A pivotal 2012 study by Shanafelt, Boone and Tan found that almost half of all physicians report at least one symptom of burnout. They found that the highest rates of burnout were in those specialties that are “front-line”, specifically primary care and, you guessed it, emergency medicine. Those of us toiling in high-demand and low-control health care areas are exposed disproportionately to excessive stress, emotional exhaustion, depersonalization, and a low sense of personal accomplishment. Moreover, when compared to other US workers, as you would expect, physicians in general work more hours and experience more burnout symptoms. These findings are alarming, and it is only recently that this problem has been recognized in the profession. Little has been done by our health care leaders and institutions to tackle this issue.
Why is this issue important? Why not tell physicians to just “suck it up”? Because burnout has been associated with increased substance use, broken relationships and suicide ideation. Moreover, burnout can affect the delivery of health care by negatively affecting patient safety and patient outcomes. In the fast-paced world of emergency medicine with exposure to a high volume of patients, burnout can have devastating effects on staff and on patients.
With high administrative burden, challenges with electronic health records, pressures to “move the meat” and “treat ’em and street ‘em”, the Emergency Department (ED) sets the perfect stage for attending physician and trainee burnout. Risks for institutions include loss of highly qualified, sought after staff resulting in inability to adequately staff the ED, which in turn burdens those clinicians who remain and puts them at risk of burnout.
There have been few studies assessing burnout specifically in Pediatric Emergency Medicine (PEM). One small study concluded that rates of burnout were not that high, while another study with a larger sample and better methodology found very high rates of burnout with 88% percent of PEM survey respondents reporting symptoms of burnout and 46% planning to change clinical activity in the next five years, including reducing hours, changing shifts, or retiring.
PEM physician burnout is at crisis levels in some institutions. It is critical that PEM leaders make physician burnout a priority. So, what can PEM leaders do?
1. Promote strong emergency department leadership. Effective leadership is important in preventing and addressing physician burnout. Why? Because effective leaders set the tone with regard to work-life balance, make department policies and engage the staff. As a field, we need to ensure that we choose the best leaders. Just because someone is a physician or has a lot of publications does not make him or her an effective leader. A good leader has a high emotional quotient (EQ) and can effectively communicate a vision and align people to the mission of the institution. A good leader engages the physician staff.
2. Hospital and department leaders must engage employees. In a similar way that department leaders engage employees, if the culture within the larger institution is not employee focused and does not embrace work-life balance, the PEM department leader will be challenged to create a culture that reduces or eliminates burnout amongst the staff.
3. Create clinical schedules that prevent/reduce exhaustion and sleep deprivation. Shifts that are random can create erratic sleep schedules. The medical literature has shown that working similar shifts daily and/or advancing over time (e.g. day, then evening, then night shifts) can reduce fatigue. Also consider reducing or eliminating night shifts for physicians over the age of 50 when possible since older age and sleep deprivation can be problematic for older physicians.
4. Seriously address work-life balance. Physician staff have cyclic life requirements. The needs of someone without children differ from a physician with young children. Some clinicians may prefer working nights. Physicians with school age children may prefer day/evening shifts. Someone may voluntarily work a higher number of night shifts for a period of time but then someone else could step up to take a turn working more nights. Work with the group to ensure fairness. Incentivize evenings/nights and weekends through increased compensation or alternatively credit nights and weekend hours at a higher rate. Since loss of control can lead to burnout, give staff more control over their schedule.
5. Reduce administrative burden. Excessive administrative tasks and/or process heavy requirements of staff can lead to burnout. Provide support such as scribes for clinical work so that the physician spends less time on the EHR and more time with patients. EDs with administrative and academic expectations should provide adequate administrative and research support.
6. Ensure fair compensation. Nothing kills morale better than variable and unfair compensation. Department directors should review physician compensation at regular intervals to ensure fairness based on productivity, time worked and other objective criteria. Ensure parity between the sexes. Bad morale and a sense of unfairness can be a contributor to burnout.
7. Encourage and support professional development. Department PEM leaders should ensure that their staff has the tools and resources to advance professionally. Leaders should support conference attendance and educational experiences. Promoting collaborations both within an institution and within the field will help the PEM physician feel supported.
Dr. Adirim is a physician executive who still practices pediatric emergency medicine as a moonlighting physician. She is a tweetiatrician who tweets at @TerryAdirimMD . She has no conflicts of interest to report.