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doi: 10.1111/1742-6723.12135 Emergency Medicine Australasia (2013) 25, 491–495

REVIEW ARTICLE

Review article: Burnout in emergency

medicine physicians
Manit Arora,1 Stephen Asha,1,2 Jason Chinnappa1 and Ashish D Diwan1
1
St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia, and
2
Department of Emergency Medicine, St George Public Hospital, Sydney, New South Wales, Australia

Abstract
Training and the practice of emergency medicine are stressful endeavours, placing emer-
gency medicine physicians at risk of burnout. Burnout syndrome is associated with
negative outcomes for patients, institutions and the physician. The aim of this review is to
summarise the available literature on burnout among emergency medicine physicians and
provide recommendations for future work in this field. A search of MEDLINE (1946–
present) (search terms: ‘Burnout, Professional’ AND ‘Emergency Medicine’ AND ‘Physi-
cians’; ‘Stress, Psychological’ AND ‘Emergency Medicine’ AND ‘Physicians’) and EMBASE
(1988–present) (search terms: ‘Burnout’ AND ‘Emergency Medicine’ AND ‘Physicians’;
‘Mental Stress’ AND ‘Emergency Medicine’ AND ‘Physicians’) was performed. The authors
focused on articles that assessed burnout among emergency medicine physicians. Most
studies used the Maslach Burnout Inventory to quantify burnout, allowing for cross-study
(and cross-country) comparisons. Emergency medicine has burnout levels in excess of 60%
compared with physicians in general (38%). Despite this, most emergency medicine phy-
sicians (>60%) are satisfied with their jobs. Both work-related (hours of work, years of
practice, professional development activities, non-clinical duties etc.) and non-work-related
factors (age, sex, lifestyle factors etc.) are associated with burnout. Despite the heavy
burnout rates among emergency medicine physicians, little work has been performed in
this field. Factors responsible for burnout among various emergency medicine populations
should be determined, and appropriate interventions designed to reduce burnout.
Key words: burnout, emergency medicine, Maslach Burnout Inventory, physician.

Introduction accomplishment among individuals who work with

people in some capacity.1 Two common symptoms
Emergency medicine is emotionally, physically and of burnout are treating patients and colleagues as
intellectually challenging. The potential adverse conse- objects rather than human beings and feeling emotion-
quences of burnout on emergency medicine physicians, ally depleted. Symptoms of burnout also include physi-
their patients and health institutions, have generated cal exhaustion, poor judgement, cynicism, guilt, feelings
much interest and underscores the importance of of ineffectiveness, and a sense of depersonalisation in
understanding burnout among emergency medicine relationships with co-workers or patients.
physicians. Physicians and other healthcare workers are believed
Burnout is a syndrome of emotional exhaustion, to be particularly susceptible to burnout compared with
depersonalisation and a reduced sense of personal the general public.2 Factors identified as contributing to

Correspondence: Dr Manit Arora, St George Private Hospital, Kogarah, Sydney, NSW 2217, Australia. Email: [email protected]
Manit Arora, BScMed (Hons), MBBS (Hons), Associate Lecturer; Stephen Asha, MBBS, FACEM, Consultant; Jason Chinnappa, MBBS, MS,
Resident; Ashish D Diwan, PhD, FRACS, Chief.

© 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 M Arora et al.

Table 1. Categorisation of Maslach Burnout Inventory score

data into low, moderate and high-risk groups for burnout based
on overall score data1
Low Moderate High
Emotional exhaustion ≤18 19–26 ≥27
Depersonalisation ≤5 6–9 ≥10
Personal achievement ≤40 34–39 ≥33

burnout among workers include work overload, lack of

control, insufficient rewards, lack of community (social
and peer support), lack of fairness and conflicting Figure 1. Prevalence of burnout (tool: Maslach Burnout Inven-
values (work vs family).3 tory) among emergency medicine physicians versus physicians in
Burnout is associated with negative outcomes for general versus general US population.10
physicians, including physical and emotional illness,
and drug abuse,4 decreased physician satisfaction5 and
poor health, including headaches, sleep disturbances, medicine physicians and provide recommendations for
hypertension, anxiety, alcoholism and myocardial future work in this field.
infarction.6 For institutions, physician burnout is asso-
ciated with increased turnover, absenteeism, poor per-
formance and negative attitudes.4 Finally, for patients, Method
burnout in their treating physicians is associated with
decreased quality of medical care,7 decreased patient A search of MEDLINE (1946–present) (search terms:
safety and increased medical errors.8 In a study of 7095 ‘Burnout, Professional’ AND ‘Emergency Medicine’
surgeons (American College of Surgery), Shanafelt et al. AND ‘Physicians’; ‘Stress, Psychological’ AND ‘Emer-
found that reporting of a medical error (over a 3 month gency Medicine’ AND ‘Physicians’) and EMBASE
period) had a strong correlation with all three domains (1988–present) (search terms: ‘Burnout’ AND ‘Emer-
(emotional exhaustion, depersonalisation and personal gency Medicine’ AND ‘Physicians’; ‘Mental Stress’ AND
accomplishment) of burnout. Using the Maslach ‘Emergency Medicine’ AND ‘Physicians’) was per-
Burnout Inventory (MBI) to assess burnout, they found formed. The authors further searched available litera-
that each one point increase in depersonalisation score ture using Google Scholar (search terms: ‘Burnout’ AND
(range: 0–33) was associated with 11% increase in ‘Emergency Physicians’) and the reference lists of
medical error report rate, and each one point increase in selected articles were reviewed for additional relevant
emotional exhaustion score (range: 0–54) was associated articles. Studies were included in this review if they
with a 5% increase.9 assess burnout primarily among emergency physicians,
The MBI is a validated instrument commonly used to and used a validated instrument. A total of seven
assess burnout.1 It consists of three subscales: nine studies were found.
items measuring emotional exhaustion (a drained,
depleted feeling arising because of excessive psycho-
logical and emotional demands); five items assessing Results
depersonalisation (tendency to view others in an exces-
sively detached, impersonal manner); and eight items Burnout rates
assessing personal achievement (a sense of competence
and accomplishment). Categorisation into low, medium In a recent study by Shanafelt et al., emergency medi-
and high levels of burnout is based on overall score cine physicians were found to have the highest rate of
compilation (Table 1). Another validated tool used less burnout (65%; tool: MBI) compared with physicians in
frequently to assess burnout is the Copenhagen Burnout general (n = 7288) and the general population (n = 3422
Inventory (CBI). working US adults; Fig. 1).10 This level of burnout is
The aim of this review is to summarise the current similar to a previous study of 1272 US emergency phy-
literature available for burnout among emergency sicians (American College of Emergency Medicine) that

492 © 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 Burnout in emergency medicine physicians: review

found that 60% of emergency medicine physicians had physicians in Romania, it was found that the more
moderate to high burnout scores (tool: MBI).11 the number of years in the profession, the greater the
Emergency physicians are significantly more burnt likelihood of burnout − 11% of physicians had high
out compared with their nursing colleagues. A study of emotional exhaustion scores by their fourth year of
30 British emergency medicine nurses found that 20% work versus 17% by their seventh year of work (tool:
had high emotional exhaustion scores, 0% had high MBI).16 However, this is not a consistent finding, with
depersonalisation scores and 100% had medium to high no association being found between years of practice
personal accomplishment scores (tool: MBI).12 However, and burnout (tool: MBI) among 1272 US emergency
a study of emergency medicine physician assistants physicians.11
(tool: MBI) found that 59% had medium to high emo- The role of professional development activities
tional exhaustion scores, 66% had medium to high and non-clinical duties on burnout was evaluated by
depersonalisation scores and 34% had medium to high Lloyd et al. in their study of 268 Canadian emergency
personal accomplishment scores.13 medicine physicians. They found that successful
research publication in the last two years was associ-
Burnout and satisfaction ated with decreased emotional exhaustion.14 Further,
depersonalisation scores decreased and personal
In a study of 268 Canadian emergency physicians, accomplishment scores increased with number of non-
Lloyd et al. found that 61% of emergency medicine phy- clinical emergency medicine hours worked per year.
sicians were satisfied with life (tool: Satisfaction with Emergency medicine physicians who did not attend
Life Scale) and 76% were satisfied with their jobs (tool: continuing education activities were three times more
Emergency Physician Job Satisfaction Measurement likely to burn out compared with those that attended
Instrument). Despite this high degree of satisfaction, such activities.17
there were high levels of burnout, as measured using the Further, in a study of 193 US emergency physicians
MBI − 46% had medium to high emotional exhaustion (American College of Emergency Physicians), high
scores and 93% had medium to high depersonalisation anxiety caused by concern for adverse clinical outcomes
scores.14 was a strong predictor of career burnout (tool: MBI).18
In a longitudinal study of 771 US emergency medi-
cine physicians (tool: self-developed scale), 65% were Non-work-related factors
highly satisfied with their career, 13% had low career The role of demographic factors on emergency physi-
satisfaction and 31% reported burnout as a significant cian burnout is controversial. Some studies have
problem.15 Physicians who reported that stress or found that demographic factors are not associated
burnout were serious problems were less likely to report with burnout.11,18 Contrarily, Lloyd et al. found that
high levels of career satisfaction. depersonalisation scores decreased with age and
personal accomplishment scores increased with age.14
Factors associated with burnout Similarly, Shanafelt et al. found that older age and
being married were associated with lower level of
Factors associated with burnout can broadly be burnout.10
divided into work-related factors and non-work-related In a study of 1924 French physicians, a subgroup of
factors. 538 emergency physicians had high burnout scores of
52% (tool: CBI), with 21% of emergency physicians
Work-related factors intending to leave the profession.17 Work–family con-
In a study of 1272 US emergency physicians, self- flict and quality of teamwork were associated with
recognition of burnout, lack of job involvement, nega- burnout, and being burnt out doubled the risk of leaving
tive self-assessment of productivity, dissatisfaction the profession. Work–family conflict was the highest
with career, sleep disturbances, increased number of risk factor for burnout among female emergency physi-
shifts per month, dissatisfaction with specialty services cians, whereas quality of teamwork ranked highest for
and intent to leave practice within 10 years were sig- their male colleagues.
nificant predictors of burnout among emergency medi- Goldberg et al. found that higher levels of alcohol
cine physicians.11 consumption and lower levels of exercise were signifi-
Higher burnout scores were associated with more cant predictors of burnout among emergency medicine
hours worked per week.10 In a study of 263 emergency physicians.11

© 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine 493
 M Arora et al.

Discussion emergency medicine and burnout. However, it appears

that time spent away from active clinical duties (e.g.
Our review found that there were few studies evaluating research) and time spent in continuing professional
burnout among emergency physicians. These studies development might reduce burnout. We recommend
were conducted at different levels (local vs national), studying the burnout levels for academic versus non-
countries and institutions. As such, it is difficult to academic emergency physicians and evaluating further
make sound inferences about appropriate interventions the role of continuing professional development on
to combat the high level of burnout. We instead focus on burnout. Based on this, there is a need to design strat-
analysing the available data and providing recommen- egies to increase the scope for non-clinical duties and
dations for future work in this field. continuing professional activities in clinical practice.
We recommend that future research in this area be There are conflicting data on the role of demographic
multicentre. Single-centre studies are highly likely to factors (age, sex etc.) on burnout among emergency
have problems with generalisability, as the results physicians. Studies are needed to evaluate this relation-
might well represent an institution-specific issue pro- ship and to explore whether demographic factors are
ducing staff dissatisfaction/burnout that would not be influential in certain populations. The role of lifestyle
relevant to other hospitals. We would also recommend factors (such as alcohol, smoking, exercise etc) needs to
that muticentre studies include both small community be studied further.
hospitals and large referral centres. This would be more Further to the study by Kuhn et al.18 showing concern
likely to produce a representative study sample, as well for adverse clinical outcomes as a strong predictor for
as allow comparisons between staff in small and large career burnout, further work is needed to compare
institutions. burnout in hospital-indemnified physicians versus non-
Burnout is highly prevalent (>60%) among emer- hospital-indemnified physicians to explore the role of
gency medicine physicians. Despite the negative out- litigation in burnout. Appropriate strategies need to be
comes for patients, health institutions and physicians, developed to reduce anxiety with decision-making in
there has been little work performed in this field. Much emergency departments.
of the research into burnout among emergency physi- As there is a lack of clear consensus about the factors
cians has been carried out in North America, with no related to burnout, it is difficult for individuals or insti-
studies on prevalence rates of burnout among emer- tutions to predict which members of their team are
gency physicians in places such as Australia or New going to be burned out. Self-assessment of symptoms of
Zealand. There is a need for studies to be conducted at burnout, as mentioned before, is at best subjective. The
a national level in each country to assess burnout levels use of validated instruments, such as the MBI, as a
among emergency physicians and the factors contribut- tracking tool, will help institutions identify individuals
ing to it. The use of a validated instrument, such as the who are burned out or at high risk of burnout (high
MBI, would facilitate cross-study and cross-country scores on any of the three subscales of emotional
comparisons. Despite the high level of burnout among exhaustion, depersonalisation or personal accomplish-
emergency physicians, job satisfaction is also high ment), and to assess the effectiveness of interventions in
(>60%). Further work is needed to understand the combating burnout.
interplay of burnout and job satisfaction in emergency Despite the lack of interventions combating burnout
medicine physicians. in the field of medicine, there is a role for adopting
Different roles in the emergency team expose to dif- measures from other fields. Master music teachers,19
ferent stresses and perceptions of personal accomplish- dental educators20 and army intensive care nurses21 are
ment. The one study in this area suggests that examples of professions highly prone to burnout, and
physician assistants were more burnt out compared research in these fields has identified several strategies
with physicians who, in turn, were more burnt out than for combating burnout that might be applicable to the
nursing colleagues, although drawing conclusions is emergency setting – exercise, networking with other
difficult from the small sample size. A comparative sufferers, rest and relaxation days, and development of
study of burnout and its contributing factors among new hobbies or interests. Further, the Australian con-
different emergency medicine staff is suggested. struction industry has introduced the ‘compressed work
Both work-related and non-work-related factors influ- week’ (shorter working week, increased working hours
ence burnout among emergency physicians. There per day)22 – an initiative that might be translatable to
are conflicting data on the impact of years worked in the emergency setting by reducing total shifts and

494 © 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 Burnout in emergency medicine physicians: review

increasing single shift duty hours, effectively creating 6. Shanafelt TD, Sloan JA, Habermann TM. The well-being of phy-
sicians. Am. J. Med. 2003; 114: 513–9.
more total free days for staff. Further, group social
activities, ‘bring your child to work’ days and spouse/ 7. Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ 3rd.
Effects of limited work hours on surgical training. J. Am. Coll.
child-centric group activities could further improve Surg. 2002; 195: 531–8.
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1000.
Emergency medicine physicians are highly prone to
10. Shanafelt TD, Boone S, Tan L et al. Burnout and satisfaction with
burnout, with burnout rates of this specialty higher than work-life balance among us physicians relative to the general us
any other specialty area. However, emergency physi- population. Arch. Intern. Med. 2012; 172: 1377–85.
cian job satisfaction is also high and the complex inter- 11. Goldberg R, Boss RW, Chan L et al. Burnout and its correlates in
play between burnout and job satisfaction needs to be emergency physicians: four years’ experience with a wellness
studied further among emergency medicine physicians. booth. Acad. Emerg. Med. 1996; 3: 1156–64.
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14. Lloyd S, Streiner D, Shannon S. Burnout, depression, life and job
Competing interests satisfaction among Canadian emergency physicians. J. Emerg.
Med. 1994; 12: 559–65.
None declared.
15. Cydulka RK, Korte R. Career satisfaction in emergency medicine:
the ABEM Longitudinal Study of Emergency Physicians. Ann.
Accepted 20 August 2013 Emerg. Med. 2008; 51: 714–22.e1.
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© 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine 495