According to a survey published last year, nearly two-thirds of emergency medicine physicians report burnout, the highest among all specialties. In some ways, this is unsurprising. Emergency medicine is a hard job. We treat multiple ill patients simultaneously in a chaotic environment with little control over patient volume.
Emergency physician burnout has always been high, but it’s spiking. The average shift is harder. Post-pandemic patients are sicker and more complex. Nursing shortages have decimated emergency department (ED) and hospital efficiency. EDs are more dysfunctional. Boarding has increased. The result is fewer ED resources and less space. Rates of patients leaving without treatment are way up.
Another factor: erosion of emergency physician payments. The federal No Surprises Act was intended to protect patients, but it has been weaponized into a tool for insurance companies to withhold fair reimbursement to physicians. The federal government is also cutting Medicare payments to emergency physicians.
During the pandemic, emergency physicians were heroes. That applause has receded. U.S.-based medical students are avoiding emergency medicine. Emergency physicians are leaving practice. Emergency medicine social media pages are on fire. Some blame emergency physician practices for the situation. The undercurrent of social media posts: anger about a deteriorating work environment, threats of lower pay, and the fear it’s getting worse. Exhaustion, cynicism, and a perception of diminished accomplishment — what psychologist Christina Maslach, PhD, calls the burnout trifecta — are the result.
Some say burnout is destroying emergency medicine. We beg to differ — we believe there are tangible ways for hospital administrators, government, and physicians themselves to combat emergency medicine burnout and foster success.
Address ED Inefficiencies
Let’s push hospitals to fix our EDs. This means fixing ED boarding, which stems from insufficient hospital capacity and inefficient processes. While increasing staff numbers may be near impossible at present, re-engineering inefficient hospital processes is not. It’s time for known solutions, tactics like push versus pull, full capacity protocols, surgical schedule smoothing, early hospital discharges, bed czars, and so on. Ultimately, keys to success in implementing programs include the involvement of emergency physicians, utilizing organizational resources, exhibiting strong hospital leadership, and a sense of urgency.
EDs are a public service regulated under the Emergency Medicine Treatment and Labor Act and funded in part by government insurance. Therefore, the government needs to hold hospitals accountable for delivering functional ED care. The Joint Commission should also enforce its own patient flow standards. If prioritized, efforts would undoubtedly improve patient care and reduce burnout. And we as emergency physicians, should take an active role.
Promote Career Development
It might seem paradoxical to recommend career development, which involves doing more with our careers, when data demonstrates we are burnt out from work. Yet, building an area of focus can prevent burnout.
In our experience, the least burnt-out emergency physicians have developed a niche, or area of expertise. That may be a clinical niche like critical care, or a non-clinical niche like research, teaching, or administration. They balance ED shifts with their niche, which may be 80% clinical and 20% niche, 50%-50%, or even 20%-80%. A niche stimulates new cognitive challenges, establishes a platform to solve problems, provides respite from empathy fatigue, creates positive relationships with colleagues, expands our skill sets, and more — all of which combat burnout.
Advocate for the Specialty
Our government needs to address the faulty implementation of the No Surprises Act. This means fixing the arbitration process. It means creating disincentives to insurers for withholding payments and for pushing physician groups out of network. It means not gutting our Medicare payments. At the Medicare Payment Advisory Commission’s (MedPAC) December meeting, commissioners unanimously agreed that trajectory of payment declines for physicians was unsustainable and should be updated. MedPAC noted that despite the lower physician payments, access to care for Medicare patients remained robust. Applying this logic to EDs is misguided. Unlike other specialties, we have to care for every patient who walks through our doors, including Medicare patients.
How do we advocate for our interests? Through organized action. This could mean with your own practice, partnering with several practices, or with professional societies. Joining groups like the American College of Emergency Physicians, the Emergency Department Practice Management Association, and others can help you network and advocate for emergency physician interests and work towards addressing the external drivers of burnout.
Increase Resiliency
We list resilience last. Advice to “get tougher” is never easy to deliver or hear. Resilience is about adaptation in the face of challenge. Self-care is key — nutritious diets, regular exercise, enhanced sleep, avoiding toxic substances (including excessive smartphone and social media use!), and stress reduction strategies like practicing gratitude, journaling, meditation.
You don’t have to do it all at once. But focusing on addressing at least one element can have significant impact. Emergency physicians can also take restorative actions on shift: eating something healthy, walking outside for a moment, or simply taking a bathroom break. Boundary rituals allow you to leave work at work, rather than bringing it home.
Skeptics denigrate such recommendations, exclaiming, “Don’t tell me to meditate when the ED is crumbling!” We are not suggesting that these are operational cures. But they can help empower you to avoid becoming consumed by work challenges. Don’t believe us? Try gratitude — say thank you to three people today. Be genuine and be specific. Try turning your phone off for a few hours. It just might make you feel less upset and defeated, especially if you can make it a habit.
We also need to consider reframing how we view our job. Yes, it is challenging. That’s a reason we chose it! It is easy to dwell on issues we can’t personally fix. It is also easy to lose sight of the privilege it is to care for patients on their worst day, or forget we are in the top 5% of U.S. wage earners and well above the top 1% worldwide. We should understand that “moral injury,” like physical injury, can be a temporary and treatable condition.
We are living in a dark time in emergency medicine’s history. Listening to negative voices will amplify, not reduce, this darkness. The road to success for emergency physicians is paved not with victimhood, but with empowerment. This can only occur when we push for improvements in our environment, our development, our specialty’s standing, and ourselves.
Jesse M. Pines, MD, MBA, MSCE, is chief of clinical innovation at US Acute Care Solutions, a professor of emergency medicine at Drexel University in Philadelphia, and a clinical professor at George Washington University in Washington D.C. Amer Aldeen, MD, is chief medical officer at US Acute Care Solutions.
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