Author: Sean M. Fox, MD (Associate Professor, Assistant Program Director, Emergency Medicine Residency Program, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC – @PedEMMorsels – www.PedEMMorsels.com) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)
During residency interview season (it really has its own season, like a long cold Winter or an endless Summer), I am treated to a vast lexicon of adjectives that are used to describe what Emergency Medicine embodies to all of the enthusiastic and talented applicants. “Exciting,” “fast paced,” and “controlled chaos” are skillfully tempered with “exhausting,” “challenging,” and “demanding” as these young aficionados of Emergency Medicine attempt to portray the right balance of enthusiasm with realism. Unquestionably, even the newly indoctrinated can witness the dichotomies that frequently exist within the daily practice of Emergency Medicine.
The practice of Emergency Medicine leads one to function in an interesting world of extremes. The fast-paced excitement often breaks the moments of monotony. The control of chaos is often brought about through meticulous training and practice. The Emergency practitioner’s calm exterior is the facade obscuring the frenetic and paranoid mind. The person who is adept at traversing these extremes and holding seemingly incongruent concepts together in time and space is the person who finds Emergency Medicine to be satisfying.
It takes a substantial amount of resilience to be able to deal with, understand, and manipulate scenarios with such obvious extremes and it is this resilience that is the basis of what I believe to be one of the core “mindsets” of Emergency physicians. The “mindset” of an Emergency physician is certainly different from many other specialties of Medicine. To outsiders, it may seem like an over-reaction to constantly consider the “worst first,” but for Emergency Medicine providers it is what is necessary to remain vigilant and protect against those lurking life threats. It may seem like paranoia, to a passerby, to always be worried about the potential patient(s) that have yet to arrive and to strive for expeditious dispositions with a weary eye on the ambulance bay that becomes as congested as the DC beltway at rush hour without warning. Practitioners of Emergency Medicine may appear schizophrenic as we convey the care plan to the patient while listening to the incoming medic on the radio at the same moment we review our next patient’s ECG, but the ability to have a split-brain is a requirement of the job. All of these are attributes of the Emergency Physician’s mindset that are well known and constantly considered with continued efforts to master them.
While all of these mindsets, and others, are unquestionably important to integrate into the practice of Emergency Medicine, there is one that is just as important yet often underappreciated: Humble Arrogance.
Let us be honest, working in an Emergency Department is tough. Sure there are times when everything works perfectly and every order gets processed without a hiccup and every patient presents with a complaint that is taken right out of the textbooks, but those days I can count on one hand. Sure there are shifts when there are no interruptions during the critical seconds when you are pondering the best course of action, but I have not ever experienced those shifts personally. More often the presentations have subtle and confounding elements that complicate the pre-test probability equations that are running through our brains like a scrolling ticker tape. Patients often have multiple causes of their current complaints. Most often the clues are obscured by the patient’s demeanor or our previous experiences or both. To make things even more difficult, disease processes are just that, a process and may appear quite different based on how early or late in the course we have the privilege of evaluating it. Of course, let us not forget that many people present when they are at dramatic crossroads and those people’s lives are literally in our hands.
It requires a substantial amount of arrogance to believe one is able to make a positive difference in this difficult environment surrounded by deadly trapdoors and disguised death. “Cowboy” may be the term used by those who are not indoctrinated, but in reality, the Emergency Department can substitute for the historic Wild West and it requires the intestinal fortitude of Wyatt Earp to even walk in its hallways.
While the Emergency Department demands a certain amount of arrogance to be able to believe you can perform complex medical calculus while you juggle all of the chaos, it also engenders a lot of humility. No matter how proficient of a juggler a person is, eventually gravity wins. Being humble and accepting the reality that no amount of arrogance will provide perfection in the Emergency Department is necessary for one’s sanity. While the arrogance provides the fuel to enter the next patient’s room, it is the humility that helps guide the decision making. Knowing that each individual patient encounter offers the equal opportunity to be a hero or a dumbfounded moron requires courage to take those odds; however, it is one’s humble mindset that settles the sympathetic surge and prevents the Emergency physician from taking unnecessary risks.
Just as the Emergency Department, itself, exists in an interesting world of dichotomous extremes, the Emergency practitioner’s mindset also represents a delicate balance of extremes. Being arrogant allows the Emergency clinician to be present and to be able to offer assistance to patients. Being humble allows the practitioner to be reasonable and offer the patient what is realistic while extending true compassion. Humble Arrogance is our yin and yang that allows us to remain balanced.