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 (@ – 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.