Category Archives: EM Mindset

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>

Cognitive Load and the Emergency Physician

Author: James O’Shea, MD (Assistant Professor of EM, Emory University / Grady Hospital) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) & Justin Bright, MD (@JBright2021)

“The greatest weapon against stress is our ability to choose one thought over another.”  William James.

This article aims to review cognitive load theory (CLT) as it applies to clinical work in Emergency Medicine (EM). It will introduce key concepts in cognitive load theory, discuss the measurement of cognitive load, and will outline sixteen simple strategies that the working emergency physician can start using today to reduce their cognitive load on shift. These practical strategies will help to free up some of your latent cognitive processing power, allowing you to work more efficiently and with less stress.

You may not know what cognitive load is, but if you work in an Emergency Department (ED) you are probably carrying a ton of it.  Cognitive load refers to the total amount of mental effort burdening your working memory at any given time. Working in an ED can involve extremely high cognitive load, and learning to understand and manage it can make you more efficient and less stressed on shift. In the field of ED management, the ED bed is often described as the ‘Million Dollar resource’. If that is true, then the cognitive machinery of the Emergency Physician has to be the ‘Billion Dollar resource’. Ventilators have some complexity and your EMR can hold and manipulate a generous amount of data (when it works) but by far and away the most complex and valuable piece of equipment in the department is resting between your ears. Intuitively you are probably aware of the individualized capacities and limitations of the caffeine-powered intracerebral supercomputer that you expertly operate during your shifts. However, it is important for the working ED physician to understand the cognitive science behind how that well-trained and maintained machinery deals with (or not) the demands of the work that we do.

The mind of the ED physician at work relies heavily on memory. You may already be familiar with the basic Atkinson and Shiffrin (1) model of memory that includes three primary sub-systems (sensory, working, and long-term memory). Sensory information is stored in sensory memory just long enough to be transferred to short-term memory allowing us to retain impressions of sensory information after the original stimulus has ceased. Long-term memory is a nearly unlimited store where retrievability and accessibility constrain use rather than shear capacity. Working memory is different from the other two in that it is severely constrained by a small storage capacity, and yet it is absolutely vital to learning and performing tasks. It is a single limited cognitive resource that we rely on in a work environment with seemingly unlimited demands.

Excessive cognitive load can lead to psychological stress, which may be defined as the state that occurs when the demands of a situation outstrip our perceived ability to cope with it (2). The nature of ED work can often place a cognitive load on physicians that is beyond our innate ability to process, which can result in errors and stress. There has been a growing interest in Emergency Medicine in recent years on personal organizational efficiency, and these strategies often have the effect of reducing the cognitive load on working physicians. We also learn by hard-won experience to ameliorate the excessive demands of our work by employing learned strategies that temporally distributes that load, but it’s hard not to get overburdened sometimes on shift.

In Miller’s (1956) seminal ‘Magic Number’ paper (3) he found that most people can only hold 7 +/- 2 units of information in their working memory at any given time. In contrast to a limited working memory, there is an almost unlimited long-term memory holding cognitive schemas constructed during the learning process and these are the schemas that give rise to expertise. You could think of these schemas as files in your memory holding nodes of learned information such as ‘EKG findings in pericarditis’. In reality, memories are probably distributed in interconnected neural networks but thinking of them as files in a filing cabinet is a helpful image.

In building on Miller’s work, John Sweller developed cognitive load theory (CLT) (4) in the 1980s. CLT was designed to help optimize learning by considering the effect of how information is presented to learners and it’s resulting effect on intellectual performance. As with Miller’s work, it emphasizes the inherent limitations that working memory load places on your ability to process information.

Sweller’s theory goes on to break cognitive load into three subcategories: intrinsic, extraneous and germane cognitive load.

1) Intrinsic cognitive load is the inherent level of difficulty associated with a specific problem and cannot easily be altered. Adding 239.1 + 67.56 is just intrinsically harder than adding 2+2, although it is possible to reduce the cognitive burden of the first equation by breaking it up into steps. Similarly, the dizzy old lady with multiple co-morbidities is just intrinsically more challenging for an Emergency Physician than a young healthy male with bronchitis. That assumes, of course, that the assumption of diagnostic simplicity is not itself the beginning of a cognitive error!

2) Extraneous cognitive load is vital to understand as an Emergency Physician. This load is made up of distractions and unnecessary processing requirements that take up room in your precious, limited and heavily taxed working memory. The goal for the EP is to keep this precious resource clear and available for the type of high-end processing that makes us valuable, such as the initial assessment of a complex patient, the making of clinical decisions and the ability to maintain situational awareness. These situations should not have to compete in real time for processing capacity with thoughts about your house repairs, the latest cat video you watched on YouTube, or even thoughts about non-emergent work items.

3) Germane cognitive load is that load devoted to the processing, construction, and automation of schemas. We construct new schemas in working memory so they can be integrated into existing knowledge in long-term memory. These schemas represent successful learning; they can be retrieved, added to, and used for further problem solving. As our medical expertise expands through clinical experience and training, schemas change so that relevant tasks can be handled more efficiently by working memory. Being an active learner and investing in your knowledge therefore increases your efficiency on shift. CLT as a learning theory is ultimately about diverting cognitive processing power towards this germane cognitive load by reducing the other two.

MEASURING COGNITIVE LOAD

Now for some board prep. Which one of the following is the best way to detect an emergency physician’s cognitive load during a shift?

  1. An assessment of skin translucency over the MCPs during coffee cup grip.
  2. When today’s total number of new job searches (completed on shift) is equal to your raw score on the Maslach Burnout Inventory.
  3. Task-invoked pupillary response.
  4. Number of complaints currently being filed against you by patients and nurses.

If you have no idea of the answer, circumvent the intrinsic cognitive load of the problem and just pick C! It would be surprising if muscular tension, interpersonal problems and burnout did not correlate with a chronically high level of cognitive load, particularly if it causes psychological stress. However, the evidence shows that greater pupil dilation is associated with high cognitive load and pupil constriction occurs when there is low cognitive load (5,6), implicating stress physiology in our response to demands on working memory. It is also possible to measure cognitive load by examining ‘relative condition efficiency’, which combines subjective ratings of your mental effort and objective performance scores on a given task (7). A third ‘ergonomic’ approach uses the product of your heart rate and blood pressure as an estimate of load (8), which again reminds us that our physiology changes with load, and that there is a physical cost to carrying the cognitive burden of our work.

These measurement tools are helpful for researchers but are not accessible moment to moment on shift. There might be comedy value in having a staring match with yourself holding a make-up mirror at the bedside while trying to take your blood pressure with your free hand, but I think the efforts at measurement would themselves represent unacceptable levels of cognitive load. Therefore, we will focus on management rather than measurement, and hope that increased knowledge of cognitive load theory will bring with it greater self-awareness of its effects.

According to Clark et al (2006) the goal with CLT is to reduce the extraneous load, maximize the germane load, and manage the intrinsic load (9). So how do we convert this knowledge of cognitive load into workable solutions on shift? While the theory was originally developed for educationalists, I believe that it is directly applicable to our work in the ED whether we are teaching, learning ourselves, or just trying to get through the day. In the next section, I will outline 16 simple strategies that the working emergency physician can use to help reduce and manage the cognitive load of our unique work environment.

16 Strategies for Dealing with Cognitive Load

  • Take advantage of external memory – use written or typed lists as an extension of your working memory. Patient lists can allow you to track multiple bits of information without the stress of having to hold them in memory. They can be used to track care to disposition and ensure your paperwork is done. Smart EMR design can help here and designers of EMRs could improve systems for EPs by being focused on reducing extraneous load. Frequently EMR programming uses computational steps that make sense from a software design point of view, but may actually involve a shift of processing demand from the software onto the physician’s cognitive processing load. EP’s should be actively involved in EMR design to ensure the software is smart enough to help reduce our cognitive load.
  • Minimize interruptions – Be a gatekeeper for your working memory. Just as you triage patients; you must triage the competing extraneous demands on your limited resource. One way is to try to minimize interruptions. Chisholm et al (2000) noted that we are interrupted every 6 minutes and have a ‘break in task’ every nine minutes, with a correlation between these events and number of active patients (10). This can lead to clinical error. Interruptions will inevitably occur, but if necessary politely defer unimportant ones, delegate to a junior or keep a list of started but uncompleted tasks to unload your memory.
  • Use simple algorithms on shift if you can’t write it on the back of a postage stamp, don’t bother, you won’t remember it when it matters. Complexity = increased intrinsic cognitive load.
  • Use aids without guilt – An example is the need to remember formulae that you use infrequently, it’s harmful to try. Use an online tool on your phone without guilt because you, my friend, are not looking it up because you can’t remember, you are looking it up because your working memory works in America and loves freedom. Another perfect example of this is the use of the Broselow tape. In children, cognitive load is increased by the unique component of variability of pediatric age and size (11). Remove the load; roll out the tape, turn on the app, or use MDCalc.
  • Front load to unload – be an active life-long learner and do your thinking and learning before you need to act or make a decision in the heat of battle. If you work hard off-shift to build schemas into your long-term memory, and pregame difficult decision scenarios, you will use up less processing power when it matters, when your fight or flight physiology is trying to rob you of your ability to use your working memory. Incremental increases in your expertise will help you manage intrinsic load and work more efficiently. This will in turn divert cognitive power towards increasing germane load, helping you to learn from your work.
  • Channel your supercomputer – listen to your intuition and answer the questions that it raises, this is the mark of an expert. Most processing is done without your conscious awareness in the interest of mental economy, we just evolved that way (12). That is why we can form impressions within seconds of seeing a patient. Also be aware, that this mental economy leaves us open to error, if things aren’t turning out the way your gut told you they would, reexamine your thinking carefully for common cognitive errors such as anchoring or early closure.
  • Reboot before starting – you need an unburdened mind at the start of your shift to prepare for the inevitable torrent. Working in the ED is the cognitive equivalent of taking a drink from a fire hydrant. If you arrive wound up about your taxes or a difficult interpersonal interaction you had an hour before your shift, you are likely to carry that extraneous load into your first patient encounter, and the second… In order to clear my mind, I meditate for at least 5 minutes before every shift (often in my car) and find that it prepares me mentally for the work ahead.   http://marc.ucla.edu/mpeg/01_Breathing_Meditation.mp3
  • Use ‘When-Then’ and ‘If-Then’ thinking – where possible learn to use decision points in management as triggers, not opportunities for philosophical argument. An example would be Dr. Levitan’s call to use ‘when I can’t intubate or ventilate, then I will cric’. A simpler example would be, ‘if my patient is young and female with abdominal pain, then I will order a urine pregnancy test’. In behavioral psychology this is called ‘The Granny Rule’…’when you pick up all your toys, then you can go and play in the park’.
  • Control your patient volume hard to do I know, but sometimes pushing yourself to take that extra patient when you are stretched can lead to excessive cognitive load, and you, your new patient and your active ones are open to the effects of cognitive error. Eat what’s on your plate before serving yourself more.
  • Tune up your equipment – Faith Fitzgerald, a renowned internist was smoking a cigarette in a meeting one day when she reportedly said ‘Frankly guys, wellness bores me’. Many professional athletes report that having to constantly look after their diet and physical training can become tedious. However, they do it so they can perform at a high level. Be an ED athlete; give the job, yourself and your patients the respect you all deserve. Your cognitive equipment relies on a healthy well-perfused body. Turn up well fed, well hydrated, well rested, and having exercised and your mind and shifts will run smoother.

Please see the following source for more info on this aspect: http://health.usnews.com/best-diet/mind-diet
http://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/exercise/art-20048389

  • Use checklists where possible – for the same reason that you use online or physical aids, they free up your mind to think, reduce cognitive load, ensure high standards across changing clinical scenarios and improve patient care (13). A great example is Scott Weingart’s Intubation Checklist (14), (I have no financial interest in Dr. Weingart’s website, and it seems to his great credit neither does he, so we’re all good!).
  • Turn up your speakers – it can be helpful to talk and think aloud because group processing is powerful. Do this with your assembled resus team or one-on-one with a trusted colleague. It generates team cohesion, allows for closed-loop communication and avoids error. The decisions are always yours to make, but it’s ok to check your thinking. Learners also appreciate access to how you think, which is often more useful to their educational progression than simple information.
  • Learn to breathe – the emotions generated by the intensity and nature of our work are not vapors in the wind, they create physiology, cognition, and influence action. If you are anxious, angry, or trembling like a gun dog then your working memory and motor skills are taken over and unavailable to you. Even in a crowded resuscitation room, you can still discretely take a few tactical breaths, center yourself, connect to your body to anchor yourself in the present moment, broaden your awareness to include the room, and the situation you are in. Then act.   Please see the following for more information: http://www.livestrong.com/article/74944-box-breathing-technique
  • Close the loop – dispositions free processing capacity and reduce cognitive load, push yourself to close out cases in order to free your mind for the next challenge. Work hard to definitively finish with issues before moving on. As you move around the ED with tasks being fired in your direction you are like an elephant being shot at by little spears. You can keep crashing through the trees with a certain number of spears in your back but eventually if you don’t brush some off you will be brought to your knees.
  • Touch it once – If you are working on a chart or any other task, do whatever you can to complete it ideally in one go. This is a well-known efficiency principle that also reduces cognitive load. When I was growing up in Ireland my father and I would repair the stone walls on our farm and he taught me that once you pick up a stone, despite its shape, you should never put it back on the ground, find a spot on the wall for it, otherwise you’ll be picking up the same stone all day and, well…stones are bloody heavy.
  • Accept your limits – Unfortunately ‘Subitis Department Hominis’ is not a separate tougher species of human first discovered in a hospital basement 40 years ago, we are just a variant on plain old ‘Homo sapiens’. If you need to alter one of your own schemas due to a hard and surprising clinical experience, give yourself the time and honor to do so, before running headlong into your next patient. The physiological consequences of a stressful clinical encounter are significant and can last for days. This directly affects the working of your cognitive machinery.

BEYOND YOUR OWN COGNITIVE LOAD

We are all unique, and as such, we differ in our cognitive processing capacity. This difference also occurs within ourselves across time as we move from novices to experts. The experience and knowledge that helps us work intuitively from heuristics significantly reduces our cognitive load as we train, and marks out a key difference between the experienced attending and the junior trainee.

Many of us will work directly with residents, medical students or other learners, and they will experience a much higher cognitive load when dealing with problems that you as an expert can complete with hardly a thought. This type of intrinsic load is best dealt with by simple-to-complex ordering of learning tasks and working from a low-to high fidelity environment where possible (15). Interestingly CLT would recommend instruction that de-emphasizes traditional problem-solving, preferring worked examples that provoke the learner to actively explain the problem to themselves. This unburdens the novice learner so that processing can focus on building schemas in long-term memory. The idea is that the learner has to sweat too much to close the gap between the problem and the solution, and much of that load in traditional problem-solving is not devoted to building a retrievable piece of knowledge in long-term memory. The benefit of using more worked examples decreases with increasing expertise, and so the strategies that benefit your intern may be inappropriate for the senior resident.

This reminds us that learners are still constructing the memory schemas that you have already built with hard work and experience during your training. Allow time and support to recognize this reality for them, and for yourself. It is interesting to note that these learned strategies, so vital to our work, find no place in our current model of EM education, and are left to the variable abilities of physicians to put together themselves, which seems to be an important omission in our training.

Communication with ancillary staff and nursing colleagues needs to be clear, collegial, and patient-centered. Clear plans with defined end-points require very little additional cognitive processing. Regular paper or screen rounds with the charge RN can allow problems to be identified and resources to be distributed in ways that avoid sudden surges in demand on your cognitive capacity. Be aware that ED work is a true team sport, and there is a shared team cognitive load that needs careful distribution across members whose cognitive capacity varies, both between individuals and across time.

It is also important to consider the role of cognitive load in our patients. Princeton psychologist Eldar Shafir studies the brain on scarcity and his research group has shown that poverty significantly impedes cognitive function (16). It places a load on our limited cognitive resource that produces what Shafir has termed, ‘bandwidth poverty’. The constant need to focus on what you have a scarcity of, such as money or time, saps your attention and reduces effort. This reduces your ability to make decisions and may be detrimental in the long run.

This is an important fact to remember when providing effective and compassionate care to our patients who struggle with poverty. The demands of being financially stretched, disabled or homeless on a cognitive resource perhaps already limited by drug addiction, physical or mental illness and social isolation is very significant. It also directly affects our personal interactions with patients as we try to process complex social problems. Research has shown that the more cognitive load physicians carry, the more likely they are to allow preformed stereotypes about a patient’s race to influence their opiate prescribing and general medical decision-making (17,18). In addition, the bandwidth poverty described by Shafir’s team could impact our patient’s ability to follow-up with specialists, their primary doctor, or to comply with the advice and medication that we prescribe for them.

COGNITIVE LOAD AND BURNOUT

Many studies have shown that lack of sleep, stress and anxiety negatively affect our cognitive processing capacity and deplete our working memory. Studies of healthcare providers have found that higher levels of acute and chronic stress, fatigue, psychological distress, depression, and burnout are associated with a greater likelihood of making medical errors and providing suboptimal or poorer patient care (18,19,20,21,22,23,24,25).

Each shift can produce ‘bandwidth poverty’ as a consequence of the cognitive load placed on us. The science of scarcity tells us that we may be prone to thinking excessively about what we don’t have, such as adequate personal time, rest from work demands, time to process the things that impact us on shift, or just time to intentionally plan and develop our careers. This response to scarcity then negatively affects our ability to plan and make positive decisions.

The problems our cognitive machinery deals with on shift are often complex and this complexity won’t change. However, the expert deals with complexity quicker and with efficiency because time has been spent training to deal with them. According to Sweller, this intrinsic load can “only be altered by changing the nature of what is learned or by the act of learning itself”(26). In order to reduce intrinsic cognitive load on shift the EP must continually improve their experience, knowledge and skills, so that a difficulty today can be translated into a greater ease tomorrow. Part of this process is incremental and built-in to our training, but a large part of it is also the individual dedication we bring to bear on our reading, thinking and active processing of clinical experience. Work hard today, and you will be unburdened going forward. This is particularly high-yield in our field because of our exposure to repeated cardinal presentations that allow the active learner to build deep complexity over time into their knowledge schema’s of, for example ‘chest pain’, or ‘dizzy elderly female’.

IN CONCLUSION

A knowledge of cognitive load theory can help the overburdened emergency physician reduce their cognitive load, free up space in their working memory, and become more effective and less stressed. In this article, I have introduced the concepts of intrinsic, extraneous and germane cognitive load, discussed them in the context of emergency medicine, and outlined sixteen simple strategies that emergency physicians can start using today. The work we do is uniquely challenging, and learning the knowledge and procedural skills to be an emergency physician is only the beginning of understanding how to do our job well. We should routinely seek out and apply knowledge and strategies from other branches of science to aid us in our work, and I believe that these strategies should be incorporated into our practice and the training of emergency medicine residents.

References / Further Reading

  1. Atkinson RC, Shiffrin RM. (1968). Human Memory: a proposed system and its control processes. In: Kenneth WS, Janet Taylor S, editors. Psychology of Learning and Motivation. New York: Academic Press; pp. 89–195.
  2. Segerstrom, S. C., & Miller, G. E. (2004). Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry. Psychological Bulletin, 130(4), 601–630.
  3. Miller, G.A. (1956). “The magic number seven plus or minus two: some limits on our capacity to process information”. Psychological Review 63 (2): 81–97.
  4. Sweller, J (June 1988). “Cognitive load during problem solving: Effects on learning”. Cognitive Science 12 (2): 257–285.
  5. Buettner, Ricardo (2013). Cognitive Workload of Humans Using Artificial Intelligence Systems: Towards Objective Measurement Applying Eye-Tracking Technology. KI 2013: 36th German Conference on Artificial Intelligence, September 16-20, 2013, Vol. 8077 of Lecture Notes in Artificial Intelligence (LNAI). Koblenz, Germany: Springer. pp. 37–48.
  6. Granholm, E. et al (1996). “Pupillary responses index cognitive resource limitations”. Psychophysiology 33 (4): 457–461.
  7. Paas, F.G.W.C., and Van Merriënboer, J.J.G. (1993). “The efficiency of instructional conditions: An approach to combine mental-effort and performance measures”. Human Factors 35 (4): 737–743.
  8. Fredericks T.K., Choi S.D., Hart J., Butt S.E., and Mital A. (2005). “An investigation of myocardial aerobic capacity as a measure of both physical and cognitive workloads”. International Journal of Industrial Ergonomics 35 (12): 1097–1107.
  9. Clark, R. C., Nguyen, F., & Sweller, J. (2006). Efficiency in learning: Evidence-based guidelines to manage cognitive load. San Francisco: Pfeiffer.
  10. Chisholm, CD, Collison EK, Nelson DR, Cordell WH. (2000). Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. Nov;7(11):1239-43.
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EM Mindset: Alex Koyfman – A Career Worth Pursuing

Author: Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) // Edited By: Manpreet Singh, MD (@MPrizzleER – Clinical Instructor & Ultrasound/Med-Ed Fellow / Harbor-UCLA Medical Center)

Special acknowledgements to: Alina Gorelik (my brilliant/beautiful wife); Justin Bright, MD (Henry Ford EM); Mike Winters, MD (UMaryland EM); Reuben Strayer, MD (Mount Sinai / NYU EM); Mike Runyon, MD (Carolinas EM); Compton Broders, MD (UTSW EM / EMC COO); Brit Long, MD (SAUSHEC EM); Manpreet ‘Manny’ Singh, MD (Harbor-UCLA EM)

Happy Holidays from all of us at emDOCs.net! Thank you to all of the amazing EM docs  that have contributed to our new EM Mindset series this past year. As we take a break from this series to accumulate more of your pearls, wisdom and life lessons through your journey in EM for our next chapter in this series, we at emDOCs leave you with this EM Mindset. Enjoy!

#1: Address the vital signs + triage/nursing notes

Every abnormal vital sign needs a reason – whether observed or charted. Don’t forget both sides of the spectrum – we freak out over fever, but forget that subtle hypothermia can indicate serious pathology too.  An unexplained tachycardia is a predictor of serious illness and adverse outcomes. Symptomatic bradycardia cases are some of the most exciting. Beware of tachypnea; it is the most sensitive vital sign for critical illness, especially in the elderly patient who may not display any other vital sign abnormality. Be wary of the documented respiratory rate of 16; all of our patients seem to be breathing at this rate at triage. Take a moment to watch the patient breathe and look for truncation of their sentences as a subtle sign of dyspnea. Vital signs don’t happen in a vacuum. Normotension in a patient who normally lives with a relative hypertension must be explained. Don’t flood every hypotensive patient with fluids, as you may make them worse; take a thorough history, do a focused physical, and connect the dots with the RUSH exam (go here for further discussion: http://www.emdocs.net/rush-protocol/). Why is your patient hypoxic? Is it the heart, lungs, central process, perfusion state, etc? Sign out is the most dangerous time for patient care in our ED – don’t forget to sign out abnormal vital signs, your thought process on each, and expectations for your colleague(s).

Read each triage and nursing note; acknowledge this in your patient evaluations. It isn’t necessary to chase every piece of information, but you must address the triage statement and tie it all together via documentation of your thought process. Complaints in the triage note that are not addressed, or nursing notes that don’t correlate with your notes, can sink both you and your patient.

#2: Invest in others

Emergency medicine was started out of necessity in the 1970s and has developed into the heart of medicine. Each generation of emergency physicians has moved the field forward.  Dedicate time and resources to your students and residents; one day they are destined to wow you. Teaching the next generation of physicians is the greatest contribution you can make to our field.

#3: Read and learn something new each day

We are the masters of many skills, and we leverage that skill in our patient’s favor; never stop learning. We are fortunate to be surrounded by many engaged colleagues in the era of social media. Leave your shift and elevate your care for the next patient. Run cases by your colleagues. If you work in an academic setting, contribute to and grow from conference.  If you don’t work in an academic setting, be proactive and deliberate in seeking out conferences. Read a new journal article or textbook chapter. Listen to a new podcast. Do this each and every day with focus to improve your care.

#4: Love your patients / believe them

Each patient holds the story to their disease process. These stories don’t always flow logically.  Sometimes, the patient is so eager to help you help them, that they offer information they think is helpful, but really just throws you off the path.  It’s your job to put everything into context.  The burning a patient is feeling in their chest is not from the chili dog they ate 6 days ago – it’s a heart attack.  Be a detective and dig for what made the patient present today specifically. When we forget to connect with our patients and believe in them, we make mistakes.

#5: Initial 5 items in your differential diagnosis

Train your mind to be the best it can be… the eye doesn’t see what the mind doesn’t know. The more you read, the more you know and will recognize. For each patient, put together a thoughtful DDx (5 possibilities is a good place to start). Even with patients who present with benign causes, consider life threats… this doesn’t mean that it has to be followed with labs/imaging. If you consistently think of life threats, you’ll pick them up when they present. We don’t tend to miss atypical illnesses presenting classically; we get burned on the classic illness presenting in an atypical way. You will not solve all cases; it’s prudent to enter some patients into a diagnostic uncertainty pathway. Keep asking: what else could this be?

#6: Mental simulation

Before a shift or to bounce back after an extended time off, run through cases that scare you a bit.  We all have them. After shifts, read up on one case you managed.  It reinforces what you learned when you can picture a patient.  During stressful times, we rise to the level of our training; nothing magical happens if you’re not prepared. Visualize yourself performing each step of infrequent procedures (cricothyrotomy, thoracotomy, etc) so that you will be prepared when the opportunity arises.

#7: Give back

Contrary to popular belief, not all doctors are multi-millionaires. Donate money if and when you can, but realize that volunteering your time is of even more value. We are fortunate that our hard work has paid off and we get to contribute to the betterment of others each day. The diversity of our skill sets and interests can translate into many positive changes for those around us. We see the best and worst of people. We have the privilege of treating those in need. By giving back to the community, you not only help one person, but many. A physician should be an advocate for all walks of life.

#8: You will miss things

We are risk managers who work in a chaotic, stressful, and humbling environment. We are tasked with working up undifferentiated patients with limited information – we are effectively educated gamblers. I guarantee you will make mistakes along the way.  Let yourself off the hook. The key is to learn from our mistakes… and do better for the next patient in front of us. Scrutinize cases and disseminate key learning points, whether from your own cases or those around you. Grow your curiosity and foster your humility.

#9: Commit to your work-up

You will be wrong as discussed above, however it’s important to fully commit to your decision-making. If you’ve ordered an EKG/troponin and are worried enough about ACS, then give the patient aspirin. If you’ve ordered a complete sepsis work-up, then give antibiotics early. Be thoughtful and aggressive; move quickly but smoothly.

#10: Push yourself outside of your comfort zone

There is always more to master and learn. Medical school and residency are a good start, but medicine centers on life-long learning. Develop a personal learning network of individuals who are smarter than you in areas you need to work on. Attend national conferences to understand care outside of your region. Pick up another article. Read another textbook chapter. Listen to another podcast. Information and knowledge are out there; all you have to do is reach out to better yourself and provide better care. Continue to push the limits of the number of patients you feel you can safely see during a shift. Challenge the status quo as a form of patient advocacy.

#11: Advocate for EM

We are the 23rd recognized medical specialty in the US and we’ve developed into the core of healthcare. Being the young kid on the block isn’t always easy, but it sure is exciting. We regularly have an immediate impact on our patients. The future is bright for our field. Ensure our specialty continues to evolve by becoming involved in the decision making and politics of it.

#12: These are our patients

The patient who arrives through the ED doors is our patient. As soon as we begin to care for that patient, we enter into a partnership to provide the best care. We guide them through the process and educate them along the way. When the ship is sinking, don’t be afraid to get others on board (consultants). It’s ok to say “I don’t know.” At the same time, don’t let the consultant walk you off of the cliff. Remember, a consultant looks at a patient through the lens of their specialty.  You hold all of the information and context about your patient. You are the only one who clicks the order button and the dispo button. Be wary of the “telephone diagnosis” and when in doubt, respectfully request that the consultant evaluate the patient. Digest the recommendations, synthesize with remaining data, and do what’s right for your patient. Remember, the patient comes first.

#13: Understand your system

Each hospital has its quirks. Know / study / adjust to pitfalls of your system.  Become a proactive member of your hospital leadership. If you find something that needs improvement, consider how you can better it and talk about it with others. Improve what you can; develop potential. Let go of what is out of your control.

#14: The 3am plan

Have a reliable peripheral brain when folks are known to not be at their sharpest. Study the content of the books/apps on which you regularly rely; know their content and ensure that they serve as a refresher of what you know and not as an excuse to delay learning. Know the high-risk practice items (i.e. deep night, holidays, atypical presentation of disease, etc.) and how you’ll adapt. Being systematic isn’t sexy or cutting-edge, but it’s thorough and that’s what our patients are counting on. Strive for personal and situational awareness. You need to know your triggers and recognize when they’re occurring so sleep deprivation and stress don’t derail your interaction with the rest of the team. At these points, you have to be extra careful and double/triple check everything you do. Discuss the plan out loud with colleagues and nurses. By hearing yourself say something, you’ll be more apt to catch a mistake or find a solution.

#15: Cognitive checkpoints

Each patient needs a clinical re-evaluation / time to stop and ask what could I be missing? Based on new data (vitals, labs, imaging, etc.), what does the differential look like? For each patient, take one minute extra and consider everything you have and what you could be missing. What could cause the patient to decompensate or bounceback? Don’t hesitate to consult a resource or ask a colleague. If in doubt, search out a senior colleague; they can be a wealth of knowledge.

#16: Focus on the patient in front of you

In the ED Rubik’s Cube there’s always more to do. Learn 1 new fact about each patient. Assure due diligence for each case. Don’t count out the underdog; it’s amazing the kind of pathology our patients are able to walk around with.

#17: Know yourself

Know your strengths and take advantage of them during the shift. At the same time, know your weaknesses and what type of patient you struggle with. Take extra time around your weaknesses or patients you struggle with. Recognize when you are struggling. Continuously work on yourself in areas of improvement. Manage what pushes your buttons and role model appropriately. Leadership is a lifelong journey.

#18: Why did the patient present today?

As great as you are, the patient isn’t there to spend his/her (free) time with you. Figure out the acute hit. What’s different today? What’s their primary concern? What is concerning to the family / other provider? In my eyes, this is the million dollar answer that completes the story.

#19: What doesn’t fit?

We often focus on the classic risk factors for a disease and forget about what doesn’t fit and what that points us towards instead. Premature closure and anchoring bias are dangerous creatures. Think hard before blaming a dirty urinalysis as the patient’s reason for presenting when they have no urinary symptoms. The elderly gentleman with syncope who states “everything is alright and I don’t know why my family brought me” has a significant chance of worrisome disease. The same can be said for an elderly patient who presents in the middle of the night. The examples are bountiful; you get the point. And if there is no clear explanation for multiple visits, consider psychiatric illness, life stressor(s) and physical / emotional / substance abuse.  There’s nothing wrong with simply asking a patient, “What are we missing? How can I make it so you don’t need to come back here?” Sometimes, the answers will absolutely blow your mind. Be particularly wary of the “crazy” or “difficult” patient. Serious pathology can underlie presentations that seem overly dramatic. Give your patient the benefit of the doubt, within reason.

#20: Little Old Lady phenomenon

The elderly female makes or breaks your shift. The humor, stories, wisdom, kindness, and tincture of history are all worth it. For me personally, shifts without these patients aren’t as enjoyable. If you’ve ever had one of these patients stationed next to your workstation for the better part of your shift, you’ll know exactly what I’m talking about. And yes, these patients will humble you both with their vitality and atypical presentations of badness.

#21: Labwork/imaging isn’t the be-all and end-all

Stop ordering “routine labs”. You are responsible for all of the info in the patient’s chart. Ancillary testing can and will deceive you. Know the meaning and limitations of each piece of labwork you order. Beware of false positives and false negatives. If the test isn’t going to change your management, then don’t order it. Don’t let lab results dissuade you from your clinical gestalt and the appearance of the patient. No imaging modality is 100%; if your clinical evaluation says otherwise then pursue it. Trust your spidey sense that has come from seeing patients. If your spidey sense is tingling, examine why and what could be setting it off.

#22: Beware the Bounceback patient

The majority of people don’t even want to be in the ED the 1st time, to come back a 2nd or 3rd time is even stranger. Sit down with the patient and family, start from scratch, and ask yourself what you could be missing. Figure out where the holes are in the previous workups, and fill those holes in.  Address what worries the patient and/or family the most. Don’t anchor on what a previous provider thought or diagnosed. Dissect these cases in great detail and learn from them; they will shape your career.

#23: Over-/under-testing

Your practice style will be shaped by your upbringing, personality, a few mentors, a lot of experience, and a few sprinkles of randomness. A lot of questions don’t have clear-cut answers. Keep down the path of lifelong learning and re-visit your habits regularly. Have self-awareness whether you tend to be risk averse or test averse, those tendencies will accentuate when tired. Develop a self-regulation method during these times.

This is only the beginning of the story with many more greys in between…

EM Mindset: Christopher Doty – Approaching the World

Author: Christopher I. Doty, MD  FAAEM  FACEP (@PoppasPearls – Program Director & Vice Chair, Associate Professor of Emergency Medicine, Department of Emergency Medicine, University of Kentucky-Chandler Medical Center) // Edited by: Manpreet Singh, MD (@MPrizzleER – Clinical Instructor & Ultrasound/Med-Ed Fellow / Harbor-UCLA Medical Center) and Alex Koyfman, MD (@EMHighAK – EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

The Emergency Medicine mindset to me is a multi-factorial way of approaching the world. Often, I think this way of approaching the world goes beyond just our ED shifts. An emergency physician has many of the same characteristics outside of the clinical area, as they do inside.  Confidence, excellent people skills, good judgment, and resilience.

People Skills

One of the fundamental skills in the emergency medicine mindset is to develop a quick rapport with our patients. Successful emergency physicians have to be extraordinarily efficient and need to have the skills to develop a quick rapport with their patients. The ability to get a patient to see you as being on their side quickly is the first step informing a good therapeutic alliance. This alliance is necessary to move them forward through the process of diagnosis and therapeutics.

Clinical decision-making

Another key part of the EM mindset is that we must set our “default position” for the patient to sick. As we walk into a room, we begin assessing the patient almost immediately.  Does the patient look toxic? Are they unkempt? Do they have social support? Is the mental status normal? What are the vital signs? This all happens before we even speak a single word to the patient.  We begin to put patients into one of 3 “buckets”. There is the bucket for the well patient that does not require acute emergency intervention. There is the bucket for the really sick patient that obviously needs emergency medicine expertise, and there is a bucket in-between. I try to instill in my residents the idea that if they are not sure what “bucket” the patient belongs in, their default action should be to put the patient into the sick bucket. In my opinion, junior practitioners make a tremendous error by assuming patients are not sick and minimizing their complaints. The reason this is so dangerous is that most junior practitioners have not seen enough patients to realize that not all sick patients follow the pattern in the clinician’s mind. Assuming that patient’s are sick allows the clinician to be conservative and to err on the side of safety for the patient.  We need to focus on what is going to kill the patient first. It is acceptable for the emergency physician to miss a distal renal tubular acidosis, but to miss a thoracic dissection is a mortal mistake. Therefore the mindset of an emergency physician must focus on threats to life and limb first. While this seems very easy and too basic to say, it is a huge problem in Emergency Medicine today. We all forget to put the worst diagnosis highest in the differential. I do not mean to say that all of these “bad” diagnoses must be ruled out by labs or imaging, many can be ruled out by a careful history and physical examination, but we must think about them and take them off the list deliberately.

This brings me to my next tenet, which is that pattern recognition is critical to the EM mindset. A wise person once said that “Good judgment comes from seasoning and seasoning comes from bad judgment.”  This highlights the point that most of what we do is related to pattern recognition. We recognize the classic pattern of angina, the classic pattern of pulmonary embolism, and the classic pattern of sepsis.  As we become savvier with more experience, we begin to see the way the patient’s patterns deviates from the classic description. I think, that pattern recognition is the most fundamental skill that emergency physicians must have.  Emergency medicine has been described as the medical equivalent of jazz music. It is improvisation based on fundamentals. We have an incomplete data set when the patient first shows up at our ED and yet we have an obligation to practice safe therapeutics in the context of clinical uncertainty. This is different than most other specialties and often not understood or downplayed by our colleagues from other services.

Many specialties focus on being very sensitive… having a high likelihood to ruling in the disease. Often in Emergency Medicine, we want to be more specific. We want to know with certainty that a patient does not have a dangerous disease. For example, it is less important to me to know exactly what the cause of the chest pain is, it is much more important that it does not represent a STEMI or a thoracic dissection. This focus on specificity instead of sensitivity is often different than other specialties and a frequent cause of disagreements with other specialties.

Resilience and team play

Emergency physicians are spectators to some of the worst ills in our society. Those that have been forgotten, left behind, mentally abused, physically beaten, and mortally injured.  We bear front-line witness to the low points in peoples’ lives on a consistent basis. Emergency physicians often struggle to develop efficient strategies to deal with the negative energy that ensues with these tragic cases. As we witness a young child severely injured, we must then go console the parents. We, broken and fatigued from the emotional roller coaster that was the pediatric trauma resuscitation, must now go give news to parents that is absolutely decimating. Because we must function in this environment, make decisions before all the data is in, and work at peak efficiency during times when we would rather be with our families; developing resilience is critical to our success. Emergency medicine is a team sport. We must rely on our colleagues, staff members, and sometimes our significant others to take care of us so that we may take care of others.

Confidence

Emergency physicians live in a fishbowl. Specialists will look at the care that was rendered in the emergency department and now, with the complete data set, pick apart the management as if all of those variables were known prospectively. Successful emergency physicians will begin to place less and less value on external validation from others. Many of our colleagues from other specialties understand the challenges faced in the emergency department, but most do not. Emergency physicians must possess the confidence to do what they believe is the right thing and be able to weigh feedback from specialists in order to improve the care they provide based on that feedback, and still function in the future even if the care was not optimal in retrospect. We must believe in ourselves and not need validation from others.

Making it all worth it

What is a normal Thursday for us may be the worst day of a patient’s life. Sometimes this manifests in the emergency physician having to serve as an emotional “punching bag” for the patient or the family. This is part of the gig.  What makes it all worth it is the ability to directly impact people’s lives when they need it the most. We must get our energy there.  Emergency physicians often have the opportunity to step in to challenging situations, learn intimate details about their patients’ lives, and work to make things better for the patient… relieve pain, alleviate suffering, share in mourning, and celebrate victory. To steal a line from Dr. Mel Herbert, “What you do, really matters”. We make a tremendous impact on patients’ lives and remembering that impact is critical to longevity in our specialty. On the really tough days, I find it very helpful to remember all of the people that I helped on that shift.

EM Mindset: Charlotte Wills – Black Clouds

Author: Charlotte Wills, MD (EM Program Director / Attending Physician, Highland Emergency) // Edited by: Manpreet Singh, MD (@MPrizzleER – Clinical Instructor & Ultrasound/Med-Ed Fellow / Harbor-UCLA Medical Center) and Alex Koyfman, MD (@EMHighAK – EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

Many years ago during a residency interview, I was asked by a program director what I would be if I couldn’t be a doctor. Without a moment’s hesitation, and maybe just a little too quickly, I answered “a meteorologist”.  So it’s probably fitting that very early in my training, I garnered the label of a “black cloud”.

As an intern, my days and nights were littered with patients crashing in spectacular fashion, taking unexpected clinical twists and turns on their way to asystole. My reputation grew. Soon, the flurries of admissions, megacodes, and exotic diagnoses abundant in any busy county teaching hospital were attributed to my particular presence.

Routine patients were anything but routine: the young man presenting with a distinctly unexciting seizure until we discovered he was a homeless poorly compliant hemophiliac now with a head bleed. Utterly stable patients were rendered unstable: the gentleman who for two months had been living a symptom-free life in respiratory isolation while being treated for multidrug resistant TB during my night on call perforated his duodenal ulcer. On hospital day #152. Even the most trustworthy of historians proved challenging: the nun with chest pain who during her workup for ACS complained of tinnitus and was discovered to be suffering from a salicylate overdose from continually popping baby aspirin. I was once even thwarted by a lunch tray: the lady with the chief complaint of ear pain whose aortic dissection was discovered after a plate of Highland meatloaf provoked her resultant mesenteric ischemia. One of my most beloved attendings pronounced this “classic WADS”: Wills Associated Dissection Syndrome.

My black cloud label persisted as I became an attending myself, and even to this day – perpetuated as much by my physician and nursing colleagues as the volume or esoteric diseases of my patients themselves. Battle-tested, I have come to embrace my cloud. My cloud means that it might be a good shift or a bad shift, but never a boring shift.

The mythos of the black and white clouds in medicine has long been debated, and even studied. The most referenced and possibly only scientific article on clouds profiled the clinical experiences of nineteen pediatrics interns in relation to their perceived clouds. The authors Tanz and Charrow concluded that, in reality, these interns all had similar clinical experiences, despite the perceived color of their cloud. The notion of a black cloud may actually be more a phenomenon of how people manage their workload and stress.

While I do disagree with the paper’s conclusion that all clinical experiences are created equally (any student of evidence-based medicine will be weary of a claim made with an N=19), the real take home point of that paper is that you are ultimately much more in control of your work than you may think or feel. This is good news, as it implies you can be the master of your cloud. So, here are some tips for dealing with your local weather:

  1. You can’t control the weather, but you can prepare ahead of time. Since early on in residency, I have been in the habit of coming ten to twenty minutes before my shifts to walk the department and run the board before sign-out. Since I’ve seen what the ED looks like, the anxiety of the unknown is gone. I have a sense which patients have the potential to go south, and I have a general impression of the weather for the beginning of the shift.
  1. Read the forecast. Or at least the nursing notes. It’s amazing how often clues to cases gone sideways were there in front of us in the triage or nursing notes. Always read the nursing notes and review ALL of the vital signs. We would never ignore a CBC or a chest x-ray. So don’t ignore this data. Nursing documentation is temperature and barometric pressure of your forecast. Use it.
  1. Forecasts change. So do patients. The weather right now might very well NOT be the weather four hours from now. Flexible thinking and frequent reassessments will stop you from getting soaked.
  1. Listen to your local weather spotters. The National Weather Service utilizes the observations of volunteers for minute-to-minute updates on local ground conditions. In the ED, we are surrounded by our own army of weather spotters. They include radiology techs, ED techs, volunteers, and family members, in addition to our nursing staff. LISTEN when they express a concern about a patient. That could be your clue that bad weather is about to go down.
  1. Sometimes you don’t need hi-def Doppler radar, you just need to go outside. Lovingly presented at our journal watch by one of our most testing-averse faculty, an article by Kroenke in Annals of Internal Medicine concluded that history and physical alone contribute between 73 and 94% of the diagnostic information needed to make a correct diagnosis. This is staggering, and makes the very valid point that we just need to get outside/talk to our patients more, and rely on testing less.
  1. Don’t wait to evacuate when you know a storm is coming.  And don’t wait to intubate patients you think have a high likelihood of needing a definitive airway. Think of these patients as the stalwart locals your see on the news – refusing to leave their beloved house on the beach despite dire warnings from local officials. Maybe they will get lucky and dodge the storm, or maybe they will need many more personnel, equipment, and heroic maneuvers to save them when the storm hits.
  1. El Nino is fueled by ocean warming. And atrial fibrillation and DKA are fueled by some other disease process. To successfully treat and remedy those conditions, you MUST find and neutralize the provoking illness. Check anywhere infected fluid or tissue can hide – the lungs, the bladder, the CSF, the appendix, skin, and soft tissues. In women, look for pregnancy and pelvic infections. Because as that huge swath of ocean near the Equator continues to warm, El Nino continues to strengthen.
  1. Some areas are more prone to violent weather. Central Oklahoma experiences more tornadoes per square mile than anywhere else on Earth. Elderly ED patients have the highest rates of hospitalization for abdominal pain. Multiple studies have revealed that as many as 30-40% of those patients will ultimately need surgery for the cause of their pain. The elderly are the Central Oklahoma of abdominal pain. So start looking for that EF5 tornado in their gallbladder or their bowel wall. Because admission to the medicine service is not much of a tornado shelter.
  1. When a storm hits, quickly call the National Guard. Sometimes despite our best forecasting and preparedness, a storm hits and causes a huge amount of damage. Ultimately, it is our quick response and mobilization of appropriate resources that can make a difference in that patient’s outcome, as well as how that care is later viewed. Take any natural disaster, and you will see leaders judged largely on how quickly they recognized the scope of the event and effectively deployed needed aid. We are no different in the emergency department. Communicate to everyone involved the critical nature of the situation and mobilize all of your available resources rapidly and efficiently. Treat every crashing patient like a natural disaster.
  1. Learn from prior storms. The single best piece of advice I have ever received was early in my career from the chair of my department. When my cloud seemed most furious and forboding, he urged me to join our department’s QA committee. Adopting somewhat of a “if you can’t beat ‘em, join ‘em” mentality, I became a member. Fourteen years later, I still find looking at these cases uncomfortable as they inevitably evoke the icky and aching feeling of “that could have been me”. However, debating the patient care and studying the systems and medicine behind the outcomes has informed my practice more than any other educational endeavor I have been involved with. I am a better forecaster for it.

So do I really have a black cloud? Hells yes. However, those pediatricians in Chicago were likely onto something when they attributed clouds to how those newly minted physicians were responding to their patients and clinical environment. To my fellow black clouds out there, my comrades in arms, I would offer that the sky isn’t actually falling – even when it feels that way. Be resilient and adaptable, and you can indeed control at least a bit of the weather. And to all you white clouds, you should look up once in a while – you might be about to get rained on.

References / Further Reading

Tanz RR1, Charrow J. Black clouds. Work load, sleep, and resident reputation. Am J Dis Child. 1993 May;147(5):579-84.

-Kroenke, K.  A Practical and Evidence-Based Approach to Common Symptoms: A Narrative Review. Ann Int Med.  Oct 2014 161 (8): 579-586.

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-Tornadoes in the Oklahoma City, Oklahoma Area Since 1990 National Weather Service Forecast Office Norman, OK http://www.srh.noaa.gov/oun/?n=tornadodata-okc

Accessed 11/20/15

-Oklahoma Leads the World in Tornadoes June 8th 2013 USATODAY.com: http://usat.ly/ZWI5gT