“So, what do you do for a living?”

“Oh, Emergency Medicine! You must have some wild stories, what’s the craziest thing you’ve seen?”

If you work in Emergency Medicine (or to be honest any aspect of medicine) you have likely had some version of this conversation while making small talk with someone you just met. This question often gives me pause as I try and come up with something that is not too gory, not too sad, and not too technical. That often results in me talking about a foreign body that was somewhere it shouldn’t be or a relatively straightforward partial amputation of a limb. I feel this need to shield the questioner from the unfiltered aspect of our job because our job is filled with hard moments (and talking about a poor geriatric patient who was found down after four days on the ground is certainly a conversation killer at a dinner party).

Fundamentally, we are faced every day at work with patients who are suffering in a system that is struggling to keep up; often leaving us feeling powerless to help. Whether it is elderly patients living at risk at home, young patients with mental health issues who can’t access resources in the community, or surgical patients waiting years for their elective procedures, we are often faced with the feeling that we are falling short in providing the care we would want for our loved ones. This morale distress (often synonymous with burnout) can be cumulative over time, leading to more serious moral injury (and essentially PTSD).

In light of all this, it is unsurprising that a study done in 2020 found that 86.1% of Emergency physicians surveyed met at least one criteria for burnout (and that was before the COVID-19 pandemic) (Rodrick Lim, et al., 2020). The pandemic has exposed a health human resource crisis as many of those front-line healthcare providers struggle with feelings of burnout. Ultimately many have decided to either retire or find other clinical work elsewhere. A survey of nearly 2000 international frontline healthcare workers found that higher levels of burnout were associated with a 47% increased desire to change workplace (with working in the ED being the only independent factor associated with burnout status) (Petrino R, 2022).

As we go through the many years of medical training and residency, it is hard to not let medicine become a core aspect of your identify. With the gruelling hours on call and on the wards, there are times when you can feel there is not much left outside of medicine to call your own. This becomes challenging however because your foundational self then is dependent on how you function as a physician. This leads to a medical error, poor patient outcome, or near miss no longer just being a “bad day at work” but to you being a “bad person.” That can be destabilizing in a world where medical errors do happen and you will make mistakes (G. Ross Baker, 2004). The question then is how do you stop those bad days at work from making you question your value as a person?

Previous blog posts have discussed personal resiliency and agency and I think it is an important topic to touch on in the context of occupational wellness and our daily exposure to events that are morally distressing. Fundamentally, I believe that moral distress is an integral aspect of the medical care we provide every day. There are countless shades of grey in medicine and each one has its own nuance and ethical considerations. This cannot be separated from the pathophysiology of the diseases we treat and is the reason we haven’t been replaced by AI yet (here’s looking at you chatGPT). How you internalize and process those morally distressing events is important to your continued ability to function as an Emergency physician.

What I always tell learners is that medicine is just what you do, it isn’t who you are. I’m an ED doctor, but I’m also a husband, a father, and a member of a community that knows me for more than just the medicine I practice. As such, when I’m faced with patient complaints or poor patient outcomes, I can try and separate the negative feelings around my work from who I am as a person. It’s a work in progress (my heart still sinks whenever I get an email from patient relations) but an important cognitive exercise for me to try and maintain my sense of self and ensure I’ve got enough gas in the tank to effectively show up to work on the next shift.

So, when people ask me “what’s the craziest thing you’ve seen?” I reflect on the past few years of this COVID-19 pandemic. I’ve seen nurses, physicians, residents, med students, and countless allied health adapt to a constantly changing landscape. I’ve seen acts of true compassion in a time when people have been pushed to their limit and I’ve seen people continue to come to work, be exceptional colleagues, and provide the best care they can to the patient in front of them despite all of the challenges they face. Peoples’ ability to show up to work over this pandemic and continue to care for their patients has been nothing short of exemplary; maybe that will be my answer at the next dinner party.