Well-being and burnout: One size does not fit all.

Well-being and burnout are concepts that have become well described throughout emergency medicine. In the past, both well-being and burnout have been defined and addressed as a singular phenomenon, similar for all physicians, regardless of career stage. However, unique stressors may exist for physicians, as a function of their work environment and stage. In this concepts article we present clinician well-being as a dynamic and continuous process, subject to unique factors along the professional lifespan. Specific individual and system-level factors are discussed, ranging from demographic variables, to evolving administrative and professional responsibilities depending on the career stage of a clinician. This detailed description of stressors spanning an emergency physician's professional career may help create more targeted physician well-being and burnout interventions.

INTRODUCTION

Within medicine, rates of clinician burnout have reached endemic levels, with emergency physicians reporting amongst the highest rates of burnout. Complementing this concept of burnout is the idea of clinician well‐being, defined as an “active process of becoming aware of and making choices toward a healthy and fulfilling life.” The recognition of clinician burnout and support of physicians to ensure well‐being are critical not only for career satisfaction but also patient care outcomes. Physicians reporting higher rates of burnout have been associated with both reduced career satisfaction and adverse patient care outcomes. , Currently, well‐being and burnout have been largely conceptualized as a singular construct of which the causes are the same for all physicians, across all specialties and across the professional lifespan. However, such a conceptualization may not take into account some of the unique challenges that physicians face across their professional career. For example, past work has found that individual solutions and systemic answers may be different depending on the stage of the life cycle of the physician. That is to say, perhaps solutions for an emergency medicine resident, a newly graduated emergency physician practicing for <10 years, a physician 10–20 years post‐graduation, and a late‐career physician in the final years of clinical work may be unique and differ depending on the individual career stage.

The life cycle of an emergency physician has never been comprehensively studied with regard to the causes of burnout and well‐being. Solutions in the past have primarily focused on encouraging individuals to improve themselves with techniques to reduce stress rather than on the external and environmental factors that place the individual under increasing demands and stress. The National Academy of Medicine Action Collaborative on Clinician Well‐Being and Resilience recently introduced a conceptual model in 2018 updating a working definition of burnout to emphasize that extrinsic and environmental factors affect physicians’ well‐being. Building on this model and creating a framework that conceptualizes well‐being as a dynamic process of unique external and extrinsic challenges occurring across the professional spectrum may help in the identification of targeted interventions for clinicians throughout their career. The goal of this concept article is to provide a novel framework for describing well‐being and conceptualizing causes of burnout as a dynamic construct posing unique challenges across the professional lifespan of clinicians from trainees to new faculty to senior clinicians.

THE TRAINEE AND EARLY CAREER EMERGENCY PHYSICIAN (<10 YEARS POST‐GRADUATION)

Well‐being, resilience, and burnout are important concepts throughout the professional life span of emergency clinicians. Trainees and early faculty appear to suffer from high rates of clinician burnout and emotional fatigue. , Although many of the challenges encountered by young physicians are also shared by more established clinicians, burnout in the early‐career emergency physician is marked by the presence of unique stressors. Training and much of the early years as young faculty is marked by expectations of formal and informal assessments, in addition to structured educational responsibilities, all occurring in the context of a steep learning curve experience at the bedside. This milieu of frequent standardized testing and assessments has been reported to be a significant driver of self‐reported stress among trainees. Additionally, although not unique to young faculty, concern for acknowledging diagnostic uncertainty and revealing errors to other physicians also have been found to be prevalent among trainees and early faculty and associated with increased levels of burnout and early career dissatisfaction. Past work has found that other diverse stressors, ranging from familial obligations, social support, and perceived lack of administrative autonomy were associated with increased levels of burnout.

For many trainees and young faculty, the challenges of professional development occur alongside significant financial obligations as well as personal milestones, including relationships and family planning. Recent work by West et al, found that greater educational debt was associated with burnout symptoms, with a debt over $200,000 associated with almost double the odds of having at least one symptom of burnout. This combination of professional, financial, and personal demands for early‐career clinicians may create a period of increased vulnerability for the development of burnout symptoms such as emotional exhaustion, and if not dealt with early on, may lead to sustained effects lasting throughout the professional lifespan of such clinicians.

THE JUNIOR TO MID‐CAREER EMERGENCY PHYSICIAN (10–20 YEARS POST‐GRADUATION)

Compared to early and later careers, mid‐career is an especially challenging time for physicians. The mid‐career physician has the lowest job satisfaction and perceived work‐life balance along with the highest rate of exhaustion. Mid‐career physicians are twice as likely to leave their current practice for reasons other than retirement. Additionally, mid‐career physicians, especially in academics, feel a loss of direction and do not feel the support and mentorship awarded to them as a junior physician.

These findings are not unique to physicians. “Mid‐career Crisis Syndrome” is a common phenomenon across many career paths. This “syndrome” results in the successful individual feeling unsatisfied, stagnant, losing self‐confidence, or losing a sense of purpose. The “crisis” appears to stem from mid‐career physicians arriving at a transition point within their career paths. Unlike early career physicians, mid‐career physicians are less concerned about professional liability and mastering clinical skills. The imposter syndrome and the concern for medical errors are less acute. To re‐engage and re‐ignite their passion for emergency medicine, the mid‐career physician frequently pursues a career transition, such as seeking a promotion, a new job opportunity, or establishing a new collaboration. Similar to physicians of other stages in their career, mid‐career physicians deal with many factors contributing to their overall lack of well‐being and burnout burden. However, mid‐career physicians also have the additional internal struggle of career satisfaction and the uncertainty of a career transition.

THE ESTABLISHED EMERGENCY PHYSICIANS (21–30 YEARS POST‐GRADUATION)

The established emergency physician is a growing group of individuals within the specialty. However, unlike other disciplines, the pathway to operationalizing seniority among emergency physicians is less clear. For example, orthopedic faculty often begin their careers with full involvement in a wide range of orthopedic illnesses and injuries and, as they mature in their professional lives transition to performing a singular procedure. Similarly, OBGYN physicians initially start their careers with a broad scope of procedures and then may transition to perform solely gynecologic procedures. Limiting one's scope of practice seems to make clinical practice more manageable and fulfilling. Given the relative newness of emergency medicine, the expected maturation of the emergency physician is yet to be determined.

It is generally perceived that senior emergency physicians represent a wealth of experience and knowledge and are facile in most aspects of their clinical work. For many such physicians, they may play important roles within the emergency department outside of direct patient care. They might also serve as informal and formal mentors for early‐career physicians and help offer academic and clinical guidance for early career faculty. However, senior emergency physicians may face challenges including adapting to rapid technological innovations within the electronic health record as well as interfacing with a system increasingly digitalized, while also potentially working demanding clinical shifts.

LATE‐CAREER EMERGENCY PHYSICIANS: (>30 YEARS POST‐GRADUATION)

The late‐career physician has a unique set of stressors compared to those in earlier stages of their professional career. As physicians approaching the horizon of a professional career, issues of continued competency may disproportionally affect this cohort of providers. Education in novel practices and techniques, such as bedside ultrasound, now commonplace in residency training, require late career physicians to “play catch up,” while increased productivity requirements and quality metrics may provide additional strain by demanding late career physicians to change longstanding clinical practices. Financial concerns, similar to junior attendings, may be a source of tension for late career physicians. However, unlike recently graduated attendings who may be more concerned about educational loans, different financial pressures exist for late career physicians, including ensuring that they have adequate retirement funds. Furthermore, late career physicians may also encounter a unique challenge finding a life outside of clinical medicine. Finding other engaging interests to replace clinical practice might be challenging and lead to post‐retirement depression if not navigated successfully.

DISCUSSION: FUTURE CONCEPTUALIZATION OF WELL‐BEING ACROSS A CAREER

Being a lifelong learner is critical for both emergency physicians and the patients we serve. Emergency physicians must study and maintain skills such as the management of difficult airways, ultrasound‐guided line placement, and chest tube placement. Skill courses such as Advanced Cardiac Life Support and Advanced Trauma Life Support are taken early in training and used regularly throughout the life span of an emergency physician. Although updated periodically, these basic skills do not radically change over a clinician's career. Well‐being strategies need to be a skill taught, just like procedural skills. In contrast to the aforementioned proficiencies, different resilience skills and techniques are required as one progresses through a career in emergency medicine. Moreover, unlike intubation, these skills are not easily defined, taught, learned or maintained. “See one, do one, teach one” is not necessarily a realistic method for well‐being strategies. An individual's well‐being and level of burnout varies according to the person, the individual career path and where the individual is in their career. In addition, the workplace environment and location of practice: urban versus rural location or community versus academic, contribute to an individual's level of burnout. Stressors from outside the workplace (ie, family, relationships, and finances) that differ depending on where the physician is in their career also contribute to the physician's overall well‐being. As a specialty, we need to look holistically at well‐being education and interventions to comprehensively support the clinician's on‐going career. It is vitally important to incorporate factors such as generational differences, the effects of roles and ever‐changing responsibilities, gender identity and race, location of practice, and most notably where physicians are in the life cycle of their practice.

For well‐being education and initiatives to be beneficial, the life cycle of emergency physicians must be taken into account. The factors affecting emergency physicians vary greatly depending on where individuals are in their career, early versus mid‐ or late career. Properly crafted well‐being education and initiatives can assist physicians and organizations in identifying specific life cycle stressors that may decrease the rate of burnout and increase career longevity. Focusing on how different career stages affect well‐being and burnout is crucial in addressing the varying stressors that play into the life of an emergency physician.

Meaningful solutions to support a long clinical career are difficult to create and are multifactorial. Presently emergency physicians have at least 3 options at the senior stage in their career: leave the clinical practice of emergency medicine, remain in emergency medicine at a similar level with similar burdens, or transition to a modified schedule or role. Physicians who leave emergency medicine can partake in fellowships such as intensive care medicine, palliative medicine, sports medicine, emergency medicine services, and pain medicine. Other alternatives include transitioning to full administrative duties, a strictly academic role or “re‐inventing” themselves in online educational platforms, blogs, free‐standing telemedicine “emergency departments” and board certification preparation courses. Physicians also have opted to transition to locum tenens affording them complete control of scheduling and allowing them to pursue projects outside of clinical work. For these physicians, supplementary income may include paid lectures, expert witness testimony, and increased administrative duties with a reduced clinical load. Without a pathway for the clinical maturation for emergency physicians, senior physicians may have no alternative but to leave clinical medicine or transition to another specialty creating an unfortunate loss of collective wisdom and clinical experience. A study of over 30,000 emergency physicians showed that of the physicians who had a career change, 45% opted to work in a non‐emergency medicine clinical practice and the rate of attrition at 30 years post‐graduation was 25%. As a specialty, we must simultaneously create a work environment to retain the mid‐career and senior emergency physicians while supporting growth in trainees and early career physicians.

One solution is the establishment of peer mentoring and focus groups for different life stages to determine best practices for each of those stated stages. Although systemic issues remain, early‐career physicians may benefit from mentors who focus on work‐life harmony, clinical knowledge, and financial advice. Mid‐career physicians may benefit from workshops or lectures focusing on career transitions and how to re‐engage in medicine. Late‐career physicians may benefit by creating relationships with colleagues who will allow them to pass on their wealth of knowledge. In addition, developing relationships and learning about the challenges of retirement may benefit physicians who are close to making the transition to retirement.

Mentoring and focus groups are likely not enough to curb this phenomenon. Emergency medicine should create a work environment that allows physicians to have a long rewarding clinical career within emergency medicine. Well‐being research addressing emergency medicine system challenges across different career stages may help physicians thrive over the span of their career. Studying the work place environment and determining its effects on physician well‐being may be a good place to start. Looking at both the emotional demands, work demands and job satisfaction within emergency medicine, as well as,the level of work to life conflicts across lifespans may help mitigate some of the most challenging aspects of working in a difficult environment such as the emergency department. This idea is consistent with a study involving mostly primary care physicians that found that “day‐to‐day practice issues” were key factors in physician satisfaction. The survey study also found that specific components (ie, family demands), varied between subgroups depending on gender and practice location. By studying individualized factors across career lifespans, the results may help develop specific well‐being interventions allowing individuals and organizations to create a supportive working environment and allowing physicians to finish their career through a clinical path.

CLINICIAN WELL‐BEING IN THE COVID‐19 PANDEMIC

The emergence of COVID‐19 as a pandemic affecting the world in late 2019 has resulted in a tremendous strain on existing health care systems, particularly among health care workers in emergency medicine. Early data have found significant rates of depression and anxiety among emergency responders to the pandemic and this number is only expected to grow. Well‐being initiatives supporting staff across the lifespan during this crisis should include offering departmental mental health resources, ranging from behavioral health specialists to peer support sessions. In addition to psychological stressors, COVID‐19 has presented unique challenges for clinician well‐being, as threats to physical well‐being (eg, disease exposure and transmission) are acutely elevated. During this crisis, individual departments should provide structured assistance based upon the concepts presented in this article regarding the physician professional lifespan. Advanced‐age emergency clinicians or those with existing medical comorbidities may be at elevated risk of disease severity, and strategies should be considered to mitigate that risk. These strategies may include shifting of these providers to different clinical areas or to telemedicine opportunities, where available, to reduce exposure risk in this vulnerable clinician group. Regardless of age, high levels of psychological distress and fatigue will likely be prevalent. Emergency medicine departments nationally and individually need to examine these pressing issues and address them across the generations to provide relevant and timely assistance.

As the specialty of emergency medicine continually evolves, the professional life span of the emergency physician plays a key part of this conversation. Promoting targeted well‐being education and initiatives will aid emergency physicians to ride the generational waves of financial challenges, job satisfaction vacillations, career transitions, clinical competencies, and national medical emergencies ideally supporting them to continue their careers and lifelong professional development in a satisfying and rewarding manner.

AUTHOR CONTRIBUTIONS

JC, BC, RM, and JK all participated in concept design, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. JC oversaw all phases of manuscript production and takes final responsibility for it's submission.