Take Your Practice from Good to Great

Dear Director,
I just finished my first year as an attending and while I feel like I’ve made progress since residency ended, I am not the “master” physician I thought I would be. Will I always feel this way or will I eventually be a true expert in my field?
Signed,
No Master Yet

Dear Noobie,
As some of my former nurse colleagues will tell you, I thought I was pretty hot stuff coming out of residency. But in my first several months I watched all kinds of people in my group run circles around me. As my first year went along, I improved in many facets of my job, but it’s only now, in hindsight, that I fully understand the complexity of our job. When I think about the master clinicians that I’ve worked with, none have been only a couple years out of residency. All have been working in the field for some time and brought a variety of experiences to their current job. So are you are on the right track towards mastering your craft?

The Secret of Success
In his book Outliers, Malcolm Gladwell expounds on superstars, asking the question: What makes some people so much more successful than everyone else? Depending on the activity, success could spur from a range of things, from one’s physical size (ice hockey players), early access to computers (Bill Gates), or the opportunity to perform countless times (The Beatles). Two common themes that routinely come up when evaluating success stories are opportunity and time. What made the Beatles and Bill Gates successful was that each were given the opportunity to hone their craft over literally thousands of hours. The Beatles played eight-hour shows in dive bars in Germany before they were famous and Bill Gates, as a high schooler, spent endless hours programming computers long before most people had access to the machines. In fact, it turns out that there is a magic number for how long it takes to master complex tasks: 10,000 hours. Research shows that hard work, in fact, does pay off. Gladwell describes a published psychology study from the 1990s comparing music conservatory violinists on track to be either world-class soloists, “good professionals,” or music teachers. A clear correlation could be traced to cumulative lifetime hours spent practicing. By the time these violinists were 20 years old, the best had practiced for over 10,000 hours in their lifetime while the other two groups practiced 8,000 hours or 4,000 hours respectively. This study showed that no one had such innate talent that they could get to the top of their profession without putting in the necessary practice hours.

This same principle can translate to physician performance. It’s pretty basic; given the right opportunity in the ED, young physicians can master their craft by reading, continuing to learn, and by spending time working clinically. One could argue that with an 80-hour work week for 50 weeks a year for three years, new residency grads have already put in 12,000 clinical hours and should be a master of the emergency medicine craft. And while I’m willing to concede that all of that time spent as a resident physician can be useful when it comes to honing your bedside manner and learning how to interpret medical literature, a large portion of residency has little to do with direct emergency care. Even less time is spent on efficiently managing an emergency department as an attending physician. Therefore, it’s reasonable to think that attendings will continue to develop as clinicians over several years after residency is completed.

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I’ve now seen enough new residency grads start life as attendings to realize there are two learning curves. The first takes between three and 12 months and has to do with the speed that docs can see patients. Some docs get it faster than others, but almost everyone achieves an adequate work pace by the end of one year. The second learning curve takes two to three years after residency and has to do with the ability to think two, three or four steps down the line with a patient. This is necessary to shorten disposition time and anticipate the minefields as you order one test or don’t order another. It’s in these first two to three years of practice that most of us round out our true 10,000 emergency medicine clinical hours and become masters of our craft. Coincidentally, it coincides with the board certification process and with fellowship status for ACEP.

What To Do
First, it is good that you recognize that you have improved since finishing residency and yet have more to learn. There are certain skills and experiences that come with time. Intuitively knowing that the septic nursing home patient who needs to be intubated will also be in acute renal failure and therefore succinylcholine is contraindicated takes years. But eventually you will see enough septic nursing home patients and develop this ESP-like sense. In the end, the solution is simple: keep working and practicing so you reach your 10,000 hour mark. Also, try to recognize any clinical weaknesses. Instead of taking the CME course that corresponds to your desired ski vacation, find the course that supplements your needs. From there, come back to work and practice hard on those new skills. Learning to use an NP scope at an airway course is great, but you’ll only truly own the skill set if you return to work and take every opportunity to improve your technique. I once had an attending tell me that even if I never make the same mistake twice, I’ll still have killed a lot of patients. Therefore, maybe there’s some opportunity to learn from the mistakes of others. I’ve learned a tremendous amount of medicine from doing department chart reviews (projects and quality assurance). If this opportunity exists for you, it could be a great opportunity to see a huge volume of cases, including some that were not managed perfectly.

Conclusions
The good news is that I never expect the new kid on the block to be the master clinician in the ED. Talk to your medical director and make sure they are happy with your progress and work to identify weaknesses or areas that need improvement. Keep in mind that showing up and doing shifts is not “practicing” in the classic sense that musicians or athletes practice and train with teachers and coaches. However, success should come with time and time in the clinical area alone should improve your skills and provide a broader background of experience. Also continue to develop professionally with CME and direction from your director. By doing this and recognizing where you should be on your career development path, you’ll be that much farther along on your journey to master clinician.

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