May 13, 2023

The Messy Middles of Emergency Medicine and Life

"Only the paradox comes anywhere near to comprehending the fullness of life." - Carl Jung.

To say that the last few years of emergency medicine have been a heaping dumpster fire is only an approximation of how horrendous it has been. Even though the shifts are hard, I am struck by how it's not all bad. It's an "and" situation. It's hard and (at moments) beautifully simple, like reducing a nursemaid's elbow and seeing the joy wipe away a furrowed parent's brow. It's heart-wrenchingly sad and joyous. When I return from shifts, my engineer husband hears the good, bad, and everything in between. When I finish talking about the frustration, the anguish, and the absurdity, he often says, "You do meaningful work, Andrea."

If it's so meaningful, why are so many of us burning out? Approximately 65% of emergency physicians experience burnout.1 As I recover and relapse into burnout throughout my career, I am perpetually looking for new insights to survive our field and thrive. For many emergency physicians, the first part of our career is honing our clinical acumen and the well-being practices to sustain ourselves, such as fatigue mitigation, on-shift nutrition, and other self-care routines. In the mid-career phase, I've reached near optimization of self-care, and now, I'm looking at how to have a better on-shift experience. I know I'll be okay when I get home, but how do I be okay and, dare I say, thrive during the shift? This is difficult, especially as we face the increased challenges of waiting room medicine and boarding. I've been pondering, what gets in the way of enjoying and embracing the good parts of shifts?

On the way to most shifts, I feel excitement and optimism (less so for night shifts). For the first few patients, I also feel good. In the first few hours, I usually spend a little extra time and am patient with the inevitable interruptions and other annoyances in our work. The trouble is the middle of the shift. There is almost always a phase of the shift when it feels like the wheels are coming off the bus, especially since COVID-19. More patients are checking in or stacking up in the waiting room than we can see. Sometimes, I physically struggle to walk through the hallway due to the number of ambulance stretchers lining the passageway. I've termed this phase of the shift “the messy middle.”

After naming it the messy middle, I initially felt annoyed. Ugh, here it is: the messy middle has arrived. The messy middle is difficult because it flirts or entirely crosses into overwhelm, which Brené Brown describes in her book Atlas of the Heart as more than stress. “Overwhelmed” is the emotion we feel we cannot move forward without a break or more support. I've been doing a lot of work on my mindset, and I began to ask myself, "Is there any other way to think about the messy middle?" Then I recalled episode 39 of The Drive Time Debrief, in which Dr. Shideh Shafie spoke about coaching around coping with stress. She tells herself, "I am made for this." What if I told myself, "I'm made for the messy middle. This mess is where I thrive."

When using self-talk, research suggests that it also helps to add your name. Say, "Andrea, you were made for the messy middle. This is what you do. You got this." Speaking to yourself in the third person may sound weird (or, to a group of ED doctors, possibly psychotic), but there's research to support doing this in your self-talk from the book Chatter by Ethan Cross.

Messy middles are the second act of all great plays. Act 1 is the introduction of the characters and plot lines. Act 2 is when the protagonists face challenges, and things get interesting. Can I experiment with thinking about the messy middle as the part of the shift that gets interesting and challenging? Is this where I, as the protagonist, show my true character and strength?

After my coaching session, I walked out to my porch and sized up the large cracks we are repairing after spending 8 years in my house. Sometimes, I get frustrated that I still have to learn and relearn various strategies for a better shift. I feel like the cracks provide a good metaphor: some of the cracks we have from medical school and residency run deep and take time to uncover and repair. Sometimes, we need a consultation from a peer mentor, coach, or therapist to find the cracks and start the repair. Perhaps, those cracks are not all bad; they are part of being human, and when filled in, they strengthen us. Extending the metaphor of the messy middle to my life, I'm in the messy middle of my career. This might be when things start to get really good, and I thrive.



  1. Kang CS, Terry AT, Schmitz G. March 2023 Board Blog - ACEP Leaders Say EM's Systemic Challenges Need Shared Solutions. American College of Emergency Physicians Board Blog. March 27, 2023.


Inspiration for this piece came from listening to The Whole Physician's podcast “Drive Time Debrief, episode 39 with Shideh Shafie” and from conversations with my coach, Sharee Johnson. I'd love to hear how you're navigating your messy middle. Please email me, leave me a voice message, or Tweet at me (@EMSimGal).


Andrea Austin, MD, CHSE, FACEP


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