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.

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.