Best Foot Forward

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Dear Director: I’m finishing residency and starting my first job. I’m pretty good but want to make a good impression and not screw up. What advice can you offer about getting started on the right foot?

For better or worse, your actual first impression came months before your first shift, when you interviewed. This impression was then enhanced or harmed as you completed your credentialing paperwork (early, on time or late) and interacted with the medical staff office. It’s not unusual for these administrative folks to tell me that a doc will be high maintenance or a pain in the butt prior to their first shift. And they are usually right.

The First Shifts
Starting off strong in the ED and getting liked and respected by the nursing staff is the next hurdle. Review your orientation manual prior to your first shift and make sure you understand how to troubleshoot difficult issues, and then get paired with an experienced provider for a number of orientation shifts. I think three is a minimum for a new grad. No matter how experienced or comfortable you are in a job, it’s always a good idea to show up early for your shift. However, as a new doc, you also need to recognize that you’ll be inefficient for several months (I think it takes 45 shifts to really become efficient in a new environment) so plan on staying late without being compensated to wrap things up. This helps establish yourself with your colleagues as a hard worker rather than someone who is just punching a clock. Each ED has a somewhat different culture and these extra hours also give you an opportunity to learn the sign out culture of the department. There is likely also a culture related to who picks up the next chart, scheduling hierarchy, and clinical pathways (3 or 6 hour chest pain rule outs, portable lateral c/spines to clear a neck or CT for trauma patients, etc…). Check your ego at the door and be willing to put your residency’s model of care on the back burner for a bit since it may not work well in your new facility. As your experience and understanding of the ED culture grows, your efficiency will improve so that you can leave closer to the end of your shift over time.


As an experienced and productive attending, I’ve watched my productivity drop by about 20% each time I’ve changed EDs. Fortunately, because of experience, it comes back up pretty quickly. As a new grad, your productivity is likely to be well below the group average to start, and that’s okay. I usually give a hall pass when it comes to productivity for the first few months after residency. All experienced docs know that they’ll need to carry a little bit more of the load when they work with a new grad. However, very quickly you’ll want to be conscious of your productivity. I’ve seen enough new grads to realize that their speed and efficiency varies considerably over 3-12 months and, in fact most docs continue to improve their productivity for 3-5 years. However, by month 6, you should begin to know your metrics. While you don’t need to be the most productive doc in the group, you also don’t want to be at the bottom either.

New docs can easily make mistakes in caring for VIP patients. The definition of a VIP will vary by hospital, ranging from an actual celebrity to the spouse of a hospital board member. I’ve found that the secret to taking care of VIPs is simple: do the right thing and never cut corners (like skipping the rectal exam or an NG tube in a potential GI bleed for instance because it’s uncomfortable or embarrassing). It’s also important to thoroughly communicate with all involved—PMD and specialist but also potentially your chairman or the hospital VP of marketing who shouldn’t be surprised if the newspaper calls in the morning. If it’s your patient, don’t gossip about the details. If it’s not your patient, don’t look them up in the computer—can we say HIPAA violation? These records are always audited for digital IDs.

Bad things can happen in the clinical area when you are new as well. These range from as straight forward as missing a core measure to something more substantial such as having a patient who walked into the ER and died three hours later. While at no point in your career do you want to screw up clinically, it’s more challenging to recover from a mistake in the first several months while you’re building your reputation and credibility. Recall that core measures matter because they’re tied to hospital reimbursement and publicly reported. If you don’t understand them, get a tutoring session from your medical director. If you think you missed one, let your medical director know. More significant issues, such as a bad clinical outcome (unexpected death), failing your boards, getting a letter of complaint from a governmental agency, or getting sued, necessitate that you inform your medical director immediately. The medical director should be able to offer advice about how to navigate the situation as well as prevent potential fallout within the hospital (bylaws may require passing boards within two years to be fully credentialed).


When it comes to political interactions there’s plenty of ways to screw up when you are the new guy. To minimize these opportunities, start with good, honest, and pleasant communication. Over-communication with the patient’s PMD is usually better. And know when to put on the kid gloves and play nice. Dr M. showed up for his first day armed with an incredible amount of knowledge. Two hours into his first shift, he got on the phone with a PMD to admit a patient with an upper GI bleed. When asked what the rectal exam showed, he got in an argument over the futility of a rectal in this patient. What he didn’t realize was that this private attending was the president of the medical staff, had the largest practice in the area and was far and away the biggest admitter to the hospital. Put together, this gave him “Platinum Card” status and first class access to the CEO’s office. It was only a matter of hours before the CEO called me to ask whom the new ass was that I hired and why was he picking fights with the privates. Bottom line: know who the big fish are, and know when to play nice. Pugnaciously quoting literature may work in some hospitals whereas in others, physicians will just think you’re an arrogant ass. Also, your orientation should have included medical staff hot buttons. These are things that have been issues over the years that the med staff overreacts to because they continue to happen. For example, one standard hot button is waiting until after 6pm to call the nephrologist or gastroenterologist for a patient who needs dialysis/endoscopy even though the patient was in the ED at 2pm and the disposition in their mind was inevitable.

On a personal note, be professional and take in the environment. Dress professionally and in line with the other physicians. If you need a role model, dress like the chairman. While it might be tough, try to hold your tongue initially at meetings – or at least don’t initially be confrontational. Increase your participation in meetings over time. Listen first, offer your opinion when asked, and then as you get more comfortable and the group knows you better, start to interject your opinions more in the discussion. Be careful of whom you criticize and where you do it until you know the players and the background. Keep your schedule requests reasonable so you’re not the scheduler’s biggest headache. Finally, even if you think you’re going to leave, try to keep your job for at least one, if not two years. It’s a red flag when I interview someone who jumps ship quickly and I’m less likely to offer them a job for fear that they’ll never be satisfied and may leave my site quickly too.

There are numerous opportunities to get in trouble when it comes to social interactions. Work hard to learn everyone’s names as quickly as possible, including the department secretaries and EMS providers. Friendly and approachable physicians get more help, which can prevent bad outcomes. I use 360 degree evaluations to gauge the individual physician-ED staff relationship and then provide feedback. As an attending, you’re now in a position of authority when it comes to your relationships with nurses. This is a different position than being a resident and this means that any outside social situation is still a work environment for you. Blurring the lines socially can lead to an unprofessional environment in the ED. Don’t sit at the nurses’ station talking about where you’re all going out later. We work in a fish bowl; patients and their families don’t want to hear it, and some nurses could feel that you’re creating a hostile work environment.

There are some social functions that you should make great effort to attend. These include any formal party or event that your hospital or company sponsors. Also, be sure to attend your department staff meetings and your hospital general medical staff meetings (usually quarterly and a requirement for maintaining privileges). Say yes when you’re asked to join a committee. Ultimately, commit to being a good citizen of the group and your hospital.


As a new doc, there are lots of opportunities to screw up and get started on the wrong footing. Most of my new providers generate some sort of complaint within 3 months. But many of these pitfalls can be avoided by taking the time to prepare, being professional, and having a good attitude. Give yourself some time to settle in, learn from any mistakes you do make, and commit to being a valuable member of the team. Good luck.


EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Director of the Alteon-Mid Atlantic Leadership Academy. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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