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Emergentology

Emergentology

Depersonalization, Emotional Exhaustion, Burnout

Walker, Graham MD

doi: 10.1097/01.EEM.0000791964.64273.78
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    EP life, mental health, wellness
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    About 20 minutes into my shift, I struggled to find a place to sit and put in orders. Or even stand and place orders. The ED was packed.

    The hospital upstairs was entirely full. EP colleagues were staying past the end of their shifts, charting and wrapping up, signing out and dispositioning patients. Consultants had temporarily moved in as well, commandeering workstations with residents and camping out while seeing even more patients. I had just arrived, and I should have been fresh and ready to see a number of low-acuity patients quickly, address their issues, and discharge them to make some bed capacity.

    Instead, a voice I had never heard before popped into my head, chanting a sentiment I had never had: “Wow, I hate it here.”

    “I really hate it here,” continued the voice.

    “Maybe emergency medicine isn't right for me anymore.”

    “Maybe I should do something besides medicine.”

    Never, in 13 years of shifts from residency through the present, have I ever had any of those thoughts. Not even anything remotely close. I've felt crispy and tired and numb and running on empty and exhausted, usually at the end of a long day. I've had days with only dizzy patients. Days where everyone needs a CT. Days where no one is happy or satisfied despite my trying to go above and beyond. But never before had I heard that hate-quit-leave voice. Ever. Certainly, I had never had all of those feelings at once, let alone 20 minutes into a shift.

    I felt kind of done. Over it. Over everything. Just ready to give up, no fight in me.

    I felt like a lab- and CT-ordering monkey, not an emergency physician with 13 years of medical education, training, and experience. I thought about a patient: You're old, you have had three months of abdominal pain, and you haven't seen your doctor because of COVID. Now, you can't get an appointment to see your doctor because society is opening back up. Fine. I'll do some tests that will all be normal because nothing has worsened in the past three months, and then still tell you to follow up with your regular doctor.

    Rinse and repeat with another seven patients in a row. Reduced personal accomplishment, no sense that what I do matters or has any impact on or importance to my patients' lives.

    I could barely smile at coworkers I hadn't seen in weeks. I was avoiding nurses to whom I would normally be showing vacation pictures or texting a stupid joke I saw on Instagram. In fact, I didn't even want to make eye contact with them because eye contact leads to small talk, and I didn't want to make small talk with anyone when I was so numb and empty inside. Depersonalization.

    I struggled to be compassionate toward a worried parent. A pediatric patient will normally reset me and get me out of a funk. Even if I'm having a rough shift, I'll mentally and physically pause before I walk in the room, remind myself that this is a scared child and a worried parent, and try to put myself into their shoes for a second.

    I make a joke or be silly with the kid, get a smile from him, create some rapport with mom or dad, and feel like I helped. I bring down a fever, get a smile from a crying baby, reassure a parent who will be able to sleep better tonight. But none of that charm was available that day. I wasn't even interested in trying to whip some up. I wasn't rude, dismissive, or mean, just direct and straightforward. Not cold but certainly not warm.

    “It's a subconjunctival hemorrhage,” I said. “That is very common and not dangerous. Goes away in a few weeks. Nothing to worry about. I'll print out some more information for you.” Emotional exhaustion.

    Feeling Despondent

    Just a few months ago, I wrote about languishing, and kind of summed up how I was feeling with the term medical despondency: a state of low spirits caused by the loss of hope or courage. I actually like the Latin roots more: Despondent comes from the Latin despondere, from the prefix de- (from, away) and spondere (to promise). “Away from my promise” is as good a descriptor as any, I guess.

    I'm pretty sure what I felt was textbook burnout: reduced personal accomplishment, depersonalization, and emotional exhaustion. I am thankfully feeling much better, and I have had three shifts (two of them overnights) under my belt since, and I'm wondering what helped.

    I'm also wondering when (not if) that feeling will return and what I can do about it. I was able to talk about how I was feeling with some colleagues, and I do think that helped a lot. It's one of the reasons I'm writing this, but it's also to help anyone else out there who might be feeling the same and having trouble putting a finger on it. I certainly wasn't sure what had come over me.

    From one EP to another, this is how I experience burnout. It's common, it comes surrounded by a cloud of shame and disappointment in oneself, and we need to be able to recognize and talk about it if we're ever going to make it better.

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    Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter@grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.

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    • heathjolliff11:22:52 AMAs an emergency physician and executive coach, I see burnout as a primary concern with my colleagues and clients. We all have a burnout story, and I appreciate Graham for sharing his. We must speak up and speak out for us to ever find real solutions in the house of medicine. We are in this together and together we CAN make a positive difference.