EM Burnout, Solve It Here

[Tipsy McStagger]

Why in the world is PMR so unhappy at work and among the most burned out?

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[bravotwozero]

Because they spend all day looking at wankers.

Lolz..knew somebody was gonna say that. But would that burn you out more than the 20y with the flu saying 'how come I feel so bad' x 20 per shift?

In all seriousness, urology is a pretty good field. Sure they take call, but I've seen them come in the middle of the night maybe twice in the last five years. They earn more than us and have more control over their jobs.

Which is why i think those survey results are pretty suspect....

 

[Birdstrike]

Why in the world is PMR so unhappy at work and among the most burned out?

Likely emotional exhaustion of dealing with stroke and spinal cord injury patients they can't help. Either that or they're sandbagging the survey so everyone else stays out of the field so they can keep max-chillaxin' under the radar

 

[Birdstrike]

Because they spend all day looking at wankers.

Dick doc-in' ain't easy

 

[killerleaf]

like other fields, urology has to deal with non-compliant patients...when you tell someone that they have to curtail fluids after 4pm, or cut out all caffiene, you get a lot of "but I can't do this" and come back in 6 months later whining how they are still having issues.

 

[Tipsy McStagger]

Either that or they're sandbagging the survey so everyone else stays out of the field so they can keep max-chillaxin' under the radar

 

[RustedFox]

Lolz..knew somebody was gonna say that. But would that burn you out more than the 20y with the flu saying 'how come I feel so bad' x 20 per shift?

In all seriousness, urology is a pretty good field. Sure they take call, but I've seen them come in the middle of the night maybe twice in the last five years. They earn more than us and have more control over their jobs.

Which is why i think those survey results are pretty suspect....

1. Yes.
2. I forgive the 20 year old with the flu for being dumb, because once upon a time - I was 20; and maaaan, was I dumb.

 

[GeneralVeers]

1. Yes.
2. I forgive the 20 year old with the flu for being dumb, because once upon a time - I was 20; and maaaan, was I dumb.

I don't forgive the 30 year old mother of 4 with Grandma in tow bringing her perfectly healthy 18 month old to the ER for a "fever". Seriously? After 4 kids you haven't figured out how to deal with this at home?? And your Mom who is with you right now couldn't give you any pointers??

 

[killerleaf]

I don't forgive the 30 year old mother of 4 with Grandma in tow bringing her perfectly healthy 18 month old to the ER for a "fever". Seriously? After 4 kids you haven't figured out how to deal with this at home?? And your Mom who is with you right now couldn't give you any pointers??

But Dr. Veers, my mother is so old...she doesn't know how to raise kids anymore because everything has changed. Why, she said to put the 5 year old on table food!! The horror!!!

 

[Shufflin]

Why in the world is PMR so unhappy at work and among the most burned out?

Because their big kahuna reimbursement source, EMGs, were slashed and burned to the mother-F-in ground.

 

[gamerEMdoc]

I know I get flack for this, but with epic burnout levels, we really need to aggressively counsel med students, and I think PDs really need to do a better job of counseling residents on the importance of an exit strategy, which I didn't hear a word of in my residency. Everyone but me is now in UC, FWIW. I think they also need to emphasize taking a high paying job right out of residency. PDs focus on good medicine, but they need to focus on their residents' health, happiness, and financial security.

I've been an attending at my residency for 7 years. I've had one graduate go on to Urgent Care over EM, and she recognized midway through residency that she didn't like the anxiety of taking care of sicker patients, so she went into UC straight out of residency. She is the only resident in 7 years that is not practicing EM. So if you are saying that everyone but you from your residency class is in UC, then your program didn't prepare you well for practicing on the outside unless you graduated 20 years ago and everyone of your classmates is in their pre-retirement gig. I don't mean that as an insult, if anything I feel like you were done a great disservice. This is highly atypical of EM residencies to graduate classes where no one practices EM. If that is happening at a residency, something is going on where the residents aren't prepared for the tough parts of the job when they get out.

 

[enalli]

Work hard for 10 yrs until you are 40

You will not be burned out at 40.

Strongly disagree.

 

[miacomet]

I've been an attending at my residency for 7 years. I've had one graduate go on to Urgent Care over EM, and she recognized midway through residency that she didn't like the anxiety of taking care of sicker patients, so she went into UC straight out of residency. She is the only resident in 7 years that is not practicing EM. So if you are saying that everyone but you from your residency class is in UC, then your program didn't prepare you well for practicing on the outside unless you graduated 20 years ago and everyone of your classmates is in their pre-retirement gig. I don't mean that as an insult, if anything I feel like you were done a great disservice. This is highly atypical of EM residencies to graduate classes where no one practices EM. If that is happening at a residency, something is going on where the residents aren't prepared for the tough parts of the job when they get out.

Oh, I agree with everything you just wrote.

Maybe it's partly that EM in NYC pays really badly, and UC and telehealth don't really pay significantly less, but it seems like a reasonably large percentage of EM grads from there burn out, or aim for academic gigs with very little clinical time.

 

[scummie]

A lot of these suggestions sound amazing. Part of the angst relates to feeling hopeless about your situation, whether it’s a never ending contract, working way too much to support a certain lifestyle or meet obligations, or a sense that things will never get better.
I have wanted to be a doctor since I was about 7. I don’t want to be a Joan of Arc. I just want to practice good medicine for my patients. Instead, that’s a lower priority compared to spending an entire day off on a seminar on workplace violence without compensation. There’s a massive disconnect between the C-suite and the people actually working. It’s really hard, if not impossible to find a good advocate.

 

[sloh]

Why in the world is PMR so unhappy at work and among the most burned out?

4th year PMR resident here. Selection bias could be factoring into the results. Many who choose PMR have expectations of it being very lifestyle friendly but the reality is not meeting their expectations. PMR is more lifestyle friendly than other specialties but still has its own issues.

 

[TooMuchResearch]

Strongly disagree.

L. O. L.

 

[TooMuchResearch]

Oh, I agree with everything you just wrote.

Maybe it's partly that EM in NYC pays really badly, and UC and telehealth don't really pay significantly less, but it seems like a reasonably large percentage of EM grads from there burn out, or aim for academic gigs with very little clinical time.

UC doesn't pay significantly less than EM in NYC? Holy shirt.

 

[Old_Mil]

Mostly great suggestions. I'd make a few tweaks:

1. Night shifts after 45 banned.

2. Shifts longer than 10 hours banned. I've worked everything from 8 to 24s. My personal experience is that you lose efficiency after 10, and lose effectiveness/safety after about 13 except in the lowest volume departments where you can get a good nights sleep.

3. Not sure about the time and a half / double time mandates. I would prefer to leave compensation matters like that left up to individual groups as to whether a higher base hourly rate or night/vacation overrides are appropriate.

4. Cap at 2 pph, enforced. Consider that the 2.5 pph number is an ACEP-CMG creation. it works out to 24 minutes per patient. Consider that FM physicians in a clinic setting who (1) are seeing cases with dramatically lower acuity, (2) order and interpret far fewer tests, and (3) have a history with the patienst in question for the most part get 15 minutes per patient. Even FMs in many clinics get a 30 minute appointment for new or complex patients. A 2.0 pph cap would be more realistic.

5. I oppose top down one size fits all MOC and CME requirements. We all have different strengths and weaknesses and practice in different environments and so such things actually weaken our ability to be proficient by preventing us from focusing on those areas we need to. However, I believe the oral boards hold value by measuring the ability of our graduates to translate what they have learned and been tested on in multiple choice format to a simulation of the real world.

 

[namethatsmell]

Mostly great suggestions. I'd make a few tweaks:
2. Shifts longer than 10 hours banned. I've worked everything from 8 to 24s. My personal experience is that you lose efficiency after 10, and lose effectiveness/safety after about 13 except in the lowest volume departments where you can get a good nights sleep.

I agree that 10 hour shifts seem to be the longest ones that most folks can reliably meet the sweet spot of safe/efficient care. As a further requirement: mandate one hour of overlap between shifts. It effectively creates a 1-1.5 hour period at the end of your shift to dispo and finish up charting and only pick up simple stuff if you want. Fewer signouts, safer for patients, better for your sanity, and less uncompensated time.

 

[GonnaBeADoc2222]

I agree that 10 hour shifts seem to be the longest ones that most folks can reliably meet the sweet spot of safe/efficient care. As a further requirement: mandate one hour of overlap between shifts. It effectively creates a 1-1.5 hour period at the end of your shift to dispo and finish up charting and only pick up simple stuff if you want. Fewer signouts, safer for patients, better for your sanity, and less uncompensated time.

They can overlap or not, I stop seeing patients 1 hour before my shift end time regardless. Obviously if a sick patient rolls in I see them. My notes are done and signed by the time I leave. Documenting the encounter is part of our professional services. I'm quite certain that none of us are paid for documenting at home, so why should you?

 

[TooMuchResearch]

I agree that 10 hour shifts seem to be the longest ones that most folks can reliably meet the sweet spot of safe/efficient care. As a further requirement: mandate one hour of overlap between shifts. It effectively creates a 1-1.5 hour period at the end of your shift to dispo and finish up charting and only pick up simple stuff if you want. Fewer signouts, safer for patients, better for your sanity, and less uncompensated time.

I really like my 24 hr rural shifts, so much less stress than a hectic 8.5 hour big ED shift, even if it's a busier rural 24.
But that's just my preference.

 

[Groove]

I really like my 24 hr rural shifts, so much less stress than a hectic 8.5 hour big ED shift, even if it's a busier rural 24.
But that's just my preference.

Is your pay/hr comparable? How rural are we talking about...what's the annual volume at the ED you're working at out of curiosity? I've never really thought about working in a rural ED...outside of a locums assignment.

 

[Uranium678]

I don't forgive the 30 year old mother of 4 with Grandma in tow bringing her perfectly healthy 18 month old to the ER for a "fever". Seriously? After 4 kids you haven't figured out how to deal with this at home?? And your Mom who is with you right now couldn't give you any pointers??

This is everyday. If grandma is not there it’s weird.

 

[TooMuchResearch]

Is your pay/hr comparable? How rural are we talking about...what's the annual volume at the ED you're working at out of curiosity? I've never really thought about working in a rural ED...outside of a locums assignment.

My pay is the same, but I'm an employee of a SDG. Partners get paid a somewhat lower hourly but similar RVU bonus compared to our meat grinder. Most rural site probably around 6000 visits/year but those are numbers from maybe 2016.

 

[turkeyjerky]

My pay is the same, but I'm an employee of a SDG. Partners get paid a somewhat lower hourly but similar RVU bonus compared to our meat grinder. Most rural site probably around 6000 visits/year but those are numbers from maybe 2016.

So avg 17 patients per 24 hr shift? Yeah, I'd take that...def less hectic than 25 Ina 10 hr shift. You're essentially getting paid 3x as much per patient.

 

[TooMuchResearch]

They're also more straightforward patients (on average) than in the higher level referral center. Though when the **** hits the fan, there is no help.

 

[bravotwozero]

I don't forgive the 30 year old mother of 4 with Grandma in tow bringing her perfectly healthy 18 month old to the ER for a "fever". Seriously? After 4 kids you haven't figured out how to deal with this at home?? And your Mom who is with you right now couldn't give you any pointers??

Even better, while I was working in the peds ED as a resident, grandma told the daughter to dial 911 because the kid had a fever. 10 minutes after the ambulance brought the kid to ED, she starts asking about when they can be discharged, because her kid has an appointment with his pediatrician...

 

[GonnaBeADoc2222]

Automatic security escort out the door for aggressive behavior of any kind.

I didn't work my *** off in college and medical school and train for 4 years to be yelled at.

 

[westsidestoryz]

There are unicorn jobs in Portland, OR (good luck), Seattle (uh-huh), Salt Lake, Boise, Colorado Springs, Albuquerque, the entire state of Texas outside the major cities, Birmingham, Wisconsin, Phoenix, Tucson, Maryland, and rural California. There are no unicorn jobs in Denver, Boston, NYC, SF, San Diego, DC, or Philly.

Some places are so unicorny that there are waiting lists and it's nearly impossible to get a job. These include Jackson Hole and Bozeman.

Recently accepted and want to practice in around Phoenix in the future.
Why are EM jobs around Phoenix unicorny?

 

[miacomet]

Recent accepted and want to practice in around Phoenix in the future.
Why are EM jobs around Phoenix unicorny?

Most of the good jobs are gone since the major groups sold to CMGs. It's a quality, not quantity, issue. YMMV.

 

[westsidestoryz]

Most of the good jobs are gone since the major groups sold to CMGs. It's a quality, not quantity, issue. YMMV.

Still trying to play catch-up, but what is a CMG and why is it a bad thing? More red tapes and bureaucratic nonsense?

 

[GonnaBeADoc2222]

Still trying to play catch-up, but what is a CMG and why is it a bad thing? More red tapes and bureaucratic nonsense?

Many many many threads on this.

Also, you just got accepted to med school? You're basically a stem cell - stay undifferentiated for now.

My advice - go into surgical sub-specialty - resistant to midlevel nonsense and corporate influence.

 

[westsidestoryz]

Many many many threads on this.

Also, you just got accepted to med school? You're basically a stem cell - stay undifferentiated for now.

My advice - go into surgical sub-specialty - resistant to midlevel nonsense and corporate influence.

Got the main gist of it:
"Though the CMGs provide the convenience of billing, collecting, and paying taxes, in some cases physicians have lost a considerable amount of autonomy."

plastic surgery here I come!

 

[Birdstrike]

Got the main gist of it:
"Though the CMGs provide the convenience of billing, collecting, and paying taxes, in some cases physicians have lost a considerable amount of autonomy."

plastic surgery here I come!

Autonomy is one of those things you don't miss until it's gone. And when it's gone, it hurts bad. Real bad. Then you realize the strategy of, "Show me the money! Show me the easy paycheck!" may not feel so easy, after it plays out over time.

I'll take twice the autonomy and 1/2 the paycheck all day long.

 

[314117]

4th year PMR resident here. Selection bias could be factoring into the results. Many who choose PMR have expectations of it being very lifestyle friendly but the reality is not meeting their expectations. PMR is more lifestyle friendly than other specialties but still has its own issues.

Practicing PMR here. I guess if you work inpatient PMR this may be true, but not many people coming out of residency these days want to do this. Many PMR such as myself and colleagues work outpatient jobs that are very lifestyle friendly.
I currently work from about 830-430 M-F, no nights/wknds ever, I "take call" for my own patients which averages about 5-10 after-hours phone calls from home per year.
I have had a few jobs since finishing fellowship and have interviewed for many others and they are all similar. But you are a resident so you can't be expected to know this.

And as far as this statement:
"Because their big kahuna reimbursement source, EMGs, were slashed and burned to the mother-F-in ground."
EMG reimbursements may have decreased, but there are many more ways to make much better money in PMR than doing EMGs.

 

[sloh]

Practicing PMR here. I guess if you work inpatient PMR this may be true, but not many people coming out of residency these days want to do this. Many PMR such as myself and colleagues work outpatient jobs that are very lifestyle friendly.
I currently work from about 830-430 M-F, no nights/wknds ever, I "take call" for my own patients which averages about 5-10 after-hours phone calls from home per year.
I have had a few jobs since finishing fellowship and have interviewed for many others and they are all similar. But you are a resident so you can't be expected to know this.

And as far as this statement:
"Because their big kahuna reimbursement source, EMGs, were slashed and burned to the mother-F-in ground."
EMG reimbursements may have decreased, but there are many more ways to make much better money in PMR than doing EMGs.

Thanks for the input. Surveys do have their limitations but it still doesn't explain the results which show high burnout rates in PM&R

 

[miacomet]

Save, get out in ten years, do something else, or nothing.

 

[314117]

Thanks for the input. Surveys do have their limitations but it still doesn't explain the results which show high burnout rates in PM&R

My guess is that the high burnout rates in PMR are from those experiencing "emotional exhaustion of dealing with stroke and spinal cord injury patients" as noted by Birdstrike above.
You have the choice in PMR what to do. I can honestly say that I will likely never be dealing with those kinds of patients or any inpatient work for the rest of my career. Spine is the way to go for PMR.

 

[Birdstrike]

Spine is the way to go for PMR.

Yes. All office based, no hospital work. Do lots of spine procedures, a few meds as possible.
And no nights, weekends, holidays or call. Ever. Pretty much what I do. Not a bad gig.

The vast majority of PM&R people answering that survey reporting burnout are not practicing Spine or Pain. So, whatever is to explain for the high burnout rate in that survey, likely is coming out from the majority, which is not made up of Spine or Pain subspecialized people.

Again, this is why many subspecialties and fellowships are competitive.

 

[Old_Mil]

I really like my 24 hr rural shifts, so much less stress than a hectic 8.5 hour big ED shift, even if it's a busier rural 24.
But that's just my preference.

Practicing in rural departments can be really rewarding. Some of my most satisfying shifts have been in rural EDs.

That having been said, you really have to take a look at 24 hour shifts when you get above the 4000-5000 patient mark. The reason is that as that visit volume begins to creep up, there's a certain level beyond which you'll start getting a trickle of patients overnight and sleep deprivation becomes an issue.

If I had to make a list of "top 25 stupid things I've ever done in life" things like marrying my ex-wife would be on there, as would taking a job at a single coverage 11,000 visit ED with 24 hour shifts right out of residency. The visit volume wasn't the problem, the 24 hour shift length was.

 

[Old_Mil]

Still trying to play catch-up, but what is a CMG and why is it a bad thing? More red tapes and bureaucratic nonsense?

A contract management group.

Basically a corporate entity that contracts with a variety of hospitals in a region or nationally to provide coverage for and bill on behalf of the Emergency Department.

They then turn around and offer physicians 1099 independent contractor positions with no benefits (health insurance, workmen's comp, retirement, disability insurance) aside from malpractice coverage. You also get to pay both halves of your medicare and social security taxes.

End result: Dollars that should be going into either your pocket or patient care are diverted to support a large, expensive, corporate structure with multiple millions in annual profits.

 

[GonnaBeADoc2222]

A contract management group.

Basically a corporate entity that contracts with a variety of hospitals in a region or nationally to provide coverage for and bill on behalf of the Emergency Department.

They then turn around and offer physicians 1099 independent contractor positions with no benefits (health insurance, workmen's comp, retirement, disability insurance) aside from malpractice coverage. You also get to pay both halves of your medicare and social security taxes.

End result: Dollars that should be going into either your pocket or patient care are diverted to support a large, expensive, corporate structure with multiple millions in annual profits.

So I've wondered about the workmen's comp issue with being 1099. What happens if you stick yourself on an HIV or Hep infected needle on shift? Or a patient assaults you? What is your recourse?

 

[Arcan57]

So I've wondered about the workmen's comp issue with being 1099. What happens if you stick yourself on an HIV or Hep infected needle on shift? Or a patient assaults you? What is your recourse?

Many hospitals will cover private docs injured on premises as if they were employees. That of course is important to find out prior to injury happening.