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InFocus: How to be a Good EP

Roberts, James, R., MD

doi: 10.1097/01.EEM.0000535019.78567.39
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, PNP, at http://bit.ly/EMN-ProceduralPause, and read his past columns at http://bit.ly/EMN-InFocus.

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Dear Doctor:

You did it. You graduated from residency and became a real EP. Your first day of work looms, and at the top of the agenda are unknotting your stomach and minimizing your palpitations.

Odds are in the next month or so, you'll make your first big mistake, see a condition you never heard of before, miss your first intubation in years (in front of the medical students), and order a BMW pending spouse approval.

It's time to consider the magnitude of your plight: A real patient's life is squarely in your hands, and you are alone in a real ED. It scared the hell out of me when I started and still does. 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 is the quintessential example. A lot of the following is what I strive for, 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 comes with experience.

Even after 44 years in emergency medicine, I still struggle with the ideal and philosophical versus the real world, which is rife with serious limitations of resources and time, disappointing colleagues, unbelievably ignorant policymakers, and the unavoidable stresses of treating the sick, injured, frustrated, downtrodden, 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.

Few will ever believe the bizarre and macabre milieu that is the ED. Most of society could not begin to fathom what you chose to do. Most ignore or disbelieve the unpleasantness, and think it's a really cool job. Your significant other or parents will never understand your day at the office. (Why do you wear those scruffy scrubs? When will you get a real office like all those other doctors?) Your spouse will 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? The vomit on your shoes and the dried pus and blood on your scrubs should send a powerful and obvious message, but go figure.

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, collected, compassionate, caring, and erudite, a sympathetic and interested listener to even the most annoying tales, a quintessential politician, and a role model 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 or befuddled at least once each shift, you are not paying enough attention.

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, you picked the wrong hospital and probably the wrong profession. Should have been a plastic surgeon in Beverly Hills like your mother wanted.

The system is imperfect, very imperfect. It always has been and always will be. 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.

Above all, always, always, always be nice. Patients and family rarely remember what you said, but they always remember 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 an angel of mercy. 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. 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 want. That 280-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.

Many patients need a lesson in manners, and many colleagues need ones 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 temptation always to be right. You won't be. Take the high road; emergency physicians respond to a higher calling anyway.

Don't publicly criticize another physician or 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 a jerk to all who witness his barrage against you, a hardworking clinician making difficult real-time decisions on the job at 4 a.m. on Christmas Day, hoping to get home in time to see the kids come down the stairs.

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 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 shatter their self-esteem with a single thoughtless encounter. House staff may seem totally in control on the outside, but 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 a better doctor than you are. Students are expected to surpass their teachers, and if they do not, maybe you were not such a good teacher.

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. If your patient wasn't happy with your first plan or diagnosis, maybe it was flawed, so reconsider. Calling a consultant is a good way to share the liability.

A family can accept that a loved one will die, but when the time comes, it is a harsh reality, even if they are in hospice. 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 life, but you can listen and usually do something to console them. 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. That old guy from the nursing home can't remember what that 12-inch scar on his abdomen was from, but he 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 like to be drug-free if a better life were in the offing.

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Most physicians shy away from the mentally ill, and it's 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. 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 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. 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?” I find patient rudeness, belligerence, and most importantly, 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 he is 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 bad knees.

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 weeding.

The schedule is sacred. Don't miss a shift for two inches of snow. Show up on time. (You know who you are.) Here's a novel idea: Be that doctor who shows up 10 minutes early.

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 someday, so be ready to help a colleague with a similar request.

We 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. 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 work 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!

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. If you can get rid of one bad doctor or get compensation for someone injured by indifference or incompetence, go for it. But it rarely works out like you planned. Don't sell your soul with absurd opinions to a doctor-hating jury. If you testify for money, and there is so much of it to be readily made, your colleagues will recognize what you have become.

Finally, be careful with alcohol and your ready access to Vicodin and Percocet. Addiction can ruin a lot of lives, and it's 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 years. Perhaps not. Maybe selling shoes at Nordstrom's is not such a bad idea after all.

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Earn CME!

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

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