IU School of Medicine strives to address burnout, mental health stressors and gender inequities faced by emergency medicine physicians.

State of Emergency

IU School of Medicine strives to address burnout, mental health stressors and gender inequities faced by emergency medicine physicians.
Matt Rutz walks down a hospital hallway filled with hospital beds on wheels. He is wearing dark blue scrubs.

INSIDE A RADIO DISPATCH room, Matt Rutz, MD, sat patiently as gentle static filled the air. An emergency physician, he was waiting for a voice telling him if a 62-year-old woman who had taken a volatile mixture of narcotics and alcohol would be coming to see him at Sidney & Lois Eskenazi Hospital.

Finally, the crackling voice of a paramedic piped up. "She's made multiple suicidal comments to her son,” the medic said. “She wanted to die, and she wanted him to come over and hold her." Yet, the woman's heart rate, blood pressure, and oxygen levels were normal. And the medic relayed this: She doesn’t want to be trucked to the ER.

Rutz's eyes grew wide. He shook his head in slight exasperation. While disconcerting, the woman's behavior and condition didn’t clear the bar for Indianapolis police to force her to go to the hospital. "I need you to talk to her and make sure she understands the implications of not going to the hospital," the medic said.

Rutz stood up and walked briskly back to the desk at the front of the unit where patients in severe condition receive care. He met Natalie Moore, MD, a second-year resident, with her head tilted and a walkie-talkie pressed to her ear. Only two months into the most brutal stretch of her training, Moore must try to sway a patient she cannot see.

"I hate these," Moore said.

"You carry no risk," Rutz said. "Just try to do your best for the patient."
She pressed a button on the walkie-talkie and spoke slowly. "Can the patient hear me?" Fifteen seconds of silence. Then, the medic gave her a garbled go-ahead. "I would encourage you to come to the hospital so we can take care of the thoughts you're having of harming yourself," Moore said. For 30 seconds, more silence.

Finally, the medic reported: "She's tired and wants to go to bed.”

With the call over, Rutz summoned Moore for a quick sidebar. "We're not on scene to evaluate the situation," he says. "We have to hope they're doing what's right."

Together, on this Sunday overnight shift in October, Rutz and Moore saw more than 25 patients—three from minor car accidents, two with complications from going off dialysis and one man who was faking alcohol withdrawal, tremors and all.

Even the night's highest drama—a man who showed up with a gunshot wound— unfolded calmly. After he was stripped in a shock room, trauma surgeons delivered the good news: the bullet had passed harmlessly through fat tissue in his belly.

"So, I'm good?" he asked.

By 3 a.m., the tide of patients ebbed, enabling Rutz and Moore to quietly update their charts, enter orders, parse CT scans, and leave concise notes for colleagues. At 4:30, Rutz tossed out a question. "Does it feel slow?" he said.


Emergency Medicine residents working on charts

emergency room has always been hectic. Stress and burnout are not new. Finding a work-life balance is not easy, said Peter Pang, MD, who chairs the Department of Emergency Medicine at IU School of Medicine. But even among those who know the territory, the past couple of years ratcheted up the strain.

First, there was a pandemic. Waves of gravely ill patients, some of whom couldn’t be saved. Even as it has receded, patient visits increased, with physicians seeing even more patients than before the pandemic. By 2022, 60 percent of emergency physicians reported feeling burned out, a 17-percentage point spike over the previous year.

The vocation instills an unyielding mantra: The sickest patient is in the waiting room, the one yet to be seen. A physician must quickly pivot from running a code in a shock room to treating a patient with a minor cut on their head. There's scant time to take a beat, refocus, and process what they've witnessed.

"How do you tell a parent their 3-year-old is dead? That's not a normal thing to do," Pang said. “You're also expected to give the next patient your very best. And rightfully so, they deserve our best."

A smooth-functioning emergency department is a marvel of close team coordination among physicians, nurses, techs, specialty consultants, and hospitalists. But national staffing shortages have been felt locally as the demand for patient beds has increased. Teams supporting physicians manage overflow care and wait times tick up.

"They're being asked to do more with less," said Heather Kelker, MD, who practices at Riley Hospital for Children and is an assistant professor of clinical emergency medicine at the School of Medicine. "If we're used to a certain way of running something that's now strained, it doesn't feel too good."

While physicians draw six-figure salaries and enjoy a particular esteem, they're not immune to economic pressures. In one study, 70 percent of ER physicians agreed that "corporatization of medicine" strongly impacted job satisfaction.

Charting, for example, can be a flash point. It's no longer just a tool to share clinically significant information. It now folds in billing, coding, and litigation protection. To keep up, some physicians spend hours charting at home after a shift ends. "Those day-to-day stresses of how an ER functions add up and impact us over time," Kelker said.


Emergency medicine resident with a patient

, the department has moved to try to reverse trends gnawing at its faculty and the next generation of physicians they train.

Faculty like Julie Welch, MD, ramped up research to understand the mechanisms that drive burnout, erode work-life balance, and create gender inequity. Others study the impact of peer-support programs and policy changes. That requires investment—dollars Pang deems well spent.

"My sense is we've done more than most, and it has to stay that way," Pang said.

The School of Medicine, IU Health, and Eskenazi Health worked to support their teams during the pandemic. IU Health and the School of Medicine were already striving to improve wellness and that work intensified during the pandemic. In emergency medicine, wellness was embedded into the incident command structure, demonstrating its importance.

Our approach to wellness is to have a learner's heart. We don't have all the answers, but this work matters. We're going to work toward solutions.

Peter Pang


Both groups spent the past year amassing information. IU Health’s group found emergency physicians believe they lack the tools—mostly staffing—to work efficiently. The school's group joined similar committees from peer institutions working toward the same end. "Wellness is a vague term,” said Kelker, who serves on both committees. “We need tools that can help us define it."

Pang's department has already rolled out tangible policy changes.

During the first and third trimesters of pregnancy, residents can opt out of night shifts. When the child is born, the resident gets six additional weeks of flexible scheduling. There’s now financial support for wireless equipment for lactating mothers, and bereavement leave: the department foots the cost when a resident picks up a shift for a grieving colleague. A peer support group for physicians facing malpractice claims has also been created.

Some research shows that working at an academic medical center provides a buffer. Physicians at medical schools like IU devote more work hours to non-clinical duties like teaching and research, which can boost feelings of personal accomplishment. Some studies—albeit with small sample sizes—also report lower burnout rates.

It's not without tradeoffs.

Academic faculty make less money than physicians in a community practice. Yet they experience a shared commitment to training physicians, scholarship, and innovation.


A flyer taped to the wall lists daily affirmations over a background photo of physicians standing together.

of this dynamic is visible at Eskenazi, where the ER handles more than 100,000 patient visits a year–a new patient every five minutes. Many are uninsured. They might be dealing with the acute consequences of a chronic condition. Or the results of street violence.

Two years ago, Eskenazi felt the tug of the trends pulling on emergency medicine. Nurses were fed up with the abuse from patients. Managers told them to jot down incidents on a form and drop them in a box. Eventually, those reports made their way to Marla Doehring, MD, who practices at Eskenazi and serves as one of the leaders of committee for residency safety.

"The incidents didn't shock me," said Doehring, an associate professor of clinical emergency medicine. "The sheer volume did. I thought we needed to do something."

The result: a study on workplace violence. It found offenders were often men who came to the ER voluntarily. Usually, an incident—most often reported by nurses—involved swearing or threats of legal action. But sometimes the lack of civility extended well beyond vulgarity and threats. Despite that, most healers default to their ethical code.

Esknazi took the data to heart. It increased security, tweaked no-tolerance policies to include non-violent harassment, and posted QR codes to streamline incident reporting. Even so, those efforts can't erase lousy behavior.

That was true when Rutz encountered a patient writhing on a bed. Paramedics brought him to Eskenazi after an aide at a long-term care facility found him on the floor of his room and agitated. He looked to be in his late 50s. He had a patchy white beard and wore only his underwear.

Moore, two nurses, and a paramedic surrounded him, each trying to hold him in place. His words were slurred. A medic said the patient had suffered a stroke two months earlier. Rutz moved to the foot of the bed, placed his hands just above the left knee, and pressed.

The patient muttered at Rutz: "I will f—- you up."

"Just relax, dude," the medic said slowly.

But the man didn't heed the advice, wriggling onto his side. Moore called for a dose of droperidol, a sedative used when a patient is aggressive. Rutz asked the medic about the man's condition when they found him. Details were scant. A nursing aid suspected he'd been down for an hour before she discovered him.

"I'm gonna sue all of you," the patient yelled.

"Seems fair," Rutz quipped.

Good humor embodies Rutz's approach to the stresses of his profession. When overseeing the unit, he keeps the vibe breezy. Any small favor—like a nurse handing him a chart—is met with a pleasant "Grazie." But when he steps into a patient's room, he sounds like a man catching up with a neighbor as they’re knocking out some yard work.

What sustains his affable bearing? "The patients," said Rutz. "A lot of folks are grateful for any care they can receive. Sometimes, it's as simple as giving them meds for high blood pressure or info on how they can get transportation to another clinic."


colleagues in the emergency department smile and chat during a break in a busy day.

, Rutz personifies a cultural shift in his field. He finished residency in 2015, coming up in an environment that emphasized the grind: no breaks, no running to the restroom, and, crucially, not vocalizing stress.

Now, those topics are atop the docket when new residents arrive.

Kyra Reed, MD, an assistant professor of clinical emergency medicine and an assistant program director, hosts a retreat at her home where future ER doctors learn about the department's policies and programs. When they open their Outlook calendar, a session with a counselor is already booked. They also complete a psychological needs assessment.

"We want to remove any barrier or stigma," Reed said. "That all conveys just how crucial their mental health and well-being is to us."

Throughout their intern year, lectures return to topics around burnout. The department also uses peer support for residents working ICU shifts—often a young physician's first exposure to caring for very sick patients. During those sessions, a resident leader sits down with the intern to discuss any issues. Older residents, though, have different needs. For those in their second year, their workload ramps up dramatically. Almost half their shifts are in high-acuity areas, leading resuscitations in shock rooms.

"You're making high-level decisions and you’re newly on your own," Reed said. "That's a lot of weight."
Two months into her second year, Moore feels every ounce of it pressing down. "It's very overwhelming," she said. "I pretty much feel all the time like I'm missing something or doing something wrong."

That sensation is normal. Second-year residents might receive a lecture focused on efficient charting, coping with exhaustion, and maintaining work-life balance. By the third year, content shifts to maintaining empathy and workplace safety.

To cope, Moore thinks only of the next step for each patient in her care. She knows the volume she sees at IU—sometimes six patients an hour—surpasses other programs. Stress now means competence later.

Rutz said Moore's experience is unfolding normally. "She's getting her butt kicked," he said. Soon, though, her baseline will reset. Once that acclimation ends, Rutz said his attention would turn to building confidence.

Rutz paused and looked up. Moore had stepped into a room and started chatting with a patient. He grinned. "She's so good," Rutz said. "She just doesn't know it. There's a little bit of imposter syndrome. We need to work through that, but she's got what it takes."


IU School of Medicine trains many of the state’s emergency physicians. To help us offer a stellar training environment, contact Ken Scheer at 317-278-2122 or kescheer@iu.edu.

The views expressed in this content represent the perspective and opinions of the author and may or may not represent the position of Indiana University School of Medicine.
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Matthew Harris

Matthew Harris is a communications specialist in the Office of Gift Development. Before joining the School of Medicine in 2015, he was a reporter at newspapers in Pennsylvania, Arkansas, and Louisiana. He currently lives in Indianapolis with his wife and two basset hounds.