EM Mindset: Upping your extra-clinical game – the key to professional satisfaction in EM

Author: Eddy Lang, MD (@EddyLang1, Professor and Department Head for Emergency Medicine, Cumming School of Medicine, University of Calgary) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

From my vantage point and with a quarter century of experience under my belt, emergency physicians are among the most fortunate of healthcare providers. We enjoy the unique privilege of accompanying patients during some of the most terrifying moments of their lives.  We are equipped with a powerful armamentarium of treatments and tests which have their limitations to be sure, but which can almost always relieve suffering or at least provide reassurance when assessments are negative.  We work in an exciting, vibrant, and collaborative work environment and in many settings enjoy remarkable control over when and how much we want to work.  Why then do emergency physicians report some of the highest levels of burnout, compassion fatigue, and job dissatisfaction?

As rewarding as clinical emergency medicine can be, it actually exercises only one chunk of our intellect, leaving other parts unstimulated and unchallenged.  The kind of problem-solving and multitasking we engage in on a regular basis in the frenetic environment in which we work can be exhilarating, but can also plateau as a source of professional satisfaction.  Emergency physicians are among the most driven, intelligent, and ambitious members of the professional world.  This is increasingly the case as the specialty attracts the best and brightest medical students.  Lacking in a purely clinical career path is the opportunity to tackle larger issues and projects that require planning strategies, an injection of creative efforts, and a series of leadership skills that are quite different from what the EM setting demands of us.  Extra-clinical opportunities abound in emergency medicine and can range from community outreach to committee work to involvement in educational opportunities in residency programs or medical schools.

The literature on physician burnout, inextricably linked to job satisfaction, supports that involvement in leadership activities and other professional endeavors is protective.  Despite this, many emergency physicians do not complement their clinical careers with extra-clinical pursuits in medicine or other fields, and many hospitals, healthcare systems, and emergency departments fail to support their doctors in this regard.  I am the Department Head (Chair) for a large academic department with 190 faculty covering four EDs and caring for 300,000 visits a year.  One of my primary concerns is that our department is failing to engage our faculty, especially recent hires, onto meaningful extra-clinical activities.  You might be thinking that as a chair I have a vested interest in wanting my faculty to engage in extra-clinical activities, and you’d be absolutely right.  If the talent of our group was leveraged in ways that can improve our missions, we’d have far better working conditions and provide better care.  A liaison with consulting services and radiology, someone to look after making our ED elder-friendly, someone tackling inter-professional education with our nursing colleagues would certainly be a boom.

The reasons for this are myriad.  Graduating residents are under intense pressure to perform and succeed clinically as they transition to practice.  Many have young families that may have already have made significant sacrifices during the arduous phase of residency training.  Those who work in you eat what you kill / fee for service environments are drawn to the allure of well-deserved but dramatic increases in pay.  The ingrained culture in some of these settings is such that the only way one should get involved in extra-clinical pursuits is if it is remunerated at the same rate as clinical work.  This is a destructive and arguably a non-professional mindset.  With the privilege that comes with being society’s most esteemed professional comes the moral obligation to give back and improve local or global emergency medicine through advocacy or other extra-clinical contributions.

There are a number of dangers associated with this all too common largely clinical career trajectory.  The skill set that was carefully cultivated during residency and medical school and was operationalized through scholarly or QI projects is at risk of whittling away in a sort of use it or lose it scenario.  These include the ability to plan or participate in a project with objectives and timelines, critical appraisal and critical thinking skills, and the ability to capture ideas and communicate them in writing.  A clinical career trajectory may also limit one’s ability to see the big picture and identify critical system issues or opportunities for improvement.  These physicians can become disengaged from departmental and hospital issues sticking uniquely to a need to know perspective for what is needed to be an effective clinician.  Now somewhat marginalized from departmental and hospital politics, one’s ability to engage and advocate on key issues becomes compromised.

Developing an extra-clinical skill set can also relate to developing niche expertise in some aspect of emergency medicine or some other area of focused interest that resonates and connects to what one is passionate about. Being the department’s point person for a particular area of expertise is rewarding and a key to professional satisfaction.   Importantly, it sets the stage for transitioning out of EM clinical practice which is rarely sustainable into one’s sixties.  A strong portfolio of extra-clinical expertise can set the stage for exciting mid and late career possibilities like the ones I have had the distinct privilege of enjoying.

In society’s contract with physicians, the nature of that role is becoming richer and more developed.  As delineated in the CanMEDS 2015 framework, physicians are more than medical experts, as we also function as advocates, scholars, educators, and leaders in our healthcare settings and beyond when wearing our physician hat.  Paradoxically and in the interest of optimizing time management and burnout, physicians in early practice may shy away from opportunities to take on or participate in extra-clinical activities.  Physicians in the later phases of practice who have not fostered the development of their extra-clinical skills may find it difficult to resuscitate those skills.  My argument is that maintaining an awareness and interest in the extra-clinical opportunities that our field offers is actually an exceptionally valuable return on investment and a key to a long and happy career as an emergency physician.

A common refrain one often hears mixed with early career advice is to make sure you establish yourself clinically before branching out into other activities or projects.  Similarly young faculty are warned to be extremely selective about what kinds of extra-clinical projects they get involved with.  They need to be fiercely protective of their time and only get involved in things that they know will be rewarding and a perfect fit.  I think this is actually harmful advice.  My take is to have an open mind to what extra-clinical opportunities might avail themselves and immersion with the option to step away may be the only way to discover your true path to personal and professional success.  Walking through the doors of opportunity always opens others.

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