There’s always at least one thing, it seems, that grates on the emergency room staff. Maybe it’s the continual clang of alarms sounding on medical monitors. A cart that always gets in the way. Then there’s the harsh lighting.
In their own small — or perhaps not so small — way, these things can contribute to physician burnout, an ever-present concern that may be hitting crisis proportions in many hospitals in the age of COVID-19.
Now, Thomas Jefferson University and the University of the Arts have teamed up to study physician burnout in the emergency department, how the physical environment contributes to it, and what changes would mean a better workplace for everyone.
The project will involve medical professionals, virtual-reality experts, and architects from Jefferson’s Health Design Lab and the Emergency Medicine Department, the University of the Arts’ new Center for Immersive Media, and Philadelphia-based KieranTimberlake Architects.
The multidisciplinary research team includes coprincipal investigator Alan Price, director of the Center for Immersive Media; physicians Morgan Hutchinson and Jennifer White, leaders in clinical operations at Jefferson; and Billie Faircloth, an architect at KieranTimberlake.
We spoke recently with the principal physician investigator for the study, Matt Fields, an associate professor of emergency medicine at Jefferson.
Unfortunately, burnout in emergency medicine happens far too frequently. Nearly 60% of emergency physicians report experiencing burnout. Physicians who report burnout are two times more likely to leave their career within two years. At present rates of physician burnout, there may be a critical shortage of practicing physicians by 2025.
Burnout in the emergency room occurs for many reasons. It’s a place where providers and staff have to rapidly adapt to changing patient needs. One moment things may be calm, and the next the emergency department may be filled with patients in hallways, the air filled with the cacophony of alarms and the sounds of people in pain. Providers must rapidly establish rapport with patients who are scared, upset and need emotional support while simultaneously trying to diagnose and treat.
The advent of the electronic health record means that providers must do this while going between patients and computer screens desperately trying to document every action and ensure nothing is missed. The speed of the provider and the ability to keep seeing patients is constantly scrutinized through administrative scorecards and feedback, which can serve to make the individuals feel a sense of depersonalization and lack of dignity.
The downsides of physician burnout can result in negative effects on both patients and providers. Burnout can lead to lack of patience, lack of empathy, and poor clinical decision making. In the most severe cases, it can contribute to depression, addiction and even suicide.
The pandemic has magnified these issues and, in many cases, made them worse. The environment, which was already overburdened, has been unable to accommodate the needs of the victims of the pandemic. Waiting rooms are not designed for social distancing and there are inadequate rooms for isolation. The pandemic is emotionally exhausting for providers. Sometimes patients come in and they are dying and there’s really nothing you can do beyond making them comfortable. And they are people who shouldn’t be dying. They should be living another 10 years or more. That is pretty rough for a lot of people to see. As emergency providers, we are often caught between the patient in need of help and a system that is overburdened. We feel powerless, sad and afraid. At its best, the pandemic is disheartening. At its worst, it’s traumatic.
The link between the physical environment and workplace burnout is not new. It has been studied for years. People have correlated space, layout, lighting, sound, views of nature, placement of windows, and line of sight to burnout in many different types of work environments. It’s intuitive that everyone wants the corner office.
Emergency departments are not built with physician and staff wellness as a priority. They are built around function and efficiency to triage and rapidly treat patients. So they tend to be crowded, windowless, poorly lit, without areas for breaks, respite or views of nature.
Many people don’t see the emergency department environment as something they can change. But if there’s something we can fix, something that people are going to experience daily and constantly, it could affect everyone. If we can improve the built environment in a way that meaningfully reduces provider burnout, that’s a no-brainer.
I’m an emergency physician but I also work in the Health Design Lab, which is a unique entity at Jefferson. We seek to innovate and reimagine health care.
Previously, a colleague created “journey maps” of the department. They tracked how everyone moved through it: patients, providers, nurses. They created maps of lighting and sound. They had all these maps of how things occur and how it influenced things like physician-to-patient communication, nurse-to-patient communication, physician-to-nurse communication.
Then Alan Price showed me some of the work he has done with modeling disaster scenes that can be used in simulation environments. I wanted to bring the cutting-edge work he was doing into the emergency department. We thought it might be a great way to understand the environment and bring to the surface the pain points for people.
Alan uses a 360-degree camera to take pictures of the total environment. He maps that into the model. So, if you’re walking through it virtually, it looks the same as walking through the actual emergency department. The technology is amazing.
He has found that whenever people reexperience their environment in this model, they have insights. There are stories that people all of the sudden tell. It’s almost like going back to an instance that was really chaotic at the time, but being able to deconstruct it in a calm and controlled way.
The goal is to have our physicians experience this model virtually, and we guide them through it in a way that gets them to elicit where there are problems in the environment and what contributes to their stress and their sense of depersonalization. People tend to think they know what the physical environment is. But when you really get in and talk about it, when you magnify it, that’s when you really start to elicit the full picture.
Ideally, we will better understand where the true pain points are in the physical environment and identify ways to solve them. My hope is that, by exploring our space in such a novel way, we can start to reimagine spaces in ways we never considered.
Based on the information we get, we can identify areas for improvement that can actually be put into the virtual-reality model. Maybe it’s changing a layout, or lighting. Then we’ll be able to create a new virtual-reality model that people can experience. It can be prototyped immediately. You can’t just go change things in the chaotic environment of the emergency department. It can be incredibly expensive to do things just to test them out. But this technology allows us to quickly implement things and visualize it.
The changes we identify won’t necessarily mean demolishing walls or building new emergency departments. That being said, we also hope to help develop best practices for future builds that balance workplace efficiency with human dignity. Finally, we also hope that virtual modeling of health-care spaces can also help us better understand other variables in a complicated system and identify ways to improve patient care.