loss of control over work, problems with work-life integration, and erosion of meaning in work. Technology has improved the workload in many professions, but electronic health records have increased the clerical burden on physicians, they said.
The authors recommended that health care institutions make physician wellness a marker of organizational wellness. “Supervisors [who may or may not be physicians] who lead physicians need to recognize the key effect they have on the well-being and professional fulfillment of those they lead,” the authors wrote.
The special report, “Hospitalists, Emergency Physicians, and Cross-Subsidization,” in the February issue incorrectly identified the leader of Brevard Physician Associates' Emergency Medicine Division. The CEO is Marty R. Brown, MD. A corrected version of the article can be found at http://bit.ly/2Gi69kO. EMN apologizes for the error.
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