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It is a truth universally acknowledged: Physicians are at high risk for burnout. But since the end of the COVID pandemic, burnout among one specialty has soared. In Medscape’s 2024 Physician Burnout & Depression Report, nearly two thirds of emergency physicians said they felt it.

“Some of the magnifying glass of emergency medicine is reflective of what we see in medicine in general,” said Resa E. Lewiss, MD, an emergency medicine physician and professor of emergency medicine at the University of Alabama at Birmingham. “We’re taught you don’t complain, you don’t need to sleep, you don’t need to eat. You can get a lot done, and the sacrifice is inherent in the training.”

But there are indications that things will get better: While mental health issues used to be something to hide, healthcare systems’ new wellness efforts are bringing them out into the open.

“The first way to deal with a problem is to talk about it,” Lewiss said. “And we’re certainly talking about it.”

Before and After: A Global Pandemic

Before COVID-19, emergency physicians experienced burnout — but nothing like what we’re seeing now. In Medscape’s 2020 survey, which reflected responses from the year before the pandemic hit, 43% of emergency physicians reported feeling burned out. The specialty landed right in the middle of the pack, coming in 14th out of 29. Counterintuitively, during the height of the pandemic, that number held. As stressful as it was, a sense of support for emergency medicine workers may have helped to prevent a spike.

But consider what we saw in 2022, after quarantine ended, when staffing was still reduced: Emergency physicians leapt to the top of the list, the first time any specialty hit the 60% mark. And now that things have settled into a new normal of staffing shortages and extreme boarding, burnout is hitting emergency physicians harder still. For the past 2 years, more than 60% of them have reported burnout.

“Before, we had major problems with boarding and crowding,” said Jesse Pines, MD, chief of Clinical Innovation at US Acute Care Solutions and clinical professor of emergency medicine at George Washington University in Washington, DC. “During the pandemic, it was a war zone. What’s happened since early 2021 has been an increase in nursing shortages, which has led to an increasingly dysfunctional operational environment. It’s become a harder place to work.”

Why Emergency Medicine?

Emergency medicine tends to attract people who thrive under duress. They may think they can handle anything.

“Emergency physicians are some of the grittiest and most resilient people on the planet,” said Heather Farley, MD, chief well-being officer and professor of emergency medicine at the Medical University of South Carolina (MUSC) in Charleston, South Carolina. “But emergency medicine is a very high-demand field, often unpredictable, and then suffers frequently from insufficient job resources or supports.”

When you look at the changes in the healthcare system in general and hospitals specifically, it’s easy to see why emergency physicians experience burnout so often.

• Workload: For many patients, the emergency department (ED) is the main entry point to healthcare. Because they may not see a primary care physician regularly, this shifts the workload onto emergency physicians.
• The nursing shortage affects patient care, of course, but it also adds to physicians’ stress levels. In order to meet demand, many hospitals now recruit nurses straight out of school rather than from other departments within the hospital.

  “We have new nurses who aren’t familiar with how to give medications. They may have never had a truly sick patient before,” said Andrea Austin, MD, an emergency physician and physician development coach in San Diego. “It used to feel like a seasoned ED nurse could snap to it and get that difficult IV, but now our workload keeps increasing as the attrition from nursing continues.”

• Moral injury: While an emergency physician may know exactly what kind of care their patient requires, too often bureaucratic policies keep them from providing it. “There’s this dissonance, and a psychological distress is experienced,” Lewiss said. “It goes against either your moral beliefs or your principles of being a healthcare worker, a physician, when you can't provide the level of care that you'd like to provide.”
• Boarding crisis: It’s become commonplace for admitted patients to remain in the ED, often in the hallway, until a bed becomes available within the hospital. “It causes a bottleneck, with patients trying to come in and there’s no room for them,” Austin said. “I’m the face those patients see, and they say, ‘Why am I still in the waiting room? Why aren’t you helping me?’ I don’t have a good answer for them.”
• Employment structure: Emergency physicians may feel like they have less agency than other specialties. Fewer practitioners have an ownership stake — and more are independent contractors — than in any other specialty. Many are employed by corporate emergency medicine groups, which hold contracts with hospitals.

  According to Austin, this can lead to complaints going unheard. “We’re seeing feckless leadership. People are scared to lose a contract, so they’re not taking care of their employees,” she said. “But if your group is asking for basic protections and hospital administrators won’t listen, maybe that’s a contract worth losing.”

• Trauma: A trip to the ED often happens during the worst day of a patient’s life. Emergency physicians bear witness to seemingly relentless trauma, which compounds all the other factors.

Addressing Burnout Head-On

• The Dr. Lorna Breen Heroes Foundation was founded to recognize an emergency physician who died by suicide in April 2020. Her death made headlines because it shone a light on the pressure healthcare workers face to hide their struggles with mental illness. Many licensing boards required disclosure of treatment, which had a stigmatizing effect. The Foundation now works to remove such barriers to help.
• The American College of Emergency Physicians, too, is working to make change. The organization is piloting a tiered Emergency Department Accreditation Program, which will recognize hospitals that meet requirements in staffing, capabilities, and working conditions.

• Big-picture wellness. Whether they’re forming wellness committees, offering employee wellness programs, or going all-in by creating the role of chief wellness officer, hospital systems have begun to recognize how physician stress and burnout negatively affect patient care.

  Farley joined MUSC in this newly created position earlier this year, after 5 years as the chief wellness officer at ChristianaCare in Delaware. At MUSC, she oversees quality-of-life issues for staff, medical students, and residents alike. Kelly Holder, PhD, is the first person to serve a similar role for Brown University’s Warren Alpert Medical School, Providence, Rhode Island. “One of my jobs as a chief well-being officer is for us to figure out: How do we create an environment that's welcoming and allows everyone we've invited into the space to bloom and grow?” she said.

• Getting Rid of Stupid Stuff (GROSS). GROSS began at Hawaii Pacific Health in 2017. The initiative, since adopted by the American Medical Association, aims to reduce the many small bureaucratic requirements that add to physicians’ workload. It covers things like electronic health records, billing, and compliance.

  “It’s not about working harder or faster,” Farley said. “It’s about removing the pebbles in your shoes, the inefficiencies that get in the way.” At MUSC, they’re hiring a GROSS manager.

These initiatives only work if they seem authentic and are backed by real change, Farley warns. Mandated attendance at wellness lectures may feel like it’s adding more to a physician’s workload. Then it becomes what’s known as “carewashing” — creating wellness initiatives that check off boxes but don’t necessarily make a difference.

“It's not well received when we’re like, Oh, we're going to teach you to be more resilient,” she said. “All you need to do is eat better, sleep better, and meditate, and then go work a 24-hour shift with no resources.”

The Next Generation

While the culture is changing slowly, today’s residents and early-career emergency physicians are feeling the stress just as much as previous generations.

“Medical education has made a shift so that we can help learners sustain the career of becoming a physician,” Holder said. “But the support we give students during medical school often bumps up against some of the cultural changes that have not been made in residency and in healthcare.”

At Brown, she’s implemented programs intended to ingrain an awareness of mental health. It begins in medical students’ first year, when she meets individually with each student to make sure they have the support they need.

“There are skills students should have to take with them, like an awareness of their own mental health and being able to check in with themselves,” she said. “And then not being afraid to reach out for help.”

The idea is to normalize mental health care among physicians.

Farley sees her role similarly at MUSC: “To support our medical students and help them be prepared as they make that transition from medical school to residency and from residency into attending.”

If these medical school wellness programs have the intended outcomes, the results could reach far beyond campus.

“The tentacles of emergency medicine reach into so many areas of our healthcare system,” Farley said. “If we can get this right in emergency medicine, it’s the front door of the hospital. That would have a ripple effect to the rest of our health systems.”