EM Mindset: Anand Swaminathan – Lessons from John Hinds

Author: Anand Swaminathan, MD, MPH (@EMSwami – Asst Professor/APD, NYU/Bellevue) // Edited by: Adaira Landry, MD (@AllaroundDoc), Salim Rezaie, MD (@srrezaie), Manpreet Singh, MD (@MPrizzleER) and Alex Koyfman, MD (@EMHighAK)

Things I learned from a non-EM doc about the EM Mindset (lessons from John Hinds)

Too much pride in EM rises from all the fights we have had to become our own specialty in order to separate ourselves. But in separating ourselves, we have also put up many barriers. It’s time now to break down those barriers and unite the tribes of medicine. I need to learn this as much as anyone.

1. Take the best of what everyone has to offer
2. Carve your own path
3. Avoid acts of omission
4. Choose your colleagues well
5. Behave as you want to be remembered

The EM Mindset series has been a wonderful opportunity to hear great leaders in EM discuss what they see EM to be and what it can be. Many of my thoughts echo those who have already written for this column.

Early on, in the life of our specialty, we had to fight relentlessly to be recognized in the house of medicine as a necessary piece of that house. We were called glorified triage monkeys and many (including our families) had a hard time understanding why any self-respecting doctor would choose to work in the Emergency Room as a career. As a result of all these fights to establish ourselves, to build a separate specialty, we built up many barriers between ourselves and our colleagues. The SMACC conference takes pride in breaking down the barriers and uniting the tribes of medicine and I think emergency providers need to do the same. There is an inordinate amount we can learn from our colleagues in critical care, EMS, anesthesia, oral surgery etc as long as we are willing to. This is why I wanted to discuss the lessons I learned from a non-EM doc – Dr. John Hinds (@DocJohnHinds).

I had the pleasure of meeting John at SMACC Chicago and having dinner with him the night before the SMACC workshops. His talk during the opening session provided many messages and thoughts that have made me think deeply about our specialty.

1. Take the best of what everyone has to offer.

When I was a medical student, I remember telling faculty who were non-EM that I was applying for an EM residency and uniformly, they would all answer, “Emergency Medicine? They don’t even have a specialty. They’re the jack of all trades and the master of none.” Although, I have grown to realize that EM actually has a number of specialties (time, risk stratification, the undifferentiated patient etc.) the moniker “jack of all trades” isn’t completely untrue either. Clinically, it is critical for us to understand various features of a number of specialties ranging from ENT to OB/GYN. There are many physicians in EM who have developed interest in these areas and become ED experts who we can learn from but we should also be open and willing to learn from the specialists as well. I’ve had respiratory therapists teach me their tricks on getting a patient to comply with NIPPV. I’ve had urologists show me their approach to draining a priapism or reducing phimosis. Oral surgeons have amazing techniques to teach us on draining dental abscesses, splinting teeth, and doing dental blocks.

This doesn’t mean you have to do everything your consultant does or says. Despite what my urologists say, I don’t give tamsulosin to the majority of ureteric colic patients. Despite what my hand surgeons say, I don’t give antibiotics to patients with distal fingertip amputations. Learn from your consultants but when you know better, do better.

Beyond just your consultants, there is an incredible amount you can learn from your nurses, your patient care techs, respiratory therapists, and of course your patients. Don’t be too proud or you won’t be open to receive those messages. Remember that your colleagues in nursing often have more experience than you and definitely have mastery over areas you don’t (equipment set-up, certain procedures etc.).

Take Home Message: Take the best of every specialty and make it part of your practice of Emergency Medicine.

“Even today, I dare not say that I have reached a state of achievement. I’m still learning, for learning is boundless.” -Bruce Lee

2. Carve your own path.

Every time a new field or area within a profession is founded, whether it be medicine, education, finance or technology, there are those individuals who are trailblazers. These are the Steve Jobs types who decide there is a better way to do things regardless of what the entrenched hierarchy says. Emergency Medicine has a long list of these leaders (most of whom are still living) including Peter Rosen, Brian Zink, Judy Tintinalli, and Lewis Goldfrank. Each of these legends refused to simply listen to and follow authority when they believed there was a different path.

In spite of the great things these leaders have accomplished, there is always more work to be done. Our specialty is far from completed. In order for us to continue to grow and develop to deliver the best care to our patients, we need new generations of trailblazers within the field. Today, those leaders are people like Michelle Lin, Scott Weingart, Chris Nickson, Rob Rogers, Mike Cadogan, Mel Herbert, and many more. People who see new and innovative ways to deliver education and build better clinicians. Each of these leaders could easily have plugged themselves into the traditional pathway towards academic achievement but chose a different route.

Take Homes Message: We need to continue this rich tradition of continually innovating. Think differently, find your own route, and strive for greatness.

“Always be yourself, express yourself, have faith in yourself, do not go out and look for a successful personality and duplicate it.” -Bruce Lee

3. Avoid acts of omission.

During John’s incredible opening session talk at SMACC, he discusses performing a thoracotomy on a trauma patient with clear indications for thoracotomy and the misguided criticism he received as a result. John anticipated the criticism he would face but pressed on with the procedure nonetheless. Why? Because he knew it was the right thing for the patient. If John had passed on performing the thoracotomy, no one would have thought differently of him but he refused to allow for the act of omission – not doing something for a patient when it was clearly the right thing to do.

Early on in our specialty, many non-EM physicians saw us as cowboys: often shooting from the hip without knowing what we were doing. This critique was never accurate but many early emergency providers embraced the stereotype. We love the idea of being a cowboy in the Wild West that is the ED. Over the last decade, though, I have seen the reverse occur, particularly in academic settings. Instead of reducing that hip, just call ortho. Instead of floating that pacemaker, just call EP. Just get the septic patient up to the unit and let them put in the central line. I find this behavior unacceptable. If you’re uncomfortable doing a procedure, get your consultant to teach you to do it. 24 hour subspecialty consultation is a luxury, not the norm and it’s a fast fleeting luxury as fewer and fewer specialists are taking 24 hour call.

Take Home Message: Take on all the procedures and learn how to deliver them to the patient so that when you are alone without backup and that procedure will be lifesaving you won’t hesitate to deliver.

“Knowing is not enough, we must apply. Willing is not enough, we must do.” -Bruce Lee

4. Choose your colleagues well.

This one is pretty straightforward but often ignored. A life in Emergency Medicine is filled with overnights, weekends, and holidays. You’ll miss some important family events along the way (hopefully, not too many and not the really important ones) and plenty of nights out with friends. The best way to make this all work is to make a work family.

Find colleagues who share your drive for improvement, who are interested in discussing cases; both the good and the bad, and can be both critical and supportive. This will push you to become better and what you do and how you deliver care.

Take Home Message: Try to find a place where you enjoy the people you work with and you will enjoy work.

5. Behave as you want to be remembered.

Another simple concept but one that isn’t focused on. This is more than professionalism: it’s feeling and expressing empathy. Back in 2008, Art Kellerman gave a wonderful set of remarks at the Emory School of Medicine commencement ceremony. He talked about Mama’s rule and we should all learn to embrace this approach.

Take Home Message: Embrace the Hippocratic Oath and if you’re ever unsure how to act, think about Mama’s rule.

“The key to immortality is first living a life worth remembering.” -Bruce Lee

Finally, a last parting word from my favorite modern day philosopher:

“Be shapeless. Be formless. Like water. When you pour water in a glass, it becomes the glass. When you pour water into a cup, it becomes the cup. When you pour water into a tea pot, it becomes the tea pot. Water can flow, or water can crash. Be water my friend.” -Bruce Lee