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InFocus: How to be a Real EP Advice for New Graduates (and a Good Reminder for Seasoned EPs, Too)

Roberts, James R. MD

doi: 10.1097/01.EEM.0000499524.73875.7b
InFocus

Dr. Roberts is a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, CEN, at http://emn.online/ProceduralPauseEMN, and read his past columns at http://emn.online/InFocusEMN.

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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, and you are alone, in a real ED. Awesome and frightening. It scared the hell out of me when I started and still does.

Allow me to pontificate with 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.

Any philosophy is much easier said than done, and this one is the quintessential example. A lot of the following is what I like to strive for personally, but I have all too often fallen short. I screw up about three times a week; I'm just better at hiding it than you are. That talent will also 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 if not totally incompetent colleagues, unbelievably 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 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 (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. 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 or parents will never understand your day at the office. (Why do you wear those scruffy scrubs and when will you get a real office like all those other doctors?) Your wife will never understand that hearing, “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, queries my wife. The answer to that is ... duh! The vomit on your shoes and the dried pus and blood on your scrubs should send a powerful and obvious 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 really sucks. Love/hate does not even begin to describe the ED.

Nothing is allowed to annoy or faze you, not even an impossible bipolar crack addict, the child molester with AIDS, hellacious maggot-filled bedsores, an acutely paralyzed teenager, or sudden infant death. You will be expected to be cool, calm, and collected, a compassionate, caring, and erudite individual, a sympathetic and interested listener to even the most annoying tales, a quintessential politician, and a role model doctor at the same time. You are often called upon to perform medical interventions far above your comfort level and way above your level of training. News flash: There is no training to equip you totally for this job. If you are not scared, befuddled, or flummoxed at least once each shift, you are simply not paying close enough attention. Many of your patients will have no other advocate or support system. If not for you, they would be toast.

You are the anointed team leader, and you're always expected to portray a positive attitude and professional demeanor and to set the tone for the entire staff. Any negative attitudes toward the hospital, paramedics, administrators, house staff, 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 war zone-like atmosphere. If you want a quiet ED with all the bells and whistles and a respectful, polite, sweet-smelling, cash-paying clientele in Ralph Lauren or Versace, you picked the wrong hospital and probably the wrong profession. Should have been that plastic surgeon in Beverly Hills like your mother wanted.

The system is imperfect, so very, very, imperfect. It always has been and always will be. The ED can be simply 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 far more than you actually do, so take advantage of that lovely yet secret scam, and step up and portray the Godsend they expect and want to believe 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 yourself 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. And learn their names; they know yours.

Talk effusively to your patients, talk to them again, and always, always, always talk to the family. Look them in the eye, not into the computer record. Sit down whenever possible; it says you are truly giving them the personal time and attention you would also want. That 280-pound demented nursing home patient with bedsores and a feeding tube is somebody's mother, and just maybe she was just the best third grade teacher Philadelphia ever had. Last month we unknowingly treated Joe Frazier's father, the governor's cousin, and one of Gladys Knight's Pips.

Many patients need a lesson in manners, and many colleagues need lessons in compassion and basic common sense. 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. You won't be. Take the higher road; emergency physicians generally respond to a higher calling anyway.

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 house staff 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 their barrage against you, a hardworking clinician who has to make the difficult real-time decisions, and actually is on the job at 4 a.m. on Christmas Day, hoping to get home in time to see the kids come down the stairs.

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, not that smart, or not 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.”

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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. House staff 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 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, a 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 statistically to 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 was flawed, so reconsider it. Calling a consultant is a good way to share the liability.

The family can accept that their loved one will die, but when the time finally comes, it is a harsh reality, even if they are 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 or with 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 that 12-inch scar on his abdomen was from, 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 in the offing for them. Usually there is none.

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 their 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-shaped 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 personally, you are truly blessed. And dementia is likely the result of aging for most of us.

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 and think you make half a million to start, confusing you with that orthopedic surgeon who graduated the same year you did. I find patient rudeness, belligerence, and most importantly, ubiquitous entitled attitude the hardest 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 you are not an NFL player, you do OK in the grand scheme of things — and are usually spared the repeated concussions and don't have to retire with bad knees at 35.

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 do fondly 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. Your significant other probably gave up a lot to be with you.

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 use the internet to 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.

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Emergency medicine is not just a job, it's 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 or daughter fishing. In a heartbeat your children will be on their own, and will likely have trouble finding time for you. Remember that you might need a shift off some 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 (until they worked their first ED shift). Next time you think you are underpaid and overworked, consider the GP who works 70 hours a week, gets 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, or 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. But it rarely works out like you planned. 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 so 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 in court 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 or inscrutable or blatantly concocted definition of standard of care that you yourself would never follow. If you become a testifying whore for the 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 Nordstrom's is not such a bad idea after all.

Reader Feedback: 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 emn@lww.com.

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This column does not offer CME credits as usual because ACCME requires CME articles to offer clinical education. But you can still earn credit for Dr. Roberts' past columns — and future ones — by visiting http://CME.LWW.com.

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