Rules of the Road: Tips for the New Class


Congratulations! You’ve completed your emergency medicine residency and you’re ready to finally start your life – less stress, more time and more money. Sounds nice, right?

Congratulations! You’ve completed your emergency medicine residency and you’re ready to finally start your life – less stress, more time and more money. Sounds nice, right?


Not so fast. Before you can really settle in and relax, you still have a few hoops to jump through, including, but not restricted to: obtaining new state medical licenses, new hospital credentialing/paperwork, meeting your new colleagues, getting used to your new facilities, meeting your new ED team, written boards, oral boards, and perhaps most anxiety provoking – your first few shifts as a new attending.

The reality of the situation is that being a new attending is akin to being a fresh intern, except you hold a lot more power and even more responsibility. You are carrying the weight of all of your patients’ ED experience squarely on your shoulders. Additionally, you will be expected to manage your team of nurses, coordinate with charge nurses and hospital administration, maintain throughput times and benchmarks and meet patient satisfaction expectations. For those of you entering academic institutions, you will be expected to teach residents and medical students, as well as have a thriving academic portfolio.

Every freshly minted attending handles the new reality a little differently, but we all reach for our crutches to help us along, as coping mechanisms to reduce our cognitive load. My personal crutch was a list on my smartphone that I started right after my first shift, when I felt like a fish out of water. The list evolved over time and became a letter I sent to the graduating class at my institution this year, to give them a game plan for the first day on the job and a few axioms to help them get through the day.


1. If you’re worried about a patient, pick up the phone
I have always cared for my patients. However, as an attending, I really worry about them (and occasionally lose sleep over them) and how my decisions may have affected them. If you’ve discharged them and you’re still worried, give them a call to check on them. They’ll appreciate it, and you’ll sleep better.

2. Make your own hard and fast rules to reduce your own cognitive burden
For example, for all patients presenting with abdominal pain, I will palpate their abdomens twice. Also, if it hurts, image it.

3. Don’t let your mid-levels run you
At the start of your shift, have either an individual chat or team huddle to set your general rules for the shift. For example, “Don’t wait more than 30 minutes to present a patient, tell me before you order a d-dimer or CT, I want to be present for all procedures (bedside ultrasound), see all wounds before you suture them up, and for all patients with abdominal pain, please document a re-examination note and PO trial before discharge.”

4. Don’t procrastinate
Don’t delay the inevitable. Force yourself to see the expected complicated patient, and make the management decisions sooner rather than later. Simply moving onto the easier patient won’t make the problem go away.


5. Ask for help
A favorite quote at my ED is “Upstairs care downstairs with a friend”. Don’t expect to know everything. You don’t. So ask your co-attendings or senior PAs for help if you need it. The sick and not sick are often the easiest to deal with while the grey middle will always be a challenge.

6. Round frequently
Organize your patients by length of stay and try to get dispositions for your longest duration patients as soon as possible.

7. Double check
Double check all labs, imaging (looking for subtle findings), progress notes and vital signs BEFORE discharging patients, and remind your midlevels to do the same. If you are discharging a patient with your preliminary read, make sure there is a Radiology or ED callback service in place and let the patient know that the read is preliminary.

8. Question your midlevels
If a junior midlevel tells you they want to discharge a patient right off the bat, be very skeptical. Make them sweat during their presentation to prove their point to you. Strongly encourage them to chart everything from medical decision-making to every consultation or important interaction with the patient. Double-check their orders. Your midlevel will burn you occasionally. Expect it.

9. Learn how to chart
Charting is worse than you imagined. The only way to survive is to chart as you go along. Most hospitals are expecting that admitted patients’ charts will be done by the time of admission, and by the end of the day for the rest. Make yourself a set of shortcut templates if possible; these can help with your speed. Read other attendings’ notes to see how they chart.

10. Take your time with EKGs
Time has to stop when you are scrutinizing an EKG. You will catch the obvious STEMIs, however, the subtle ones will get you. Always remember that a large number of EM lawsuit payouts are due to missed ACS/MI.

11. Be the team captain
Lead by example. Make sure your team is in good shape, give them the game plan, ensure they take time to eat and use the bathroom. Round with them once or twice a shift. Try to teach them one thing per shift.

12. Slow down
You have permission to take time for yourself if you feel overwhelmed. Take 10 undisturbed minutes to think, review results, eat, chart and use the bathroom.


  1. “If it hurts, image it.” Every chest pain, every abdominal pain, every headache, every ankle sprain?? C’mon… be reasonable.

  2. Not the 1980s... on

    Your view of “midlevels” is a bit outdated… For a seasoned provider who has proven themselves these arbitrary requirements are somewhat ridiculous, especially given the fact that this article is geared towards brand new EM Doc’s. I work with seasoned ER PA’s and NP’s who can run circles around some of the newer docs. Of course the attending is ultimately in charge, but that doesn’t mean they are always correct. Learn to value experience, whatever form it comes in, and don’t pre-judge based on the letters after a person’s name.

  3. You have a very incorrect view of “midlevels”. They are not ‘yours’, they are medical professionals, and often they have far more experience than you do. Are you really the type who wishes to micromanage people? You will quickly get a reputation for being a piss poor attending when you micromanage people, have a sense of domain over them, especially when they are far more experienced than you are. Come off your high horse, New Attending. You’ll be a better clinician for it.

  4. Dave Mittman, PA, DFAAPA on

    Midlevels is a term not particularly used anymore. Even so, the remarks made about PAs and NPs should be made about new grads or students, not seasoned veterans.
    Memo to Daniel, some of us are really good-we get that way you know. Especially after 5-10-15 years of learning from other great PAs, NPs and physicians. Some of us do residencies and even get doctorates in advanced trauma (see Baylor College of Medicine’s EM Program).
    Your article was demeaning and showed your true colors. Sorry you feel the way you do.

  5. As an update and to add a clarification – the article was directed to the brand-new attending, who is starting at a new location, with new jobs, meeting new people. The emphasis of the article was suggest to the attending that it is better to be very cautious at first – not to trust until trust is earned, and yes, even micromanage at first. I don’t think this is unreasonable for the highly nervous attending who is 3 days post-graduation.

    I do apologize if the term mid-level is inappropriate (I wasn’t aware it was being phased out), and I did use it to encompass residents. As well, I do apologize if the article was demeaning in any way – I highly value the PAs/NPs I work with and acknowledge that many of their experiences exceed mine and often ask them for their opinions with full confidence in their judgment.

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