The Search for Satisfaction Often Lies Beyond the ED

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Combating the grind of the daily shift can be overcome by branching out

Dear Director,

I’m an experienced emergency physician but I’m looking for more than just seeing patients.  What ideas do you have for me?

I think the first few years after residency are about learning and mastering your craft as a physician, and enjoying the new free time and financial freedom you have as an attending.  At some point in a physician’s career, I advise them to diversify a little and look for something outside of just clinical shifts. We generally all went to residency with a passion for emergency medicine, and throughout residency, we developed areas of interest that we focused on.

However, over the years, the daily grind of shift world combined with increasing family responsibilities can erode at this passion and leave us just doing the shifts and wondering what else is out there. Being a full-time clinician can be very fulfilling, but many people look to a little diversity to help prevent burnout. As we look to diversify your career a touch, ideally you can bring your expertise to an area of medicine you’re passionate about.

In the hospital

I got into administration because I wanted to help more than one patient at a time. But the personal benefit to me as a medical director is that I’ve really enjoyed getting to know the docs from different specialties throughout the hospital.  I’ve done this by working side by side with them on committees, as we worked through clinical issues, and by just spending time in the doctor’s lounge.   Even as an attending physician, given your training and skill set, there are numerous committees and projects throughout the hospital that could benefit from your experience and expertise.

These will generally require coordination (and likely a nomination) from your chair, but it’s the rare chairperson who can’t find an opportunity for one of their docs within the hospital.  There are numerous benefits to you (and the department) by getting involved around the hospital.  These include breaking up your clinical week, impacting care on a broader scale and getting to know non-emergency physicians better, which has the added benefit of often making your day job easier when you need to admit someone or get a consult.

I went into emergency medicine to save lives and I still think one of our biggest opportunities to improve care and reduce mortality is in managing patients with septic shock and severe sepsis.  This has been a hot topic for a couple of years so most hospitals probably have a doc or two on it.  But that doesn’t mean there’s not room for another champion for this cause.  Opportunities exist for reviewing cases, providing education and feedback to docs and nurses, and working with your EMR team to build new documentation phrases to handle the ever challenging changes to the quality rules game.

If sepsis was an emerging clinical focus two years ago, I think managing the opioid crisis will garner increasing attention in the months and years to come.  While there are a few experts out there already, most of us don’t know exactly how we can intervene.  Each ED needs an expert in this area who can review the current recommendations and help to get your department on the right course.  The first steps may be working with your EMR team to get provider prescribing data. For example,  how many opioid prescriptions per provider per 100 patients seen and what percent of those are for more than three days, perhaps defined as quantity greater than 15 pills and how often patients are being prescribed naloxone.

Next might be generating non-opioid treatment options for common diagnoses often treated with opioids (renal colic, headache, undifferentiated abdominal pain, etc…) and educating your docs and nurses about these options.  Perhaps, even developing pathways or order sets.  Finally, in some areas, the emergency physicians are providing medically assisted therapy with buprenorphine or other medications for patients who are in withdrawal or present after an overdose.  Some are even working with/for their local health department or establishing their own clinics that treat patients with opioid use disorder.

Emergency Preparedness began to receive a lot of attention, starting 17 years ago.  Many of the docs who have been involved in this field for nearly two decades may be retiring, or at the very least, looking to hand over the torch.  And although preparedness today isn’t the overriding concern it was after 9/11, it’s no less important now. The Ebola crisis was just a few years ago and requires a diverse skill set and the opportunity to learn new things. The emergency preparedness expert may also double as the EMS liaison, since most sites need someone to coordinate with EMS.  The EMS role may vary from case review to education, to coordinating the next drill.

There are several other committees around the hospital that benefit from the expertise of an emergency physician.  The most notable clinical committees, not previously discussed, include those involving STEMI and Stroke.  While most hospitals should have STEMI on auto-pilot by now, the updated stroke guidelines that extend the window of endovascular care, have most directors on their toes.

One of the best ways to apply your expertise to the patient is to review patient complaints.  Often, complaints are based on the perception of not meeting the patient’s needs or what patients believe is a bad outcome. Reviewing the ins and outs of a patient record and ED course requires experience and expertise and an understanding of best practices and physician thinking.  This role also involves coordination with the involved physician and nursing staff and the hospital’s patient relations team, and communication with the patient themselves. That often requires the confidence and empathy of an experienced physician. Along with quality of care work, there is also a need for someone to focus on patient safety.  Hot projects in patient safety recently have focused on patient sign out and airway management.

Out of the Hospital

There are numerous opportunities outside of your hospital where you can apply your experience.  These range from volunteering with your professional organization to high hourly compensation for legal reviews.

I’ve been involved with my state chapter of ACEP on and off for over 20 years.  I’ve really enjoyed the people I’ve met and the networking it’s allowed me. It’s also been a great opportunity to represent my colleagues.  State chapters usually work to improve patient care throughout your state via advocacy and representing you to your state government.  Most state chapters also provide some educational benefits to the members.  Malpractice and balanced billing are popular topics for us, but I’ve also seen colleagues become experts and then testify before lawmakers on the impact of psychiatric boarders and issues involving pediatric emergency medicine in the community hospital. Some of these opportunities will pique your interest and remind you why you went into EM. There is a huge need for docs to advocate for our specialty and our patients at the local, state and federal levels.

There are some skills from your hospital experience that may translate into money outside of the hospital.  If you’ve been doing quality reviews, you may find doing legal reviews to be very similar – but pay better.  Not only do you have to be able to review the case and provide an opinion, but attorneys really want someone who will remain calm yet be able to get their points across during a potentially aggressive deposition and can also break the medicine into straightforward messages for a jury to understand.  You probably know at least one doc doing legal reviews and this person may be able to review a case or two to you to get started.  I started by having two easy cases sent my way from a colleague who got too many referrals. As I’ve slowed way down on cases that I take, I’ve gotten others started who were interested.  After you’ve done well on a couple of cases, others will find their way to you.

Another skill set that may translate from the hospital to the community is working with EMS.  If you’re passionate about EMS and have been heavily involved, there may be an opportunity to expand beyond the hospital.  Perhaps start by teaming with the private company that does transfers to and from your ED.  You can offer education or to review cases for starters and then look for opportunities to provide medical control.

Telemedicine presents an exploding opportunity for emergency physicians.  Insurance companies are looking for opportunities to keep patients out of the ED.  It’s amazing what can be done with a webcam and a phone.  I like the idea of working from home and having flexible hours.  There may be a variety of licensing requirements, but I know several colleagues who have tried this and like it as a part time way to supplement income.

At the same time I was a sideline airway physician for an NFL team, I was also the “team physician” for every soccer and lacrosse team my kids played on.  While I felt lucky to never have to address an airway emergency in the spotlight of national television, I also was happy to assess numerous kids who got hurt on the field.  Injuries ranged from contusions and sprains to head injuries and an ACL tear.  For those interested in sports medicine, there may be a way to provide medical care to your local high school teams.  This may require malpractice insurance separate from your ED coverage, but you can provide valuable services while spending your Friday nights under the lights.

There are numerous teaching options throughout the community.  Many hospitals have a team that coordinates outreach to groups and provides specialists to increase community awareness about things like stroke and heart disease.  Our nursing director recently teamed with a doc and EMS to create a very successful program teaching “hands-only” CPR.  Other docs speak to church and community groups.  I also have a couple of docs who teach history and physical exam skills to local first and second year med students and/or advance practice provider students.  While this may require jumping through some hoops at the med school and with your medical staff office, it also serves as an opportunity to give back to younger medical students. And we certainly have a great patient population that benefits students because of all the abnormal physical exam findings that patients in the ED have.

Conclusions

If you want a more in-depth view, there are numerous conferences around the country that could give you an introduction into almost any topic listed above and help you find the next hot topic in that area.  But that’s not necessary as you can just sit down with your chair and talk about opportunities within the department. The benefit to you of taking on some extra work is that it may make your day-to-day work a little more interesting and serve as a professional distraction to the daily grind of shift work.  If you are successful at it, it could also lead to new opportunities and increased pay for that work.

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

1 Comment

  1. Randall M. Levin, MD, FACEP-Life on

    You have highlighted the importance of addressing the one central question in the medical profession and specifically Emergency Medicine. How do I or how can I stay connected to my inner calling as a healing professional. We are a summation of all the “pieces” which make up our inner spirit. We are physicians by training and education, but working “just in the arena”, will not always connect us to all of our strengths or interests in our career or in our personal/family lives. I am in total agreement that participating (respecting respecting boundaries) in leadership, being actively involved with committees, task forces, or other opportunities within the hospital/system setting will not only connect us to our own self-worth but it builds professional relationships while improving communication, engagement, and empowerment. Outside activities allow us to be “us” separate from only being “the doctor”. For my 28 years of practice I was that physician leader, committee and task force member, while building connections, relationships allowing us to be a team for the benefit of patient care and staff well-being.
    My outside projects and family time allowed me to be the husband, the father, the son, the brother, the nephew, the cousin, and the friend. The projects allowed me to be adventurous, to be artistic, to be the carpenter, the plumber, the outdoor hiker, fisherman, camper, to be spiritual and yes the “healer”, the doctor next door, when needed. As an Emergency Physician, my specialty allowed me the opportunity to open the doors within and outside the my practice setting – Wellness Section Chair-Elect
    My advice to new physicians, is to take an inventory of who you are inside – and make sure that you are addressing those parts of your “whole person”.

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