With the rapid development of emergency medicine, emergency physicians are working around the clock,^[1] including additional workloads due to sudden public health emergencies and disasters. Occupational risks for emergency physicians are significantly high due to an increasing number of patients with acute and severe diseases, an increased workload, and a potential danger of medical malpractice.^[2] The emergency department (ED) environment is frequently characterized by stresses and uncertainty, with a high incidence of trauma and violence.^[3,4] An increasing occupational risk leads to a vicious circle of physicians losing patience and subsequently compromising doctor-patient relationships. This study aimed to explore the occupational risks of emergency physicians and their causes in China, in order to pursuing and delivering a high quality of emergency care.

The study was approved by the Ethical Committee of Beijing University of Chinese Medicine (2022-01-021-05). We conducted a cross-sectional investigation among physicians on duty in 24-hour EDs. Other non-clinical staff, such as administrators, secretaries, full-time scientific researchers, and full-time teaching staff in the EDs, were excluded. The participants were mainly from EDs of first-tier cities in China characterized by limited medical resources, large population flows, and high demands for emergency services. A questionnaire was designed based on the relevant literature, practical and personal experiences, and expert consultations. The study was conducted from November 16 to December 10, 2021.

Data were collected via an online questionnaire accessible on mobile phones. Informed consents were obtained from all participants prior to participation. The questionnaire collected demographic and professional information, including sex, age, years of working experience, working hours, job title, exposure risk, mental stress, occupational satisfaction, and countermeasures for these risks.

To ensure the quality of the data, the questionnaires were distributed by the Emergency Medicine Society of the Chinese Medical Association, and the returned answers were cross-checked by the investigators. Any missing or anomalous data were sent back to the responsible physicians for further verification.

The open-ended question results were summarized using Microsoft Office Excel™. SPSS 20.0 (IBM, USA) was utilized for statistical analysis. Skewed continuous variables are reported as medians with interquartile ranges, and normally distributed variables are presented as the means ± standard deviation (SD). Between-group comparisons were conducted using analysis of variance (ANOVA) for continuous variables. Categorical variables are expressed as frequency and percentages and were compared using the Pearson Chi-square test. All tests were two-tailed and performed at the 5% significance level.

A total of 953 qualified questionnaires were analyzed from 1,120 emergency physicians, yielding an 85.1% valid response rate. The sample consisted of 599 male and 354 female physicians across 24 territories in China, with an average age of 38.4±8.6 years (Figure 1A). As the backbone of EDs, attending physicians and resident physicians accounted for 64% of the participants.

The average working experience of emergency physicians in hospitals was 12 years, with an interquartile range of 6 to 20 years (Figure 1B). More details can be found in supplementary Table 1.

The average working time for emergency physicians was 9.7±2.2 h per day and 58.2±13.2 h per week. Among them, 69.5% had a normal workload of 8-10 h per day.

The most common exposure risk for emergency physicians was biological, including contact with infected blood, excretions, or other body fluids, reported by 88.8%. The second most common exposure risk was physical, involving exposure to medical sharp instruments, for a total of 57.1%. This was followed by occupational exposure and chemical exposure, which involved trauma caused by tumbles, sprains, or bumps and contact with sanitizers, chemotherapeutic agents (Figure 2).

The emergency physicians reported experiencing mental stress due to the increasing number of patients with acute and severe diseases, the increased workload, and the potential danger of medical malpractices.

When asked about occupational satisfaction, some emergency physicians expressed dissatisfaction with their career development. The primary cause was a lack of understanding and emotional support (41.9%), difficulties in achieving a work-life balance (39.4%), challenges in obtaining a sense of accomplishment from their work, obstacles to promotion, and poor interpersonal relationships and workplace atmosphere (supplementary Table 2).

Physicians, who aged between 30 and 40 years or who had 10 to 20 years of professional experience reported lower occupational satisfaction. Attending physicians or associate chief physicians expressed lower occupational development satisfaction (P<0.05). There were no significant differences in mental stress among participants at various professional levels. The main findings are presented in supplementary Table 3.

In our study, the working time of emergency physicians was 58.2±13.2 h per week, which was significantly longer than that of physicians in other specialties.^[5] A study has shown that workload was an important reason of stress, leading to negative emotional reactions.^[6]

During the diagnosis and treatment processes, emergency physicians must handle with blood, body fluids, urine, feces, vomitus, and secretions of patients in some invasive operations, which are associated with a high risk of biological exposure. In addition, disinfectants are often used in EDs, which cause long-term exposures to human skin, mucous membranes, respiratory tract, and nervous system,^[7] and cause chest tightness and headaches, even asthma, pulmonary edema, occupational dermatitis, and ophthalmia. All these factors result in a heightened risk of occupational exposure and may have adverse effects on health.^[8]

Owing to the nature of their work, emergency physicians face an imbalance between work and family, feel guilty about being unable to fulfill their family duties that further aggravates their pressures at work.^[9]

Overload and high pressure at work, and physical and psychological discomfort decrease emergency physicians’ occupational satisfaction. A report showed that the career satisfaction of emergency physicians was 65.2%.^[10] However, our data showed that occupational satisfaction decreases with age and professional title. The reason may be that young physicians have higher enthusiasm for work and fewer burdens on their livelihood. As time progresses, the pressure of work and life leads to job burnout and consequently results less occupational satisfaction. As income and social status stabilize and work experiences increase, physicians become more experienced in communicating with patients that improves their career satisfaction.

Based on the above analysis, we proposed some countermeasures to improve and minimize occupational risks for emergency physicians. For physicians, they must pay more attention to recognizing occupational risks and preventing potential harm. Socially, it is necessary to publicize medical and legal knowledge to patients, and litigation channels must be improved to prevent violent injuries to physicians.^[11]

There are some limitions of the study. First, our data were self-reported and not verified by others. Second, the loss in data from our survey may more likely represent dissatisfied physicians, which may influence the results. Third, the terms “burnout” and “stress” were not defined in the survey, so all the physicians may not have had the same understanding of these words when completing the survey.

Our study provides an overview of emergency physicians’ occupational risks in China. Measures to decrease occupational risks are needed to improve working conditions for emergency physicians.

Funding: Beijing Key Specialized Department for Major Epidemic Prevention and Control (Construction Project); National Major Science and Technology Projects (2017ZX10305501), Beijing Social Science Foundation Planning Project (17SRC019)

Ethical approval: The study was approved by the Ethical Committee of Beijing University of Chinese Medicine (2022-01-021-05).

Conflicts of interest: The authors declare no conflicts of interest.

Contributors: HYJ and JC contributed equal to this article. All authors read and approved the final version of the paper.

All the supplementary files in this paper are available at http://wjem.com.cn.