Physician wellness/original research
Tolerance for Uncertainty, Burnout, and Satisfaction With the Career of Emergency Medicine

Presented at the Society for Academic Emergency Medicine Midwest Regional Meeting, Detroit, MI, September, 2007.
https://doi.org/10.1016/j.annemergmed.2008.12.019Get rights and content

Study objective

Questions about burnout, career satisfaction, and longevity of emergency physicians have been raised but no studies have examined tolerance for uncertainty as a risk factor for burnout. Primary objectives of this study are to assess the role of uncertainty tolerance in predicting career burnout and to estimate the proportion of emergency physicians who exhibit high levels of career burnout.

Methods

A mail survey incorporating validated measures of career satisfaction, tolerance for uncertainty, and burnout was sent to a random sample of members of the American College of Emergency Physicians. Best- and worst-case scenarios of point estimates are provided to assess for the effect of nonresponse bias, and multivariable logistic regression was used to predict evidence of career burnout.

Results

One hundred ninety-three surveys were returned (response rate 43.1%). A high level of career burnout was exhibited in 62 (32.1%; best-worst case 13.8% to 64.1%) respondents. No demographic variables were associated with burnout status. The final model identified that high anxiety caused by concern for bad outcomes (odds ratio=6.35) was the strongest predictor of career burnout, controlling for all other variables.

Conclusion

A large percentage of emergency physicians in this study, 32.1%, exhibited emotional exhaustion, which is the core symptom of burnout. Emotional exhaustion was not related to age or type of practice and was not mitigated by training in emergency medicine. Physicians studied did not feel anxiety because of general uncertainty, difficulty in disclosing uncertainty to patients, or admitting errors to other physicians. High anxiety caused by concern for bad outcomes was the strongest predictor of burnout. Despite exhibiting emotional exhaustion, the majority of respondents are satisfied with the career of emergency medicine.

Introduction

Since the recognition of emergency medicine as a specialty in 1979, questions about longevity, career satisfaction, and burnout of emergency physicians have been raised.1, 2, 3

The problem of burnout has been recognized in multiple human service industries since it was first mentioned in the scientific literature in a seminal article by Fruedenberger in 1974.4 Although popular literature mentions the phenomenon of burnout in many areas of life, researchers agree that it occurs in people who “work with people.”5 Pines and Aronson6 describe burnout as a “state of physical, emotional, and mental exhaustion caused by long term involvement in situations that are emotionally demanding.” Freudenberger and Richelson7 believe that it is a state of fatigue or frustration that comes about “when a way of life or relationship fails to produce the expected reward.” Maslach8 has stated that “…a pattern of emotional overload and subsequent emotional exhaustion is at the heart of the burnout syndrome.” The Maslach Burnout Inventory measures burnout as a 3-dimensional syndrome of (1) emotional exhaustion (feeling emotionally drained by one's contact with other people), (2) depersonalization (negative feelings and cynical attitudes toward the recipients of one's service or care), and (3) reduced personal accomplishment (a tendency to evaluate negatively one's own work) that occurs among individuals who work with people in some capacity.9, 10, 11 However, there is ongoing discussion as to whether burnout is multidimensional, consisting of all 3 dimensions, or is unidimensional, with emotional exhaustion as the central and essential state. A number of workers believe it is unidimensional, with emotional exhaustion being the essential requirement.4, 6, 12, 13, 14, 15 Emotional exhaustion can be considered central to burnout because it defines burnout to subjects when they are queried about what the meaning of burnout is for them, it is what correlates most strongly with global measures of burnout, and it appears to be the first component of burnout in those who go on to demonstrate the complete syndrome of burnout.16 Shirom15 has argued that detachment and a sense of low personal accomplishment should be dropped from the definition altogether and only emotional exhaustion retained because he considers it the core symptom. Others think that emotional exhaustion is the initial state, followed by personal detachment, which is a coping mechanism, and finally feelings of decreased personal accomplishment.17

The practice of emergency medicine involves dealing with multiple sources of uncertainty, combined with a very stressful environment, a combination of circumstances that appears to be frequently associated with burnout. In 2006, the Centers for Disease Control and Prevention reported that the number of emergency department (ED) visits was at a record high of 119.2 million, up from 115 million in 2005.18 The decade from 1996 to 2006 has seen an increase in ED visits of 32%, whereas the number of EDs has decreased from 4,019 to 3,833.19 Age groups with the highest visit rates per capita were infants younger than 12 months and the elderly older than 75 years, patients who are frequently difficult to examine and are very ill. About 2% of patients had been discharged from the hospital within 7 days before the current ED visit. More than 18 million patients, or 15.5%, arrived by ambulance and about 12% of ED visits resulted in hospital admission.19 High volumes, high acuity, and high complexity of disease are now combined and result in the need for rapid decisionmaking in a highly ambiguous environment.18

Of the various studies that have looked for correlates to burnout among emergency physicians, none have considered tolerance for ambiguity. Ambiguity tolerance in medicine refers to an internal process that influences the way in which a person structures information about ambiguous situations when confronted by an array of unfamiliar, complex, or incongruent cues.20 There is evidence that variation exists among physician specialty groups, including general internists, family practitioners, surgeons, and psychiatrists with regard to ambiguity tolerance.21, 22 The present study examines a sampling of emergency physicians with regard to this variable and its possible relation to burnout and career satisfaction.

The primary objectives of this study were to assess the role of uncertainty tolerance in predicting career burnout and estimate the proportion of emergency physicians who exhibit high levels of career burnout. A secondary objective was to assess satisfaction with the career of emergency medicine.

Section snippets

Materials and Methods

This study was conducted with survey methodology. All members of the American College of Emergency Physicians (ACEP) with a mailing address on file with the ACEP organizational office, and actively practicing emergency medicine, were eligible for inclusion. This study was approved by the Human Investigations Committee.

The questionnaire was composed of 3 sections. The first section was the longest and included 79 questions, comprising 6 work-life satisfaction constructs: administrative autonomy,

Results

As shown in the Figure, the response rate for this survey was 50.2% (n=220); however, only 43.1% (n=193) were used because of the removal of 27 cases with significant missing data or returned blank. In addition, there were 13 cases that were missing 1 response in the individual items that comprised the uncertainty scales. There were 5 cases that had up to 7 missing elements (of a possible 22 items) within the burnout inventory. Missing values within each subscale were replaced with imputed

Limitations

Limitations of this study include a low response rate. We had estimated a need for 378 surveys, but the low response rate resulted in our being able to analyze only 193 surveys. Because all surveys were anonymous, there was no way to compare the demographics or characteristics of respondents and nonrespondents. It is also possible that respondents returning surveys had higher or lower burnout scores and lower tolerance for uncertainty than nonrespondents. To mitigate possible bias caused by

Discussion

In the sample of emergency physicians studied, 32.5% experienced at least 1 aspect of the syndrome of burnout, specifically, emotional exhaustion. The feeling of emotional exhaustion is the core symptom of burnout. This finding of emotional exhaustion is not related to age or type of practice and is not mitigated by training in emergency medicine, a finding similar to that of Doan-Wiggins et al.1 Furthermore, poor tolerance for uncertainty because of a concern for bad outcomes, rather than

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    Supervising editor: Debra E. Houry, MD, MPH

    Author contributions: GK conceived, designed, and wrote the study. RG assisted in obtaining fund, suggested elements of the design, and assisted in writing the article. SC assisted with design of the study, analysis of the data, and writing of the article. GK takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Funding by ACEP was through a Section Grant to the Wellness Section and funding by Blue Cross Blue Shield was by a foundation grant. Neither funding body had any influence on the design of the study or the reported findings and manuscript.

    Publication date: Available online February 3, 2009.

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