EM Employers Should Compete To Deliver Great Working Conditions
Surveys keep showing emergency medicine as the most burned-out & dissatisfied specialty. Transparent competition among employer groups over EM working conditions is needed.
Do you know whether emergency physician job satisfaction is higher at TeamHealth, SCP Health, Vituity, or US Acute Care Solutions? Do you know whether UNC or Duke Health does more to ensure emergency department worker safety? Do you know whether ApolloMD or HCA Healthcare staff a higher ratio of emergency physicians to non-physician providers in their EDs?
No, right?
Currently, there is no comprehensive resource to compare emergency clinician working conditions at different employers, EDs, and health systems. Of note, ACEP Open Book and the ED Accreditation Program are heading in the right direction. The lack of such a resource limits the incentive of employer groups to compete by improving clinician job satisfaction. As Donald Rumsfeld would say, comparative ED working conditions are “known unknowns.”
Glassdoor, a website where current and former employees anonymously review companies, is supposed to give large-volume survey-based information about employers. Below is a chart of average employee reviews of emergency medicine employers on Glassdoor, including only those with over 100 reviews that staff more than eight EDs.
A more detailed table of the Glassdoor reviews:
The Glassdoor data is interesting - for example, what’s gone wrong at Penn Highlands? - but is not meaningful to emergency clinicians for a few reasons:
Most Glassdoor reviews for these employers are not by emergency clinicians.
Only 42 of the 96 emergency medicine employers that staff more than eight EDs have over 100 reviews on Glassdoor. Many have a single-digit number of reviews.
The survey questions are too general to generate emergency medicine employer competition and improvement.
Why should emergency medicine employers compete over working conditions?
That emergency medicine is the least satisfied specialty has become a truism. The 2024 Medscape Physician Burnout & Depression Report showed that emergency physicians had a burnout rate ten percent higher than any other specialty. Similarly, the 2023 NCCPA Statistical Profile of Board Certified PAs by Specialty Report showed that PAs working in emergency medicine had the lowest job satisfaction and highest burnout rates.
We know that job dissatisfaction and burnout are related more to working conditions than to individual factors such as gender, age, or quantity of yoga. As Jennifer Robertson, MD, Kristen Nordenholz, MD and Rita Manfredi, MD write, “When you immerse a ‘well’ physician into a broken healthcare system, those individual positive wellbeing effects dissipate very quickly…
Our dysfunctional healthcare system has contributed to physician burnout and disengagement. This is not reparable with unlimited exercise, healthy nutrition, yoga programs, or creative wellness initiatives. Rather, the only solution is to fix the ailing healthcare system itself and create sustainable careers in medicine.”
The high rate of emergency clinician burnout is not an immutable law of nature. As recently as 2019 - the “before times” - emergency physicians had lower burnout rates than four other specialties in the annual Medscape survey.
Many aspects of EM working conditions are amenable to improvement. Let’s explore.
What working condition elements should employers compete over?
ACEP has released two documents this year that detail the components of excellent emergency medicine working conditions:
From Self to System: Being Well in Emergency Medicine (ACEP Wellness Guidebook, edited by Rita Manfredi, MD and Diann Krywko, MD)
Based on those publications, items that emergency medicine employers should be competing to deliver include:
Provision of adequate resources, tools, and equipment to meet patient needs.
Workplace safety and violence prevention for patients, families, and healthcare workers.
Safe staffing levels of all workers required for patient care.
Institutional leadership at the highest level to measure, report, and solve boarding and overcrowding.
Physician-led on-site teams to adequately supervise non-physician providers.
Sick call, paid time off/vacation, bereavement, substantial family, parental and medical leave, and elder care policies.
Adequate mental health early recognition strategies to identify moral distress, physician impairment, mental health issues, and physician suicidality.
Prioritization of diversity, equity, and inclusion.
Administrative task (eg: EHR charting) burden reduction.
Transparent and equitable compensation, promotion, due process policies.
Culture of teamwork, with expectation and enforcement of interdisciplinary respect, empathy, and collegiality.
Individualized schedule optimization.
What would transparent EM employer competition over working conditions look like?
It would look like the NFL Players’ Association survey, titled “NFL Team Report Card: For The Players, By The Players.”
JC Tretter, the NFLPA President, explains:
“For many years, our players brought up the idea of creating a ‘Free Agency Guide’ that would illuminate what the daily experience is for players and their families at each team. Last year, we created the first version of that guide, and it was a success on several levels: Players were more informed about how their workplace compared to others across the NFL; some clubs made immediate improvements based on the information we published; it gave our union a platform to advocate for raising workplace standards across the NFL…
As a reminder, what were our objectives?
Highlight positive clubs – It is really important to highlight the teams that are doing things well and where players are happy. It makes a big difference when players go to work feeling supported by their club, and we want our members to know which clubs make players feel that way based on the responses from some who were at that club during this past year.
Identify clubs that need improvement - For players who have been on one team and are looking to move elsewhere for whatever reason, there is currently no centralized resource to compare some players’ feelings and opinions about their working experiences from one team to another.
Highlight best practices and standards - Players who have only played on one team for their entire career may accept their team’s standards as the norm and often think conditions are the same everywhere else. Making more information and opinions available can not only inform players about best practices, but also hopefully help raise the standards across all clubs
What are our desired results?
Educate our membership – Our goal as a union is always to bring value to our members, and getting feedback from them is a classic union tool to get a better understanding of what membership feels about certain issues. We hope this can be a resource for all players.
Information will lead to action – No problem can be fixed until it is identified and acknowledged as a problem. We hope that teams will take this feedback and improve the facilities and players’ experiences, where needed.
Progress rarely comes as fast as you would like, but we are encouraged by how many teams made substantial improvements in the wake of last year’s results. Overall, players responded to those changes positively, which is reflected in many of the grades for those clubs.”
Per the New York Times, “Lloyd Howell, the NFLPA’s new executive director, spent much of last season traveling to meet with owners of all 32 teams and discuss working conditions. Some of those conversations centered on the findings of last year’s results. Howell said many owners are receptive to improving conditions.
‘This is not a shaming exercise,’ Howell said. ‘This is really an opportunity to recognize those teams and environments that are doing well — that are doing all the right things. This is players talking about their working conditions and what they like and what they’d like to see improved.’”
An example of NFL working conditions improvement, reported in The Ringer: “Congratulations to Jacksonville on removing the rats from its laundry hampers! The Jaguars had the biggest glow-up of any team, finishing fifth a year after coming in 28th in the inaugural survey. Jacksonville opened a new training facility last season, which has been well-received; the report card noted that ‘respondents gave strong scores for their locker room, training room and weight room,’ all of which are presumably rodent-free.”
Check out the Dallas Cowboys’ 2024 NFLPA report card below:
As the ACEP Well Workplace Policy says, “Although the individual has responsibility for personal wellness, the primary emphasis should be on how the organization impacts the wellbeing of healthcare workers.”
Transparent competition to deliver excellent emergency department working conditions would be a win-win-win for employers, clinicians, and patients.
Emergency Medicine Workforce Productions is sponsored by Ivy Clinicians - simplifying the emergency medicine job search through transparency.
Great article Leon. Is ACEP surveying its membership to obtain this information (like the NFL did)? Or do you think it needs to come from an independent third party?