EM Mindset: Reuben Strayer – 8 Responsibilities of the EM Doc

Author: Reuben Strayer, MD (@EMUpdates)  // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

Featured on the LITFL Review #180 – Thanks to Dr. Anand “Swami” Swaminathan (@EMSwami) and the LITFL Review group for the shout out!

The most effective way to improve your skill as an emergency physician (EP) is to break down your job into its component responsibilities and develop a clear plan for each. I have determined that there are eight discrete responsibilities of the emergency doc, and we’ll discuss them in ascending importance, least important first. There are certainly other responsibilities emergency docs take on depending on their environment, but most of us are tasked with these eight, so let’s jump in.

1. Public Health

At least in the US, primary care is mostly available only to a privileged minority, leaving many folks to use the ED for all of their medical concerns. This has led to an expansion of the clinical purview of emergency medicine to include a variety of primary care responsibilities. Depending on where you work, such efforts could include screening for HIV, hypertension or domestic violence, offering harm reduction programs related to alcohol or drug abuse, or interventions that feel like acute care but are really public health measures like providing tetanus vaccine. Many EPs were not taught to think about public health initiatives as part of their job; it feels to many of us like a task that takes away from the acute care we’re more interested in, a task someone else should be doing. Indeed, the most successful ED-based public health programs use non-EP clinicians to carry them out. At the same time, you make a much bigger difference when you convince your patient to stop smoking or lose weight, enhance their diabetes or asthma management, or pick up an occult case of HIV, then you do resuscitating stroke or sepsis or whatever your favorite dangerous condition that mostly affects older, sicker patients. So, especially when you’re not getting creamed by the board, you will do well to do a little public health.

2. Resource stewardship

Acting as a gatekeeper for tests, therapies, and consultants is usually not explicitly recognized as a responsibility of the EP but we are often the crossroads of care between the outpatient and inpatient realms and determine which patients require the assessment of a specialist, which most of the time will entail a battery of tests and therapies, not that we don’t ourselves over-test and over-treat. As everyone grapples with the complex consequences of over-doctoring, we are all increasingly held accountable for the tests and therapies we order. The best way to overcome the barriers to reducing resource use, which are also complex but center around fear of missing a dangerous condition, is to develop departmental and institutional care pathways that are designed to optimize the balance between patient safety and resource expenditure. Otherwise, try to practice with the recognition that there is a chance of harm with every test and every therapy ordered, and that this chance of harm should always be weighed against chance of benefit. Avoid routine tests, be especially mindful of the effect of CT radiation on young people, and when you can’t decide whether or not to consult, don’t. ACEP has joined the Choosing Wisely campaign, know what our College has to say about the practices it considers wasteful: http://www.choosingwisely.org/doctor-patient-lists/american-college-of-emergency-physicians/.

3. Customer service

Many EPs would say that customer service is actually our most important responsibility, that we are in fact in the customer service business. Even if you’re not willing to go that far (I’m not), you can greatly improve your customer service – which has perhaps the biggest return on investment of any professional skill you can augment – by firstly recognizing that customer service and best medical practice are not related. That means that you can provide optimal medical care and your patient can still leave the department cursing your name and threatening with lawyers, or you can commit malpractice, try to kill your patient, and if you fail, that patient can leave singing your praises and writing letters of commendation. The point is that medical best practice and customer service are separate skills, and you have to be good at both of them.

There are a few things you can do that will have a huge impact on customer satisfaction. The first is to set expectations low: under-promise and over-deliver. Most patient disappointments center on delays in care – waits to be seen, waits for tests, for consultants, for a bed upstairs. If you routinely and proactively counsel patients with time estimates that are double how long you think these things will actually take, you might get some surprise and frustration up front, but you have set yourself and your patient and your patients’ relations up for satisfaction.

Figure out what the patient wants. Some patients want to feel better, some patients want to know what’s causing their symptoms, some patients want a Percocet prescription. If you know that a patient is here for a Percocet prescription but you focus on what’s causing their symptoms, or if you know the patient is here because they can’t handle taking care of their elderly mom at home but you focus on symptom control in the ED, you are going to have dissatisfied customers. Commonly, patients want things that you cannot or will not provide (e.g. a Percocet prescription), and making those customers happy is very difficult, but you are more likely to do so (or at least manage them more effectively) if you focus on why they came.

The most common patient desire that we cannot fulfill is to know what is causing their symptoms. In most cases of abdominal pain and chest pain, for example, what we do is make sure it’s not dangerous, we don’t determine a specific diagnosis (though many EPs assign a benign specific condition – what I call as BS condition – without conclusive evidence of such, I don’t recommend this). If you specifically acknowledge your patient’s desire to know what is causing their symptoms, acknowledge that you didn’t give that to them while emphasizing what you did give them (reassurance that it looks like the symptoms are not caused by something dangerous), your patients will leave happier, which will make your life a lot easier. 

4. Managing ED flow

Emergency Medicine is unlike all other specialties in many ways, one way is that we are entirely reactive; an EP has no idea what they will encounter when they shows up to work. Although other specialties joke at how focused we are on disposition, when you don’t control the entrance, you have to be constantly thinking about the exit. Learning how to move through patients efficiently is a core EM skill. An easy way to improve your efficiency is, after every patient you see, to run your list asking one question: what is this patient waiting on? Unless an unstable patient requires care, always take care of tasks that move existing patients forward prior to picking up a new patient, as tempting as it is to just see another one. Another lesson hard learned is that multitasking is a myth: you cannot simultaneously do two things at once that require a high level of attention, and most of what you do as an emergency physician requires a high level of attention. “Multitasking” is actually ordering and taking care of a group of tasks in series. When you are interrupted with a task that needs to get done, either stop what you’re doing and do the new task, immediately delegate that task, or write it down. The demand for your cognitive resources exceeds supply, so rely on your memory as little as possible.

5. Determination of disposition and level of care

 The essential question with regard to disposition is how likely is this patient to get sicker?  While determining how sick is this patient is a cornerstone of emergency medicine, determining how likely a currently well or mildly ill person is to become more ill is much harder and more important. Although we want to make dispositions as soon as possible, some patients require a period of observations to declare their clinical trajectory; if a patient you just admitted to an unmonitored bed decompensates shortly after arrival to the ward, you may have made a consequential error. Most of the time it’s clear what level of care an inpatient requires, but when it isn’t, don’t be afraid to watch the patient for 2, 4, 6 hours to see which way they go.

Discharging patients is of course a sharper edge. Not all discharges are the same. Sometimes you know there’s nothing going on with this patient, in which case there’s a sense in which it makes no difference what you do, send them out into the cold, godless world with a pat on the back and some shitty preprinted discharge instructions. Many patients that you discharge, however, you’re not as confident that there is no occult dangerous condition. In these cases, make it clear to them that although you don’t see any evidence of a dangerous condition right now, sometimes there are dangerous conditions that can be hidden, so, Ms. Jones, if you develop new symptoms that concern you, or you get worse, come back to the ER immediately, we’re here 24 hours a day, 7 days a week.

There are some patients that you are really nervous about discharging. You’re discharging them, but reluctantly. For those patients, bring them back. In 24 hours. In 12 hours. If they’re feeling a lot better, don’t worry, they won’t come back, and if they’ve gotten worse, you want them seen again. Bring them back.

And I give a lot of patients my phone number, with the instruction here is my phone number – if you have any concerns about today’s visit, or you feel like you’re getting worse, call me. The phone number I give them is a Google voice number, which is free, and I’ve configured it to just be a voicemail; when someone leaves a message, I get an email and can listen to the message. I give out this number routinely and only get a couple calls a month. Am always glad they called. Almost always.

6. Symptom relief

Symptom relief is a core responsibility of emergency physicians. And it’s usually pretty easy, once you remember to do it. The key is to remember to do it. All non-malingering patients who have a symptom amenable to treatment (pain, nausea, vertigo, whatever) deserve to have that symptom treated, and it’s so easy to know whether to write for another dose of morphine – you just ask the patient. Do you want more medication for pain? If you get into the habit of asking, is there anything I can do to make you more comfortable you will make your patients so happy, which will make you happy, in addition to making you a better doctor.

7. Identification of dangerous conditions

Identification of dangerous conditions is probably the toughest part of what we do, truly the hard science and art of emergency medicine. The best way to do this is to become intimately familiar with the roughly 150 immediately dangerous conditions in medicine, and, when you approach the patient, do your history and physical not in a templated, med student like way, but in a way that is specifically designed to rule out (or rule in) these dangerous conditions. When you identify the complaint as headache, you call to the forefront of your mind a list of dangerous causes of headache (there are 13 – http://emupdates.com/2015/01/15/headache-in-the-emergency-department-13-dangerous-causes) and then ask questions and perform exam maneuvers specifically to cross elements off that list. Although 150 conditions seem like a lot, and it is, those 150 conditions are the house of emergency medicine; emergency physicians live in a house made up of those 150 conditions. Welcome home.

8. Resuscitation

Resuscitation and identification of dangerous conditions are tied for the most important responsibilities of the emergency physician, but resuscitation is a lot sexier. It’s also a lot easier. Here is a particularly well-done video that gives you a framework on how to approach the first five minutes of resuscitation to give you a leg up: http://emupdates.com/2014/07/03/the-first-five-minutes-of-resuscitation/.

There is a lot more to the EM mindset than the eight responsibilities. Like being comfortable making very consequential decisions with incomplete information, being comfortable being interrupted every 30 seconds, being comfortable being screamed at (and vomited on) by strangers, being comfortable giving strangers the worst news they’ve ever had. And being comfortable reducing fractures, and defibrillating people in cardiac arrest, and delivering babies, and sewing up the laceration on the billionaire everyone’s heard of who’s lying one gurney over from the undocumented immigrant who also has a laceration and speaks a language no one’s heard of, and providing comfort care to the 96-year-old taking her last few breaths, and intubating the nearly dead 10 day-old with undiagnosed congenital heart disease.

But tackling these eight responsibilities is a good start.