By Dr. Jim Dahle, WCI Founder
I spent nearly a week on the road at the end of September 2024, first speaking a couple of times at the Bogleheads Conference and then speaking three times at the American College of Emergency Physicians Scientific Assembly. This was actually most of the work I did in September, given that I spent most of that time healing from my fall at Grand Teton.
However, there were several things at the conference that caused me to think about burnout. One was a slide from one of my own presentations.
I made this slide using a chart from the latest Medscape Burnout and Depression Report. It shows that burnout in emergency medicine (EM) has not gone away 20+ years after I started. Back then, we attributed it to the fact that so many ED physicians were not residency-trained emergency physicians. I don't think we can blame a 63% burnout rate on that anymore—if we ever could.
Change Specialties?
At dinner with one of my residency mates, she told me many of her residents are now doing critical care fellowships because they're worried about burning out of EM. I found that somewhat bizarre, given that, in most surveys I've seen over the years, intensivists generally have burnout rates similar to and sometimes worse than those of emergency physicians. Here's an example from the same survey from 2022:
Maybe the real story here is how critical care went from second to 16th in just two years. It might be pandemic-related, but they were 10th before the pandemic. Back to the subject at hand, though. I don't think doing a fellowship that allows you to transition to another similar high-burnout specialty is the best way to deal with burnout during your career.
Schedule Vacations
Let's talk about some of the techniques that might work. Another interesting slide I saw at the conference was this one:
Notice that statistic. Only 24% of emergency physicians take >15 days off per year. How can that be, you might wonder? I think it's because full-time emergency docs work 15ish shifts every month, no matter what else they do that month.
It's December, and the kids are out for Christmas for two weeks? Still work 15 shifts. Same for summer trips and Thanksgiving and that CME conference in September. We just cram our shifts for the month together to create “days off.” Instead of working four shifts a week, we work 15 out of 16 days and then take a 10-day trip, often returning to another 15 shifts in 16 days afterward.
Fifteen shifts a month might not seem bad until you realize a few things:
- There are no “clinic closures” for federal holidays or anything else.
- Most emergency docs work rotating shifts and lose a couple of days a month to transition days. If you go to work at 10pm, which day did you have off? I assure you that it feels like neither, yet there is only one shift in two days. Same thing when you finish a string of nights and walk around like a useless, grumpy zombie for the next two days.
- Emergency docs work even on days there are no shifts. It might be doing charts, attending a meeting, or handling an administrative task of some kind.
Add a couple of administrative days, two transition days, and nine days of weekends a month, and you can quickly see that 15 shifts basically eat up the rest of the days in a 28-day month. In a 31-day month, that leaves three days for “vacation.”
The first thing that emergency docs can do to reduce burnout is to take some vacations where they actually work less, i.e. have months where they work less than 15 shifts. There are two ways I've seen this done.
The first is to just work fewer than 15 shifts all the time. This is my approach. As I cut back from 15 to 12 to eight and now to six shifts per month, I freed up 3-9 days a month to go on trips (and, in my case, work on WCI). If you also get rid of transition days by not working nights and eliminate administrative days by completing charts on shift and saying no to committee assignments, you might find a few more days, too. The nice thing about this method is that it allows you to go on a vacation every month. The problem, of course, is that you're working less and earning less. Twelve shifts pay 20% less than 15 shifts.
The second way is a method used in some groups where, once or twice a year, each doc is scheduled for fewer shifts. Instead of 15 shifts, maybe you get 10. In some groups, you get paid less that month, and in some groups, you get paid the same (basically a bit of each month's earnings is saved up to be paid out in the next “vacation month”).
More information here:
Which Medical Specialties Are the Most Burned Out?
Emergency Medicine’s Popularity Plummets
Stop the Nights
Let's get real for a minute about the problem with emergency medicine. My neighbor the radiologist leaves for work at about 7 in the morning and is home at about 5, at least the days he works at the hospital. Given his subspecialty and contract, he doesn't read ED films. My neighbor the pediatrician leaves for work at about 8 in the morning and is home at about 6—except for Wednesdays, which he takes off. He does have call responsibilities at times but rarely has to actually go into the hospital in the evenings and after midnight. An emergency doc, however, must be physically present in the ED every single night. Many groups divide these up evenly, so everybody gets their share. Other groups have dedicated “nocturnists,” who either prefer these shifts or simply get paid more to work them.
Let's be honest. Nights suck. I mean, there are a few rare people who like them, but, mostly, working nights is painful. It doesn't feel good to be awake at 3am. It disrupts the rest of your life. The pathology is far less interesting (lots more drugs, alcohol, and psychiatric comorbidities). It's even a cardiac risk factor. That might not seem so bad at 35, but it's a rare emergency doc who still likes working night shifts at 50. If you want to cure burnout, your group needs a night shift solution so that the majority of doctors in the group are not working night shifts at all.
In my experience, the best night shift solution is a massive night shift differential. In our democratic group, we sat down and figured out how much more a night shift would have to pay for people to work them voluntarily. It worked out to be about 50%, i.e. it pays 50% more to work a night shift than a day shift in my group. If you pay $2,000 for a day shift, you need to pay $3,000 for a night shift to get them voluntarily covered. Who volunteers to cover them? Two groups of people.
- People who want to make more money. These are generally young docs with student loans, a big fat mortgage, and no retirement nest egg.
- People who want to work less but make the same amount of money. Instead of 15 days, they work 10 nights, earn the same, and go on a five-day trip every month.
The first modification I made in my life when I realized I had the money to do so was to drop my night shifts. Yes, it cost me some money. Yes, it was worth it.
Control the Evenings
Emergency departments are most busy in the evenings, from perhaps 5pm-1am. That means that in a department with more than single coverage, a larger percentage of your shifts involve a component of the evening. At my main site, there are five eight-hour shifts a day, starting at 6am, 10am, 2pm, 6pm, and 10pm. Plus, there's a 10-hour APC shift starting at 1pm. Basically, four of the five docs and all the APCs working in a given day can't really plan anything in the evening. This doesn't seem like a big deal until your kid has a recital you want to see. Or you want to coach a soccer team. Or play on a soccer team. Or hang out with your friends with regular jobs. Or attend some other event with your partner. There are benefits to having your banker's hours off. You can go shopping when no one else is out. You can go skiing when the lifts are empty. You can start The White Coat Investor. But after a while, you realize all those things that help with burnout (like, a real life) seem to happen way more often in the evenings.
There are three good solutions to this problem. The first is to start the day shift really early. If it starts sufficiently early (sometime between 4am and 6am should work), the day shifts will become unappealing. People will preferentially work in the evening, and you can have as many day shifts as you want. The second is to pay an evening shift differential. This works just like the night shift differential. Fewer people want day shifts so those feeling burned out can have as many of them as they want and have their evenings back. Finally, you can institute a really great shift trading culture. If you can swap out your evening shifts when something really good comes up in the evening, you can make it to many of those burnout-defeating evening activities.
My group has done all three of these. The shift trading culture alone allowed me to play on a hockey team, but it wasn't enough to play on three teams and coach two others. I needed all my evenings off to do that. Interestingly, our evening differential went away recently because enough people just hated getting up at 5am to come in for a shift starting at 6am.
More information here:
How My Burnout Led to Rage That Could’ve Ended My Career
What We Can Learn About Work-Life Balance and Retirement from the French
Work Less
Another obvious burnout solution is to just work less. Maybe this isn't as obvious as it should be. Check out this series of slides I used in a presentation recently that also comes from this year's Medscape Burnout Survey:
OK, burnout is coming from work. What do we think would help reduce it?
Wait? Not one person said to work less? Increasing compensation would allow one to work less and make the same amount of money. Increasing support staff would allow one to work less while at work. It's the same with lightening patient loads. But it doesn't appear cutting back was even an option in the question. They did ask what people did to treat their burnout, though:
Maybe we do something healthy like exercising, building relationships, or sleeping, but it appears that many of us just become loners, eat crap, and smoke crap. Apparently, nobody thought about cutting back.
The first thing I ask anyone who is burned out is, “Have you thought about cutting back to full-time?” And if you're already just full-time, you might try cutting back a little more. My original financial plan drawn up as a resident called for me to be working six shifts a month by age 51. The needs of WCI forced me and financial success allowed me to get there a little earlier. I've combined this with dropping nights and evenings, too. But I challenge you to burn out when you're working six day shifts a month. I don't think it's possible.
It's probably not even that smart financially for me to continue to work. Medicolegally, I have more to lose than gain, and besides, more effort put into WCI would probably grow it faster and generate more than my clinical income anyway. Yet, as I sit here writing this six weeks into my 10-week short-term disability from falling off a mountain, guess what I miss a lot? Yeah, just being a regular old doctor.
Staff Adequately
Another painful thing about emergency medicine is when you're always running around like a chicken with your head cut off. We all learned in residency to see four patients an hour and make sure none of them die. But guess what, it's a lot more fun and a little more safe to see 1.5 patients an hour. That requires more doctors to be on shift, which means the doctors get paid less. But it's probably worth it long term. The biggest financial risk you run is burnout.
Eliminate Pain Points
There are always some problems you can complain about. But if it's the same problem over and over again, it's time to do something about it. Form a committee, line up the troops, get administration involved, and pound on that biggest pain point until it's gone. Then, start working on the next one until the remaining issues feel trivial. This will help you to feel in control instead of powerless, which is also good for burnout.
More information here:
Strengthening Your Mental Health
Understanding Veterinarian Burnout and Mental Health
Plan for Early Retirement
I wanted to share one more slide I saw at the conference.
I didn't totally grasp this chart (and my picture is out of focus), but I think the Y axis is age and the width of the graphs is the number of docs leaving the specialty. The baby blue is men, and the purple is women. Apparently, women emergency physicians are now retiring (or at least leaving EM) at an average age of 43. It's a little better for men, but the trend from 2013 to 2019 is terrible.
My point in sharing it is to demonstrate two things. The first is the importance of actually doing something (preferably multiple somethings) to stave off burnout.
The second is simply to show how important it is for emergency physicians to live their financial lives consistent with a FIRE (Financial Independence, Retire Early) philosophy, because there is a surprisingly good (and increasing) chance you're going to want to FIRE. If you want to retire after 13 years on an income of $150,000 in today's dollars, you're going to need to save just over 50% of a $400,000 gross income each year. Even if you're OK working 15 years and living on $80,000 after that, you're still going to need to put away $93,000 a year. Remember my 20% savings rate guideline is for a full career. That's not going to cut it for FIRE.
Burnout is a real problem in the house of medicine, but it is particularly bad for emergency physicians. Live your financial life in such a way that you can implement burnout-reducing changes. The more you have and the less you live on, the more you can do when burnout rears its ugly head.
What do you think? What can doctors do to reduce burnout? Why is it so bad for emergency docs right now?
This is a great perspective & with data to think about. I do critical care, and formerly did respirology and GIM at one point as well. It’s funny because my senior ICU colleagues advised me to keep my resp/GIM to fall back on when I burnt out of critical care. Ironically, I dropped them because it was too much. A combination specialty can go two ways. The most common way is that you are expected to work almost full-time in both specialties. Not good. If you work part-time in both, it can be great because you get variety and different paces/types of work. Few seem to do that. I think our field attracts people who have a hard time sitting still – clinical work is an attractive lure and often in abundant supply.
After coming up for air and taking “forced” vacations (to get my money’s worth out of a motorhome I bought), I gained some perspective. I did cut back (12wks ICU/yr and then teaching/writing in between). It is way more enjoyable and sustainable long-term, but felt very counter-cultural. Without adhering to some of the FIRE principles and targeting the ability to retire before 50, I would not have had that flexibility. You often don’t realize that you need options until you need them imminently. Like airway management.
-LD
Countercultural is a good word for it. It feels almost transgressive to do any self-care as a doctor.
Why is that? Because burnout is baked into our profession. Our culture is steeped in it. We have some of the darkest gallows humor and sharpest passive-aggressive tendencies you will find anywhere. The patient always comes first. We only learn top-down leadership styles in residency. Asking for help is a sign of weakness, and so on.
It takes real courage to advocate for your own needs as a doctor, and it helps to have a coach or a mentor or at least a good self-help book to guide the way. The financial side of burnout mitigation is huge, and I am so grateful for what WCI has done for us.
There are many other skills that will help: team leadership, workflow efficiency, and work-life boundary defenses have been particularly helpful for me. My employer has a standard 4-day work week, which has made a huge difference to my life. The good jobs are out there, if you give yourself permission to look for them.
A good coach, mentor, and financial health helps you to make positive moves (like muscles). WCI has done wonders in that area for a long time – and at scale. Another aspect is changing the culture/group in which you practice to make the muscles work less hard to move. Your employer’s move to 4-day weeks is a great example. We are largely self-employed in our practice. However, we changed our practice from a 24/7 on-call week to have alternating nights off. The workload of the pandemic pressured us into breaking the week into 3 or 4 days as an option and beefing up night coverage further. I started the shift as our Chief, but it really gained momentum as our members saw the benefits.
Our pay dropped slightly, but the flexibility and ability to shift around our non-clinical focus have been priceless. And improved patient care. We have been less burnt out, produced more research, and implemented quality improvement projects. It took about a decade to shift our culture and system, but we’d never go back. Earning over a career is area under the curve, not just the peak.
-LD
I am an EM attending almost 3 years out of training, working at a community site. I have a wife who has a fairly busy marketing job and a 1 year old at home.
Unless you have a nanny, stay-at-home spouse, or family nearby, I feel that this specialty is not conducive to raising a family. I have cut down to part-time (as Jim mentions, about 6-8 shifts per month is a great spot to stave off burnout), but am still actively looking for ways out into a non-clinical career. I don’t know how the full-time folks do it with a family!
Additionally, there are fundamental issues with EM – lack of staffing, boarding, demeaning consultants, lack of resources – that I think contribute to the burnout at a much higher rate than seen with other specialties.
I have always known that being a doctor was supposed to be hard. But I think many in my generation are wondering – is this worth it?
Maybe not worth it but you have to look at your current situation with the sunk cost of all the training. Assuming you are making $2k / shift $16k / month is still a better income than the majority of Americans, and not so easy to find another job that pays $200k / year. Plus your wife works so maybe household income is in the $250-300k range, probably putting you in the top 5-7% of incomes.
Perhaps appreciate your part time situation and keep spending low compared to many of this site, but still high compared to a teacher. Doesn’t hurt to look around at other options but I don’t think these are a large number of non-clinical jobs out there paying that well.
There are definitely challenges, many of which we dealt with by having a stay at home parent. It’s particularly challenging to be a military doc without a stay at home parent. Every time you get deployed, it’s a single parent family. But single parents raise families all the time, so I suppose the idea is to adopt a lot of what they do (nanny, child care, after school programs, latchkey kids etc).
Jim – I’m in anesthesia where burnout rates can be incredibly high as well (depending on the data you’re reviewing). How much of burnout do you think is attributable to the loss of physician ownership / sovereignty due to market pressure? In anesthesia, practices have consolidated (corporate, PE, and health system mergers) such that most anesthesiologists are now employed. This clearly affects compensation, autonomy, sovereignty, and has turned many ologists into mere transactional employees or locums tenants. What’s your sense on this?
I think it’s a big part. Control matters, especially by the time you get to mid career.
I’m not an ER doc. I was a family doctor. My stress was the sheer number of hours it took to get through the day.
But my hat’s off to ER docs. I think that type of stress would be the worst. Having to cover an ER and not being able to predict or control the level of acuity that comes through the door would be nerve wracking to me. I’ve been in the ER admitting a patient and seen one doc running two codes while an ambulance delivers a bleeding patient and listen to patients grumble about the wait, totally oblivious to the circumstance.
Nice and timely article. As a hospitalist, I’m very grateful to the ED docs, and am not surprised that ED is the highest burnout specialty. My solution to feeling burned out a few years ago was what you suggest – reduce the number of shifts/month. That works. Yes, I make less, but I’m happier. That is what it is all about.
After a grueling internship in OB/GYN that averaged between 80 and 120 hours per week with periods of every other night call…I quit.
I interviewed at an ER program and did not get that coveted 2nd year spot with a bright new ER. I also interviewed at three Psychiatry programs and got accepted by all three. Having chosen life at that time, I took the one near a beach with the least call (2 nights a month), a gym for residents, and moonlighting.
I would never have survived ER medicine. In Psychiatry residency I worked about 40-50 hours a week and took much less call. This seemed like half a job after OB/GYN, so I did all the moonlighting and doubled my 3rd and 4th year wages.
After a busy Psychiatric career in mixed inpatient outpatient positions, I dropped to outpatient only at about age 47 and did weekends as a “side gig”. I did too many of them, but they helped me drop to two days a week at age 58. Even at the worst of it all, I never worked over 55 hours a week with the added “extra money” weekends.
I used every strategy I could think of to be able to go to all of my kid’s sports and school events and be home by 2:00 for all the holidays I worked. By working weekends and holidays, I got paid the differential Jim mentioned…essentially double time, which helped stoke all the retirement and college accounts.
I think one has to use all methods available to minimize burnout in almost any specialty, especially the ones with night call and weekends.
One of the real solutions to the burnout is not to have a “job” ( for the ED, this means one of those CMG jobs, where you feel like in a conveyor belt scene out of Charlie Chaplin’s “Modern Times” https://www.youtube.com/watch?v=6n9ESFJTnHs), but to have “career” (like, say, in academia, when you become an assistant/associate fellowship director of US/EMS/Critical care fellowship, teach, mentor, grow professionally, do research, go to the conferences, have a gaggle of grateful residents, etc.)
I completely agree. In medicine we’ve become simply high income employees (this job not career minded). Problem is market pressure is exacerbating this problem. I think careers are eroding and turning into medicine into a job due to health system conglomeration, loss of private practice, devaluation / erosion of the academic physician who’s academia is tangibly valued.
One of the ways I have found to beat burnout is the idea of buying back my own time. Once I got my consumer debt paid off and was saving for the future, I then used the idea that I could buy things or I could buy my own time back to work less or differently. It allowed me to be at home more with our children who we wanted to homeschool through eighth grade. Easier to give up all the shiny things when I was clear about what I was getting in return.
I am an ER doctor, graduated in 2009. I basically followed WCI/Boglehead principles from the start. When graduating my spouse and I increased our spending only a little every year which allowed us to pay off my $300k+ school debt and get a decent nest egg started pretty early. It took about 11 years to get to a place where we were sort of financially independent. We had all our needs and most of our wants covered by a 25x portfolio. At that point I started slowly cutting back shifts. Today, I work 6-8 shifts a month which includes my share of nights and evenings.
When you only work 1-3 days a week with 1 week off every month to do whatever you want, life is pretty good. Even if I have a bad shift it is likely I have a stretch of time off coming up and that “I hate this job.”feeling dissipates rather quickly.
Having early financial security and the ability to cut back is the cure for burnout.
The real fix to burnout in medicine requires physicians to take control of medicine back from the insurance industry, the corporations, and the hospital. We should have the control, but that also requires us to not be greedy and to make decisions that don’t just pad our wallets but actually improve patient care and our quality of life.
Good luck with that. To many docs can’t afford to make less money and/or unwilling to fight.
EM Doc here – 12 years out of residency married to another EM doc.
When I was a 2nd year resident, I emailed Jim about some financial advice. He gave me a lot of pearls that my wife and I truly took to heart. Early on I personally had several years making 500+ in the community (I worked a ton of hours) and we invested, saved, lived moderately and RENTED in a high cost of living area. We are now more or less financially independent (our monthly costs are covered by our cash flow from our investments, any clinical time covers vacations/luxuries/new investments).
We both work 1-2 days a week and love EM more now than we ever have had to before despite having a 2 year old and 4 month old. Shifts energize us, we talk about clinical medicine when we’re not working, and we genuinely feel blessed to have the jobs we have. If I could do it all over again I’d do the exact same things.
The keys for us:
1) Being able to work less when we needed to (my wife took 4-6 months maternity so she was itching to go back), if I had a few months that were brutal, I went to half time for a few months to recover.
2) Becoming financially indpenedent to where work is a CHOICE not a necessity.
I’ve also done a lot with leadership which has also given me a significant amount of autonomy in my clinical practice which makes my clinical time significantly more enjoyable.
I unfortunately see new grads finish residency and buy a house year one – one that is 3x annual income – now tied to a 10k mortgage. Get married and put their kids in private school. Buy a brand new Tesla. Then need to work 20 shifts a month to break even… forever.
Also somewhat interesting that, with some exceptions, the specialties at the top of the burn out list are the ones who get their butts kicked by Hospital administration and the ones at the bottom get their butts kissed by Hospital administration 🤠
Fair point.
90% of this (and every problem we have in EM) comes down to corporate control of our practice. When we lose autonomy and non physicians (or lackey physicians who have no spine) decide how the department runs and is funded you get second world working conditions in a first world country. Frankly stated our healthcare system ranks 37th in the world despite being more expensive than the top 10 combined and physicians have consecutively been losing money each year when accounting for inflation. ACEP needs to stop mincing words, corporate ownership of physician practices is bad for patients and is creating the burnout FULL STOP.
I’m an EM doc also, 9 years out of residency, prior HPSP. Wife is a dentist, and we’ve invested aggressively, so we’re rapidly approaching sort of a coast scenario where extra income above our general COL doesn’t necessarily need to be invested in order for us to reach our retirement goals. I really agree with your thoughts on avoiding night and evening work to stave off burnout, especially while our kids are young. However, I’m wondering how to enact that as part of a group and not feel that I’m simply picking up the ‘princess’ shifts, and leaving my partners to pick up the undesirable shifts. How has your group felt about you picking up only day shifts? How did you broach that? I have a feeling that in many ER groups, doing that might shift you to more of a PRN status without guaranteed shifts. Our current night shift differential is modest at best, and there is no evening differential.
Thanks for your thoughts.
We deal with it by money. Night shifts pay about 50% more than day shifts and evening shifts 25% more. They’re worked voluntarily by those who want/need more money. Why more groups don’t do this I have no idea.
Thanks, that makes sense. I agree that setup would solve a lot of scheduling problems. But probably much harder to successfully make that argument as an employed doc to the non-physician bean counters who control the money. I assume yours is a democratic group with profit sharing?
If not I’d be curious to know how you made the argument.
Thanks
It’s definitely harder if you don’t control the pot. But either way there is a pot and the bean counters shouldn’t care how it is split up if it makes you all happier. The downside is that the day shift docs get paid less. You have to be okay with making less during the day to make more during the night.