EM Mindset: Corey Slovis – Excitement vs. Dread & Anger

Author: Corey Slovis, MD (@CoreySlovis – Chairman of EM, Professor of EM / Medicine, Vanderbilt University) // Edited by: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

I approach my shift with not one, but two mindsets: one of excitement and another of dread and anger.  My mindset of excitement going into a shift is based on the challenge of what it means to be an emergency clinician in an academic emergency department of a university hospital.  The challenge of “cheating death”, of looking calm in a storm of the chaos of a busy emergency department, of being able to teach smarter and smarter residents, the excitement and daily challenge of whether I can teach anything new to trainees, trying to be sure I haven’t previously asked them that same question, or taught them that fact already.  I focus on trying to be a role model, teacher and clinician.  I want to walk into each patient’s room and be the physician I envision walking into my own ED room when the day comes that I go from being the emergency care provider to being the emergency care consumer.  And, yes, I worry, even this many years into my career, that I won’t know how to best treat a new, or even old, disease or condition.

But I also face my shift with negative thoughts of what emergency medicine has become.  I went into emergency medicine because we got to see other specialties’ emergencies.  We got to treat, stabilize, or cure the most exciting and challenging acute problems of every single specialty and subspecialty.  Shock, difficult airways, penetrating chest wounds, status asthmaticus, triple acid-based problems (they, too, are exciting to some people)… the list was, and is, limitless.  Instead, what I face every shift is the failure of our society to provide basic medical care to its members.  No, not just the poor, the homeless, the uninsured, but everybody: from the demands of a VIP who can’t get into his PCP and expects concierge care, to the hospital clinic patient who has a minor problem that’s “too acute” for her long-time provider.  Time spent calming down others as I silently seethe over the inappropriate transfer which was wrongly sent a long distance for any number of reasons, including that the specialist on call at the outlying hospital does not take evening or night ED call.

I have always wanted to be a doctor, but now many shifts focus on me being somebody else: a social worker trying to find follow-up for a patient with no or the “wrong” insurance; a drug abuse counselor saying no to a drug seeker with 40 visits to 30 providers listed in our state narcotic usage database who then yells at me and claims not to routinely ED shop.  I’m a clinical psychologist trying to find the right approach to coax one of my inpatient colleagues to take an “inappropriate” admission.  Finally, I think of how I need to guard myself from all of the anger.  I went into medicine to help people, just like every medical student applicant claims, but when there are 40 inpatient admissions laying in my ED and every bed, chair, classroom and hallway ED slot is filled, all I feel is the anger of patients and families who believe we, the doctors and nurses, aren’t doing enough to get them or their loved ones upstairs.  The worst of this occurs right after you finally do get someone upstairs and you walk in to greet the next new patient with a smile on your face only to be welcomed by the new patient’s disdain and chastisement over their 2-4 hour wait to get back into the ED.

The ED is a victim of its own greatness.  More than 136 million ED visits clearly say we work faster and quicker than anyone else 24/7/365.  We do a 2-3 day in-hospital work-up in 6-12 hours, we live our shift in STAT mode while most everyone else is at home resting for tomorrow’s well-scheduled day.

So, I close by saying the obvious: I love my job, I hate my job.

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