Introduction: Paul Atkinson (@PaulAtkinsonEM)

In the constantly evolving landscape of healthcare, emergency medicine has always stood out as a different, exciting, fulfilling, and meaningful career path. Yet, as we peel back the layers of this dynamic specialty, a disconcerting narrative emerges; perhaps one that compels us to reassess our longstanding endorsements of this career path. This CJEM debate, “#StillTheOne” invites introspection and critical discussion on the current state and future of emergency medicine.

For decades, emergency medicine has been celebrated for its fast-paced, diverse clinical challenges, and its unique ability to provide care at critical junctures. It has attracted those drawn to the adrenaline-fueled, immediate gratification of saving lives. However, beneath this veneer of dynamism and heroism lies a reality marred by burnout, administrative burdens, and an increasingly unsustainable work–life balance.

In this CJEM debate, we delve into the multifaceted nature of emergency medicine, examining both the intrinsic rewards and the mounting challenges that define it. We explore the evolving landscape of healthcare, the escalating pressures on emergency departments, and the profound impact these factors have on the mental and physical well-being of practitioners. The question at hand is not just a matter of job satisfaction, but of the fundamental sustainability of emergency medicine as a viable career path for future physicians.

Faced with the proposal that emergency medicine is #Stilltheone, Dr. Shahbaz Syed from the University of Ottawa argues that emergency medicine has lost its lustre, and that overall the career takes more than it gives. His colleague, Dr. Hans Rosenberg, responds and counters these points, outlining why he believes that there is still hope for emergency medicine and that the EM path provides a meaningful and balanced career, even with the current challenges faced by our specialty.

Would you do it again? Or recommend emergency medicine to someone starting now? Readers can follow the debate on X/Twitter and vote for either perspective, by going to @CJEMonline or by searching #CJEMdebate.

For: #StillHopeforEM. Hans Rosenberg (@hrosenberg33)

Nearly 20 years ago as a medical student, it struck me like a thunderbolt; I want to practise emergency medicine! I will admit, at that time in my medical career I was fairly ignorant about emergency medicine, what a career in this field truly meant, and how I would feel about it 20 years later. Fortunately, one thing has remained constant, I still want to practise emergency medicine. As I sat down to write this debate section, I read Dr. Syed’s very well-articulated reasons why he found himself in the #EMNoMore side of the argument. But I genuinely feel that there are many compelling reasons why emergency medicine is #StillTheOne and overall remains the single best specialty in medicine.

Against: #EMnomore. Shahbaz Syed (@DDxDino)

Just like my colleague, I was an ‘emergency medicine gunner’ pretty early in medical school—I tried my hand at a few specialties but emergency medicine was the one that kept calling to me. The acuity, sick patients, procedures, and the ability to tackle any problem that rolled in the door. I still love that about emergency medicine, and don’t get me wrong—I love my job for all the reasons that my colleague ascribes. But, I think the medical student version of me that was keen to do it was a bit naive; no one had talked to me about what the landscape of emergency medicine was really going to look like as I dug into my career. Maybe they didn’t know—but when we talk to medical students we tend to glorify our specialty because we want people to think that we have a fun job, while ignoring the scars we carry.

Shahbaz: Burning out on the frontline

Prior to the COVID pandemic, the majority of emergency physicians across Canada met the threshold criteria for burnout and carried a three times higher incidence of moderate to severe depression than the general population [1]. The fallout of the pandemic has certainly enhanced this feeling, and once thought to be ‘journal fodder’—the idea of burnout in emergency medicine is now so mainstream that Dr. Glaucomflecken uses it for meme content on his (very popular) social media platforms. Since 2020, burnout rates have gotten substantially worse, with prevalent themes around a broken healthcare system, a lack of support, and systemic workplace challenges [2]. The sensation of burnout is palpable, as many allied health professionals and physicians search for an ‘exit strategy’. Already, we’ve seen too many good nurses leave the profession as the challenges increase.

While we often comment on the rate of burnout in emergency medicine, it is sometimes more challenging to look for the root cause—a complex issue for sure, but contributing to this is the mixture of moral injury and a lack of control over our environment. For years, physicians across the country have spoken out about issues relating to the overcrowding of admitted patients; we don’t even have our Emergency Department (ED) as a space of our own. This problem continues to get worse, and as a result, we resort to hallway medicine or have patients languishing in chairs in the waiting room for hours. We have no control over our physical work environment, and the conditions afforded to us make it challenging to do our jobs well.

Conjointly affecting this is a staffing crisis that began with the pandemic; with each of us covering for those off sick, or for those who decided to leave for ‘greener pastures’. We often talk about the importance of ‘staff, stuff, and space’ in emergency medicine—well, we’re losing staff, we’ve already lost our space, and in terms of ‘stuff’, it feels like too many essential items are often on ‘backorder’.

Our environment certainly isn’t the only challenging one—providing outpatient care is becoming increasingly challenging for primary care providers, and as those challenges mount and fewer people have access to primary care, the Emergency Department stands as a safety net for those without access to care, adding to the volume pressures.

In theory, we get to leave it at work, but a lot of the moral distress we feel permeates through our consciousness and cements itself as moral injury—and those are the scars we carry home with us.

Hans: Burnout is an important consideration, but you can’t dismiss the positive aspects!

It is without a doubt that burnout is a huge issue in emergency medicine. But there are multiple factors that can protect against burnout. However, I honestly believe that part of this surge in burnout is due to the fact that a lot of the focus in our specialty has been on the negative aspects of the specialty which has snowballed into a problem that seems irredeemable. But perhaps, we can think back as to why we originally fell in love with the specialty.

One of the major factors for medical students choosing emergency medicine is the variability of practice profiles available in emergency medicine, Anytime, anywhere, in any situation. You need me to work a day shift in a resuscitation area of a busy academic centre and tertiary care hospital; no problem. You need me to work an overnight shift in a remote community hospital; no problem. I am not claiming that all of us would fit perfectly in each of these scenarios, but rather that we have the skillset and mentality to take on these challenges more than any other specialty out there. Furthermore, being trained in emergency medicine also provides you with pathways to work in areas like critical care, pre-transport medicine, disaster medicine, wilderness medicine, sports medicine, and many more [3]. Your work location and environment can change based on what you find most rewarding in emergency medicine.

Another major reason to choose emergency medicine is that it is one of the few specialties where you get to use your mind and hands every single day. Sure, the internist might have a great time figuring out that a patient has multiple myeloma explaining their fatigue or a plastic surgeon may repair a tendon that returns function to that finger, but I get to do all of this kind of work every day! Clinical challenges and surgical procedures are so common, we take them for granted, yet this is such a unique feature of our specialty. We get to keep our minds and hands engaged at all times during our typical workday. [4]

Shahbaz: can we control any of it?

Part of the fun of emergency medicine is that it is unpredictable. Still, a lack of control over our environment creates non-modifiable stress, and further compounds much of the moral distress that we already feel. One can be resilient, enjoy aspects of their job, and thrive in emergency medicine, but these systemic factors are an inevitable daily challenge for us.

In the ED, we are entirely reliant on a hospital administration to provide space to see patients and to ensure that we have bed movement so that we can assess and treat patients, rather than accommodating the boarding of admitted patients. When the hospital is full, we’re full—and so we’re unable to do our jobs, because of variables beyond our control.

Emergency physicians are the only doctors who cannot refuse, reject, or re-direct consultations. We are here to see everyone. But, we are also expected to be gatekeepers for the entire system. A system that is predicated on access to primary care and outpatient resources, which right now, is a significant problem.

As such, the healthcare system is in a state that can at times, seem to pit us against our patients. It is challenging to act as a steward for the system while simultaneously acting as its safety net. It isn’t the patient’s fault that they had no choice but to come to the ED to seek out care, but it does become our burden to bear when we see the many holes within the system’s safety net.

We talk about it, sure, but there seems to be little unified political representation and advocacy for emergency medicine specialists. So, many of the issues we face daily are heard about only within our small echo chamber.

Hans: it is chaotic, but it’s controlled chaos

It is challenging to be everything to everyone, but this also brings with it one of the most appealing aspects of emergency medicine; something new, every day! One of my mentors, who has been practising for about as long as I’ve been alive, continues to tell me about new cases he has seen that were interesting and new to him, and with a big smile on his face he says “I love emergency medicine, after 40 years I see or learn something new every single day”. If that is not a ringing endorsement for the specialty then I don’t know what is.

Every shift there is some clinical/procedural/logistical problem that requires our ingenuity and constant quest for learning to solve. It is unmatchable in medicine, our door is open to everyone and all their problems. Some might scoff at this idea, but the crux of emergency medicine is that we see whatever comes through our door and we do our best to help that person with that problem on the day they’ve presented. There is a great sense of pride in having “MacGyvered” your way through a problem that arose in the Emergency Department.

Shahbaz: shift work is bad for YOUR health

There are pros and cons to shift work. Sure, it’s nice to be able to take care of some things during business hours, but studies consistently demonstrate that there are negative physiologic, mental, and emotional consequences to shift work.

  1. a.

    Shiftwork has recently been labelled as a possible carcinogen for its harm and associated risk of cancer. [5]

  2. b.

    From a social perspective, shiftwork can make healthy social balance challenging with navigating weekend and evening shifts; leading shift workers to have a higher rate of divorce and increased risk of substance misuse. [6, 7]

  3. c.

    We know there are negative physiological consequences to shiftwork as well; increased rates of metabolic syndrome, heart disease, increased risk of mood disorders, motor vehicle accidents, and issues with fertility and immune function. [8]

  4. d.

    Sleep is such an important component of health determination, and yet shiftwork is a direct inhibitor of this. As a medical student, I found shifting my sleep schedule around no problem, but as I was warned—this is a challenge as I get older.

Hans: Shift Work has its advantages

If there is one constant theme I hear, it is from my primary care colleagues who are often inundated with paperwork that keeps them in their offices an extra two hours each day, or at home documenting for hours just to catch up on the day. In emergency medicine, our clinical work stays at work. We have our schedules, come in at a specific time, and expect to leave at a specific time. Once you sign out, there is nothing left to do for your patients, and the great majority of us finish our documentation while at work and it’s done. I get home and don’t have any paperwork to do, no lab results to go through, no patients to call for follow-up, and no pager to respond to. The fact that it’s shift-based and not longitudinal without a start and stop time facilitates being able to shut it out of our lives. It’s no wonder studies have shown that medical students rank lifestyle factors such as shift work as the number one reason they choose emergency medicine [9, 10]. Emergency medicine is amazing, as I’ve already said here, but it has its place and time, and it’s not in my house.

Shahbaz: Complexity is a serious challenge

Where I work we have an ‘urgent care’ area—where the ‘walking wounded’ come through. It is supposed to be the ‘easy stuff’. But all too often, we see complexity and nuance that requires more than a few minutes to sort out. Sure, the patient has a urinary tract infection, but they’re also a renal transplant patient with a history of renal colic, the patient with back pain has a history of an aneurysm repair or previous cauda equina. We’re supposed to be fast, and efficient, but also thorough—we can’t miss things. Complexity makes this a major challenge in emergency medicine, and with medical advancements, this becomes an increasing issue within healthcare spheres.

My colleague mentioned our ability to provide care to a diverse population ‘anytime, anywhere and in any situation’—which is great, except that often it comes not in the form of medicine, but in the form of logistics, forms, and trying to figure out where patients can access outpatient follow up. So while at times we may be stewards of the system, it more often feels like we’re shepherds, trying to help patients navigate the system, rather than practising medicine.

Hans: complexity is what we are good at

Who says we must be fast and efficient rather than thorough? One of the benefits of the pandemic and the subsequent ED crowding crisis has been the realization that we must resource our service. More and more, we can embrace our role as the safety net, provide the care people need, and serve the many Canadians who have no other way to access the system. Showing compassion and generosity in this setting can only bring satisfaction.

Shahbaz: patients ‘can’t get no satisfaction’

The things that patients care about are not necessarily the metric that I measure things by. Mostly, people are not having a great day when they come to the Emergency Department. The sickest, and those who need our help the most, are usually not in a position to be grateful or thoughtful about the care they receive. Many others are going to be dissatisfied purely because of wait times, or because we cannot tell them why they have pain, despite a normal assessment. While surgeons may get gifts, we tend to get complaints.

Long wait times are a problem. Have you ever worked a shift where you saw 20 people, all of whom waited over 12 h to see you? No one is happy. If every interaction you have in a shift is challenging, neither you nor your patients are going to have a great day.

When we recruit students into emergency medicine, we often sell the glorified view of resuscitation, high acuity, and interesting procedures. I think it is incumbent upon us to also highlight the reality of our job; primary care, chronic pain, drug addiction, diabetes, untreated comorbidities, upset patients, hallway medicine, overcrowding—because we spend more time wading through that type of work these days than we do practising emergency medicine.

Hans: patients mostly leave satisfied, and so do we

Although I wholeheartedly agree that in a situation where wait times exceed those that any individual would expect to be reasonable is disheartening, I cannot count the number of times when patients whose wait times in the emergency department have exceeded 6 h are nothing but grateful for the care they receive. This is not the exception, but rather the norm. Sure, I will get a few people commenting on the long wait, or perhaps one who is genuinely angry, but I remember that anger is not truly targeting me, they have been let down by the system…but not by the hardworking individuals who make up our emergency medicine healthcare team. For the number of people who are upset, those who are grateful easily outnumber them, and are the ones that I remember and appreciate.

Let’s not forget, one of the biggest reasons why we do what we do: our patients. We also receive significant satisfaction from our jobs. No other specialty gives you the opportunity to help diverse populations from all aspects of society every single day [11, 12]. When you walk into an emergency department, it doesn’t matter whether you are black or white, wealthy or unhoused, have lived a dull life on the straight and narrow, or have had the wildest life imaginable; I will get a chance to see you, hear your story and provide for you, the care you need at that moment, no matter what. I can’t begin to describe how thankful I am for this opportunity; it truly makes me feel like I am helping my community every single day.

Conclusion

Shahbaz: #EMNoMore

Dr. Rosenberg has some wonderful things to say about emergency medicine, but I am not sure the current landscape of emergency medicine resembles what I thought I was getting into. I think when picking any specialty you must recognize that there are ‘undesirable’ parts to the job, and while you don’t have to love them, you must be able to tolerate them, and not become miserable because of them on a daily basis. Right now the difficult parts of emergency medicine are eating away at a large part of our workforce, and so as much as I love my job, I feel that it is important that people understand what they are signing up for.

Hans: #StillHopeForEM

I honestly could go on and on about the wonderful aspects of emergency medicine, but space constrains me. Dr. Syed writes thoughtfully and from a good place. However, it is still clear to me that emergency medicine is simply the most appealing specialty in medicine and we should continue to encourage future physicians to follow our path, enjoy the aspects that we love, and work hard to advocate to fix some of the foibles that cause Dr. Syed to refrain from a full endorsement of the career that is emergency medicine.