Senior EM residents reflect on their training and upcoming attending life, giving a glimpse into the millennial mindset.
July 1st marks a special transition in medicine every year. It is the first day that new residents step into a hospital as physicians, and the day graduated residents finally manage an ER by themselves as attendings.
We sat down with a few senior residents in their final shifts of residency to gain insight into how they view this transition into attendinghood, what they’ve learned, and what they hope life will look like on the other side.
When asked about some of the greatest surprises of resident life, the answers ran the gamut.
“I thought it would be so hard to take on the agitated patient throwing feces and that the fast track patient would be so easy,” said Ted Fan, M.D., chief resident at George Washington University. “But then you end up stressed about insurance and how will the patient follow up, or you get stressed about unusual fractures or complicated lacerations of the hand. As a more senior resident and as a future attending, I also realized I would rather see four more patients than jump for an extra procedure most of the time. Some things became way harder and some way easier over the years.”
For Michael Burla, D.O., chief resident at Beaumont Hospital in Royal Oak, Michigan, one of the great challenges was learning to appreciate the mysteries beneath the surface – that sick patients can come in looking relatively well. “I also learned to appreciate that the elderly have no reserve and decompensate quickly,” said Burla. “I have respect for certain comorbidities and chief complaints, and non-classic presentations.”
Another surprise? Shifts in the ED bear little resemblance to what is portrayed on TV. “I thought it would be at least a little like on TV, everything’s hitting the fan at the same time but it all works out at the end,” says William Beeler, M.D, from Truman Medical Center in Kansas City.
For Beeler, one surprise was positive – that his residency had a modern sensibility and was changing with its residents. “Our program director runs a very modern department,” he says. “The male-to-female attendings ratio is around 50/50. He is very aware that education has changed and understands that residents want kids and a family.”
The Ideal Work Environment
When asked what type of work environment they hoped to work in next, the answers were split between large academic centers and community hospitals.
“I don’t want to be at a small, outside hospital,” says Beeler. “I want a good ICU that can handle MI, stroke, and DKA patients.”
Similarly, Michael Burla expressed a preference for a hospital with plenty of support. “I don’t enjoy places without resources or teaching opportunities, or are single coverage.”
Peggy Landel, D.O., from Inspira Health Network in New Jersey plans to work at a large, multi-coverage community ED to “harness some of my abilities as a new attending.” For other residents, community hospitals hold the exciting promise of a more independent practice.
“I want to get my feet wet and practice on my own first,” says Blake Buchanan, M.D., from Truman Medical Center.
Shannon Lee, M.D., of Oregon Health & Science University, looks forward to a hybrid of academic and community medicine, where “the practice of medicine is night and day. High acuity patients present later in their disease, and the staff is efficient at anticipating my needs.”
Professional expectations such as the number of shifts, departmental support and time for more than clinical shifts were deciding factors for job selection. Aurora Richard, D.O., of Arrowhead Regional Medical Center, expressed a common theme of seeking a position where “you can pick up extra [shifts]but it’s an option not a requirement.” With so much recent emphasis on wellness, residents unanimously agree that too many shifts and too little time working outside the ED is the quickest path to burnout.
Michael Burla also emphasized the importance of an ED responsive to physician needs. “It’s great to get paid more, but I’d rather have an administration that listens and a non-malignant work environment.”
For Ted Fan, the key is to find a place where you can have “a broader sense of the hospital community to ground my practice because I will be part of a hospital family and not practicing in isolation. I don’t want to be a ‘locker doc’ and clock in and clock out.” Charles Hall, D.O., chief resident at University of Nebraska Medical Center, wants to do more than “just grind out my shifts and go home” and plans to participate in international medical missions.
Surviving the Stress of Residency
As part of the first graduating class of her residency, Peggy Landel came in not knowing what to expect. But “we were pulled aside for every procedure and I got a lot of exposure.” Meeting her future department chairs also brought her stress level “right down. If I ran into a problem, I would feel totally comfortable going to them.”
Comfort and stress reduction didn’t just come from the work environment, however. “Just when I thought I had no scrubs or underwear, my husband was like ‘Oh I did the laundry.’ If it weren’t for him, I would never have clean clothes and would be living on lean cuisine.”
Shannon Lee agreed, emphasizing the role her husband played in surviving residency. “My husband is so accommodating and thoughtful. He has come to terms with my life. It is hectic, but we communicate very well day to day and keep tabs on each other.”
“She totally gets it,” says Charles Hall of his marriage during residency. “Going through this together has been the best three years of our marriage.”
“My wife is a PA and gets it better than most,” adds Blake Buchanan. “She runs everything at home and made the process a million times better.”
On Longer Residency Shifts
When asked about resident shift length, our respondents were mixed. Shannon Lee said she’s a little wary of the proposed extended hours for interns. “24-36 hour ICU calls were nightmarish. It was so unsafe that there was little educational value. You were just trying to stay above water, but with the right support it could be totally great.”
“There is just more opportunity to break duty hour rules with longer shifts,” says Charles Hall. “But it does decrease handoffs, where things do get missed, and the scutwork finally stops at 5 pm and you can really concentrate on patient care.”
Ted Fan leaned towards the longer shifts, but for a different reason. “I preferred 24 hour calls because then you had fewer of them,” says Fan.
William Beeler’s feelings were a bit more extreme, though shift length wasn’t the only problem. “I have PTSD from my intern year,” says Beeler. “Lack of supervision was the problem, not duty hours. There were increased hand-offs and the focus was not on patient care.”
Shorter ED shifts were hailed as a positive by Hall. “I’d rather have the extra three hours a day to do something with my family or go to the beach or the gym.”
After years of strenuous shifts, the residents we talked to were quick to share the things they were looking forward to on the other side, things that had nothing to do with the emergency department. For some, travel to destinations like Dubai and Thailand will be a much-deserved reward. For others, rewards closer to home seem just as thrilling.
“I look forward to having a yard that isn’t out of control,” says Shannon Lee. “I look forward to having time to walk my dog, and to buying my groceries at Whole Foods! I also plan to do some financial planning for kids, and pay off loans.”
Blake Buchanan will be devoting time to interests outside of medicine, “like sporting events and day adventures, hiking and going to parks. And free food at the hospital!”
Our culture has labeled millennials as entitled and demanding. In our interviews we found that EM senior residents do fall into this stereotype, but in positive ways which could ultimately improve the practice of emergency medicine. Today’s young doctors operate under the belief that they are entitled to a profession with more than just shift work. They demand a career that encourages self-care instead of obliterating it. They know that emergency medicine extends beyond the department, and wealth isn’t determined by a bank account. Most importantly, young physicians seem to know that self-preservation isn’t selfish. It’s the answer to an elusive “wellness” that everyone wants, but which millennial grads may be the first to grasp.
Michael Burla, DO
Royal Oak, Michigan
On Money: Its great to get paid more, but I’d rather have an administration that listens and a non-malignant work environment. I am going to spend half my life there.
On Resident Hours: 24 hours of call is gonna suck, but we were all there all the time anyways. Whether you sleep at home or in the hospital doesn’t really matter. It’s a fallacy that duty hour changes will help with resident wellness.
On Consultants: Initially I didn’t push back and didn’t know how to frame things. Now I know how to tell them what they need to hear.
Ted Fan, MD
George Washington University
On New Rhythms: I used to jump for procedures, but now I’d rather go see four more patients.
On Duty Hours: I preferred 24-hour calls because then you had fewer of them. 16-hour shifts can be exhausting, you only end up sleeping 4-5 hours before you have to be back again.
On Consultants: As an intern, I got to know the cardiologists and surgeons on off-service rotations more than my own class. This really helped with consultant rapport later.
Shannon Lee, MD
Oregon Health & Science University
On Life Balance: I look forward to having a yard that isn’t out of control, having time to walk my dog, and to buying my groceries at Whole Foods! I also look forward to a hybrid of academic and community medicine, where high acuity patients present later in their disease, and the staff learns to anticipate my needs.
On Extended Call Shifts: I am a little wary. 24-36 hour ICU calls were nightmarish. It was so unsafe that there was little educational value. You were just trying to stay above water, but with the right support it could be totally great.
Peggy Landel, DO
Inspira Health Network
Vineland, New Jersey
On Good Leadership: When I met my future department chairs, my stress level came right down. If I ran into a problem, I would feel totally comfortable going to them.
On Marriage During Residency: Just when I thought I had no scrubs or underwear, my husband was like ‘Oh I did the laundry’. If it weren’t for him, I would never have clean clothes and would be living on Lean Cuisine.
On Getting a Life Back: I look forward to harnessing some of my abilities as a new attending and concentrating on getting my personal life back.
William Beeler, MD
Truman Medical Center
Kansas City, Missouri
On Reality vs. TV: It’s more like controlled chaos, but I thought it would be at least a little bit like on TV, everything’s hitting the fan at the same time, but it all works out at the end.
On Duty Hours: I have PTSD from my intern year. Lack of supervision was the problem, not duty hours. There were increased hand-offs and the focus was not on patient care.
On the Millennial Mindset: Our program director runs a very modern department, the male to female attendings ratio is around 50/50. He is very aware that education has changed and understands that residents want kids and a family.
Aurore Richard, DO
Arrowhead Regional Medical Center
On Perception vs. Reality: I didn’t realize it’s so much primary care, more coughs and colds than I thought.
On Spousal Support: He works from home, so his schedule is more flexible than mine. But it can be hard for him to understand residency requirements and that you can’t just call in sick.
On Family Balance: Our program breeds alpha females. The attendings are not coddling, but our program director was very supportive of our families.
My advice to new graduates is to never stop learning. And not just the science and best evidence of medicine but the “art” of medicine. Listen to your patients, anticipate their needs, confort the sick, improve your communications skills, and above all never forget to treat each and everyone of them with the dignity and respect we all deserve.
Also, find a more senior physician you respect and learn from that person’s wisdom through a mentorship relationship.
Congratulations and Gods speed.
My advice: although they say, “there is no I in team..”. The reality is that there is no ” team” in a court house. And when the stuff hits the fan, and it will, the stuff will only stick on you. Am I cynical? You bet. The “art” of medicine is dead, except in third world countries. There are only algorithms and customer satisfaction scores. Everyone in healthcare has patients but you. They are there to protect them from you, the provider. Everyone wants to be called a doctor, but they only want to call you my your first name. Everyone thinks you make too much money, and the reason and solution to the high cost of heath care. Oh, one more. You are only as good as your last patient. People could give a rats ass what and how much you know just how much you APPEAR
to care. Who ever said, “life is short; art is long; experience difficult”. Was very wise. Would I do it all, all over again, you bet but I sure wish someone would told me the above beforehand. Whoever said, “there’s to much primary care” in EM made me laugh. Maybe she’d be happier in “critical care-emergency medicine” fellowship. Good luck. Your challenges will not be the patients, believe me. It will be the nurses, the computers, the consultants, the parents, the lawyers, the politicians, the medical directors. You know, “the TEAM” that your so happy to join.
Sorry about the typos. Didn’t proof read.