Burnout Among Emergency Medicine Physicians in the US
Physician burnout has long plagued the medical profession; however, burnout has been steadily increasing among physicians in recent years (Erickson et al., 2017). In 2018, burnout among physicians reached levels of 42% nationwide (Berg). According to the Agency for Healthcare Research and Quality, burnout refers to a long-term stress response characterized by emotional and physical exhaustion, depersonalization, cynicism, and a sense of failure or lack of purpose regarding one’s professional achievements (2017). One doctor noted that burnout in medicine relates to a loss of “professional spirit” and is intensified among physicians due to their intimate and often extremely emotional interactions with others (Parks, 2017). In the United States, burnout disproportionately affects physicians; they work, on average, 10 hours more per week than the general US population and report lessened work-life satisfaction (Parks, 2017). Burnout in the medical field has been attributed to the instability of the current US healthcare system, fluctuating and value-driven physician reimbursement per the Patient Protection and Affordable Care Act, long working hours, mandated use of cumbersome electronic health record systems, the burden of administrative responsibilities, and the computerization of medical practice (Gooch, 2018; Berg, 2018).
Clinician burnout has been linked to medical specialty, and emergency medicine physicians have continually reported the highest or near-highest levels of burnout since the American Medical Association began to survey physicians on burnout and mental health through its annual Medscape Lifestyle Report in 2013 (Parks, 2017). In 2018, 45% of emergency medicine physicians reported feeling “burned out”—a decrease from reported levels of burnout above 60% among the specialty in 2017, which may be attributed to different polling techniques (Parks, 2017). Despite lowered levels in 2018, burnout has been on the rise in the emergency medicine specialty for the last five years (Parks, 2017). In addition, physicians practicing emergency medicine are reported to be 3.18 times more likely to develop burnout than the average physician during the course of clinical practice (Berger, 2013).
Burnout in the emergency room (ER) has been more frequently reported among ER physicians for a number of reasons. Emergency medicine is characterized by its high-stress, high-stakes, and time-sensitive culture (Berger, 2013). ER medicine relies on limited data, and the majority of ER decisions will eventually be critiqued by other physicians with the benefit of hindsight for case-review (Berger, 2013). Patients entering the ER are often there on the “worst day of their lives” and in severe pain or emotional distress; these negative feelings can then affect the emotions and the dispositions of consulting emergency medicine specialists over long periods of time (Berger, 2013). In addition, clinical case uncertainty, low control of care pace, the potential for incoming trauma cases, a steady stream of patients, and the enclosed “fishbowl” ER setting render emergency medicine physicians even more prone to develop burnout than their colleagues involved in non-emergent practice (Berger, 2013). The costly use of ERs as complementary care to primary care services by the underserved, impoverished, and uninsured has also contributed to a high patient influx that can add to the stress of emergency medicine physicians and increase their reported levels of burnout (Cox, 2015). In this vein, approximately 65% of ER visits are deemed unnecessary and are likely to exacerbate feelings of burnout among ER physicians (Cox, 2015).
Bureaucratic requirements, such as the charting of patient outcomes and the completion of paperwork for ER discharge and treatment reports in electronic health record systems, perhaps represent the greatest contribution to ER physician burnout (Lagasse, 2018). Time spent on these responsibilities by physicians has decreased the amount of one-on-one time that they spend with their patients (Lagasse, 2018). In a 2014 study, nearly 60% of surveyed physicians felt that electronic health records systems lessened efficiency in the clinical setting, were too costly, and were a poor return on investment (Westgate, 2015). A sense of time pressure regarding data entry into electronic health records in the midst of patient interactions only worsens ER physician burnout. A recent study found that, during a 10-hour shift, 44% of ER physician time is spent on data entry, and only 28% of time is spent on direct patient care—the remaining practice time is spent reviewing tests, discussing cases with colleagues, and on miscellaneous activities (Hill Jr. et al., 2013). During a typical shift, ER doctors log approximately 4000 mouse clicks for patient charting activities (Hill Jr. et al., 2013). The time required of ER physicians for bureaucratic tasks highlights the need for greater efficiency in data entry within the ER setting.
Emergency medicine burnout not only affects physicians, but patients and the entire chain of command among ER personnel. Burnout can lead to impaired attention, executive function, vigilance regarding patient safety, and memory, as well as depression and substance abuse, among physicians (AHRQ, 2017). Physician detachment has also been linked to impaired decision-making and worsened communication with other healthcare providers, leading to perceived lapses in physician safety, as noted through safety gradings completed by their peers (Lyndon, 2016). These factors may affect the quality of care afforded to patients, as well as patient communication, satisfaction, and health outcomes (AHRQ, 2017). In cases of severe burnout, physicians may also temporarily leave or be asked to break from clinical practice; this departure from the clinical setting may limit patient access to care (AHRQ, 2017).
Burnout is a systemic problem within the field of medicine that must be addressed, specifically within the emergency medicine specialty, to retain ER doctors, to enhance their well-being, and to improve patient ER experiences. A potential policy solution to the high levels of burnout reported by ER physicians may be the recommended use of emergency medical scribes to assist ER doctors with administrative challenges and data entry. Medical scribes help physicians by documenting patient consultations, by retrieving nursing and diagnostic notes regarding patients, and by assisting with the completion of physician clerical duties (Ryan, 2017). Emergency medical scribes can input patient information and physician notes into hospital electronic health records—the chief source of the administrative burden faced by emergency medicine specialists (Ryan, 2017). Scribes can also obtain past family social history and a review of systems from patients to garner their medical histories; however, scribes cannot interact with the patient independently and miscommunication may ensue if scribes are not in frequent contact with ER doctors (Ryan, 2017). Scribes can help to improve the financial returns on investment from electronic health records (Ryan, 2017). In summary, scribes are primarily data care managers that are hired to enhance clerical productivity and to thereby allow physicians to spend more time with their patients (Ryan, 2017). According to a 2017 study, medical scribes improve overall physician satisfaction and uphold chart quality and accuracy (Gidwani et al.). In addition, scribes do not seem to affect patient satisfaction with clinical care (Gidwani et al., 2017). These results suggest that the recommended employment of emergency medical scribes will alleviate high rates of ER physician burnout.
Despite the potential benefits of emergency medical scribes, they also require extensive training and need to be integrated into physician and ER workflow to function effectively and safely in the clinical setting (Westgate, 2015). Furthermore, emergency medical scribes draw upon hospital and ER financial resources, as they are paid employees—typically earning between $13 and $16 per hour (Westgate, 2015). In addition, ER physicians must ensure the competency of emergency medical scribes, as their data logging must be an accurate reflection of the quality of the clinical interaction between the patient and the provider (Westgate, 2015). Due to this pressure, the time required to check the data entry of medical scribes—although far less than the time required for physicians to log clinical encounters themselves—may deter ER physicians from wanting their ERs to hire emergency medical scribes (Westgate, 2015). Finally, many medical scribes are pre-health or pre-medical students; therefore, their longevity within the hospital may be limited as they pursue other clinical experiences or graduate training (Westgate, 2015). Some ER physicians may consider the hiring of emergency medical scribes to be a burden rather than a benefit due to the time required to complete scribe training and evaluation proceedings, as well as due to the provision of scribe salaries. Regardless, policy actions recommending and raising awareness of the potential benefits of emergency medical scribes may be effective in decreasing ER physician burnout by enhancing workplace productivity and by maximizing the time that they spend interacting with patients.