We Are The Champions!?

crispydoc Uncategorized 2 Comments

It’s official: a study published in the Mayo Clinic Proceedings showed that as of 2014, Emergency Medicine (EM) took the top slot for physician burnout (59%).  Suck it, critical care (50%). In your face, OB/GYN (56%).  We’re #1, we’re # …huh?

How did my beloved field of EM win the race to nowhere?  When I was in medical school, the pioneering faculty insisted that EM’s reputation for early burnout was based on the fact that those docs who’d burnt out had trained in another field, couldn’t hack it in their chosen specialties, and ended up woefully underprepared to spend their careers in EM.  As a medical student, I saw EM transform from Rodney Dangerfield disrespected to George Clooney sexy.  A full 13% of my class at UCSF matched in EM.  We smugly believed we knew what we were getting into, and we took for granted our ability to work as lifers.

So what happened?

The Job Changed
The emergency physician used to be the expert in deciding who was sick enough to require admission and well enough to go home.  The expectation was for the ED to stabilize the patient and hand off to continue or extend the workup under the admitting team.  That’s no longer the case. Patients admitted from the ED are expected to arrive completely worked up. A septic patient is expected to arrive with labs; films; body fluid cultures (blood, urine, and spinal fluid when appropriate); approved IV antibiotics started (within guideline time limits, please, or the hospital compliance officer will be calling you); central lines placed; and consults to infectious disease and critical care obtained by the emergency physician. The work in progress admission has gone the way of the dodo bird. We do more testing, more quickly, over more time. We call more consultants than ever.
The Stressors Increased
Volume has increased steadily for those EDs that remain open.  A decade ago, my hospital saw 60,000 patients a year.  Now we are on track to see 85,000 by December. This is a common experience.
Crisis has become the new normal. Hospitals routinely operate at or near capacity. This has created the “ED Boarding” phenomenon, which can make a difficult job impossible. Like a restaurant manager who serves breakfast without sending home any of the morning crowd, then serves lunch at the remaining open tables, by the time the dinner crowd arrives there is no physical space to seat the new and impatient diners. The ED deals with this scenario. Every. Single. Day. There are innovative solutions, but few hospitals are interested in solving the problem, since the chaos can be confined to the ED alone and is felt to be someone else’s problem. Until the day your mom or child appears in the ED waiting room, you’ll never feel that pain personally.

With the advent of managed care contracts constituting a significant portion of hospitalized patients, HMO hospitalists often arrange time-consuming transfers to rehab facilities that occupy ED beds.  This is fine when the ED is not busy, only today’s ED is always busy. Parking a managed care patient in a bed for 5 hours until they can be transported to a rehab facility exacerbates ED boarding. I regularly start workups in hallways, because at peak times it’s the only remaining space.

Top it all off with psychiatric patients in crisis who are placed on involuntary holds with no available psychiatric beds in LA County, and you have a recipe for frustration. If society has an intractable problem that has not been dealt with, the solution of choice is to send it to the ED.

Big Brother Became Real, And Customer Service Became A Thing
Dan Ariely, the guru of behavioral economics, has written movingly about
asymmetrical rewards in medicine. Success is taken for granted or mildly praised at best, while failure is excoriated publicly. Newspapers tout estimates from the Institute of Medicine warning of thousands of patient deaths attributable to physician error, but you’d be hard pressed to recall articles commenting on the number of lives saved or improved thanks to medicine.

Press-Ganey surveys mean patients must like us even if they don’t get what they want (antibiotics, the pain shot that starts with a d), as if our scrub bottoms touted an 800 number with a “How do you like my doctoring?” teaser.

Computer-based orders and documentation are planting new landmines for us to step on, because information that was formerly easy for us to see (vital signs, nursing notes) is now ten clicks removed from our access. Computer overlords now track our digital footprints. Every breath you take, every click you make, Big Brother will be watching you.

The explosion in medical knowledge means we live in fear that years from now, someone will point to the care we provided as not being the most current; because we can never possibly stay current on every change in medicine all at once.

Behavioral research by Ariely and others has shown that when punishment is extreme, we focus more mental energy on our fear of making mistakes…which significantly increases our chances of making those mistakes.

ED Physicians Became Employees Instead Of Owners
Emergency Medicine, like many fields that are hospital-based, has been taken over by for-profit corporate medical groups. As a result, there are more physician employees and fewer physician owners – with the attendant lower pay, decreased autonomy, and decreased morale that comes from not being master of your financial fate. I am fortunate to be part of an independent group, but according to national trends, we are a dying breed. Gather ye rosebuds while ye may.

Can Emergency Medicine Be Saved?
Champions of the ED, like Peter Viccellio, are working hard to pave the way for emergency physicians to solve ED overcrowding with novel solutions like full-capacity protocols, smoothing scheduled elective procedures and discharges, and inpatient overcensus placement (putting low-risk admitted patients in hallways on the wards until their rooms are ready).

ED groups, including my own, are increasing staffing and negotiating reasonable limits on patients who await placement into a rehab; our hardworking hospitalists know the ED is not an unlimited resource, and most are respectful of our role in the hospital and our need to take back our real estate (our ED beds) during times of crisis.

More than ever, I am grateful for the opportunity to do important work for the sick and marginalized patients we serve. More than ever, they need my help.

As a doc pursuing financial independence, you’ll have the luxury of being able to reduce your shift load to avoid the risk of burnout and compassion fatigue. The way to make the career sustainable is to allow adequate time for those people and pursuits outside of medicine that restore you, so that you can be fully present and on your game when you are inevitably asked to do the impossible on your next shift.

Comments 2

  1. As a fellow EM doc, I can relate to a lot of these points. I think as residents you are shielded from some of the not-so-sexy side of EM… metrics, patient satisfaction, core measures, etc. One other thing that wears on me is that the majority of the patients are non-emergent. You know, the cough and congestion, sore throats, afebrile fevers, chronic pain, etc.
    For the most part I still like what I do, and love the people I work with. But as it stands I don’t think I can make a 20-year career of it.

  2. SRGO,
    I’ve enjoyed your commentary on several sites (grabbed my attention with the clever online name), and your posts surreptitiously (“Poopy Diapers Everywhere” brought back memories, not all of them fond. Welcome to the all joy, no fun club.).
    As a middling old guy (15 years out of residency) in EM, I can tell you that sticking to your FI plan will make all the difference. I’ve recently cut back to 6 shifts a month, and all of the challenging patients you cite become far more tolerable when you are working fewer shifts while enjoying better balance in life.
    We are in LA, so like your Bay Area home, the HCOL slows the pace but a sound plan still saves you from burnout at the end of the day.
    Thanks for stopping by,

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