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First Person

The Written Boards Are Finally Over; Now What?

Pandit, Kiran MD, MPH

doi: 10.1097/01.EEM.0000616500.45604.02
First Person

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Congratulations! You're done with the written boards! You started your first attending job by learning everyone's names in the ED, mastering the departmental policies and protocols, and studying for the written boards. But if you are like most attendings, you might be experiencing a transition from an educational environment in residency with milestones and formal evaluations to a work environment, in which you may not receive any feedback. You might be wondering how well you are doing your job and how you are supposed to continue to learn and grow. Before you start preparing for the oral board exam, take some time to consider how you might set yourself up for success in your clinical practice.

Strategy 1. You sign out to Dr. ABEM and see her in the hallway two days later. You decide to ask for feedback about the signout you gave her the other day. Smart move! Many physicians are reluctant to ask these questions because they are anxious that they might have missed a diagnosis or that a patient decompensated. We are all afraid of being embarrassed or ashamed. It helps to reframe our clinical practice as a continual learning opportunity instead of an expectation of perfect performance. It takes several years at minimum to achieve a state of unconscious competence as an attending physician, and even then, the best doctors are always trying to learn how to be even better.

Strategy 2. You are in the middle of a shift and unsure how to manage a patient. It's an atypical case or something you did not see in training. You have a plan in mind, but you wish you were a senior resident again so you could present to the supervising attending to make sure your plan is OK, especially when that is to discharge the patient home. Aside from calling consults, how else can you get some advice on the case? One idea is to approach more experienced attendings by asking to run a case by them. You can try saying something like, “Can you help me make sure I'm not missing anything with this patient?”

Experienced attendings generally love to give advice and help new attendings. After all, they were new once. Just verbalizing the case often helps to clarify the thought process, and the discussion sometimes ends with you realizing that talking it out helped you figure out what to do, with the more experienced attending simply acting as a mirror. If an experienced attending is not available, there is usually someone in a leadership position who is happy to help out. And even if you're working single-coverage in the middle of the night, there is probably an attending you know who is working a shift at the hospital where you just completed your residency.

Strategy 3. Some electronic medical record systems allow attendings to automatically create a running list of all the patients they have seen. It's a great way to follow your cases and learn about the clinical course of your patients, admitted and discharged.

Strategy 4. If you don't have time to follow up all your cases but just want the high-yield ones, ask your departmental leadership or administration if they can help you learn and improve your practice by providing you with monthly case lists that meet certain criteria, e.g., patients who bounced back to the ED within seven days of discharge, patients who were admitted to the hospital for more than seven days (suggesting higher complexity or morbidity), or patients whose outcome was death within one month of your care. Follow up these cases by researching the medical record or calling the patient or family, and ask yourself what was unexpected about the clinical course and what you might have done differently in managing the patient in the ED. Bonus: Review your thoughts with an experienced attending who you respect to get feedback on your perspective and learn even more.

Strategy 5. If there are at least three new attendings in your group, you can create an informal peer-mentorship group by meeting once a month to learn together. Take 10 minutes to reflect on and write a response to this prompt: “Recount a case in which you had a difficult interaction with a patient, family member, or staff.” Share what you wrote with each other and ask each other for suggestions on how to manage a similar case in the future. You'll learn even more if you can get a more experienced attending to join your session.

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Dr. Panditis the director of faculty development and an assistant clinical professor of emergency medicine at Columbia University/New York Presbyterian Hospital in New York City. She created and now directs the emergency medicine selective rotation for Columbia University medical students.

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