At my first job as an attending, I found myself consulting with one of my favorite elder statesmen of cardiology about a very concerning ECG with a worrisome story: “But he has positive Sgarbossa criteria!” My residency program considered the Sgarbossa Criteria gospel. We trained on it, and I followed it, but this cardiologist had never heard of the Sgarbossa criteria.
I've been an attending emergency physician for two years now, and I still think back to that conversation whenever the subjects of confidence and ego come up. I've still got a ways to go if you believe the theory popularized by Malcolm Gladwell that you're not really an expert in anything until you've done it for 10,000 hours. (The New Yorker, Aug. 21, 2013; http://bit.ly/1qBrDzV.) Ten thousand hours of practicing medicine translates to four to six years of being an attending, not two.
Yet, I was right about the Sgarbossa criteria. New attendings are usually on the cutting-edge of current research and best practices. It's easy to become a little gung-ho when you come out of the residency door, rearing to go with the latest treatments. You're a little more willing to push the envelope in an academic setting, and so are your teachers. That's sort of the whole point of academia.
When you begin practicing medicine in a community hospital setting, however, you may be asked to do things that are, frankly, outdated. And you'll have the studies to prove it. When this occurs, you have to play nice, and check your ego at the door. The trick is to do that without letting go of one of an EP's most precious assets: confidence in her training.
You are going to discharge most of the patients you see all by yourself. You will consult with experts on individual cases, and the cardiologist will usually think you don't enough about treating heart attacks, and the pediatrician will think you don't enough to treat kids, and so on. But you are still the most qualified person to handle whatever comes through that door.
A new attending must be simultaneously confident in decision-making and humble when it comes to the more experienced providers in the department and throughout the hospital. They are there to help you, and most of them are talented professionals with more experience than you.
It's a tough balance to strike. You have to appear consummately confident to your nursing staff, some of whom may also be very fresh graduates looking for leadership. The task is to make them comfortable enough to voice their own questions and concerns, so that you can also rely on their eyes and ears but still be the unequivocal leader of the team.
I'm always particularly attentive to this need for balance when I'm running a code. It's a chaotic situation that requires the directed leadership of a single person who will be giving clear instructions at a time when there is no room for error or confusion. At the same time, with someone's life in your hands, you need to be extra careful that you haven't missed anything, and sometimes it's a nurse or a tech who will be the person to notice something that you haven't.
When I was a medical student and we were working a code, I was once the only person in the room who noticed that no one had remembered to plug the patient's bag valve mask into the wall. This patient was too far gone to resuscitate anyway, but it still took me three minutes to work up the courage to tell someone that no one had plugged it in.
Those are the situations where we as emergency physicians will be tested. But often it's not our medical expertise that's being tested; it's our capacity to stow our egos while maintaining our confidence. That's a huge part of what makes us good at what we do and why they hire us to do it.
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