EM Mindset – The Dichotomies of EM Practice

Author: Patricia Nouhan, MD (EM Program Director at St. John Hospital and Medical Center / Clinical Associate Professor at Wayne State University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

What is the most accurate description of an Emergency Medicine persona? Is there a pattern to the skills that strong EM physicians bring to their practice? When I started many years ago as a young resident, the EM doc was cartooned as a less learned, procedure-hungry, loud, risk-taking cowboy who was destined to burn out.  I was questioned as to why I would want to pursue that career as a more introverted person.  I found my strongest EM teachers, however, were quick-witted, calm, observant resuscitalogists who could juggle many simultaneous, difficult tasks. I wanted to be like them. EM physicians were the MacGyvers of the House of Medicine. Some of them were even loud cowboys who suggested I needed a megaphone in resuscitation upon graduation! Still, I knew I could manage resuscitation confidently without maximum volume because of my strong training.  Over the multiple years of my EM career in a busy, urban center in Detroit, I have observed many dichotomies that coexist in the practice of Emergency Medicine and in those who are drawn to EM.  What are the qualities of the best Emergency Medicine physicians who deal with the changing complexities of our practice? The EM mindset is complex, fluid, and dynamic.

Focused but Broad-Thinking

EM physicians must focus on the more life-threatening causes of a chief complaint. They must hone in on the major problem a patient presents with, but their differential diagnosis must remain broad. They must have facility in readjusting their focus when the case does not fit a typical pattern or when there are multiple problems.  This broad-thinking skill in patient care applies to the overall running of an Emergency Department as well. For the effective functioning of the ED, an EM physician must remain focused on the patient at hand while simultaneously thinking more broadly about the overall status of the department.

Expert in Resuscitation but a Generalist

There has been much debate over the years on whether Emergency Medicine physicians are Specialists or Generalists.  We are both. EM physicians are specialists in resuscitation and generalists in our overall practice.  Who else but an EM physician is more of an expert on the resuscitation of an undifferentiated patient? Who else but an EM physician is able to successfully perform a life-saving procedure on any unresponsive patient – child or adult – scooped up off the street, with no obtainable history but a full stomach? Despite having these resuscitative skills, the ED physician must also be facile at addressing the general, more routine medical and social concerns of every patient who walks through the door.

Short-order Speed but Gourmet Quality

The EM physician is expected to work at amazing speed without any compromised quality. This demand for speed is a function of the volumes in emergency practice that have no limit or caps. Despite the onslaught of patient numbers, the quality and level of acute care given by an EM physician is expected to reach that of any consultant. Except for the performance of certain specialized invasive procedures, an EM physician must be adept at all manner of high level care. Even when a consultant errs with their recommendation, the EM physician inevitably is asked why they followed the consultant’s plan or why they did not solicit another consultant to see the patient.  We are fast and consistently good – like your favorite local bistro.

Confident but Humble

The most effective EM physicians are confident in their abilities and advocate for their patients. Simultaneously while assertive, they are humble in their knowledge and collegial in their interactions with other physicians. It is only with a confident humility that the EM physician is able to recognize, analyze, and respond to the many moving parts and flow of a busy Emergency Department.

Quick but Effective Communicator

EM specialists need excellent communication skills. In just a few minutes, they need to understand a detailed medical situation and gain a patient’s trust – a relationship that can take years in other specialties to achieve. That short communication time has much impact on the patient because of the life-threatening events that often play out in the ED. Communication by the Emergency Physician must be quick, relevant, and content rich.

Impressionist and Realist

If medicine subspecialties could be compared to art genres, Emergency Medicine would be a congruence of two opposing styles – Impressionism with a component of Realism. Many of the details of the patient history are missing as is the case with Impressionist painting, but the patient is understandable and solvable by the EM physician.  The scenes are typically colorful, vivid, and real. Some parts of the painting are seen with intense detail (Realism component) but the majority of the scenes are dabs of color that depict various types of light (or insight) hitting objects or people (the patient).

ADD with OCD

Continuing with analogies, if Emergency Medicine mirrors Psychiatry, the EM physician might be diagnosed as ADD with a touch of OCD. Strong EM physicians must be good at juggling many competing patients and problems and must be able to work with incessant interruptions.  That ADD component of EM forces creative problem solving for any patient who comes through the door. The OCD nature of EM keeps us on task and attune to the important details. EM physicians tend to tolerate chaos well (ADD), but work to eliminate chaos and move towards order (OCD).

Calm Risk-Taker

Emergency Medicine clinicians must be able to act quickly without all of the details.  We can tolerate more risk and uncertainty in our practice compared to most other specialties. We also need to know when not to act and when to stop futile efforts. Triaging in a disaster scenario is most illustrative of this skill. Most EM physicians are adventurous and tend to be risk-takers in and outside of their clinical practice, but they remain calm under pressure. They are the clinical equivalent to the team player that performs best in the clutch.

The dichotomies of Emergency Medicine practice reveal interesting contrasts. Not every EM physician has all of the characteristics listed above, but I have found most of the descriptors hold true to the practice overall. We are a varied group of physicians with a colorful mix of defining strengths that though appearing to oppose each other, work to strengthen us.

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