In March of 2023, while skiing in Jasper, I crashed into a chairlift post at full speed, dead on. Needless to say, I do not ski anymore. I woke up with my friends hovering around me while the ski patrol prepared to take me down the mountain. I was put into an ambulance and driven to the local emergency room, where they told me I had broken my leg. I got a cast, crutches, and the instruction to leave it on for 8 weeks and then check in with a doctor back home. Instead, my parents took me to an orthopaedic specialist as soon as I got home; away from the rush and stress of the emergency room, the specialist found that I had partially torn the ACL in my other leg (and should have been in a wheelchair rather than using crutches), a bone chip floating around in my knee, and a severe hematoma in my arm that had lacerated the fat protecting the muscle there – an injury which could have forever impacted the functionality of my arm if not treated. In addition to that, they did an x-ray of my broken leg and found that the cast hadn’t been set properly – the break in my bone had gotten worse and required surgery. Two out of three injuries I accrued went completely ignored, with one being improperly dealt with, as a result of overstimulation in Canadian emergency rooms. Incidents like this happen more often than we would like to think in emergency medicine. Moreover, the average wait times in ERs all across Canada is astounding: fifteen-plus hours, with only 23% of patients being admitted before hitting the eight-hour mark in 2023. To many Canadians, this seems completely unacceptable – it is understandably frustrating to be told one needs to wait for urgent care. However, the sobering reality of the mental strain ER physicians face must be taken into consideration when discussing how to improve emergent care in Canada.
Burnout is defined as the exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration. A doctor’s job is stressful, this is a universal truth. Holding the health of another person in one’s hands is a big responsibility. However, the severity of stress faced by Canadian emergency physicians is often forgotten, and they go unsupported because of it. Emergency physicians do not get the luxury of time. The state of emergency rooms is always high-paced, high-stakes, and stressful. ER physicians must identify issues and create treatment plans in a matter of minutes for an unbelievably wide variety of patients. Furthermore, ER physicians must be emotionally tough enough to effectively deal with the injuries they witness on a regular basis or to make snap judgements that severely impact a patient’s health – positively or negatively. Additionally, an essential part of being a doctor is interactions with patients and their loved ones. Due to stress and anxiety in ERs, physicians are often forced to deal with aggressive, hostile, and at times violent, individuals all while treating injuries that require the utmost focus, and maintaining a professional composure. The mental toll that this would take is massive – unimaginable for the average person. Considering these factors – and more – it is no surprise that long wait times and insufficient amounts of doctors to preform quality work is afflicting Canadian emergency rooms – factors which only worsened after the Covid-19 pandemic. All this to say: there is an epidemic among ER doctors that they are not supported to treat: burnout.
When looking at any problem that needs fixing, such as burnout among ER doctors and the subsequent challenges it poses to emergency care, it is imperative to find the source of the problem. While band-aid solutions work at times for smaller scale issues, problems in the health-care system require more focused attention in order to truly improve the quality of care for Canadians. In medical fields, the most common place where issues begin is residency. While being an exciting endeavour full of knowledge, new people, and experiences, residency is an incredibly stressful and taxing part of the path to becoming a doctor. It poses negative impacts on residents’ health, whether that be mental or physical. The transition from medical school to residency is a big one and residents often face high levels of burnout as they do not feel supported to seek wellness resources. Canadian residents have reported wellness concerns from cardiovascular disease to suicidal ideation – overall decreased qualities of life – because of the stress residency causes. To boot, even though there are wellness resources available to Canadian residents, the rate of individuals who access said resources is very low. That is to say, given the stressful or, at times, toxic, nature of residency and the relationship between residents and doctors, Canadian emergency medicine residents do not feel supported to access these resources, do not feel supported in learning how to properly manage their mental health in order to build good habits at the start of their career. This demonstrates how the epidemic of ER doctors facing burnout begins from the get-go, how problems in the culture of medicine are ignored from the moment physicians begin training in Canadian ERs, and how physicians do thus not learn how to properly manage their mental health. Ignorance of one’s own wellness from the beginning of one’s career, especially in emergency physicians, only serves to encourage burnout; residents should be more involved in their training and encouraged to point out problems to remedy the continuous mental health epidemic ER physicians face.
The general discourse around burnout among emergency physicians is usually centered around the effects of Covid-19 and the strain it put on emergency rooms; however, it is crucial to remember that physician burnout was not caused by Covid-19 but merely exacerbated by it. Even though the impact that the global pandemic posed to emergency rooms and their physicians cannot be ignored, burnout was still a prominent issue pre-Covid-19. Emergency medicine, in general, is a high-risk specialty for physician burnout. In a national study done pre-Covid-19, 86% of Canadian ER physicians reported being privy to feelings of burnout. Likewise, 42% reported having some feelings of depression, and 14.3% had contemplated suicide before – 4.3% of those being in the last year. Even though percentiles such as 14 and 4 do not seem like large numbers, any deficit in motivation or zest for life among doctors hugely impacts their performance – there is no room for depression or burnout in an emergency room. Considering this, there is a higher turnover in physicians resulting in longer wait times and periods where emergency rooms have deficits in doctors. This gives rise to lower productivity and lower patient satisfaction. Furthermore, emergency physicians with underlying mental health conditions (such as depression) have very high associations with burnout, indicating that emergency physicians who face mental health struggles are not effectively supported to manage them, to preform to the best of their abilities. Coupling such high rates of burnout and the correlation between underlying depression and burnout it becomes clear that Canadian emergency physicians are not supported to manage the toll that practicing emergency medicine poses. Without proper access to wellness-management information such as meditation and exercise, the standard of care in Canadian emergency rooms obviously suffers.
Burnout and its effects were already prominent in Canadian emergency rooms before Covid-19 – then came the effects of the pandemic: the masses of patients, the long hours that had to be worked, the incredibly high death rates among patients, and the practice of emergency medicine for maintenance rather than the beginning of long-term solutions. Physicians faced moral injury (which is characterized by the shame and guilt experienced after violating a personal, moral code) leading to feelings of disappointment with their care and thus job dissatisfaction. The effects of the Covid-19 pandemic were seen immediately: ten weeks in, 16% of participants in a survey conducted on emergency physicians from British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, and Quebec reported experiencing high levels of emotional exhaustion. Additionally, due to the high-stress environment of emergency rooms and moral injury that emergency physicians faced from not being able to provide a quality standard of care (also taking into account the general feelings of dread and worry that were widespread for all individuals during the pandemic), Canadian ER doctors who worked during the pandemic faced effects more complex than burnout. Workplace safety, childrearing woes for physicians with children, and stress from constant exposure to illness were all particularly taxing to emergency physicians. Moreover, if exposed to Covid-19, emergency physicians were burdened with losing their income, (Canadian ER physicians get paid on an hourly basis) adding an extra level of stress. Remember: these effects were all seen in the first 10 weeks of the pandemic – conditions only worsened as the pandemic carried on. In a survey done on emergency physicians in all provinces and territories in Canada (with the exception of Yukon) in 2020 (during Covid) and then again in 2022 (as Covid began to calm down) burnout levels were significantly higher in the 2022 survey. This survey discusses how the effects of the pandemic were seen more severely in younger generations. This proves how broken emergency healthcare is in Canada. Older generations were less affected, they were already used to the harsh conditions and burnout. Newer physicians were not yet broken in, and were not cognizant of resources to manage wellness.
As mentioned, Canadian emergency physicians, during the pandemic, were faced with more than just burnout. They had to deal with “the brunt of [the government’s] failures,” the “meter of what is excellent care wavering,” and “seldom moments of levity,” as said by two Canadian ER physicians who were asked to discuss their experiences working in emergency rooms during the pandemic. Emergency physicians faced burnout that affected their spirits and challenged their passion for their profession – severe moral injury. Being invested in one’s work is crucial to adept performance; burnout among emergency physicians breeds a debt of efficiency and an inconsistent supply of doctors, negatively impacting the effectiveness of Canadian emergency rooms and leading to their overstimulation. The burden of the pandemic was obviously put on emergency physicians. Not only did they face unmanageable workloads but also criticism from the public: “no recognition” of the harsh conditions they were working under, and “no room to perform as human beings”. Doctors were feeling dissatisfied with their care, and thus unsure if they would be able to continue in their profession after the pandemic. Burnout rates before versus after the pandemic were hugely different: 74% of people who responded to this survey on Canadian burnout before versus after the pandemic saw higher emotional exhaustion and depersonalization scores after the pandemic than before the pandemic. The effects that the pandemic brought about forever altered how emergency physicians view their jobs; lack of resources from the government, brutal criticism from the public, and the creation of toxic working environments led many Canadian ER physicians to quitting the profession, massively contributing to the overstimulation in emergency rooms we see today.
Finally, aside from the stress of the job and the effects of the global pandemic, there are hospital policies that have emergency physicians facing burnout and a lack of motivation in their work: their salaries. For doctors who practise emergency medicine, experience and mastery of their work is crucial – it could mean the difference between life or death. However, for Canadian emergency physicians, their pay does not reflect this. Unlike other doctors in Canada whose salaries are based on their experience, an emergency physicians’ salary does not take this into account this at all. Not being paid for their experience can lead to dissatisfaction with compensation, and thus dissatisfaction with the job. Feeling dissatisfied and unfairly compensated in the long term results in burnout and switching to other specialties that implement a hierarchical scale, where experience is considered. Remedying the inequality between pay and experience through the implementation of a hierarchal scale for Canadian emergency physicians could improve morale with the effect of more career longevity and less turnover of emergency physicians, less burnout, and overall, more encouraged doctors. It is important to feel fairly compensated and supported for the work that physicians are doing, especially in fields that are mentally taxing and have extremely high rates of burnout such as emergency medicine. Changing the methods of compensation for Canadian emergency doctors could change the landscape of the entire field, and improve the oversaturation of Canadian emergency rooms on a grand scale.
Overall, the Canadian healthcare system is extremely flawed, but one of the biggest issues seen today is the oversaturation of emergency rooms. When looking to tackle this problem and improve urgent care for all Canadians, it is important to look at the source of the issue: degradation of doctors. Withal, when looking at the core of the problem, people often blame Canadian emergency physicians without considering the extremely high levels of burnout they face, nor do they consider the enormity of the effect that the Covid-19 pandemic had on Canada’s emergency physicians. To solve the problem fully it is vital to go past the statistics that illustrate long wait times and imperfect medicine and to instead discuss ways in which Canadian healthcare workers can be better supported to perform their jobs, by including Canadian emergency physicians in the conversation. Hearing from physicians first-hand about the issues emergency medicine faces is imperative to improving the system overall.
