It’s a busy day in the emergency department. The waiting room is full, and we are short-staffed. I just read an email from administration that morning about how our treat and release times are “slipping,” and in the same breath, they remind us of the importance of patient satisfaction. There are many patients in the department with chronic medical problems or chief complaints that could be interpreted as non-emergent. I am seeing patients as fast as I can to make the board less red.
The next patient walks into my assessment room and stops to sit in a chair. We don’t allow them to lie down anymore to keep them “up and vertical.” I introduce myself rapidly, “Hey, I’m the PA. How can I help today?” There’s no time for casual banter. The patient likely immediately recognizes that I am busy and have no time for small talk. I get the best history I can, and unfortunately, that only comes after having to interrupt the patient from topics unrelated to the actual reason they are being seen today. I’m sure that at that moment, the patient feels underwhelmed regarding my bedside, or should I say chairside, manner. I am rushed and spread thin, and it shows. I immediately recognize this, but despite this, it is difficult for me to do this job any other way when it’s this busy, and it’s always this busy. If I work slower, my colleagues start to judge me, and nursing starts to ask, “What’s going on up there? Why are we missing treat and release times?”
I’m ready to discharge a patient home, but the patient isn’t in a private room but is sitting in a chair in an internal waiting room with other patients, some of them crying, some of them vomiting. Privacy is no longer a priority in today’s emergency department. I look around and try to find somewhere private to speak with them. The only private place I can find is an empty stretch of hallway. I bring the patient down the hallway and give them a quick and dirty explanation of what is or isn’t wrong with them and tell them the discharge plan. I can read the patient’s body language and can tell they may be a little confused or that they have questions, so I ask them if they have any questions. They hesitate and say “no,” likely because they can see that I am very busy and they don’t want to bother me with the inconvenience. I escort them back to the holding area, and the patient is discharged home. Total time spent with the patient: 6 minutes. Rinse and repeat 27 times during an 8-hour shift. Near the end of my shift, a nurse comes up to me and asks, “I heard you’ve been grumpy recently, what gives?” Instead of making an excuse, I simply turn to her and say, “I’m burned out. It is what it is.”
I have been doing this job for 15 years, and in that time, I have realized that this job is causing me to lose my humanity. I feel rushed and spread thin all the time. I now make less eye contact. I care less. I am detached and dissatisfied. Patients have become “the ankle” or “the pelvic pain” or “bed 3.” These days, the only time my humanity and sympathy seem to come out to play is when a patient is critically ill. I recognize these feelings. I am experiencing clinical burnout and moral injury. The solution to this would be to slow down and to see fewer patients per shift, but this will never happen. As long as we have a for-profit business model in health care, we will always staff the EDs as lean as possible.
Over my 15 years, I have only seen a negative trend in emergency medicine. A trend of “do more with less.” A trend of valuing metrics and money over providing good care. A trend that seems to care less and less about provider job satisfaction. A trend of spending more and more time at the computer and EHR than at the bedside. We now even have patient assignment software that tells us what patients to see and how many patients we have to see in a shift. We providers have lost all forms of autonomy in this system. We are now practicing assembly-line medicine, and most of us are severely burned out and suffering deep moral injury. These are the reasons that medical providers suffer from the highest suicide rate compared to all other professions. We spend our entire lives learning and training to take care of other people, and then we get into a system that doesn’t give a care about us and treats us like machines. I don’t need a “relaxation room” in the department or more advice on how to meditate. We need to change the system from within, and we need to do it now before we lose more amazing, smart, dedicated people that the world desperately needs. I don’t know the solutions, but I do know that we doctors, physician assistants/nurse practitioners, and nurses should make the decisions on how we work and how we take care of our patients.
For now, I will keep my nose to the grindstone and continue to practice assembly-line emergency medicine and hope I don’t miss a diagnosis because I interrupted a patient during the history or missed an important concern not mentioned in the hallway at discharge.
The author is an anonymous physician assistant.
