Up until this past week, I thought I had a good handle on burnout. I thought I had figured it out.
At some point during the past year, during a string of overnight shifts in a low acuity zone by myself, working through one social disaster after another, I started feeling incredibly worn down. I started to hate my patients. I barely saw them as humans, merely obstacles in my way of efficiency — “things” I had to move through the department. It was at that point that I decided to take my first “Zero Day” (coined by one amazing attending) — a day where nothing work-related was allowed. It was a mini-vacation, and it helped me reset.
“Zero Days” soon became routine and helped me cultivate other non-medical interests. I believed burnout was being held at bay. That is, until this past week, when I was proven completely wrong. During a stretch of shifts that left me sleep-deprived, I went to sew up a laceration. It was no big deal — until I stuck myself. Unfortunately, this patient was a frequent flier in our emergency department and had a history of drug abuse. Whatever small reserve I had left disappeared. I held my composure long enough to make it back to the workstation, at which point the floodgates opened and I sobbed, hard. Everything came out at that moment — all the stress, exhaustion, frustration, fear.
As I went to get my blood drawn, an attending asked me what else was going on. He was the first person to realize there was more to this story. I cried again and told him how stressed I had been feeling. His response was something I will never forget: “We are human grief sponges. We see people on the worst days of their lives, and it is our responsibility to help them. If your grief sponge is already full because of stress and exhaustion, how can you help others? You need to take care of yourself first and foremost.”
It hit home.
It made me realize that whatever I had been doing to convince myself I wasn't burned out was the best lie I had ever told. Denial truly is powerful.
During a stretch of shifts that had left me sleep-deprived, I went to sew up a laceration. It was no big deal – until I stuck myself.
What Can We Do About Burnout?
Burnout is a three-sided spectrum, composed of emotional fatigue, depersonalization, and a reduced sense of accomplishment.1 It is caused by many factors, including a high-stress environment, fear of litigation, unhealthy lifestyle, risk of blood-borne illness, and lack of normal sleep patterns with associated sleep deprivation.1 It places physicians at risk for work dissatisfaction, poor job performance, and substance abuse.
Emergency medicine is an inherently risky job.1 We see patients quickly, often 2 or more per hour, and frequently with limited interaction. Fear of litigation in this type of environment can lead to burnout. Although we may feel protected as residents, this underlying fear may shape how we practice and where we choose to practice after residency.1 For example, we may be overly conservative with ordering tests, or we may choose to practice in a state that is less litigious or has better tort reform. It is key to acknowledge this risk but not let it dictate our practice and lifestyle. If sued, it is important to have a good support system of family, friends, and coworkers.
Substance abuse, though underreported, has a rate of approximately 8-15% among emergency residents, with the most common substance being alcohol.2,3,4 Emergency physicians overall are at a 3-times-greater risk for substance abuse than those in other medical specialties.2 Among residents who participated in one survey, 7-8% answered yes to at least one at-risk alcohol abuse question.2 In the same survey, alcohol use was listed as the third most common coping mechanism, after exercise and hobbies.2,3 It is important to recognize alcohol abuse within yourself and your peers. Residency programs should have a safe place to talk about alcohol or substance abuse and provide appropriate resources.
Many residents, pushing the limits of work-hour restrictions in any given week, find little time to commit to a healthy lifestyle.2 It is often difficult to have a healthy meal at the hospital, because most hospitals do not provide adequate options. Even the Centers for Disease Control and Prevention has released guidelines to help hospitals improve nutritional options.5 Many residents at my own institution have taken to either not eating during a shift or bringing meals from home rather than eating our hospital's food. Eating healthy snacks throughout a shift can help reduce post-shift binge eating. In addition, I have found that setting a goal of drinking 2 bottles of water during a shift has made me feel more energized. Finally, many residents forgo exercise in favor of sleep or other obligations during their busy weeks. Exercise has routinely been shown to decrease stress and improve energy, as well as contribute to an overall sense of well-being.2 It is important to not lose sight of the huge benefit of a fairly simple act.
Sleep deprivation and the circadian sleep disruption can also lead to or worsen burnout. As emergency providers, we work all hours and all shifts. Working while sleep-deprived is associated with more errors or risky exposures (such as needlesticks, in my case).2,6 Sleeping in darkened rooms during the day can increase overall sleep quality. Additionally, many programs have adopted a circadian-style schedule, which has been shown to help reduce overall disruption.
Conclusion
Burnout is ubiquitously prevalent in every residency. Within the last few months, I have been honest about the fact that I am tired and burned out. I have done self-reflection to identify what changes are within my control. First, I have focused on making sleep a priority, recognizing that I function poorly with less than 6 hours of sleep. Additionally, I have leaned on friends and coworkers for support and have worked on being more open with my emotions. With these simple adjustments, I have experienced a better sense of overall well-being and purpose. I hope you will too. We simply cannot afford to continue burning the candle at both ends.
References
- Takayesu JK, Ramoska EA, Clark TR, et al. Factors associated with burnout during emergency medicine residency. Acad Emerg Med. 2014;21(9):1031-1035.
- Schmitz GR, Clark M, Heron S, et al. Strategies for coping with stress in emergency medicine: Early education is vital. J Emerg Trauma Shock. 2012;5(1):64-69.
- Hoonpongsimanont W, Murphy M, Kim CH, Nasir D, Compton S. Emergency medicine resident well-being: stress and satisfaction. Occup Med (Lond). 2014;64(1):45-48.
- Houry D, Shockley LW, Markovchick V. Wellness issues and the emergency medicine resident. Ann Emerg Med. 2000;35(4):394-397.
- Creating Healthier Hospital Food, Beverage, and Physical Activity Environments: Forming Teams, Engaging Stakeholders, Conducting Assessments and Evaluations. http://www.cdc.gov/obesity/hospital-toolkit/pdf/creating-healthier-hospital-food-beverage-pa.pdf. Published August 2014.
- Blazejewski S, Girodet P, Orriols L, Capelli A, Moore N, CESIR Group f. Factors Associated With Serious Traffic Crashes: A Prospective Study in Southwest France. Arch Intern Med.2012;172(13):1039-1041.