EM Mindset: Steve Carroll – Masters of the Undifferentiated Patient
- May 4th, 2015
- Alex Koyfman
During medical school, I was working with a very personable anesthesiologist who was incredibly helpful in helping me accomplish my goal of getting as many intubations as was physically possible during my short 2 week rotation. I told him upfront that I wanted to go into emergency medicine for which he was slightly disappointed given my enthusiasm for airways. He told me “I thought about EM but they are the jack of all trades but master of none. I wanted a specialty where I could really master a skill set.”
This comment stuck with me for a while (and fortunately didn’t dissuade me from pursuing EM) but it took a few years before I could come up with a reply. My reply is this – first, what’s wrong with being a jack of all trades? What’s wrong with being the “MacGyver” of medicine, the doctor who is prepared to see any patient at any time? Second, we are the master of something – we are the masters of the undifferentiated patient. In no other specialty would you be expected to acutely manage (and possibly resuscitate) anyone who comes to you for care – young or old, surgical or medical, sick or not sick.
As an Emergency Medicine Physician you should be proud of the fact that you can deal with literally anything that comes through the door. Would an Internal Medicine doctor be expected to see a septic child? Would a general surgeon be expected to diagnose and initially manage an ectopic pregnancy? Would you expect a primary care doctor to run a major resuscitation in their office? The answers to all of these are a firm “NO” but those three scenarios could be the first hour of your shift.
When talking about how to get into the EM mindset, I think of it as a few discrete stages – what you do before you arrive to a shift, what you do on shift, and what you do after a shift. Some of this will be about building your EM mindset while some of it will be about how to maximize your physical and mental performance.
Before your shift
A commitment to lifelong learning
A commitment to practicing in EM is a commitment to lifelong learning and thinking about medicine a lot. Before you even set foot in an Emergency Department there is so much preparation that should go into your everyday practice. This means keeping up with the latest studies, literature, and expert opinion. This has been made easier with blogs, podcasts, electronic journals, and the entirety of the FOAMed world but it still takes time and effort. You have to figure out what learning style works for you and commit yourself to doing it on a consistent basis. If you aren’t committed to doing this, you will never get into the EM mindset that you will need to be a well-functioning EM physician.
Mental preparation for each shift
You have to figure out how you will mentally prepare for each shift. Maybe this involves a medical podcast or two as you drive into work. Maybe it means blasting the radio and singing at the top of your lungs. Perhaps you like to pray or do some sort of self-affirmation as you walk into your shift. This may sound like New Age touchy feely hogwash but the bottom line is that you need some sort of way to stay positive, stay happy, and stay motivated while doing this job. Regretting coming into work each day will leave you miserable and wanting something else.
Rule out (but not necessarily test for) all life/limb/eyesight threatening emergencies
This is frequently the hardest concept for EM trainees to grasp and it is something that we are all working to develop and fine tune – even if you have been in practice for years or decades. It is hard to find that balance between being concerned about everything and being concerned about nothing. The temptation for new EM people is to either order lots of tests or order almost no tests. Keep in mind that a good history and physical will frequently give you enough data to rule out a deadly diagnosis without performing a whole bunch of tests. While this “gestalt” or “gut feeling” takes time to develop, you should be aware of your thought process behind each patient. Listen to your supervisors when they share their own thought process. Make sure to make it known to your supervisor that you have considered all of the possible deadly diagnoses. If you don’t think you need to test for it, that’s fine but be prepared to explain why. When I am on shift I like to tell residents: “Sick patients need lots of tests. Not sick patients need a good history and physical and targeted testing to make sure they aren’t sick”.
Recognize your biases
We all have biases. To deny that fact is to deny that you are human. In this context, I am not referring to those biases based on things such as race or nationality (you shouldn’t have those) but instead those biases about certain patients that creep up in our subconscious without us realizing it. Perhaps you don’t like dealing with chronic pain patients. Maybe you can’t stand parents that bring their well-appearing child into the ED. Perhaps you don’t like dealing with the tidal wave of asymptomatic hypertension that is flooding our EDs on a daily basis. These biases can color our patient interactions in a negative way and they lead to us missing bad things. Instead of burying them or denying them, acknowledge them and make a plan to move on. When you find yourself groaning when you pick up a chart after seeing the chief complaint, take a second to reset and commit to doing the best that you can for your patient. Maybe it will be a difficult patient interaction, maybe it won’t but if you come into the room with a bad attitude you will fail. Remember that part about treating every patient that comes through your doors?
I’ll share a quick story. I was working at a busy community ED, single coverage overnight shift when I picked up a chart of a middle-aged female with chronic pain due to fibromyalgia. I groaned a little but I caught myself. Before I went into the room, I committed to helping her out as much as I could. I came into the room cheerful and did my usual history and physical. When that was over the patient said “Doctor, I’ll be honest, all I need is some Toradol and I will feel so much better”… Sure enough, after one dose of Toradol, the patient felt much better (evidence-based medicine be damned) and she was happily discharged. Here I was prepared for requests for mega-doses of opioids and a difficult patient encounter but she turned out to be the nicest patient I had on that shift. So don’t let your preconceived notions taint your patient encounters because no one wins when that happens.
Recognize your physiology and do something about it
There is no possible way that you can form a good differential diagnosis if all you can think of is your full bladder. If you find yourself not doing well on a shift, ask yourself three questions:
- Do I need to use the bathroom
- Am I thirsty or hungry
- Am I stressed or overwhelmed?
If the answer is yes to questions 1 or 2, then fix them as soon as possible. The myriad of idiotic hospital rules against consuming food on shift can make these tasks problematic so find a way around that. If you are feeling stressed, then sit down, take a few deep breaths, and find one task that you can accomplish to get you back on track. This will help you from feeling like you are losing control.
Don’t assume that patients came to you for tests
Believe it or not, most patients are more interested in your educated opinion as to whether they are sick or not rather than what a slew of tests show. Young parents just want to know that their child running around the room with a fever is going to be okay. The worried family in the next bed just wants to make sure that their patriarch isn’t having a heart attack. In EM, you will be in the reassurance business much more than you will be in the resuscitation business. Don’t roll your eyes at those parents – tell them that their child will be just fine and that they are doing a good job.
EM is a team sport
Committing to a career in EM is committing to being a team player. Those who are not team players are not around for very long. Running an ED is an exercise in collaboration starting from the housekeeping staff all the way to the very top. It is very easy to get stressed out and take it out on your staff. If that happens, recognize it and prevent it from happening. Whenever possible, let your nurses know your plan. Say please and thank you. Listen to the input from your nurses and acknowledge it. If you don’t agree with their suggested course of action, explain why in a calm and professional way. If you screw up and lose your cool, apologize. We’ve all been there and people are forgiving if you acknowledge your mistakes. Finally, after you take care of a sick patient and at the end of the shift, go around and thank everyone for their help in a sincere way.
EM is about being an advocate for your patients
During a lecture in my third year of medical school, after an incorrect answer from a classmate, a cardiologist exclaimed “For the first two years of your education it was all about you. Well guess what, it’s not about you anymore, it’s about the patient!” While I don’t agree with the manner in which he used this phrase to belittle an incorrect answer, the last part certainly stuck with me. Most importantly, it means that you hold yourself to a high intellectual and educational standard. Next, it means advocating for your patient. You will be calling other doctors at all hours of the night to ask them to do work. Most of the time, your consultants will be professional, collegial, and nice. Sometimes you will need to fight for what you think your patient needs. Keep it calm and keep it professional but never lose sight of the fact that you are an advocate for your patient.
You will have bad outcomes
Bad outcomes are a fact of life in EM. Some of them you can’t prevent, you’ll think some of them could have been prevented, and there will be ones where you just plain screwed up. This is a high stakes job with constant interruptions and a million ways that things can go wrong. It’s amazing that we get it right as often as we do. Find a way to mentally process these bad outcomes without being self-destructive. A good EM doctor is always critiquing themselves to figure out how they can do better the next time. However, they don’t let bad outcomes consume them and bring them down. You will beat yourself up over your mistakes and that’s ok but give yourself some sort of time limit. A few days is ok – a few months isn’t. I’m not saying to forget about your mistakes forever (that will probably be impossible to do) but rather move on in a productive way. Talk with a trusted mentor, colleague, spouse, partner, or friend about these patients to help you decompress and gain perspective.
After the shift
Have something else besides medicine in your life
I can’t stress this enough. You cannot be an effective EM doctor if all you have is EM. While I will admit that having “something else” during medical school and residency is difficult, it is still possible. Some people like to skydive, others like to knit. Some people like to run ultra-marathons, some like to read books. Whatever it is – find something outside of medicine that you enjoy or you will burn out.
Find some sort of physical activity that you enjoy and do it
Do not fall into the trap of “I just ran around the ED for 12 hours, that is all the exercise I need”. Even if you have a sky high metabolism and are still the same weight as you were in high school, you need to do some sort of physical activity. It doesn’t have to consume hours of your day but it needs to be something you do on a regular basis for your physical and mental health.
Realize that you have the best job in the world
If you don’t think this more days out of the week than not, then you may want to find another line of work. Realize how lucky you are to have a job that challenges you on a daily basis and is never the same day twice. You get to go into the ED, make a whole lot of people feel better, and go home (without a pager!). Figure out a way to stay healthy and mentally well so you can have a long career in EM.