The morning was crisp and still dark as I sat in my car in the hospital lot, summoning the will to open the door and leave for my shift in the emergency department.
Like many frontline providers in early 2021, I felt pancaked by the two pandemic surges — emotionally and morally. Not getting out of the car wasn’t an option. Responsibility to others demanded I get moving. My overnight colleagues were ready to jump into their beds and waiting patients expected to see a doctor.
When I returned home that evening, I opened my laptop and, without premeditation, crafted what turned out to be my letter of resignation. I wasn’t quitting medicine, I thought, just playing with the idea. But there were tears, and they were wet, and the sitting-in-the-car thoughts kept playing in my head.
But writing my resignation letter has had a surprising and paradoxical effect. What I assumed was my ticket out of medicine led me back in.
To be a veteran of emergency medicine — I’ve logged 30 years as an emergency physician — is to be a veteran of burnout and burning in. I shrugged at a recent Mayo Clinic Proceedings study showing how physician burnout was pushed to an all-time high at the height of the Omicron wave in late 2021 and early 2022. I don’t know what to do with data when it’s used to capture my mental state. Even well-done research on burnout feels inadequate as reflections of complex human experiences.
Knowing that I wasn’t alone didn’t offer any solace. A Medscape survey at that time reported that roughly 1 in 5 physicians were considering leaving their jobs.
For all the burnout studies and headlines about physicians leaving the field, there’s less attention on those of us searching for reasons to stay. I can’t say I can adequately explain this turn of events. To say goodbye is to shake hands with loss, and I recognized while writing the resignation letter the cherished parts of working in medicine that I’d leave behind.
My intention to walk away freed me from the tug of negativity. Research shows our tendency to register and think about negative stimuli more often, remember them more vividly, and factor them more heavily when making judgments. No longer consumed by the endless barriers to patient care or leaders tone-deaf to the struggles and the mental health consequences facing doctors and nurses, I found my attention liberated. Being psychologically prepared to walk away also restored a sense of control. I strode into each shift in search of the answer to one question: Why should I come back tomorrow?
To be honest, part of that answer had nothing to do with medicine but instead with a mortgage, bills, college tuition, and a 401(k) that looked more promising if I didn’t touch it — though I couldn’t count on these obligations to push me out of the car. If anything, they added to my panic.
“To look is an act of choice,” writer John Berger said, and my attention was now receptive to potent moments I had previously overlooked or didn’t register as powerful.
A laugh with a patient. Supporting a young man guilt-ridden about an opioid relapse. Securing insulin needles for a patient with diabetes lost in the system. Talking to a distrustful older woman about vaccinations. Sitting with patients and their families to explain a CT scan showing cancer has returned, or giving the thumbs up that the imaging is clear. Exchanging snarky comments with nurses and staff members I respect dearly.
One physician’s stubborn pursuit for meaning with one foot out the door doesn’t make a neat sound bite. But the reality of medicine is messy. It’s a house constructed from seeming contradictions. These experiences don’t lend themselves to clean narrative arcs or research outcomes. I believe what makes them challenging to figure out or measure is what makes them worthy of our most vigilant attention.
For example, the epidemic burnout plaguing physicians during the pandemic coincided with record spikes in applications to medical schools for the class of 2025. Experts attributed this trend to several factors, from physicians being lauded as heroes early in the pandemic to the role of physicians as leaders in social justice and health equity and the Fauci effect.
But the problems hadn’t been a secret either. Hordes of health care workers were pushed to the breaking point, turning healers into casualties. Patients treated in hallways because treatment rooms were full. Making crisis standards of care decisions that kept us awake at night. And health care institutions responding with salary cuts and wellness emails.
I’m inspired that many brilliant and passionate young applicants are pounding on the doors to get into medicine. When busy plotting an escape, it’s easy to forget I belong to a special house where meaningful work is done.
During the Delta wave in mid-2021, a nursing assistant asked if I would choose medicine if given a chance to do it over again. That’s a tricky question, I said. I’d be a different person if I hadn’t gone into medicine, specifically emergency medicine. The challenges that hammered me, that tested my clinical, emotional, and moral limits, also shaped the person I’ve become, how I see the world, and my place in it. Obstacles forced me to grow. I thought about these co-existing tensions when sitting in my car in the hospital lot — confused about whether I was traveling the dark side of another cycle in my never-ending maturation or fanning a dying flame.
I recognize the dire economic pressures facing hospitals and hospital systems and the severe pressures behind “no margin, no mission.” But without a mission that prioritizes patients and nourishes the hearts of doctors, nurses, and staff, then medicine becomes a cold place. And should health care workers be tested by another pandemic wave as winter approaches, or if flu cases surge as early data suggest — medicine might become emptier, too.
Resignation is an interesting word. It means more than retiring or giving up. It has etymological roots in terms for balance or “canceling the claim it represents.” When I told a colleague that every shift could be my last but I’m not going anywhere right now, I meant I was monitoring the ledgers, trying to find balance in this bureaucratic, profit-driven beast that wears the mask of a moral profession.
In the months after writing my resignation letter, my metaphorical glass didn’t miraculously become half-full, but I started checking the integrity of the glass more often. At times, being a half-filled glass was enough.
Despite claims to the contrary, the pandemic is not over. Conditions are now worse than ever for many of us working in emergency departments. We face sicker patients with extra layers of needs, only now there are fewer workers and more crowding. Patients face unconscionable wait times. The ecosystem of caring is losing oxygen, and it’s unsustainable without systemic changes. In the meantime, health care workers with their feet on the ground are desperate for pockets of air.
Now, more than 20 months after writing my resignation letter, I’m still asking each shift to show me why I should come back tomorrow. Surprisingly, such moments are often staring me in the face, which is not to say they’re necessarily easy to see.
During an overnight shift marked by intense overcrowding, an emergency medicine resident told me about a young man who had been in a minor motor vehicle crash. As he examined the man in a space strewn with waiting patients, he learned the man also suffered from depression and was interested in getting help for it. “We can do that,” he said, typing in resources, excited that he was doing something important for this patient. “This is why I went into medicine,” he said, during a night riddled with frustration for patients and staff.
Here’s why I believe my resignation turned complicated. I saw that burnout and idealism were living side by side in my mind. Squaring these accounts is challenging because meaning and distress are often entwined, making each difficult, if not impossible, to disentangle and measure.
Take the intoxicated crew of emergency department regulars hooting and hollering outside the room where an older man circled in and out of cardiac arrest. We had no other place for them to sober up due to crowding problems. When the man took his final breath, he was surrounded by teary family but also serenaded by men with substance use problems and unstable housing for whom the emergency department might be the closest semblance of home.
After calling the time of death, the docs, nurses, and staff stood with the family, our heads bowed in silence, paying our respects, privileged to be on this bridge where life ends and lives change forever. “This is why we do what we do,” I thought.
Then another round of catcalls from outside the room rattled the solemn moment. The team shared looks of embarrassment, even shame. And we shrugged. What can we do? But I was also thinking: This is precisely what we do and why we do it. Here were the reasons we might sit in the car, but also why we finally get out.
Jay Baruch is an emergency physician, professor of emergency medicine, and director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University; and author of “Tornado of Life: Constraints and Creativity in the ER” (MIT Press, August 2022).
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