Conversations on Burnout – ACEP Now

With recent studies showing emergency physicians topping the charts with 65 percent reporting burnout, the specialty is facing a crisis.1 Today, I’m (MK) joined by several experts, Dr. Daven Morrison (DM), Dr. Greg Couser (GC), and Dr. Andrew Brown (AB), all of whom are psychiatrists and published authors on burnout, to explore this crucial problem and how we can begin to address it.

MK: What got you interested in studying burnout?

GC: I have been following the literature for burnout, which actually has been around since the 70s, but it was more in industrial study populations at that time. In the early 2000s, it seemed to become more vogue, to study it within health care populations. We all know it’s a big problem, but at a certain time we sort of all get burned out about hearing about burnout and wanted to know: What are the solutions?

I think eight years ago or so, I started a CME course regarding preventive mental health concepts. A lot of it was around also some burnout models, like the effort-reward imbalance model, and the demand-control-support model, and things that people could do on an individual level to help their own burnout while some of the more organizational concepts were being developed.

MK: Can we define burnout and talk about what’s the scale of the problem that we’re facing in medicine right now?

GC: As far as classical definitions, burnout is decreased effectiveness at work. There’s certainly a depersonalization component. Then there’s an emotional-exhaustion component as well. People just sort of feel like they’re spinning their wheels.

Christina Maslach was one of the original people who started to measure burnout back in the 70s. It’s been measured over time with lots of different inventories. There’s been lots of different ways to measure. How do you define it?

Do you say you’re burnt out if you just have emotional exhaustion or do you have to have depersonalization and feelings of decreased personal accomplishment as well? There hadn’t been a consistent way of measuring burnout over time.

MK: How about the scale of the problem? You made several references in your recent work, Getting Serious About People Over Profit: Addressing Burnout by Establishing Meaning and Connection,2 to very high burnout rates. It certainly seems that from what we’re seeing in the data, this is a really sizable issue that we’re facing, not just in emergency medicine, but medicine in general.

GC: It’s huge. And part of it might be a publication bias, just from the standpoint that for a long time, burnout really wasn’t measured that much in health care populations. Now it is being measured and we’re paying more attention to it and numbers are rising. But even anecdotally, I’ve seen in my own career and work at the same institution for 18 years, it’s accelerated in what I’ve seen for the acuity of people and issues they present with: not just burnout, but mental-health issues in general. Prior to the pandemic we were used to being really connected.

Some good things came out of it like we might not be having this conversation, I didn’t even know how to use Zoom before the pandemic, and now we’re on Zoom pretty much every single day in some form or another. There’s some good things that came out but people were a lot less connected, people were feeling a lot more alone, and still the world is changing at such a rapid pace. Meanwhile, you had all these health care workers trying to respond to everything related to the pandemic, initially with all the COVID deaths that came about and changes in policies and competing worries while you take care of your patients.

Moral and ethical issues come up and then people get to a point where they’re working so hard and they’re just tired, particularly in nursing where there’s a big shortage and people leaving.

Then we have a millennial generation at the same time coming up that is valuing, maybe, things differently than the previous generation. And they’re looking at work-life balance.

MK: What are the implications of this for health care in this country?

GC: There’s a lot of opportunity in this chaos right now. I think that hospital systems are scrambling to figure out how to do this because this is uncharted territory. And meanwhile, things leading to burnout like electronic medical records and documentation aren’t going away. If anything, that’s continuing to get worse.

I think the hospital systems that figure it out are going to be the ones that survive throughout all this too; it’s not just how much throughput that you can have. It’s how can we sustain an organization? Which means that you can push people to a certain extent, but then at a certain point, there’s going to be diminishing returns.

MK: In some of your work, you coined a term that I found particularly impactful, “high effort, low reward conditions.” Can you talk a little bit about it?

AB: Work should be rewarded and we want to reward our physicians in a manner that’s commensurate with their value. One of the problems we run into when we transpose the business model onto the medical model is that rewards for physicians tend to be conceptualized almost exclusively in terms of extrinsic reward. If we think of extrinsic rewards, the question becomes, “How am I going to be compensated as a physician for the work that I perform?”

That’s obviously very necessary. People need to feel that their material needs and their need for social recognition are satisfied. Unfortunately, one thing that’s often missed is—and this is critically important in terms of the quality of the work we perform—is that the rewards that are derived are intrinsic to the work itself. In order to create conditions that are conducive to the performance of quality work, we need to find some way of finding meaning and satisfaction in the work that we’re performing.

How can organizations organize work in a way that’s not demoralizing? And demoralizing is an interesting way of putting it, because it’s at once a psychological and an ethical phenomenon. If I feel demoralized in my work, it can have a literally de-moralizing impact. Emergency physicians perform a role that has a moral dimension. Their job is to alleviate suffering and cure disease. Yet there’s something about the way health care organizations sometimes do business that can distract us from this reality. Part of the challenge arises when we approach health care as a business.

MK: We’re in a situation where, post-COVID, health care systems are still struggling financially. To talk about the first part of the rewards, how can health systems try to balance their own financial stresses with the need to be rewarding people?

AB: The general principles that should inform decision-making involve ensuring that emergency physicians are compensated in a manner that is commensurate with the value that they’re providing. There’s all this pressure to ensure that quality of care remains high. But such decisions also need to be informed by considerations that have to do with the on-the-job experience of physicians. When changes are considered we need to ask: How will such changes affect the way we do medicine and our on-the-job experience? How is it going to affect the minute-by-minute experience of the patient, obviously, but also the physician? This is the critically important ingredient that is often missing. I don’t think the physician’s capacity to derive meaning from his or her work is consistently considered.

One would expect that this problem would never arise, that it would be reasonable to assume that an emergency physician would rarely if ever feel that their work lacks meaning. (But) it does arise because the problem doesn’t necessarily have to do with the nature of work itself, but rather with the way the work is organized. There’s a system of incentives and expectations that aren’t precisely aligned with the interests, inclinations and intentions that motivated physicians to pursue this type of work. Why would an emergency physician ever, how could they even possibly feel burned out? It’s the most meaningful job on earth and yet, as you know, it doesn’t necessarily have to do with the nature of work itself. It’s the way the work is organized. It’s the incentives that are in front of you. It’s the expectations of the work that aren’t precisely aligned with or don’t conform precisely to the way that you would work, to what brought you to this profession.

MK: That brings up a crucial question, are we considering how our compensation and reward models are impacting patient care? Despite everybody’s absolute best intentions in medicine, systems are perfectly designed to get the results they get. If you reward people in a specific way, you are going to incentivize specific behavior. You can be well meaning and yet still find yourself with some difficulties.

AB: The last thing you want is to create incentives and conditions where physicians are showing up to work exclusively to get paid. Or a system that induces physicians to work in ways that maximize their income. Ultimately, that’s going to be to the physician’s own detriment. They’re going to begin to feel a sense of meaninglessness because these are not the kind of values that are sustaining or that produce quality work.

DM: All of you are closer to the clinical action than I am. But what I’ve seen outside looking in at the system level is concerning to all organizations. And we can use the ER doc to highlight the challenge. The ER doc is caught between two pressures. As Andy notes, one of the intrinsic rewards is inside, “I feel good about my work, and my work is meaningful. I see that others appreciate the meaning of my work.” Meanwhile from leadership, they are saying, “no, you’re just a cog in the machine, pump out the patient visits. We want to see these kind of numbers. You don’t need any more support. You don’t need any more pats on the back. I’m not going to come down and see you in the emergency room, just show up and see patients.”

Then on the other side, outside the clinical workplace, I’m curious particularly with you both, Mitch and Greg, how much burnout follows from the disinformation and nastiness in the broader society about experts and physicians? You come in to work and usually, the tradition and the way we were trained is to lean into our expertise. We think, “look how well respected the attending doctor is, or the chief physician in the highest-ranking team.” If you’re the head doctor in the emergency room and you’re getting yelled at or told that it’s a farce or people are coming in to look for whatever the latest made-up story is, that’s got to be exhausting as well. There is a real pinch between leadership demands and societal hostility.

AB: I would be very surprised if that’s not a major factor because what we’ve got now is a really unviable cultural phenomenon. It’s not about formal education or academic credentials. It’s about having appropriate respect for people who know something about the subject matter that is most relevant to the problem one is confronting. If your pipes burst and your home is underwater, you need a plumber. You want the plumber in there because he or she knows more about fixing plumbing and pipes than you do. Our culture is really in a very dysfunctional place right now, such that this basic fact—that when you have a problem you want to consult someone who can reasonably be expected to know something about the problem you have—is constantly questioned. If you’re having a medical emergency, an emergency medical doctor is going to know a lot more about what’s ailing you than you do. Doctors feel a lot of disrespect now, they don’t feel that patients are appreciating their skills, their expertise, their training, or their experience. One of the things that helps sustain us as physicians is the sense that our knowledge, skills and experience are appreciated. If you take that out of the equation, you’re going to deprive the physician from a very important source of meaning and sustenance.

GC: Physicians want to be part of the decision-making process by personality. Physicians are hard-working. They’re self-driven and so they are looking for intrinsic rewards, but then I hear from many workplaces, they’re sometimes held to metrics that they can’t change and that might seem meaningless to them or might not even be explained. There might be one set of metrics that they’re beholden to one week and that changes the next week, sort of a management du jour.

MK: I think many people who became emergency physicians did so because they believe strongly that emergency departments are the safety net in this country. You go into this job knowing that you’re going to see some very difficult situations and that you’re going to be that person that’s there for whatever walks through that door at any time of day or night. Then if you’ve got people that don’t respect that expertise or that role, that certainly weighs on physicians who are making big sacrifices, being there at three in the morning, being there on major holidays, or missing family events, and making the sacrifices that are asked of physicians. How does that social contract hold up in this post-COVID world?

DM: I was watching the hostility and bizarre theories escalate on social media and Twitter in particular. As I did, medical students, residents, fellows, and practicing physicians, were basically throwing up their hands and walking away from the profession. Not as much from the volume of COVID-19 related work, that played a significant role, but it was this social dynamic.

All of us can envision that really decompensated, mentally ill person, who’s out of touch with reality, and hurling insults and everything else at us; that’s what we train for. We know how to deal with that, but not when it’s a systemized broader cultural attack on all of medicine. We see it on the news, and then maybe we see it on a bumper sticker as we’re driving into work, or in some other way. We appreciate that the pathology is no longer in this really severely mentally ill person, but there’s some kind of attack on our profession coming from the broader society.

In the 90s at the VA there were Vietnam veterans. Although it had been 20+ years since returning, the wounds they had from coming back to this world, a world that had been very positive about a soldier, was not anymore. Previously, the world was generally very happy about the US World War II veteran. They were seen as soldiers of the just war. But the Vietnam veteran came back to this hostile world with accusations. For many who had seen combat, they’ve been through misery, they’ve been through hell. I think the ER doctors are kind of experiencing a little bit of that as, “Whoa! This is not the deal. This is not what I signed up for. This is not my social contract to be treated this way, to be accused of “injecting some weird mRNA” or other amplified disinformation. Doctors have been generally immune from that.

MK: This week was the emergency medicine match where we saw a significant number of unfilled emergency medicine slots, I believe roughly 550 slots, about one sixth. People are taking notice of what’s going on. I think this is now the second year in a row where we’ve seen a significant number of unfilled slots from what was, pre-COVID, becoming a very competitive specialty.

GC: Well, along that line, I don’t know if medical students are looking at the burnout stats for emergency medicine physicians, because Shanafelt looked across all specialties at the burnout rate, and emergency medicine was the highest, but it also was really interesting because on the flip side, they had reported that they were having good work-life balance overall.

MK: We did get viewed for a long time by people as a lifestyle specialty. Anecdotally, I think that viewpoint has changed. People have started to see that the constantly rotating schedules, the night shifts, and the holidays all take a special sort of toll on you.

Author’s Note: this interview has been edited for brevity and clarity.