Written By Gary Gaddis MD PhD, Professor, Emergency Medicine, Washington University in St. Louis
School of Medicine
One of the occupational hazards of being an emergency physician is “burnout.” A “burned out” physician has often begun to hate their job, and dreads going in for their next shift. To be a “burned out” physician is not good for patients, physicians’ families, and especially physicians. Much has been written about the topic of burnout, and it is said that over 70% of emergency physicians either suffer from it sometime in their career, or have it now.
In this essay, I will make the case that becoming involved in organized medicine, an opportunity such as the Missouri College of Emergency Physicians (MOCEP) can provide, by membership on a committee or by eventual leadership within MOCEP, is a great thing to do. Such activities are likely to decrease your risk of becoming that burned out physician you never wanted to become. Or, perhaps it represents a “way forward” to fight your incipient or pervasive sense of burnout with which you battle now.
When we are young, the newness and excitement about what we do for a living is enough to carry us forward with enthusiasm. However, that newness often wanes over time, just like the newness wore off from your favorite toy you were given as a child. Despite this, career burnout does not have to be inevitable for you. My goal is to suggest a way to return or reinforce the joy you first had in this difficult calling of a specialty.
We are a specialty at risk for this problem for a number of reasons:
- Patient expectations: Patients typically arrive to an emergency department thinking that they may have an emergency condition that threatens their life or health. Indeed, the right to a medical screening exam is enshrined in the Emergency Medicine Transfer and Active Labor Act of 1986, which we know as EMTALA. At its core, EMTALA is a non-discrimination statute that obligates us to see everyone and stabilize those who need stabilizing, while doing so without regard to a patient’s ability to pay for our services. This channels the egalitarian impulse shared by many of us, who not so secretly hate it when we have to “fast track” a “VIP.” Most people present with issues that could be an emergency. Fortunately, many patients can begin to have their evaluations started in the waiting room leaving rooms for patients who are sicker. However, a patient who fears for their life often does not understand why they must wait to get to a room or why another patient is seen ahead of them. Therefore, patients often don’t tolerate reasonable waiting times well, and they may complain when they think we are not addressing their problem with sufficient speed and gravity.
- Doctor response: I bet all of us can channel these would-be responses to patients who complain about the wait to see us:
- “I know no one likes to wait, including myself. Indeed, when I go get fast food, I gauge whether the walk-up or drive-through will be faster, and I pick that line. Yes, you have had to wait for me. However, I am pretty certain that it took less time than it would have taken to see your primary care doctor in their office. And, as a bonus, when you leave, I can tell you your test results, rather than sending you off at the end to go to the phlebotomist for tests who results you may not get back for a week.” OR
- “I know you’ve had to wait, but I was working to be careful with every one of my previous patients, rather than rush through things and make a mistake. I am sure you don’t want me to rush and not be careful with you, and I am sure you will understand that the other folks I have cared for didn’t want me to do that either!”
- Doctor response: I bet all of us can channel these would-be responses to patients who complain about the wait to see us:
- Doctor expectations: Most of us went into emergency medicine because of the variety it offers and the opportunity to “save lives”. Well, as to variety, we have that in spades. However, we still do our patients a lot of good even if we determine they don’t have a life-threatening illness. Once an emergency physician figures out that they can alleviate fear and give good news more often than we actually save lives (such as by interpreting that a head ache is due to carbon monoxide, and thus saving a family from asphyxiation), they will be happier. Plus, we can derive joy by allaying fear much more often than we encounter those dreaded requirements when we need to give bad news. So, the next time you go to work, take on the attitude that you know you are going to be able to tell several people that they don’t need to heed their worst fears. Yes, they will die some day in the future, but probably not of the condition for which they are being evaluated by you! Channeling a 1980s movie starring Bill Murray here, as an emergency physician, you are a bona-fide “Fear-Buster.”
- Administrators: This is such a topic unto itself that that I will not belabor here, but at its core, it is best to remember that administrators are generally fair-minded persons with a strong ethical bent, whose priorities may differ from yours. It is good to give these folks the benefit of the doubt, where appropriate. Their job description is not the same as yours. While we like to focus on the patient in front of us, someone has to look out for the bigger picture which at times may place them at odds with the practitioner delivering care.
- Bottom line: It is never bad to try to walk a mile in someone else’s moccasins even if you don’t agree.
- The Electronic Health Record: Again, I could not cover this in sufficient detail in this column. I keep repeating these two mantras:
- The E.H.R. is like an itemized receipt to the party that pays for my services. I’d not give anyone else a blank check, and neither should the insurers or the government give a blank check to me. I owe those who reimburse for my services the courtesy of providing an itemized receipt. (This is what I say when I’m in a good mood.) OR
- “The presence of more data does not necessarily confer the presence of a greater amount of accurate and useful intelligence” (Sometimes, we have to resort to “gallows humor”).
- “Temporospatial Disorientation” or “Circadian Disruption”: To me, this is the hardest thing about our job. Sometimes, I think I should have thought things through better, before I matched in emergency medicine in 1986. I thought it was an attractive thing that so many leaders of the specialty were young. Well, perhaps the demands of the job scared the older guys off! (And, that was before academic emergency physicians actually stayed up all night with their residents…they did not start doing that until the late 1980s.) This circadian challenge has, for me, been the hardest thing.
- Job insecurity: An emergency physician’s job is only as secure as his or her group’s relationship with other doctors in the hospital, and the administration. The best way to become expendable at the hospital is to avoid becoming an active and integral part of your hospital’s “family.” So, welcome the opportunity to serve on a committee. Socialize with peers from other specialties. Become family. Your experience will be richer for it. Job security will benefit, too.
- Threat of Malpractice: I can’t make this go away, and neither can you. Having been named as the alleged perpetrator of a civil tort, malpractice, I can attest that it will disrupt your “dharma.” However, I will state right here and now that I have settled in a matter of alleged liability, my name appears in the National Practitioner Data Bank, and yet I was recently added to the medical staff at Barnes Jewish Hospital, where I am a Professor of Emergency Medicine at Washington University in St. Louis. If my prior settlement was going to wreck my career, this appointment could not have occurred.
- We all strive for perfection, but we are all human, and we all make errors.
- Sometimes, those errors come back to bite us, other times not.
- However, to have your name appear in the NPDP associated with a settlement is NOT a career-ending event.
- To say more about the issues that torts present to us is another conversation for another day, but let’s de-mystify something and de-stress you a bit RIGHT NOW. To settle a case or two will not make you a pariah and will not end your career. At the end of the day, as W Edwards Deming, the father of modern quality improvement said, “All processes were designed to give EXACTLY the outcomes that they deliver.” We live and work in a process-intensive world and a litigious society. We are powerless to prevent all If you make peace with this fact, it will help your fear level to abate.
- However if are unfortunately going through this, ACEP does have resources that may be able to help you with what we know is a difficult time in your life.
All of this said, our specialty has some great aspects, too. You never have to worry about whether a tee time is available in the middle of the week, and you never have to fight crowd shopping during the holidays unless you simply fail to plan ahead.
However, no matter how exciting it is/was to be a resident, at some point, all of the “newness” of the specialty wears off, for most, if not all of us. I know that it takes an awful lot to get my sphincters tightened or my heart rate up any more. Not that I have seen it all, and not that I am blasé or careless, but really, how many heart failure resuscitations or procedural sedations does one need to do before the passion for this specialty starts to wane?
- Reinforcing humility and gratitude: I have volunteered and will continue to volunteer to be a Missouri State Medical Association “Doctor of the Day” during the legislative session. As the “Doctor of the Day,” one gains the opportunity to be introduced to the entire House and Senate, and one has the opportunity to see first-hand the general esteem with which we are held, as a profession. In addition, one gets to meet their State Senator and Representative. I make sure to mention that I am an emergency physician and I say a thing or two to them that are of interest to us as a specialty. Additionally, every January MOCEP organizes an Advocacy Day which is a chance to meet with your state representatives and senators and discuss important issues. More on our self-interest, in a minute.
- Activity in organized medicine: If there is some medical issue about which you are passionate, it is highly likely that other like-minded persons exist in your hospital and in your specialty. Organizations like MOCEP help you channel your passion with other like-minded doctors.
So, here comes the “pitch”. The Legislature of the State of Missouri passed the “Daubert” expert witness standard in 2017. This did not happen in a vacuum, but it benefits us all because we all deserve to have real experts and scientifically reliable information to guide a jury. As we in the medical community move toward a more evidence-based practice, this new standard represents an effort to move the judicial system toward a more uniform, systematic method of evaluating expert testimony. This was one of the wins for MOCEP this year in coordination with caring and involved doctors in multiple organizations.
Our Board of Directors is always actively looking to diversify with members from different backgrounds and of different genders, races, orientation, and nationality. Even if you do not want to be on the board, there are multiple opportunities to participate in committees. Additionally, our board meetings are open to all of our members.
MOCEP leadership greatly wants more community physicians, women, and smaller-town doctors to join our committees, add your voices, and cultivate your leadership potential. Diversity makes us better and more effective.
A characteristic of a strong organization is the possession of a good succession plan and a deep “bench” from which future leaders are drawn. MOCEP has a very clear succession plan, but a thin “bench.” And, that is where you potentially come in.
I think that if you would choose to become involved with MOCEP, you would gain more than you’d give, because at the end of the day, to be involved actively and passionately with others of a like mind is one of the best ways to alleviate burnout.