Six Things I Wish I’d Known When I Finished Residency

Congratulations! You have made it to the next round in your career to become an emergency physician. Here are a few things I wish I’d known.

Dear recent residency graduate:
You have spent the last seven or more years accumulating a wonderful, enormous amount of information and skills, and you are now entering the world to see where your great gift meets the world’s great need. However, there are many things they don’t teach you in medical school and residency.

In order to pass along wisdom and save some painful growth, here is a list of things I’ve learned in 20 years of practice at a community hospital. I have learned this by some painful personal experiences or by the better method of learning from the wisdom and advice of colleagues. Here is an attempt to help you avoid the aphorism of “wisdom is what you get right after you needed it.”

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1) Never get angry at a patient or a family member
It will never help you. It can only hurt you, sometimes badly. It is a learned behavior not to be reactive when attacked verbally or emotionally. It is usually not about you, but about a wait, or some prior event. The patients and their families are scared, confused, and worried. Say things like “I am sorry” a lot and reassure them that you will help them and they have come to the right place. Learn how to absorb the patient’s anxiety and emotion and reassure them at the same time.

2) Never get angry at a nurse or tech or anyone working with you
And try very hard to never get angry at a colleague. There will be many stressful conversations as we deal with lives not commodities or ideas. When you have a challenging conversation, try to think about what is best for the patient, focus on that, and then, if you are at a real impasse, move the challenging conversation to another venue and time.

3) Patients are often worried about something in particular
Find out what that is by asking “Do you have any thoughts yourself?” or ask directly “what are you concerned about?” If you do not discover this, you will often be missing the value of the interaction for the patient, and sometimes, you will be missing the key diagnosis.

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4) Work efficiently and let common things be common
Colicky, right upper quadrant pain an hour after eating is usually biliary colic. Do not spend too much time looking for other things unless you can’t diagnose the common one. However!

5) Do not fall prey to bias! Know where to look for it
We all bring bias to our perspective of the world and our patients. One of the most important is anchoring bias, which is the tendency to anchor on what you think/want the diagnosis to be based on initial information, like the chief complaint. Don’t anchor or fix yourself to a particular diagnosis if things don’t fit or make sense as you continue your workup. And when things don’t make sense, try not to fall into the trap of confirmation bias, which is the process of making the data fit your first diagnosis. Many years ago, I saw a patient with sud-den onset flank pain and some microscopic blood in his urine. His kidney stone CT with-out contrast did not locate a stone or renal obstruction. I had treated him with generous analgesia. When I returned to talk to the patient and his wife at the bedside and told them about the CT results, the wife astutely asked, “what else can this be?” Anchoring on my diagnosis that I had already made, I said, “he likely passed a kidney stone when he void-ed.” What else might he have had? Most physicians, new or experienced are guessing that when this patient returned two days later, he had an aortic dissection. “How Doctors Think” by Jerome Groopman is a book well worth reading about this type of thing.

6) Never let a patient hear you say they have nothing
We rarely say this, but what the patients hear when you come into the room and say “everything is normal” is that you found nothing and feel that they have nothing. If a tumor or an infected gallbladder occurs in a year or a week, you missed it because “you said they had nothing”. The way to avoid this and to improve communication is to end your visit with the patient by asking “what other questions do you have?” which will get at the “what else is the patient worried about that I didn’t get” and will allow them to review what you have said. When presenting a work up with normal labs or studies, begin by saying “the good news is that everything looks good so far. We have looked at these labs and studies. Here is our plan for treatment and follow up so that we can follow this until you are fully improved and your symptoms have resolved.” Ask them to repeat the plan verbally.

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Your career will be full of joy and hardship, challenges and victories, laughs and tears, as these are human lives we are dealing with. If you can start with these few hard earned, irregular pearls of wisdom, you can save some pain, work efficiently without bias, avoid some missed diagnoses, and make a few more patients happy and save a few more lives.

We asked some of our editors for their best advice for new grads. Here’s what they had to say:
“Channel your Dr Phil. Learning how to manage difficult people in difficult situations is probably the number one critical skill for EM longevity. Fortunately, just like technical skills, effective communication skills can be learned. Take the time to master them.” – Jeannette Wolfe, MD

“While everyone gets some complaints, you generally want to try to avoid them, especially before you establish a track record of excellent patient care. Most complaints I see are related to communication, or lack thereof. Effective communication cannot be stressed enough throughout the ED. Communication involves both talking and listening. Listen enough and your patients will guide you to that difficult to make diagnosis. Take the time to explain your thought processes and treatment plan to your patients and your nursing team. Solicit the opinion of your nursing team. And ask a clarifying question or express your concern if a consultant provides a recommendation that makes you uncomfortable.” – Mike Silverman, MD (more articles by Dr. Silverman on this topic – Step It Up: 5 Habits of Successful EPs & Best Foot Forward)

“Serial EKGs are your friend. Order a pregnancy test for every woman with a menstruating uterus. Palpate all your belly pains at least twice. Back pain patients need to ambulate without assistance prior to discharge. Better have a great explanation for why a patient is being discharged with tachycardia. Ask at least one unscripted question from all your patients. I heard this at a grand rounds once and realized I had started doing this a few years out of residency. It will change your practice. It has allowed me to connect with my patients in a way I had previously been unable to do. I have obtained critical information from their history with these questions. It also reassures them I am truly interested in what they have to say and not just trying to rush through to the next room.” – Jyoti Mahapatra, MD

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“Live modestly. Resist buying that Porsche Turbo. Buy a house you can easily afford. Get out of debt. Start paying off any student loans. If you are looking for a life partner, this is a harder task than finding the right job. But trial and error is easier (without getting married) in that relationships may come and go. Not fun, but not catastrophic.” – Rick Bukata, MD