I walked into the emergency department's radio room of our community hospital for my 4-12 p.m. shift on July 4, and there was a cake! And balloons! We were celebrating 30 years of emergency medicine practice at the same hospital for one of my partners, Stephen Marshall, MD.
I marveled at his longevity and that he was still working holidays. But then he said something really amazing. “Crazy thing is,” he said, “I took over today from the exact same physician I took sign-out from 30 years ago.”
How is it possible that a physician could start his career on July 4 and then 30 years later take over for the same physician? That got me thinking about my partners and their longevity in a remarkable specialty that is known for adrenaline, saving lives, burnout, and extraordinary challenge.
We recently celebrated the careers of four retiring physicians, and I felt compelled to capture some of their wisdom before they sail off into the sunset. All four have practiced emergency medicine for more than 30 years, and three of them have worked at the same hospital for more than 30 years, one for 37 years.
What allowed them to thrive for a combined 122 years at one shop? What propelled them to overcome the challenges during those 20,000 shifts? What is the proverbial secret sauce of emergency medicine that worked during those 160,000 hours and evaluations for approximately 350,000 patients? These pearls from Dr. Marshall, Thomas Miller, MD; David Bronstein, MD; and David Roselle, MD, are worth retaining.
Cookies and Kindness
Dr. Bronstein is famous for bringing biscotti to shifts, particularly during the holidays. I don't think I even knew what biscotti were until I met Dave. He believes humor is indeed the best medicine, and that people won't forget your kindness. Share your food and fellowship with your partners and nursing colleagues, and celebrate and struggle together, he said—keep the job enjoyable. The ED is one wonderful, dysfunctional family that is best experienced through respectful humor and, of course, comfort food, he said.
His second nugget of advice: Invest in night physicians. You don't want to work nights for your whole career, and it isn't good for you either, he said. Nights and late shifts become much more difficult with time. “A person has to know his limitations, and you need to pay attention to your own health,” Dave said. “We all know this, but you have to financially incentivize younger physicians to work nights so you don't have to. It's a wonderful symbiosis.”
Investing in People
Dr. Miller has always advised emergency physicians to become involved in medical staff leadership. “You must be involved in the hospital to influence policy for the good and to elevate the status of your EM group,” said Dr. Miller, who served as the hospital's chief of staff and director of quality. Care passionately about patient outcomes and the quality metrics at your hospital. Support your nursing colleagues as much as you support your partners. The nurses, techs, and support staff are essential companions on this journey. Treat them well.
Tom also said we should all invest in our community and family. He was famous for going on campouts with his four sons while they were Boy Scouts and for playing in a band, the Code Blues, with medical colleagues. Your identity can't be derived only from your career, he said. Medicine is what you do, not who you are.
“Invest in your family and friends. They will support you through the challenging times and hopefully be there when your career concludes,” he said. In addition to family and patients, Dr. Miller recommended that we all be compassionate with ourselves as well. “Realize what you can and cannot control, and don't waste time or emotional effort on that which you cannot control.”
Put Patients First
Dr. Marshall is a grandson of a Titanic survivor! He advised creating a stable democratic group with transparency. Our practice utilizes a spreadsheet that lists every dollar in our physician-led company. Every partner knows exactly what we pay in expenses, salary, and administrative costs. Invest in the schedule, and make sure it is equally unfair.
“We committed to career longevity early in the 1990s with eight-hour shifts, dedicated night-shift doctors (with seven-hour shifts), and a maximum of 15 shifts a month,” he said. “We also deployed a one-month sabbatical program to allow physicians to re-energize and avoid burnout.”
Time and the schedule will quickly become more important commodities than money during your career, he said. Focus on the outcome. Rested physicians make better decisions. Steve was the figurehead of our group for two decades as the medical director and company president. “Share your group's philosophy of transparency, pay, scheduling, and patient priorities with everyone—hospital administrators, job applicants, regional EM leaders, and colleagues.” The transparency improves the practice of emergency medicine.
He also advised being involved in the American College of Emergency Physicians and advocating for your patients, nurses, and peers. There is no better way to avoid burnout than attempting to solve the problems we all face, he said. Stop barking at the moon or, worse, barking at your physician partners or spouse and do something about the problems we encounter. Build common ground with other physicians, physician groups, and care organizations to promote excellent patient care. Your career will thrive as you direct your energy toward ideals.
And, Steve said, put patients first. The high ground in medicine is always putting the needs of the patient above your own, above the hospital, and especially above money. Debates may rage about particular topics and process, but centering on the health and needs of the patient will clarify any ambiguity. Don't allow the business of medicine to conquer the compassion of patient care. As the Hippocratic oath declares, I will remember that I do not treat a fever chart or a cancerous growth but a sick human being.
Paying It Forward
Dr. Roselle lived his advice: Be selfless. Dave is Jewish, and he has extraordinarily volunteered to work Christmas Day for the past 31 years! No one asked him to do this. No one expected it. He just requested it for his partners' sake.
Another example: Approximately five years ago, I was working in our fast track. I was discharging a patient and took the after-visit summary off the printer, but quickly realized I had the wrong form. As I scanned it, I saw some unusual instructions: “Pay it forward.”
I thought that was a strange instruction. Who would write that? I looked at the physician involved, and it was Dave. He was standing there next to me, so I inquired incredulously about his note. Dave sheepishly shuffled his feet, and replied, “It was nothing really. This nice homeless patient with diabetes didn't have any money for his insulin, so I went to the cash machine and took out $100 to give to him to pay for his insulin.”
I was really touched by what he had done, and I joked with him, “Dave, that was the nicest thing I have ever heard anyone do in the ED. But, please, never do it again because the patient will expect $100 with every ED encounter from now on.”
Dave also advised making an investment in EMS. It is a mutually beneficial relationship that will support your patients, hospital, community, and you. He was our EMS medical director for four years. He said the ED and EMS are kindred spirits in the battle against death and disease. Treat them like brothers and sisters in that heroic battle.
He also advised investing in yourself and your education. Dave had a perfect score on his EM boards two years before retirement. Maintaining intellectual curiosity and studying medicine to remain sharp are extremely important. Medicine are vast. Don't allow your knowledge to stagnate. “Being an emergency physician offered me the opportunity and challenge to be the best person I could be in a way that most other careers would not have offered,” he said.
A Winston Churchill quote seems appropriate after 122 years, 20,000 shifts, and 350,000 patients: “Let us be contented with what has happened to us and thankful for all we have been spared. Let us accept the natural order in which we move. Let us reconcile ourselves to the mysterious rhythm of our destinies, such as they must be in this world of space and time. Let us treasure our joys but not bewail our sorrows. The glory of light cannot exist without its shadows. Life is a whole, and good and ill must be accepted together. The journey has been enjoyable and well worth making—once.”
Dr. Shipleyis the medical director of Overlake Hospital Emergency Department and the managing member of Puget Sound Physicians in Bellevue, WA.