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Emergency Medicine News:
doi: 10.1097/01.EEM.0000433396.55302.9e
After the Match

After the Match: Flipping Burgers at 50

Cook, Thomas MD

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Dr. Cook is the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC.

Act 1: Have you ever seen a picture of your residency attendings when they were in training? Man, they look pretty goofy. I'm sure you're thinking, how did they become my mentors?

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We were all young then. We went into emergency medicine for the same reasons that attract smart, engaging folks today. We saw the advantages, and took a chance on a new specialty. We hated pagers. We wanted to work hard when we were on and not be bothered when we were off. We wanted the freedom to travel without having to worry about our “practice” back home. We didn't mind working half our career at night because we could recover in a day or so. And the pay was good for only three years of residency training. In fact, we thought it was GREAT compared with what we earned before.

But something funny happened. We got old. And all that we had heard “old doctors” complain about (you know those guys in their 40s) started to make more sense. The nights really started to hurt. Our backs and knees ached. We developed serious coffee habits (among others). We experimented with ways to get sleep. Some built caves in their homes. Others tried a variety of over-the-counter and prescription concoctions. Our families took on the wrath of our sleep-deprived grouchiness when little annoyances drove us nuts. Partners went through divorce. Occasionally they left the group, left town, left the specialty, or all of the above.

But most of us carried on. We had responsibilities: mortgages, student loans, kids‘ needs, spouses’ needs (and desires), college savings plans, taxes, insurance premiums, new cars, and nice vacations. We needed the money to land safely in our checking account each month to meet our growing obligations, and the best and fastest way to consistently make a lot money in a relatively short amount of time was to get ourselves in the ED. Eventually we hit 50 and were still working three straight night shifts during a holiday weekend. Your kids are at the beach, and you are hanging out with cops, paramedics, social workers, nurses, and the “bread-and-butter” of society. What happened to seniority? Why aren't I working weekdays and hanging out with my family this weekend?

And then reality hits us: we are shift workers. We are just like the guy down the street at McDonald's. We clock in, clock out, and keep things moving. We flip the burgers of humanity all day, all night, every weekend, and every holiday.

Act 2: I sit with each resident for about an hour at least twice a year. We review their performance, and discuss their strengths and weaknesses.

The rest of the time we talk about them. This gives me the chance to listen to their thoughts and dreams and maybe, just maybe, give them a little advice that will change the arc of their careers and lives. I always ask, “What do you want to do after residency?”

Most come up with a boilerplate answer. “I want to go out and practice, but I think I want to be involved with education in some way, and after a few years I might look for an academic job.” Most are consumed by the idea of “making hay while the sun shines.” Get the “big money” now and then improve their work lifestyle.

This is unlikely to happen. The cash starts coming, and people get used to it. They get all the things they deprived themselves of during those long nights of studying that junk we never use in patient care. (Used calculus recently?) A few will do it, but the stars have to be perfectly aligned. Spouses, kids, friends, partners, and your financial planner need to be on board when you reboot your career and turn off the dollar faucet.

I give them my standard retort. “Imagine three straight night shifts on Memorial Day weekend in the 20th year of your career. How will it feel? What will it be like at 2 a.m. with a full ED and your partner getting ready to go home from her evening shift, leaving you to fend off the masses for the next four hours just when all the bars in town are giving last call? Can you see yourself doing this?”

My point is not to talk them out of emergency medicine and its fundamental 24/7 mission but to think about what it's like to do this job when they are old. They have spent their entire lives thinking in terms of three-to-five year periods. High school, college, medical school, and residency are relatively short bursts of time. Sure, it seems long when you are doing it, but it's nothing compared with decades of doing the same thing week after week. You are accustomed to thinking you will move on when your current endeavor gets old. The difference now is that after graduation you will be in the middle of a 30-year stint that will last the rest of your professional life. You will not do anything else. No more endings until retirement. This is what you do. And do. And do.

Act 3: Trying to get a 26-year-old resident to imagine life at 40 is like hitting yourself in the head with a hammer. It just feels so good when you stop. But I keep trying, and sometimes I see a flicker of light in the worn-out incandescent bulb rooted somewhere in their cortex labeled “thinking about my future.”

The faculty at our program have a lot of gray hair (and a lot of male-patterned baldness), and the residents see how they look and behave after a long run of shifts. But we also have several folks who have acquired skills that have altered their lives in fantastic ways. They all work clinically (everyone, including our chairman, works nights), but they also have professional activities that provide income. These skills do not just rely on fellowship training in some emergency medicine niche, but include master's degrees in business, medical management, and health information technology. Of course, pulling this off takes a lot of work, but it also keeps the fire of creativity burning through the second and third decades of a long career (and it's a ton of fun). They have diversified so their career does not depend on clinical work, and that decreases the wear and tear on older EPs in a young man's game.

We are lucky! No other specialty encompasses the breadth of emergency medicine. We learn a little about everything and a lot about life. It's a never-ending soap opera of personal disasters and high drama. But we also interface with everyone. I am not talking about just consultants but also mental health facilities, nursing homes, police, fire, EMS, government, disaster services, social services, global health, the media, and politics. We are the straw the stirs the drink of medicine.

This knowledge can be used in so many ways because so many people value it. No one really wants to know what your day was like if you are a dermatologist. It's boring. Do yourself a favor now and leverage what you are learning. Talk to faculty whose careers you admire. Dream a little. That's how you got to where you are in the first place. And consider this: do you want to be a physician in his 40s who can't wait for his career to end, or do you want to be that person at 50 who is still excited about what he is doing in the first half of a great career?

© 2013 by Lippincott Williams & Wilkins

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