Seasons of Life for an Emergency Physician

The practice of Emergency Medicine (EM) is unique; fast-paced, dynamic, requiring quick thinking with robust decision making and 24/7 service provision at the front door of a hospital. The specialty equips Emergency Physicians (EP) with the knowledge and skills to be able to manage life-threatening and urgent conditions, perform critical, time-dependent resuscitative measures and manage undifferentiated emergent presentations. It is a practice that requires astute clinical capabilities, stamina and a broad spectrum mental model in approaching acute cases. The Emergency Department (ED) is a place with much uncertainties. To thrive in such an environment, EPs must learn to manage these uncertainties, such as upsurge in patient load, complex medical and clinical cases, as well as handling mass casualty incidents, which can happen suddenly [1-3]. 

As in many specialties, medical students and young medical officers choose EM, with a view to having a life-long career and practice. However, not all can sustain this “life-long” practice and there may be a variety of reasons which could include lack of in-depth understanding of the full extent of EM practice, inadequate consideration and projection of their career trajectory and the multi-faceted aspects of EM practice (directly and indirectly). They could also be affected by the rapid, dynamic, ever-changing trends in EM practice (eg. increasing patient load, ageing population and its consequences, increasing use of technology), which may pose challenges in coping for some. The EPs role is investigative, as they ascertain the problems to get the diagnoses, which is then followed by solving the problems, treating the patients and managing all their issues. This requires a lot of empathy, creativity and imagination as well as good grounding in the network of assistance, besides just strong clinical acumen and knowledge [3-5]. 

The EPs’ career trajectory represents the journey they move through in their professional lifespan, such as their jobs, achievements and accomplishments. To plot their career trajectory, various metrics can be used as deemed practical and easy for them to track. How success, meaningfulness and fulfilment is measured is also industry-specific. Career success is usually conceptualized along two dimensions; extrinsic (eg. salary, promotions, job knowledge and performance) as well as intrinsic( which is more subjective eg. personal evaluation, satisfaction with career and managing expectations) [5,6]. EPs may go through rapid career development (career growth) in the earlier years and find that, at times, this may plateau, later on. The plateau phase does not always mean stagnation, but may represent a period where more value is created eg. attending a new course, doing a Masters or PhD programme, self improvement training or upskilling. These will serve to enrich an EP’s growth and development. What is important is for the EP to define and track their career trajectory and know what they wish to achieve and do in the future (eg. 2 years, 5 years, 10 years) [4,6].

The first point of contact with EM is usually as a medical student, often during the EM posting. Students get to observe first hand the work of an EP, be embedded in the shifts and get exposure to the wide spectrum of “interesting” acute cases, which makes their textbook narratives come alive. They will inculcate their initial interest and impression, which will be coloured further as they move into the more senior years. At this juncture, they may not have any major responsibilities allocated but they are expected to get involved in clerking, performing physical examination, vene-puncture and other simple procedures as well as plan patient management with their mentors/ faculty. This contact may be short but probably impactful enough for them to keep in view the practice of EM and their inclination towards it [1,7-9] (Table 1). 

Table 1: The Journey in the Career Trajectory of an Emergency Physician. 

The next level of exposure will be upon graduation from medical school where they will serve as Medical Officers  and then Residents in EM (if they have selected the specialty and are successfully chosen). They will now have more responsibilities in the care of emergency patients. They will be exposed to and be fully immersed in the practices. This will help them strengthen their clinical reasoning process and consolidate their interests. Knowledge, skills and attitude will be nurtured and uplifted during this phase. There will be both direct and indirect supervision by faculty as appropriate and they will develop in domains such as Clinical and Patient Care, Communications, Inter-professional Collaborative Practice/ Teamwork, Systems-based Practice and Evidence-based Practice. The MO will progress become senior MOs and the Residents will progress from Junior to Senior Residents. At this stage, they should be excited, motivated and energized in their career development and learning process. This is also where their mindsets and mental model of the practice of EM is inculcated and strengthened, which will set the foundation for the many years ahead as an EP [3,10]. By now, they would have completed  the required post-graduate examinations recognized in their country of practice. Post- residency, they will graduate to become junior faculty (known as Associate Consultant in Singapore) and then, senior faculty or attending (the equivalent of Consultant and Senior Consultant ). Their knowledge may then seem to reach a so-called “steady state”, but the work profile will continue to remain dynamic and knowledge and skills acquisition will continue for many years to come in view of the rapid changes, adaptation and development in EM. This phase will take up the bulk of the years in their career trajectory [3,11]. This is also the phase where they will make decisions on: 

1. a) Sub-Specialization
2. b) Fellowship and further training
3. c) Involvement in Academic EM
4. d) Focus on research and educational activities
5. e) Building and strengthening their portfolios
6. f) Taking on leadership and other roles
7. g) Customization of their work-life balance 

During the more senior years, some would become established as educators,  researchers or build up their capabilities and reputation in specific areas. Their networks (local, regional and international) will continue to expand. Some may go on to pursue other qualifications such as MBA, Masters or PhD in a variety of areas close to their hearts. Some may be thrusted into leadership and directorship roles (eg. Director of Emergency Medical Services, for those interested in Prehospital Care Medicine, or Director of Simulation-based Training). In some institutions, senior consultants may take a sabbatical to refresh and upgrade their interest in specific areas of specialization. Today, the spectrum of areas to pursue has certainly expanded (Table 2) [1,3,10,11]. 

Table 2: Choice of Post-Graduate EM Career Tracks.

As the practice of EM is very demanding, EPs have to know themselves well, be realistic about their capabilities, know when to ‘let go” and also commence grooming others to take over certain roles. In many countries where EM is recognized as a specialty, there are no written and standardised policies pertaining to pre-retirement and retirement of EPs [11-13]. This shows how variable the trajectory can be when these years are reached. Even the retirement age from active employment varies across industries and countries. In general, there is no standardised mandatory retirement for physicians in most countries (Table 1). 

The pre-retirement years are also when some may start to think about other options such as more administrative roles, teaching commitments, venturing out into businesses and other areas. Health related issues may become manifested. For those with existing medical conditions, this may be of higher concern. For those without chronic medical conditions, age related concerns may surface eg. joint related and muscular-skeletal problems, visual and auditory changes as well as stamina capabilities. The health-linked detriment of rotating and overnight shifts can be challenging. Changes in the diurnal variation, sleep deficit and need for longer rest-recovery period should be taken into account. All these may impact longevity of the EP in practice [14-19]. One study concluded that the three most important concerns for EPs in the pre-retirement years are: [20] 

1. Adjustment of workload as needed
2. Wellness and social equity and
3. The values of the EP 

The concerns may also be categorized along the lines of: 

1. Cognitive Capabilities: Decision making, fast thinking, memory and retention, cognitive load, handling interruptions, multi-tasking ability and focus strength.
2. Physical Capabilities: movement, agility, arthritis and standing for long hours, stamina, handling of physical stresses, vision and eye sight, hearing abilities, dexterity and procedural skills, other diseases with physical effects.
3. Emotional/ Psychological: sleep cycle, sleep deficit management, compassion and compassion fatigue, stability, calmness n the face of stressful situations, personal values, coping strategies 

The pre-retirement age EP may also experience issues related to generational divide, especially when they are on the same ‘shop floor’ as younger and incoming EPs. The different mindsets and prior career trajectory may set them apart or cause misunderstandings and misperceptions. Requests for shorter shifts and no night shifts may not be looked upon favourably by these younger colleagues. This is not unique to EM and is observed in many industries where the range of employees can be from the millennials to the baby boomers [5,21-26]. Thus, adaptability and flexibility are important values for the EPs in this age-range. If they are able to keep up, upskill and even be as competitive or versatile as their younger colleagues, they will continue to be relevant, sought after and be able to make their contributions, just as many of them would have made impact in the earlier years of EM, when the specialty was at its infancy. As generational differences can affect function and culture in the ED, it needs to be handled in a sensitive way [5,27]. 

Despite the challenges, there are also benefits of having senior EPs around as stabilizing figure looking out for the younger EPs and residents. They demonstrate maturity in handling challenging situations  which arise often in the EDs, and model positive communications skills. Others do maintain their experience with technical skills and procedures, making them well respected. It is also very crucial for management and leadership to understand the needs and expectation of senior EPs. They will continue to have much to contribute, if they are well-engaged [28,29].

The career longevity of EPs has become a topic of heightened interest in more recent years. This is topic an EP should not leave till the tail part of their career to plan and think about.  How an EP performs throughout the earlier years of his career may be a significant determinant of his pre-retirement years. Some examples of this would include the expertise and experience accumulated and the reputation attained. 

When discussing longevity of an EP, the issue of maintaining and upkeeping competencies (both knowledge and skills) will always surface [26-29]. These are crucial in the practice of EM which is extremely dynamic, and fast moving. They would have to keep abreast of the latest developments and accepted techniques in procedures. For skills, credentialling is a necessity and contributes towards accreditation. Renewal of skills and procedural capabilities are well-embedded in EM practice. For the aging EP concerns can arise in the Cognitive as well as the Physical/ Skills domains. With aging, memory and recall may not be as sharp and forthcoming. There may be greater knowledge deficit because of this. The rate of learning and reading may not be as fast as in the younger years. Visual and hearing deficits may also start to become more prominent. Often, the EP himself may not realize these deficits and challenges he may be encountering. Colleagues are the people who would make certain observations when they work together. This can be a very sensitive issue to be discussed openly and must be handled with care and sensivity. Physical capabilities will be also changing: slower in many aspects, tremors, joint pain and arthritis, deteriorating eye-sight, auditory sense and decline in other coordinated skills. 

The other major issue when discussing longevity of an EP is that of ‘the value of an (senior/ aging) EP’. How you feel about yourself will affect how others view you. This is linked to the accumulated career trajectory and pathway an EP has gone through to develop capabilities, expertise, confidence and a whole lot of other factors. Armstrong and Reynold put forth the term “crystallized intelligence” which they defined as the experience and wisdom between the ages of 40 to 70 years [22]. This would be difficult to measure and quantify. 

As an EP with close to 30 years of practice the following factors have influenced my career trajectory and longevity in some ways: 

• Strong passion and interest in EM.
• My Comfort level with the practice, which is laced with stressors (ability to flourish under pressure) and uncertainties.
• Adaptability to change.
• Seriously curious nature.
• Resilience in handling challenges, u-turns and the unexpected incidences during my career.
• Systematic prioritization in handling work-life commitments.
• Building on my strengths eg. medical education, simulation, leadership, serving humanity in international humanitarian work.
• Strong faith and spirituality which helps maintain my equilibrium. 

Every EP is unique in their experiences and values that keep them going. Reflection and taking stock at intervals is crucial to review and refresh one’s career trajectory. In a paper from Korea, the authors concluded that to promote career longevity amongst EPs, there was a need to improve emergency room safety, workload intensity, professionalism through a stronger vision of EM and strengthening of the patient-doctor relationship [30]. Some of these factors are unique to certain groups of EPs and may be culturally-driven as well. 

In the later phases of the career trajectory of an EP, some may choose to go into academic EM full time or part-time. This is where they need to find their individual balance of clinical versus academic work. Academic work appeals differently to different EPs. In order to enhance the “academic marketability” of an EP, the following are some important considerations: [9,31-32]

• Involvement in research
• An established track record of scholarly work and publications
• Awareness and expert of the literature in certain areas/ topics of the specialty, ie. development of an academic niche
• Involvement or membership in specialty organizations or committees
• Strong educational skills
• Recognition awards in areas such as research and education
• Have been through fellowship training, followed by advanced acquisition of knowledge and skills in certain areas. 

This is an area where senior EPs can share how they achieve the balance with the younger EPs, based on their experience. Their accumulated track record throughout their career will have significant contribution to this. However, it should also be borne in mind that in some institutions and academic medical centres, the contributions will have a ‘long tail’, depending on the individual career trajectory. This means academic work will likely continue, despite the decreasing clinical work with seniority. An adequate ratio between the two is important to maintain an EP’s credibility [32].

Despite having been in practice for many years, the senior and pre-retirement EP can still be sensitive to the way they are treated. They look for respect and courtesy, which should be accorded to them. Maintaining their psychological safety is important as the department continue to engage them. They wish to be included, have their views heard, be well engaged and consulted as necessary. In fact, in some cases they may even have very fragile egos. Managing them appropriately can reduce any potential moral injury. They should also be a part of the active dialogue in the ED as they may have useful views and inputs. Certainly, there is zero tolerance for abuse or violence against senior EPs in all departments [33-36]. With all these considerations and interventions, the contributions of the EPs can be maximised, as they certainly would have a lot to share. When it comes to new skills and technology adoption, they may have to upskills and attend training courses as appropriate. They should be open to these and should not feel their capabilities are undermined. Afterall, upskilling, upgrading and continual learning is part and parcel of the practice of EM [13,37].

With a meaningful and fulfilling career, an EP can remain active and contribute for a longer period; barring any unforeseen issues or health reasons. The work is challenging and hectic but it does offer a broad spectrum of exposures for growth and development of the EP in practice. With some of these challenges and increasing age, the outlook may change. Some may retire early, change professions or leave practice. There are studies which have noted that EPs retire earlier than their other physician counterparts, or even have a shortened lifespan [38,39]. The literature also reports a higher incidence of burnout amongst Eps [15,16,25-27].

The National Academy of Medicine’s Action Collaborative on Clinician Wellbeing and Resilience has put forth the following 6 recommendations to mitigate burnout and physicians leaving early: [40] 

1. Creation of positive work environment
2. Creation of positive learning environment
3. Reduction of administrative work burden
4. Enabling technological solutions
5. Providing adequate support and resources for clinicians and learners, as well as
6. Investment in research 

These may seem like very generic recommendations but they are certainly worth a trial in implementation with customization, as appropriate for the department.

The seasons of life for an EP’s career will go through the following phases: 

• The enthusiasm of a medical student
• The excitement of a young resident
• The tenacity and hopefulness of a junior EP, pushing forwards
• The balance and maturity of a senior EP and
• The guarded outlook of the pre-retirement EP 

There will be ups and downs, tears and laughter, joy and sadness. At every stage maintaining psychological safety is important.  Inculcating well being principles and resilience is necessary. Support should be made available when needed to help mitigate burnout and reduce premature retirement.   At the end of the journey they should ask if they feel fulfilment and accomplishment, or if they have done enough to leave a legacy. Rittel and Webber have described the EPs well being as a ‘wicked problem’: one that lacks clear-cut and obvious solutions [15,41,42]. This aligns with all the complexities an EP’s career trajectory can take. Sinsky JL et al also put forth some suggestions to manage this ‘wicked problem’, which requires departments to [15]: 

For ED to,

• Optimise workflows and staffing to enhance efficiency
• Have mental health support programmes
• Have training on resilience strategies
• Promote positive work culture
• Have more flexible scheduling
• Continuing professional development programmes
• Address moral injuries appropriately and in a timely fashion
• Plan some employee assistance programmes
• Do workload monitoring and assessment
• Manage workplace violence as appropriate
• Put in effort in research and data collection 

These suggestions align and is synergistic with the National Academy of Medicine recommendations [40]. The well being of an EP is a shared responsibility between him and the leadership/ management of the ED as well as the employer.

Whilst the management of EPs in the earlier part of their career is well defined, it would be helpful to have a framework with the principles of managing the senior and pre-retirement EPs. Both are necessary to facilitate the growth and contributions of EPs throughout the seasons of their career lifespan and trajectory.

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