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What to D.O.

Welcome to What to D.O.
What to D.O., formerly known as Little White Coats, is the brainchild of Richard M. Pescatore II, DO, the director of emergency medicine research for the Crozer-Keystone Health System in Chester, PA.. He chronicled his experiences here as he completed his studies at the Philadelphia College of Osteopathic Medicine and in the emergency medicine residency at Cooper University Hospital in Camden, NJ.

Dr. Pescatore has served as an EMS and law enforcement medical director and advisor throughout New Jersey and Pennsylvania. He was graduated from the U.S. Naval Academy with a degree in aerospace engineering, and had planned to pursue a career as a nuclear submarine officer until an EMS run five years ago took him to a familiar but unexpected place. That call made him realize that EMS was more than a hobby and that his future was in medicine.

Read more about how Dr. Pescatore ended up as a "little white coat" in his first blog post, "Changing Course," and don't forget to sign up for the RSS feed for this blog to read his new entries.

Tuesday, August 15, 2017

Proud to be an EP—Finally

​So, it happened. Residency ended, and I became the ER doctor I've always wanted to be. It's funny, really, that such a long road can end so uneventfully. My final shift as a resident ended just before midnight, a rather unremarkable few hours punctuated not by last-minute heroics and Hollywood procedures, but filled with the routine parade of familiar complaints that define the daily practice of all of us. I had manipulated the schedule and stacked the department with my closest friends and me staffing the final shift.

As the oncoming team came to relieve us, we quickly signed out and walked one more time into the ambulance bay. We sat along the low wall just beyond the ED doors and listened to the shrill of sirens piercing the night air, their keepers en route yet again to the place we had come to know as a second home. It was hot but not overly so. Still, the smuggled bottle of champagne we'd brought to commemorate our last shift together was sweating profusely, and it nearly slipped from my hands as we poured celebratory drinks into the Styrofoam cups we had stolen from alongside the graham crackers. We toasted to three years and a shared experience that changed our lives.

Just a few hours later, I was back in the department, only this time in a different ED a few towns over, and now all on my own. It was simultaneously similar while being profoundly different—patients presented with the same complaints, but suddenly I didn't know how to order their tests in the foreign EMR, who to call to facilitate care, or where to find supplies that I had always been able to locate at a critical moment. Patients asked for directions to the bathroom, and, while I could assure them that we almost certainly did have one, I had no idea where it was. I found solace and comfort in the patient interactions that are the same in every emergency department, the familiar complaints, the consistent scripts, even the reassurance that every ED in the world has an unfortunate recurring cast of the intoxicated, inebriated, and mentally ill.

A month has passed since that first attending shift, and I've slowly begun to settle into a routine. I found the bathroom and am slowly learning the ins-and-outs of the computer. I've begun to recognize a few of our more frequent patrons, and they've already started to greet me by name as I walk to the bedside. With each shift comes more familiarity and comfort, and I truly look forward to every day in the department.

For so many years I've always looked to each step with an eye toward what comes next. The next move, opportunity, fellowship, or task, all in an effort to march my career toward where I am now. Experience seemed inextricable from ennui, as every stage was qualified by so many more that needed to come next. Finally, I've taken the time to relax, to feel content with the end of this long road and to enjoy the privilege to serve the sick and the scared that I've worked so hard to obtain. Two years ago here, I wrote about being defined by the present but obsessed with the future, torn apart by personal and professional confusion and uncertainty about times to come. No longer do I struggle with my daily purpose, and I'm proud to be able to call myself an emergency physician

Sunday, May 21, 2017

Goodbye, Little White Coat

I began writing Little White Coats at the request of my medical school seven years ago. I was flying around the world on the same kind of trip that has become commonplace for neophyte medical students, and was asked to chronicle the experience as a small experiment in medical education—a token journal that better minds than mine hoped to use for some as-yet developed educational purpose.

It quickly became my own catharsis, a way to hard-stop and reflect upon my days. What was only ever meant to hold a month's worth of travel memos transformed into a diary of sorts for my entire medical training experience. My regular readers (that is, my Mom, editor, and occasionally my wife) have seen the ups and downs of residency and medical school. I've shared the joy of graduation, the trepidation of intern year, and even (to some degree) the dark depths of residency—the uncertainty and the burnout. Little White Coats was there while life happened along the way—when I married my wife, and when I became a father. When my grandfather died. Sharing the journey with you became a fundamental part of living it.

Tomorrow I give my senior presentation, a 15-minute soapbox where I'm supposed to tell my classmates, colleagues, and fellow residents just exactly what I've been doing all this time. It's a recognition, I guess, that a lot can happen in seven years, but I'm not sure whether the purpose of the presentation is to remind us of that or to hold us accountable for what the hell we've been doing all along. Certainly, I've been busy. The clinical load of residency is quite different from the attending-life schedule I've been admiring for July, and I filled all the rare spare moments along the way. I did my fair share of writing, entered the world of podcasting with EMN Live, and watched Disney's Frozen with my daughter more times than I care to count.

But as far as what I'll say when I stand in front of the room tomorrow, I'm just not sure. Certainly, there's little value in rattling off my PubMed bibliography—not that it would take more than a few very unimpressive seconds—and as much as I'd delight in a slideshow of baby pictures and Anna and Elsa references, I doubt anyone else would appreciate it. My thought, after too many hours of pondering and perseverance, is to speak briefly on something I've only recently learned.

Becoming chief resident was a tempered mix of pride, anxiety, and caution. I had been named a leader before and fallen disappointingly short of any objective measurement of success. A decade later, this opportunity felt like a chance to show so many lessons learned or a possibility to prove that little had changed. I feared repeating the mistakes I've regretted over the years—neglecting to set an impeccable example, forgetting to protect those under my charge, failing to inspire. Sure, the nominal elevation of chief resident is a world apart from the military authority with which I was comparing it, but the pitfalls and possibility of poor leadership remained.

Where I work, there's little in the way of official responsibilities for the chiefs. We click the button that populates the schedule and add our own little tweaks, but any ex-officio authority stops there. We have no sticks or carrots to help us herd our colleagues, but we certainly rely on the illusion that we do. Any projects we undertake or policies we enact are successful solely because of the good faith of our friends, and any achievement is more a function of the residents' characters than any chiefly brilliance. Nonetheless, it's this incredible experience that will shape my parting words tomorrow morning.

When I started this finishing challenge, I opted to focus my role on education. It's my thought, you see, that knowledge holds the key to residency success in so many ways—that competence drives fulfillment and pride, reinforces its own pursuit, and insulates against the deepest depths of burnout and depression that threaten every medical trainee. I thought that if I could teach the core concepts and foster an environment of scholarship that my juniors and colleagues would then inspire themselves, and share the passion I've found for our craft.

I "mandated" (read: hoodwinked) my interns into weekly review sessions and flooded their inboxes with FOAMed favorites. On-shift teaching grew as my incredible classmates took on the task and committed to improving the experience for our medical students, shepherding our interns, and challenging our juniors. I watched as friends and mentors worked together to develop their own educational projects: a residency curriculum in an important subject, a collaborative website that continues to grow, a lecture exchange program, and countless more scholastic pursuits. I stood back as I realized that the leadership victory I once sought would never really come. I realized that the inspiration of leadership is not that your followers are inspired to be like you, but that you're inspired by them—by their accomplishments, passion, and growth.

My message, I think, is that while the journey of my Little White Coat has come to an end, the emblematic jacket has been so much more than a tagline, a title, or even a hackneyed calling card. My parting presentation—my final thought to teach my interns—is to show them what they have taught me during this chiefly experiment. The Little White Coat—the learner—is the means to my end. Teaching, sharing, and participating in the journey of these learners is the answer to the question I've been asking all along about what comes next, about who I am. It's the beautiful irony that Little White Coats, developed years ago with an uncertain educational purpose, would ultimately fulfill that mission through teaching me.

Wednesday, March 22, 2017

We’ll Care for You, Even If You Don’t Yell

​It had been a rough night. The crowd in the waiting room never seemed to shrink; each patient brought back was only replaced by the never-ending flow of ambulances bringing another wave of the ill or injured. Our team had endured the devastating blow of a child injured beyond repair, pulled countless overdose patients away from the brink of disaster, and brought thoughtful and compassionate care to the bedsides of dozens of the city's residents. Some were sick, requiring extra attention. Most were simply scared, yet caring for them still required time that was already at a premium. Everyone was doing his best, working ceaselessly to bring some comfort to the endless tide of patients rolling through our doors.

Then the shouts of an angry family member broke through the dull roar of the early morning hours. Upset at the wait and offended by the hallway bed hurriedly prepared for his loved one, he hurled accusations and threats at anyone within earshot, including empty promises of lawyers and news reports. He demanded attention but could not be satisfied, even as our exhausted and weary team tried in vain to address his concerns. Tensions continued to rise. Fists flew.

The emergency department is a high-stress environment ripe for passionate interactions and fervent fury. Pain and fear concentrate in a cauldron of uncertainty, and the simplest of misunderstandings can devolve into fist fights in a moment. Growing censuses and worsening throughput provide the perfect fuel for an explosion of personalities, and ED nurses, techs, and EPs are well acquainted with the dangers posed by unruly and uncooperative patients.

Recently, Psychology Today published an article detailing one physician's experience with his mother in his local emergency department. When his mother manifested some brief neurologic deficits concerning for a TIA, Peter Edelstein, MD, (a colorectal surgeon and author of the article), brought her in for evaluation. He provided a detailed timeline of their experience, including a rapid evaluation and head CT immediately upon presentation. The story quickly descended, however, into (odd) accusations of inadequate care and criticism of those in nonsurgical specialties. The author wrote in detail about his castigations of the nurses and doctors doing the best to care for his mother, and advocated for the reader to replicate this behavior — going so far as to title the article "If You Go to the ER, Get Ready to Yell." (The headline on the article has since been changed, but you can read it here: http://bit.ly/2mU79lN, and here is Dr. Edelstein's response: http://bit.ly/2ntpw1N.)

It is frustrating that anyone would write such an inflammatory and ill-informed impugnation of a team that clearly was trying to do nothing more than provide the best care possible in a resource-limited environment. It is infuriating that such a piece could be produced by a physician, one who ostensibly is well aware of the difficulties faced by all those who provide patient care on the frontlines and who almost certainly has encountered the dangers of an unhinged patient or family member.

Advocating hostility toward fellow medical professionals is reckless. To suggest that yelling, screaming, and arguing with a family member's care team is the best way to champion their care is a dangerous contributor to the pressures and uncertainties that plague acute and emergency care. It is also an intolerable violation of professionalism. Dr. Edelstein's article is nothing more than a poorly informed slander of hardworking medical professionals who labor tirelessly to provide the best care for all who pass through the emergency department.​

Wednesday, December 14, 2016

Break the Teaching Mold

The role of a senior resident is a paradox, at once a veteran learner and a neophyte teacher. Each shift is spent suspended between scholar and student, and we are tasked with striking a delicate balance between familiarity and inexperience. Often, this is difficult, ripe for the trap of the Dunning-Kruger effect. (http://bit.ly/2hghFUf.)

It's an emblematic interval, a year of evolution from student to teacher. We have committed ourselves to studying, learning, and acquiring knowledge for so long, stopping along the way for dedicated instruction not just in our topics of interest but in learning how to learn. Message boards and medical school libraries are replete with discussions about the superiority of blue highlighters or the farce of the lecture hall. FOAMed sings the praises of spaced repetition (http://bit.ly/2gLZGoh) and critically evaluates learning tools (http://metriqstudy.org/). Given so much focus on the science of learning, it is striking that so little attention is paid to the art of teaching. Senior residents and junior faculty are often expected to learn by example, to develop excellence in guiding the following generations by building on the best and worst of those who have come before.

Recently, leaders in our field have tried to change this disparate culture. With forward-thinking opportunities like the Teaching Institute (https://flippingmeded.com/#about) and the ACEP Teaching Fellowship (https://www.acep.org/tf/), a light is shining on the critical importance of developing educators while our specialty continues to lead the way in evidence-based medicine and medical education. Just as we celebrate the pioneers in emergency medicine who made education and learning so fundamental to our progress (http://bit.ly/2hFYwbg), we now turn to this new focus on teaching, a critical next step in ensuring the emergency medicine tradition of excellence in education continues.

Poised to graduate and further my transition from student to teacher, I now look to these courses and classes to help me become the educator I aspire to be. I have been fortunate throughout residency to learn from wonderful lecturers and bedside mentors, but I hope to learn the strategies and innovations that distinguish the greatest clinical teachers.

Recently I had the opportunity to attend Keynotable (http://keynotable.net/), a two-day workshop designed to help its attendees develop inspiring and elegant presentations that break the mold of the ubiquitous bulleted slides that darken every residency conference room. Under the tutelage of some of the best teachers in emergency medicine, I learned intricacies and techniques that can't be gleaned from simple observation and osmosis. Just months from graduating and having residents of my own to teach, I've learned a whole new way to translate knowledge and help others share my passion for our field.

Learning is a lifelong process, and while we never abandon our roles as students, our responsibilities as educators and teachers only grow with time. Just as we are taught how to learn, dedicated instruction in the art and science of teaching is a critical element in academic development.

Tuesday, November 1, 2016

The Symbiosis of Urgent Care and Emergency Care

​The patient in room two had the look I've come to associate with years of hard living — nights spent on the street and days spent searching for another high. Her chart held the results — a litany of conditions sprung from dependence and the use of dirty needles. Her chief complaint had always been neck and back pain.​

Her second visit was for the same thing, with the Prescription Monitoring Program (our newest tool in the opioid fight) indicating we weren't the only place she had visited with this problem. She had walked away more than once with frustratingly large prescriptions of opioids and muscle relaxers. I braced myself for what I anticipated would be a difficult encounter.

She had little new information to share. Her shoulder and back were firm and tender beneath my fingers and shot lightning bolts of pain toward the back of her head. Every motion caused her agony, but she put on a brave face for the 6-year-old grandchild at her side. The dynamic was different from what I'd expected, and every minute I spent in the room, I learned something new about this woman's struggles. Far from seeking medication for an imagined complaint, I realized she only wanted relief from debilitating pain.

I gave her an injection, and almost immediately, it abated the agony with which she had struggled for weeks. I watched, satisfied, as she turned her neck from side to side, enjoying the movements and motion that just seconds ago had brought immense pain. Tears fell from her tired eyes, and she grabbed me in a hug, grateful that someone had "taken the time" to fix the pain rather than sprinkling more morphine on the ache. "We can finally take our morning walks again," she whispered tearfully to her granddaughter as they made their way to the door, discharge papers and no prescription in hand.

It was just another encounter that I've found to be the most unexpected of escapes from the routine of the emergency department. Despite once despising the minor complaints and rote care of the Fast Track, I discovered a love and enjoyment that I hadn't anticipated in urgent care. Every day has brought new challenges, enhanced and focused by the experience of working without the safety nets to which I've become so accustomed. Like any new attending, I find myself laboring over every x-ray and prescription, taking extra steps with each diagnosis and operating with a conservativeness that starkly contrasts with the aggression and speed in the emergency department.

Urgent care makes it possible. The slower pace gives me the opportunity to walk away from each case with greater confidence while also allowing me to connect with patients in a way I haven't since I've accelerated in the ED and taken on the additional responsibilities expected of a rising resident. The patient encounters in urgent care reinvigorate me for the ED shifts to come, with problem-solving as frequent as it is refreshing.

But it's being an emergency physician that makes me a good urgent care doctor. My sick/not sick radar is what helps me triage what is appropriate for urgent care and what is best sent down to the resources I so regularly use. The tips and tricks I've learned in the department translate well to the minor emergencies in urgent care. Wound repair and splinting are regularly required, of course, but my most satisfying cases have been those where my ED training made the difference: a hemorrhoid excision in a truck driver, a ring removal that didn't destroy the ring of a newly widowed woman or a trigger point injection in an oft-dismissed addict with neck pain.

At the same time, urgent care has made me a better emergency physician. I've learned to trust and rely on my physical findings in a way I haven't needed to before. I've learned how it feels to have the buck stop with me — to hold the responsibility and accountability that have been shouldered by my attendings for so long. I read about the cases I see in urgent care and bring those lessons with me into the ED. I listen each month to the pearls and wisdom of Urgent Care RAP, and am amazed at how often the teachings and knowledge become integral to my work in the ED.​

As my final year of residency churns on, it's incredible to take a step back and see where I am and where I've been. My training has given me the tools to make a real difference in urgent care and the emergency department, and I'm so grateful to have the opportunity to play such an important role in peoples' lives. I never anticipated that minor complaints and weekend emergencies could be such an important addition to my clinical practice, but I look forward to including more urgent care experience in my career.