Battling Burnout in the ED
By John M. Howell, MD
Burnout" is a euphemism for a process that, in many instances, results in an emergency health care provider leaving the specialty. The causes of burnout are multifactorial and include family difficulties, inadequate training, disaffection with emergency medicine, medical problems, and unusual diurnal rhythms. The final common pathway is usually increased personal stress.
My personal observation is that physicians and nurses burn out when they practice in situations where they are uncomfortable or for which they are inadequately trained. For example, insufficient education and experience in either trauma or pediatric emergency medicine quite naturally leads to stress when emergency nurses and physicians practice in trauma centers or high-level pediatric EDs. When faced with this situation, the options are either to seek additional training or remove oneself from the practice environment. Alternatively, seek counsel from your chairperson and consider a sabbatical for supplemental training or clinical experience.
Scheduling, diversification can help
An effective strategy is to diversify your career. For example, plan to mix a clinical practice with administrative or educational responsibilities. This is particularly effective as a medium-term to long-term strategy because it limits the effects of shift work and the physical wear and tear of 100% clinical work.
Maintaining personal health is vital to a long career in emergency medicine. Medical disorders associated with clinical emergency medicine include hypertension, depression, heart disease, and orthopedic disorders (e.g., mechanical low back pain). Be aware of these potential difficulties, and do not deny they exist. This is especially true after the age of 40, when we should all be seeing a physician on a regular basis.
Stress and the resulting medical difficulties are mitigated by a few practical considerations when working clinically. Regular exercise is essential. This is especially true during periods of time when you are working off-shifts (e.g., nights and evenings). Many emergency physicians and nurses find that maintaining a minimal level of aerobic exercise through periods of off-shift assignment helps sleep patterns and limits the "hangover" experienced after such work schedules. Anchor sleep is also essential. This may mean eliciting the support of your family to ensure protected time in a quiet, dark area. Even if you are unable to sleep, relaxing in a quiet area for one or two hours before a night shift is very helpful.
Use advancing clinical schedules (i.e., periods of days, then evenings, then nights) and avoid haphazard interruptions in your diurnal schedule. Many physicians and nurses find that one or two isolated night shifts are more manageable than longer strings of these off-shifts. Limiting night-shift exposure in this way shortens the rebound phenomenon that inevitably follows.
Diet is also a consideration. Consider a protein meal before a shift to maintain energy. Avoid simple sugars that can lead to rebound insulin levels, lower serum glucose, and periods of inattention and irritability. Complex carbohydrates following a clinical shift are helpful for prolonged sleep. Avoiding alcohol improves the quantity and quality of sleep and avoids periods of hyperactivity that may occur several hours after drinking.
Perhaps the most important consideration is recognition. Remain alert to the possibility of burn out, especially during periods of increased responsibility and busier work schedules. Time management is important, but just as important is knowing when and how to say no. Do not feel guilty about limiting your work schedule if it means time with your family or a needed hiatus from work.
[Dr. Howell is chair of the department of emergency medicine at Georgetown University Hospital in Washington, DC.]
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