An intern came to me last fall after seeing a patient, lamenting that no one had taught him “any of this” in medical school. This is not unusual to hear from a new resident. I bypassed the resident's presentation, and walked into the patient's room. It took all of 10 seconds for the hair on the back of my neck to pop up and for me to realize that this was a patient who could make or break a shift.
He was a montage of chronic pain, prescription narcotic abuse, and Axis II mental illness that had caused him to burn every bridge imaginable. Throw in his poor hygiene and non-ambulatory status, and it was a drastic understatement to say he was a tough case.
The temperature is still a bit low (even in South Carolina) as I write this in March, but the anxiety level of hundreds and hundreds of applicants to emergency medicine programs is at the boiling point. This year's applicants have filled my inbox with questions, comments, promises, and even some pleading. This would have ended weeks ago in past years, but a lot of these folks are worried not only about matching in emergency medicine but about having a job in July, as I explained in my column last month. (“Doctors Waiting Tables;” http://bit.ly/NnUPHr.)
The “Ides of March,” however, will bring an incredible sense of achievement to 1,744 medical school graduates with a position in an emergency medicine program. Match Day summarizes all of the sacrifices in a single envelope after at least eight years of competing against thousands of others seeking the esteemed place in society called “physician.” I have the great honor that afternoon of calling each matched applicant to welcome him to our program. Most of them are altered. Good for them.
Their euphoria is palpable. They will spend the next three months basking in this achievement, and all of them will look a back on the 100 days between Match Day and July 1 as some of the sweetest in their lives. They can finally flush away all the midnight cramming for exams, interviews, and living off loans (and Mom and Dad) to start their journey to patient care, prestige, and an actual income. Then the new intern class meets with me on the last day of June for the first time in their official role as a resident. And what do I tell them? “It's reality time. You are a now glorified social worker.”
Sounds a bit rough for the first day, doesn't it? But it depends on how you look at it. Our expectations are a huge component of judging how we are doing in life. New interns expect lots of procedures (that were promised by the program director), time off for personal pursuits, and opportunities to explore the various niches of our incredible specialty.
But what about the social problems that will inevitably darken their door? What's the deal with those? New residents don't always see this coming, and they never had a class in medical school about how to manage these problems. (Med schools avoid this topic so they all don't drop out and get MBAs.)
Medical students rotating in the ED often get to cherry-pick cases. They get the lacerations, UTIs, simple orthopedic cases, and the like. They also get pulled over by residents and attendings to see the STEMIs, obvious CVAs, seizures, and great traumas. They get a courtside seat for the sexy stuff that EPs get to do. It's not that they do not see the chronic pain, drug abuse, borderlines, and domestic violence cases, but that ball will inevitably land in the resident's court, and the students will be spared the painful dispositions, cranky consultants, and families saying, “You have to do something.”
Those of you in training know these patients well. You refer to them on a first-name basis with your classmates as you routinely play a casual game of one-upmanship. (The resident who has seen a patient the most or who saw him last gets the most points.) But you are beginning to realize as you progress through your career that shifts will eventually become less about the cool stuff you did and more about how much anguish these types of patients will cause you on any given day.
But is it really that bad? After all, what's wrong with being a social worker? Figuring out the right approach for these patients is incredibly difficult and takes years of training. Acquiring these soft skills help you avoid the verbal land mines that will escalate the frustration and help you develop the catch-phrases that streamline the amount of time you spend with them while juggling your other patients. Managing these patients is the real art of emergency medicine. This is why seasoned consultants at your hospital will shake their head, and say to you, “I don't know how you do this day after day.”
This is why you will be paid really, really well. And this is why you are worth every nickel of it. This work is hard.
Telling you to “embrace it” is patronizing at best, but I can tell you that our specialty has so many more tools than ever before. I come from an era when CTs just barely existed, ultrasound machines were as big as refrigerators, and everyone in the hospital looked down on us. You are in a great place, but you have to accept the downside of emergency medicine with the upside. If you do not enter residency with some understanding of this, it makes the pill called “reality” that much harder to swallow.
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