Reading Maketh a Full Emergency Physician

This month I’ve taken a detour from my typical diatribe to bring you a conversation with three esteemed colleagues. We talk about required reading for emergency physicians, life influences, and how to succeed in emergency medicine.

The Panel 
RICHARD STENNES: For those of you who are not in wheelchairs, Richard was President of ACEP 30 years ago. Richard is the person who forced us – dragged us kicking and screaming – to have a Washington office, which is the best thing that ever happened. To this day, the ACEP Washington office is considered the finest medical society organization in the nation’s capital.

JUDITH TINTINALLI: If you don’t know Judith Tintinalli, you must have been living under a rock for the last 40 years. Dr. Tintinalli’s book, which I participated in the first edition and many after that, has been the mainstay of the repository of knowledge in emergency medicine since before the specialty officially occurred. I remember back when the first edition was loose-leaf in three binders. Judy really took us to becoming an academic specialty.

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EARL REISDORFF: Earl is the Executive Director of the American Board of Emergency Medicine (ABEM). Earl is the only musician/EP I know whose compositions have been presented at Carnegie Hall. He’s one of the smartest folks I know.

HENRY: Dr. Stennes, you being the oldest and wisest of the crowd, what has pushed you in your career over the years?

STENNES: Well, Greg, the first influences that I recall that probably had a lasting impact goes all the way back to Aesop’s Fables, which represented some things that my mother and father always talked about. One of the things in that stable was: Quarreling about the shadow, we often lose the substance. And so I’ve tried to focus in my life and trying to get to the substance when sometimes the shadows tend to overcome. The other lesson was this: you’re kind of known by the company you keep. We lived on a farm, didn’t have much. But whenever we went to town, went to church, my mother always wanted me to have clean underwear because, well, you never knew, you might go see the doctor. My parents always admonished that when you’re outside the house, you’re always representing the family and keep that in mind.

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HENRY: Dr. Reisdorff, you’re an elegant person. So, I will quote Francis Bacon: ‘Reading maketh a full man, conference a ready man, and writing an exact man.’ Do you care to comment on that?

REISDORFF: Well, I’m not any of those things, Greg. But there’s a real opportunity for all of us to head down that path and do what we can to be better readers and writers. I think books can be mentors of sorts. And one of the books more recently that I found to be helpful was Getting to Yes by Roger Fischer. If you think about emergency medicine, there’s so much of what we do throughout the course of the day that is negotiated. Getting to Yes is a book about effective negotiation. Being right is not always the most important thing. Really getting the patient the care he needs has greater value. And it’s not about getting the best deal in every case. But again, accomplishing what we need to as physicians to get the patient what’s most helpful to them.

TINTINALLI: One article that for me has been very important was Slow Ideas, by Atul Gawande, which appeared in The New Yorker. He talks about why some things can change very quickly and other things just take forever to change. I use that idea a lot in different lectures. A good example is trauma care. Somebody has an auto accident and it may hit the news media and it’s led to a lot of changes quickly in road design, in trauma care. And then you compare that with mental health. It’s a slow idea. Things like that should never be expected to change very quickly. And that has helped me a lot in, for example being a department chairman, to see what kinds of changes you might really be able to make immediately.

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The two biographical books I like – and I’m not really a feminist so it’s kind of surprising to myself to pick these two books – are the biographies of Madeline Albright and Ruth Bader Ginsburg, who of course is pretty famous because she fell asleep during the State of the Union Address and all.

HENRY: In all fairness, Ruth is famous for more things than falling asleep.

TINTINALLI: Madeline Albright started out as an ordinary housewife. I did not know that. And her husband left her for a younger woman. And she picked herself up by her bootstraps and look what happened to her. Ruth Bader Ginsburg, similarly she had great difficulty with self-confidence. She had a husband who really, really supported her, spurred her on, said: You can do it. You can do it. And look what those two women have accomplished.

STENNES: I probably spend too much time reading current events. But when I get up in the morning I read the newspaper of whatever town I’m in and then the Wall Street Journal and if I have time I get the New York Times and the Financial Times. I try to look particularly for anything by Thomas Sowell, which doesn’t appear very often because he’s a conservative economist. He’s got one of the best basic economics books in my opinion. Also, George Friedman has a thing called the Stratfor Report, which I highly recommend to everybody. I get it every day. It gives you world intelligence and in-depth analysis of what’s going on I don’t think with necessarily any political bias. It just reports kind of what is. But there’s a book that Friedman wrote called The Next 100 Years. It explains in there how the geography of the United States – rivers going north to south, water on both sides, land masses north and south – and a unique composite of politics led to the creation of this country. He talks about why we see political swings every 50 years. I highly recommend that one, together with the Stratfor Report.

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REISDORFF: If I had to think about a nonmedical book that I’ve read probably five, six times over the past three decades, it would be Victor Frankl’s Man’s Search for Meaning. Frankl was a war camp survivor from Nazi encampments and founder of logotherapy. I think the way that he was able to salvage humanity through maintaining his ability to choose – to choose how he felt, to choose how he reacted to things – had a really profound impact on the way I think. You know, we’re encounter such miserable circumstances from time to time. Knowing that in these situations, where it seems as though we have no options, if we think hard enough, if we dig deep enough there really is a choice we can make about those things. I think it’s interesting, you know, that Judy has found meaning or value in books that have a biographical nature to them. And I think that biographies just magnify the idea that books can actually be mentors.

HENRY: I can’t agree with you more on the choice of Frankl’s book. I’ve also read it probably three or four times. And when you think about it, things couldn’t be worse for Viktor. He was a Jewish prisoner of the Nazis. The fact that he was even going to breathe the next day was always in doubt. But he says: We always have choices and we can’t throw it off on other people. I think you may have hit the one book I think that everybody at some point needs to read because pretty much our life consists of our choices. I always thought an interesting comment in that book was he had more freedom than his German captors. Because he could be anything he wanted. He could stick a feather in his butt and run around and crow if he wanted to because he didn’t have to play the tough guy or the hard guy. He had a choice of being whoever he wanted. It’s a magnificent work.

TINTINALLI: Annie Applebaum, who writes for The Washington Post, wrote The Iron Curtain: The Crushing of Eastern Europe. It is absolutely amazing. In order to understand what is happening today in the world, you have to read that book. Because everything that’s going on with the Soviets, Crimea, Finland, what is going on in Finland; you can see that it’s a repeat absolutely of 1938 to 1945. So, if you haven’t seen that; she got the Pulitzer Prize for that book. It’s just wonderful.

HENRY: About ten years ago some residents asked me: “How did you get to know a lot of things?” And I wrote down a list of the 30 books you ought to read early in your career. How would you respond to that question?

STENNES: I have a Constitution around and I try to read it with some regularity. It’s important when doctors are out in company to be able to talk about something other than something in medicine. There is a book called The Dictionary of American Cultural Literacy. And I’ve had it by my bedside for many years. It’s fairly thick. But every night or periodically I try to read a page. And it’s got little vignettes about important things in the culture and history of the United States and the world. And if you read that book, if you go out into polite company and talk about things and people will say: Boy, that guy really knows something about something. Now it may only be a half-an-inch deep and ten miles wide, but it gives you the impression that this doctor maybe knows something about something other than medicine. I’ve always found that to be helpful.

TINTINALLI: I think what we’re really talking about is: How do we become broader people? As opposed to just doctors who are worried about CBCs and CTs. Because that’s the real thing of life: You have to be more than a doctor to be a good person and a satisfied person. Medical students can have very erudite, interesting, diverse conversations because they’re at a point in their life where they’re still trying to find out a lot about everything. Once you get into residency, most people have a very, very narrow focus and that is: How do I get through today? How do I get through this rotation? How do I handle the new child that I’m expecting? They don’t have time for anything. Plus, I can tell you they don’t read books.

Now, faculty could be different. I read the New York Times Op Ed columnists and I prefer reading current stuff rather than classic books. Guys like Paul Krugman, David Brooks, Friedman; their articles are well written. They’re usually short enough, which fits well with emergency medicine and the need for immediate gratification when you read things. That’s where I get a lot of my stimulation in terms of modern politics, modern economics, and what’s going on in the world.

REISDORFF: Yeah, taking this notion of reading beyond what you can buy in hardcover, I really like David Brooks as a columnist. I would recommend a very specific one of his: The Moral Bucket List. I push that out for everybody within my circle to read. But one of the other ways in which people are getting information that I think is challenging or replacing reading a little bit are YouTube and Ted Talks. There’s a lot to be gained I think sometimes in 18 minutes from hearing someone like a Kathryn Schulz condense her book on “being wrong” into a talk. And so I think there are these other opportunities to learn that historically we did in 250 pages in a hardbound book. But now a well-written column or an 18-minute video presentation can have every bit as big an impact.

HENRY: Ok, what books have been your major influences in terms of the essentials for success for any physician?

STENNES: Well, very early on in one’s career the best favor you can do for yourself is to read this basic book on economics. The Richest Man in Babylon, basic concept: ten percent of all that you’ll earn is yours to keep. It’s a very short read. It’s probably a half-inch thick. It’s got lessons of life that everybody ought to have. And I heartily endorse it.

I’d also mention Sun Tze, The Art of War as being important to emergency physicians, particularly as you rise in positions of leaderships in your medical staff. To know your enemies you need to know yourself. And you’ll not be put at risk even if you’re in a hundred battles if you know both yourself and your enemies. I’m not saying medical staff are your enemies. But it is so important whether it’s the good, the bad or the ugly; it makes a world difference if you know a lot of things about the people around you as you rise in positions of power and influence in your medical staff and in your life.

Another one similar in nature of course is Attila the Hun. One of the basic lessons in Attila the Hun that is so important for emergency physicians is the development of leadership, which doesn’t come quickly. He said that Huns got to learn throughout their lives; you never cease being a student. As doctors, you’re never above gaining new insights, innovative procedures, methods, whatever the source. And then, of course, The Prince by Machiavelli, I think is important for everybody to read. Some of the basic things in life: Far safer to be feared than loved if you cannot be both. A political issue that people may take some differences with but it’s one of those things which you need to read.

REISDORFF: I think if a young physician is going to get into leadership and administration, Jim Collins’ book, Good to Great, is helpful and has much to give, just the language and the lexicon of philosophy that have really permeated a lot of healthcare systems. A less well-known book that is really quirky and not necessarily easy to get through is a book by Zimmerman called Edgeware. This looks at the application of chaos theory for healthcare systems. We operate in a very complex adaptive system in the emergency department and in the hospital at large. There’s also a book in particular that I used a lot when I was doing some of my entrepreneurial things in the past: Innovation and Entrepreneurship and The Seven Sources of Opportunity by Peter Drucker. He’s written a number of books on management. He’s the god of management. I regularly look at The Seven Sources that he talked about and think: What do I see in the practice in the emergency department, particularly in today’s rapidly changing environment? What things can I use? What is unexpected? What changes are taking place in the market? What’s changing demographics? What meaning, what new knowledge? If I’m looking at something, how can I make something better based upon one of these seven sources of opportunity?

HENRY: One of the things they did when I became President of ACEP was they made me attend three courses: One was negotiation techniques, very valuable. One was how to handle the press. And the last one was on: How do you conduct meetings? How do you form committees? And what can you do as a leader to make sure everybody’s time is being used in a valued manner? I can’t tell you how many meetings I’ve sat in in my career where I thought to myself: Oh, my God, I want to get out of here. That one course and the book, The Closing of the American Mind by Allan Bloom, that went with it were very valuable in moving me ahead.

STENNES: Back in 1978 or so I was going to become President of Cal ACEP and I thought it would be good to try to learn how to walk and talk. So I found this guy named Carl Terzian & Associates in Beverly Hills. He had a major influence on my life in terms of trying to teach you the importance of dressing for success. And there’s a book, Dress for Success, by Tom Molloy, that’s still out there that talks about these essentials. I got some of the doctors in my group way back when to go to Dale Carnegie because they didn’t look very presentable. One of them went to become the President of AAEM. I never would have guessed it back in those days. But how to dress for success I think is a very important thing for all physicians to understand. It gets back to that issue of your parents: When you’re out and about, you’re representing the family. If you go back to the ‘70s and all of us can recall the scientific assemblies when flip flops and long hair and surgical scrubs perhaps were in order. It may be okay but not if you really want to get ahead in life. People are impressed by your presence.

HENRY: Absolutely.

TINTINALLI: Oh, yes. I always tell people to look at Brooks Brock if you want to learn how to walk the walk and talk the talk, that’s the guy to really emulate.

HENRY: Yeah, my wife always used to say: Greg, when you grow up, can you look like Brooks Bock? And I said: I wish I could. First of all, when he speaks he sounds like God and secondly, his tie is always done perfectly.

I don’t want this panel to sound like a bunch of old fogies who say: Oh, my God, those kids, yada yada. But I think that we need to instill in them a need to go back to primary sources to do some reading. We’ve raised a generation now who’s looking for the Wikipedia view of the world. But to get what they want for their patients, they have to deal with the bigger world on the outside.

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Doctus cum libro
We are taught by books