Purpose

The current state of emergency physician health poses a significant threat to sustainability and effectiveness of healthcare systems. Burnout, an often overlooked risk to healthcare providers, directly compromises safety and quality of patient care [1]. A complex interplay of burnout, workplace violence, moral injury, and workforce attrition drives the system’s decline, demanding urgent action [1].

Background

Emergency Medicine plays a vital role in healthcare system operations but faces critical challenges. Physicians treating acutely ill or injured patients increasingly face vulnerabilities. Current evidence reveals a distressed workforce necessitating immediate and ongoing attention. Factors contributing to the decline in readiness of emergency departments include severe overcrowding, nursing shortages, budget cuts, limited access to primary care, workflow inefficiencies, physician attrition, workplace violence and mistreatment, escalating administrative burden, and moral injury, all risk factors for burnout.

Physician burnout and workforce attrition indicate a substantial health gap, threatening the future of healthcare delivery. This issue aligns with the United Nations’ Sustainable Development Goal of achieving ‘Good Health and Well Being.’ Adopted across North America, these goals initially served as a global roadmap for enhancing health financing and improving the health workforce's recruitment, development, and retention [2].

Emergency Medicine consistently ranks as the specialty with the highest rates of physician burnout. Recent Canadian studies reveal 60–86% of Emergency Medicine physicians experience burnout [3, 4]. The 2017 Canadian Medical Association’s National Physician Health Survey reported that 48% of Canadian physicians and residents met criteria for depression, and 14% had considered suicide in the past year [5].

The Canadian Medical Association has reported a rise in burnout among all physicians, from 31% in 2017 to 53% in 2021 [5]. A 2019 United States study found a trend of 10–12.7% of emergency physicians leaving the specialty within five years of completing residency [6]. The Canadian Medical Association survey indicates half of the physicians plan to reduce clinical hours in the next 2 years [5]. In Ontario, the Ontario Health Coalition recorded 868 Emergency Department closures in 2023 due to staff shortages.

The financial impact of burnout on healthcare systems is profound. A 2019 cost–consequence analysis estimated burnout-related costs due to physician turnover and reduced clinical hours nationally and at the organizational level at an annual expenditure of approximately $4.6 billion in the United States [6]. At an organizational level, this equates to around $7,600 per employed physician each year. These figures highlight the substantial economic benefit of investing in strategies to reduce burnout.

Analysis

The Quintuple Aim, an internationally recognized framework, promotes an effective and sustainable healthcare system and includes: (a) Improving the patient and caregiver experience, (b) Improving the health of populations, (c) Reducing the per capita cost of health care, (d) Improving clinician well-being, (e) Improving health equity. The framework expanded the original Triple Aim to “‘improving the work life of providers” and a lens on the impact of social determinants of health [7, 8]. Despite heightened awareness, it appears clear that physician retention risks and career longevity have not been adequately addressed.

Emergency physician well-being is a ‘wicked problem,’ a concept introduced by Rittel and Webber, lacking straightforward solutions due to complexity and dynamic nature. Systemic factors, like inefficient workflows and resource shortages, root deeply in burnout. Effectively addressing this ‘wicked problem’ requires ongoing interdisciplinary collaboration among healthcare administrators, policymakers, and medical professionals [9, 10]. Challenges like moral injury, workplace inefficiencies, and systems issues, such as overcrowding, compound the problem, creating a tangled web of interconnected challenges. Moral injury, for example, is an important driver of burnout that occurs when clinicians participate in, witness, or fail to prevent actions conflicting with their core beliefs and values. For example, in Toronto Emergency Departments, patients with housing insecurity have surged by nearly 70% since 2018, highlighting the toll of social inequities.

These challenges resist simple one-step solutions and blur lines of responsibility or accountability. Addressing these problems requires acknowledging the systemic responsibilities within healthcare organizations and institutions. Burnout extends beyond individual physicians and is deeply rooted in systemic factors like inefficient workflows, inadequate staffing, and resource shortages. Solutions must shift from individual blame to broader changes in the healthcare system, fostering a culture that prioritizes and safeguards emergency physicians' mental health and well-being, ensuring a safe and thriving work environment. A safe work environment is not just desirable but a fundamental requirement. The Canadian Association of Emergency Physicians commissioned the EM:POWER Task Force, with the goal to propose a new framework for the future of emergency care within a redesigned healthcare ecosystem, one that is sustainable and fulfills the goals of the quintuple aim.

Stanford's Model of Professional Fulfillment outlines essential elements for optimizing clinician well-being and reducing burnout. The model emphasizes organizational-level changes to foster a culture of wellness and practice efficiency. Our recommendations to address this wicked problem center around 11 categories: optimizing workflows and staffing to improve the efficiency of practice, mental health support programs, training on resilience strategies, promoting a positive work culture, flexible scheduling and autonomy, continuous professional development, addressing moral injury, employee assistance programs, workload monitoring and assessment, a workplace violence coalition, and efforts toward research and data collection (Table 1). As well, the interplay between burnout drivers, these initiatives, and the shared responsibilities are important to state and can work together to drive positive change (Table 2).

Table 1 Recommendations to Promote Emergency Physician Well-being
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Table 2 Interplay of drivers of Burnout, interventions and responsibilities
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Conclusion

The crisis of burnout and attrition among emergency physicians demands immediate, multifaceted action. It represents a ‘wicked problem’ requiring a unified, sustained systemic responsibility. Solutions should prioritize the mental health and well-being of emergency physicians, ensuring a safe working environment, and cultivating a more resilient and sustainable healthcare system, ultimately benefiting everyone.

On behalf of all authors, the corresponding author states that there is no conflict of interest.