Guest Columnist: reflections from a newbie

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As the final days of residency passed by, there were many things I looked forward to after graduation, but I never fully imagined what the real world would bring. Here’s what my first year as an emergency physician taught me…

I remember well my first few months as an intern, as I looked forward to the day when I’d graduate and branch out on my own. It seemed like an eternity away. As the final days of residency passed by, there were many things I looked forward to after graduation, but I never fully imagined what the real world would bring. Here’s what my first year as an emergency physician taught me.

Floor codes are no fun at all. I thought I had left that behind after my intern ICU rotations, but in some community hospitals it is a reality for EPs. These situations are worse when you are new to a facility and don’t know the quickest way to get from A to B.

Basic equipment I once took for granted (ED dedicated ultrasound machines, bougies, EZ-IO, airway rescue devices) may not be readily available at any given facility. Some of these things you can lobby for and get the available equipment, sometimes it takes approval from a lot of people and several meetings to get basic things done.


Consultants mostly are fair and reasonable, but not every community physician is up to date. I had one surgeon ask me to withhold pain medications (“until I can examine the patient”) in a lady with a CT documented small bowel obstruction. Needless to say, she got her pain meds despite this request.

Administrators can make life miserable. I’ve been told by one I can’t wear scrubs to work. I’ve fought battles for equipment upgrades that have fallen on deaf ears. I’ve seen places where patient flow could be improved substantially with better RN staffing and/or MLP coverage, only to find these battles were beyond my (and my medical director’s) control, left to people who sit in offices all day and have no clinical exposure in their daily routine.

Being the “new kid on the block” can be tough. My colleagues, overall, have treated me very well. Patients and nurses, and consultants on occasion, have been a different story. In a county hospital where residents are running around everywhere, people are accustomed to dealing with young doctors. As an attending in July (resident plus one day) and throughout my first year, I’ve had many a patient ask inquisitively, “How old are you?” And on rare occasions I’ve suspected nurses treated me a little different than my colleagues who have 15-20 years’ experience and a few grey hairs. At this point I’d rather be in my position. The grey hairs will come in time—hopefully later rather than sooner.

Just say no. Whether it’s a scheduler trying to fill some gaps or a colleague trying to get an extra day off, there are plenty of opportunities to pick up extra work. As an eager “newbie” with substantial debt and a desire to be a team player, it’s hard to turn those opportunities down. Before I knew it I found myself working as many hours as I did during residency; something I swore I would never do in the real world.


Even newbies need a day off. I finally reached a point where I know how to turn them down on occasion. Here’s my favorite line: “I’ve been spread pretty thin lately and I don’t think it would be good for me—or for the patients— if I picked up an extra shift right now.”

Single coverage can  be tough. Everyone always told me I’d miss the camaraderie we had as residents. How right they were. There’s something about single coverage that just wears on you. Even if the volume is manageable; something about feeling all on your own, isolated, none of your colleagues to chat with between patients, it takes you to a lonely place. As EPs we are social creatures. If we weren’t, we would’ve gone into radiology or pathology.

Always consider PE. To the best of my knowledge I haven’t missed any, but I’ve had some with unusual stories and I’ve seen more in my first year out than I did throughout my residency. My favorite: the patient who complained of flank pain (he probably used the word “flank” ten times when I took his history) with no chest pain, no shortness of breath, normal heart rate and respiratory rate. His SpO2 was 94% and that was my only clue. D dimer was off the charts and he had massive bilateral emboli.

Focus on finances. I didn’t get into medicine for the money, but I don’t want to practice forever because I haven’t saved enough either. My budget may be a little bit different than when I was an intern, but I still have one. And I’ve discovered that while my salary is pretty nice, there will always be things that are out of reach and limits have to be set. I can do a few nice things I couldn’t do before, but I can’t do those things all the time at every whim. I’ve also gained a lot of insight from talking to colleagues who have been around for a while. Many of them have opened up to me and said, “If I’d have done X or Y when I was your age, I’d be retired by now.” When it comes to conversations like that I’m all ears. The goal is not to retire young, but to have the ability to retire and keep working because I still enjoy it when I’m older.

As one of my attendings from residency put it, “if you’re not a little bit nervous your first six months out on your own, something is wrong with you.” Well, I was certainly a little nervous flying solo, but I gained a tremendous amount of confidence during my first year post-residency. The first year is a steep learning curve, but I believe I’ve emerged a little more seasoned, a touch more skeptical, a bit more conservative in the way I practice, and optimistic for the future. I’ve learned to pick my battles, take the good with the bad, and never stop learning. I’m grateful for the opportunities I’ve had this year and the many colleagues I’ve met and had the pleasure of working with, as each has taught me something in their own right. I look forward to whatever the future may hold.


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