InFocus: How to be a Real Emergency Physician: An Open Letter to the Recently Graduated and the Seasoned Veteran : Emergency Medicine News

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How to be a Real Emergency Physician: An Open Letter to the Recently Graduated and the Seasoned Veteran

Roberts, James R. MD

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doi: 10.1097/01.EEM.0000425844.57109.65
    It's all in the presentation and attitude, says Dr. Jim Roberts, who identifies himself in this photograph as the old, yet seasoned, gray-haired emergency physician. Here he presents a patient with vague chest pain for admission to a skeptical internal medicine resident, Suneeta Sotti, MD, in the ED of Mercy Hospital of Philadelphia. Newly minted EM attending Artemis Khojasteh, MD, physician assistant student Laura Burger, and experienced emergency physician assistant Andrea Dabney look on. They pick up on the tone, mannerism, body language, interaction, and professionalism (or lack thereof), and subsequently incorporate these observations into their practices when involved in patient care. Although easier said than done, it's best to always, always, always be nice, and set a positive tone.

    Dear Doctor:

    You've found the bathroom, unknotted your stomach, minimized your palpitations, made your first huge mistake, saw a case you never even heard of before, missed your first intubation in years (in front of the medical students), and ordered a BMW pending spouse approval. And you so loved that 10-year-old Honda Civic.

    Now it's time to consider the magnitude of your plight: a real patient's life or a child's future are now squarely in your hands in a real ED. Awesome and frightening. It scared the hell out of me when I started, and it still does.

    Allow me to pontificate my personal perspective. I don't want to sound like your father or be too maudlin, corny, or holier than thou, but bear with me; I've been around for a while.

    Any philosophy is much easier said than done, and this one is the quintessential example. A lot of what I say here is what I like to strive for personally, but I have often fallen short. I screw up about three times a week; I'm just better at hiding it than you. That also will come with experience.

    Even after 42 years in the ED, I still struggle with the ideal and philosophical versus the real world. The real world is rife with serious limitations of resources and time, disappointing to incompetent colleagues, ignorant policy makers, and the unavoidable stresses of treating the sick, injured, frustrated, and downtrodden as well as the noncompliant, drugged, drunk, demanding, and overtly hostile. Keep in mind, however, that the 19-year-old with PVCs and the 43-year-old with obvious musculoskeletal chest pain truly think they are going to die. The prisoner TASERed and beaten with a cop's nightstick or the 26-year-old single mother of five (with two screaming infants in tow) with lower abdominal pain probably does not want to be in the ED at 3 a.m. any more than you do. And maybe those two dudes actually did jump that drunk guy for no good reason.

    Few will ever believe the bizarre and macabre milieu that you know as everyday life in the ED. Most of society could not begin to appreciate or fathom what you have chosen to do, most opt to ignore or disbelieve the unpleasantness and think it's simply a really cool job. Your significant other and your parents 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 “It's your turn to watch the kids,” or “Can you walk the dog in the snow because I did it four times already” is really not what you want to hear after a 12-hour shift. My wife forgets that I told her not to get that yappy dog in the first place. They muse, how hard can it really be chatting up loquacious nurses, schmoozing with those all too flirtatious medical students, and ogling those much-too-attractive drug reps? Why are drug reps all so hot, anyway, my wife always asked. The answer to that is … duh! The vomit on your shoes and the dried pus on your scrubs should send a message, but go figure.

    Talking to the spray paint cans under the Kmart blue light special will often win you a free trip to the ED. The ED will always be at the end of the social, medical, and unsolvable problem funnel. It comes with the territory. You are expected to handle problems that no one else could ever solve; many would not even try. Welcome to reality; sometimes it sucks. Love-hate does not even begin to describe the ED.

    Nothing should annoy or faze you, not even an impossible bipolar crack addict, the child molester with AIDS, hellacious maggot-filled bedsores, a paralyzed teenager, or a sudden infant death. You will be expected to be cool, calm, and collected, a compassionate and caring individual, a sympathetic listener to even the most annoying tales, a quintessential politician, and a role model doctor at the same time. You often perform above your comfort level and way above your level of training. News flash: No training totally equips you for this job.

    Many of your patients will have no other advocate or support system. If not for you, they are toast. You are the team leader, and you should always portray a positive attitude and professional demeanor and set the tone for the entire staff. Any negative attitudes toward the hospital, paramedics, administrators, housestaff, or especially the patients are quickly transmitted to and adopted by everyone.

    You are often treating the disadvantaged, poor, helpless, hopeless, and hapless in a warzone-like atmosphere. If you want a quiet ED with all the bells and whistles and a respectful, polite, sweet-smelling, cash-paying clientele in Versace, you picked the wrong hospital and probably the wrong profession. Should have been a plastic surgeon in Las Vegas.

    The system is imperfect, so very, very imperfect. It always has been and always will be. The ED can be God-awful. You will never ever have enough time, resources, 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? Which credit card? Now that's a cake job. On a good day, you have a cold pizza job.

    Always put the patient's well-being and the family's expectations first and foremost. Everyone thinks you know a lot more than you actually do, so take advantage of that secret, step up, and be the Godsend they expect and think you are.

    Above all, always, always, always be nice. Remember, patients and family rarely remember exactly what you said, but they always remember exactly how you made them feel. There is only one time to make that first impression, a great opportunity to brand you as a hero and angel of mercy or a complete jerk. Be nice to the cleaning lady, security guard, cafeteria worker, and x-ray tech. Learn their names; they know yours.

    Talk effusively to your patients, talk to them again, and always, always, always talk to the family. Sit down whenever possible; it says you are truly giving them the personal time and attention you would also want. 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 your city ever had. Last month we unknowingly treated Joe Frazier's father, the governor's cousin, and one of Gladys Knight's Pips.

    Many colleagues and patients need a lesson in manners and compassion. Do not argue with patients over nonissues such as a few Percocet, an x-ray, a blood test, or even admission to the hospital if it's a close call.

    Resist the ubiquitous temptation always to be right.

    Don't publicly criticize another physician or another hospital. You will develop a firm grasp of hindsight, but you are in the fishbowl every day and often talked about by name at surgery's M&M conference. You may not know them, but the housestaff know you, and they develop a lasting impression after their first encounter. Let that overpaid prima donna surgeon look like an ass to all who witness his barrage against you, a hardworking clinician who has to make the difficult real-time decisions. Take the higher road; emergency physicians respond to a higher calling anyway.

    The nurses' station is a recording booth — with megaphones. Your vociferous opinions about anything quickly become common knowledge with a very long half-life.

    Hubris should be eschewed at all times; you're simply not that good, that smart, or that accomplished to be inflexible or pious with a colleague or a patient. Arrogance gets you into trouble more quickly than incompetence. As Clint Eastwood said, “A man's got to know his limitations.”

    Residents, nurse practitioners, and medical students can be fragile and insecure. You can give them confidence in their ability and career choice or totally shatter their self-esteem with a single thoughtless encounter in the middle of the ED. Housestaff may seem totally in control on the outside, but they are often scared stiff on the inside. 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 a better doctor than you are. Students are expected to surpass their teachers in many talents, and maybe you were not such a good teacher after all if they do not.

    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. Even a pediatrician probably possesses some talents that you do not. If the husband of a woman with her 100th migraine demands a CT scan and neurology consult, tell him they are already ordered, then whisper instructions to the clerk. Then let the family hear loud and clear, “Where the heck is that neurologist I paged?” It's not your money, she won't live long enough to statistically get cancer from the test, and just maybe she does have a bleed this time. Again, arrogance is worse than incompetence. If your patient wasn't happy with your first plan or diagnosis, maybe it is flawed, so reconsider. Calling a consultant is a good way to share the liability.

    The family can accept that a loved one will die, but when the time finally comes, it is a harsh reality, even if the patient is in hospice for comfort measures only. The children will always remember their father's last ED encounter. Make that time as painless as possible for all concerned. Someday you will face that reality yourself, as a patient and a relative. You can't change much at the end of one's life, but you can listen, care, and usually do something to console the patient and family. A bed in hospice is waiting for many of us.

    Be especially nice to old people; you will be one in a heartbeat. Trust me, I have already had those heartbeats. That old guy from the nursing home can't remember what caused that 12-inch scar on his abdomen, but he just might remember the jungles of Vietnam.

    Be nice to the homeless; these patients don't need your attitude or comments about their lifestyles superimposed on their illnesses. Get them a meal tray, and don't discharge them at 3 a.m. That sickle cell patient, alcoholic, or heroin addict would probably like to be drug-free if there were a better life for them. Usually there is not.

    Having a baby at age 14 can be a normal lifestyle when your mother had you at 13. The next time you make a snide comment about the pregnant 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 a similar fate.

    Most physicians, even family members, shy away from the mentally ill, and it's very, very difficult to be that patient's relative or doctor. Usually they can't find a good friend, let alone a good physician. That's why they are always in the ED. They actually like you, and sometimes you even seem to care and listen. Nobody wants to be 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, who will? Few will even try.

    If AIDS, mental illness, teenage pregnancy, or drug or alcohol addiction have not courted you or a member of your family, you are truly blessed.

    When things are the darkest, remember what Mel Herbert told you: “What you do really does matter.”

    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?”

    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 don't really care. They think you make half a million to start, confusing you with that orthopedic surgeon who graduated the same year you did. I find a patient's rudeness, belligerence, and most importantly, ubiquitous entitled attitude the most difficult to ignore. Get over it or it will drive you nuts.

    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 we are not NFL players, we do OK in the grand scheme of things, and are usually spared the repeated concussions.

    Please don't whine or complain. Nobody likes a high-maintenance employee, especially a highly paid professional who should be innovative and self-sufficient.

    If you can find a better job, don't tell me about it, or bargain with it; just take it. But remember that greener grass always requires more fertilizer and more weeding.

    I remember some very fun times in the on-call room as an intern, but it's best to keep your love life (and lover) out of the ED.

    The schedule is sacred. Don't miss a shift for two inches of snow. 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. We pay you enough to buy a new car, and find a different route to work. Here's a novel idea: be that doctor who always shows up 10 minutes early. And getting out on time is not one of life's sacred privileges.

    Emergency medicine is a lifestyle, but there is more to life than medicine. You can never make up a missed championship soccer game, anniversary, birthday, or chance to take your son fishing. Remember that you might need a shift off one day, so be ready to help a colleague with a similar request.

    In my opinion, we currently have the medical world by the tail. Set schedule, 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 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 GP who works 70 hours a week, calls with lab results at 7:30 in the evening, 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 doubt it. You will be lucky if you are not making less and working harder five years from now. I suspect these days are the good old days of tomorrow.

    If you plan to give expert medical testimony, start a side business, speak for a drug company, watch out for common pitfalls we all make. I have never turned down a chance to earn an honest buck, but it's a very seductive world out there, and your reputation can sink like a stone.

    Malpractice litigation is a slimy business that makes little sense. 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. We all need to support a patient wronged by neglect or injured by negligence, but many horrible cases are often bad luck and bad diseases, not bad doctors. It's easy to second-guess a colleague with a retrospective analysis or the autopsy in hand. But you can build a home in Hawaii on what you make by using your Ivy League education, bloated CV, meaningless titles, and EM board status.

    Don't sell your soul to the plaintiff with absurd opinions and outright lies, doled out so eloquently to a clueless doctor-hating jury with a bizarre, inscrutable, or blatantly concocted definition of standard of care that you yourself would never follow. If you testify for money, and there is so, so much of it to be readily made, 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, ever materialize. Hopefully this will help you endure a bad shift, embrace your profession, and avoid many of the same mistakes I have made over the past 42 years. Perhaps not. Maybe selling shoes at Nordstroms is not such a bad idea after all.

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    Reader Feedback: Readers are invited to ask specific questions and offer personal experiences, comments, or observations on InFocus topics. Responses will be published in a future issue. Please send comments to [email protected].

    Dear Dr. Roberts: I found your latest column on Neisseria gonorrhoeae to be very informative. (EMN 2012;34[10]:10; Maybe you can answer a question that has plagued me for years. Because many of the women we end up treating for gonococcal infections in the ED have an IV placed during their workup, do they really need to be stuck again to deliver ceftriaxone IM? Why isn't the IV route ever listed as an alternative delivery option for this medication? Thank you. — Paul Leibrandt, MD, Haddonfield, NJ

    Dr. Roberts responds: To my knowledge, you can give the same dose IV with the same efficacy. I would opt for that route if an IV is established. I think the CDC considered guidelines for the asymptomatic exposed patient or the ones with simple uncomplicated urethritis or cervicitis, but most of these patients do not have an IV. If venous access is needed, I would assume you might be thinking PID, septic arthritis, etc., in which case different therapy is required. Of course, few ID specialists or CDC policymakers seem to be actively working in the ED so I can see why this evolved as it did.

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