Author: Aditya “Al” Lulla (MS-IV, UCLA David Geffen School of Medicine) // 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)

It’s our fourth year of medical school. We made it through the rigorous first and second year curriculum in the lecture hall. We survived on nothing but stale Cheetos from library vending machines. We acquired irreversible kyphosis as third year students in the operating room. After sampling all of our major core rotations, we chose emergency medicine.

For many of us, the decision to pursue emergency medicine was based on a multitude of personal experiences. This included working with our mentors, exposure to the ED while consulting on other services, the idea of treating all-comers, or just a connection with the people and a gut feeling that the ED is where we were meant to be. We crave the diversity, the frenetic yet stimulating pace, and the challenging nature of working in the emergency department.

The first of the challenges we face is letting go of most of what we have learned over the past three years. Gone are the days of exploring Howell-Jolly bodies across microscopic landscapes. Gone are the principles of extensive open-ended patient histories that have been hard wired into us all. The EM mindset is a refreshing departure from the traditional “medical student mindset”.

Timekeeping

Time is the currency of emergency medicine. It is something so basic yet so necessary for delivering care to patients, and also something so scarce in the ED. Early on in our training, we had the luxury of having ample time in our patient encounters. Sometimes we were allowed upwards of one hour to conduct a very detailed history. We were applauded when we performed very elaborate exams, which included diaphragmatic excursion and reflexes on every patient. We took pride in our extensive notes, which were on par with such classic literary works as War and Peace and Great Expectations.

Although initially it is normal for us as medical students to be a little slower in our workup of patients, an important step to understanding the EM mindset, and increasing our efficiency is to first understand the time pressures that are placed on the department. While extensive histories and physical exams are an important part of medicine, the time crunch in the ED ultimately requires us to adapt and embrace a different approach. This approach involves using our judgment to conduct a focused assessment of the patient so we can learn to quickly identify a potentially life threatening problem and learn how to intervene in a timely manner.

The front door of the ED is a bottleneck with hundreds to thousands of very sick patients that trickle in every day. While it is still early on in our training, from observing our attendings and residents, it is easy to appreciate the enormous social burden faced by emergency medicine practitioners in terms of keeping the department moving. While every patient within the four walls of the ED deserves undivided attention, the EM mindset accounts for the patient in the waiting room or in the ambulance bay with a potentially life threatening illness who needs help as well.

If you are interested in reading the rest of this and other EM Mindset pieces, please see “An Emergency Medicine Mindset,” a collection evaluating the thought process of emergency physicians. This book is available as ebook and print on Amazon.