Category Archives: EM Mindset

EM Mindset: Longevity

Author: Loice A. Swisher, MD (EM Attending Physician, Mercy Philadelphia Hospital, Drexel University, College of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

It was the waning few hours of my 3rd year resident’s sixth twelve hour shift.  There were a handful of drunken men sleeping on stretchers, likely to metabolize to freedom by the time the sun rose.  A couple asthmatics were sitting on chairs getting a breathing treatment, as they had run out of their inhalers.  A patient with knee pain for two years was just registering.  Then the ambulance doors opened letting forth sounds that would put screaming banshees to shame.  The accompanying officers in blue yelled, “running in and out of traffic naked; probably PCP.”  The resident, who had been doing admirably, sputtered “How have you been doing this for a quarter of a century?  How does this not get to you? “Her eyes silently pleaded, “What is the secret?”

Sure, the question regarding burnout was frequently bantered about thirty years ago when I was a 3rd year medical student considering this new specialty as my career.  The ‘party line’ so to speak was that few in emergency medicine at that time actually chose and trained for this field.  It was likely many, if not most, came to EM after ‘burning out’ in their chosen specialty.  Thus, they were already essentially behind the 8-ball when they moved their job to the emergency department.  We wouldn’t be at such risk.  We were going into this with eyes wide open.  We were trained for exactly the situations we would encounter.  We would know all the pitfalls, plateaus, and rewards.  We would be able to deftly negotiate the punishment of shiftwork, chaos, and lack of control to be able to leave the hospital enjoying life without being on call.  We got this.

Burnout has increasingly entered conversation, ever since the landmark 2012 article by Shanafelt showing nearly half of physicians at that time suffered from at least one symptom of burnout [1].  Since that time emergency medicine has consistently taken either the first or second spot within the house of medicine [2,3,4,5].  I was wrong.  We don’t ‘got this’.

The resident’s question was a fair one.  How does one have longevity and sustain passion in this line of work?  How do we avoid burnout from the systemic pressures piled on us?  How do we combat compassion fatigue or PTSD from constant flow of people being seen on the worst days of their lives?

At that moment, I desperately wished I had an answer.  Given the luxury of time for reflection, I came up with my top three.

  1. Find a passion: This is true both within and outside of work. I love to travel.  It gives me something to plan and dream about.  It is an identity outside the hospital.  What matters most is that it is something that brings you satisfaction and a sense of joy or worth.
  1. Identify someone to talk to: There is tough stuff in what we do. Sharing stories can decrease the intensity of emotions.  Knowing one is not alone is key to human existence.
  1. Carefully craft your mantras: A mantra is generally thought to be a repeated word or phrase that is a ‘sacred utterance’ which one tells themselves. It comes from “man” for mind and “tra’ for transport.  Thus, these words transport the mind to a vantage point with which we view the world.  The words we tell ourselves can change the way we see the world.

Returning to that resident, I wanted to say there are several things that keep me doing this, but in those moments the strongest one is the soundtrack in my mind.  You can create phrases that make patients seem like enemies, or you can develop others that reorient the world.

When those ambulance doors open unleashing ungodly sounds, my first thought is, “sounds like one of my kids.”  When I get out of my car for my shift I tell myself, “Tonight I have the opportunity to relieve pain and suffering. What could be better than that?”  Throughout the shift I tell myself “Emergency medicine is the last best place in medicine.”  And I mean every single one of them.

References / Further Reading:

[1] Shanafelt TD, Boone S, Tan L, et al.   Burnout and satisfaction with work-life balance among US physicians related to the general US populations. Arch Intern Med. 2012 Oct:172(18)1377-1385.

[2]http://www.medscape.com/features/slideshow/lifestyle/2017/overview accessed March 8, 2017.

[3]http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=2 accessed March 8, 2017.

[4]http://www.medscape.com/features/slideshow/lifestyle/2015/public/overview#2 accessed March 8, 2017.

[5]http://www.medscape.com/features/slideshow/lifestyle/2013/public#2 accessed March 8, 2017.

EM Mindset: Reading My Mind

Author: Judith E. Tintinalli, MD MS (Professor of EM / Chair Emeritus, Department of EM, University of North Carolina) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

A style of working, teaching, and learning in Emergency Medicine takes time to develop.   We don’t get much opportunity to see how our colleagues operate, except perhaps on change-over rounds, which are always pressed for time, and which don’t allow for discussions about why different attendings do things differently.  I’ve always thought of myself as a middle-of-the roader in our group: middle in terms of times, patients/hr, decisions to admit versus discharge. But I’m pretty good at documentation, work generally on the careful and compassionate side, can work at the speed of light when necessary, and have learned from the past so hopefully current mistakes are few and far between.

So, step into my office and I’ll share with you some of my habits, behaviors, and opinions that I’ve developed over the years.

Supervising Learners

Working in an academic medical center has great rewards.  Being surrounded by shadowers, medical students, and residents of all specialties keeps you on your toes. Medicine has moved from time-lapse to fast-forward, and residents who have recently completed inpatient rotations are terrific sources of changes in specialty practice patterns.  But the growing number of learners you are responsible for on a shift can be intellectually overwhelming and certainly slows down the process of patient care.  A different approach is needed for each level, so that one can loosen (but never eliminate) the level of supervision for the most senior learners.

I start my shifts explaining how to structure presentations. The goal is to get a good mental picture of the patient – ill-appearing, obese, amputee, in pain, blind or deaf, angry, demanding.  Then a concise statement of the triage note and patient’s problem, but with a listing of key meds/conditions that will affect the ED workup.  ‘This is a 65 year old patient with atrial fibrillation on Xarelto with 2 hrs of acute abdominal pain’.  Key meds for me are antithrombotics, immunosuppressives, steroids, insulin.  I’ll never forget a ‘routine’ intern presentation of a 65 year old woman who fell at home, and now had a femur fracture. When I went to evaluate her, I was aghast at not being told she had a heart transplant and had severe COPD requiring home oxygen.  How many times have I been told confidently that vital signs were ‘rock stable’, only to find a pulse rate of 120 or a BP of 230/170.

So, focused and concise presentations help a busy attending prioritize which patients need to be seen as soon as possible. They also teach learners how to present to consultants.

Teaching in the ED

There’s a growing body of EM literature that focuses on clinical teaching in the busy ED.  Each of us has to develop our own style.  I like to ask for the main, and then major differential diagnoses, before the learner spews out the orders, so the learner can demonstrate why each order is needed. I keep trying to minimize laboratory orders, but one of our jobs is to let each learner order stuff, and with experience, to be able to gain confidence in clinical judgement and stop ordering unnecessary labs and imaging. That is a trial and error process. One good tool is to ask the resident ‘If this patient came into your office, would you send them to the ED to get these lab tests or imaging?’

One of the best teaching tools I use is to ask a question that I myself cannot answer.  Like – ‘OK this person with prior DVT and PE is on Xarelto, and now we’re concerned about another PE. What’s the failure rate for Xarelto and does this patient have any risk factors for failure?’  Another tool is to come armed with a recent article you’ve read, ready to whip it out when needed.   For example, our residents like to order stress tests out of the ED for patients with low probability chest pain, because we have a protocol, but ask them ‘why’, ‘how’, or ‘what does it cost the patient’ and you’re met with silence.  So for a while I kept a copy of Long and Koyfman’s article  ‘Current Controversies in the Evaluation of Low Risk Chest Pain (JEM Dec 2016)’ in my doctor bag,  let them see the current data on the topic, and then give the opportunity to re-evaluate their decision.   Another one I kept with me recently was the recent study on single-dose decadron 12 mg po for adults with mild-moderate asthma.  As residents don’t read journals anymore, it gives them the opportunity to at least read a journal abstract.

Procedures and Consultations

In emergency medicine, we’ve structured our residency programs so the majority of learning and teaching is in tertiary care centers.  Consider the disadvantages: where specialty consultants are available 24/7, it can be a lot easier to call ortho to reduce a hip, evaluate a fracture or tap a joint, to call GU to place a difficult Coude catheter, or to have neurology decide who gets tPA for possible stroke.  The community EM practices that most of our residents will select after graduation will typically have a very limited menu of emergency consultants, and I’m not sure we are training them well for these environments.  I always have residents think through their treatment plans before calling the consultant, as this is their future reality.  I remember during the early days of EM training, moonlighting was really frowned upon.  The philosophy was that the only time anybody cared about resident learning was during residency, so every minute should be spent reading, seeing patients, and learning.  The medical environment has changed, and our senior residents get invaluable experience moonlighting that we cannot give them in a tertiary care environment.

Disposition and Follow-Up

This is where I think attendings and residents diverge.  I explain that everyone, learner or attending, has his or her own inherent ability to tolerate uncertainty.  If a resident strongly wants to admit a patient that I feel can be safely discharged, I challenge him or her to present the case to the admitting team. This gives a chance to practice skills needed in a community ED setting.  Another area of divergence is how far to go to exclude specific diagnoses in the ED. In our current medical care system, where so many patients have no insurance, giving them a clean bill of health in the ED means a lot. So ultrasounds, MRIs, and CT scans, and sometimes consultations in the ED to provide a clear follow-up plan, are more and more part of routine management.  Disposition requires a lot of stepped-thinking. Recently I took over a shift where a young Spanish-speaking woman came into the ED with a disc of a head CT identifying a brain tumor. Imaging had been done at an outside community hospital without neurosurgeons, and the patient was told to make an appointment with a neurosurgeon.  Mystified, she came into the ED.  Her discharge had already been written by the previous shift team, and the phone number of neurosurgery clinic was provided.  We held the discharge and consulted neurosurgery.  The CT was reviewed, an MRI was then done, decadron and Keppra were recommended by the neurosurgeon, and a clear follow-up was arranged in 3 days in neurosurgery clinic.  These steps would be very difficult to manage as an outpatient, where waits for an MRI can be weeks; payment is required before testing; the clinic appointment team may or may not speak Spanish; and it can take weeks to get an appointment in an overburdened neurosurgery clinic.  Another important principle I try to teach is ‘we cannot predict the future’.  Residents will sometimes say, oh, why get this specialized imaging; why call the consultant, they won’t do anything; why try for admission – there’s an easy answer.  I cannot predict the future – can you?

Why I love Emergency Medicine

A recent JAMA article reported that emergency medicine has the highest burn-out and fatigue rate of any other specialty.  If that is so, why are medical students flocking to our residency programs? Not every shift is wonderful – some are exhausting, filled with contentious problems or patients. Most times I look forward to a shift, but sometimes it is hard to put one foot in front of the other as I walk to my desk.  But I think all of us would rather be emergency physicians rather than anything else.  We have the unique ability to help patients when they are most vulnerable.  We have to establish rapport within minutes, not weeks or months.  We work in a terrific team environment.  We learn to be flexible, can calm down irritable consultants, and like to make fast decisions.  We can work a lot of shifts or fewer shifts. We don’t carry our patient burdens home with us. Life is good.

EM Mindset: the Fickle Gravity of Fear

Author: Shannon Moffett, MD (EM Attending Physician and Clerkship Director, Rutgers New Jersey Medical School) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Reading through my predecessors’ work on this topic, I am struck by the absence of any specific mention of fear. Perhaps it is because fear and anxiety, like bad odors, are omnipresent in the emergency department, and so we become accustomed to them.  Like city smog, the sulfur in your hometown’s tap water, or the pop-pop of gunfire outside your ambulance bay, live with anything long enough, and it becomes background.  Which is as it should be – on any given day, an EM doc should be blind to fear – examining fear on shift is as unhelpful as a lecture on gravitational acceleration during a tightrope act.

Or it would be, if fear were constant, like gravity: a steady tug on your arm as you intubate, the pit in your stomach the exact same depth day after day.  Which, for stretches, it is.

But conditions fluctuate during our medical high-wire acts, and our muscle tone varies. Often, the change in our conditioning is linear and slopes up.  We are scared the first time we stick a needle through the skin of another human being, the first time we order a paralytic, the first time we discharge a patient we haven’t diagnosed. But for long periods, we proceed in our fear-grapple like a baby hitting milestones – we cruise on by.

There comes a time – perhaps you are in that glorious period now – when you feel wary but confident; you have so much under your belt.  There is little that surprises you – you’ve learned from your mistakes, or been super-blessed and been able to learn from others’ mistakes (all the knowledge, none of the pain!).  You are a sprinter, not an aerialist – your movement is in a different plane.

And then, later, something happens – the earth tilts on its axis; you’re chucked into a human centrifuge; the bottom drops out and your epigastrium plunges into the canyon where your umbilicus once was, like a stone off a cliff. Suddenly, like an astronaut just back from the space station, your usual tasks take all your accessory muscles – “what if…?” whines incessantly in your head as you plan your work-ups, send patients to the floor or home on the bus.  As with food-poisoning, it’s usually hard to pinpoint the source of the disturbance.

Or worse – you develop one of the flavors of emergentologist’s periodic paralysis: Type A (spastic) – the moment you’ve glimpsed the vocal cords in your zone two stab wound, your arm starts joggling and your ears start whistling and suddenly it’s like trying to intubate in the back of a flatbed truck whizzing down a gravel road at midnight. Or Type B (flaccid) – the unresponsive infant arrives, and you lose all tone while your brain goes still and dead-white as the baby. And then there’s Type C (mixed with cognitive/axis 2 features) – you reach the bedside of the agitated patient with the deeply creepy eyes, and a single quaver in your voice betrays you and alienates your patient, so you leave the room to re-set, snapping at the nurse for it-doesn’t-matter-what on the way out. Meanwhile, you feel your grip on the department slip, slipping, sliding, until suddenly: tunnel-vision.  The rest of the department falls away, and you sit down to take care of some charting.

And this is where the problem with our usual fearless funambulism presents. We become so accustomed to fear, even to the odd intermittent surges in the fear-force, that we fail to recognize when we are in the free-fall commonly known as panic.  And, because we’ve become so good at masking our response to fear, even if we ourselves know we are scared, we fail to give off the signs that would tell someone else we are in trouble and allow them to help.

We are ashamed of our fear, of what it says about us, and most of all of what fear has made us do.  Even now, I’m scared to write down here the stupid things I’ve done while in the grip of fear.  Snapped at nurses, sure.  Just gone ahead and done something despite suboptimal conditions? Check! From removing a urethral foreign body in a teenager in a semi-public area to trying to intubate a crashing kid in an ambulance in a parking lot, resisting suggestions that we scoop him up and move him the few feet into the ED, I’ve failed in my attempts to stay sensible in the face of fear, allowing panic – masquerading as efficiency or commitment – to force my hand.  That second one died, by the way.  As did the man whose critically low calcium I didn’t notice before quickly discharging him to jail in my fearful pursuit of an unclogged ER.  There are more.  But already my fear is telling me to shut up and quit exposing myself as the rotten doctor I’m terrified that I am.

Which, I suppose, is my point with all this.  Because fear feeds on itself, and on the idiocies you commit while in its grip.  If you are in any way introspective, which based on the fact that you are reading this I assume that you are, the mistakes you make while in fear’s clutches will haunt you forever, festering and bubbling and tumescing out of sight, breeding more fear. The more calamitous fodder you give fear, the stronger it gets, and the stronger it gets, the more ravaging fear’s effects on your capacity to walk the tight-rope of our practice.

Even more difficult than admitting fear is admitting that we have two fears – we fear for our patients’ wellbeing, of course.  But when we really look in the dark crannies of our souls (in that place where we know that whatever we call it, what we are doing is deep sedation) we must admit that, perhaps even more, we fear SCREWING UP. That fear comprises concern for our patients, but also intense self-interest.  Usually, our systems are set up (and we should be deeply grateful for this) so both types of fear prod us to do the right thing for our patients. But retaining our clarity of thinking on this division allows us to consciously address the rare cases in which what is in our own self-interest is not in the best interest of the patient (Think repeat abdominal CT. Think the quick opiate prescription to avoid an argument. Think rushing a jail-bound patient out before sign-out so you can present a tidy ED and head home for a beer.)

So what to do? The first thing, I believe, is to acknowledge fear, something I’ve found remarkably difficult in the cowboy culture of EM. We acknowledge it obliquely (who hasn’t retrospectively discussed the tone – or lack thereof – of their own sphincters during a code), but when was the last time you said – or heard any other ER doc say, in the moment – “I’m scared.” I’m not advocating dwelling on your fear (at least not while on-duty), just a tip of the hat, a reminder to tare the scale.  And, once you trust your nurses and your colleagues, admit it to them as well.  Don’t dwell, just acknowledge.  You’ll burn up some of the fog surrounding your thinking, they’ll be ready to help, and you might just let them access and stabilize their own fear one day.

Then, of course, there is our balance-pole of knowledge, which well-tended and polished will consistently counter-act the eddies of fear. Don’t forget that if you don’t have a balance-pole, an umbrella might do the trick, by which I mean – grab a book, your phone, a friend – it’s so rare that there truly isn’t time to look something up, but so easy to let fear delude us into thinking we’re better off using that time elsewhere.

When you don’t have those couple of minutes, that’s when you may have to follow the famous twin-tower tight-rope artist Philippe Petit’s advice: “Wirewalker, trust your feet! Let them lead you; they know the way.”  Just don’t forget that he spent six years planning his twin towers walk, including hiring a helicopter to surveil the area, sneaking into the towers during construction, and building his own scale model of the towers to practice on.  He studied, he collaborated, he made friends with workers at the site.  You have, too.

Petit acknowledged that his performance is simple, a single path; it’s life on the ground that’s complex, and therefore hard. Due to the intricacy and monumental stakes of our own job, we will make terrible mistakes.  Deny your fears, allow their exposure to make you angry and defensive, and the winds begin to blow and the line to pitch.  Beat yourself up, hold yourself to the rigid and pristine standard we all have in our heads and you, and your patients, will suffer.  Perhaps you cannot be the doctor you wanted to be.  But ask yourself this: are you better than no doctor at all?  If the answer is yes, then you must tip your hat to fear, forgive your missteps, even the unimaginably appalling ones, then climb back up the ladder, grab your pole and set your eyes forward, and – trust your feet.

 

References / Further Reading:

-Wikipedia, https://en.wikipedia.org/wiki/Philippe_Petit, accessed 2017-03-03

-Philippe Petit, To Reach the Clouds: My High Wire Walk Between the Twin Towers. North Point Press (September 4, 2002)

EM Mindset: Tips on Becoming a Supreme Educator

Author: Benjamin H. Schnapp, MD (@schnappadap, Assistant Program Director, Assistant Professor, Department of Emergency Medicine, University of Wisconsin) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

I can’t pretend to know more about how to be a great EM doc than the amazing folks who have already written for this series – the archives are filled with endless pearls of wisdom and are well worth a look (http://www.emdocs.net/category/em-mindset/).  Educating in the midst of a busy EM shift, however, requires its own dedicated mindset to be successful.  Here are some of the things I’ve learned about teaching in EM along the way.

Every great teaching shift has a beginning, middle, and end.

I sometimes find myself at a loss as to what feedback to give residents at the end of shift; the day goes by so quickly, it’s hard to remember what points I once wanted to communicate.  This is almost always because I didn’t organize my day properly from the start.  If I ask learners at the beginning of the shift what their goals are for the day, it helps organize my interactions with them.  Rather than trying to evaluate everything they do, I can zero in on one aspect of their performance, which is easier to accomplish.  The feedback conversation at the end of shift also flows naturally – it’s easy to bring up your initial conversation and immediately have specific suggestions that you know the resident is interested in.

Bring a toolbox to work.

You wouldn’t show up to build a house without the proper set of tools for the job.  Why would you show up for your next teaching shift similarly unprepared?  All sorts of great teaching tools have been developed to help you deal with any educational quandary you might come across.  Need to work on developing a learner’s differential diagnosis?  You’ve got to know about the SPIT technique.  Don’t have time for a verbose presentation right now?  Aunt Minnie may be just the thing.  “Teaching When Time Is Limited” (http://bit.ly/2kQPs9S) is a great place to learn more about these essential skills.

Smaller is better.

It’s easy to feel that if you aren’t sitting your team down for an extensive lesson on every patient that you’re not doing much teaching on shift.  However, these extended moments for teaching can be hard to come by in the ED.  Instead of looking for big teaching opportunities that may never come, think small.  One article, pearl of wisdom or even a simple fact can have a huge impact on your learner’s future practice, and there’s no risk of distraction from extraneous information.  This goes for feedback at the end of shift too – if you’ve got an important point to get across, don’t bury it in a pile of less essential feedback.

Don’t signpost.  Billboard – in neon.

Signposting refers to the practice of telling residents that you’re about to teach them before you do.  In theory, this avoids the common problem of residents underrecognizing the educational pearls you impart throughout the shift. In practice, I find even this is often insufficient.  You need glaring, unmistakable indications of ongoing education.  Grab a giant whiteboard (@amalmattu is a fan of this one).  Stick brightly colored post-its to your computer (a la @M_Lin).  Stand up and shout (I have been known to do exactly this prior to a mini-teaching session).  Find something that meshes well with your teaching style and get credit for your great work.

Eliminate mindreading.

It is fun to teach evidence-based medicine, but the world we encounter every day in the ED is highly complex. Often, great evidence to aid us in managing our patients is lacking.  In this setting, learners can see wide variations in attending practice patterns, which can be frustrating to their learning.  Why does this elderly patient who has fallen get admitted and this one goes home?  Aid learners in developing expert-level thinking by lending them some of yours.  For particularly tricky cases, I highlight my diagnostic process out loud to my learners, including what pieces of the case I am keying in on most.  Though some may worry that verbalizing their thinking may expose a lack of solid grounding for their decisions, learning to make good choices with limited information is an essential part of the job.

Hidden teachers are everywhere.

While EM docs like to think that we have the most interesting job in the department, there is a ton of important work that’s constantly being done by nurses, pharmacists, techs, social workers, and others that can offer incredibly valuable learning experiences, especially for more junior learners.  While you shouldn’t unload your learner onto another staff member for a whole shift, helping a nurse place an IV or catheter, assisting a pharmacist with dosing medications or watching a tech do a 12-lead EKG can be great opportunities for learners to get involved and learn new skills one on one from staff that will likely be thrilled for the teaching opportunity.  Don’t be afraid to utilize your resources.

Be there.

Woody Allen once said that 80 percent of life is showing up, and in many ways, the same goes for educating in the ED.  There are a million reasons not to leave your chair on shift – the chair is warm and close to your coffee, you have charts to complete, the resident doesn’t need your help, etc.  Resist this impulse and go observe your learners at work.  You’ll be surprised what knowledge gaps you find – there are senior residents out there with poor laceration repair skills!  This is also an excellent method to uncover previously hidden communication and efficiency issues that may not come to light elsewhere.  Even the most skilled learner can benefit from your experience and perspective on how to fine-tune their approach to patients and procedures.

Silence is golden.

When learners don’t know the answer to one of your questions, it can be tempting to just give it to them rather than sit in awkward silence.  Resist this urge, and embrace the awkwardness.  Some learners may need more time to think about your question, and you won’t understand the exact nature of their deficit unless you wait.  One learner might know exactly the right answer but not be confident enough to share.  Another might misunderstand the entire concept you’re inquiring about.  The next step in your teaching is completely different for these two learners, but unless you stop and wait to hear what they have to say, you’ll never know the difference.

Be humble.

The ED is a constantly humbling place.  You make thousands of decisions per shift: the best you can hope for is only getting a few of the small ones wrong.  Occasionally though, you may find yourself humbled by a bigger error.  The resident orders a CT scan that you tell them wasn’t needed and there’s a major finding.  The patient you sent home comes back septic.  Own up to these errors.  I’ll even email the resident directly to point out what happened – if the unexpected outcome was a learning experience for you, it will also be one for the resident.  Open dialogue will go a lot further for promoting trust and a positive learning environment than futilely trying to preserve an aura of invincibility.  Similarly, don’t be afraid to ask your learners for feedback on your teaching – they may have a great tip that you’ve overlooked!

You are always teaching.

There are days when all the consultants are difficult, all the dispositions are complicated, and by the way, your electronic medical record system is going to be down for the remainder of your shift.  When catastrophes (large or small) occur, teaching is often the first thing to go – who has time to sit down with the medical student when the ED is falling apart?  It’s important to remember in times like these that you are actually doing some of the most critical teaching that you’ll ever do.  As the captain of the ship, all eyes are on you for how you’ll manage the crisis.  Bad behaviors like avoidance, blaming others, or taking frustrations out on patients will quickly establish for all of your learners that these are acceptable behaviors when circumstances get difficult.  Show them instead how you lead through tough situations – even if that’s all you teach them that day.

Ultimately, I think it’s your intrinsic interest in improving as a teacher that will get you the farthest as an educator, and if you’ve made it to the end of this post, you likely have this quality in spades!  Do you have experience with any of the above techniques?  Words of wisdom of your own?  Feel free to share in the comments.

Special thanks to Dr. Abra Fant (@DrAbracadabra) and Dr. Aaron Kraut (@akraut23md) for their assistance with this piece.

EM Mindset – Louis Ling – Mistakes, Teaching, Connecting

Author: Louis J. Ling, MD (Senior Vice President for Hospital-based Accreditation, ACGME; Professor of Emergency Medicine and Pharmacy, University of Minnesota Medical School) // Edited by: Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

When I work in the ED, I have to get in the right frame of mind; to psych myself up for the busy, hectic, and chaotic environment that I have grown to love. For the first few years of practice, I dreaded going to work; afraid I was going to miss something or make a mistake.  After two years as an attending, I realized that with the number of decisions that occur during every shift, mistakes and errors were inevitable.  I gave myself permission to make mistakes, but to make them safe mistakes when possible and to learn from my mistakes.  (Safe mistake does not mean overtreatment.)  That is my first mindset that I take to work every shift.

My second mindset is to teach and supervise while not getting in the way of the learners.  Most teachers are so busy telling their learners what to do, they never have a chance to learn; they only regurgitate what they were told.  I now see my role as primarily the hint generator for the “Pit Boss”.  For that to make sense, let me explain the Hennepin layout.

There are three major team centers, each with approximately 15 rooms, staffed with two to three PMPs, primary medical providers and a Pit boss and a faculty.  The Primary medical providers can be PAs, G1 residents of both EM and off service and junior EM and IM residents.  They are the primary contacts for the patients, nurses, and consultants and responsible for the charting. This team is supervised by a Pit boss, a senior EM or EM/IM resident, who also sees every patient but does no charting, except for patients seen with a medical student.  The goal is to have pit bosses make as many decisions as possible without the burden of charting (a dream job).

When I see patients, I will ask the pit boss questions as to the differential and the plan and why or why not certain tests were ordered.  The patient does not have to be managed exactly how I would if the pit boss has reasonable answers that justify their decisions, however, if pit bosses are shot gunning or missing key tests, or generally in need of advice, the management can change.  One of the challenges of being a resident is trying to guess how each particular faculty would manage each patient.  My goal is to let the pit boss manage the patient independently, while avoiding errors, not to manage the patient exactly the way that I would.

I prefer to see patients along with a resident. (I am told this is rare for faculty to observe) This is easiest at the start of each shift especially when the patients and residents are all new, or when a patient is brought in by ambulance or roomed and freshly seen by a resident. When I listen to the history, I assess how the questions flow in a logical order where the resident is trying to raise the suspicion of or to narrow the differential or to rule out possible maladies.   It is common for novices to ask from a checklist without knowing the significance of each question.  Watching the exam is instructive and residents often listen to the heart and lungs, to meet my expectation. I frequently give permission to them to skip the automatic response and simply focus on the problem area but to always examine something (for the patient’s expectation, not mine).  It is common that problem specific exams are incomplete or improperly done, again from a checklist and not to elicit information to rule in or rule out specific conditions.  Examples include joint exams, abdominal and back exams.  When we leave the room, I try to give one positive observation that they should continue and one suggestion on how to improve.  If I am commenting on the exam, I might repeat certain portions to demonstrate and to have them repeat it.  Of course, seeing patients with PMPs is inefficient and I know I will fall behind so when that happens, I resort to cruising the rest of the rooms and seeing patients quickly until I catch up.  Seeing patients with a pit boss can be efficient since they are usually quick and much more focused and this is a good way to develop a plan with the patient present that the pit boss can share with the nurses and the PMPs. We often will discuss the possible dispositions at the same time.  Because I try to actively be involved, I typically get way behind on my charting.  I write short notes emphasizing the thought process and keep current on the patients who are admitted.  For patients who are discharged, I save the charting for after my shift.  Thank goodness for CITRIX.

The Pit Boss also has primary responsibility for all resuscitation and unstable patients in the stabilization room.  (The hope for all pit bosses is to spend the day in the stab room instead of seeing patients with me.)  During those times, I take over the Pit boss role and will manage the patients directly with the PMPs.  Some PMPs are nervous about approaching me directly so I usually ask the PMPs how I can help or how their plan is progressing.  When I see patients as a PMP myself, I have learned to pick the quick and straightforward ones and move them along to decompress the area.  I discovered that when I pick up complicated patients, that despite my best of intentions, I often get distracted from them and their time in the ED is longer than if they had a different PMP.

When I picked emergency medicine as a specialty in 1979, the year emergency medicine became a specialty, I had thought the reward would be saving lives and doing dramatic procedures and never having to provide chronic care.  I now know that those moments are indeed rewarding but much less often than I had imagined.  The surprise diagnosis, solving the puzzle, and the well done procedure is still fun but the day to day reward is connecting with patients as human beings, providing a little comfort and caring, some reassurance and education.  That is a wonderful mindset to have.

When I started working for the ACGME several years ago, I had considered seeing patients in Chicago but realized that I would never become facile with the System-based practice.  The EMR would be awkward and I would be a drag and hindrance to a resident.   I only work one shift a month (and I skip July), so I have tried to minimize my system-based errors by working in the ED that I have spent 30 years, where I understand the culture, I still know the nurses and the consultants, the code to the bathroom and EPIC knows my password.  I always work in the same team center on Saturday and there are always two other faculty present in the ED.

I no longer manage resuscitations.  When I did, I still saw my role as giving hints and whispering in the Pit boss’ ear, but letting them manage the care and direct the traffic.  My other role was to keep the attending surgeon or consultant out of the way when they became meddlesome.  While I miss those cases, it was unfair to take that experience from the full-time faculty, and to care for the sickest of patients when I am no longer at the top of my game.

I often wonder when my clinical skills might become so sclerotic that I should quit clinical care altogether.  When I work with the Pit bosses, senior residents a few months away from independent practice, I realize I may not be smarter than they are but I am still much trickier.  Although I am not as fast and efficient as I once was, I am better than a new graduate.  I have to be extra careful when it comes to up-to-date and new treatment but the essence of connecting with and caring for patients is still there.  I have to ask more questions and rely on others for bedside ultrasound.

So there it is; my mindset of going to do a shift includes 1) realizing that I am going to make mistakes but to try and make them safe mistakes, 2) teaching while staying out of the way of learners’ learning, and 3) remembering to connect with human beings during their time of need.

EM Mindset – Joe Lex – Thinking Like An Emergency Physician

Author: Joe Lex, MD (@JoeLex5 – Clinical Professor of Emergency Medicine, Temple University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

“Emergency Medicine is the most interesting 15 minutes of every other specialty.”

– Dan Sandberg, BEEM Conference, 2014[1]

Why are we different?  How do we differentiate ourselves from other specialties of medicine?  We work in a different environment in different hours and with different patients more than any other specialty.  Our motto is “Anyone, anything, anytime.”[2]

While other doctors dwell on the question, “What does this patient have? (i.e., “What’s the diagnosis?”), emergency physicians are constantly thinking “What does this patient need?[3]  Now?  In 5 minutes?  In two hours?”  Does this involve a different way of thinking?

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues.  Yes, we do it on a daily basis, many times during a shift.  Every time I introduce myself to a patient, I never know which direction things are going to head.  But I feel like I should give the following disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time as it takes to determine whether you are trying to die on me and whether I should admit you to the hospital so you can try to die on one of my colleagues.[4],[5] You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  After today, we will probably never see one another again.  This may turn out to be one of the worst days of your life;[6] for me it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many months or years, possibly even for the rest of your life.

I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me the story, and for me to understand that story I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part, but in an average 8 hour shift I will make somewhere near 10,000 conscious and subconscious decisions – who to see next, what question to ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, which consultant will give me the least pushback about caring for you, is your nurse one to whom I can trust the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  So even if I screw up just 0.1% of these decisions, I will make about 10 mistakes today.[7]

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio: gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG.  I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise, I am more likely to be led down the wrong path and come to the wrong conclusion.[8]

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up the odds are very, very good that you will be fine.  Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.”  For the most part this has not changed.  In addition, Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.”[9]  Remember, you don’t come to me with a diagnosis; you come to me with symptoms.

You may have any one of more than 10,000 diseases or conditions, and – truth be told – the odds of me getting the absolute correct diagnosis are not good.  You may have an uncommon presentation of a common disease, or a common presentation of an uncommon problem.  If you are early in your disease process, I may miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or use of drugs and alcohol, I may not follow through with appropriate questions and come to a totally incorrect conclusion about what you need or what you have.[10]

The path to dying, on the other hand, is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.[11]

You may be disappointed that you are not being seen by a “specialist.”  Many people feel that when they have their heart attack, they should be cared for by a cardiologist.  So they think that the symptom of “chest pain” is their ticket to the heart specialist.  But what if their heart attack is not chest pain, but nausea and breathlessness; and what if their chest pain is aortic dissection?  So you are being treated by a specialist – one who can discern the life-threatening from the banal, and the cardiac from the surgical.  We are the specialty trained to think like this.[12]

If you insist asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know, but it’s safe for you to go home” without giving you a diagnosis – or without doing a single test.  I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved and other doctors will anchor on that diagnosis and you may never get the right answers.[13]

Here’s some good news: we are probably both thinking of the worst-case scenario.  You get a headache and wonder “Do I have a brain tumor?”  You get some stomach pain and worry “Is this cancer?”  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that, no matter how trivial your complaint, you have a fear that something bad is happening.[14]

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, trying to clarify an obscure order for a nurse, or I may get called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.[15]

I will use my knowledge and experience to come to the right decisions for you.  But I am biased, and knowledge of bias is not enough to change my bias.[16]  For instance, I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this diagnosis at least half the time it occurs.[17]

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).[18]  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).[19]  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.[20]

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is essential for me to do so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  The final chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.[21]

What’s that?  You say you don’t have insurance?  Well that’s okay too.  The US government has mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact I can be fined a hefty amount if I don’t.  And a 2003 article estimated I give away more than $138,000 per year worth of free care related to this law.[22]

But you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracostomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter.  I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure, and I can talk you through your bad trip.[23]

Emergency medicine really annoys a lot of the other specialists.  We are there 24 hours a day, 7 days a week.  And we really expect our consultants to be there when we need them.  Yes, we are fully prepared to annoy a consultant if that is what you need.[24],[25]

Yes, I have seen thousands of patients, each unique, in my near-50 years of experience.  But every time I think about writing a book telling of my wondrous career, I quickly stop short and tell myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others.[26]  What you construe as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings – they are so trite, so threadbare.  Nonetheless, they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”[27]

Have you ever heard of John Coltrane?  He was an astonishing musician who became one of the premier creators of the 20th century.  He started as an imitator of older musicians, but quickly changed into his own man.  He listened to and borrowed from Miles Davis and Thelonious Monk, African music and Indian music, Christianity and Hinduism and Buddhism.  And from these disparate parts he created something unique, unlike anything ever heard before.  Coltrane not only changed music, but he altered people’s expectations of what music could be.  In the same way, emergency medicine has taken from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and we have created something unique.  And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?[28]

References / Further Reading

[1] https://twitter.com/jeremyfaust/status/447822776447930368 Accessed 27 December 2015.

[2] http://www.amazon.com/Anyone-Anything-Anytime-Emergency-Medicine/dp/1560537108.  Accessed 27 December 2015.

[3] http://emupdates.com/wp-content/uploads/2010/09/eThinking-Slides.pdf.  From a talk by Reuben Strayer.  Accessed 27 December 2015.  See slide #12

[4] Alimohammadi H, Bidarizerehpoosh F, Mirmohammadi F, Shahrami A, Heidari K, Sabzghabaie A, Keikha S.  Cause of Emergency Department Mortality; a Case-control Study.  Emerg (Tehran). 2014 Winter;2(1):30-5.

[5] Olsen JC, Buenefe ML, Falco WD.  Death in the emergency department.  Ann Emerg Med. 1998 Jun;31(6):758-65.

[6] http://www.smh.com.au/national/the-day-i-meet-you-in-the-emergency-department-will-probably-be-one-of-the-worst-of-your-life-20151105-gkrbm7.html  Accessed 27 December 2015

[7] Croskerry P.  Achieving quality in clinical decision making: cognitive strategies and detection of bias.  Acad Emerg Med 2002;9:1184–204.

[8] Phua DH, Tan NC.  Cognitive aspect of diagnostic errors.  Ann Acad Med Singapore. 2013 Jan;42(1):33-41.

[9] Thomas L.  Your very good health.  N Engl J Med. 1972 Oct 12;287(15):761-2.

[10] Croskerry P, Sinclair D.  Emergency medicine: A practice prone to error?  CJEM. 2001 Oct;3(4):271-6.

[11] Rosen P.  The biology of emergency medicine.  JACEP. 1979 Jul;8(7):280-3.

[12] Zink BJ.  The Biology of Emergency Medicine: what have 30 years meant for Rosen’s original concepts?  Acad Emerg Med. 2011 Mar;18(3):301-4.

[13] Croskerry P.  Commentary: Lowly interns, more is merrier, and the Casablanca Strategy.  Acad Med. 2011 Jan;86(1):8-10.

[14] Croskerry P.  The cognitive imperative: thinking about how we think.  Acad Emerg Med. 2000 Nov;7(11):1223-31.

[15] Chisholm CD, Collison EK, Nelson DR, Cordell WH.  Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”?  Acad Emerg Med. 2000 Nov;7(11):1239-43.

[16] Croskerry P.  From mindless to mindful practice–cognitive bias and clinical decision making.  N Engl J Med. 2013 Jun 27;368(26):2445-8.

[17] Pineda LA, Hathwar VS, Grand BJ.  Clinical suspicion of fatal pulmonary embolism. Chest 2001;120:791-795

[18] Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121 (Suppl):2–33.

[19] Redelmeier D. The cognitive psychology of missed diagnoses. Ann Intern Med 2005;142:115–20.

[20] Norman GR, Eva KW.  Diagnostic error and clinical reasoning.  Med Educ. 2010 Jan;44(1):94-100.

[21] Hill RG Jr, Sears LM, Melanson SW.  4000 clicks: a productivity analysis of electronic medical records in a community hospital ED.  Am J Emerg Med.  2013 Nov;31(11):1591-4.

[22] http://www.acep.org/Clinical—Practice-Management/The-Impact-of-Unreimbursed-Care-on-the-Emergency-Physician/  Accessed 27 December 2015.

[23] https://www.acep.org/uploadedFiles/ACEP/Practice_Resources/policy_statements/2013%20EM%20Model%20-%20Website%20Document(1).pdf  Accessed 27 December 2015.  See pp 44-47.

[24] Johnson LA, Taylor TB, Lev R.  The emergency department on-call backup crisis: finding remedies for a serious public health problem.  Ann Emerg Med. 2001 May;37(5):495-9.

[25] Asplin BR, Knopp RK.  A room with a view: on-call specialist panels and other health policy challenges in the emergency department.  Ann Emerg Med. 2001 May;37(5):500-3.

[26] Norman G, Young M, Brooks L.  Non-analytical models of clinical reasoning: the role of experience. Med Educ.  2007 Dec;41(12):1140-5.

[27] South Wind by Norman Douglas.  THE MODERN LIBRARY; Thus edition (1925).  Page 176.

[28] Wolffhechel K, Fagertun J, Jacobsen UP, Majewski W, Hemmingsen AS, Larsen CL, Lorentzen SK, Jarmer H.  Interpretation of appearance: the effect of facial features on first impressions and personality.  PLoS One. 2014 Sep 18;9(9):e107721..

One Physician’s Advice to the New Grad

**Author’s note: This was originally posted on June 24, 2015

To the Class of 2016 – Congratulations!!  You’ve made it.  After at least 11 years of post-high school education, you have finally reached that proverbial finish line and are ready to transition from resident to attending.  What I would like to share with you is some advice about what life is like on the other side.  Now that you have finished residency, it’s safe to say that you know the medicine really well.  But, I have come to find that your learning about life as a professional is just beginning.

First piece of advice – and I realize it’s as cliché as it comes – you never get a second chance to make a first impression.  You’re walking into a new place and a new culture.  You will know all the newest technologies and latest research fads.  But, you won’t know simple things like, where can I go to the bathroom?  How do I literally get someone admitted?  What service takes care of particular problems at your institution?  I can say with absolute certainty that your stress level will be higher than baseline just by walking in on your first day.  Higher stress correlates with less patience and poorer communication.  Snap at one nurse on your first day and it will take over a year to recover.  That piece of advice is from firsthand experience.  You really need to focus on situational self-awareness.  You need to recognize when you’re running a little hot, and be able to harness it.  Be cordial, grateful, and vulnerable.  Don’t hesitate to ask for help.  People like feeling needed.  Your clerk is going to be your best friend.  Introduce yourself right away and tell him/her, I’m going to need your help getting through the day.  Getting help with the logistics in the beginning won’t undermine anyone’s view of your clinical competence.

This leads me to my second piece of advice – on one of your first shifts, buy pizza for the entire ED staff.  Depending on the size of your shop, it may cost a few hundred bucks.  The investment will be worth 10x that in good will.  The staff will talk about it for months.  You will be the doc that values his staff and wants to show how appreciative you are.

Try your best to learn everyone’s names.  It’s hard – there’s one of you and tons of them.  And our pesky name tag lanyards always seem to turn so the ID is not facing outwards.  I try to memorize one person’s name per week.  The most important names to remember: your security guards and housekeepers.  Be the one doc who values everyone’s role in the department.  I assure you most doctors walk by the housekeepers like they don’t exist.  They keep your department clean and mop up things you definitely wouldn’t want to.  Security guards keep you safe so you can go home to your loved ones.  They deserve to know that you value their role.

After a month or two of work, you’re going to have a moment walking into the hospital where you realize, “this is my life now.”  You will be able to imagine parking in the same spot and walking into the same ED for the next 20 years.  It’s going to be a mixed emotion.  In residency, you had different rotations to break up your ED months, and you were continually being exposed to something new.  Now you’re an attending, and there are no rotations.  There is no finish line you are trying to reach.  There’s just you and your colleagues working a shift and going home.  To make it through residency, you probably kept telling yourself how great attending life was going to be.  You were going to be making a lot more money and it wasn’t going to be nearly as grueling.  While the money part is definitely true, attending life can be every bit as grueling.  It can be hard when your expectation of what the future would be like doesn’t meet your reality.  It’s a totally normal feeling to have.  You are not alone, and it doesn’t mean you chose the wrong specialty, wrong job, or city.  It’s all part of the transition, and it almost always passes.

One of the best pieces of advice one of my attendings gave me was: whenever possible, go to the physician lounge.  Introduce yourself to whoever is there.    Serve on a committee.  Get to know the physicians by their first names.  Take an active stake in the future of the hospital.  Your phone calls will go infinitely better when your colleague has a face to put with a name.  The more involved you become within your department or hospital, the more indispensable you make yourself, and the more job security you will have.

If you want to have a great reputation with your consultants, be cordial with them, be grateful for their ED referrals, and never oversell an admission.  They will know very quickly if you are someone who is clinically competent, or if you are a liar.  I have gotten incredibly soft admits taken care of by saying from the outset, “This is a soft admission, but the patient can’t go home because… here’s what needs to be done on the inpatient side, and I’d be happy to take care of X, Y, Z for you while the patient is in the department.”  They will also appreciate the times you take care of their patient at 2am, get them squared away, and don’t call until 6am to inform them of what you did and that they will be calling the office that morning.  They value their sleep, and they value that you’re awake to take care of their patients.  After a while, they will know that when you’re waking them up in the middle of the night, you genuinely mean it and you need their help just as they have needed yours at other times.

Do whatever you can to resist the urge to pick up more shifts.  In the early years, you will be shocked by the number of zeros you can put in your paychecks.  You will start thinking to yourself, if I work “X” shifts I can pay for “Y.”  You will rationalize it as, I worked this hard as a resident, and I can still do it as an attending.  In the short term, this may be true, but over the long haul, it’s the best way to insure you burn out well before you intended to stop practicing medicine.  Use allotted vacation time.  Give yourself adequate sleep and turnaround time on shifts.  Don’t outspend your means.  Don’t buy a massive house when one half the size would be more than sufficient.  Treat yourself from time to time, but don’t buy every last thing you’ve ever wanted.  The more you spend, the more you become a slave to the shifts, and the cycle is hard to break.

Don’t freak out about your student loans.  Most of us got into this career by going more than $250,000 into debt pursuing our education.  It was an investment in your brain and livelihood.  There is a difference between being in debt and having no means to pay it off versus being in debt and making a 6 figure salary.  You will pay it off.  Just as I stated before, resist the urge to moonlight like crazy to pay off your debt in 3 years.  Do not make yourself cash poor by paying off more than you should in a given month.

You may find yourself working in a department that places a significantly larger emphasis on metrics and patient experience than where you trained.  This will be a tough transition for many.  I have worked for groups that had total transparency with metrics – each month we got data on every member of the group and where we fell on the bell curve.  It felt very threatening at first.  I felt like the group didn’t care about patient care, only numbers.  In truth, they cared very much about patient care.  But they also cared about throughput, efficiency, and how the patient felt about their experience in the department.  While we have altruistic feelings about helping others, we also like being compensated for what we do.  The money comes from patients choosing your department over the one down the street.  Be very aware of this.  The stability of your job and the group’s contract may rely heavily on it.  Be a proactive member and work to improve the experience of your patients; don’t ever publicly complain about it to the very people who have set up that culture of service.

In closing, as I walk into my shifts I find myself striving to live up to what I heard Amal Mattu say once: “Be the Tigger of your department, not the Eeyore.”  When you are on shift, you set the tone.  If you are happy to be at work, promote teamwork, and make sure those that do a great job are recognized, others will follow suit.  If you are slow, negative, and stressed out, the same holds true.  Be the doc that shows up and the nurses go, “Yes!” not the doc that causes nurses to say, “This is going to be a long day.”

We have chosen to work in an incredible specialty.  We get to help people who have nowhere else to turn.  People in their most vulnerable and scared state.  Every once and a while, we even literally bring someone back to life.  We are a specialty trained to run towards problems when everyone else’s instincts tell them to run away.  It is an amazing feeling.  There will be hard days, and no doubt days where you question why you ever chose to become a physician.  Those days are likely to be few and far between.  What you are more likely to feel is elation with the knowledge that you chose the best specialty in the best profession there is.  Good luck to you as you move on with your career.  It is such an exciting time!  Your teachers are very proud of you, and excited to see the physicians you will become.

Reflections on Leadership and Resilience in Emergency Medicine

Author: Justin Bright, MD (Senior Staff Physician, Henry Ford Hospital, Detroit, @JBright2021) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Your department volumes have outgrown your physical plant.  There is not any additional space to build on, and even if there were, there is not any money budgeted for a new department.  It is clear that both logistical and cultural changes need to occur if the department is going to survive the increased growth.  Who is going to lead that change?

An emphasis on patient experience is taking on a continually increasing importance in your health system.  However, your current Press Ganey scores are low.  There is a directive from the C-suite to improve, but how will you do that?  Who will help create the new vision and drive a change in culture?

A mass casualty incident occurs in your town.  Your emergency department takes on the brunt of the victims.  Who in your department will lead the team through the chaos?  Who will the department look to as the team goes through the debriefing and healing process afterwards?

Who are the people you consider the biggest leaders and influencers of change in our profession?  What traits do they have that seem to make them a natural for their role?  How did they get there?  Perhaps even better questions to ask – what makes some people more engaged in their job? Why do some people bounce back from the stress of our jobs better than others do?  Are there common traits that overlap leadership and resilience?

The first thing I am absolutely certain of – title does not mean leadership.  I don’t think anyone reading this would have to think too hard to come up with an example of someone with a leadership title that really didn’t seem capable of the job.  Leaders embody the very best work ethic that everyone else strives to have.  Leaders set the tone in the department and in the boardroom.  Dr. Randy Pausch in his famous “Last Lecture” challenged everyone to be the Tigger, not the Eeyore.  Be positive. Encourage others. Model ideal behavior.  Be willing to outwork everyone else.  That is the key to being seen as a leader.  Don’t strive to be “President” or “Chairman,” strive to be the first person a nurse mentions when asked who she would take her kids to.  That is the ultimate sign of respect, and no leader can lead without the respect of others.

So how do you get respect?  Respect comes when your colleagues see you as someone who practices with integrity and humility.  People see through those who are disingenuous – acting all-in for the team in public while making moves privately that are self-serving.  Moral character can be sniffed out in pretty short order, and nobody will respect someone that they perceive to be dishonest or only “in it” for themselves.  The best leaders are transparent and fair.  The team knows positive behavior will be celebrated, and detrimental behavior will addressed and corrected.  Leaders are accountable, taking responsibility for failures, and they demand equal accountability from everyone else on the team.  Leaders are very quick to deflect personal acclaim when they are successful.  They recognize that the team is the key to achievement, and the best leaders are downright uncomfortable with individual successes.  Using your role as a leader to make sure colleagues are receiving their due for their role in the success reinforces positive behaviors and makes the rest of the team hungry for more of it.  They will work harder to achieve team goals, and be more willing to follow the direction of a leader they know has their back.

Every single text I’ve read on leadership demonstrates that superior leaders are incredibly confident.  Humility is what makes toeing the fine line of confidence and arrogance possible.  A leader has a natural confidence grown from passion and a knowledge that they will ultimately be successful in achieving their goals.  But confidence is more than that.  The best leaders are confident enough to know that there’s also a time to follow.  They seek outside opinion and ideas without feeling threatened.  A confident leader is comfortable saying “I don’t know” without fear that it makes them seem less capable of their job.  Confidence comes from preparation, exploration, and education.  With it, leaders can make decisive decisions in the face of adversity, and swiftly make decisions to adjust course when things occur unexpectedly.

Leaders are passionate about their objectives.  They have an innate ability to motivate others towards a common goal.  They understand how to achieve buy-in from others. The best leaders clearly communicate directives, giving the rest of the team a clear path to success.  Furthermore, leaders value the role of everyone on the team.  There is no “top-to-bottom” or menial role.  Teams with the best leaders feel like every single role is mission critical to ultimate success.  This comes from publically recognizing team members doing great work.  Members of the team also feel valued because strong leaders delegate essential work and continually develop and retain top talent within the unit.

Resiliency is not the same as leadership, but it seems they have some common overlapping traits.  Most prominent is a refusal to give up when faced with a seemingly insurmountable challenge.  Resilient people know that everybody gets knocked down in life, but it is how you get back up that defines you as a person.  The resilient leaders see challenges where others see obstacles.  What’s more, they thoroughly enjoy the journey of the challenge, sometimes even more than the final success.  As a result, they seem to effortlessly change directions or come up with a new plan when first attempts don’t succeed.  The most resilient people are absolutely certain that they will ultimately succeed in their objective because they will outwork their counterparts and continue to look at a problem from different angles until a solution is apparent.

Those that are successful in the face of adversity have a keen self-awareness.  They know their strengths and weaknesses.  The most resilient and prominent leaders keep the company of great people who are able to supplement the areas of their own perceived weaknesses.  In fact, the best leaders purposely seek the council of people with views or knowledge in direct opposition to their own as a way to make sure the problem is evaluated from all-sides.  With information comes power.  With power comes the will to continue on because a resilient leader knows they have both the information and the work ethic necessary for success.

Resilient leaders refuse to give up because they are so invested in the task at hand.  It is not a blind commitment, but rather a devotion to a principle that they see as being greater than themselves.  It is this altruistic, optimistic attitude that often makes the resilient person one of the most engaged and invested people within the group.  The passion and the desire to help others makes them willing to push through hardships and do whatever it takes to overcome a challenge.  With that success comes fulfillment.  It becomes an addictive cycle of finding ways to overcome challenges and motivate others to do the same, and they feed off the high that comes with the success.

But why are some people wired to be this way, while others are seemingly ill-fitted to be a leader?  Why do some people cave at the first sign of trouble?  Is it innate?  Can resiliency and leadership be learned?  I think the answer lies somewhere in between.  There is no doubt that there are certain personality traits people have while others don’t.  Someone’s ability to see the world as half empty, half full, or glass overflowing has to do with the experiences they have had in their life that ultimately shape their view of it.  Some people are just naturally more charismatic and inspiring than others.  But, I also think there’s a choice to be made in all of us.  I think we choose how hard we are going to work.  We choose at what point we are going to give up.  We choose to recognize others and build them up, and we choose when we are going to break somebody else down.  Everything we do in life has an equal effect on someone or something else.  I think this post demonstrates there are definitely leadership traits we can acquire and make a decision that we are going to improve upon.  Transparency, humility, praising and developing others – these are learned behaviors that earn respect and build political currency necessary to lead.  Mix in some innate passion, and imagine the leader you can be.  Imagine the change you can drive forward.  Imagine an engaged workforce of colleagues as invested as you are.  Imagine the possibilities.  Strive to be the Tigger in your department.  Commit to model ideal behavior.  Who knows, one day perhaps we will be talking about you the way we talk about some of the other great and respected leaders in our field.

References / Further Reading

-Freitas, Robert. “Leadership in Emergency Medicine.” Emergency Department Leadership and Management: Best Principles and Practice. N.p.: Cambridge UP, 2014.

-Heath, Chip, and Dan Heath. Switch: How to Change Things When Change Is Hard. New York: Broadway, 2010.

-Giuliani, Rudolph W., and Ken Kurson. Leadership. New York: Hyperion, 2002.

-Merlino, James. “Leading for Change.” Service Fanatics: How to Build Superior Patient Experience the Cleveland Clinic Way. N.p.: McGraw-Hill, 2014.

-Pausch, Randy. “Last Lecture: Achieving Your Childhood Dreams.” Web. 20 December 2007. Web. 29 March 2016. < https://www.youtube.com/watch?v=ji5_MqicxSo>

-Prive, Tanya. “Top 10 Qualities That Make A Great Leader.” Forbes. Forbes Magazine, 12 Dec. 2012. Web. 15 Mar. 2016. <http://www.forbes.com/sites/tanyaprive/2012/12/19/top-10-qualities-that-make-a-great-leader/#5a161e353564>.

-Farrell, Rachel, “23 Traits of Good Leaders.” CNN. Cable News Network, 03 Aug. 2011. Web. 21 Mar. 2016. <http://www.cnn.com/2011/LIVING/08/03/good.leader.traits.cb/>.

-“Gannett Health Services.” Gannett: Qualities of Resilience. Web. 29 Mar. 2016. <https://www.gannett.cornell.edu/topics/resilience/qualities.cfm>.

-Feloni, Richard. “7 Habits Of Exceptionally Resilient People.” Business Insider. Business Insider, Inc, 05 June 2014. Web. 22 Mar. 2016. <http://www.businessinsider.com/habits-of-resilient-people-2014-6>