ED/EQ: You Had a Bad Day

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Simple things you can do to turn that shift around

One of the great things about Emergency Medicine is that when you push those doors open into the ED the waves of activity and sound and urgency wash over you and carry away any cares and concerns. Usually. Sometimes and rarely if we are fortunate, arriving to the ED can bring anxiety, unwanted pressure or simple irritation at all the interruptions and requests and demands.


This article is based on the principle “if you want to change attitudes, start with a change in behavior” forwarded by psychiatrist William Glasser. Here are seven practices that will help you turn bad starts into strong finishes—or at the minimum help you avoid consequences like bad patient/staff interactions or a viral video of you saying something you wish you hadn’t.

1. Feeling low? Start your day by looking your best.

Psychologist Karen Pine studies the link between mood and clothing, and has found that that mental processes and perceptions can be primed by clothing. She said, “Clothing doesn’t just influence others, it reflects and influences the wearer’s mood too.”  Because of this, “we should put on clothes that we associate with happiness, even when feeling low.”  In her book, Mind What You Wear, she shares a study of interest by Adam Galinski, who found that a person’s mental agility improved when wearing a white coat. So, when your day is off to a bad start, dress your best, take a little extra time to polish your look and consider putting on a white coat.

2. Salutations are key

When you say hello to coworkers, smile, or extend your hand to a new patient, you are setting up your next series of interactions with them to be good ones. Moods are contagious, and even fake smiles will generate smiles in return. You may not have the emotional energy to make small talk but it is easy to slip into the routines that we were taught as kids, and the emotional bang for the buck is the highest with the simplest: “Good morning, hello, how are you, nice to meet you.” You never get a second chance to make a first impression, after all.


3. “Thank you, thank you very much” — Elvis Presley

Be like The King and say thank you. Much is written about the powerful effects of gratitude, and scientists at the Greater Good in Berkeley have used fMRI to show the differences in subjects’ brains when they are expressing gratitude. Expressing gratitude seems to block negative emotions and over time, keeping a gratitude journal decreases depression. Saying “thank you” rewards the person to whom you say it and builds their good will towards you, all while giving your brain a dose of good hormones.

4. Pull up a chair

I have always found it ironic that every book on patient satisfaction recommends that physicians sit down to talk with the patients, yet few patient rooms have any place to sit—but that is a separate issue. The truth is that sitting down is not only good for the patient, it is good for you. Use the time to rest, straighten your back and release the tension in your neck by dropping your shoulders down. Use the moment to relax and think about your next response to the patient you are seeing. If the patient is agitated or agitating you, slower responses will cause them to feel heard and give you time to find the right words. I have trained myself to sit whenever I start feeling negatively towards a patient and somehow the physical relaxation leads to emotional relaxation also, with an improved interaction almost every time.

5. Time out

Sometimes nothing is going to help an interaction that is going sideways or is just too much for you to take at that time. If this happens, you always have an out. These five magic words can get you out of any interaction, at any time, for free. No explanation needed, no excuses and no white lies. “Will you please excuse me?” is the ace in your hole for any situation when you need an immediate out. It is polite and will not be refused. You can follow it up with an “I’m sorry…” as you leave the room—or not. If you are at the point where you might say something you regret, use the five magic words and simply step away. No explanation required and this may save you from saying something you regret.

6. One liners are your friends

Pulling out those witty comments when your bedside manner is not naturally at its finest is a great idea. Most of us have favorite one liners —use them when you are down. Some of the scripts I use are modifications of Studor, “Would you like your curtain closed for privacy or open for entertainment?”, or when they gasp at the touch of my cold hands “You should never trust a doctor with warm hands.” When putting in stitches, try “Now don’t worry, this won’t hurt me a bit!” How about saying to a child in a minor car accident “Gee, how fast were you driving?” and “Aren’t you a little short to see over the steering wheel?”


Have go-to phrases and deploy them regularly when you are not at your best; they are conversational and will evoke a smile or laugh, which makes it much more likely that you will smile or laugh (since moods are contagious!).

7. Doctor, heal thyself

This is not about getting exercise or building strong social networks or physician wellness, which are all critical. This is about getting through a bad day and not letting it get worse. Make sure you eat and stay hydrated. Empty your bladder when it is full. Take ibuprofen if your back hurts or you have a headache. Step outside for sunlight and fresh air, even if it’s just five minutes. It’s all pretty basic, but so many of us spend all our time taking care of others and end up neglecting ourselves. When you are having an off day, try to take extra good care of yourself so that you can still take care of others.

Summary: It is not shameful to have a rough shift, it is human and inevitable. You know what you are going to do when you confront hard IV starts or tough airways—have your “go-tos” for bad days as well. Prevent negative vibes from causing any lasting damage by being prepared to handle them.  Start by polishing your exterior when the interior is cloudy, make a point of greeting everyone and looking for opportunities to say thank you, sit when things aren’t going well and say “will you please excuse me” when they worsen; create your one liners that are touchstones for you. Lastly and primarily, always take care of yourself — if your basic needs are not met you will not be able to care for your patients. Sometimes these tactics will turn it all around and it will end up being a great shift. But even if it doesn’t, those doors are going to open again with your relief, and you can give your last smile and hello and thank you all to that fresh face who is going to take it all away from you and let you go home.



Keri Gardner, MD, MPH, FACEP is an emergency physician and Chief Medical Officer of Alaska Regional Hospital.

1 Comment

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

    As I read through the 6 steps, I recall that during my practicing years I was actually able to perform all of them naturally, to help stay connected to the primary reason why I was in the department, to be there for others. Well, not quite all, actually I would dress down – off came the white coat. I felt more relaxed without it on and more connected to the “Art of Medicine”, without it on. I was able to be “myself” without it on. At times I felt it was a barrier to the clinician/patient interaction, a paternalistic symbol so to speak, which was not as healing as being who I was as a human being connecting to another human being.
    The question remains however, what does it mean when these behaviors do not help to maintain or nurture our well-being anymore – will we be able to know that we may actually be succumbing to the burning-out process, and seek help and support early during that process.

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