Learning Objectives: After reading this article, the physician should be better able to:
- Describe the realities of being an attending physician for the first time.
- Define the limitations of an attending physician.
- Summarize the responsibilities of an attending physician.
Release Date: November 2009
Every year, I send a letter to all the new emergency medicine resident graduates who begin to work at my hospital. I wrote it a few years ago, and continually update it. I think it is both an inspiration and a wake-up call, and I thought it might be of interest to you. I think I covered the waterfront, but any suggestions or comments would be appreciated and passed on to the readership.
TO: All Emergency Physicians
FROM: James Roberts, MD
SUBJECT: Roles and Responsibilities of Emergency Physicians; Philosophy of the Department
By this time, all of you newly minted emergency physicians have found the bathroom, unknotted your stomach, minimized your palpitations, made your first huge mistake, saw a case you never heard of before, missed your first intubation in years (in front of the medical students), and ordered a BMW (pending review by your spouse).
Now it's time to consider the magnitude of your position: You're actually in charge of a patient's life in a real emergency department, and you're contemplating exactly how to act. The transition is quite difficult for most; hopefully yours will be smooth, but don't get discouraged. This, too, will pass.
For your perusal and edification, I have enclosed a letter that I send to all recently hired physicians. It was written a few years ago and was intended for recent graduates, but everyone can benefit from reading it every few years. Think of it as some sort of recertification.
I am delighted that you have decided to join our emergency medicine group. You are one of 28 residency trained, board certified physicians practicing in a challenging environment that combines resident education and a very busy clinical practice in an academic milieu, and in a setting of a faith-based medical system. I am looking forward to the enthusiasm and competence I know you can bring to our organization. I have enclosed a copy of our Missions and Values statement, and I urge you to read it carefully and ponder its significance to you and our patients.
This letter describes the philosophy of the department (my personal perspective). I don't want to sound like your father, or get too maudlin, corny, or holier than thou, but bear with me; I've been around for a while.
Philosophy of the Department (AKA How to Survive as a New Attending)
Any philosophy is much easier said than done, and this one is no exception. A lot of this is what I like to strive for personally, but I have not always been successful. I screw up about three times a week; I'm just better at hiding it than you are. That also will come with experience.
Everyone must evaluate his particular approach, skills, interests, and capabilities, but I would like to set the tone for the department with this letter. Like you, I also struggle with the ideal and philosophical versus the real world with serious limitations of resources and time. These mechanical limitations are always coupled with the omnipresent human limitations and the ubiquitous stresses of treating the sick, injured, and downtrodden, and often the noncompliant, drugged, drunk, demanding, and overtly hostile. It's prudent to keep in mind, however, that the 84-year-old with chest pain for the 99th time, the prisoner beaten with a cop's nightstick (maybe those two dudes actually did jump him for no reason), or the 26-year-old mother of six (and the two screaming infants with her) with lower abdominal pain probably does not want to be in the ED at 3 a.m. any more than you do.
Few will ever believe the bizarre and macabre scenarios that you eventually come to view as everyday life in the ED. Most of society could not begin to appreciate or handle what you have chosen to do, and like most of the unpleasantness in the world, they opt to ignore or disbelieve most of it. Your spouse, significant other, and mother will never understand your day at the office. (When will you get a real office like all those other doctors?) They will never understand that “Now it's your turn to watch the kids” or “Can you walk the dog in the snow because I did it four times already?” are really not what you want to hear after a 12-hour shift. They muse, how hard can it really be chatting with loquacious nurses and schmoozing with those cute medical students and much-too-attractive drug reps? The vomit on your shoes and the dried pus on your scrubs should send some message, but go figure.
The ED will always be at the end of the social, medical, and unsolvable problem funnel, so a lot of grief and even a lot more frustration come with the territory. You are expected to handle problems that no one else could ever solve; many would not even try. I laud your efforts and enthusiasm, however naïve. Welcome to reality; sometimes it sucks. Love/hate does not even begin to describe it.
We are all at this hospital partly because of resident education, but you will be expected to be a bedside teacher, compassionate and humanistic individual, competent businessperson, quintessential politician, and a role model clinician at the same time. I expect that you will always practice emergency medicine at least at the level for which you have been trained, but you will usually perform above that level. There is no training to totally equip you for this job. You are no longer the resident; you are now the mentor.
The buck stops with you now. You have the final responsibility for your patients' lives and well-being; many will have no other advocate or support system and that is indeed an awesome and often stressful responsibility. You are the team leader, and I expect you always to portray a positive attitude and professional demeanor and to set the tone for the entire staff. Any negative attitudes toward the hospital, the staff, or especially the patients are quickly transmitted to and adopted by everyone. Medicine is a tough job, always stressful, and it may be difficult at times to remain focused in the heat of the moment. It is your responsibility, however, to predict and minimize potential problems with families, attendings, consultants, nurses, lab, x-ray, and paramedics. In essence, you are the hospital that is on display for the public.
You are often treating the disadvantaged, poor, helpless, hopeless, and hapless in a war zone-like atmosphere. The beach invasion on D-Day in “Saving Private Ryan” is a vivid example of a bad day in the ED. If you want a quiet ED with all the bells and whistles and a cash-paying clientele in three-piece suits, you picked the wrong hospital and probably the wrong profession. The system is imperfect. It always has been and always will be. At times, the ED is simply God-awful. Use your ingenuity to provide the best care for your patients with the always-limited resources. You will never ever have enough time, personnel, equipment, or backup to make this job an easy one. Deal with that reality. If you want a thank you, or even a lunch break, go sell shoes at Nordstrom's. “What size? What color? How do they feel? Which credit card?” Now that's a cake job. On a good day, you have a cold pizza job.
You will never get complete agreement on any issue in medicine or with any political or logistical problem. As a general guideline, always put the patient's well-being and comfort and the family's expectations first and foremost in your plans. As a last resort, you can always keep the patient in the ED until the sun comes up and you can get assistance or resolution.
Above all, always, always, always be nice. (That's clearly easier said than done.) Be nice to the patients and family, but also to the cleaning lady, security guard, cafeteria worker, and x-ray tech. Talk to your patients, talk to them again, and always, always, always talk to the family. Try to sit down whenever possible; it shows the patient you are giving him your time and attention. Many patients, residents, and attendings need a lesson in manners and compassion. You probably can't teach them much at this stage, but you can always be nice to everyone, even if it hurts. That 300-pound demented nursing home patient with bedsores and a feeding tube is somebody's mother, and maybe she was the best third grade teacher Philadelphia ever had. And just maybe her daughter is on the city council or the hospital's board of directors. Do not argue with patients over nonissues, such as a few Percocet, an x-ray or blood test, or even admission to the hospital if it's a close call. Resist the temptation to always be correct or vindicated.
Don't publicly criticize another physician, another hospital, or some other physician's views. You will develop a firm grasp of hindsight, but you are in the fishbowl every day; no need to convey that feeling back to a colleague. Take the higher road; emergency physicians generally respond to a higher calling anyway. Let that overpaid, underworked prima donna surgeon, internist, or board member look like a jerk to all who witness the barrage against a hardworking clinician who has to make the difficult real-time decisions.
Your impressions of another physician or administrator quickly become the impressions of the patients, residents, and nurses. Do not get into public shouting matches with patients or staff. Do not argue in public, in front of patients, or with residents or attendings from other departments. Try to keep cool under seemingly impossible circumstances. If you see a problem with an attending, nurse, consultant, or tech, write me a note with documentation. You can personally step in where reasonable, but don't try to navigate high stakes political waters alone; you may often make it worse. Remember that there are always two sides to every story. As Clint Eastwood said, “A man's got to know his limitations.”
Hubris should be eschewed at all times; you're simply not that good, smart, or accomplished to be inflexible or pious with a colleague or a patient. Arrogance gets you into trouble more quickly than incompetence. By the way, I like to be aware of your potential problems before I hear about them from someone else.
Residents and medical students can be fragile and insecure. Remember the first time you presented to the erudite senior professor instead of a resident who had only a few years on you? You can give them confidence in their ability and career choice, or totally shatter their self-esteem with a single encounter in the middle of the ED. While house staff and students may seem totally in control on the outside, on the inside they are often scared stiff. It's a fine art to learn how to critique without criticizing, to instruct without insulting, and to evaluate without emasculating. Teach them how to be good doctors, not how to ridicule a trainee when they are in your position. Students are expected to surpass their teachers in many talents, and if they eventually do not, maybe you were not such a good teacher after all.
There is no shame in calling a consultant for a medical problem or situation that is going poorly or if you are in over your head. Anesthesia, neurology, and pediatrics probably possess some talents that you do not. If the husband of a woman with her 200th migraine demands a CT scan or neurology consult, give it a lot of thought before taking a contrary stand. It's not your money, and just maybe she has a bleed. You cannot practice medicine under the constant fear of malpractice, but remember that many malpractice cases are filed because of personality clashes, a physician's insensitive comments or actions, his failure to communicate, or merely perceptions of physician negligence or physician inaction by the family. Again, arrogance is worse than incompetence. The family can accept that their loved one may die, even if they are in hospice for comfort measures only, but the emergency physician at least has to listen, hopefully has to care, usually has to try something, and always has to communicate these feelings.
Be especially nice to old people; you will be one in a heartbeat. That old guy from the nursing home may not be able to remember his doctor's name or what that 12-inch scar on his abdomen was from, but he just might be able to remember fighting for his country in the Korean War. Be nice to the homeless; you are lucky enough to have a home and a regular paycheck. Remember that HIV is a death sentence; these patients don't need your attitude or comments about their lifestyles superimposed on their illnesses. That sickle cell patient, alcoholic, or crack addict would probably like to be drug-free if there were a better life in the offing for them.
Having a baby at 13 can be a normal lifestyle when your mother had you at 12. The next time you make a comment about the teenager with herpes or the kid who took an overdose after being dumped by his girlfriend, remember that your son or daughter may not be immune to life's temptation and stresses either. Most physicians and family members shy away from the mentally ill, and it's very, very difficult to be their doctor. Usually they can't find a good one. Nobody wants to be neurotic, bipolar, or psychotic; just be thankful that your serotonin and dopamine levels are under the bell curve most of the time. If you won't help this segment of society that can't help themselves, who will? As I said, few will even try. If AIDS, mental illness, teenage pregnancy, or drug addiction has not courted a member of your family, you are truly blessed.
Medicine is a proud and noble profession, but it is actually just another service industry. Get used to hearing “When are you going to wait on me?” Hopefully you do not feel like a glorified server, but the patient is sort of a customer similar to the guy in front of you at McDonald's. He wants his hamburger cooked to order, and “special orders don't upset us.” Your customers, however, wait a heck of a lot longer to be served, and they have the bellyache before they eat the greasy meal. If your patient wasn't happy with your first plan or diagnosis, reconsider it, work out something else, or get a consultant. Remember when you had to take your car back to the dealer for the same problem three times? Everyone feels entitled to the best health care; some feel more entitled than others. No one will ever know how hard you work, and most patients think you make half a million to start. I find a patient's rudeness, belligerence, and most importantly, the ubiquitous entitled attitude the hardest issues to ignore. Get over it, or it will drive you nuts.
There is also the harsh reality of running a business. Charting, documentation, and billing issues are part of the annoying routine that pays your salary. Good charting and good medicine go hand in hand. Charting can be you best friend or worst enemy, especially in a malpractice case. Don't write anything on the chart that you would not want to see in the Philadelphia Inquirer or would be embarrassed to read to your mother or a colleague. Medicare et al also commonly reviews your records. All those former Cold War CIA agents with a lot of time on their hands are now are looking for Medicare fraud. At some point, you will be sued, almost guaranteed, by one of the six zillion lawyers on TV at 2 a.m. and on every bus and phone book cover in Philadelphia. This can be minimized if you pay homage to the paperwork! If you are just beginning with us, I will give you a crash course on charting, your role as a supervising physician in the eyes of the accountants, and some potential ways to stay out of or limit your time in the courtroom.
A few other nuts and bolts issues. Being a doctor can be viewed as a privilege or an entitlement; choose the former. You are well compensated for your time, no one gets paid what they are worth, and although you are not an NFL player, we do OK in the grand scheme of things. Although I am always more than willing to discuss issues and problems, I would appreciate it if you would not whine or complain. Nobody likes a high-maintenance employee, especially a professional one who should generally be self-starting, innovative, and self-sufficient. I can't run your social, personal, or financial lives for you; life is tough in the big city. I can name 20 people who came to me last week with problems, but offhand I cannot name a single one who came to me with a solution. Note that the schedule is sacred. Don't miss a shift, and learn how to show up on time. No one likes a replacement who is always 10 minutes late. (You know who you are.) That dead battery or behind-a-school-bus excuse only works a few times. There also may be a lot of days where you won't get out on time. And by the way, keep your love life (and lover) out of the ED.
Emergency medicine is a lifestyle, not simply a job. On the other hand, there is more to life than medicine. You can always make up a switched shift, but you can't make up a missed championship soccer game, anniversary, birthday, or chance to take your son fishing. Remember that you might need a shift off some day, so be ready to help a colleague who asks for a schedule switch. Stop looking for a shift switch if you won't work for someone else in a pinch.
In my opinion, we currently have the medical world by the tail. We show up for work, work hard, and then go home. No beepers, no calls for orders, no insurance forms to fill out, and no bills to collect. Heck, we get paid even when the hospital does not collect a cent. You don't have to interview for a clerk, fill the nursing schedule, or even find a replacement for your vacation time. You clearly work hard for your paycheck, but any general practitioner or pediatrician would take your job and salary in a nanosecond. Next time you think you are underpaid and overworked, consider the pediatrician or GP who works 60 hours a week and makes less than you do. And never discuss your salary with a hospitalist! Let's hope Camelot lasts until retirement, but the way things are headed, I suspect today is the “good old days” of tomorrow.
Finally, if you plan to give expert medical testimony, start a side business, work out a deal as a consultant, speak for a drug company, or do any professional activity that will reflect on Mercy, speak with me beforehand to avoid common pitfalls. I have never turned down a chance to make an honest buck, but it's a very seductive world out there, and your reputation and the hospital's good name can sink like a stone. I would particularly warn you to watch out for the occasional egregious plaintiff's malpractice attorney. They all sound so caring and righteous on the phone, and money is never an object.
It's so easy to second-guess a colleague with a firm retrospective analysis, often only based on a single vital sign or nonspecific lab test. If you can rid the profession of just one bad doctor or get compensation for someone injured by blatant indifference or incompetence, go for it with gusto. And count me in to write a similar opinion. We all need to support a wronged or injured patient but not simply a bad outcome from circumstance or a heinous disease process. Those truly harmed by malpractice need to be rightfully compensated, as do their families. But you can build a home in Hawaii on what you make by using your Ivy League background, bloated CV, and EM board status to sell your soul to the plaintiff with absurd opinions and outright lies to a clueless lay jury about the inscrutable concept of standard of care. All of your colleagues will recognize you for what you have become. Shame on you!
Finally, be careful with alcohol and your ready access to Vicodin and Percocet. Addiction can ruin a lot of lives in a very short time, and it's so easy to succumb.
Many of those idealistic halcyon thoughts of being a doctor, coupled with the blissful insouciance you had as a medical student, will sadly never materialize. Hopefully this will help you adjust to your new reality, and perhaps you will avoid many of the same mistakes I have made over the past 40 years in the ED. Perhaps not. Maybe selling shoes is not such a bad idea after all.
Caveats for New Emergency Medicine Attendings
- ▪ Always put the patient's well-being and comfort and the family's expectations foremost in your plans.
- ▪ You are no longer a resident; the buck stops with you.
- ▪ You are the team leader. Portray a positive attitude and professional demeanor, and set the tone for the entire staff.
- ▪ Deal with the reality that you will never ever have enough time, personnel, equipment, or backup to make this job easy.
- ▪ Always, always, always be nice to patients and families but also to the cleaning lady, security guard, cafeteria worker, and x-ray tech.
- ▪ Be especially nice to old people; you will be one in a heartbeat.
- ▪ Talk to your patients, talk to them again, and always, always, always talk to the family.
- ▪ Try to sit down whenever possible; it shows the patient you are giving him your time and attention.
- ▪ Do not argue with patients over nonissues, such as a few Percocet, an x-ray or blood test, or even admission to the hospital if it's a close call.
- ▪ Resist the temptation to always be correct or vindicated.
- ▪ Don't publicly criticize another physician, another hospital, or some other physician's views. Don't argue in front of patients or with residents and attendings from other departments.
- ▪ Eschew hubris at all times. You're not that good, smart, or accomplished to be inflexible or pious with a colleague or patient.
- ▪ Instill confidence in residents and medical students.
- ▪ Call a consultant for a medical problem or situation that is going poorly or if you are in over your head.
- ▪ Remember that charting, documentation, and billing issues are part of the annoying routine that pays your salary.
- ▪ Don't write anything on the chart you would not want to see in the newspaper.
- ▪ Remember this: You will be sued.
- ▪ Be self-starting, innovative, and self-sufficient.
- ▪ Go to your chief with problems — and solutions.
- ▪ Don't miss a shift, and show up on time.
- ▪ Be ready to help a colleague who asks for a schedule switch.
- ▪ Be careful with alcohol and your ready access to Vicodin and Percocet.
Readers are invited to ask specific questions and offer personal experiences, comments, or observations on InFocus topics. Literature references are appreciated. Pertinent responses will be published in a future issue. Please send comments to email@example.com. Dr. Roberts requests feedback on this month's column, especially personal experiences with successes, failures, and technique.
Dr. Roberts: As usual, a superb article on ECG findings of TCA overdose. (“Electrocardiograms You Need to Know: Tricyclic Antidepressant Toxicity,” EMN 2009;31:24.) I would like to comment on your statement, “Not even the best toxicologist in the world can save a patient once his TCA overdose precipitates ventricular fibrillation, severe hypotension, or seizures.”
We just reviewed in our journal club an article by Archie J. Sirianna, MD, et al (Ann Emerg Med 2008;51 :412) in which just such a patient was successfully resuscitated with the use of lipid emulsion after all other measures had failed. I would be interested in your comments. — George E. Goldman, MD, Akron, OH
Dr. Roberts responds: Dr. Goldman is on the cutting edge by commenting on lipid emulsion therapy (brand name: Intralipid 20%) for severe lipophilic drug overdose. This was first tried by anesthesiologists for bupivacaine overdose, and it seemed to work wonders. Our anesthesiologists now carry the milky white fluid on their crash carts, and also use it for parenteral feeding. Not to be outdone (and a Pharmacy & Therapeutics Committee triumph), a few bottles of Intralipid are now in our ED PYXIS. Trying to get it from the pharmacy in an emergency is impossible, and it is not in any nursing protocol. Our toxicology service has used it a few times for critically ill calcium channel blocker and beta blocker overdose, with mixed results. It's difficult to tell the effect when so many other interventions are used. It's safe and easy to use, and I suggest trying it early on, hopefully prior to cardiac arrest. Theoretically Intralipid will soak up some circulating TCAs. The suggested dosing is a 100 ml (1.5 mg/kg) bolus, then 0.25 ml/kg/min for 30 to 60 minutes, with repeat bolus if no improvement. This is a lot of Intralipid, but don't be stingy. (Before trying, also read Toxicol Rev 2006; 25:139.) As luck would have it, there is actually a web site for this use of Intralipid: www.lipidrescue.org.
Dr. Roberts: I want to thank you for introducing us to Wellens' criteria in residency as well as for refreshing my recollection in EMN. A few months ago, I diagnosed type 2 Wellens' criteria on a 50-year-old man. The cardiologist at my institution was not totally familiar with Wellens' criteria so I asked him if I could talk to the interventional cardiologist directly. I did, he accepted the patient on a Friday evening, and he called me back two hours later to say that the patient had a solitary lesion in his proximal to mid-LAD. His EKGs were better than textbook. I also had a case of Sgarbossa's criteria (with left bundle branch block and concordance) who went to cath lab, and had a stentable lesion. — Ritesh Bhandari, MD, Oakland, CA
Dr. Roberts responds: Dr. Bhandari is another stellar graduate of the emergency medicine residency program at the Drexel University College of Medicine in Philadelphia where all the residents who have stayed awake in conference have heard of Wellens' and Brugada syndromes. It looks like Dr. Bhandari actually remembered a few uncommon yet important EKG findings. Bravo, Ritesh; you probably saved a life. Cardiology consultants who need a refresher can download the erudite discussions on these zebras, complete with EKGs and references, from the July, August, and September issues on EM-News.com.
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