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The Ring of Fire

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POSTED: December 7th, 2017
POSTED IN: EM Pulse - The Official Newsletter of MOCEP, November/December 2017,

Written by Ken Milne, MD, and Chris Carpenter, MD

“I fell into a burnin’ ring of fire / I went down, down, down / And the flames went higher

And it burns, burns, burns / The ring of fire, the ring of fire”

Ring of Fire – Johnny Cash

This month we are going to talk about physician burnout. Our job is emotionally demanding as we often manage multiple patients and families on the worst day of their lives in a pressure cooker where the clock is always ticking to see the next patient and keep the waiting room empty while also assuming the role of transcriptionist (with our complex billing-driven EMR), primary care physician, psychiatrist and addiction specialist.

This issue of burnout was covered by Rick Bukata in 2011. The topic of burnout has only gotten hotter since Rick’s essay from six years ago. But let’s go back in time to 1974, which is even before emergency medicine abstracts started 40 years ago in 1977.

The term burnout was first coined by Herbert Freudenberger in 19741. He defined burnout as “a state of fatigue or frustration that resulted from professional relationships that failed to produce the expected rewards”.

There are a number of ways to define burnout, but one of the most widely known is by Maslach, who created the Maslach Burnout Inventory (MBI) Score2. The MBI score has three components:

  1. The first component is emotional exhaustion – This is when people express fatigue tiredness, somatic symptoms and diminished emotional resources. It can lead to increased sick days and missing shifts.
  2. The second component is depersonalization – This is when people develop cynicism, callousness or hostility towards patients or staff. It can lead to derogatory remarks about patients and/or colleagues. (GOMERS, Frequent Flyers, can’t fix stupid, etc.).
  3. The third component of the MBI score is reduced feelings of personal accomplishment. This is when people feel like they are not getting anything done at work. It can lead to poor performance and lack of motivation.

Some ACEP members may know about the MBI as it has been available as part of the Wellness Booth at the ACEP Scientific Assembly for over 25 years. In fact, EMA’s own Billy Mallon used some of that ACEP data and published some of the early work on EM physician burnout. This research group published a three-part series called: A Survey of Wellness Issues in Emergency Medicine in the Annals of Emergency Medicine.3,4,5

There was some thought that burnout leads to an increased attrition rate in emergency medicine. The number is somewhere around 1-2%/year. However, it has been challenged that burnout is associated with attrition and the issue may be more complex.6,7,8

What is clear is that physicians have reported a high level of burnout. A recent study of US physicians showed that more than 50% had at least one symptom of burnout. Emergency physicians reported the highest prevalence of burnout at around 70%.9

Different factors have been found to be associated with burnout during emergency medicine residency.10 Interestingly, a higher prevalence of burnout was seen in residents having a significant other or spouse (60% vs. 40%, p = 0.002). The authors were not sure why but suggested that peer support may help. However, burnout was not related to other demographic factors or level of training.

Other things that were correlated with burnout included:

  • Poor global job satisfaction (p < 0.0001)
  • Lack of administrative autonomy (p = 0.021)
  • Lack of clinical autonomy (p = 0.031
  • Intolerance of uncertainty (p = 0.015)

Burnout can have negative consequences on physicians and may lead to depression,11 suicidal ideation,12 illness,13 and increased alcohol use.14  It has also been associated with negative impacts on patient care including self-perceived medical error,15 risk of medical errors,16 and quality of care.17, 18

There has been a call to arms for action in preventing burnout, particularly in graduate medical education.19 But what can be done to prevent burnout?  Rick Bukata gave 17 different ways to help mitigate this problem in his 2011 essay. Here are five that we choose to highlight:

  1. Recurrent exercise, plenty of sleep and adequate time off are part of the investment to protect your career.
  2. Don’t overspend – instead save and invest conservatively. Resist the temptation to get into serious debt. Only buy the toys when you can truly afford them. Having to work because of substantial monthly bills gives physicians very little flexibility should they want the option to slow down or change occupations. And be aware that your monthly debts may suddenly be substantially and unexpectedly increased by unforeseen circumstances – divorce being at the top of the list.
  3. Don’t start out sprinting – pace yourself for a long career. Remember, younger physicians are particularly prone to burnout. Excessive work commitments can leave little time for critically important personal and family relationships and precipitate the most important element of burnout – exhaustion. Set boundaries. Learn to say “no.” Make sure there is more to your life than medicine. An authority on burnout has said, “Being a physician should be what you do, not who you are.”
  4. Become an expert in something related to your work – a specific aspect of medical practice (pediatrics, cardiology, etc.), practice management, medicolegal consulting, etc., have been associated with less burnout.
  5. Find a safe confidant. Someone with whom you can talk and share concerns and feelings. Being isolated simply adds to the risk of burnout when stressors mount. It may be another physician, a close friend or family member.

A systematic review (SR) and meta-analysis was published on interventions to prevent and reduce physician burnout.20 Most of the interventions involved resident trainees and none included emergency medicine personnel.  This is important because the fish bowl of emergency medicine is quite unique, as are the societal expectations that EM be there 24/7/365 for anyone, anything, and at any time.  Nonetheless, this systematic review provides a glimpse at approaches to alleviate burnout. 

Since we’re always emphasizing contemplation about both potential harms and benefits of interventions on EMA, we should note that the SR-noted potential harms of these interventions included decreased ability of trainees to evaluate attending physicians and vice versa with reduced work hours, perceptions by physicians of “negative effects” on patient care related to multiple hand-offs and less face-to-face time as a consequence of reduced work hours, and decreased resident satisfaction with their training program.

One intervention shown to have a positive impact on reducing burnout is mindfulness-based approaches.20,21,22 Mindfulness is paying attention to both the internal and external world, being in the present moment and being non-judgmental.

Mindfulness meditation was started about 2,500 years ago by Buddha, not to cure illness but rather to end mental suffering. It spread out from Northeastern India near Nepal and eventually was discovered by the Western world in the 1800s with British colonization.

There was another wave of mindfulness into the West in the mid-20th century. The Beatles were a huge part of bringing meditation and mindfulness to the West when they became practitioners. Another wave was from the Peace Corp in the 1960s. Young Americans went to the East, became interested in Buddhism and meditation, and brought that back to the US.

In 1975 a group of individuals started the Insight Meditation Society in Massachusetts. Then, in 1979, a molecular biologist from MIT named Dr. Jon Kabat-Zinn started the Mindfulness Based Stress Reduction (MBSR) program that consisted of an eight-week course. It was first used as an adjunct to regular medical treatment for patients with chronic pain and other chronic illnesses.

Researchers have been looking at the therapeutic effects of mindfulness ever since. If you search “mindfulness meditation” in PubMed you get close to 1,500 hits. One hit is for an RCT using mindfulness to reduce stress and burnout in interns on their emergency medicine rotation.23 This RCT was published after the systematic review we mentioned earlier. This study showed that a ten-week mindfulness training intervention significantly reduced stress and burnout.

I do mindful meditation once or even twice a day with an app that gives me a ten-minute guided meditation. I use it first thing in the morning when waking up or when I arrive ten minutes early for my shift and listen to it in the car. It really makes the shift much more enjoyable. The other time I use it is at night to help me unwind before going to sleep. It clears out the day and helps me to relax and fall asleep. There are a number of apps available but the one I mainly use is called Headspace.  https://www.headspace.com

More research will be available on mindfulness for emergency medicine. Diane Birnbaumer and I have started a research project that will incorporate an eight-week mindfulness intervention. The population is the group FEMINEM (Females in Emergency Medicine). https://feminem.org. The primary outcome is the impact on the Maslach Burnout Inventory.

One important point we want to make is that preventing burnout cannot just be placed on the individual. We do not want to blame the emergency physician and say they have to be more resilient. There is also a problem with the system and that needs to be addressed at the same time.

Reducing stressors in “the system” is much more than rhetoric – it is essential if society wants to retain talented and compassionate healthcare providers throughout a career, yet the business of medicine and political correctness have colluded in recent decades with developments like EMTALA (the U.S.’s only unfunded mandate as far as I understand it, with every U.S. EM physician delivering over $100,000 of unreimbursed care every year), EMRs, the malpractice lawyer’s zero-miss mentality, and an increasing expectation that every ED is like a fast food restaurant with no wait and a menu of options from which one can order.  Personally, I think healthcare systems would be wise to follow the Stanford model – last month they hired the first Chief Physician Wellness Officer.  In 2015 Stanford Emergency Medicine introduced the “time banking” program that permits their physicians to count time spent on traditionally undervalued activities like hospital committee meetings, reviewing for journals, research manuscript writing, and mentorship.

Clinicians should try to minimize the negative impact of the system while it is being improved. If you feel like you are suffering from burnout there is help available. If you are a resident there should be a wellness program available to you. If you are an attending physician various local and national resources are there if you need them. Here are just a few of those resources:

We have a wonderful job and can have a fantastic career. However, we should not be consumed by the practice of emergency medicine.

I recently read a fabulous book that helped me to conceptualize burnout in my professional life and reshape the pace and priorities that I place upon my work tasks.  “When Breath Becomes Air” describes the experience of the late neurosurgeon Paul Kalanithi who was diagnosed with late stage lung cancer during his final year of residency training.  He and his wife Lucy vividly describe the experience of transitioning from physician to patient – and the realization that time is finite for all of us.  Does Paul return to his life’s work of neurosurgery when he has perhaps two years to live just as his career is taking flight?  How do we weigh the values of our work with our life outside of work?  Paul and Lucy don’t provide answers, just their experience and how seemingly small decisions or interactions can carry a tremendous impact on us and those we care about.  Be prepared to cry when you read this book.  None of us should go down, down, down into that burning ring of fire.

Be well and don’t forget to breathe.

References:

  1. Freudenberger HJ. Staff burn-out. J Soc Issues 1974;30:159–65
  2. Maslach C, Jackson SE, Leiter MP. 1986. Maslach burnout inventory. Palo Alto (CA): Consulting Psychologists Press.
  3. Lum G, Goldberg RM, Mallon WK, Lew B, Marguties J: A survey of wellness issues in emergency medicine (part 1). Ann Emerg Med January 1995;25:81-85
  4. Lum G, Goldberg RM, Mallon WK, Lew B, Margulies J: Annotated bibliography: A survey of wellness issues in emergency medicine (part 2). Ann Emerg Med February 1995;25:242-248
  5. Lum G, Goldberg RM, Mallon WK, Lew B, Margulies J: Annotated bibliography: A survey of wellness issues in emergency medicine (part 3). Ann Emerg Med March 1995;25:407-411
  6. Ginde AA et al. Attrition From Emergency Medicine Clinical Practice in the United States. Ann Emerg Med. 2010;56:166-171
  7. Hall KN et al. RESIDENCY-TRAINED EMERGENCY PHYSICIANS: THEIR DEMOGRAPHICS, PRACTICE EVOLUTION, AND ATTRITION FROM EMERGENCY MEDICINE. J Emerg Med, Vol. 17, No. 1, pp. 7–15, 1999
  8. Mallon WK. Letter to the Editor. J Emerg Med, Vol. 18, No. 2, pp. 259–264, 2000
  9. Shanafelt TD et al Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613
  10. Takayesu JK et al. Factors Associated With Burnout During Emergency Medicine Residency. Acad Emerg Med 2014;21:1031–1035
  11. Martini S, Arfken CL, Churchill A, Balon R. Burnout comparison among residents in different medical specialties. Acad Psychiatry 2004;28:240–2.
  12. Shanafelt TD, Balch CM, Dyrbye LN, et al. Special report: suicidal ideation among American surgeons. Arch Surg 2011; 146: 54–62
  13. Lemkau JP, Purdy RR, Rafferty JP, Rudisill JR. Correlates of burnout among family practice residents. J Med Educ 1988;63:682–91.
  14. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg 2012;147:168–74.
  15. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006; 296(9):1071-1078.
  16. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6): 995-1000.
  17. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997; 44(7):1017-1022.
  18. Grol R, Mokkink H, Smits A, et al. Work satisfaction of general practitioners and the quality of patient care. Fam Pract. 1985; 2(3):128-135.
  19. Ripp JA et al. Well-Being in Graduate Medical Education: A Call for Action. Academic Medicine: July 2017 – Volume 92 – Issue 7 – p 914–917
  20. Ireland MJ et al. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Medical Teacher, 2017 Vol. 39, No. 4, 409–414
  21. Forntey L et al. Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study. Ann Fam Med 2013;412-420. doi:10.1370/afm.1511.
  22. Krasner MS et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA, September 23/30, 2009—Vol 302, No. 12
  23. Ireland MJ et al. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Med Teach. 2017 Apr;39(4):409-414.

 

 

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