EM Autonomy

Emergency medicine autonomy is under siege

In Commentary, Opinion by Jesse KellarLeave a Comment

The opposite of a motivated physician is a burnt-out physician. In healthcare, preventing physician burnout and promoting physician wellness is of increasing importance. Healthcare organizations are under tremendous pressure to retain quality physicians and push physicians to perform at the highest level possible.  The key to getting these results is to truly understand what motivates physicians to do their job, and to foster it.

I recently watched a YouTube video1 that summarized a Daniel Pink book on motivation, entitled “Drive: The Surprising Truth about What Motivates Us.”2  The book was reviewed last year by the ALiEM.3 The talk focused on some new research that explains what motivates people. The talk contended that while the old carrot and stick model (i.e. a bigger carrot (reward) will lead to higher performance, and a bigger stick (penalty) will prevent poor performance) may be true for some fields, it is not true for many.

What motivates us?

Pink asserted that organizations which require their employees to perform more complex tasks and/or creative solutions (such as in Emergency Medicine), a simple bonus or pay raise will likely not result in higher performance. In addition to these conclusions, research by Jha, et al. in the New England Journal of Medicine showed no difference in mortality benefit when hospitals utilized pay-for-performance type incentives.4 Pink continued by stating that when a certain income level is achieved, other factors besides pay or bonuses actually provide a means to increase employee performance.  In Emergency Medicine, physicians are reasonably well-compensated compared to other specialists, however burnout and fatigue are still huge problems.5  Simply encouraging doctors with monetary incentives is not likely to motivate them to provide better care, nor will it prevent burnout.  Instead of pay, Daniel Pink suggested that individuals want mastery, purpose, and autonomy in their careers, and anything done to increase these three factors will likely result in higher performance and job satisfaction.

The loss of autonomy in emergency medicine

Most EM physicians have both mastery of their field and a deep sense of purpose. I believe lack of autonomy is the key aspect contributing to decreased motivation in clinical Emergency Medicine. To be autonomous, physicians I talk with want control over their time at work, to be treated as the 7+ years of advanced education deserves, and to be trusted to think critically based on the patient and situation. For example, a 120 kg male with a history of end stage renal disease on hemodialysis and CHF with an ejection fraction of 30% presents to the ED with an obvious community acquired pneumonia. He of course happens to trigger all known sepsis makers. No sooner than I start placing orders in my EMR (electronic medical record), red warning boxes pop up politely informing me of the order sets I should now complete as per the hospital sepsis committee. I am now forced to chart ad nauseam that I do not think giving the 30 cc/kg bolus (that the EMR red boxes tell me to do) would be appropriate for this patient. Even if I think my care is medically appropriate and defensible to both lawyers and doctors, I have to chart detailed explanations so that my hospital sepsis committee doesn’t come after me for missing a quality metric. Although I admit this example is a bit exaggerated, the point is this: more and more barriers hinder us from patient care and prevent us from doing what we love to do.

To contribute to this lack of autonomy during a shift, we have no control over our time. This is because time is at the mercy of our patients, our charting responsibilities, and other departmental staff. For instance, EM physicians can’t eat a quick snack, take a lunch break, or even use the restroom when they want. Add the constant pressure of endless charting, clicking boxes, and signing orders, how EM physicians spend their work day is largely out of their control. The addition of the EMR only contributed to our lack of autonomy. It literally sucks time away in an endless sea of clicking. Yes, the push away from simple paper charting and verbal orders was great for patient safety and record keeping. However, when it takes 20 clicks to write for Acetaminophen for a patient, it probably wasn’t the best use of an Emergency Medicine physician’s time. Creative solutions are needed that will actually increase our control over our time in the Emergency Department, prevent burnout in clinical medicine, and increase the physician’s ability to devote more time to patient care.6

Addressing the problem

What type of creative solutions? First, I think we need to start with getting our hands dirty and getting involved. Complaining is easy but serving on committees is hard. It seems backwards in terms of burnout to serve on a hospital committee or work on process improvement projects, but these measures can go a long way to improve the life of the emergency doctor. Don’t like the sepsis order sets? Time to sign up for the sepsis committee! For physicians wanting leadership positions, this is the right time to do it. More and more hospital administrators realize the importance of physician leadership, and we as Emergency Physicians can step up to the task.

In conclusion, too often we sacrifice our physician autonomy without a fight. We complain about our loss of control without seeking ways to change it, basically waiting for the next round of encroachments. Yet, our only hope for a brighter future depends on us getting involved and having a stronger voice at the table. So the next time you’re asked to be put on a hospital committee, and your gut sinks and you want to say no, realize that your voice on that committee can actually help make all our lives better at work. Actually improving an order set or decreasing the amount of clicking we all have to do will make a bigger difference in the long run for our wellness than an organized wellness retreat. Just make sure that whatever committee you’re placed on, speak out for physician autonomy.


        TR. RSA ANIMATE: Drive: The surprising truth about what motivates us. YouTube. https://www.youtube.com/watch?v=u6XAPnuFjJc. Published April 1, 2010. Accessed January 31, 2017. [Source]
What Motivates Us? Harvard Business Review. https://hbr.org/2010/02/what-motivates-us. Published February 18, 2010. Accessed January 31, 2017.
Thoma B. ALiEM Bookclub: Drive – Synopsis and Discussion. ALiEM. https://www.aliem.com/2014/aliem-bookclub-drive-synopsis-discussion/. Published February 22, 2014. Accessed January 31, 2017.
Jha AK, Joynt KE, Orav EJ, Epstein AM. The Long-Term Effect of Premier Pay for Performance on Patient Outcomes. N Engl J Med. 2012;366(17):1606-1615. doi: 10.1056/nejmsa1112351
Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1377. doi: 10.1001/archinternmed.2012.3199
Schrijver I, Brady KJS, Trockel M. An exploration of key issues and potential solutions that impact physician wellbeing and professional fulfillment at an academic center. PeerJ. 2016;4:e1783. doi: 10.7717/peerj.1783

Jesse Kellar

Jesse is an emergency physician in Michigan with an interest in physician empathy and medical education..

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