key: cord-0865324-rjo3ctct authors: Ting, Daniel K.; Poonja, Zafrina; Lee, Kenneth; Baylis, Jared title: Burnout crisis among young and female emergency medicine physicians during the COVID-19 pandemic: applying the six areas of worklife model date: 2022-04-11 journal: CJEM DOI: 10.1007/s43678-022-00298-w sha: 490fd713aa71b442c07030e1b6b83e8e4ce3ab68 doc_id: 865324 cord_uid: rjo3ctct nan There is an old adage within emergency medicine (EM) that the specialty is a "young man's game." The conventional wisdom, created in a once male dominated specialty, suggests that young individuals are more suited to deal with the rigors of shift work and the disquiet of the emergency department (ED). Therefore, the study by Mercuri et al. [1] should raise a red flag for EDs and hospital systems across the world. This paper shows that contrary to assumption, young physicians are at higher risk of burnout in the context of the COVID-19 pandemic. Females also have an elevated risk. These findings are a microcosm within a worldwide crisis of burnout [2] . We are writing from the perspective of three early-career EM physicians and one senior trainee, who have all experienced increased burnout during the pandemic. We seek to describe how the COVID-19 pandemic has particularly affected young and female physicians using the Six Areas of Worklife model [3] . This model comprehensively explores the major organizational factors that lead to burnout. Young EM physicians commonly worked a greater number and variety of shifts that included evenings and nights, which are physiologically more disruptive, and may have led to chronic exhaustion. As new clinical roles emerged to respond to COVID-19, EM physicians were recruited for their broad skill set. Many EM physicians were enthusiastic about taking up these fresh responsibilities. However, as the pandemic dragged on, EM physicians became overworked, especially young physicians with a higher baseline shift commitment. For female EM physicians, responsibilities at home increased disproportionately as well, specifically those with children who could not attend daycare or school [4] . Increasing workloads and the resulting workforce exhaustion significantly reduced ED schedule flexibility. Trading or dropping shifts became challenging. For young physicians, the decrease in schedule flexibility may have caused additional stress for those who were planning to start a family or who had young children, due to the shift accommodations that tend to accompany those scenarios. During the first phase of the pandemic, the social rewards from patients, the public, and the media towards EM physicians were very high. These expressions of support led to a sense of accomplishment and professional camaraderie. Eventually, effort to manage patient volumes increased while social rewards diminished, and in some cases, reversed direction. Patients became less understanding, and some even protested outside hospitals. This shift in societal attitudes was amplified on social media, where young physicians were more likely to engage. As a result, young physicians were more susceptible to cynicism around the public support for frontline work. As social activities were canceled due to public health restrictions, physicians missed out on regular team building activities with their colleagues. While older physicians could rely on prior years of working experience and established relationships, young physicians were exposed to potential loneliness at work. Physicians who were pregnant or new mothers were particularly affected by limits in social contacts. Additionally, young physicians were more likely to be single and to not have children who protect against depersonalization [1] . Females faced unique inequities, which may have led to feeling underappreciated. In fee-for-service payment models, female EM physicians have been estimated to bill 46% of what their male counterparts obtain, for complex and multifactorial reasons [5] . Additionally, females experienced microaggressions, and were more often asked to complete tasks outside their scope of practice than males, causing an overall increase in their workload. Young EM physicians emerged from their residency training at a peak of their knowledge and skills, with an idealized perspective of what they would encounter in the ED. The pandemic exacerbated an acute-on-chronic mental health epidemic and many patients came to the ED as their only option to be seen in person. Prepared to manage life-threatening emergencies, EM physicians were instead asked to treat a snowballing number of chronic mental health conditions. With comparatively less clinical experience, young EM physicians felt this mismatch more acutely, especially as there was an inadequacy of mental health support both within the ED and the community. The inability to provide solutions for these patients could have led to a loss of personal accomplishment, one of the main drivers of burnout. The Six Areas of Worklife model demonstrates that burnout is multifactorial and will require thoughtful solutions. Although many factors are at the system level, it is important to identify feasible steps within individual control. When chronic mismatches exist within the areas of worklife, physicians can feel they have insufficient opportunity to find meaning in their work [3] . Ironically, in pursuit of this fulfillment, physicians may overextend themselves outside of the workplace setting, which leads to exhaustion at work, perpetuating a dangerous cycle. Young EM physicians are chiefly at risk of this phenomenon as they have recently been encultured during medical school and residency to take on extracurricular activities. Young physicians also experience many competing priorities at the beginning of one's career: paying off debt, family pressures, trying to establish oneself as a clinician and/or academic, and suffering from imposter syndrome. It is sometimes tempting to feel that it is one's individual responsibility to continue to do more, otherwise who will? Instead, it is essential to recognize and break the cycle. As one EM physician writes, reflecting on his early career, "I would tell young me that no matter how important I think work is, I am really just another cog in the never-ending gears of the health care system" [6] . Taking control of one's personal agency and establishing wellness as a foundation on which to build a healthy career is long overdue. Consider pausing to think about whether another commitment, when it crosses one's path, is contributing to burn out or combating it. Simple steps such as debriefing difficult experiences with a trusted colleague, seeking out counsel from mentors about how they have managed burnout, and routinely checking in with others beyond a superficial level can be insightful and normalize the need for help. A silver lining of the pandemic is to bring global attention to the burnout crisis. All physicians need to be part of a change, for ourselves, and for our patients. Canadian emergency medicine physician burnout: a survey of Canadian emergency physicians during the second wave of the COVID-19 pandemic Beyond burned out. Harvard business review Six areas of worklife: a model of the organizational context of burnout Caring for their children: impacts of COVID-19 on parents Gender-based differences in physician payments within the fee-for-service system in Ontario: a retrospective, cross-sectional study Physician, heal thyself The authors would like to acknowledge the continued hard work of emergency healthcare workers across Canada and abroad. Conflicts of interest All authors confirm that they have no conflicts of interest to declare.