Emergentology: I Used to

Walker, Graham MD

doi: 10.1097/01.EEM.0000406948.90371.fa

If you took high school French with Madame Jiskra or Madame Mortko like I did, you know that the imparfait tense describes actions that happened in the past, but without a specific beginning or end: “I was sewing up the lac when the patient had a seizure,” for example. In English, you just add “was” before your verb, and voilà (pun intended), it's past tense. But it also expresses a second, related idea: actions that happened frequently or repeatedly in the past but do not any more. For this concept in English, we say, “I used to.”

I used to sleep well. (Until I became an attending, that is.)

Now with a few attending shifts under my belt, I toss and turn at night, hoping that I have made the right decisions. The admitted patients are easier. They're at least being watched by someone else or multiple someone elses: an intern, a resident, an attending, a nurse. It's the discharges that make me queasy. Not the ankle sprains or the stuffy noses or even the “negative workup, feels better, send them home” folks. It's the “they're almost assuredly going to be fine, but just what if?” patients who get to me. Workup is negative, but could I be missing something?

Right lower quadrant pain but not tender? And feeling better on his own? And normal vitals? And normal labs? And an hour later, still not tender? That can't possibly be appendicitis. No way. Definitely. Not. Appendicitis. I'm definitely not sending home appendicitis.

Am I?

(Yes, I realize in the vast technology of American medicine, I could just CT the hell out of everyone who looks at me the wrong way, but I think most of us agree that's not good medicine and that the history and physical exam should still count for something.)

I used to think I was confident.

What was it about being a resident that made me so damn sure of my diagnosis? The familiar surroundings? The “safety net” of having an attending staff my cases? Wanting just to keep the team moving? A month more senior than a resident now, I've got nothing but doubt and second-guessing. Is it just that I'm in a new hospital with new faces? I don't think so.

It's incredibly strange. “My” patients were “my” patients when I was a resident, but I was just so much more confident in my assessments of them. There's something so different about having your name on that line as the attending. And I'm not talking legally; I'm talking about just wanting to get it right. To prognosticate correctly. The old adage of “trust no one” certainly applies here, but not even myself?

I used to think I was a pretty middle-of-the-road worker-upper, but now I feel myself drifting closer and closer to conservatism. I think this will pass with time as I grow more grizzled and seasoned as an attending, but right now I still crave that intrinsic reassurance you get from seeing normal vitals or studies. It's a hard urge to fight.

I used to know everyone in the ED, and they knew me. I feel like a Head & Shoulders commercial here: You never get a second chance to make a first impression. (I think) I'm known at my old stomping grounds for being a friendly, fun, sarcastic guy who's a reasonably good, hard-working physician. But now that I'm the new kid on the block, who knows what reputation I'm getting? Am I too relaxed? Too casual? Too conservative? Too confident? Not confident enough? Is getting the nurses' opinions on a patient a sign of weakness? Or of good judgment?

I used to spend much more time worrying about getting results back and making sure things are happening. Now I spend much more time with the patient. It's one of the best parts of being an attending. I get to be the good guy. I introduce myself as the supervising doctor, here to answer any questions the residents haven't already answered and explain everything again. Sometimes I even draw diagrams on bedsheets. I see the patient, meet his family, confirm his story, and make sure we haven't missed anything. I get to smile, tell a joke, and reassure the patient with my infinite wisdom. (It's about this time that they say, “Dr. Walker, you sure you're not 15?”)

I used to appreciate having residents and great nurses, but now I really do. I'm sure I'll soon miss the procedures, but for now it's really nice to be able to make the decision that a patient needs a central line, and with the appropriate supervision and presence for the key portions of the procedure, of course, to have the resident put it in. It leaves me free to see the next patient, write up a few charts, or follow up on some labs.

I used to like medicine, but now I really love it. As challenging as it is and as sleepless as some of the nights are, it's exhilarating finally to start to get to the point where things are getting easier, to know that the final decision on a patient is mine, and that the schedule actually make it feasible for me to love my work.

I think the imparfait does a good job of summing up what it's like to be an attending for the very first time. It's a whole lot of change, a lot of questioning, a healthy amount of doubt, and luckily some excitement and reward along the way. We all feel these things as we move from one position to the next in life, and yet it's a quality with which we, especially as physicians, are incredibly uneasy. Coincidentally, it's probably best expressed by the English translation of imparfait: imperfect.

Comments about this article? Write to EMN at emn@lww.com.

Dr. Walker is a fellow in simulation medicine in the Stanford/Kaiser Emergency Medicine Residency Program. He has been blogging since medical school, first at Over My Med Body, and now as the developer and co– creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications (www.mdcalc.com), and The NNT, a number-needed-to-treat tool to communicate benefit and harm (www.thennt.com).

© 2011 Lippincott Williams & Wilkins, Inc.