A Briefing on Professional Sustainability and Performance in Emergency Medicine
Executive Summary
The "ACEM 1000 hour exam" is the nickname for the rigorous preparation needed to pass the Australasian College for Emergency Medicine (ACEM) Fellowship exams. It refers to the substantial time commitment & high-quality study required to be successful. The Royal College of Emergency Medicine Exams are no different. Therefore, before you can contemplate preparing for fellowship exams, portfolio pathway or a career in Emergency Medicine (EM) you need to look after yourself & your family physically, mentally, emotionally and financially. This document synthesizes key strategies and insights for Emergency Medicine (EM) professionals to enhance on-shift performance, mitigate psychological challenges, and build sustainable, fulfilling careers. The demanding nature of EM necessitates a proactive, multi-faceted approach to wellbeing, which is a shared responsibility between individual clinicians and the healthcare system. Critical takeaways include the need for structured strategies to manage the predictable chaos of an ED shift, the implementation of deliberate boundary rituals to separate work and home life, and a deeper understanding of psychological phenomena such as moral injury and compassion fatigue. Systemic support, a positive organisational culture, and robust long-term career planning are equally crucial. By integrating these evidence-based tools and frameworks, clinicians can improve their daily professional experience, reduce burnout, and ensure career longevity.
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1. Mastering On-Shift Dynamics
Effective management of the high-stress, unpredictable ED environment requires deliberate preparation, real-time regulation techniques, and a disciplined approach to core tasks. Success is not a matter of willpower alone but of implementing reliable systems and mental frameworks (1).
1.1 Preparing for the Shift: The "Pregame" Ritual
Like other elite performers, physicians benefit from pre-shift rituals to achieve peak performance and increase professional joy. Mindset is a key controllable factor (2). Effective pre-shift preparation can involve a sequence of physical, emotional, and mental activities (2).
Examples of Pre-Shift Rituals:
- Mental Preparation: Utilising tools like the 5 Minute Journal (2), practicing mindfulness (2), or engaging in mental visualisation of challenging scenarios (2, 3).
- Setting Intentions: Before a shift, setting a clear intention, such as "I am open to accepting gratitude from my patients," can reframe perspective and build a foundation for joy (4, 5).
- Physical Preparation: Engaging in exercise like biking or walking to work (2), or ensuring adequate nutrition and hydration (6).
- Environmental Preparation: Arriving early to connect with the team (2), or isolating from social media and email for 1-2 hours prior to the shift to reduce cognitive load (2).
1.2 Navigating Mid-Shift Overwhelm
The middle part of an ED shift is consistently the most demanding, characterised by waning energy and maximum task saturation (1). Relying on brute force to "muscle through" is an unsustainable long-term strategy (1). A structured approach is essential.
The "Kraken" Action Plan
Dr. Brit Long conceptualises the feeling of mid-shift overwhelm as "The Kraken." The key is to recognise its initial stirrings and implement an action plan before it becomes a raging beast (1). An example of an ordered, five-priority plan is as follows:
- Critical Patients: Stabilise and manage any critical or potentially critical patients. This is the immutable first priority.
- New Patients: Assess new patients and initiate their workups. A limit can be set on the number of patients or time allotted before moving to the next priority. Critical Action: Complete an H&P after each initial encounter.
- Results and Delegation: Batch review results to identify actionable items and potential dispositions. Critical Action: Huddle with the team or charge nurse to run the board and delegate tasks.
- Dispositions: Focus on dispositioning 2-3 patients (admit, discharge, transfer). Critical Action: Finish the chart immediately upon disposition to free up mental space and close the loop.
- Rate-Limiting Steps: Complete procedures or other tasks that are bottlenecks for patient flow.
This sequence should be re-triaged repeatedly until the overwhelm subsides (1). Variations exist, such as prioritising dispositions over new patient intake, and the plan should be adapted to individual workflow preferences (1).
1.3 Real-Time Stress Regulation: The BTSF Protocol
For moments of acute stress, such as during a difficult resuscitation, the "Beat the Stress Fool" (BTSF) protocol offers a method for rapid physiological downregulation (7).
- Breathe: Exhale for twice as long as the inhale (e.g., inhale for 4, exhale for 8) through the nose to activate the parasympathetic nervous system.
- Talk: Use positive self-talk or acceptance-based noting (e.g., "I notice I am having the thought that this is overwhelming").
- See: Use mental rehearsal to visualise not just the steps of a procedure, but its successful outcome.
- Focus: Anchor your mindset with a pre-conditioned trigger word (e.g., "smooth") to summon a state of flow.
For events of extreme emotional intensity where this may not be sufficient, a technique of gratitude flooding—actively focusing on something or someone for which you are deeply grateful—can act as a buffer against absorbing secondary trauma (7).
1.4 Shift Endurance Strategies
Long-term career sustainability requires attention to self-care during shifts. The adage that "the patient always comes first" can lead to neglected personal needs, which ultimately results in suboptimal care (6). Three core strategies enhance shift endurance:
Strategy | Description |
Nutrition | Plan and pack food and hydration for the entire shift, aiming to refuel every 2-3 hours. Protect this time as you would time for a procedure. Avoid relying on stimulants like caffeine, which can have effects lasting up to 12 hours and disrupt recovery (6, 8). |
Tension & Relaxation | Be deliberate about upregulating focus for critical tasks and downregulating during interstitial moments. Regularly perform a "tension check-in" and consciously release physical tension in the jaw, shoulders, or back using elongated exhales (6). |
Intention | Setting a clear intention before a shift (e.g., "I will bring curiosity to each encounter") expands your sphere of control and sense of agency, which creates a foundation for experiencing joy at work (6). |
1.5 The Importance of Documentation
Timely documentation should be viewed as "a procedure you do for YOU" (1). Deferring charts is a seductive but slippery slope that leads to a "pit of despair" at the end of the shift. Completing notes in real-time frees mental bandwidth, allows for a final check of the clinical encounter, and is critical for getting home on time. This approach requires a robust library of templates and is not feasible when relying on free-texting (1).
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2. Recovering and Disconnecting Post-Shift
The ability to process the day's events and disengage from work is one of the strongest predictors of reduced burnout (9). This requires deliberate rituals and frameworks to avoid carrying mental residue home.
2.1 A Framework for Recovering from a Bad Shift
Dr. Sara Gray proposes a four-step framework (APSS) for coping with a difficult shift or a tough case (10). Having a pre-defined plan makes recovery smoother (10, 11).
- Step 0: Awareness: Recognise that you are in a difficult situation and need to activate your recovery framework. Acknowledge the event and allow yourself to feel the associated emotions.
- Step 1: Processing: Talk about the event with a supportive person, such as a "failure friend"—someone who listens without judgment and does not try to provide solutions.
- Step 2: Self-Care: Practice self-compassion. Engage in activities that bring joy and support recovery.
- Step 3: Silver Lining: Find the lesson from the experience and use it for growth. This helps move toward acceptance.
It is crucial to forgive yourself after a bad outcome, as incessant suffering will not serve future patients (11).
2.2 Boundary Rituals: Leaving Work at Work
Boundary rituals are deliberate actions designed to process the day and create a clear transition between professional and personal life (9).
Effective Boundary Rituals:
- The Guesthouse Approach: Based on Rumi's poem, this involves viewing difficult emotions as temporary "guests" (12). Acknowledge them, name them, and then gently release them rather than internalising them (9).
- Physical Separation: Simple acts like changing out of scrubs before leaving the hospital create a powerful symbolic and mental separation between work and home (9).
- Gratitude and Reflection: Before leaving, take a moment of gratitude toward colleagues. During the commute, use silence and deep breathing to focus on positive moments from the day, rather than fixating on negative ones (9, 4).
- Cutting Strings Visualisation: For a particularly heavy case, use a visualisation technique. After reaching a neutral state (e.g., through deep breathing), bring the patient to mind with compassion, wish them well, and then imagine cutting the emotional tie, allowing them to drift away (13).
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3. Understanding and Mitigating Psychological Challenges
The pressures of EM can lead to specific forms of psychological distress. Recognising these conditions and implementing both individual and systemic solutions is paramount for clinician wellbeing.
3.1 Burnout: A Systemic Issue
Burnout is frequently driven by factors in the external environment, such as administrative burden or lack of autonomy, rather than individual weakness (14, 15). A study of two hospitalist groups during the COVID-19 pandemic highlighted a successful systemic intervention that reduced burnout by nearly half and doubled job satisfaction compared to a control group (15). The intervention's mandate was threefold: Listen to clinicians, Identify the pain points, and find Agency by focusing on areas within the group's control (15). This was facilitated by regular, psychologically safe debriefing sessions (15).
3.2 Moral Injury: The Crossroads of Conscience
Moral injury is the psychological distress caused by actions or inactions that violate one's deeply held moral or ethical code (16). It is distinct from burnout and is characterised by feelings of guilt, shame, betrayal, and inadequacy (16).
- Examples in EM: Bad patient outcomes, difficult triage decisions, resource allocation conflicts, or providing care perceived as futile or objectionable (16).
- Individual Mitigation:
- Acknowledge the injury, even on shift, to create a psychologically safe space (16).
- Practice self-compassion (9, 16).
- Focus on agency—what is within your control (16).
- Use a moral injury journal to process events (16).
- Systemic Mitigation:
- Provide organisational support and prioritise clinician wellbeing (16, 17).
- Ensure transparent decision-making that bridges clinicians and administrators (16).
- Pursue systemic change through advocacy (9).
3.3 Compassion Fatigue: The Cost of Caring
Compassion fatigue is profound emotional and physical exhaustion stemming from exposure to the suffering of others, also known as "secondary traumatic stress" (14). While it shares symptoms with burnout (e.g., depersonalization, cynicism), it is distinct because it is directly related to the act of caring and empathy (14).
The antidote to compassion fatigue is cultivating compassion satisfaction: the pleasure derived from helping others. This involves introspectively asking what parts of the job are nourishing and finding ways to incorporate more of those activities into your practice (14).
3.4 Supporting Colleagues in Distress
Clinicians are trained to conceal weakness, making it difficult to detect when a colleague is struggling (15).
- Identification: Warning signs can be subtle. Trust your instinct when something seems off (15).
- Approach: Express genuine care and curiosity (e.g., "I just noticed something doesn’t seem quite right. I care about you. I just wanna check in."). Your job is not to fix them but to offer support and leave the door open (15).
- Asking Hard Questions: Directly asking about mental wellbeing, including suicidal thoughts, can normalise the experience and provide an avenue for someone to seek help (15).
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4. Fostering a Healthy Professional Culture
A healthy culture is foundational to professional wellbeing and high-quality patient care. It is defined by "the way we do things around here" and encourages discretionary effort beyond mere compliance (18).
4.1 The Seven Virtues of a Healthy Culture
Organisational culture can be built upon seven classic virtues, which must be modelled by leaders (18):
- Trust: Confidence that team members will look out for each other.
- Compassion: Moving toward the pain of another to offer help.
- Courage: Doing the "hard right rather than the easy wrong," including having difficult conversations.
- Justice: Ensuring all team members are treated equitably.
- Wisdom: Using foresight and good judgment for long-term benefit.
- Temperance: Remembering that "calm is contagious" and avoiding anger.
- Hope: Believing in and communicating a vision for a better future.
4.2 The Impact of Cultural Context in Patient Care
Frustrating patient encounters can be a source of burnout. Understanding the patient's cultural context can transform these interactions into opportunities for connection (19).
- Cultural Safety vs. Cultural Competence: The goal is not to become an expert in every culture (competence) but to practice cultural safety. This originated with the Maori population in New Zealand and focuses on humility, self-awareness, and recognising power differentials in healthcare (19).
- Leading with Curiosity: Ask patients respectfully about their background to bridge gaps in understanding. This demonstrates effort and builds trust (19).
- Language of Non-Compliance: Avoid blaming terms like "non-compliant." Instead, non-judgmentally document the specific reason a patient provides for not following medical advice (e.g., financial constraints, fear), which keeps the focus on addressing root causes (19).
4.3 Civility and Anti-Bullying
Rudeness and bullying significantly decrease job satisfaction, impair performance, and compromise patient safety (8). Witnesses to rudeness experience a 20% reduction in performance (8). It is essential to remember the mantra, "the standard you walk past is the standard you accept," and actively foster a culture of respect (8).
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5. Career Longevity and Professional Development
A sustainable career in EM requires proactive planning, periodic recalibration, and attention to professional and financial development.
5.1 A Framework for Career Recalibration
To assess your career satisfaction, ask the central question: "How do you feel about the core of your work?" (20). If the core is still engaging, but the surrounding "smoke" (bureaucracy, metrics) is the problem, adjustments can be made. If the core itself no longer provides fulfilment, a larger change may be needed (20).
- Micro-Recalibration (Tune-up): Small adjustments within your current role (e.g., improving workflow, setting boundaries, changing shift numbers) (21).
- Macro-Recalibration (Remodel): More significant changes within medicine (e.g., changing practice setting, taking on a new leadership or academic role) (21).
- Mega-Recalibration (Rebuild): A complete career overhaul, stepping away from clinical medicine (21).
5.2 The "Portfolio" Career and the N+1 Concept
Sustaining a long-term clinical career is challenging. Developing a "portfolio" job plan or a "Clinical Medicine + 1" can enhance satisfaction and prevent burnout (22, 23). This involves incorporating an additional pursuit alongside clinical practice, such as:
- Education (e.g., College Tutor, Director of Medical Education) (22)
- Research (22)
- Coaching and Mentoring (22)
- Leadership (e.g., Clinical Director) (22)
- A side business or hobby (21)
A true "+1" is an activity that recharges rather than drains, aligns with your values, and does not overwhelm you (21).
5.3 Returning to Practice
A return to clinical practice in EM after an absence of greater than three months should be Supported, Safe, and Sustainable (22). This requires a structured process.
- Pre-Return Meeting: Meet with a supervisor or mentor 8-12 weeks prior to returning to assess needs and create an individualised plan.
- Adjustments: Consider a period of increased SPA time or supernumerary shifts.
- Skills Update: Utilise return-to-practice courses and life support updates (22).
5.4 Financial Health for a Sustainable Career
Financial security provides the freedom and flexibility to make career choices that prioritise wellbeing (24). Key principles include:
- Financial PDP: Create a financial personal development plan with clear, written goals.
- Tax Efficiency: Ensure you are claiming all eligible tax rebates for professional expenses (e.g., GMC fees, Royal College fees, exams). Check your tax code is correct, especially after changing jobs (24).
- Protection: Build an emergency fund of at least 3 months' essential outgoings and secure appropriate income protection and life insurance (24).
- NHS Pension: The NHS pension is a valuable asset. Check your Total Rewards Statement (TRS) annually for accuracy (24).
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6. The Shared Responsibility for Wellbeing
The "Wellbeing Charter for Doctors" defines wellbeing as encompassing physical, mental, emotional, and cultural health, cultivated through relationships based on kindness and compassion (25). Responsibility for this is shared across the system.
Group | Key Responsibilities |
Doctors | Practise self-care (sleep, exercise, nutrition, boundaries). Have a GP. Foster a personal support network. Show compassion to self and colleagues (25). |
Colleagues | Be aware of and sensitive to the professional and personal needs of colleagues. Be prepared to support each other (25). |
Managers & Leaders | Foster wellbeing as an obligation. Proactively discuss wellbeing in meetings. Ensure a safe environment for raising concerns. Model the seven virtues of a healthy culture (18, 25). |
Hospitals & Jurisdictions | Provide a safe, healthy, open, and inclusive working environment. Ensure reasonable working hours, flexible options, and cover for sick leave. Place doctor wellbeing at the core of healthcare strategy (25). |
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MEM:EM Podcast
Useful resources
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