CONCEPTS
depression, emergencyphysiciaas; stress, emergeneyphysicians
A
Study of Occupational Stress and Depression Among Emergency Physicians From the American College of
Michael E Gallery, PhD*
Emergency Physicians, Dallas,
Theodore W Whitley, PhDt
Texas;* Department of Emergerwy Medicine, East Carolina University
Leah K Klonis, MA* Robert K Anzinger, MD, FACEP*
School of Medicine, Greenville, North Caroiina;t Univers~yof Texas SouthwesternMedical Center, Dallas, Texas;¢ and Battelle Medical TechnologyAssessment and Policy Research Center, Washington, DC.§ Receivedfor publication July 1, 1991. Acceptedfor publication September 8, 1991.
Dennis A Revicki, PhD§
Objective: To determine the level of stress and depression among emergency physicians and whether these variables were related to the emergency physician's decision to leave the specialty. Study design and type of participants: The study involved a random sample of 1,350 emergency physicians who received a questionnaire containing scales on depression and occupational stress as well as questions about their future plans for remaining in the specialty. Results: Seven hundred sixty-three usable surveys (56.5%) were returned. Mean scores for the locus of control, Work-Related Strain Inventory, and the Center for Epidemiologic Studies - Depression Scale (CES-D) were within normal ranges. However, a disproportionate number, ie, more than 2.5% of the sample, scored more than two standard deviations from the mean. With the exception of the work satisfaction scale, there were no significant differences between the scores of fellows and nonfellows on measures of locus of control, stress, or depression. Of the population, 12.4% indicated that they were somewhat likely to very likely to leave the clinical practice of emergency medicine within the next year; 26.7% planned on leaving in the next five years, and less than half (42.9%) planned on seeing patients ten years from now. Older men, women, and those with high levels of stress and low job satisfaction were more likely to leave the specialty over the next ten years. Conclusion: While the vast majority of emergency physicians reported normal levels of stress, a disproportionate number reported high levels of stress and depression and plan on leaving the specialty of emergency medicine. The number of individuals planning to leave appeared to be greater than the number that will be replaced through residency training. [Gallery ME, Whitley TW, Klonis LK, Anzinger RK, Revicki DA: A study of occupational stress and depression among emergency physicians. Ann Emerg Med January 1992;21:58-64.]
70/59
ANNALS OF EMERGENCY MEDICINE 21:1 JANUARY 1992
STRESS & D E P R E S S I O N
Gallery et al
INTRODUCTION
MATERIALS
Occupational stress and "burnout" have been the focus of concern in hundreds of articles over the past two deeades. While many of these studies have focused on the medical community, little has been written about levels of stress experienced by emergency physicians. Although Anwar, in her longitudinal study of residency-trained emergency physicians, did not specifically address stress, she did attempt to measure "career commitment" and the degree to which emergency physicians planned to continue practicing the speciahy. Her data indicated that of the cohort of residents graduating between 1973 and 1979 only 5% had left the field of emergency medicine. Burnout or attrition did not emerge as an issue in that early and landmark study. 1 While nmnerous studies have investigated the level of stress among residents in various specialties,2-9 including emergency medicine, 1° few studies have focused on practitioners of emergency medicine. Keller and Koenig recently conducted a cross-sectional study of 77 emergency physicians in the greater Los Angeles area. They noted that "60% of the physicians reported medium to high emotional exhaustion and 78% medium to high depersonalization. ''11
The population for this study was emergency physicians who were members of the American College of Emergency Physicians
These studies notwithstanding, little has been done to document the degree to which emergency physicians experience stress or, moreover, the degree to which such stress may lead to a decision to leave the practice of emergency medicine. As Keller et al wrote, "Concern has been expressed that the daily stresses and demands of this speeiahy will prevent many young practitioners from functioning as practicing emergency physicians when they are in their 40s and 50s. ''11 Given the current shortage of emergency physicians, as identified by the American College of Emergency Physicians, 12 accurate estimates of the degree of attrition take on added importance in being able to properly assess future manpower needs. The present study was designed to address the following questions. What is the level of work-related stress perceived by emergency physicians? What is the level of depression reported by emergency physicians? Do emergency physicians have an internal or external locus of control, ie, do they perceive their lives as being controlled by internal or external events? How long do emergency physicians plan to continue to practice emergency medicine? What variables (eg, measures of stress, depression), if any, are related to an emergency physician's decision to leave the specialty?
JANUARY 1992
21:1 ANNALSOF EMER6ENCY MEDI01NE
AND
METHODS
during the fall of 1989. A stratified random sample of 1,350 members was used for the study. The variable of fellowship in the College (ie, board certification and an active member of ACEP for three years or more) was used as a stratifying variable. Of the 1,350 emergency physicians randomly selected for the study, 350 (26%) were fellows. The questionnaire compiled for the survey was based on Levenson's 13 revision of Rotter's I-E scale to measure locus of control (LOC), a construct referring to the extent to which individuals believe they themselves, other individuals, or chance control their personal destinies. Respondents use a six-point Likert scale to indicate their agreement or disagreement with 21 statements such as "When I make plans, I am almost certain to make them work." Three subscale scores - - Internal, Chance, and Powerful Others - - are obtained by summing responses to the seven statements that appear in each subscale. Internal consistency reliability coefficients (Cronbach's (x) for this sample were .62, .78, and .82 for the Internal, Chance, and Powerful Others snbscales, respectively. The work satisfaction and organizational commitment scale consists of 12 statements measuring one's degree of satisfaction with aspects of work. Adapted from an inventory used by GrayTort and Anderson, a¢ respondents use a four-point Likert scale to express their satisfaction or dissatisfaction with aspects of the work environment such as participation in decision-making, scheduling, and benefits. Cronbach's c~ for this sample was .87. The Center for Epidemiologic Studies - Depression Scale (CES-D) is designed to assess depression in the general population. 15 Developed by the National Institutes of Mental Health, the CES-D has a demonstrated capacity to identify clinically abnormal populations. 13 Respondents use a four-point Likert scale ranging from "rarely, never" (less than once a day) to "often" (at least once for five to seven days) to indicate the frequency with which they experienced each of 20 symptoms of depression such as "people were unfriendly" or "I felt sad" during the last week. Cronbach's ot for this sample was .88. The Work-Related Strain Inventory (WRSI) 16 was used to assess work-related stress. Based on a conceptualization of strain as the physiological, psychological, and behavioral manifestations of stress, the 18 statements included in the WRSI ask respondents to characterize their personal productivity, relationships with coworkers, and capacity to disregard work-related matters when they are away from work. Respondents l~
5 9/ 7 1
STRESS
& DEPRESSION
Gallery et al
use four-point Likert scales anchored by "Does not apply to me" to indicate low stress and "Does apply to me" to indicate high stress from a particular source. Cronbach's ~xfor this sample was .88; evidence of the validity of the WRS1 is available) 6 Respondents also were asked to provide demographic information (eg, age, gender, practice location) and to answer questions regarding their future plans relative to the practice of emergency medicine (eg, "How likely are you to leave the practice of emergency medicine next year?" "In the next five years?"). The questionnaire was field-tested with six emergency physicians to determine the clarity of the questions and whether the amount of time required to complete the questionnaire was reasonable..As a result of the field-test, some of the demographic questions and questions about future plans were revised. Questionnaires were mailed with a cover letter and a consent form to each member of the sample in the spring of 1989. Nonrespondents received a second mailing during the summer of that year. In addition to descriptive statistics, Z was calculated to compare the proportion of fellows in the group of respondents with the proportion in the sample drawn for the survey, and t-tests for independent means were calculated to compare the scores of fellows and nonfellows on the affective scales. An a level of .05 was set as the criterion for determining the statistical significance of Z, and Bonferroni's procedure was used to establish an ~x of .008 as the criterion for determining the statistical significance of the t values. Finally, three logistic regression analyses were performed to identify variables that differentiated respondents on the basis of whether they were likely to leave emergency medicine in the next year; whether they were likely to leave emergency medicine in
the next five years; and whether they anticipated practicing clinical emergency medicine for six or more years in the future. Age, gender, marital status (dichotomized into married and not married), the three locus of control subscales (internal, chance, and powerful others), WRSI scores, CES-D scores, and scores on the work satisfaction scale were the independent variables. An level of .05 was used to determine the significance of the logistic regression models and the predictor variables in each model, and the logistic regression coefficients were used to calculate odds ratios.
RESULTS A total of 763 usable surveys with consent forms were returned, for a return rate of 56.5%. Of these, 516 (67.6%) were nonfellows and 247 (32.4%) were fellows. Table 1 shows the demographic composition of the samples. The vast majority were Caucasian (89.4%), married (79.7%), and male (86.6%). Practice location was evenly distributed throughout the continental United States @able 2). Table 3 presents the results for the locus of control scale, the WRSI, the CES-D, and the work satisfaction scale. In a normal distribution, one would expect 2.5% of the population to score two standard deviations above the mean. In each of the three LOC subscales, the respondent's scores were disproportionately skewed. I1~
Table 2.
Practice location Table I.
Survey sample Race Afro-American American Indian Caucasian Latin American Asian-American Other Marital Status Divorced Married Separated Single Widowed Gender Femare Male
72/60 |
N
%
17 3 681 13 37 11
2,2 0.4 89.4 1.7 4.9 1.4
51 609 11 90 3
8.7 79.7 1.4 11.8 0.4
102 662
13.4 86,6
Location East Midwest South/Southwest Mountain/Pacific 0if-continent
N 215
% 28.3
179
23.6
182 171 12
24.0 22.5 1.6
Table 3. Re.~ults qf .~cales
Scale
N
X
SD
Individual Belief and Behaviors -Internal - Chance Others WRSI (stress) CES-D
Cronbach's
763 763 763 759 762
15.19 31.48 30.33 32.03 9.16
3.93 5.34 6.06 8.98 8.23
.67 .78 .82 .88 .88
Work satisfaction
760
35.85
6.89
.87
ANNALS OF EMERGENCY MEDICINE 2 1 : 1 ,JANUARY 1992
STRESS & DEPRESSION Gallery et al
Table 3 also reveals that emergency physicians overall report a high work satisfaction score. However, once again a disproportionate number scored two standard deviations below the mean. A score of 16 or greater on the CES-D is an indicator of depressive symptomatology. Despite an average score of 9.16, 19.3% scored above 16. Also, while the mean score on the WRSI was 32.03, 22.7% had scores equal to or greater than 38, indicating high levels of stress.
mergency ambulatory care was the choice of 20.58%. Only 1.44% reported they would enter research; 9.83% selected academic emergency medicine. All three logistic regression models were statistically significant (Table 7). Examination of the statistically significant independent variables revealed consistencies among the three models. For example, older respondents were significantly more likely to indicate that they might leave the specialty during the
Table 4 compares the scores of fellows and nonfellows on the measures of LOC, stress, depression, and work satisfaction. With the exception of work satisfaction, t-tests revealed no statistically significant differences (P < .05) in any of these scales. Although statistically significant, the difference between mean scores on the work satisfaction scale did not appear to have any practical significance. Table 5 displays data concerning future plans. When asked if they had ever considered leaving the specialty, 55.8% of the respondents indicated that they had. The next question reveals how active those thoughts are. Of the respondents, 12.4% indicated they are somewhat likely to very likely to leave the clinical practice of emergency medicine within the next year. That number increases to 26.7% in the next five years. Less than half (42.9%) plan on seeing patients ten years from now. Respondents also were asked "If you have thought about leaving clinical emergency medicine, what are you thinking of doing in its place?" They could select more than one option. The most frequently selected option (Table 6) was to leave medicine entirely and pursue another career (31.85%). Practicing none-
next year or within the next five years, and they were significantly less likely to indicate that they would be practicing clinical emergency medicine seven or more years in the future. Similarly, respondents who perceived higher levels of work-related stress were more likely to report plans to leave emergency medicine in one year or five years and were less likely to report that they expected to remain in clinical practice seven or more years into the future. Although satisfaction with work did not have a significant impaet on plans to leave emergency medicine during the next year, respondents who were more satisfied with their work were less likely to report plans to leave the specialty in Table 5. Future plans
Question Have you considered leaving the specialty of emergency medicine?
Response Yes No
N 425 336
% 55.8 44.2
Are you currently thinking of leaving clinical emergency medicine (seeing patients)?
Yes No
200 555
26.5 73.5
How likely are you to leave emergency medicine in the next year?
Very likely Somewhat likely Probably not Not at all
44 50 195 469
5.8 6.6 25.7 61.9
How likely are you to leave emergency medicine in the next five years?
Very likely Somewhat likely Probably net Not at all
75 127 284 272
9.9 16.8 37.5 35.9
How many more years do you anticipate practicing clinical emergency medicine (seeing patients)?
0-1 1-3 4-6 7-10 >10
29 77 119 205 323
3.9 10.2 15.8 27.2 42.9
Table 4. Comparison of fellows and nonfellows on scales
Scale IB8 Scale IBB-Internal Fellow Nonfellow IBB-Chance Fellow Nonfellow IBB-Others Fellow Nonfellew WRSI (Stress) Fellow Nonfellow CES-D Fellow Nenfellow Work Satisfaction Fellow Nenfellow
JANUARY1992
21:1
N
X
SD
T
P
247 516
14.79 15.38
3.7 4.02
1.946
.0519
247 516
31.64 31.40
5,11 5,46
0.582
0.581
247 516
30.75 30.13
6.04 6.05
1.320
0.187
247 512
31.74 32.18
8.72 9.11
0.630
0.528
246 516
9.18 9.88
7.75 8.44
1.096
0.273
246 514
37.21 35.20
6.62 6.93
3.80
0.0002
ANNALS OF EMERGENCY MEDIC1NE
Table 6. Where those who leave clinical emergency medicine plan to go
Source To academic emergency medicine To emergency medicine administration To emergency medicine research To nenambulatory care To different specialty To another career
N 75 114 11 157 113 243
% 9.83 14.94 1.44 20.58 14.81 31.85
61/73 |
STRESS & DEPRESSION
Gallery et al
five years and nmre likely to indicate that they would be involved in clinical practice seven or more years in the future. With respect to gender and marital status, women respondents were less likely to indicate plans to leave the specialty during the next year, and married respondents were less likely to report plans to leave the specialty in five years and more likely to indicate that they planned to be practicing clinically seven or more years in the futm'e. With the exception of the one odds ratio indicating that women were approximately 2.5 times less likely to plan to leave emergency medicine during the next year, none of the odds ratios were especially dramatic.
DISCUSSION The results of this study are consistent with many of the findings of previous investigators. For example, these data indicate that women report higher levels of stress and depression than men. This finding is consistent with those reported by Whitley et al in their study of enmrgeney medicine residents in training. 1° It has been noted in the literature that women experience more pressure in their social lives and often experience role conflict trying to balance the demands of a career with those demands placed on them in managing a home, where they often must carry an unequal burden of the workload. 17'1a It has also been postulated that female physicians may be negatively affected by the small number of role models available within medicine. 19 In addition to normal professional stresses women share with their male counterparts, they also are often exposed to stresses associated with discrimination in the workplace. For example, female residents reported that they "felt left out of conversations which may have been of interest" to them and were "subjected to stereotypical behavior based on preoccupations with their gender status. "2°
Spouses appear to play an important role in reducing the level of stress and depression among physicians. Our results are consistent with those of previous studies that indicate that married persons report less stress than their unmarried counterparts. Anwar, in her landmark 1983 longitudinal study of residencytrained emergency physicians wrote, "It remains to be seen whether the variety and rapidity of work [in emergency departments] will be tolerable in the long run. Perhaps defined working hours will balance the work i t s e l f . . , yet no one knows how the pressures of being the first graduates in a new residency will affect practice patterns in the future. 'q The data in our study provide some potentially alarming answers to the question of longevity. The American Medical Association (AMA) projects an annual attrition rate based on retirement, death, and leaving practice to be about 3% per year for all physicians,m The data in the current study indicate an attrition rate of 12%, four times the rate for the rest of the physician population. These data become even more alarming when one considers the practice life of an emergency physician. The AMA estimates the average practice life of a physician aged 35 to be from 33 to 36 years; for a physician aged 50, practice life ranges from 19 to 22.2 years, m The data from this study offer evidence to indicate that the practice life of an emergency physician is much less than that. The average age of the population in our study was 41 years. A majority of those responding indicated they did not plan to be practicing ten years fiom now. While our data indicate that older individuals were more likely to answer that they would not be practicing ten years from now, the fact that the majority answered in the affirmative suggests that most emergency physicians do not plan to be in active practice beyond their 50s. These data also have serious implications for manpower resource planning. It has been reported that there are approximately between 23,000 and 25,000 full-time equivalents •
Table 7.
Logistic regression resulL~ Independent
Dependent Variables Leave in Five Years B X2 P
Leave in One Year
Variables
B
Age
Xz
P
Practice More Than Six Years B Xz P
0.05
I3.04
< .001
0.06
27.19
< .0001
-0.07
39,57
Gender
-0.95
10.65
< .01
8.17
0.04
NS
0.29
1.34
Marital status*
- 0.38
1.98
NS
-0.5
5.27
< .05
0.45
4.5
LOC-Internal
- 0.01
0.4
NS
0
0.01
NS
- 0.02
083
LOC-Chance
-0.04
2.41
NS
- 0.63
1.84
NS
0.02
1.21
NS
L0C-Powerful ethers
- 0.01
0,32
NS
- 0.02
0.89
NS
0
0.05
NS
WriSt
0.05
9,16
< .01
0.06
20.33
< .0001
-005
17.07
< .0001
CES-D
0.01
0,41
NS
0.01
0.53
NS
g
0.08
NS
- 0.03
3,41
NS
- 0.05
0.04
8.55
< .01
Work satisfaction Model
X2 -
51.79dr = 9 P < . 0 0 0 1
X2
10.4
94.05 df = 9
< .01 P
depression, emergencyphysiciaas; stress, emergeneyphysicians
A
Study of Occupational Stress and Depression Among Emergency Physicians From the American College of
Michael E Gallery, PhD*
Emergency Physicians, Dallas,
Theodore W Whitley, PhDt
Texas;* Department of Emergerwy Medicine, East Carolina University
Leah K Klonis, MA* Robert K Anzinger, MD, FACEP*
School of Medicine, Greenville, North Caroiina;t Univers~yof Texas SouthwesternMedical Center, Dallas, Texas;¢ and Battelle Medical TechnologyAssessment and Policy Research Center, Washington, DC.§ Receivedfor publication July 1, 1991. Acceptedfor publication September 8, 1991.
Dennis A Revicki, PhD§
Objective: To determine the level of stress and depression among emergency physicians and whether these variables were related to the emergency physician's decision to leave the specialty. Study design and type of participants: The study involved a random sample of 1,350 emergency physicians who received a questionnaire containing scales on depression and occupational stress as well as questions about their future plans for remaining in the specialty. Results: Seven hundred sixty-three usable surveys (56.5%) were returned. Mean scores for the locus of control, Work-Related Strain Inventory, and the Center for Epidemiologic Studies - Depression Scale (CES-D) were within normal ranges. However, a disproportionate number, ie, more than 2.5% of the sample, scored more than two standard deviations from the mean. With the exception of the work satisfaction scale, there were no significant differences between the scores of fellows and nonfellows on measures of locus of control, stress, or depression. Of the population, 12.4% indicated that they were somewhat likely to very likely to leave the clinical practice of emergency medicine within the next year; 26.7% planned on leaving in the next five years, and less than half (42.9%) planned on seeing patients ten years from now. Older men, women, and those with high levels of stress and low job satisfaction were more likely to leave the specialty over the next ten years. Conclusion: While the vast majority of emergency physicians reported normal levels of stress, a disproportionate number reported high levels of stress and depression and plan on leaving the specialty of emergency medicine. The number of individuals planning to leave appeared to be greater than the number that will be replaced through residency training. [Gallery ME, Whitley TW, Klonis LK, Anzinger RK, Revicki DA: A study of occupational stress and depression among emergency physicians. Ann Emerg Med January 1992;21:58-64.]
70/59
ANNALS OF EMERGENCY MEDICINE 21:1 JANUARY 1992
STRESS & D E P R E S S I O N
Gallery et al
INTRODUCTION
MATERIALS
Occupational stress and "burnout" have been the focus of concern in hundreds of articles over the past two deeades. While many of these studies have focused on the medical community, little has been written about levels of stress experienced by emergency physicians. Although Anwar, in her longitudinal study of residency-trained emergency physicians, did not specifically address stress, she did attempt to measure "career commitment" and the degree to which emergency physicians planned to continue practicing the speciahy. Her data indicated that of the cohort of residents graduating between 1973 and 1979 only 5% had left the field of emergency medicine. Burnout or attrition did not emerge as an issue in that early and landmark study. 1 While nmnerous studies have investigated the level of stress among residents in various specialties,2-9 including emergency medicine, 1° few studies have focused on practitioners of emergency medicine. Keller and Koenig recently conducted a cross-sectional study of 77 emergency physicians in the greater Los Angeles area. They noted that "60% of the physicians reported medium to high emotional exhaustion and 78% medium to high depersonalization. ''11
The population for this study was emergency physicians who were members of the American College of Emergency Physicians
These studies notwithstanding, little has been done to document the degree to which emergency physicians experience stress or, moreover, the degree to which such stress may lead to a decision to leave the practice of emergency medicine. As Keller et al wrote, "Concern has been expressed that the daily stresses and demands of this speeiahy will prevent many young practitioners from functioning as practicing emergency physicians when they are in their 40s and 50s. ''11 Given the current shortage of emergency physicians, as identified by the American College of Emergency Physicians, 12 accurate estimates of the degree of attrition take on added importance in being able to properly assess future manpower needs. The present study was designed to address the following questions. What is the level of work-related stress perceived by emergency physicians? What is the level of depression reported by emergency physicians? Do emergency physicians have an internal or external locus of control, ie, do they perceive their lives as being controlled by internal or external events? How long do emergency physicians plan to continue to practice emergency medicine? What variables (eg, measures of stress, depression), if any, are related to an emergency physician's decision to leave the specialty?
JANUARY 1992
21:1 ANNALSOF EMER6ENCY MEDI01NE
AND
METHODS
during the fall of 1989. A stratified random sample of 1,350 members was used for the study. The variable of fellowship in the College (ie, board certification and an active member of ACEP for three years or more) was used as a stratifying variable. Of the 1,350 emergency physicians randomly selected for the study, 350 (26%) were fellows. The questionnaire compiled for the survey was based on Levenson's 13 revision of Rotter's I-E scale to measure locus of control (LOC), a construct referring to the extent to which individuals believe they themselves, other individuals, or chance control their personal destinies. Respondents use a six-point Likert scale to indicate their agreement or disagreement with 21 statements such as "When I make plans, I am almost certain to make them work." Three subscale scores - - Internal, Chance, and Powerful Others - - are obtained by summing responses to the seven statements that appear in each subscale. Internal consistency reliability coefficients (Cronbach's (x) for this sample were .62, .78, and .82 for the Internal, Chance, and Powerful Others snbscales, respectively. The work satisfaction and organizational commitment scale consists of 12 statements measuring one's degree of satisfaction with aspects of work. Adapted from an inventory used by GrayTort and Anderson, a¢ respondents use a four-point Likert scale to express their satisfaction or dissatisfaction with aspects of the work environment such as participation in decision-making, scheduling, and benefits. Cronbach's c~ for this sample was .87. The Center for Epidemiologic Studies - Depression Scale (CES-D) is designed to assess depression in the general population. 15 Developed by the National Institutes of Mental Health, the CES-D has a demonstrated capacity to identify clinically abnormal populations. 13 Respondents use a four-point Likert scale ranging from "rarely, never" (less than once a day) to "often" (at least once for five to seven days) to indicate the frequency with which they experienced each of 20 symptoms of depression such as "people were unfriendly" or "I felt sad" during the last week. Cronbach's ot for this sample was .88. The Work-Related Strain Inventory (WRSI) 16 was used to assess work-related stress. Based on a conceptualization of strain as the physiological, psychological, and behavioral manifestations of stress, the 18 statements included in the WRSI ask respondents to characterize their personal productivity, relationships with coworkers, and capacity to disregard work-related matters when they are away from work. Respondents l~
5 9/ 7 1
STRESS
& DEPRESSION
Gallery et al
use four-point Likert scales anchored by "Does not apply to me" to indicate low stress and "Does apply to me" to indicate high stress from a particular source. Cronbach's ~xfor this sample was .88; evidence of the validity of the WRS1 is available) 6 Respondents also were asked to provide demographic information (eg, age, gender, practice location) and to answer questions regarding their future plans relative to the practice of emergency medicine (eg, "How likely are you to leave the practice of emergency medicine next year?" "In the next five years?"). The questionnaire was field-tested with six emergency physicians to determine the clarity of the questions and whether the amount of time required to complete the questionnaire was reasonable..As a result of the field-test, some of the demographic questions and questions about future plans were revised. Questionnaires were mailed with a cover letter and a consent form to each member of the sample in the spring of 1989. Nonrespondents received a second mailing during the summer of that year. In addition to descriptive statistics, Z was calculated to compare the proportion of fellows in the group of respondents with the proportion in the sample drawn for the survey, and t-tests for independent means were calculated to compare the scores of fellows and nonfellows on the affective scales. An a level of .05 was set as the criterion for determining the statistical significance of Z, and Bonferroni's procedure was used to establish an ~x of .008 as the criterion for determining the statistical significance of the t values. Finally, three logistic regression analyses were performed to identify variables that differentiated respondents on the basis of whether they were likely to leave emergency medicine in the next year; whether they were likely to leave emergency medicine in
the next five years; and whether they anticipated practicing clinical emergency medicine for six or more years in the future. Age, gender, marital status (dichotomized into married and not married), the three locus of control subscales (internal, chance, and powerful others), WRSI scores, CES-D scores, and scores on the work satisfaction scale were the independent variables. An level of .05 was used to determine the significance of the logistic regression models and the predictor variables in each model, and the logistic regression coefficients were used to calculate odds ratios.
RESULTS A total of 763 usable surveys with consent forms were returned, for a return rate of 56.5%. Of these, 516 (67.6%) were nonfellows and 247 (32.4%) were fellows. Table 1 shows the demographic composition of the samples. The vast majority were Caucasian (89.4%), married (79.7%), and male (86.6%). Practice location was evenly distributed throughout the continental United States @able 2). Table 3 presents the results for the locus of control scale, the WRSI, the CES-D, and the work satisfaction scale. In a normal distribution, one would expect 2.5% of the population to score two standard deviations above the mean. In each of the three LOC subscales, the respondent's scores were disproportionately skewed. I1~
Table 2.
Practice location Table I.
Survey sample Race Afro-American American Indian Caucasian Latin American Asian-American Other Marital Status Divorced Married Separated Single Widowed Gender Femare Male
72/60 |
N
%
17 3 681 13 37 11
2,2 0.4 89.4 1.7 4.9 1.4
51 609 11 90 3
8.7 79.7 1.4 11.8 0.4
102 662
13.4 86,6
Location East Midwest South/Southwest Mountain/Pacific 0if-continent
N 215
% 28.3
179
23.6
182 171 12
24.0 22.5 1.6
Table 3. Re.~ults qf .~cales
Scale
N
X
SD
Individual Belief and Behaviors -Internal - Chance Others WRSI (stress) CES-D
Cronbach's
763 763 763 759 762
15.19 31.48 30.33 32.03 9.16
3.93 5.34 6.06 8.98 8.23
.67 .78 .82 .88 .88
Work satisfaction
760
35.85
6.89
.87
ANNALS OF EMERGENCY MEDICINE 2 1 : 1 ,JANUARY 1992
STRESS & DEPRESSION Gallery et al
Table 3 also reveals that emergency physicians overall report a high work satisfaction score. However, once again a disproportionate number scored two standard deviations below the mean. A score of 16 or greater on the CES-D is an indicator of depressive symptomatology. Despite an average score of 9.16, 19.3% scored above 16. Also, while the mean score on the WRSI was 32.03, 22.7% had scores equal to or greater than 38, indicating high levels of stress.
mergency ambulatory care was the choice of 20.58%. Only 1.44% reported they would enter research; 9.83% selected academic emergency medicine. All three logistic regression models were statistically significant (Table 7). Examination of the statistically significant independent variables revealed consistencies among the three models. For example, older respondents were significantly more likely to indicate that they might leave the specialty during the
Table 4 compares the scores of fellows and nonfellows on the measures of LOC, stress, depression, and work satisfaction. With the exception of work satisfaction, t-tests revealed no statistically significant differences (P < .05) in any of these scales. Although statistically significant, the difference between mean scores on the work satisfaction scale did not appear to have any practical significance. Table 5 displays data concerning future plans. When asked if they had ever considered leaving the specialty, 55.8% of the respondents indicated that they had. The next question reveals how active those thoughts are. Of the respondents, 12.4% indicated they are somewhat likely to very likely to leave the clinical practice of emergency medicine within the next year. That number increases to 26.7% in the next five years. Less than half (42.9%) plan on seeing patients ten years from now. Respondents also were asked "If you have thought about leaving clinical emergency medicine, what are you thinking of doing in its place?" They could select more than one option. The most frequently selected option (Table 6) was to leave medicine entirely and pursue another career (31.85%). Practicing none-
next year or within the next five years, and they were significantly less likely to indicate that they would be practicing clinical emergency medicine seven or more years in the future. Similarly, respondents who perceived higher levels of work-related stress were more likely to report plans to leave emergency medicine in one year or five years and were less likely to report that they expected to remain in clinical practice seven or more years into the future. Although satisfaction with work did not have a significant impaet on plans to leave emergency medicine during the next year, respondents who were more satisfied with their work were less likely to report plans to leave the specialty in Table 5. Future plans
Question Have you considered leaving the specialty of emergency medicine?
Response Yes No
N 425 336
% 55.8 44.2
Are you currently thinking of leaving clinical emergency medicine (seeing patients)?
Yes No
200 555
26.5 73.5
How likely are you to leave emergency medicine in the next year?
Very likely Somewhat likely Probably not Not at all
44 50 195 469
5.8 6.6 25.7 61.9
How likely are you to leave emergency medicine in the next five years?
Very likely Somewhat likely Probably net Not at all
75 127 284 272
9.9 16.8 37.5 35.9
How many more years do you anticipate practicing clinical emergency medicine (seeing patients)?
0-1 1-3 4-6 7-10 >10
29 77 119 205 323
3.9 10.2 15.8 27.2 42.9
Table 4. Comparison of fellows and nonfellows on scales
Scale IB8 Scale IBB-Internal Fellow Nonfellow IBB-Chance Fellow Nonfellow IBB-Others Fellow Nonfellew WRSI (Stress) Fellow Nonfellow CES-D Fellow Nenfellow Work Satisfaction Fellow Nenfellow
JANUARY1992
21:1
N
X
SD
T
P
247 516
14.79 15.38
3.7 4.02
1.946
.0519
247 516
31.64 31.40
5,11 5,46
0.582
0.581
247 516
30.75 30.13
6.04 6.05
1.320
0.187
247 512
31.74 32.18
8.72 9.11
0.630
0.528
246 516
9.18 9.88
7.75 8.44
1.096
0.273
246 514
37.21 35.20
6.62 6.93
3.80
0.0002
ANNALS OF EMERGENCY MEDIC1NE
Table 6. Where those who leave clinical emergency medicine plan to go
Source To academic emergency medicine To emergency medicine administration To emergency medicine research To nenambulatory care To different specialty To another career
N 75 114 11 157 113 243
% 9.83 14.94 1.44 20.58 14.81 31.85
61/73 |
STRESS & DEPRESSION
Gallery et al
five years and nmre likely to indicate that they would be involved in clinical practice seven or more years in the future. With respect to gender and marital status, women respondents were less likely to indicate plans to leave the specialty during the next year, and married respondents were less likely to report plans to leave the specialty in five years and more likely to indicate that they planned to be practicing clinically seven or more years in the futm'e. With the exception of the one odds ratio indicating that women were approximately 2.5 times less likely to plan to leave emergency medicine during the next year, none of the odds ratios were especially dramatic.
DISCUSSION The results of this study are consistent with many of the findings of previous investigators. For example, these data indicate that women report higher levels of stress and depression than men. This finding is consistent with those reported by Whitley et al in their study of enmrgeney medicine residents in training. 1° It has been noted in the literature that women experience more pressure in their social lives and often experience role conflict trying to balance the demands of a career with those demands placed on them in managing a home, where they often must carry an unequal burden of the workload. 17'1a It has also been postulated that female physicians may be negatively affected by the small number of role models available within medicine. 19 In addition to normal professional stresses women share with their male counterparts, they also are often exposed to stresses associated with discrimination in the workplace. For example, female residents reported that they "felt left out of conversations which may have been of interest" to them and were "subjected to stereotypical behavior based on preoccupations with their gender status. "2°
Spouses appear to play an important role in reducing the level of stress and depression among physicians. Our results are consistent with those of previous studies that indicate that married persons report less stress than their unmarried counterparts. Anwar, in her landmark 1983 longitudinal study of residencytrained emergency physicians wrote, "It remains to be seen whether the variety and rapidity of work [in emergency departments] will be tolerable in the long run. Perhaps defined working hours will balance the work i t s e l f . . , yet no one knows how the pressures of being the first graduates in a new residency will affect practice patterns in the future. 'q The data in our study provide some potentially alarming answers to the question of longevity. The American Medical Association (AMA) projects an annual attrition rate based on retirement, death, and leaving practice to be about 3% per year for all physicians,m The data in the current study indicate an attrition rate of 12%, four times the rate for the rest of the physician population. These data become even more alarming when one considers the practice life of an emergency physician. The AMA estimates the average practice life of a physician aged 35 to be from 33 to 36 years; for a physician aged 50, practice life ranges from 19 to 22.2 years, m The data from this study offer evidence to indicate that the practice life of an emergency physician is much less than that. The average age of the population in our study was 41 years. A majority of those responding indicated they did not plan to be practicing ten years fiom now. While our data indicate that older individuals were more likely to answer that they would not be practicing ten years from now, the fact that the majority answered in the affirmative suggests that most emergency physicians do not plan to be in active practice beyond their 50s. These data also have serious implications for manpower resource planning. It has been reported that there are approximately between 23,000 and 25,000 full-time equivalents •
Table 7.
Logistic regression resulL~ Independent
Dependent Variables Leave in Five Years B X2 P
Leave in One Year
Variables
B
Age
Xz
P
Practice More Than Six Years B Xz P
0.05
I3.04
< .001
0.06
27.19
< .0001
-0.07
39,57
Gender
-0.95
10.65
< .01
8.17
0.04
NS
0.29
1.34
Marital status*
- 0.38
1.98
NS
-0.5
5.27
< .05
0.45
4.5
LOC-Internal
- 0.01
0.4
NS
0
0.01
NS
- 0.02
083
LOC-Chance
-0.04
2.41
NS
- 0.63
1.84
NS
0.02
1.21
NS
L0C-Powerful ethers
- 0.01
0,32
NS
- 0.02
0.89
NS
0
0.05
NS
WriSt
0.05
9,16
< .01
0.06
20.33
< .0001
-005
17.07
< .0001
CES-D
0.01
0,41
NS
0.01
0.53
NS
g
0.08
NS
- 0.03
3,41
NS
- 0.05
0.04
8.55
< .01
Work satisfaction Model
X2 -
51.79dr = 9 P < . 0 0 0 1
X2
10.4
94.05 df = 9
< .01 P
