The First Year in Practice

Or "Why Didn't They Tell Me it Would Be Like This?''

by John L. Meade, M.D., FACEP

During your Emergency Medicine residency, you are trying very hard to master your field, which is so broad and virtually all encompassing. A few of you will stay in the academic world, and teach those coming behind about the science of Emergency Medicine. For those who become full-time academic faculty, the biggest change in your practice (aside from the larger paycheck!) will be the heavy responsibility of being an Attending. These colleagues must refine their abilities to supervise without being too intrusive, and learn to coax the best out of different personalities. They must make sure they stay current on the subject matter, so residents get the best possible information. These emergency physicians are moving up a rung on the academic ladder that they have spent at least the past eleven years climbing.

However, most emergency physicians do not stay in the academic setting, taking instead positions in hospitals across the country. Obviously, there are far more of these positions available, and often they offer a higher salary than academic jobs, but the responsibilities are quite different.

CAN YOU PLAY WELL WITH OTHERS?

The new kid on the block has much to learn, and should try very hard to do so. Mastering the art of medicine is as important as mastering the science of medicine, When you join a group, you may find yourself working with people whose style of practice may be very different from your own. They may not order tests that you think are routine, or may do many more radiographs than you think are required.

Before assuming your new partners are incompetent, determine why these different practice patterns exist. There may be important reasons why things are done a certain way in your new setting. State laws vary, as do hospital policies. Learn, before you complain. At your monthly group meetings, start a Journal Club, to allow everyone the opportunity to discuss the cutting edge of our field, and share various ways of doing things. You may even be able to start an area-wide Emergency Medicine Journal Club, which will enable you to learn from your colleagues at neighboring hospitals.

If you feel the group practice needs improvement, volunteer to spearhead a project to deal with it. This might include writing new discharge instruction sheets, doing an inservice for the nursing staff on chest tube insertion, or working with the hospital public relations department on creating a public service announcement. Make sure you get consensus from the rest of the group, so it does not appear that you are criticizing established policies or procedures.

Some issues that appear more mundane can be important for the success of a group. For example, get to work on time so your partner can be relieved. If you must turn over a patient, document your history and physical up to the point of the turnover, and be clear in the documentation at what time you signed the patient's care over to your colleague Let the patient know someone else will be taking over, but reassure him/her that you will tell the new doctor all about their case.

Nothing causes more discontent in an Emergency Medicine group than the feeling that some are working harder than others. In a fee-for-service situation, those seeing more or sicker patients usually are paid more. However, in a straight hourly fee payment situation, any physician who shirks the unpleasant cases, or sees too few patients per hour, is sure to cause ill will with the rest of the group. Some groups deal with this by having some sort of 'performance factor' built into the payment scheme. Others monitor the numbers and types of cases seen by the physicians, and give feedback to anyone who is not carrying his share of the load. Thus, it is always important to carry your fair share of the load. Most important, make certain your group has addressed this issue if applicable.

GETTING ALONG WITH NURSING/ANCILLARY STAFF

A savvy emergency physician will say little and listen a lot when starting a new position. Everyone will scrutinize the 'new guy, and whatever he does will be analyzed and critiqued by one and all. Ask lots of questions, and try to learn as much about your new facility as you can. The nursing staff, along with respiratory therapists and other ancillary staff, will quickly determine if the new physician is someone with whom they want to work. If they like you, your life will be much easier.

Anytime a new emergency physician starts to work in an ED, he brings with him certain methods, preferences and procedures that may be new to the staff. There is sure to be resistance from the nursing and ancillary staff regarding any change. Change means people must learn something new, and carries a message that the previous method was wrong.

Resist the temptation to tell people about how wonderful things were at your prior institution. In fact, you should step back and learn how and why things are being done at the new hospital. Perhaps there are some institutional idiosyncrasies that make their way of doing things work better. Remember that most new emergency physicians are not brought in fresh from residency to change an ED. Only after you have been in the new job for a while will you be in a position to effect changes that may be helpful. Moreover, such changes should be carefully thought out.

GETTING ALONG WITH THE MEDICAL STAFF

Emergency medicine group directors will say that people finishing an EM residency are expected to be excellent clinicians. That is now considered baseline and should be a source of great pride to our specialty and its residency programs. However, this shifts the focus to personality. Social skills do matter and unfortunately are not taught in most residency programs.

In a teaching hospital, once the EM resident is ready to make a disposition on the patient, he usually runs it past the attending emergency physician. If a decision to admit the patient is made, a resident from another specialty is called down to the Emergency Department, and told to admit the patient. They will rarely argue, although they may moan and groan about the extra work. The hierarchy is such that they know it is unlikely they will get out of admitting the patient, so they just do it The EM resident then goes on to the next case.

In the "real world', situations are often very different. As the attending emergency physician, you must call another attending physician in another specialty to have the patient admitted Some physicians will call back almost immediately, and others will call only after numerous voice pages. If the latter is the case, resist the temptation to start the conversation with irritation in your voice. Remember that few on the medical staff ever want to get a call from the Emergency Department! Even your friends on the staff do not want to hear from you during your shift. Your call means only one thing-more work for them. Try to remember what it was like when you were a resident on another service and how you disliked hearing from your fellow EM colleagues. Instead, go out of your way to be pleasant with the other doctors. It helps ease the sting they feel and will make them more agreeable in assisting with the patient.

At the outset, tell the other doctor why you are calling, and what you expect from him. As a student, and perhaps even as a junior resident, your patient presentations were long, sometimes rambling, and very detailed. You did not want to take a chance of leaving out something that was important, so everything was included. Just as you learned to take a focused history and physical examination, you must learn to make a focused presentation of patients to other physicians.

For example, after a few pleasantries, you could say "I have a patient here tonight with chest pain who needs to be admitted. She is a 54 year-old black woman, hypertensive, and diabetic, who smokes two packs a day. Her chest pain started about three hours prior to arrival, and was relieved after two sublingual nitroglycerines in the ambulance. Her ECG and chest X-ray are normal, and the labs are pending' Very few physicians would argue that this patient should go home. By presenting the case this way, you have informed the doctor of all the important details, and he knows you have the situation under control. He now understands that he does not necessarily have to drop everything and come see the patient in the ICU. He is then able to ask for whatever further data he needs, and you have not bored him with needless information. You have effectively set the ground rules for the discussion, without being overbearing. The rest of the conversation is just details.

Some physicians will disagree with your decision that a patient needs admission. If they are familiar with that particular patient and have important background information to share, listen with an open mind. You will find that their additional knowledge is valuable and may sway you to agree with an outpatient plan for the patient If in spite of that, you feel strongly that a patient should be admitted, stand your ground. You are the physician of record for the patient on that presentation and responsible for the disposition.

In some instances you could find yourself at an impasse, and the only action left is to inform the other doctor that you will not discharge the patient. Although you do not want a reputation of being disagreeable, you always must do what is best for the patient. Be certain within yourself that you are doing what is best for the patient if such a standoff is necessary. If you are not sure, or the political ramifications are likely to be high, contact your ED director and discuss it with him before drawing up battle plans. These kinds of confrontations are costly in terms of good will and should be avoided whenever possible.

Modern Emergency Medicine is a specialty on par with every other specialty. If we are to receive the respect that other physicians get, we must earn that respect by paying the dues to join the club. We must not be faceless voices on the telephone bearing bad news in the middle of the night. Get to know the rest of your staff informally and do whatever it takes to be considered a fellow member of the staff, not an intern or the house doctor.

Due to the nature of our practice, we are often in the hospital at hours counter to the rest of the medical staff We may never have time to dine with colleagues or do any of those other things that allow physicians to get to know each other and create some sort of relationship. Thus, it is up to you to create those occasions Join the county medical society, and let the other doctors see you at meetings in a pleasant environment. Invite some of them to play golf or tennis with you. Serve on a hospital committee. Make presentations to local specialty groups on Emergency Medicine or some other issue. Go out of your way to help eliminate the stigma of the "ER doc" as an itinerant worker, who is never a real member of the medical community.

GETTING ALONG WITH ADMINISTRATION

The first thing to know about dealing with hospital administration is that generally they do not have a medical background. They are business people, and any discussions you have with them must take this into consideration. Additionally, physicians are trained to do what is best for a single given patient, regardless of the cost. Administrators are concerned with the ongoing health of the hospital. Both approaches are valid and necessary for the continued delivery of health care in your community. However, these differing mindsets are bound to come into conflict at some point. For example, no protests about quality of care will stand against an administrator who says, "We cannot afford it".

The best approach is for you to learn more about the hospital's long term goals and plans, and show the administration how your group can help the hospital achieve those goals. That may mean diversification of your group into new areas, such as observation units, walk-in clinics, occupational medicine, and others. Such diversification, if done well, can create additional jobs for your group and consolidate your positions. Older members of the EM group, or those with physical limitations may find such areas a great pathway to continued employment with less stress or fewer night shifts.

Another aspect of management emergency physicians must accept is that, as far as the Administration is concerned, no news is good news. Patient or staff complaints about you are taken seriously. Even if the complaint is without merit, it is time-consuming and stressful for the administrator to handle. If several such complaints are filed against you, he will start to believe that 'where there is smoke, there is fire". A busy ED may see 60,000 patients per year, while employing 10 full-time Emergency Physicians. That means each physician should see 6000 patients per year. If you made 99.9% of the patients very happy with there care, that could still result in six complaints per doctor per year. You can rest assured that no administrator wants to hear about the same physician every other month, and certainly does not want to hear five complaints a month for the group. Make sure that complaints are referred back to the ED Director, or perhaps the Emergency Physician assigned to Quality Assurance issues. Whenever possible, the complaints should be handled internally rather than by administration.

Just as you must work to make yourself an integral part of the hospital medical staff by joining committees and getting to know your fellow physicians socially, you also must become involved in community activities. You should be appointed to the Boards of the local chapter of the American Red Cross or Cancer Society. Be active in your church and the United Way. Be seen frequently on television as a local medical expert. Not only will your life be enriched, but your hospital administration may view you as a fixture in the community. Other specialists have understood this for years. It is time for emergency physicians to do likewise.

GETTING ALONG WITH PATIENTS

Most physicians think they are holistic in their approach to patients and believe they are doing everything within their power to make every patient encounter warm and pleasant. The truth is most of us do these things very poorly. We have had very few role models and we all know of occasions where patients were depersonalized or treated rudely

Most patients have a family doctor office visit in mind as a reference point for interactions with physicians. Unfortunately, a busy Emergency Department is about the farthest from this reference point that you can get. The patient is often very sick, hurt and/or scared, and his family may be just as frightened. The patient is brought in, asked to undress in a cold, noisy area, with often just a flimsy curtain to protect privacy. He must put on a gown that is sure to remove his last shred of dignity. Then the patient must sit and listen to crying, screaming, and profanity while waiting interminably to be seen. He hears everything the patient in the next cubicle says and knows others will be listening to him. Finally, someone he does not know comes rushing in asking him to quickly explain why he is in the ED. The person is assumed to be a doctor, although his self-introduction was so fast that the patient did not catch the name. This 'ER doc' asks rapid-fire questions, barely letting one get answered before spitting out the next and interrupts if the answers are not heading in the desired direction. After less than five minutes, he abruptly leaves, then someone new comes in to draw blood. Ninety minutes later, a nurse comes in with a prescription and the patient is ushered out.

Is it any surprise that patients are dissatisfied with the kind of care they get in Emergency Departments? Patients deserve better. We were taught the First Rule of Medicine: 'First, do no harm" I propose the Golden Rule is just as important: 'Do unto others, as you would have them do unto you. " If you or your loved one was a patient in an Emergency Department, you would want to be treated with respect and dignity You would expect attention from calm, caring nurses and doctors, and informed of everything that was done. For example, a simple statement that blood tests will take about an hour will do much to decrease the anxiety in the patient. At the time of disposition, the patient deserves to have the emergency physician come back in to discuss the findings and answer any questions the patient may have. Anything less than that, and you will find yourself with unhappy patients. You may have given the patient excellent care on paper, but to the patient the experience was unnecessarily negative. Studies have shown that what is most important to patients is the sense that they were cared about, not necessarily that they received excellent care. We must constantly strive to put ourselves in the patient's position, and do what is best for him; not necessarily what is most expedient for us.

CONCLUSION

In the first year of your practice of Emergency Medicine, be aware that you will be thrust into situations where people are watching your every move, while they perform in ways that are new to you. The way you practice will be questioned. You will have to prove yourself trustworthy to doctors who do not know you, and you must learn to trust them as well. You will have to learn to express to patients that you truly care for them and their concerns, even in a rushed and hectic environment.

The first year in practice will be a trying time and extremely exciting and rewarding. You are finally a full-fledged Emergency Physician. Embrace the joy that comes with the healing arts and enjoy the special role you play in being part of the greatest profession on earth.