Mary Remón: Welcome everyone to Burnout by Specialty, a specialty series. Today’s episode is on emergency medicine, and thank you to Doctors on Social Media for hosting this series. I am Mary Remón. I’m a licensed counselor and coach for doctors. And today I would like to welcome and thank Dr. Cecilia Cruz, Dr. Stephen Sabo, and Dr. Brian W. Young for joining us today.
So let’s start off with brief introductions. Dr. Cruz.
Cecilia Cruz: Sure. Hi, my name is Cecilia Cruz. As you know, I’m an ER doctor by training. I practiced emergency medicine for about 23 years. I’m not currently practicing emergency medicine at this time, but I practiced in both the academic and community settings and held some administrative roles while I was working as an emergency medicine physician as well.
Mary Remón: Thank you, Dr. Sabo.
Stephen Sabo: Hi, my name is Dr. Steve Sabo, an emergency doctor. I practiced for 28 years in New York and New Jersey. And two years ago I transitioned to prevention and longevity, and now I help health-minded professionals create a greater impact.
Mary Remón: Thank you, Dr. Sabo. Welcome, Dr. Young.
Brian W. Young: Hello, my name is Brian Young. I practiced emergency medicine for 13 years. My training was in internal medicine and surgery, but I found emergency medicine more attractive, at least initially. And so I no longer practice emergency medicine, but I was in Ohio working in community emergency rooms mostly, with a little bit of academic work but not much.
Mary Remón: Well, thank you all. Wonderful backgrounds. I recently read that once again this past year emergency medicine is the specialty with the highest rate of burnout. And so you all are survivors. I understand, Dr. Sabo, you have 28 years in emergency medicine.
Stephen Sabo: Yes, it’s hard to believe, Mary, but 28 years it was.
Mary Remón: That’s incredible. Dr. Cruz, I’m just curious from your perspective, what does burnout look like in emergency medicine?
Cecilia Cruz: Resentment. Disconnection. I’m hoping Dr. Sabo and Dr. Young will agree with me, but most ER doctors are pretty tough. And our motto — I mean, my motto — one of the mottos in my residency program way back when was, “You can do anything for 28 days.” Our rotations were all 28 days long. I did my residency at the University of Illinois in Chicago.
And so it’s really just put your head down and work. And we were okay with that. So I think in emergency medicine very few doctors will say, or even know, that they were burned out. It comes out in resentment, in anger, in feeling victimized or abused. And as this increases, again it comes out in those other ways.
Mary Remón: Thank you. Dr. Young, I’m curious from your perspective, what is it about emergency medicine in particular compared to other specialties that makes burnout different?
Brian W. Young: Well, it took me a long time to kind of arrive at some of these conclusions, but the biggest thing for me is this state of hypervigilance. You’re asked to be prepared for some potentially dire things across the spectrum. In the settings I practiced, from nearly newborns all the way up to people who are ninety to one hundred years old.
They call emergency medicine “the first 30 minutes.” What you do initially can be critical in terms of outcomes. Then when you layer that onto the fact that emergency rooms are expected to take all comers, and a lot of that is non-emergent problems that are indicative of the social decay of our society, the ER becomes one of the only places people can show up and try to get things addressed.
It was an unsolvable conundrum for me. I could not maintain that vigilance and that mindset to be ready for everything while basically running a 24-hour primary care and urgent care clinic at the same time. I don’t know how other people feel, but I know it stressed me in ways that I was never able to feel harmony with.
Mary Remón: Thank you for sharing. I can’t even imagine. Dr. Sabo, our survivor of emergency medicine for 28 years, what would you say was the part of the job that you found most draining when you were practicing?
Stephen Sabo: I’m thinking about episodes — I’m sure you’ve all seen the show The Pit, which is really quite accurate. I remember the show ER, dating myself a bit, but those shows were actually pretty accurate about how administrators will sometimes get in the way of what you’re trying to do in the ER.
You’re there trying to save lives and do your job, and they want to talk about some irrelevant protocol or other administrative issue. They’re not looking at the same thing you’re looking at. You’re looking at what’s best for the patient.
Also, as Brian mentioned, you have to recognize that a cardiac arrest or trauma arrest can come into the ER at any moment. You may be doing a laceration repair and suddenly you have to multitask. You cover up the patient’s wound and go handle a cardiac arrest.
One of my hardest days was being single coverage and having a pediatric cardiac arrest and an adult cardiac arrest simultaneously. I spent most of the time in the pediatric arrest and had the charge nurse running the adult arrest, going back and forth between the two.
Did I answer your question? I’m not sure, but that’s what came to mind.
Mary Remón: You made it very vivid. Thank you. I can imagine. Dr. Cruz, along those lines, because Dr. Sabo mentioned administrators coming in with random or irrelevant things, I’m wondering what people outside of emergency medicine don’t see.
Cecilia Cruz: That’s a good question. I feel like a lot of people don’t see that we’re human. We have families and loved ones and lives that we also have to deal with.
The expectation placed on emergency physicians is that anyone can come into the ER and it’s our job not only to treat them, which yes of course it is, but also to make it this comfortable, almost luxurious experience.
Often patients aren’t presenting with emergencies. They’re expecting to be seen in the order they arrived and don’t understand why they have to wait.
They don’t understand that our job is to take care of the sickest people first. And that there is only so much we can do within the system we practice in.
People think the ER doctor will solve every problem — do surgery, fix every issue immediately — and that’s not the case. We’re there to treat emergencies and then triage people to the next step of care.
They don’t understand why they can’t have their mole removed immediately in the ER.
Mary Remón: Thank you. I can only imagine the range of serious and benign issues people present with. Dr. Young, when you were practicing, what types of system pressures hit emergency physicians the hardest?
Brian W. Young: Throughput. The expectation that you’re going to establish rapport at light speed, make decisions at light speed, and resolve every issue in a timely manner according to patient expectations.
Where I practiced in Southwest Virginia there were billboards advertising ER wait times. But you don’t see billboards for how many days you wait to see an orthopedic doctor.
Those expectations set the tone. At the same time the ER is overcrowded everywhere. That sense of control disappears. You’re asked to do things without the ability to control the system around you.
Between thirty-three and forty percent of hospital admissions come through the ER. Yet the ER isn’t structured like a revenue center even though it’s treated like one.
Many emergency doctors feel trapped in the middle — between hospital systems, specialists, and patients — and it’s an incredibly stressful place to be.
Mary Remón: Thank you. I hear pressures coming from many directions. Dr. Cruz, what feels most unsustainable about emergency medicine?
Cecilia Cruz: Pretty much everything that’s already been mentioned. Emergency physicians are asked to do more with less every single day.
In the early 2000s there were still some slower shifts where you could catch your breath. That doesn’t exist anymore.
Patients are always in hallways. Waiting rooms are packed.
What people don’t realize is that once a patient enters the ER, that physician becomes responsible for them even if they’ve never seen or spoken to them yet.
If something happens to someone in the waiting room, it’s still on you.
You might have 40 or 50 patients waiting, sometimes for hours. And it’s impossible to manage that perfectly.
None of this is sustainable. If insurance access gets worse, where will people go? The ER. Unless something changes, it’s likely to get worse before it gets better.
Mary Remón: Thank you. Dr. Sabo, what do you think keeps people practicing despite all this?
Stephen Sabo: That’s a great question. One thing I did was leave work at work. I finished charts at the hospital and tried to be fully present with my family at home.
I also started meditating during my last few years of practice. If I had a 7 a.m. shift, I might wake up at 5 a.m. and do meditation so I could come in calm and centered.
That probably helped me maintain an even keel, which the nurses and staff appreciated. Obviously emergencies can raise your heart rate quickly, but having that baseline calm helped a lot.
Mary Remón: Thank you. Dr. Young, what do you wish leadership understood?
Brian W. Young: Leadership needs a deeper understanding of what emergency departments actually deal with.
If ER staff are saying patients are stacking up in hallways or throughput is failing, leaders need to lean in and address those problems seriously.
The ER is the front line of the hospital system. Just like the military equips soldiers with the best gear, hospitals should equip ER staff for success.
In the settings I worked in, the ER often felt like a neglected back-door operation instead of a front-line priority.
Mary Remón: Thank you. Dr. Cruz, if just one thing changed, what would reduce burnout the most?
Cecilia Cruz: Throughput. If administrators focused on moving admitted patients upstairs faster, that would make a huge difference.
It’s demoralizing and unsafe to care for patients in hallways. Doctors and nurses can’t properly examine them there.
Fixing that alone would improve things significantly.
Mary Remón: Thank you. I have one final question for each of you. How can we make emergency medicine more sustainable? Dr. Young?
Brian W. Young: Many of these problems are systemic. Emergency physicians start with idealism and dedication, but they crash into broken systems.
COVID exposed many of those weaknesses. The solutions exist — staffing, better processes, more resources — but leaders need to listen and act.
Mary Remón: Dr. Cruz?
Cecilia Cruz: Connection. Right now there’s a disconnect between emergency physicians and other specialties.
As health systems grow larger, we’re just voices on the phone. If there were stronger relationships and collaboration between specialties, it would ease a lot of the pressure.
Mary Remón: Dr. Sabo?
Stephen Sabo: Physicians should continue giving feedback to leadership, but leadership also needs to actually listen.
If they implement physician suggestions for the good of patients, the system will improve.
Mary Remón: Dr. Cruz, Dr. Sabo, Dr. Young — thank you so much for taking the time out of your busy schedules and for sharing your insights and frontline experiences. And thank you to Doctors on Social Media for hosting this event.
This concludes today’s episode of Burnout by Specialty featuring emergency medicine.
